National Certification Program for Retirement Housing Professionals

1. National Certification Program for Retirement Housing Professionals CORE COURSE III Managing the Financial and Physical Environments Lesson Dining Management and Philosophy of Service in Long-Term Care Date: November 6, 2005

2. Session Objectives • Review Changing Factors of Environment & Constituencies • Review Demographics • Define Assumptions • Introduce Choice Dining Concept • Discuss Culture of Service, Leadership, Choice • Fixed & Variable Navigation • Technology Applications National Certification Program for Retirement Housing Professionals

3. “We did the best we could, with what we knew, And when we knew better, we did better. “Maya Angelou National Certification Program for Retirement Housing Professionals

4. Insanity – to continue to do the same things and expect different outcomes It is increasingly clear that we need to change the environment, practices and culture of caring for and with residents. What we have been doing is not as effective as necessary or possible. National Certification Program for Retirement Housing Professionals

5. Changing Demographics • More Couples • More Choice & Selection • More Control • More Flexibility • Experience Consumers • More Knowledgeable of CCRC Living • Healthier – Wellness Important • Seamless Experience • Broader Constituencies National Certification Program for Retirement Housing Professionals

6. Assumptions • Envision the Future, Honor the Tradition • Imposition of Dining • Until the Experience Dining is Resident Centered, a New Culture will not Take Deep Root • What is Current Does Not Work As Well As It Can & Should National Certification Program for Retirement Housing Professionals

7. Must Rising Acuity Levels Mean Lower Dining Quality ? © National Certification Program for Retirement Housing Professionals

8. Primary Factors That Contribute To Malnutrition In Nursing Homes An Inappropriate Dining Experience For The Resident. Meal Delivery Methodology and Systems Not Conducive To Eating. Good Nutrition is of no value if it is not consumed Why Do 65% Of NH Residents Eat Less Than 75% Of Most Meals*? *Excerpted From Ch 14 Of Report To Congress “Appropriateness of Minimum Staffing Ratios In Nursing Homes” Authored By J. F. Schnelle et al, Borun Center For Gerontological Research National Certification Program for Retirement Housing Professionals

9. Skilled Care Dining TodayRestricted Service Times, Too Short For Quality & Assistance < 20 Minutes For Dining The Quality Gap National Certification Program for Retirement Housing Professionals

10. Bridging The Quality GapServe The Resident, Not The System • The System – Individual Preparation, Bulk Service • Prepare Individual Menu Items For Storage • Place On A Tray For Transport To Feeding Area • Transport and Leave In Cart • Distribute and Unwrap At Scheduled Meal Time • The Alternative – Bulk Preparation, Individual Service • Prepare Menu Items In Bulk • Transport To Dining Room Servery • Plate Individually and Serve Upon Request National Certification Program for Retirement Housing Professionals

11. What Are Factors of a Quality Dining Experience? • Individual Service Honoring Personal Eating Habits - Generational Expectations • Choice • Where & When You Eat • Residents Eat When Hungry • Defined And Met Expectation = Reputation & Consistency • Presentation Of Meal, Taste & Pace “Do Not Rush Me” • Neighbors Atmosphere, Aroma, Friendliness, Relationships National Certification Program for Retirement Housing Professionals

12. How Do You Individualize Care? • What Are Strategic Objectives? • Must Contribute • What Is The Vision for Community Dining Experience? • Choice • What Is History of “Transformation” Projects? • What Were Expectations • How Defined and Structured • How was it trained & accepted? • What Are Constituency Most Important Experiences? National Certification Program for Retirement Housing Professionals

13. Rhythms of Daily Living The core of RDL is the opportunity to exercise choice – residents’ for how they choose to live their day and staff choice for care delivery. This creates a collaborative coalition of residents and caregivers working together in a living environment. RDL facilitates the delivery of care, the experience of living and the dignity of self-determination. RDL is a management principle that aligns the natural rhythms of residents and the support they need. The organizing principle of RDL is that people should be able to make meaningful choices in their daily lives – on their own or with assistance. RDL relies on caregivers to help define and achieve outcomes that balance individual choice and system efficiency. National Certification Program for Retirement Housing Professionals

14. Choice Is The Way We Live “Some facilities studied, usually the lower turn-over ones, were in the process of thinking about how to increase individualized care. For example, the researcher asked, what are you doing if anything about resident choice. ‘We are looking at it. Ideally, we want them to eat when they want. We encourage them to tell us what care they want, a shower or bath, or to get up when they want.” Page 5-49 Appropriate of Minimum Nurse Staffing Ratios in Nursing Homes, Phase II Final Report prepared by Abt Associates for the Centers for Medicare and Medicaid Services, December 2001. National Certification Program for Retirement Housing Professionals

15. Quality of Living Considerations A large proportion of nursing home residents are malnourished and up to half are substandard in body weight, leading to serious consequences including infections, hip fractures, and even death. The environment in which residents eat and the degree to which residents may choose when and what to eat can affect residents’ health (malnutrition and dehydration) and quality of life (perceived safety, enjoyment, social relationships, individuality, autonomy, choice).[i],[ii],[iii] • [i] Burger, S.G., Kayser-Jones, J., and Bell, J. P. “Malnutrition and Dehydration in Nursing Homes: Key Issues in Prevention and Treatment.” National Coalition for Nursing Home Reform. June 2000. • [ii] Chou, S., Boldy, D., and Lee, A. “Resident Satisfaction and Its Components in Residential Aged Care.” The Gerontologist 42:188-198, 2002. • [iii] Kane, R. “Long-Term Care and a Good Quality of Life” The Gerontologist 41:293-304, 2001. National Certification Program for Retirement Housing Professionals

16. Balancing the Natural Rhythms of Resident Living and Care Work • A “More Normal” Pattern of Living and Work • Residents Eat What And When They Want Over A Longer Meal Service • Pre-Meal Medications, Bathing and Other Activities Are Less Pressured • Staff Provides Assistance As Required • 24 Minutes Is Average Optimal Feeding Assistance Time With A Range From 5 To 70 Minutes Depending On ADL Status* • 48% Of Nursing Home Population Require Some Degree of Assistance* • A Dining Experience, Not A Feeding Period • Shift Dining Service Focus From Trays To Residents and Quality • Collaborative Service Support • Aroma Therapy • Course Presentation • Minimal Distraction Environment *Excerpts From Ch 14 Of Report To Congress “Appropriateness of Minimum Staffing Ratios In Nursing Homes” Authored By J. F. Schnelle et al, Borun Center For Gerontological Research National Certification Program for Retirement Housing Professionals

17. RDL Is RealReported Results From Ten Communities That Have Implemented RDL • 40% of Residents Gain Weight In The First Few Program Months • 50% Reduction In The Number Of Residents Losing Weight. • Consistent Improvement In Resident Satisfaction • $0.25 – $0.32 Reduction In Food Cost Per Meal From Less waste. • 85% Decrease In Use of Supplements • Higher Job Satisfaction • Improved Hydration • Outcomes Exceed Regulatory Requirements National Certification Program for Retirement Housing Professionals

18. The ROI Of A Dining ExperienceBuilding “Experience Equity” Dining establishes the daily quality of life for all members of a senior living community. The culture defined by the dining experience resonates with and dictates that of the entire community. The dignity and joy of making self-determined choices are at the core of any good dining experience. National Certification Program for Retirement Housing Professionals

19. Institution-Directed Culture Staff provide standard “treatments” based on clinical Institutional defined schedule and routines – resident comply Work is task oriented and staff rotates assignments – interchangeable residents Centralized decision making Hospital environment Structured activities There is a sense of isolation and loneliness Choice – Directed Culture Staff enters into a care giving relationship based upon individualized care & resident desire Residents and staff design the schedules Care is relationship-centered, consistent assignments Frontline decision making Environment reflects the comforts of home Spontaneous activities Sense of community and belonging Comparison of CulturePioneer Network National Certification Program for Retirement Housing Professionals

20. Culture National Certification Program for Retirement Housing Professionals

21. A Culture of Caring vs. a Culture of Curing There is a significant difference between these two cultures. A culture of curing, the medical model, requires workmanship of certainty – specific, objective, regimented procedures to achieve a specific outcome. A culture of caring, the LTC model, requires workmanship of risk – the collaborative relationship to create a quality of living experience that is subjective and defined by the resident and care provider at the moment of service. National Certification Program for Retirement Housing Professionals

22. Workmanship of Riskvs. Workmanship of Certainty The distinction between workmanship of risk and workmanship of certainty turns on the question "Is the result predetermined and unalterable once production begins?" National Certification Program for Retirement Housing Professionals

23. Workmanship of Risk & Workmanship of CertaintyCultural & Leadership Attributes Workmanship of certainty requires a traditional hierarchical leadership style. Workmanship of risk is best developed with a servant leadership model of direction. Leadership defines, through collaborative development, the expectations. The role of servant leadership is to then provide the community direction and then assure that staff have the necessary resources and environment for achieving the experiential outcomes. National Certification Program for Retirement Housing Professionals

24. Servant Leadership “Servant leadership is a long-term, transformational approach to life and work, in essence, a way of being—that has potential for creating positive change within our society. . .” Ron Ortiz Dinkel “Servant leaders put other people’s needs, aspirations and interests above their own.” Robert Greenleaf National Certification Program for Retirement Housing Professionals

25. Servant Leadership “I don’t necessarily have to like my players and associates, but as the leader I must love them. Love is loyalty, love is teamwork, love respects the dignity of the individual. This is the strength of any organization.” Vince Lombardi It is the value and contribution of each individual, staff and resident, that creates a culture based upon the dignity of self-determination and choice. National Certification Program for Retirement Housing Professionals

26. STAGES of RDL • Readiness GAP Analysis • Establish clear understanding among all constituents (residents, staff and administration) as to the program impact on 6 principle areas. • Culinary Capacity • Establish a servery on the resident floor where all meals can be finished, plated and served. National Certification Program for Retirement Housing Professionals

27. Stages of RDL • Individualized Service – Establish a service program without the tray system. Meals are plated in the servery when the resident is in the dining room. Choice is based on pre-ordered menu items, however time of service is not flexible. • Point of Service Menu Choice –Establish the opportunity for the resident to choose alternate items from a menu during meal service. National Certification Program for Retirement Housing Professionals

28. Stages of RDL • Schedule Choice I[1] • Establish the opportunity for residents who are self-sufficient and independent to dine at a time of their choosing, within established service times. • Schedule Choice II • Establish the opportunity for residents who require assistance with dining but are able to determine when they would like to dine to do so within established service times. • Venue Choice (If Appropriate) • Establish the opportunity for residents to choose alternate places to dine. National Certification Program for Retirement Housing Professionals

29. Assessment Points for RDL Implementation Stages are defined against the requirements of: • Administration: fiscal, management and leadership considerations • Regulatory: compliance criteria (grouped by clinical and operational considerations) • Systems: software programs, forms, policy & procedures, protocols • Personnel: staffing requirements, training, HR. The impact on each care disciplines is identified by department • PP&E: Property, Plant & Equipment necessary to perform the tasks and functions • Community: Communications, Resident & Family education; community collaboration National Certification Program for Retirement Housing Professionals

30. Obstacles • Structure of resident ordering • Staff resistance to change • Inadequate staffing • Training of staff to new tasks • Management of change (fair process) • Need to educate the staff in the process of change • Clear explanations of the reasons/outcomes of changes • How changes will impact staff security and knowledge of job tasks and resident served National Certification Program for Retirement Housing Professionals

31. SERVICE INITIATIVE PROJECT MAPPING As dining options and program enhancements are discussed, specific initiatives are defined and envisioned by department management and staff. These new “dining experiences" require a specific process from concept to implementation. The following are the task requirements for this process: • Identify Service Initiatives • Define Their Contribution To Strategic Objectives • Define Appropriate Measurements Of Successful Experience Outcomes • Identification Of Resource And Operational Intersects • Identification Of Intersects And Roles Of Other Contributing Departments • Structure Of The Process For Resource Allocation To Develop The Defined Initiative • Sequencing Of The Tasks • Implementation of The Initiative. National Certification Program for Retirement Housing Professionals

32. Community Strategic Objectives • Community of Distinction • Financial Enhancement • Quality of Living / Quality of Work • Operational Effectiveness National Certification Program for Retirement Housing Professionals

33. Program Intersects Grid National Certification Program for Retirement Housing Professionals

34. Program Intersects Grid National Certification Program for Retirement Housing Professionals

35. Project Management National Certification Program for Retirement Housing Professionals

36. Alignment • The appropriate positioning of systems and resources to attain a defined goal, mission, outcome or culture National Certification Program for Retirement Housing Professionals

37. Fixed & Variable Navigation Points • Fixed • Budget & Cost Management System • Schedule – Timeline – Scope of Work • Process Map • Variable • POS • Resident Preference/Therapeutic Data • Production Systems • Satisfaction & Leadership Effectiveness Survey • Project Manager National Certification Program for Retirement Housing Professionals

38. POS Systems • Horizon Software • http://www.horizon-boss.com/default.htm • Micros • http://www.micros.com/ National Certification Program for Retirement Housing Professionals

39. Additional Culture Change Organizations • Culture Change Now! http://www.culturechangenow.com/index.html • The Eden Alternative http://www.edenalt.com/ • The Pioneer Network http://www.pioneernetwork.org/ • Providence Mount Saint Vincent http://www.providence.org/Long_Term_Care/Mount_St_Vincent/default.htm National Certification Program for Retirement Housing Professionals

40. Contact Information • Dan Look • 3605 Sandy Plains Road • Suite 240-269 • Marietta, GA 30066 • dcl@dm-resources.com • www.dm-resources.com • 770-565-4006 National Certification Program for Retirement Housing Professionals

41. "For every complex, difficult problem, There is a simple solution. And, it is probably wrong!" H.L. Mencken “An unreasonable man tries to change the world’s thinking to fit his own. The reasonable man adjusts his thinking to fit the world. Therefore, all progress relies on the unreasonable man.” National Certification Program for Retirement Housing Professionals

42. Technology Applications • Excel Budget & Cost Management Worksheets • Microsoft Project Manager • Visio Flow Management Software • POS • Resident Data Management • Satisfaction Survey Documents • Leadership Effectiveness Survey Documents • Operational & Compliance Gap Analysis National Certification Program for Retirement Housing Professionals