Time Line Overview

1. Time Line Overview • 2002 - RCCI facilities selected 10 facilities/4 states • 2005 - RCCI facilities expanded to 24/7 states • 2006 - Company-wide education on the principles of Culture change • 2006 - Life’s Simple Pleasures introduced throughout company • 2007 - Artifacts of Culture Change incorporated – 100 point scale • 2009 - 3 year plan developed “Cultivating Community” • 2010 - Cultivating Community 5 Domains Introduced

2. FOUR STAGES OF CARE • 1.Institutional Model – traditional - It is organized around a functional area known as a nursing unit (with a nurses’ station with medication and chart storage, and clean and dirty utility areas). • 2.Transformational Model – start of looking at more resident centered - This is the initial stage when culture change begins to show itself in terms of key culture change attributes.

3. FOUR STAGES OF CARE • 3.Neighborhood Model - This model represents one way of breaking up the typical nursing unit with 25 to 35 resident rooms, into smaller functional units (called neighborhoods). However, these neighborhoods are not self-contained as is the case with the household model. They share core services (e.g., dining, laundry, activities, and bathing) with other neighborhoods. • 4.Household Model – final stage - This is the final stage in the culture change process. To achieve this stage, renovations to the physical environment are usually necessary. Since most units in the typical nursing home have been designed to support an operational model that was taken from acute care hospitals, most lack the architectural and interior design amenities needed to support a household mode

4. Resident driven systems - Resident or Elder makes decisions about: • Waking and sleeping • Meals • Food preference • Daily Routine • Bathing frequency, time and method • ADL’s • Activities

5. Create community by shared joyful eventsLetters of thanks in prominent places.Note accomplishments-large or smallCelebrate lives of those who live and work thereActivities that support life and growthDay-to-day life provides opportunity for meaning and purpose, diversity and spontaneityResidents have the opportunity to give, teach, offer and shareDeath and Dying rituals

6. Resident empowered to live life and make choices to the optimal level of their abilityResident councilConsideration of the whole person’s spiritual, mental and physical wellbeing in all decisionsMakes data driven decisions and seeks areas for improvement based on evidenceCommitment to quality improvement - seeks innovative and creative opportunities and strategies for improving care

7. STAFFINGMake priority the creation of meaningful and lasting relationships (staff, residents, family)Allow consistent staff assignmentsAdministration is visible and knows peopleInvests in staff through time, education, commitment to personal issuesFocus on soft skills –communication, mediationchange processesPromote an environment where individuals are empowered to make decisionsEstablish self-managed work teams

8. ESTABLISH SELF-MANAGED WORK TEAMSSupport a setting where the opportunity to better the facility and individual’s lives are what’s most importantCreate opportunities for individuals to lead and take greater responsibilityLearning circles - everyone speaks, and every one listensTask forceChange Agent teamsIntegrated Care Team: NursingAssistants generate the basis of care plan and function as equals on the care plan teamInclusive decision making process (staff, residents, family)

9. ENVIRONMENT • Resolve to establish a sanctuary and shelter that provides a sense of community, safety and peace, free of unwanted intrusions • Support individualized personal environments • Organize a design which allows for accessibility • Diminished barriers • Provide for nature and natural settings as much as possible • De-institutionalize common room such as bathrooms • Enhance lighting

10. ENVIRONMENT (cont) • Decrease random alarms, alerts and pages which startle • Demonstrate affection, validation and support • Encourage artifacts, personal items that reflect individuality & autonomy (refrigerator); comfort and peace • Provide a place for reflection and solitude that allows individuals to set clear boundaries and control them • Shift towards neighborhoods, communities • Resident a key part of teams

11. SIX STANDARDS AS KEY ELEMENTS OF RESIDENT CENTERED CARE TRAINING: All facility staff must demonstrate an understanding of the principles of Resident Centered Care by participating routinely in the neighborhood, honoring resident choice, and performing some tasks outside their typical duties. • a.90% of all Associates have completed the 8-hour Person-First training. If not, is there a plan in place to provide the training within a 12-18 month period following the completion of Level Two of the RCC Implementation? Are there records to indicate that the plan is being worked according to the schedule? If so, this criteria is considered met. • b.90% of all staff has viewed “Bathing without a Battle”. In-service logs are available to demonstrate compliance. • c.Orientation with all new hires includes training on Learning Circles, Daily Pleasures, Person-First, Bathing Without a Battle video, and neighborhood participation expectations. • d.In-service records of all trainings conducted by Change Agents or designated others are maintained and available for review by FPA reviewers.

12. SYSTEMIC PROCESSES: In order to maintain the integrity of the principles of Resident Centered Care, specific systems will be in place to ensure high involvement, continuity of care, and maximum autonomy for residents and associates.a.The Steering Committee (consisting of original change agents, neighborhood coordinators and others chosen for this committee) meets regularly (at least every other week) to review neighborhood input, determine the need for training, and resolve other issues as they arise.b.Learning Circles are held at all Neighborhood and facility meetings.c.Permanent nursing staff is assigned to each neighborhood and assigned associates are working in their own neighborhood 90% of the time.d.Neighborhood teams have been assigned so that each neighborhood includes a multi-disciplinary group of associates.

13. SYSTEMIC PROCESSES: (cont) e.Attendance logs indicate that 95% of all associates attend at least one neighborhood meeting or function monthly.f.The Team Leadership model is utilized for all meetings so that responsibilities are rotated, minutes are kept and action plans are created and completed.g.A Person-Centered Care plan has been written for every resident that identifies some of the resident’s Daily Pleasures as well as the approaches staff will use to accommodate them.

14. NEIGHBORHOOD ENVIRONMENT: Residents will have the opportunity to live, socialize, and engage in meaningful leisure activities in the more intimate setting of the neighborhood.a.The facility is configured into distinct neighborhoods identifiable by theme décor and signage.b.Neighborhood associates provide programming in his/her neighborhood. Neighborhood activity calendar should indicate that at least 75% of the multi-disciplinary neighborhood members are delivering programs within the neighborhood at least monthly.c.Each resident’s bedroom is personalized according to his/her taste and interests. Whenever possible, efforts are made to accommodate a resident’s own furniture and personal items.

15. NEIGHBORHOOD ENVIRONMENT: Residents will have the opportunity to live, socialize, and engage in meaningful leisure activities in the more intimate setting of the neighborhood.d.Each neighborhood has its own dining space, as well as a kitchenette or pantry available to residents and their families.e.Residents are allowed to help themselves to snacks from the pantry at any time with staff assistance as needed.f.Each neighborhood has its own leisure living space where small groups may gather. The décor of the leisure space is consistent with the neighborhood theme.g.The neighborhood leisure spaces contain items and supplies for small group and individual leisure activities.

16. DINING: residents will enjoy greater flexibility and choice in their dining experience compared to the traditional SNF meal delivery system.a.All meals are served in the neighborhood according to the style selected by the residents (either Family Style dining, the 5 Meal Plan, steam table buffet or Russian style service).b.Residents are allowed to retain their private snack foods in the neighborhood kitchenettes or pantry according to regulations and facility policy.c. Neighborhood associates and residents assure that kitchenettes are clean, refrigerators are maintained at proper temperatures and all food is stored and marked according to regulation.

17. RESIDENT CHOICE:Residents enjoy autonomy in daily decision making and choice in lifestyle pursuits.a.Residents exercise choice in deciding what time to awake in the morning and go to bed at night.b.Residents’ choice of time and method of bathing are honored.c.Residents’ food choices are honored.d.Residents are assisted to engage in leisure activities of choice in the neighborhood or in large group settings.

18. RESIDENT AND STAFF SATISFACTION: Residents and staff feel positive about the environment and about their opportunities to make decisions in the neighborhoods.a.Interviews with residents indicate they are highly satisfied with their level of autonomy and daily decision-making opportunities.b.Interviews with staff indicate they feel increased job satisfaction by having more decision-making responsibility and direct interaction with residents.

26. Quality of Life Living Life to the Fullest Culture Change Golden Clinical Services Ed McMahon, Ph.D.

27. Home:A strong, intimate, fluid relationship between the individual and their environment Judy Carboni

28. Home • Identity • Connectedness • Lived Space • Privacy • Power/Autonomy • Safety Predictability • Journeying

29. Homelessness: The predominate state that occurs when an individual’s relationship with the environment has been severely damaged

30. Homelessness • Non-Personhood • Disconnectedness • Meaningless Space • Without boundaries • Powerless/Dependence • Insecurity/Uncertainty • Placelessness

31. Home – Homelessness ContinuumRelationship of Person to Environment HOME Strong, intimate, fluid HOMELESSNESS Severely damaged Weakened, impaired Damaged Mary Tess Crotty

32. Health Promotion New Practice Institutional Care Individualized Care Old Practice Risk Prevention

33. Life’s Simple Pleasures

34. PURPOSE • Provide a means to enhance the residents’ quality of life • Increase customer service outcomes • Adhere to F-248 guidelines • Move living centers toward a culture of person-centered care, in line with the culture change movement

35. Definition • A “simple pleasure” is anything defined by the resident or RP as something that enhances quality of life or brings joy to the resident • Examples: “Hot coffee when I wake up,” “a beer or glass of wine before dinner,” “a walk outside,” “hot dogs for lunch,” “clam chowder on Fridays,” “breakfast at 10:00 AM,” “ice cream each afternoon,” etc.

36. Responsibility • IDT identifies the simple pleasure while completing the initial assessments • All current residents should have their “simple pleasure” identified by 4/30. • Oversight of process to be determined by ED

37. The How of Change • Personalize the situation: How would you need it to be if you lived or worked here? • Compare what you would need to what is currently happening • Bring people together to figure out how to make changes. • Pilot changes

38. Steps Toward Culture Change Living Center Name: _____________________________________ Date: _________________ Facility number: ___________ Division number: ___________ District number: ____________ Current number of residents:__________ Life’s Simple Pleasures 1. ALL residents in Living Center have an identified “simple pleasure” that is delivered regularly: • A simple pleasure is defined as anything that enhances the quality of life, brings joy or pleasure to the resident • The simple pleasure is identified by the resident or RP • The Interdisciplinary team determines where it will be care planned i.e., activities, dining services, social services, nursing, etc. • The simple pleasure is incorporated in the plan of care as an intervention or distinct entry • Examples are: “hot coffee when I wake up,” “a walk outside,” “hot dogs for lunch,” “bath in the evening,” “a glass of beer or wine before dinner,” “continental breakfast at 10:00 AM,” etc. • Oversight of the process and delivery of “simple pleasures” is determined by ED _______ Met (5 points) _______ Not Met (0 points) Life’s Simple Pleasure Subtotal:Out of a total of 5 points, you scored ______

42. Leadership Artifacts 16. CNAs attend resident care conferences. _____ All care conferences (5 points) _____ Some (3 points) _____ None (0 points) 17. Residents or family members serve on home quality assessment and assurance (QAA) (QI, CQI, QA) committee. _____Yes (5 points) _____ No (0 points) 18. Residents have an assigned staff member who serves as a “buddy,” case coordinator, Guardian Angel, etc. to check with the resident regularly and follow up on any concerns. This is in addition to any assigned social service staff. _____ All new residents (5 points) _____ Some (3 points) _____ None (0 points) 19. Learning Circles or equivalent are used regularly in staff and resident meetings in order to give each person the opportunity to share their opinion/ideas. _____Yes (5 points) _____ No (0 points) 20. Community Meetings are held on a regular basis bringing staff, residents and families together as a community. _____Yes (5 points) _____ No (0 points) Leadership Artifacts Subtotal: Out of a total 25 points, you scored ______.

43. Cultivating Community • VISION – A Community of Individuals living together in an environment that honors and supports the uniqueness of every person

44. Mission • Facilitate autonomy to create a personally satisfying experience for every individual who is a part of our community.

45. Cultivating Community Model Development • This model was developed based on knowledge gained from our Resident-Centered Care pilots, the PEAK program in Kansas as adopted by our LivingCenters, the artifacts of culture change as promulgated by CMS, the principles and values of the Pioneer Network, and the work of a dedicated Golden Living Culture Change Steering Committee.

46. Cultivating Community • Domain I – Individual Empowerment • Domain II – Community Involvement • Domain III – Staff Empowerment • Domain IV – Home Environment • Domain V – The Dining Experience