The Small House

1. The Small House

2. History of the Nursing Home SS & Medicare Penicillin & Medical Renaissance Baby Boomers

3. The Nursing Home as Institution A ‘total institution’ is ‘a place of residence and work where a large number of like-situated individuals, cut off from the wider society for an appreciable period of time, together lead an enclosed, formally administered round of life that is controlled by a bureaucratic administration with set schedules and requirements and marked with depersonalization.

4. Symptoms of Homelessness • Failure to thrive • Depersonalization • Loss of self esteem • Depression • Loss of appetite • Disengagement

5. Problems Loss of dignity Decreased sense of value & respect Low levels of choice Loss of the privileges of adulthood Loss of home

6. Culture Change – Pioneer Network Live Oak Regenerative Community Mt St Vincent (early neighborhoods) Eden Alterative

7. SLOW incremental ADOPTION

8. De-institutionalizationcreate a new normal Restore Home Improve clinical Care Improve working conditions for staff

9. Green House Project Rosalie Kane, PhD professor in the division of health policy and management of the School of Public Health at the University of Minnesota, past editor-in-chief of both Health and Social Work, and of The Gerontologist. Robert Kane, MD Geriatrician Minnesota Chair of Aging and Long-Term Care at the University of Minnesota's School of Public Health  Author, Clinical Geriatrics

10. For the Organization Vision Success Excellent clinical, financial, quality of life and satisfaction outcomes.

11. Conceptual Model

12. Homea vessel for the most positive elderhood possible • Architecture that supports • Elements of home • function of the elder • Work of the staff

13. Free Standing Houses in clusters Otterbein Neighborhoods, Ohio Perkins Eastman

14. Urban High Rises Jewish Home Lifecare Perkins Eastman

15. Front door

17. For the staff A satisfying job in a serene work environment where they feel empowered and valued

18. Staffing Model • Separate schedules by house • Consistently assigned to same house • 1:5 ratios

19. Organizational structure

20. Ceiling Lift Lifts are key to staffing ratios and outcomes

21. For the elders

22. Kane Domains of Quality of Life Comfort Functional competence Autonomy Dignity Privacy Individuality Meaningful activities Relationships Enjoyment Security Spiritual well being

23. Person CenteredNothing about me without me RESPONSIVE KNOWING & Individualized Normalization Life History Individualized mornings Food preferences Lifelong Engagement Patterns End of life wishes Sleeping patterns Care preferences

24. Normalized Diets

25. Convivium + Family Style Dining

26. Individualized Care • Re- evaluate all of the “everyone” practices • Bathing • Weights • Blood pressures • Glucometer testing • And more

27. Evidence based practices CAM Advance directives No restraints No alarms NDDC dementia care Incontinent /skin care Infection control – UTIs Diabetes Falls program

28. Person Centered Medication Plans Reduce Polypharmacy Person centered administration times – aim for BID Decrease crushing Eliminate unnecessary medications

29. Lessons and Challenges

30. Interconnected outcomes

31. Overcoming the ideology of comfort and the tyranny of custom

32. Staff Training

33. Phases of Implementation Feasibility Implementation Actualization Conceptualization & Strategizing Explore Model details Select architect Select consultants Obtain stakeholder buy–in Financial feasibility modeling Identify site Regulatory review Regulatory Meetings Design Refine financials Secure financing Map project activities Create Timeline Construction Systems mapping Staff reconfiguration Policies & Procedures Training Plan Training deployment Move in plan Quality plan Move-in Continuous coaching on adaptive changes

34. DiscontinuousDisruptiveMessyParadoxical Change

35. Execution - What does it Take? Disciplined thought Disciplined people Disciplined actions