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 Lessons Learned

An administrator cares for his parents as he journeys into culture change.

 Owner, Age Speaks Publishing

What shaped Tom Zwicker, a nursing home administrator, wasn’t so much his years of experience, but rather making the decision to care for his parents in his own nursing home.
 
First, there was the disappointment that his parents had to move from assisted living into skilled care.

They had been living together, married for over 50 years. His father had a stroke, and so in order to keep them together, his mother, afflicted with Alzheimer’s, would have to move to the nursing home as well. “It was the most important thing I’ve ever done,” says Zwicker.
 
“It caused me to own my profession and embrace transformation.”
 
Second, his parents could not live together in the nursing home because of funding sources. His father used his Medicare benefit and needed to be in a Medicare bed. The separation was too stressful, and Zwicker’s father waived his Medicare benefit to live with his wife.
 
Third, Zwicker struggled with the idea of bringing his parents into the nursing home he managed. In fact, Tom’s corporate training taught him it wasn’t a good idea.
 
“By admitting my parents into my nursing home, Lakewood, I would be open to accusations of favoritism, my relationship with my parents would be judged by all the caregivers, and I would have to deal with personal sibling dynamics in a rather public way,” he says.
 
Simultaneously, Zwicker was going through a professional transformation. He was introduced to culture change and questioning the nursing home model of care.
 

The Turmoil—A Real Challenge

The combination of caring for his parents and questioning the traditional nursing home model of care created turmoil. When Tom took over Lakewood, a 246-bed nursing home, it was one of the worst nursing homes in Wisconsin. In three years, it was deficiency-free on both state and federal surveys. So, by nursing home standards, it was fixed. Yet, in Zwicker’s experience, something still didn’t feel right.
 
“We could hang a deficiency-free nursing home banner above our door, ‘Place Your Loved One Here,’” Zwicker says.
 
On January 22, 1996, the Milwaukee Journal Sentinel, Business Section, touted him as a turnaround specialist. Zwicker knew what ailed his nursing home was beyond the standards of a five star nursing home rating system.
 
Zwicker explains that he in no way meant to offend anyone—administrator, caregiver, or regulator. “All have worked tirelessly, exhaustively to deliver quality care,” he says, and he has the deepest respect for all individuals caring for frail elders and understands firsthand the stress of regulatory, legal, and financial challenges.
 
Zwicker explored the definition of an elder defined by the Live Oak Institute, founded by Deborah and Barry Barkan, and embraced the plagues of aging as loneliness, helplessness, and boredom identified by William Thomas, MD, and his wife, Jude, through The Eden Alternative. Those influences took him out of the medical model of care into the human model where elders were valued and able to give care as well as receive care.
 
As an administrator, he kept his focus on procedures, protocols, and checks and balances, but it became more inclusive to creating a place where elders would actually want to live and families want to visit. It was a mind-heart connection.
 
Zwicker came to understand that the top-down medical model of care would not support the new vision of person-centered care. He strove to find a model of care that would get the decision making closer to the elders, their families, and the caregivers. The new model of care supported the realization that humans are complex and their needs are personal.
 

A Complete Commitment

Zwicker was born to be an administrator. His mother, Betty Zwicker, was a Master’s Level Yale Graduate Nurse, Class of 1936, and she was now living in his nursing home. She was a nursing home state surveyor for most of her career in the state of Wisconsin; she was the reason Zwicker was an administrator.
 
But there were no road maps to support the new vision. “Like a white water rafting trip, there was no way to completely plan for the rough water ahead. Changing the culture of an organization is an immense task,” says Zwicker. “I found, though, that it was easier to implement culture change in a broken nursing home that is looking to right itself—more ready for change. It also helped that I owned it,” he says.
 
Organizational leadership is fundamental to the success of culture change and person-centered care. It is a process, not a program, and it takes complete commitment by the administrator’s board of directors, as well as the entire team, to implement and sustain.
 
Although animals are not essential to culture change, Zwicker embraced the value of pets providing friendship, spontaneity, and purpose, and from an administrator’s point of view, they are very cost-effective.
 
The pets made sense; the animals created laughter and spontaneity in an otherwise sterile environment. One could not walk by a room wiTom Zwickerthout seeing large kitties curled up in the spoon position with elders.
Mornings were enjoyable with bird song, except for the morning doves—they had to go, too loud and they

woke up too early.
 
A handful of early risers took the responsibility of walking the dogs, and many made new friends in the neighborhood during their walks. The animals did not leave when staff went home in the evenings or on the weekends—different from pet therapy.
 
“I would never want you to think this is simply about animals, because although animals might be the most visible part of transforming a nursing home, they are minuscule in the big picture of what I am trying to articulate,” Zwicker explains.
 

Culture Change Beyond Animals

The team reworked job descriptions and formed smaller interdisciplinary teams. The teams invited elders into management meetings. The teams utilized elders in their hiring practices and reorganized from program-based in the facility into communities where staff and residents participated in community gatherings.
 
The Lakewood team took on the issue of respectfulness when someone passes. A team, including funeral home directors, elders, family members, clergy, and more, met to determine how to ceremoniously remove a departed member of the community.
 
Lakewood became a location for training of new resident physicians. The University of Milwaukee partnered with the organization to train social workers, activity directors, administrators, and caregivers. Milwaukee Public Schools conducted work-to-school transition programs for children with handicaps and disabilities, bringing in more companionship.
 
These children cleaned bird cages and litter boxes. They walked the dogs and developed friendships, one-on-one, with the elders.
 
“Woodstock” picnics (as the address was Woodstock Place) extended invitations to neighbors and politicians for food and music—remember, elders still vote.
 
Space was created for gardening with very frail elders participating. Sometimes, it was just about bringing the person out to smell the earth being turned.
 
A candy/gift cart was crafted and managed by the elders, with proceeds going to a nonprofit auxiliary set up to support donations and culture change.
 
Staff retention took a serious U-turn. State surveys were successful, with surveyors recommending waivers related to the animals.
 
It is doubtful that the Beatles intended their lyrics, “Living is easy with eyes closed,” from “Strawberry Fields Forever” to provide a metaphor for the current American view on aging. Nursing homes are at the end of the aging spectrum, and the issues of aging play out profoundly in them—issues of guilt, unresolved issues from long lives, spiritual issues, post-traumatic stress issues, and so forth. All of it is very complex.
 
Zwicker’s family was no exception to the rule. Like any family, Tom struggled with how to visit a mother with Alzheimer’s, how to forgive a father with shortcomings, when to end medical treatment, and when to accept the gentleness of hospice.
 
Both of Zwicker’s parents died with the Lakewood family. Tom had total and complete trust in the passion, love, and skill of the caregivers.
 
Debbie Van Straten has worked in long term and post-acute care for more than 30 years with her husband Tom Zwicker. In fact, they worked side by side at Lakewood and shared their passion for person-centered care and culture change. She was named one of the Eden Alternative’s first mentors and now runs her own publishing business, Age Speaks, Embracing the Journey of Life. Van Straten can be reached at debbievanstraten@gmail.com.
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