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 Care in a Person-Centered Age

Despite its frequent buzzword reference, person-centered care is rooted firmly and deeply in long term and post-acute care.

 

Talk to any provider about what they do, and person-centered care will come up in the first few minutes. Popular phrases include “care centered around the person,” “resident-oriented” or “focused around the resident.”

A term ingrained deeply in legislation and regulation, person-centered care is both dated and new, with the latest appearances in the Requirements of Participation. But to do person-centered care well, it takes a blend of time, consistency, persistence, and dedication to not only knowing the uniqueness of a resident, but honoring it.

Person-centered care appeared in the Omnibus Budget Reconciliation Act (OBRA), also known as the Nursing Home Reform Act of 1987, which set federal standards for how care should be provided to residents and patients.

Holly Harmon, vice president, quality, regulatory, and clinical services at the American Health Care Association (AHCA), points out the quality-of-care requirement in the law, which is the requirement to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident.

The Oxford English Dictionary defines “practicable” as something that is able to be done or put into practice successfully. In the context of the formal definition, it is fundamental to know each person in order to be able to design care and services in a way that focuses on what is most important to each person and recognize the possibilities that exist within them, says Harmon.

“That practicable word means a lot, because it’s not practical, it’s practicable,” she says. “As I’ve understood from the pioneers, that really is centric in each person. What’s my highest practicable well-being is not what yours is, and so on, and that is where person-centered stories started to come to life.”

An Official Focus

These days, person-centered care is sometimes referred to as a buzzword not only in long term and post-acute care, but all of health care. But what it really means is something different for everyone, says Harmon. “While there are common approaches, really what person-centered is to me is different than what person-centered is to you and so on,” she says. “The biggest challenge in all this is when caregivers are needing to care for many residents and learn who each person is, and it’s no easy task to do that well.” 

Beyond buzzwords, person-centered care appears in regulations and guidance, like Appendix PP of the State Operations Manual and the Requirements of Participation. 

“There was this sense with the revisions to the requirements in 2016 that person-centered care was finally really incorporated and integrated in all this language,” says Sara Rudow, senior director of regulatory services at AHCA. “When you look at the requirements, person-centered care is an underlying principle.”

Catching Up

The challenge is something providers face every day, Rudow says. “They focus on the regulations and the need to be in compliance. At the same time, they step back and say to themselves, ‘Okay, what is the right thing to do for the resident?’ and more broadly, ‘How are we best implementing person-centered care in our systems and culture?’ This process goes beyond what the regulations say.”

Sara RudowOverall, providers are happy to see person-centered care be a bigger part of the regulations, Rudow says. “They sort of feel like, ‘The regulations are catching up finally to what we’ve been doing and thinking about all these years since OBRA ’87. And so it’s good to see all that language in there.”

Harmon agrees. “Over time, the shift from institutional to home is what providers—a lot of providers—have already committed to,” she says. “And it’s about moving away from that medical model to a true person-centered approach and person-directed model that wraps around that whole person instead of being solely clinical.”

Large Achievements

When asked about the biggest wins in person-centered care, Rudow points out the individual achievements of providers to involve residents in all aspects of their residence and personal decision making. “Some providers have a resident committee that interviews potential candidates when hiring a staff member,” she says. If the resident committee does not approve of the hire, the person is not hired regardless of the input of anyone else at the center. 

“Residents have not just a seat at the interview table, their voice is heard, and they have a veto. I think that’s a great example and illustrates the importance of resident choice and direction about who they will be engaging with, working with, and receiving care from every day.”

The Next Level

If person-centered care is the foundation—an approach toward decisions and care that is centered around a resident—person-directed care is the next level up. 

“Person-directed is really about being the support, similar to the servant leadership model,” says Harmon. “It’s where the resident is literally directing their own care. And not just their care but directing how things are done at the place they’re living in.” This direction dictates many areas of how the skilled nursing center operates and how decisions are made and carried out. Think resident in charge versus caregiver in charge.

A Person-Directed Approach

Rosedale Green, a not-for-profit organization offering memory care, rehabilitation, and long term care in Covington, Ky., is an example of person-directed care in action. Rosedale underwent a remodel of its entire building to offer a home experience for residents via a household model. The remodel started in November 2014 and finished early in 2018. A three-year process, leaders remodeled the 120,000-square-foot building and never looked back.

What’s the secret to remodeling a 200-bed facility while being fully occupied? Lots of communication, says Londa Knollman, Rosedale executive director. True to the person-directed method, Knollman and her team took care to not only include residents and family members from the very beginning but actually involve them in the design of what the new households would look like. First steps were coming up with the phases. It took a full month up front to plan out the entire process with the group, and there were few surprises, she says. 

“As a group, we decided that, if we were going to move residents, they would have a one-time move while their area was remodeled and then move back to a beautiful house and updated bedroom,” says Knollman. Flexibility helped staff keep one wing open; all private rooms on a wing were able to move to semi-private rooms on a temporary basis. In addition, the organization was constructing a new building at the same time, Emerald Trace, which was eight miles away. The new location has four households and offers memory care, rehabilitation, and long term care.

“We moved them as a wing, and they kept their same roommates,” says Knollman. In the end, the residents stayed together in a brand-new wing.
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Wanting to be Home

Discussions and reflections about person-centered care culture and routines started much earlier than the physical renovation, says Knollman. “Staff looked internally, and we realized that if we really thought about it, most of the time residents were living in our work environment,” she says. “Schedules, this is what time meals were, this is what time we went to an activity, etc.” After discussions with the group, staff came up with a home health worker model to follow.

“We did not want homelike, we wanted home,” says Knollman. The physical structure at that time was a 25-year-old building that was a very typical nursing center with long hallways and a nurses station like a command center.

“We brought in an architect firm, but we did not want them to meet with the leadership team and board members and then go back to their office and create something on paper, and then come back and present it,” says Knollman. She and the group, which consisted of 50 family members, residents, and staff members, began to ask questions.

“We talked about, when you enter your front door, what do you see?” she says. “What does your house look like? Where’s your guest bathroom, where’s your hall closet? Where’s the private dining room? And what we talked about, we actually designed.”

Getting the House in Order

Walking into the Rosedale Green today, one sees a reception area, a lobby, and walking a little further, four front doors. They are all decorated differently, and some may have a front porch. Entering is much like entering a personal home. There’s a foyer, and a hall closet in the foyer, and some private spaces outside of residents’ bedrooms. All of it is about keeping the integrity of the home intact, says Knollman.

Each household has space and features to entertain guests. “For the most part, you don’t entertain people in your bedroom,” she says. That’s a personal space, but like a typical home, there are other spaces available, like a small library setting.

“You also don’t build your family room for the 40 people you want over for Christmas,” says Knollman. “You build it for every day use, and then when you have 40 people over for Christmas, you’re throwing up TV trays and putting up the card tables, and you make it adaptable to host those guests.”

Such is the Rosedale Green household. Rooms are designed for home comfort, but nooks are here and there to expand space as needed. “We might have a private dining room that has pocket doors that can open up,” says Knollman. “So it just seems like an extension of the kitchen when we’re having a private birthday party with the grandchildren.”

Staff spaces were removed from the households during the renovation. “A lot of our staff are now working off laptops at the kitchen table,” says Knollman. In addition, each household has a functioning kitchen so everyone can smell what’s cooking at home. “We wanted to bring the staff out of the kitchen and into the home,” says Knollman.

Heading Up a Household

Each household includes 22 residents and consistently assigns caregivers. That is, every effort is made to assign the same caregivers to the same residents on a consistent basis so they can bond. 

Clinical care and household coordinators have replaced supervisory positions, promoting the symbiotic relationship between good clinical care and person-centered care, says Knollman.

Clinical Care Coordinator Amanda Moore, a nurse at Rosedale for 24 years, sees a difference from the past. Staff intentionally take a pause to engage residents from the beginning. “In the past, when a resident walked through the door, we pursued a nursing assessment immediately, and we wasted no time,” she says. “But now we ask questions and engage new residents in decisions when things happen.”

For example, a new resident may be asked if they would prefer a tour of the household or an opportunity to be introduced to fellow residents first before having vitals checked. That approach continues during a resident’s stay, with staff following the lead of the residents.

Like many residents’ previous homes, the kitchen is the heart of the household. Residents and team members often sit around the table and discuss past and present happenings informally.

The Beauty of ‘Unorganization’

Brad Stanford, administrator at Emerald Trace, sees a contrast between the old and the new approach to care, one that has to do with “unorganization.” “It’s this whole idea that before, in order to take care of everybody the way you thought you had to take care of everybody, you had to preprogram everything around when staff show up for different shifts and when they leave,” he says.

Now with the households, the staff in their individual positions and departments work together in different ways, allowing them to be more naturally responsive to residents’ needs.

“You don’t have to have everything organized, it could be unorganized. You can have 20 different people with 20 different ways of how they’d like to spend the day,” he says. “You set yourself up to be so much more agile than you used to be. You can respond so well and individually, especially when life happens in a spontaneous way.”

Stanford recalls a household discussion around a kitchen table one morning. The residents were telling staff how they used to drink buttermilk growing up. “That’s just not something you typically have in the house kitchen,” he says.

One of the staff members felt empowered to run to the store and buy some to share with the residents. “It meant so much for the residents to relive that and partake of that again,” he says.

Linking Interests

Staff have embraced the household model and gotten creative with the households in which they work, says Knollman. “Spending time with the residents, they’ve been able to see the whole person,” she says. 
“One staff member found out that a resident was a retired veterinarian and used to contribute to a professional magazine, The Kentucky Veterinary News. So she asked him if he wanted to continue doing that, and now he edits for a professional journal for Kentucky veterinarians.”

The same resident often advises others on issues relating to pets. While he is not currently a practicing veterinarian, he is sought out by residents and the center’s nurse practitioner for caring for pets at home. “He’s still making contributions out there,” says Knollman. “The environment that we want people to move into is one that makes them feel like they are still able to continue to do what they liked doing.”

The Most Important Challenge

While considered by many to be the foundation of person-centered care, consistent assignment is also a challenge given a national shortage of care staff. Harmon recommends setting reasonable expectations and finding the right place to start. 

“As a provider, it’s important to have reasonable expectations of your staff,” she says. “Make the small steps as you can toward consistent assignment, but don’t over-expect results from that until you are able to fully demonstrate it.” In other words, don’t give up.

The key is starting somewhere. “If you recognize that stability of staff is critical, and can’t achieve that yet with nursing staff, start with consistent assignment of your housekeeping staff, or of your social work staff, or your activities staff,” says Harmon. “This can happen before you fully establish consistent assignment with the nursing staff team.” Being flexible can also mean starting with certified nurse assistants before registered nurses or vice versa.

“Don’t limit consistent assignment to just the clinical staff, because having consistently assigned staff across the board in nonclinical is very valuable to picking up on the benefits,” she says.
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Consistent Color Coding

Across-the-board consistent assignment is something that was so important to the staff at American Senior Communities (ASC) that they color coded staff members who are consistently assigned. ASC offers independent living, assisted living, memory care, skilled nursing, and more in centers across Indiana.

“We strive to have consistent assignment, knowing that people with dementia do better with structure and predictability, and that includes the people around them,” says Melanie Perry, ASC director of memory care support services and president of the Indiana Person-Centered Care Coalition. Consistently assigned staff wear a purple shirt and khaki pants so that the residents can identify them as the people who are the helpers versus the people who might be visitors. 

Residents with dementia want to know who is going to help them in a moment of concern, she says. “There’s this concept of procedural memory that remains for many people with dementia, and that’s memory based on repetition,” says Perry. “So if they see something enough times, even in the midst of a dementia journey, they will remember it.”

ASC communities work to have consistent assignment of staff as much as possible, knowing the benefit for both the resident and the staff member, “who will also get to know the resident that much better and be able to provide for their idiosyncrasies, and thereby gaining even more satisfaction with their role,” says Perry.

As much as possible, ASC communities have consistently assigned housekeepers, who also wear purple shirts. Activity staff wear purple, and memory care leaders have the option of wearing purple. “Anybody who is a helper who is helping in some form or fashion will wear that purple uniform,” says Perry.

Trying New Things

Innovative and cutting edge are both descriptive of the ways ASC delivers person-centered care to residents. Part of Perry’s role is to teach the wellness approach to staff and introduce person-centered care practices. 

One way this is done is via directing ASC’s memory care leaders to have ASC’s eight domains of wellness represented in various forms in the activity calendar each month, for example. The domains are creative, emotional, environmental, intellectual, occupational, physical, social, and spiritual.

Residents are gently encouraged to join in social and enrichment events, but individual options are plentiful and based on science and technology. 

One offering is robotic pets. While filming a television spot in a facility in northern Indiana, Perry introduced an animatronic cat to a resident. The resident had been nonverbal for an extended period of time during Perry’s visit. The cat started to meow and move, and the resident immediately began to prolifically soothe and speak to it. 

The staff members watched the resident transform and were soon in tears, says Perry. “Seeing the transformation, interacting with the robotic cat, we all looked at each other and said, ‘This is what it’s all about.’ This is why we strive to look for those ever more effective ways to reach our residents because this is what it’s about.” 

The beauty of robotic pets and other ASC options is that it is a nonpharmaceutical way to comfort and calm residents, she says. Take residents with dementia who may experience a free-floating anxiety or feel compelled to move constantly. For these residents, ASC employs deep pressure therapy via the use of weighted blankets. Deep pressure therapy involves applying gentle distributed weight (pressure), mimicking a hug, and triggering a natural release of serotonin and oxytocin.

“We had a resident who was almost walking herself to the point of exhaustion,” says Perry. “With the blanket and music she liked, she was able to sit for a period of time and even sleep on a few occasions.”
While there have been success stories, ASC implements the use of the blankets case by case and watches each resident closely. “We look for those individuals that we think could benefit, and they have some trials that they need to do,” says Perry.

“They need to show that they can throw off the blanket, so if they find it discomfiting they can toss it off with no problem whatsoever.”

Seeing Cayenne

It’s often implied that food looks best served on a white plate. But for residents with Alzheimer’s disease or another form of dementia, it is a red plate: cayenne red, to be specific. According to recent research, a cayenne red plate is an appetite enhancer and provides a visual distinction for most of the food that residents eat, says Perry.

In addition, as some residents have visual spatial disruption as part of their dementia experience, food on a white plate can easily blend in, she says. The problem is the resident feels that he’s eaten everything because he can’t see what’s remaining. The red plate sets off the vast majority of the foods being served, and most recent research supports the use of the color, Perry says. “So the resident can more accurately realize how much food is on their plate.”

Growing a Culture

At Brookdale Senior Living, person-centered care is based on the understanding that a dementia diagnosis does not change an individual’s identity. The company provides a culture of caring and programming that puts the person living with the disease at the center of everything staff do, including providing consistent assignment of care partners.

Juliet Holt KlingerJuliet Holt Klinger is head of dementia care programming at Brookdale. A gerontologist, she specializes in person-centered programs for residents living with Alzheimer’s disease or other dementias. 

While Holt Klinger agrees that person-centered care has become a buzzword, she says it’s good to see that providers are diving in and creating new cultures with it. But new cultures take time, she observes. 

“My biggest frustration as a person-centered care provider is that folks can just put it on the brochure and say they do it,” says Holt Klinger. “But it doesn’t work like that. It’s a long process, and you have to grow the culture.”

Training Paramount

A foundation of Brookdale’s person-centered culture of dementia care and its ability to keep that culture consistent across 15 years of growth, mergers, and acquisitions has been a commitment to training. “We have a very robust training program for our memory care communities,” says Holt Klinger. “It’s really all about person-centered care and leading teams operationalize it.”

For example, Brookdale’s Clare Bridge Program, which is designed for people living in the middle to late stages of dementia, includes a 16-hour live training for incoming executive directors and nurse leaders, in which person-centered care is paramount. The program is rooted in a person-centered care approach focused on sustaining feelings of belonging and purpose while seeking to preserve residents’ identity and sense of self.

Keeping Identity Intact

A tenet of Brookdale’s person-centered care approach—keeping identity intact—is no easy task, especially when it pertains to those in the middle to late stages of dementia, as many of Brookdale residents are. 

Similar to other providers focused on person-centered care, it all starts when a resident comes in the door.
“It’s really important from day one that we have a good understanding of who the person is that’s moving in,” says Holt Klinger. The care team puts together a “life story document” designed to equip staff with what they need to know about the person from the get go. To bring the story to life, staff review the document, take elements out of it, and expand on those elements in programming for the resident. 

“Sharing that person’s life story is making sure that everyone is aware of who the person is,” says Holt Klinger. “Their achievements, their accomplishments, but also what stresses them, what soothes them, any indications that they might be stressed. We ask all those questions for that document.”
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Looking Again

To counterbalance the life story document means to step back and take another look at who the resident is, honoring how a resident sees herself. “Don’t be limited to what’s on paper about the resident,” says Holt Klinger. “But ask who they are. It’s also reinforcing that if we have folks who went by ‘Doctor,’ you might use a more formal greeting with their preferred name. 

“Or maybe if someone was a modest person, that’s really making sure that you’re protecting their privacy in care.” Person-centered care is about knowing the whole person and about knowing not just interests and what they did for a living, but everything about them, Holt Klinger says.

Consistent assignment of care partners is a sure-fire way for staff to become experts on not only the residents’ personalities, but their clinical needs as well, says Holt Klinger. 

“If I’m working with the same resident every day, I’m going to notice changes in their skin, I’m going to notice a change in their mood, increased frustration, need for more help, all those things we assess on a regular basis,” says Holt Klinger. “That care associate will notice all those things much faster than if we had interchangeable caregivers. So for us consistent assignment is really fundamental.”

Drumming it Out

One consistently assigned staff member at a Brookdale community in Michigan made an interesting discovery. A resident had been distressed with his recent move to the community and wanted to go home. After spending some time with him, the program coordinator realized he had been a booster of the local university. So she used the community’s computer system to find the rally song and play it. Then the resident began to drum. 

Seeing that, the staff member pulled up a drumming program that allowed the resident to drum directly onto a touch screen. The staff member shared the story with the resident’s daughter, who was taken aback. “She hadn’t thought of that in years,” says Holt Klinger.

The daughter recounted how her father would come home from work, immediately go to the basement, drum on his trap set for 20 minutes, and then come back upstairs. “That’s person-centered care, and it uses technology at times or other tools,” says Holt Klinger.

“Sometimes we don’t get all the information and we have to discover it, but it’s because we’re spending time in relationships with that resident that we discover those things and therefore can meet their needs and help them adjust. All those things that are on our docket to do.”

Specificity Key

Another staff member received a lesson in specificity. The resident had worked in the auto industry as a parts supplier in Michigan. The staff were looking for things for him to do, so one staff member collected auto parts and put them all in a box for him to rummage and sort through. She included the manuals and put it all in front of him. The resident said it was great, but those were General Motors (GM) parts and he worked for Ford. 

“He wanted nothing to do with those GM parts,” says Holt Klinger. “Person-centered care is not one size fits all but really working toward the individual. It can be challenging to provide that individualized programming while maintaining individual relationships, especially when you’re caring for 20 to 50 residents in a community.”

Part of the challenge that staff must rise to is in activities. Increasingly, the Brookdale staff are recognizing that large group activities do not always fit the bill for meeting the needs of residents, says Holt Klinger.

“Many times, regulators believe that if the calendar is full, and they walk in and they see 25 people in a circle, then there’s a good program going on,” she says. “That’s really not necessarily the case. Most of us don’t have pursuits that put us in a circle with 25 other people in our adult life. We really have moved away from that and more toward the individual pursuits and smaller group activities.”

What They Learned

Winning the person-centered care challenge has everything to do with commitment and reasonable expectations. “It’s not easy, and you have to commit to it and recognize that you have to be prepared for pushback,” says Holt Klinger. “And recognize that it’s not operationally an easy thing to do. It’s difficult. We have a pretty detailed staffing system.” 

Holly HarmonA former administrator and director of nursing, AHCA’s Harmon says flexibility can make a difference to overcome operational challenges. “What I learned with consistent assignment is that to really make it come alive, you have to be flexible in your scheduling but with parameters that do consistently assign staff,” she says. It also takes flexibility with staff expectations, which can help retain staff. 

“People need flexibility. And what flexibility means really depends a lot on what the staff in that center are looking for,” Harmon says. “Engage the staff early on with the desire to develop consistent assignment and find out from them what it is that they need.” 

ASC’s Perry recommends taking it slow. “It’s better to have a goal in place but realize that you can’t do it all at once,” she says. “Do not be afraid of it. Look at the low-hanging fruit, take the initial steps, and go from there.”
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