| Transporting Bariatric Residents in the Post-Acute Setting | <p><img src="/Articles/PublishingImages/740%20x%20740/wheelchair.jpg" class="ms-rtePosition-1" alt="" style="margin:5px;width:200px;height:200px;" />When caring for bariatric residents, multiple costs factors must be considered prior to accepting the resident for admission. The facility must be able to provide reasonable care for the bariatric resident in the same manner as other residents. One of the costs to consider is transporting the resident to appointments and other off-site visits. Safe options are expensive and not always available. This is not a one-size fits all approach. Some bariatric residents may do fine in a wheelchair and the facility van. Some residents may require extensive planning and an ambulance ride for a specialist visit. </p><p>Therefore, prior to admitting this resident, the need for specialist visits and other appointments (dialysis, wound care clinic, psychiatric services, support groups, and other services) should be carefully considered. Each resident will require individualized assessment to assure the service planned will be appropriate and cost effective.</p><p>In reviewing the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities,<sup><a href="https://www.cms.gov/files/document/appendix-pp-guidance-surveyor-long-term-care-facilities.pdf" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">1</a></sup> it should be noted there are multiple regulations from the Centers for Medicare & Medicaid Services (CMS) regarding appointments and transportation. Two of the most basic requirements are: F685, which indicates the facility is required to assist the resident in gaining access to vision and hearing services by arranging for transportation, and F790, which states the facility must arrange for transportation to and from dental services if necessary.</p><p>This article will review transportation options and how to evaluate cost effectiveness. </p><h3>Transport Companies</h3><p>Many communities have wheelchair transport companies that supply transportation for people with disabilities to appointments (medical or otherwise). These companies charge varying fees. Some offer an assistant that attends the appointment with the resident. Others only offer transportation to the address, and facility staff or resident families will be required to assist the resident at the appointment. The cost of these services varies widely from community to community. </p><p>The cost of this service can be as little as $95 per visit and up to $500. Insurance may reimburse some of the cost depending on the type of insurance the resident has. In some instances, the facility may be responsible for the entire cost.</p><p>Not all communities have appropriate transport companies. Many areas that are more rural may have medical transport companies, however, not all companies are capable of transporting bariatric clients. The facility must evaluate carefully the company that will be used to ensure the resident can be transported safely prior to planning the use of a company. <br><br>Items to consider:<br></p><ul><li>Do the personnel have training in safely moving bariatric clients?</li><li>Is the vehicle designed to transport bariatric clients? (Doors open wide enough, ramp or lift can support the weight, there is room in the van for resident and chair, etc.)</li><li>Will the size of the vehicle accommodate a larger wheelchair or transport chair?</li><li>Are the tie-down straps for wheelchair/transport chair appropriate for larger weights?</li><li>How will the transport personnel communicate their concerns to the facility?</li><li>Will facility staff/families be expected to accompany the resident?</li><li>Is the office/clinic wheelchair accessible? Is there a larger door at the office/clinic?</li><li>Will the resident be expected to transfer from wheelchair to exam table? </li></ul><h3>Basic Ambulance Services</h3><p>Ambulance services that provide basic life support are available in most communities. The service provided and the cost for that service will vary widely depending on locale and type of provider. A review of publications regarding basic ambulance transportation reveals an ambulance ride cost of around $950.<sup><a href="https://www.acsh.org/news/2023/07/31/chasing-cost-ambulances-17221" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">2</a></sup> Some of this cost may be reimbursed by insurance. However, a recent study by the University of Michigan found that 72 percent of clients received billing that was not expected related to insurance denials.</p><p>It must be considered that not all basic services will be able to transport bariatric clients. If the services are appropriate, the cost may be higher. It would behoove the facility to develop a contract for provision of services prior to the need for transportation. </p><p>Items to consider:<br></p><ul><li>Are the personnel trained in bariatric needs including transferring to and from stretcher? </li><li>Is there sufficient room in the vehicle for this resident and their equipment? (door wide enough, stretcher strong enough and wide enough, etc.) </li><li>Will facility staff or family be expected to accompany/meet the resident?</li><li>What will occur if a more pressing emergent transport need occurs? (Will the ambulance place the resident’s transportation needs at a lower priority and thus put the resident at risk of remaining at the clinic/office with no return transportation?)</li><li>How will the ambulance personnel communicate their concerns to the facility? </li></ul><h3>Family and Other Responsible Parties</h3><p>Some facilities request that, as a condition of admission, families or responsible parties transport the resident to appointments. While this may be a viable option in some cases, there are variables that must be considered including family availability and comfort in performing the transportation task, resident preference, need for staff to accompany resident, and resident safety with transportation arrangement. Again, an individualized assessment is required.</p><p>The family may be very familiar and comfortable in transporting the resident to appointments. If this is not the case or if the care team has concerns regarding safe transportation, further evaluation is indicated. The need for therapy evaluation of resident and family abilities to transfer to and from vehicle may be indicated. Having the resident/family sign out of the facility should be considered. </p><h3>Facility Van</h3><p>Many providers now have vans that are facility owned. These vans are normally equipped to accommodate wheelchairs. However, not all wheelchairs are made to travel in vans. Bariatric wheelchairs bring yet another challenge.</p><p>Items to consider:<br></p><ul><li>Is the lift/ramp able to address the weight requirements?</li><li>Are tie-down straps appropriate for weight and size?</li><li>Is the door wide enough to allow access?</li><li>Will the resident be required to transfer from wheelchair to exam table?</li><li>Will extra staff be needed for safe transport?</li><li>Will the office/clinic be wheelchair accessible?</li><li>How will staff communicate their concerns?</li></ul><h3>Transport Chairs</h3><p>Transport chairs used with facility vans may be the solution to many of the issues raised. There are chairs made for the specific purpose of transporting bariatric residents. These chairs have designated weight limits, are designed for outdoor and indoor use, and may serve as a stretcher as well as a chair.</p><p>The safety of these chairs may be evaluated by the Rehabilitation Engineering & Assistive Technology Society of North America (RESNA). RESNA is a professional organization dedicated to promoting the health and well-being of people with disabilities through increasing access to technological solutions. RESNA evaluates safety and makes recommendations for things such as wheelchair tie-down and occupant restraint systems for use in motor vehicles. </p><p>Items to consider:<br></p><ul><li>What is the weight capacity?</li><li>What is the seat width and height?</li><li>How will the resident be transferred to the chair? Can the resident slide from the bed to the chair as with a stretcher or will a mechanical lift be required? </li><li>Is the chair appropriate for indoor and outdoor use?</li><li>Is the chair battery powered? Is there a remote feature? How is it charged? </li><li>Where will the chair be stored when not in use? Is the charging cord long enough if it is battery powered? </li><li>If the chair is not battery powered, can the staff safely move the weight of the resident in the chair? </li><li>Is the chair cushion washable? </li><li>Will this chair be used by more than one resident during the same time-period? </li></ul><p>When evaluating the cost of a transport chair, there are several considerations, such as:<br></p><ul><li>Is there a warranty? If so, how long and what is covered?</li><li>How many chairs will be needed?</li><li>Will extra parts such as cushions be required?</li><li>Who will maintain the chair?</li><li>How can it be cleaned?</li><li>How much would other means of transportation cost the facility if a transport chair were not available? </li><li>Does the chair allow the resident to remain in the chair for examinations (by reclining or offering other positioning options)? If so, will this decrease the number of staff required to transport the resident to appointments? </li></ul><h3>Evaluating Cost Effectiveness</h3><p>As you evaluate the transport options for a bariatric resident, it may help to compare the cost of a service, such as a medical transport company or basic ambulance service, to the cost of using the facility vehicle. This will include determining the minimum number of visits the facility will need to transport the resident. Bear in mind that more than one resident may use the transport chair either in the same time-period or in a sequence of stays.</p><p>Here is a sample formula to use for calculating the cost:<br><br><span style="text-decoration:underline;">Transport Company</span><br>Transport Charges ______________ <br>+ Staff hours required to assist resident ______________ (transfer to and from chair and time spent accompanying resident to appointment) <br>= Cost of transportation</p><p><span style="text-decoration:underline;">Facility Van</span><br>Mileage to and from appointment ____________ (2023 rate is $0.585/mile) <br>+ Staff hours to assist resident __________ (transfer to and from chair and time spent accompanying resident to appointment) <br>= Cost of transportation</p><p>When calculating staff hours don’t forget to review how many staff will be required to transfer the resident to wheelchair and how many staff will be required to accompany the resident to appointment to assist in clinic with transfers if required.</p><p>Also bear in mind the cost of a transport chair might be a capital expense. This then would be able to show depreciation over the life of the chair. <br><br><em><img src="/Articles/PublishingImages/2024/Sylvia-Bennett-Josephson.jpg" alt="Sylvia Bennett-Josephson" class="ms-rtePosition-2" style="margin:5px;" />Sylvia Bennett-Josephson, RN, BSN, CDONA, CDP, CDDACT, IP-BC, FACDONA, CO-Q, has been a registered nurse for over 38 years and a director of nursing in long term care for over 30 years. Bennett-Josephson is a fellow of the National Association of Directors of Nursing Administration and is certified as a dementia practitioner and a certified Alzheimer’s disease and dementia care trainer by the National Council of Dementia Practitioners. She is certified as an infection preventionist and as a compliance officer. She also serves as a health care specialist with Med Net Consults and maintains an educational website, SJJ Education.</em><br><br>Refe<span class="ms-rteStyle-Normal">rences</span><br class="ms-rteStyle-Normal"><span class="ms-rteStyle-Normal">1. <a href="https://www.cms.gov/files/document/appendix-pp-guidance-surveyor-long-term-care-facilities.pdf" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">https://www.cms.gov/files/document/appendix-pp-guidance-surveyor-long-term-care-facilities.pdf</a></span><br class="ms-rteStyle-Normal"><span class="ms-rteStyle-Normal">2. </span><a href="https://www.acsh.org/news/2023/07/31/chasing-cost-ambulances-17221" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank"><span class="ms-rteStyle-Normal">https://www.acsh.org/news/2023/07/31/chasing-cost-ambulances-17221</span></a><br><br></p> | 2024-04-11T04:00:00Z | <img alt="" src="/Articles/PublishingImages/740%20x%20740/wheelchair.jpg" style="BORDER:0px solid;" /> | Caregiving | Sylvia Bennett-Josephson | Not all communities have appropriate transport companies. A facility must evaluate carefully the company that will be used to ensure the resident can be transported safely prior to planning the use of a company. |
| Blending Risk Strategies to Create Resiliency | <p><img src="/Articles/PublishingImages/740%20x%20740/risk.jpg" class="ms-rtePosition-2" alt="" style="margin:5px;width:230px;height:230px;" />Risk, safety, and operations managers talk about risk resiliency in terms of bouncing back from a loss but that is not “resiliency,” that is “recovery.” Resiliency is understanding your risks before they are realized and building plans to address them. It is regularly reviewing the plans as risks have a habit of mutating and innovative solutions are always being created.</p><p>There are only four risk strategies: <br></p><ol><li>Risk Acceptance</li><li>Risk Avoidance</li><li>Risk Mitigation</li><li>Risk Transfer</li></ol><p>Yet, when you realize that there are only three prime colors (red, yellow, and blue), and that all the great visual art that has been created by blending these three colors, you can start to appreciate the complexity of mixing the four risk strategies.</p><h3>Risk Acceptance</h3><p>As a starting point, you have risk acceptance. When you get out of bed in the morning, you can step down, roll your ankle, and land up in the hospital. Nonetheless, we accept the risk because we realize that getting out of bed is necessary to perform our daily tasks.</p><p>In the world of assisted living, we accept thousands of risks per day, from having visitors enter the facility, to food preparation, to storing and dispensing medication, to housekeeping and providing resident activities. At a higher level of management, licensing and finances are the ultimate risks.</p><p>Accepting risk can be a stand-alone strategy, just as an artist may paint in a single hue of blue, but skilled risk managers do not rely on one strategy. Accepting the risk is based on a number of calculations. First you need to know the extent of the risk you are accepting. Once you have identified the risk, you need to determine whether there are parts of the risk that you can avoid. By example, you obviously must feed your residents; that is a risk you accept. You might decide to avoid certain risks such as ensuring that the food does not have nuts. You may look to mitigate the risk by providing training for your food staff. You may look to transfer the risk by bringing in a food service. Ultimately, the core activity is a risk you accept.</p><h3>Risk Avoidance</h3><p>The heart of your facility is providing medical care. Residents, however, have a wide array of health issues that are beyond the scope and expertise of the facility. Most facilities have physical therapy services onsite. Some facilities have x-ray equipment onsite, or in house emergency transportation services while others do not have the risk appetite for the risks associated with the additional services. Higher risk acceptance may lead to higher financial returns--or to financial loss. If your risk appetite is too limited, your market competitiveness may also be viewed as too limited. If your risk appetite is too high, you could risk financial stability. If you have ever said or heard someone else say “that is not part of our core mission,” you have witnessed risk avoidance. </p><h3>Risk Mitigation</h3><p>This is the most powerful risk management tool available. Its power is directly proportionate to the degree of understanding the risk under consideration and understanding all options for risk management. In the aftermath of September 11, risk avoidance would have dictated that airlines stopped flying. Risk acceptance would have been to say “that’s the risk associated with air travel.” Enter risk mitigation.</p><p>The airline industry and the world accepted that air travel must continue. Risk mitigation strategies were put into place including increasing pre-boarding security, enhanced luggage and package screening, and better security on cockpit doors. In the senior care industry, lifting residents is an essential activity. And it is also a leading cause of both employee and resident injuries. Mitigation strategies include an array of hydraulic and electric lifts, and transportation equipment as well as staff training. Some solutions carry large price tags. Risk mitigation includes understanding and leveraging financial opportunities and multilayered approaches. </p><h3>Risk Transfer</h3><p>Most operation managers and too many risk managers see risk transfer as a euphemism for “insurance.” Risk transfer is so much more. Transferring risk is the act of having someone else become responsible for the risk. You pay someone to do an act that you do not want to do or lack the skills to do. For example, you lack the skill to take down the old dead tree that is threatening to fall on your house, so you pay someone else to do it. You lack the skills and equipment to care for an aging family member properly, so you pay someone else to do it. The key is that you pay to transfer the risk.</p><p>When you have a vendor replace the roof or a toilet at your facility, who is responsible if the roofer falls off the roof or drops something that hits someone? Who is responsible if the roofer fails to do the job well causing the roof to leak or damages the building while doing the work? What happens if the plumber does a poor job and the new toilet on the second floor leaks causing the ceiling on the first floor to collapse or the water soaks into the walls creating a mold situation? Yes, you assume the vendor is responsible, but are they? It depends on the language in the contract. What if the plumber who charged you $500 to replace the toilet has language in the estimate that says damages are limited to the amount of the job?</p><p>Risk transfer starts with the contract. As an attorney, I learned that lawyers and risk managers see contracts differently. It is critical to review contracts, including purchase orders, to ensure that you are certain as to how much risk you are accepting and how much you are transferring.</p><p>Finally, we get to the issue of insurance. Who will obtain the insurance to make sure that the medical waste is handled and disposed of properly? Do you need to be named on the vendor’s insurance policy as an Additional Insured? And what is the correct insurance policy for the removal and disposal of medical waste? Is it commercial general liability (CGL)? Environmental waste? Errors & Omissions?</p><p>Insurance is the last consideration because it is supposed to be a safety net. Unfortunately, the insurance industry has convinced too many attorneys, operations managers, and risk managers to see insurance as a hammock. There has even been a spate of insurance commercials that use a hammock to communicate the message. Insurance is supposed to be for those risks that you either cannot anticipate or that you cannot afford to address any other way. </p><p>For most people, insurance brings to mind auto insurance and health insurance. Both are consumer products that are heavily regulated by the state. Your car insurance may have 10 decisions such as the amount of coverage, a deductible, whether you want collision coverage or not, replacement value versus present value and not too much more. Your health insurance is equally as easy. And yet, many of us labor over those simple options. </p><p><span><span><span><img src="/Articles/PublishingImages/2024/risk.jpg" class="ms-rtePosition-1" alt="" style="margin:5px;width:345px;height:258px;" /></span></span></span>Business insurance is far more complicated. Consider a fire that destroys your kitchen facility. Unless you negotiated your property damage coverage properly, you may only receive the depreciated value of that six-year-old oven even though you have to buy a new one. How will you feed the residents until the kitchen is back up and running? That is not part of a standard property insurance policy. You need business interruption coverage. As for the business interruption policy, there are interesting deductibles associated with them. The policy may not cover the first 10 days of interruption. How do you pay for the food service during that time? What are the limits on an interruption period? Does business interruption coverage apply to the loss of computer damage caused by the fire? How about a cyberattack? And beyond all this, if the officers and directors get sued due to allegations that the fire was caused by their poor decisions regarding building maintenance or that a resident was harmed by a medical malpractice issue, does the Errors & Omissions policy protect the directors and officers or do they need a separate Directors & Officers policy?</p><p><span><span></span></span>Insurance is the last consideration because insurance companies set your rates on your loss experience (the frequency and severity of your losses), and your processes and procedures. The safer your operation, the better your rates. </p><p><img src="/Articles/PublishingImages/2024/Jeff-Marshall.jpg" class="ms-rtePosition-2" alt="" style="margin:5px;width:135px;height:167px;" />Risk resiliency is partially the ability to recover from a loss, but if that is the limit of your interest, that is called “loss recovery.” An Errors & Omissions carrier may talk about risk resiliency, but it may be solely focused on patient treatment. A workers’ compensation risk manager, unaware of federal and state medical provider regulations, may recommend increasing worker safety by (unlawfully) increasing patient medication or restraints without understanding risk resiliency’s interconnectivity to all aspects of the business operation.</p><p>Risk resiliency can be a powerful tool for management, especially if the resiliency is formulated using the four risk strategies in a blend to meet the needs of your facility. </p><p><em>Jeff Marshall is a risk and claims management consultant focusing on nursing homes and assisted living facilities. He can be reached at <a href="mailto:IManageRisk4U@gmail.com" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">IManageRisk4U@gmail.com</a>.</em><br></p> | 2024-04-09T04:00:00Z | <img alt="" src="/Articles/PublishingImages/740%20x%20740/risk.jpg" style="BORDER:0px solid;" /> | Management | Jeff Marshall | Resiliency is understanding your risks before they are realized and building plans to address them. It is regularly reviewing the plans as risks have a habit of mutating and innovative solutions are always being created. |
| Changing Perspective Part 2: My Day as a Post-Acute Care Resident | <p><img src="/Articles/PublishingImages/740%20x%20740/nurse_patient.jpg" class="ms-rtePosition-2" alt="" style="margin:5px;width:200px;height:200px;" />In <a href="/Articles/Pages/Changing-Perspective-Part-1-My-Day-as-a-Post-Acute-Care-Resident.aspx" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">part 1 </a>of this article series, I described my experience living a day in the life of a resident to understand the experience better. I was given a fictitious diagnosis that included rehab for a post hip fracture, macular degeneration, and use of a wheelchair.</p><p>In this part, I dive more into the people I encountered in the process and the take-aways I learned from my experience. </p><h3>The People</h3><p>The intake process, the resident agreement, the physical and mental evaluation. Transition management, life enrichment, social work, plans of care, therapy plan. All incredibly important and in this case, all clearly explained and laid out for me to understand. And yet, the people are what made all the difference in my stay, and the people are the all-important piece that make this profession successful. I thought I knew that, but my stay showed me some specific examples.</p><p><em><strong>Boniface, my nurse:</strong></em> I asked him why he chose nursing and long-term care. He had cared for his grandmother when she was sick, and he fell in love with the nurses that were also caring for his grandmother. At that point he made the decision to leave his studies in computer science and begin studying nursing. He told me that as he began nursing, he loved the long-term care demographic. He feels that this is when people need the most from others, as they are losing independence and grappling with physical limitations. He feels a personal benefit in learning from the life experiences of the residents he treats and appreciates their life advice.</p><p>I asked him what the biggest challenge was in his work. His answer was a single word: Burnout. He read an article saying that pre-pandemic, burnout for nurses occurred between 10-15 years into nursing, but now post-pandemic that number dropped to 8-10 years. Combined with the number of people who left the profession in the last few years, he is most concerned with an increasingly quick burnout cycle and a lack of replacement nurses. He worries about the impact for patients and residents.</p><p><em><strong>Sarah, my CNA: </strong></em>Sarah was a bartender before she became a CNA. Her mother was a social worker, so she was around senior care her whole life. She knew she wanted to be a part of the profession. She’s a mother of three so the flexibility in long-term care was a draw. She says she is hooked for good, and her plans include becoming an LPN or RN and continuing to take on more responsibility in long term care.</p><p><strong><em>Sylvie, my CNA:</em></strong> I don’t think Silvie is capable of NOT smiling. She had a smile on her face every time I interacted with her, right through her shift ending. Sylvie has been a CNA for almost two years and says she loves it. She came to the United States from Benin in West Africa in 2016. In Benin she was a secretary, a profession that she studied in college. When she got to the U.S., she went to work in Denver-area hotels, but when the pandemic hit, opportunities in hospitality dried up. She decided to make the leap to health care. Though her native language is French, she went to Emily Griffith Technical College and earned her CNA while still learning the English language. </p><p>When I ask how she got interested in senior care, she tells me that when she was in Africa she was a volunteer caregiver at a local hospital. She cares about people and loves taking care of them. She tells me stories about touching a resident’s hand or rubbing their shoulders, and I can see what it means to her to be a part of their lives. The hardest part of her job is when a resident passes away. She wipes away a tear after she gives me that answer. </p><p>I was in awe of her story. Learning a new profession, in a new country, speaking a new language, all in the midst of a global pandemic. She dismisses how hard that was and tells me that in life we should be looking for new challenges and opportunities. I am inspired by Sylvie.</p><p><strong><em>Tiphany, my transition care manager:</em></strong> How and why did Tiphany get into senior care? At age 12 she took care of her grandmother until she passed. She came from a large family and had to work part-time jobs growing up, and her mother encouraged her to look at long term care. She found that the field was good for access to part-time jobs that offered flexibility. She also cared for her father for four years before his passing. She is clearly hooked on what she does for a living and for whom she does it. </p><p><strong><em>Jackie, the life enrichment manager:</em></strong> Jackie was a hairdresser before she injured herself and wasn’t able to keep working in that capacity. She turned that injury into an opportunity to return to college. Upon entering college, she met a future mentor who told her that she was going to pursue senior care and said that geriatrics just “clicked.” She said that the majority of her clientele as a hairdresser were elderly and that she missed them when she went to college. She started as an intern at Clermont Park and moved into her current job. I asked her what it took to do her job well, and she said it’s a combination of being outgoing and being patient. </p><p><strong><em>Bobbie, the social worker:</em></strong> How did Bobbie come to LTC as a social worker? Her aunt was a nursing assistant at a nursing center. Bobbie was studying psychology as an undergraduate and decided to choose social work as a focus area. She started out working in a residential care center for people with dementia, but life changes meant that overnight hours would no longer work for her family. She went to work in a long term care center where she learned about mental health, case management, and LTC social work. She loves working in long term care because it’s homey and she has a sense of real connection with the residents. She says that it’s the only health care setting where the culture is just right for what she wants to contribute.</p><h3>Reflections</h3><p><strong>A person who moves into a nursing home is bombarded with important decisions when they arrive.</strong> When you arrive, you are faced with a long contract and deciding what kind of life-saving measures you do or do not want. You give a deep dive into your life with a great number of strangers. What are your health conditions, personal challenges, food preferences, family history? Are you coming from an abusive environment, a poverty-stricken environment, do you have enough mental capacity to make your own decisions? A gnawing sense that you might somehow be judged by your answers. I know that moving to a new home for an unknown period of time is incredibly stressful. Telling and re-telling your life story, your conditions, delineating all of your wants and needs, and making life decisions in a period of a few hours can be overwhelming. </p><p><strong>It’s hard living without full sight.</strong> Spending energy to see and craning my neck to look at things straight-on instead of out of the corner of my eye was frustrating and a little exhausting. If I wasn’t wearing a pair of glasses to simulate a sight deficiency, nobody would know about my challenges. This drove home the point that having all of my caregivers understand my conditions is critical to their ability to take good care of me. </p><p><strong>It’s hard being in a position to rely on other people for all of your needs</strong>. Everyone around me exhibited an interest in helping me any time I needed it, but I still felt guilty about asking for their time. Though I wasn’t a real resident, I can see how I would be hesitant to ask for help. I would assume someone else needed their help more than I did. </p><p><strong>The regulatory environment HAS TO CHANGE to meet modern day realities.</strong> Some of the rush of information upon move-in is done to make sure the resident receives all that they need. Another part of that mad rush is dictated by regulation. There has to be a way to ease some of that initial stress for residents and their caregivers. A resident is supposed to have choice, and their environment is supposed to be home-like. At the same time, caregivers are harshly judged when they accommodate those wishes and the outcomes don’t meet a regulator’s expectations for safety and security. The providers are equally harshly judged when a resident chooses not to comply with the caregiver’s recommendations. </p><p>My trip to the restroom drove that point home. I was told that I should not get out of my wheelchair without assistance. I decided I was fine and was going to go on my own. When I stood up without locking the wheels on my chair, I nearly fell over. If I had been an actual resident, that could have resulted in a meaningful deficiency and harm tag, an immediate jeopardy, a fine. There has to be a less formulaic way to ensure that quality care is being delivered. These caregivers want nothing more than to give the best possible life to their residents. We need to find a way to convince the regulators to work on fixing providers that aren’t trying to do it right and focus less on those who go out of their way to do it right. Even when the outcomes aren’t perfect. </p><p><strong>It’s all about the people.</strong> So many people surround you at a care center: people checking on your vitals, preparing your meals, planning your care, cleaning your room, and more. My interactions with these people were great. I don’t know what it takes for them to come to work and be happy and patient and committed every day, but it’s critical to the quality of care they deliver. Since I started my job at the Colorado Health Care Association, I have told policymakers that our staffing challenges go beyond a shortage of workers. The real challenge is that we need people that are cut out for taking care of others. We need people with the right attitudes and temperaments to care for vulnerable people, which limits the pool meaningfully. The importance of that became very clear to me during my stay. </p><p><img src="/Articles/PublishingImages/2024/Doug-Farmer.jpg" class="ms-rtePosition-2" alt="Doug Farmer" style="margin:5px;width:200px;height:200px;" />The good people working in this profession are truly inspirational. They could probably make more money in another line of work. They stay because they love their fellow humans. They stay because they gain something more than money by knowing that they give of themselves to help others. </p><p>I hope to get by as long as possible without needing anyone else’s help. If I do need the help of others at some point in my life, I hope I’ll be able to receive the kind of care and attention that I did during my short stay at Clermont Park.<br><br><em>Doug Farmer is president and CEO of the Colorado Health Care Association.</em></p> | 2024-04-04T04:00:00Z | <img alt="" src="/Articles/PublishingImages/740%20x%20740/nurse_patient.jpg" style="BORDER:0px solid;" /> | Caregiving | Doug Farmer | The people are what made all the difference in my stay, and the people are the all-important piece that make this profession successful. |
| Changing Perspective Part 1: My Day as a Post Acute Care Resident | <p><img src="/Articles/PublishingImages/740%20x%20740/senior_man_nurse.jpg" class="ms-rtePosition-1" alt="" style="margin:5px;width:250px;height:175px;" />As the president and chief executive officer of the Colorado Health Care Association, my job is to advocate for the interests of the state’s long term care providers and the residents they serve. While I have experience in health care, government, and politics, I have never worked in a care center. To do my job well, I need to be able to share the experiences and challenges of our providers and their residents in meaningful detail. I have related second-hand stories to policymakers, lawmakers, and members of the general public, but there is no substitute for first-hand experiences. So I set out to live a day in the life of a resident.</p><p>I spent the night as a resident of Clermont Park Care Center in Denver. The purpose of this adventure was for me to gain insight into the experiences of the residents and staff at a long-term care center. I wanted to understand the residents’ daily lives and what was important to them. I also wanted to hear from the team of people providing the care to understand their challenges and motivations. Three years into a staffing crisis I want to know why they chose long term care—and why they stay.</p><p>The facility administrator created a fictitious diagnosis for me that would serve as the basis of my stay, and for how I would experience my time in the care center. I was there for rehab from a post hip fracture and could only place “toe touch” weight on my right foot and leg. I was to have a history of depression, high blood pressure, and macular degeneration. My impairments were that I was hard of hearing, needed a wheelchair for mobility, and had incontinence. </p><h3>My Stay Begins</h3><p><strong><em>Check-In: </em></strong>I checked in at 1 p.m. I was greeted and shown to my room by the intake coordinator. Upon entering my room, I was told that I was being “red taped” until my evaluation process was completed—meaning that I was to stay in my wheelchair at all times. If I wanted to move to another chair, move to the bed, or use the bathroom, I needed to use the call light to ask for assistance.</p><p>The coordinator gave me a general agenda for the day that showed who I would be visited by and when I would dine. I was introduced to my CNA, Anthony, who asked how I was feeling and if there was anything that I needed. He took my vitals and let me know that everything looked good.</p><p>I was presented with the 74-page resident service agreement, and the coordinator let me know that I could have a paper or digital copy. He also said that he would be by the next day to review the agreement and respond to any questions I had. He offered to talk with family members or another representative if I would like. Finally, he asked if I had any questions or if there was anything I needed. <br><br><strong>Evaluation</strong><br><em><strong>Nurse:</strong></em> Next, I got a visit from Boniface, an RN that works full-time at a local hospital and part-time at Clermont Park. He asked me a series of questions about my condition, my medical history, and my current impairments. He let me know how my care planning would take place (including my part in that process) and who all would be coming to see me and when. He made sure I understood everything clearly and answered every question I had. </p><p><strong><em>New CNA:</em></strong> It’s time for a shift change at 2 p.m. I met two new CNAs: Silvie, who is my primary CNA, and Sarah, who is another CNA on-shift. They both ask me if there is anything I need. Sylvie takes my vitals and lets me know that everything looks good. She tells me that I should use the call button if there is anything I need and that she will be with me until nighttime.</p><p><em><strong>Transition Care Manager: </strong></em>Next, I got a visit from my transition care manager, Tiphany. I learn that in order to be a transition care manager, you need to be an RN and have some background in social work. Tiphany presents me with a Medical Orders for Scope of Treatment (MOST) form. This is a form that I have talked about, read about, and helped promote, but have never had presented to me. I’m a little taken aback by having to consider whether I want life-saving treatment or tube feeding should the need arise during my stay. It’s a lot to take in considering that I’m a relatively healthy 52-year-old that’s getting rehab for a cracked hip. I realize that our residents make life-or-death decisions within two hours of checking into one of our care centers.</p><p>Before leaving, she shows me a big binder that I will get when I check out. It includes every instruction I could possibly need as well as the business cards for everyone that has come in contact with me during my stay. When I ask if I will get that at discharge, Tiphany tells me that that they call it “move out” and reminds me that words matter. I was grateful for the reminder.<br></p><p><strong><em>Life Enrichment:</em></strong> Jackie introduces herself as a member of the life enrichment team. Her job is to make sure that my personal needs are met during my stay. She asks me a series of questions about things that are generally important to me and/or make me uncomfortable. She walks me through the access to activities and enrichment that they offer and says to call with any questions. </p><p><strong><em>Social Worker:</em></strong> I am next introduced to Bobbie, who is a social worker. I think I don’t need a social worker because I’m a stable guy who is gainfully employed and comes from a solid family. But I’m wrong as the staff can’t treat me correctly until they understand who I am and all that comes with that. Bobbie goes to work on a memory test, a mood evaluation, and a dive into my family history. They understand me better now.</p><p><strong><em>Dietary:</em></strong> Time to consider my dietary needs. Rachel sits to talk with me about my current nutritional state, weight journey, and relationship with food. She wants to know about any special dietary needs I have and any food preferences I have. She lets me know that her goal is to ensure that I have satisfying meals that meet my needs and to make sure that my weight doesn’t fluctuate in meaningful ways during my stay. She also wants to make sure that my body is processing food correctly and they will be tracking that during my stay. <strong><em><br></em></strong></p><p><strong><em>Care Planning:</em></strong> Mark introduces himself as the MDS coordinator and the person who creates care plans. He lets me know that everyone I met today will enter their evaluations into their system and then he will create a plan of care based on that information. Once the care plan is created, he will sit down with me and my family to discuss the care plan and will make any needed adjustments to ensure that it remains person-centered. If I were here for a longer stay, he would schedule regular care conferences. Since I am a short-stay resident, I will have a care plan review every Tuesday. Federal regulation requires that a care plan be created in less than 48 hours, and Mark lets me know that mine will be completed by tomorrow. I learn that to be a care planner, one must be an LPN or RN and have a Regulatory Affairs Certification.</p><p><strong><em>Therapy:</em></strong> Don, who is the executive director, was my therapy evaluator. Before we dive into my physical ability, Don walks me through a process to determine my mental acuity. It’s a process that’s pretty simple but also feels a bit intimidating. Don verbally shares a list of five objects and asks me to try and remember them. Next, he asks me to recite a series of numbers back to him in reverse order. For example, Don said 1734 and my response should be 4371. After we do this a few times, Don casually asks me to recite the five objects he mentioned to me earlier. It oddly feels like pressure to get the answers right. As we continue through the process, I start wondering how this is relevant to physical therapy. Don tells me that it’s an assessment for both physical therapy and occupational therapy. My responses give the therapy team a sense for where I am and set a baseline for improvement.</p><p>Now for the physical assessment. Don talks to me about what it means to put “toe touch” weight on my right foot. At no time should I put more pressure on my right foot than allowing my big toe to touch the floor. Next, he takes me through the process of using the walker and how I should get into and out of it. I learn to place my body weight onto my arms while placing toe weight on my right foot. I get to use my left foot normally. Don places a length of rope on the floor and asks me to use my new skill to get to the end of the rope. He’s timing how long it takes me to reach the end. After explaining that he’s using that time to set a baseline for my future progress, we move on to the Clermont Park marathon. It’s not a real marathon but it feels like one. We move into the hallway with my walker, and Don tells me that we are going to walk 100 feet up and down the hallway for six minutes. One more baseline from which to begin my therapy and gage my future progress.</p><p>Don let me know that tomorrow we will begin my therapy, asks if there is anything I need, and then it’s time to head to the dining room for dinner.</p><h3>Dinner</h3><p>Having had enough of my walker, I pivot back to my wheelchair and head to the dining hall. I start to have a little nervousness about dinner. I love food and am pretty particular about food prep, the consistency of food, the taste of my food, and how taste and consistency go together. In short, I’m picky. Food is more than just sustenance to me, and to some extent my meals can make or break my day.</p><p>In the dining room the first thing I notice is the smell. The food smells good, and I start to relax a bit. I have chicken and rice soup, chicken casserole, Spanish rice, and southwestern grilled vegetables. Having completed a marathon this afternoon, I also treat myself to apple honey strudel for dessert. Everything tasted good. I felt like the food quality was high and the taste of everything satisfying. Once my meal was finished, I realized that I would be comfortable with the food here if a longer term stay was in the cards for me. <br></p><h3>The Bathroom</h3><p>One of my bigger fears about this adventure was what would happen when it was time to use the bathroom. I wasn’t sure how far we were going to take me acting like I was a patient, and I was not excited about the prospect of someone helping me use the bathroom. Much to my relief, the acting job stopped at the bathroom door. </p><p>As I went through the evaluation process, I realized that I needed to use the bathroom. I found myself not wanting to bother anyone, or slow down their process, so I continued to wait. Finally I couldn’t wait any longer and told my therapy professional that it was time. He left the room so that I could have some privacy. I rolled myself to the bathroom and as I stood up, I realized I had not locked the wheels. The wheelchair slipped out of my reach. At that point I realized just how easy it is for a fall to occur in this situation. I managed to unintentionally pull the call light string in the bathroom, and I felt a bit foolish.</p><p>I talked to the administrator about people who refuse help with using the bathroom (or any other type of assistance). Something I would be very likely to do if I were a real resident. Specifically, I asked if I were to sign something saying that I had refused bathroom help, would that exempt the care center from liability? The answer was nuanced. A reminder that even when everything is care planned, and the care plan is followed, there can still be less than desirable outcomes. And even when that outcome was discussed with a resident in advance and the resident (or resident’s family member) had instructed the staff to allow the resident to use the restroom on their own, there can still be legal and regulatory consequences for the care provider. Note to self: we need to do better on clarifying the lines between resident choices, safety and security, and legal and regulatory consequences. </p><h3>Wheelchair</h3><p>Being in a wheelchair is a new experience for me. I am able-bodied enough so that wheelchair operation isn’t too much of a struggle most of the time. As I went through my evaluation process (which lasted about three hours in total), I began shifting back and forth not used to sitting down that much. My backside developed a minor ache, and my upper back started to get sore. By the evening, my lower back felt sore, and my hips were throbbing a little bit. </p><p>I wheeled the chair up to the more comfortable-looking recliner. Having learned my lesson about wheel locking, I remember to lock the wheels before exiting. After sitting about 10 minutes in the recliner, I decided I was getting cold and that it was time to change into my sweats. I reached to grab my wheelchair and pull it closer so that I didn’t fall. And then I remembered that I had locked the wheels. I dragged the wheelchair closer to me and released the brakes, pulled it closer, and re-engaged the brakes before attempting to transfer. Through a few awkward movements, I managed to change into my sweatpants and get myself back into the recliner. As soon as I sat down, I realized that I’d left my sweatshirt across the room. I had to repeat the whole process. </p><h3>Sounds</h3><p>I have been told that noise and sounds were one of the more disruptive things people had to adapt to when moving to a congregate setting. Having never lived in one, I could imagine that any unwanted noise would be bothersome. During the daytime hours I could hear sounds of people talking and getting through their day, but I was surprised with how quiet it was. I was expecting to hear loud voices, beeping sounds like in a hospital, lots of bustling sounds from staff members, and maybe the occasional loud noise. I heard none of that. It all sounded quiet and peaceful. </p><p>At one point during my on-boarding process, I was asked about music playing in my room. The staff asked if I was OK with the music, and I said I was. After dinner I was writing down some thoughts about my day and decided to turn off my TV, from which the music was coming. Yet, the music didn’t stop. Now the music that I hadn’t noticed much throughout the day was bugging me. I am certain that I could have pushed my call button, and someone would have quickly turned it off for me. Knowing how busy the care team was likely to be, I decided to try and figure it out for myself. </p><p>I went through the process of getting out of my recliner and loading into my wheelchair. I looked at the remote controls in my room and didn’t see anything that resembled a sound button. I decided to open the curtain dividing my room from the room next to me. I had the room to myself, but the room was designed to be a dual-occupancy space. Once I moved into the adjoining room, I realized that the music was coming from that TV. Simple enough, I’ll turn it off. I looked for the remote but couldn’t find it. I rolled over to the TV and figured out how to turn it off by hand. I realized that there is no way a person with macular degeneration would have been able to do that. I had to take off my “corrective” lenses in order to see the on/off icon that was in a very light script on the screen. </p><h3>Hearing Loss</h3><p>Part of my care profile was that I have hearing loss. I was given some cotton to stuff into my ears so that I could experience what it is like to not be able to hear clearly. Through my intake and evaluation process, everyone was considerate about making sure I could hear them clearly. They all spoke up, and I had no troubles at all. </p><p>I left the cotton in my ears for the entirety of my stay except for dinner. During dinner I couldn’t hear my fellow diners very clearly. I decided that I learned enough of the intended lesson of the cotton-stuffed ears and took it out so that I could better engage with my dining companions. I wanted to hear their stories. I now understand how hearing loss can make a person feel like they don’t want to try and be a part of a conversation. As much as I wanted to talk to the people at my dining table, the amount of effort that it took to hear was frustrating. I’ve read that people with hearing loss can become withdrawn, isolated, and less sociable. I now understand why that is true and how it feels.</p><h3>Vision Loss</h3><p>Another part of my care profile was that I had macular degeneration. I thought that I would share that fact with everyone that asked about my care needs. Instead, Don gave me a pair of clear lens glasses that had scotch tape all around the periphery. I put them on and found myself having to exert energy in order to see. I no longer had peripheral vision so I had to turn my head to see anything. Looking straight at everything due to the non-existent “corner of my eye” took more effort.</p><p><img src="/Articles/PublishingImages/2024/Doug-Farmer.jpg" alt="Doug Farmer" class="ms-rtePosition-2" style="margin:5px;width:200px;height:200px;" />When I began my therapy evaluation, I had to walk the hallway for six minutes to establish a timeline. I took the walker and pretended to not be able to place weight on my right foot. As much as that was a challenge, my mimicked macular degeneration made it that much tougher. I couldn’t see what if anything was on the floor beneath me, I couldn’t make out details of any of the people in the hall, and it was hard to ignore the people moving around. I didn’t comprehend if they were going to cross my path at some point. Now, in addition to my physical struggle I felt disoriented by the lack of clear vision. <br><br><em>Doug Farmer is president and CEO of the Colorado Health Care Association.</em><br></p><p>In a short period of time, I learned a lot about the perspective of a resident. In <a href="/Articles/Pages/Changing-Perspective-Part-2-My-Day-as-a-Post-Acute-Care-Resident.aspx" data-feathr-click-track="true" data-feathr-link-aids="60b7cbf17788425491b2d083" target="_blank">part 2</a> of this article I will share what I learned about the people who care for our residents each day.<br></p> | 2024-04-02T04:00:00Z | <img alt="" src="/Articles/PublishingImages/740%20x%20740/senior_man_nurse.jpg" style="BORDER:0px solid;" /> | Caregiving | Doug Farmer | I have never worked in a care center. To do my job well, I need to be able to share the experiences and challenges of our providers and their residents in meaningful detail. So I set out to live a day in the life of a resident. |