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 Resident Choice Made Easier

A new tool enables better care planning, delivery, and quality management for older adults.

 

Now that person-centered care is becoming the new standard in post-acute and long term care settings, providers are increasingly shifting away from the traditional medical model toward a new focus on improving consumers’ quality of life. However, making this cultural shift—to meet individualized psychosocial and physical needs—can be challenging. Providers need practical, efficient tools to translate the vision of person-centered care into on-the-ground reality.
 
A team of researchers and clinicians at a senior care provider in Philadelphia developed a new assessment tool that captures the psychosocial preferences of older adults and speeds the adoption of more person-centered care practices.
 
Known as the Preferences for Everyday Living Inventory (PELI), this useful rubric yields vital data about older adults’ individual preferences for social contact, personal development, leisure, living environment, and daily routine.
 
It can also be used to assess health care access and family involvement in care and to help providers refine and customize care plans and service delivery.
 
Nursing homes may find PELI helpful as they shift from an institutional model of clinical efficiency toward a culture of greater responsiveness to residents’ wishes, interests, and desire for a sense of purpose and control.
 
It provides a useful level of specificity that can be deployed to guide staff training; measure quality improvement; and align services more closely with expectations of consumers, families, and regulatory agencies.

How PELI Works

PELI consists of 55 questions in five domains of daily life: social relationships, growth and diversionary activities, self-dominion, and enlisting others in care. Fourteen of the questions are consistent with the minimum data set (MDS) 3.0 for nursing homes but delve more deeply into residents’ preferences for everyday living.
 
Phrased in clear, conversational language, the questions elicit basic and in-depth insights about daily preferences, such as what time individuals like to wake up, take a shower, and get dressed, and what kinds of recreational activities they enjoy.
 
Professional and paraprofessional staff can administer PELI in one sitting, or over a series of conversations. Optimally, the questions are asked annually or at more frequent intervals, as well as when a person begins receiving service and experiences a significant change in status.
 
PELI is the first tool of its kind to pass rigorous scientific testing. In 2005, it was piloted with more than 500 home health clients enrolled in the Visiting Nurse Service of New York. The tool proved to be a reliable and valid measure of preferences and was well accepted by a wide range of older adults.
 
An advisory panel of long term care experts concurred that it covered the key aspects of daily life. While PELI has been tested in home health and nursing home settings, it is also designed for use in subacute, rehabilitation, and assisted living facilities.

Residents’ Perspective On Sharing Preferences

In the pilot study, as well as at a 324-bed nursing facility, staff found that residents enjoy reflecting on what is important in their lives and appreciate the opportunity to voice their preferences to an interested listener. These kinds of focused, thorough discussions aren’t the norm in service settings. Yet they are deeply meaningful to consumers and form the foundation for comfortable, trusting relationships with staff.
 
Emerging research indicates that integrating preferences into care delivery for older adults is beneficial. When activities are appealing, or services are provided in a familiar way, seniors are more apt to be receptive, enjoy the experience, and feel validated. These positive feelings have a measurable effect on physical and mental well-being among people of all ages.
 
Data and insights elicited by PELI ensure that the consumer’s voice is heard and help the whole team—client, family, and staff—work together toward the same goals. At the nursing home, matching preferences to activities tripled resident participation in recreational activities.
 
PELI has also been used to assess broad-ranging outcomes. So far, its use has resulted in greater congruence between preferences and activities, leading to fewer behavior issues among residents, as well as reduced levels of depression and fewer falls.
 
Data are being compiled for a more comprehensive study of this dynamic.
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Advantages For Providers

Direct care staff members use PELI to get to know consumers, build relationships, and devise more successful care plans. The questionnaire provides a consistent protocol to discover each client’s unique interests, passions, and priorities.
 
“PELI is a great tool for becoming better acquainted with new residents,” says Sarah Humes, a recreation therapy supervisor.
 
“It’s especially helpful for paraprofessional staff who may not have clinical training because it provides a way for them to learn more about the residents in their care and organize the information.”
 
The nursing home team divides up responsibility for different sections of the PELI questionnaire. Recreation therapists talk to residents about their activity preferences, and certified nurse assistants handle questions about activities of daily living. Staff implement what they learn immediately and share findings at team meetings where they collaborate to customize care plans.

A Positive Response

Humes says the process also improves job satisfaction. Findings inspire staff to stretch professionally to find ways to honor customer preferences. The tool asks seniors to talk about activities that they enjoy even if they feel that they can no longer do them. When the team understands what interests and motivates residents, they are eager to work collaboratively to prevent them from giving up treasured skills and activities prematurely.
 
PELI findings have also been used to assess individual practice, such as “Am I meeting Mrs. Jones’ preferences this week?” at the unit level. Recreational therapists now aggregate residents’ preferences on each 27-person unit household to plan program offerings that meet the group’s top shared priorities.
The resulting household activity board reflects residents’ authentic interests.
 
The nationally recognized Green House Project now uses PELI in its train-the-trainers curriculum for Green House adopters nationwide. Those selected to be educators, including nurses, social workers, and activity directors, practice using PELI with an older adult and create an engagement activity based on interview findings.
 
The exercise gives educators firsthand experience with deep listening and linking preference assessment to care.
 
“PELI provides specificity for a paradigm shift that’s key to forming deep, knowing relationships with elders,” says Susan Frazier, Green House Project chief operating officer. “It helps sensitize direct care staff so they can offer life-enriching experiences that are significant to each elder. For example, residents love being asked not just if they like to read, but what they like to read and how important reading is to them.”
 
A Philadelphia nursing home began using PELI this year to measure delivery of person-
centered care. Without a structured system to gauge resident preferences, activity programming reflects the recreational therapist’s best guess as to what a resident wants. Recreational options may be biased or limited by the therapists’ own interests.
 
PELI’s impact is being measured by examining progress on one or more areas of person-centered care in both PELI and the MDS 3.0. Although quantitative data aren’t yet available, anecdotal feedback indicates that preference-based care yields better satisfaction for families, staff members, and especially residents.
When a trusted, understanding caregiver presents activities or services in a palatable way, a resident is less likely to become frustrated, confused, or agitated and more likely to become meaningfully engaged.
Studies show that staying active and connected socially are closely linked with preventing or mitigating symptoms of depression in nursing home residents.

Looking To The Future

The Abramson Center research team continues to refine the PELI tool by testing it with diverse populations of older adults. They are also conducting studies on the impact of preference-based care on nursing home residents’ quality of life, as indicated by the presence of depression or behavioral symptoms.
 
The Advancing Excellence in America’s Nursing Homes campaign recently has announced new goals that focus in part on person-centered care.
 
According to Mary Jane Koren, MD, immediate past chair of the campaign, the initiative will include PELI as one of the resources offered to nursing homes as part of its evidence-based toolkit of interventions and educational materials. “It’s an intuitively straightforward tool that’s useful not just for the long-stay population but for the short-stay population as well, because it allows you to frame rehabilitation programs around patient preferences,” says Koren.
 
For More Information
 
Kimberly Van Haitsma, PhD, is director of Polisher Research Institute, Madlyn and Leonard Abramson Center for Jewish Life, Horsham Township, Pa. She can be reached at (215) 371-1895 or at vanhaitsma@abramsoncenter.org.
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