| The Risk Management Skills Every Leader Must Have | <p></p><p>In any business or professional venture, leaders will inevitably encounter risks that present both challenges and opportunities. Possessing the necessary skills to effectively manage, mitigate, and capitalize on risk as it appears is essential for successful leaders regardless of industry.</p><p>In health care, risk management has become even more critical in recent years due to the rapid adoption of advanced technology and increasing concerns regarding patient security and satisfaction. The necessity of contingency plans in case of a cyberattack, natural disaster, or other major event became clear in 2020, further cementing the importance of risk management skills for leaders in health care and other industries as well.</p><p>For optimal risk management, leaders should ensure they foster critical skills, including an analytical mind, a solutions-based attitude, relationship-building and communication proficiency, and the ability to thrive under pressure. With these skills, leaders can be more efficient and productive risk managers in their roles.</p><h3>An Analytical Mind</h3><p>Collecting and analyzing data is a big part of risk management, but possessing an analytical mind means leaders can take this practice a step further. Identifying trends in data to assess and predict potential risks is only the beginning; leaders must also be confident enough in their analysis to make strategic decisions, many of which will be difficult or tricky.</p><p>Additional benefits of an analytical mind include an eye for detail, the ability to identify where information is inconclusive or insufficient, and a propensity to see both the larger picture and the day-to-day elements that impact financial or security risks. Leaders who are analytical can more effectively assess, minimize, and capitalize on risk because of these aforementioned tendencies and skills.</p><h3>A Solutions-Based Attitude</h3><p>Natural curiosity and a desire to identify and address the root of an issue are essential for risk management, and leaders who are determined to find and implement effective solutions through continued education, trial and error, and innovation are bound to succeed in managing risk and leading effectively.</p><p>By pursuing solutions to problems as they arise, rather than succumbing to anxiety and avoiding risk altogether, leaders who embrace risk management as a key part of their roles will likely find opportunities within challenges and achieve greater individual and organizational success.</p><h3>Relationship-Building and Communication Skills</h3><p>Effective risk managers understand that strong relationships are cornerstones in business and industry. By building trust through open, honest communication and dedicated connection efforts with key players such as board members, external experts, stakeholders, and more, leaders can ensure they have a cultivated network that can effectively address risks as they arise.</p><p>In order to form strong, lasting connections with other professionals and colleagues for the sake of risk management, leaders must be able to communicate their insights and ideas to a variety of individuals. Creating risk reports and explaining complex methods to individuals with differing levels of experience and know-how is part of the job, so leaders must develop their communication skills accordingly.</p><p>To succeed in building relationships for risk management purposes, leaders need to cultivate strong negotiation skills as well as diplomacy, tact, and public speaking.</p><h3>An Ability to Thrive Under Pressure</h3><p>Managing risk for a business or organization, especially in health care, is a stressful task with a lot of associated responsibility. Successful risk management necessitates effective use of stress as a motivator, meaning that leaders must work to remain as objective and rational as possible without allowing their emotions to interfere with their decision-making process.</p><p>Remaining calm when the stakes are high can be challenging. In fields where lives may be at stake, in addition to financial and security loss, stress levels can be high even without the pressure of assessing, combating, and using the risk involved. The ability to stay level-headed and make informed decisions even when the pressure is high is invaluable to leaders, and while developing this skill takes time, it will certainly prove invaluable to leaders in any industry.</p><h3>Technical Knowledge</h3><p>In addition to soft skills, leaders will also benefit from financial knowledge and other technical skills specific to their industries in their risk management endeavors. By increasing their awareness of relevant factors and trends, leaders can more effectively assess and approach risk daily as well as on a larger scale.</p><p>In health care specifically, leaders should have a fundamental understanding of essential technology and software. From patient databases to billing systems, health care leaders need to know how things work and why their function is critical to optimal performance, care, and risk management.</p><p>Because risk management requires leaders to collaborate with professionals and experts in other fields or specializations, technical knowledge can help provide a bridge that facilitates clear, effective communication between involved parties, promoting greater efficacy in solution generation and implementation. Because risk management is critical to preserving sensitive information, financial security, and optimized operations, leaders must be knowledgeable and open to learning more.</p><p>In any leadership position, risk management is critical for long-term success. For health care professionals, effectively managing risk can improve patient satisfaction, heighten data security, and promote higher standards of innovation, especially regarding technological evolution. Leaders who recognize the importance of risk management in their roles and strive to cultivate necessary skills are more likely to achieve greater success. </p><p><em>Avi Philipson</em><em> is CEO of Graph Group, an investment firm in the areas of capital, insurance, real estate, and health care.</em></p> | 2022-12-12T05:00:00Z | <img alt="" src="/Articles/PublishingImages/740%20x%20740/leadership.jpg" style="BORDER:0px solid;" /> | Management | For optimal risk management, leaders should ensure they foster critical skills. With these skills, leaders can be more efficient and productive risk managers in their roles. |
| Prevent Technology-Related Minimum Data Set Coding Errors | <p><img src="/PublishingImages/Headshots/JessieMcGill.jpg" alt="Jessie McGill" class="ms-rtePosition-2" style="margin:5px;width:200px;height:200px;" />While a great resource, technology should never replace the clinical decision-making of a licensed nurse or interdisciplinary team (IDT) member. The resident assessment instrument (RAI) process is complex and case-specific; it requires professional expertise to navigate appropriately.</p><p>While technology mishaps can affect anyone, the nurse assessment coordinator (NAC) and the IDT members responsible for coding the minimum data set (MDS) are particularly vulnerable. In addition to the complexities of the process, the software itself can present its own challenges. Inexperience, second-guessing a decision, or being overly trusting of the technology often lead to coding mistakes, which can have an adverse effect on care plans, resident outcomes, survey, and reimbursement. By following these two steps, the NAC and IDT members can reduce the risk of technology-induced errors.</p><p><strong>1. Validate autofill data.</strong><br>When juggling many tasks and multiple deadlines, it can be tempting to just accept as correct information that automatically populates into the MDS, but that poses the risk of inaccurate coding. When signing for an MDS item or section at Z0400, the assessor attests to the accuracy of the coding to best of their knowledge. The attestation statement does not give the assessor a pass if the information is pulled from elsewhere in the electronic health record (EHR).</p><p>Consider the following scenarios:<br></p><ul><li><em>Delayed data entry.</em><em> </em>Mr. Linden experiences a decline in function and ambulation and meets the criteria for a Significant Change in Status Assessment (SCSA). Upon identification of the decline, the physician orders physical therapy. The NAC sets the assessment reference date (ARD) of the SCSA to capture the first five days of therapy. The facility where Mr. Linden resides is in a Medicaid case-mix state, so capturing five days of therapy is necessary to achieve a rehab case-mix group. The morning after the ARD, the NAC refreshes section O of the MDS module to automatically populate the data with the therapy days, minutes, and modalities from the therapy EHR. The NAC is not aware that the therapy software was down the day before, so the therapist has not yet entered all treatment minutes. The NAC signs the completion of the MDS without double-checking the case-mix score to ensure achievement of a rehab group.</li><li><em>Not using all available data.</em><em> </em>The MDS software pulls information for section G, activities of daily living (ADLs), from the nurse aide electronic documentation. The software is very complex and calculates the Rule of 3 based on the episodes of care documented throughout the seven-day look-back period. The nurse aide documentation reflects that Mrs. Buckthorn did not ambulate during the look-back period. The NAC accepts the auto-populated ADL coding without verification. The NAC also codes Mrs. Buckthorn's restorative programs in section O, which includes a walking program. The documentation supports that Mrs. Buckthorn ambulated with a four-wheeled walker and the restorative aide provided balance support and guided maneuvering for 25 feet in the corridor on six days during the look-back period. The NAC does not recognize the error in the ADL coding in section G and does not consider other supporting documentation in the medical record, observation, or discussion with direct care staff.</li></ul><p></p><p>When using autofill for any MDS item, it is important that the facility has a process to prevent errors. For example, before signing the completion of any auto-filled item, the IDT members must refresh the MDS assessment with any new or updated information, such as the Medicaid number or other data. For any autofill MDS item, the IDT must validate the source of the information—either by the medical record, source document, or a report. Additionally, if the MDS item autofills from one source of supporting data, it is important to also consider all other medical record documentation that would impact coding. For some items, the coder may also need to interview direct care staff to validate the item.</p><p><strong>2. Use clinical decision-making when considering MDS coding suggestions.</strong><br>MDS software and scrubbers are critical tools that can help ensure the integrity and accuracy of the assessment—when used correctly. Such software may automatically check or suggest diagnoses for section I or provide helpful tips on MDS coding. However, the assessor who signs the completion of these MDS items must ensure accuracy based on RAI coding instructions.</p><p>Consider these scenarios:<br></p><ul><li><span><em>Software suggests or automatically checks diagnosis based on diagnosis list.</em></span><em> </em>Mrs. Elderberry admitted nearly three months ago with a diagnosis of pneumonia and a functional decline. The NAC is completing a quarterly assessment on Mrs. Elderberry and just refreshed the diagnoses for section I. The software has checked I2000, indicating an active diagnosis of pneumonia. The NAC checks the diagnosis list and verifies that the physician signed the diagnosis list in the last 60 days and accepts the diagnosis in section I. The NAC failed to follow all the MDS coding instructions for section I, which also requires that the diagnosis must be active during the seven-day look-back period. The NAC must make a clinical decision to determine if the pneumonia diagnosis has a “direct relationship to the resident's current functional, cognitive, or mood or behavior status, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period" (<em>RAI User's Manual</em>, p. I-7). The software cannot make this decision.</li><li><em>Scrubber software suggests changing coding.</em><em> </em>Mr. Spruce recently had a surgical procedure. The documentation during the seven-day look-back period supports the presence of a surgical wound and surgical wound care; however, the NAC only coded M1040E, Surgical wound, and missed coding the surgical wound care at M1200F on the SCSA. Prior to submitting the assessment, the NAC used the scrubber software per the facility policy. It generated 12 alerts, including an alert asking if the resident had received surgical wound care since there was a surgical wound present. The NAC reviews the first several alerts, notes that no changes are needed, and to hurry the process, resolves the remaining alerts without reviewing. The NAC submits the assessment with the error of the omitted surgical wound care.</li></ul><p></p><p>The errors in these scenarios are avoidable. The NAC or IDT members responsible for signing for the item must complete the clinical decision-making process, apply <em>the RAI User's Manual</em> coding instructions, and validate that the coding is correct. Scrubber software is an additional check to supplement the clinician's efforts. One should never apply or ignore software's alerts or suggestions without the clinical decision-making process.</p><p>The bottom line: technology is great, but it cannot replace the need for the clinical decision-making of the human brain.</p><p><em>Jessie McGill, RN, RAC-MT, RAC-MTA, is curriculum development specialist for the American Association of Post-Acute Care Nursing (AAPACN).</em></p> | 2022-12-08T05:00:00Z | <img alt="" src="/PublishingImages/Headshots/JessieMcGill.jpg" style="BORDER:0px solid;" /> | Management | While a great resource, technology should never replace the clinical decision-making of a licensed nurse or interdisciplinary team member. |
| Supporting Residents with Dementia Through Therapeutic Hospitality and Culinary Wellness | <p><img src="/Articles/Guest-Columns/PublishingImages/2022/MindiManuel.jpg" alt="Mindi Manuel" class="ms-rtePosition-2" style="margin:5px;width:200px;height:200px;" />With approximately 60 percent of assisted living residents experiencing some form of cognitive impairment or dementia, mealtimes can be challenging for both residents and staff alike. Proper nutrition is essential for older adults—especially those with cognitive impairment—to help them stay strong and healthy, while poor nutrition may lead to undesirable weight loss.</p><p>Having a holistic culinary and therapeutic hospitality program that addresses difficulties with coordination, restlessness, and problems with remembering the process of eating altogether can make a big difference.</p><p><strong>Creating a Supportive Dining Environment</strong><br>Therapeutic hospitality focuses on providing a calm, supportive dining environment that meets the individual needs of every resident. Through evidence-based design that incorporates the science of aging and dementia, the dining experience becomes an easy to navigate social experience. Focus is placed on simple and efficient layouts, appealing colors, lighting, aromas, safe furniture and flooring, and soft sounds to accommodates changes in the five senses and motor and cognitive skills that residents with dementia may experience. This helps reduce agitation and other behaviors among residents and reduces the potential for slips and falls and other risks. Bright shiny floors, for example, are replaced with darker, more muted colors and surfaces that help with visual perception and promote calmness.  </p><p>Tableside choice provides a dignified approach to dining for residents who are no longer able to use a printed menu. This not only empowers residents by allowing them to continue to participate in meal selection, but it also stimulates the senses to signal hunger and increases social engagement. Many residents with dementia have a loss of depth perception which can impact the amount of food consumed.  Use of contrasting plates and tablescapes can provide these residents visual cues that it is a space for dining. Using plate colors that contrast the food items served can increase consumption, with darker foods served on lighter plates and lighter foods served on darker plates. Solid plate colors are preferable to avoid confusion and distraction.</p><p>When possible, having an open kitchen environment and providing exhibition cooking are ideal. Open kitchens help stimulate the appetite as appealing aromas spread throughout the dining room. This also helps stimulate the appetite by reminding residents of the joy of cooking while also providing an opportunity for cognitively stimulating social engagement.</p><p><strong>Providing Nutritious, Appetizing, and Adaptable Meals</strong><br>Adaptive wellness culinary focuses on providing healthy meal options that target overall health and wellness. Meals incorporate foods rich in antioxidants, omega-3s, and vitamins and minerals that provide anti-inflammatory and vascular benefits and support cognitive health. Recipes focus on flavors and textures that will appeal to residents and that celebrate the simple pleasures of eating. Choice is essential. These menu items can be plated and served with utensils for those who are able, and prefer, to be seated. But portable, hand-held options are also available for residents who tend to wander during mealtimes. Menu items can also be portioned into bite-sized pieces, for example, for residents who have difficulty using utensils. Healthy, portable snacks are also available for residents who wander at night or may want a snack between meals. Nearly all menu items can be adapted to meet the varying functional abilities of residents.</p><p><strong>Educating Staff on Holistic Approaches and Care for Individuals with Dementia</strong><br>Onsite training helps educate staff on how to enhance the dining experience for persons with dementia. This training recognizes dining staff as an important part of the care team; dining staff are often the first to recognize changes in residents' behaviors and appetites. The training helps dining staff connect the science behind the disease with the “why" of this approach, which allows them to recognize the signs of dementia and how to apply that knowledge to care, emotional support, engagement, and the comforting strategies offered at the end of life. It emphasizes the importance of a calm, therapeutic dining environment, maintaining quality of life for residents, as well as the importance of nutrition and its link to clinical outcomes. Annual training sessions keep staff up to date on best practices in dementia care to support continuous quality improvement. </p><p>With the aging U.S. population, dementia will become a critical health issue within the next 20 years, emphasizing the need for better prevention and care strategies. By implementing a holistic approach to dementia care, we can deliver more effective, compassionate types of care that meets the needs of the individual. This person-centered approach helps residents age with dignity and maintain their independents as long as possible.</p><p>Applying a holistic dementia approach to mealtimes within skilled nursing and assisted living facilities helps shift dining from being a time for feeding to a therapeutic and social activity. It equips staff to nurture residents experiencing sensory changes associated with dementia by using smells, colors, textures, and visual cues. Serving residents at their highest level of function, empowers them to become active participants in their dining experience, prolonging quality of life, and ensuring they will be healthier and better nourished.</p><p>During a time of acute staffing challenges, dining and therapeutic hospitality can also ease stress among staff and build job satisfaction and engagement. Staff become equipped to identify and address the changing nutritional and behavioral needs of residents, and the therapeutic setting eases agitation and disruptive behaviors often associated with cognitive decline, making the dining experience better for staff and residents. More importantly, it achieves a higher level of care that residents and deserve.</p><p><em>Mindi Manuel, MS, RD, CSG, LDN, CDP, is the</em><em> senior manager of clinical support for Sodexo Seniors covering the Pennsylvania market. </em><em>She is a registered dietitian and a Certified Specialist in Gerontological Nutrition (CSG) and a Certified Dementia Practitioner (CDP).</em></p><p></p> | 2022-12-05T05:00:00Z | <img alt="" src="/Articles/Guest-Columns/PublishingImages/2022/MindiManuel.jpg" style="BORDER:0px solid;" /> | Dementia | Therapeutic hospitality focuses on providing a calm, supportive dining environment that meets the individual needs of every resident. |
| A Leader's Responsibility to Fight Compassion Fatigue | <p></p><p>Health care professionals are known for their honesty, their ethics, and their trustworthiness. For 20-years running, nurses have received the <a href="https://news.gallup.com/poll/274673/nurses-continue-rate-highest-honesty-ethics.aspx" target="_blank">highest ratings in honesty, ethics, and trust</a> than any other profession, according to Gallup's annual polls. They show up with a level of compassion unheard of in most other industries, and that compassion for their patients is what helps to enhance the quality of care.</p><p><img src="/Articles/Guest-Columns/PublishingImages/2022/BentPhilipson.jpg" alt="Bent Philipson" class="ms-rtePosition-1" style="margin:5px;width:200px;height:200px;" />At the beginning of the COVID-19 pandemic, nurses didn't let that compassion falter. They sacrificed their time—and sadly for some, their lives—to take care of a growing number of sick patients during an unprecedented time. They worked long hours and double shifts to meet the growing demand for health care workers in short-staffed facilities. They gave up time with their families and exposed themselves to the coronavirus every time they went to work, especially when personal protective equipment was so scarce at the time.</p><p>After weeks, months, and years of this, you can imagine how the exhaustion and overwhelming need to be always-on started chipping away at their compassion. This is the new reality nurses are facing. And if you're a health care executive, this is the reality for <em>your</em> staff.</p><p>What can we do to help fight compassion fatigue in our assisted living communities, long term care centers, and skilled nursing facilities? It is our responsibility as leaders.<br></p><p><strong>Understanding Compassion Fatigue</strong><br>In order to address compassion fatigue in health care, leaders must understand exactly what compassion fatigue is. In short, it's an extreme malaise that develops from caring for patients throughout their entire care journey. Over time, this “cost of compassion" results in strain and exhaustion. It starts with feelings of discomfort, transitions into stress, and then ends in a state of fatigue, which is much harder to recover from. This is why early detection and preventative measures are so important. If not addressed right away, it can permanently hinder a caregiver's ability to provide compassionate care to patients.</p><p>The extreme empathy nurses feel for patients and their families coupled with the grief they experience on the job leaves them vulnerable to compassion fatigue. They're so enmeshed in their patients' lives and, ultimately, their recoveries, which can lead them to feeling guilt, impotence, anger, or even blaming themselves when a situation doesn't have a happy ending.</p><p><strong>How to Fight Compassion Fatigue </strong><br>Health care workers are at a unique disadvantage for two reasons. The first is that there hasn't been much global recognition about the negative impacts of working in the industry—until the COVID-19 pandemic. Second, health care staff provide ongoing care to patients and their families and experience trauma on a consistent basis. They can't just walk away from these situations, which makes preventative measures and support even more critical.</p><p><strong>Prioritizing Work/Life Balance</strong><br>COVID-19 not only exacerbated the problem of compassion fatigue, it resulted in a nursing shortage crisis, <a href="https://www.vox.com/coronavirus-covid19/22763417/us-covid-19-hospitals-nurses-shortage" target="_blank">which hasn't yet resolved itself</a>. The staffing shortage only leads to more compassion fatigue, thus trapping them in a vicious cycle.</p><p>While nurses are viewed as caring and nurturing individuals, many find caring for themselves difficult. Facilities must promote a culture where work/life balance is important and give workers the necessary time to invest in themselves. When your employees have the time to focus on non-work-related activities that make them happy, it helps to alleviate the weight of work they carry on their shoulders every day.</p><p>It's difficult to leave work at work when you work in health care, so as leaders, it's even more important that we not only instill a work/life balance in our facilities, but that we model it as well.</p><p><strong>Ongoing Training/Education</strong><br>A lack of training and ongoing education can be part of the reason why your employees are struggling at work. By giving them strategies for how to better support their patients, communicate with families who are under stress, and deal with complex situations, you're helping equip your employees with the necessary skills to excel.</p><p>Nurses who feel they lack these skills may believe they're incompetent, which leads to more severe anxiety and depression. It's important for leaders to make ongoing training and education a part of their mission, especially when it comes to how to emotionally support patients and families. In skilled nursing facilities and long term centers, for example, training that's centered around end-of-life care will help prepare employees to feel adept in their roles when these situations arise.</p><p><strong>Workplace Interventions</strong><br>Making workplace interventions available to employees will help lessen the emotional strain that nurses feel. Facilities that implement these interventions <a href="https://www.frontiersin.org/articles/10.3389/fpubh.2021.679397/full" target="_blank">experience less turnover and generally have happier staff</a> as a result. The sooner we focus on these initiatives, the quicker the health care industry can begin healing itself.</p><p>If your facility currently has no offerings, or your menu of interventions is limited, here are three ideas you can start implementing:<br></p><ul><li><strong>Peer support groups.</strong> No one understands what your employees are going through better than their colleagues. Peer support groups are an easy but meaningful way to address emotional difficulties within your facility.</li><li><strong>On-site counseling.</strong> Peer support groups are impactful, but inviting in a trained therapist or counselor takes mental health support to the next level. Encourage employees to take advantage of these counseling sessions when they're available, and make sure they're accessible to everyone.</li><li><strong>Debriefing sessions.</strong> These sessions are an opportunity to share and explore an employee's thoughts after a certain event has taken place at the facility, usually one that's traumatic or concerning. These are not formal reviews, but rather should lead to genuine conversations with staff and senior leadership. </li></ul><p></p><p>While compassion fatigue is commonplace in the health care industry, we should not accept it as such. Leaders must step up to the plate and devote their attention to combating compassion fatigue in the workplace. If we don't, we're failing our employees. </p><p><em>Bent Philipson</em><em> is the founder of Philosophy Care, a consulting firm providing a range of services to skilled nursing facilities throughout New York and New Jersey.</em></p> | 2022-11-29T05:00:00Z | <img alt="" src="/Articles/Guest-Columns/PublishingImages/2022/BentPhilipson.jpg" style="BORDER:0px solid;" /> | | What can we do to help fight compassion fatigue in our assisted living communities, long term care centers, and skilled nursing facilities? |
| The Life-Changing Experience of Visiting the Elderly | <p><img src="/Articles/Guest-Columns/PublishingImages/2022/OliviaSavoie.jpg" alt="Olivia Savoie" class="ms-rtePosition-2" style="margin:5px;width:200px;height:200px;" />The first time I entered an assisted living community, I was five years old. My first-grade class and I went equipped with gifts of bananas and carefully copied Bible verses on colorful handmade cards. We passed our offerings to residents situated in a circle of wheelchairs. A tape of instrumental Cajun music played softly in the background.</p><p>My peers were mostly uncomfortable, hanging back in groups or huddling by our teacher. I was an exception to that discomfort. I eagerly handed out cards, said hello, and made friendly conversation.</p><p>I vividly remember encountering one man leaning back in his wheelchair with his head unnaturally cocked toward the ceiling and drool dripping down his chin. My mother, who volunteered to join us that day, asked me to take special care telling him hello. She said that his name was Mr. Nathan; he was the dad of one of my dad's friends and had been the district attorney a long time ago. I didn't know what all that meant, but I happily told him hello and gave him my favorite card—one with a big rainbow on it—even though he didn't seem to hear me and failed to acknowledge the slip of paper I left on his lap. Something inside me knew there was more to him than the shell before me.</p><p>As I went down the line of residents, I met some women who clutched baby dolls to their chests. On the bus-ride home, Mom explained this was because they had held so many babies of their own in their younger years that now they felt safe and relaxed holding a baby again. My cohorts were confused; to me, it made sense. </p><p>I was seven the next time I went into an assisted living community. Prompt Succor was located in a rural town north of Lafayette, Louisiana, where I lived. Mom took me there to see my granny, who worked there as a beautician. (Years later I learned that in the wake of her own mother's death, my granny found great comfort in serving other people's mothers. I thought that was overwhelmingly beautiful.)</p><p>The day I first visited Prompt Succor, I wore a green velvet dress. I remember it well because several ladies wished to touch it. That day as I walked to meet Granny, a beautiful woman named Dorothy not only said hello to me, but asked me how old I was, where I went to school, and what my favorite color was. I told her and then countered with the same questions. She answered them—91, Opelousas High School, purple. I carried on a conversation with her just like I would have with any child I met on the playground—with any friend.</p><p>I was nine years old when my mom, older sister, and I started carting our harp to assisted living communities a few times a year. My sister and I would each play three or four songs. The room would fill with oohs and aahs and offbeat claps. There would be humming and singing. Whether the words were right or wrong didn't matter—there was joy. Even at nine years old, I recognized it. It was the same joy I felt on Christmas morning when I unwrapped a new baby doll, the same joy I felt when my baby sister came home from the hospital, the same joy I felt when I raced into the ocean on the first day of summer vacation. Joy was joy—rather it was experienced by someone 90 or nine, it was the same—and I knew it.</p><p>As I grew older, the practice of visiting assisted living communities didn't subside. It blossomed. Once I had my own car, I made weekly trips to Maison de Lafayette, a community near my home. Over the years, I made a plethora of friends there.</p><p>I visited Mrs. Nettie, who put together more puzzles than I thought humanly possible. Once upon a time she had owned a flower shop, and she showed me album after album of her floral creations.</p><p>I visited Mrs. Opal, who loved to decorate her room for every holiday. If she didn't know which one came next, as she took down one's decorations, she would ask a nurse. When they responded with “Mardi Gras" or “Halloween" or “4th of July," she would excitedly pull décor from a plastic tub under her bed. Twice I happened by and helped her decorate.</p><p>I visited Mr. Al, an Italian man who reminded me of my grandfather. He always wore blue, button-down pajamas, no matter the hour of the day.</p><p>I visited Mrs. Virginia, who seemed to always be sitting on the side of her bed, an empty bag clasped in her lap, as she waited to catch the train. She would inform me over and over again that she was about to travel up north to meet her fiancé's parents. She would ask where I was traveling to. At first, I was confused. Eventually, I'd smile and sit beside her and tell her I was heading north, too, and that we could make the journey together.</p><p>I visited Mr. Larry and Mrs. Margie, an inseparable couple who moved into the community after Mr. Larry's many falls. Although Mrs. Margie was healthy and capable of staying at their ranch outside of town, she refused to part ways with him. They would do crossword puzzles together and ask for my “young brain" help when they got stuck. Mrs. Margie once opened her locket to show me a picture of her beloved rat terrier, which wasn't allowed to join them at the facility and had to live with their niece instead.</p><p>And then there was Miss Lola. One day, I headed to the side door at Maison de Lafayette and discovered her sitting outside smoking a cigarette. As I passed her with a polite smile, she stopped me to ask if I smoked. I told her I was only 16 and that I did not. She told me, “Good, these damn things will kill you" and took another drag. I liked her already. I sat down beside her. This was the beginning of our friendship.</p><p>What ensued was rating the male nurses on a cuteness scale from 1 to 10, sharing snacks, and my reading scripture—the Psalms were her favorite—aloud to her, since she could not read the small print in her Bible. I eventually bought her a large-print Bible, which she treasured. What ensued was advice about my high school boyfriends, consolation through my break-ups, and approval of my prom dresses. She told me sad stories about her childhood, outlandish stories about her ex-husband, funny stories about raising her children, brave stories about going to nursing school as a single mother. And then, one day, when I was 20 and newly married, I went to visit like I always did and found her room bare. A nurse informed me that she had passed away three days earlier.</p><p>My husband and I moved to Florida when I was 22. There, I hosted writing workshops in the assisted living communities near us. I visited dozens of facilities and met hundreds of people.</p><p>Mrs. Jan sticks out in my memory. She prided herself in being the resident ambassador at Oakmonte Assisted Living. She wore a name tag and greeted guests with a warm handshake and smile.</p><p>And I'll never forget the two women whose names I didn't get, who, during a workshop, both fell silent and became teary-eyed when prompted to recall memories of World War II. One of them, in a heavy German accent, said that her husband had been killed in the war. The other, a native Floridian, burst into tears, saying her husband, too, had been killed in the war. Both got up, hugged, and cried together.<br></p><p>Over the years, I experienced a multitude of other names, faces, and interactions. I played the harp. I helped with writing memories. I listened. I learned.</p><p>After graduating from college, I began writing life stories for people 65 to 105 years old—for veterans and doctors and stay-at-home mothers and entrepreneurs and educators and everyone in-between. I wrote them for the sole purpose of sharing cherished memories with family members. In the process, I fell in love with many of my subjects' spirits. I gleaned grandfatherly or grandmotherly advice. Some women shared secret family recipes; some men shared gut-wrenching heartaches. I have carried burdens and wept; I have laughed until I cried.</p><p>When I look back, I can trace the lines of my passion for my profession and my affection for the people I work with back to a certain field trip—back to a five-year-old handing a colorful card to Mr. Nathan. I can trace it to what I recognize now as a realization that inside what looked like an idle old man was actually 100 other versions of himself—a curious child, a bold young man, a loving father, a brilliant attorney. And with it came the realization that behind every mask that appeared aged and perhaps less productive than it once had been lived a vibrant young person waiting to be heard, to be seen, to be known, to be befriended.</p><p>Olivia Savoie is co-founder of Raconteur Life Story Writing, a family heirloom biography writing and publishing company based in Louisiana. She can be reached at <a href="mailto:Olivia@RaconteurWriting.com" target="_blank">Olivia@RaconteurWriting.com</a>.<br><br></p> | 2022-11-22T05:00:00Z | <img alt="" src="/Articles/Guest-Columns/PublishingImages/2022/OliviaSavoie.jpg" style="BORDER:0px solid;" /> | Caregiving;Assisted Living | Over the years, I experienced a multitude of other names, faces, and interactions. I played the harp. I helped with writing memories. I listened. I learned. |
| 4 Strategies to Bring Population Health to Your Food and Nutrition Services Program | <p><img src="/Articles/PublishingImages/headshots/LisaRoberson.jpg" alt="Lisa Roberson" class="ms-rtePosition-2" style="margin:5px;width:200px;height:200px;" />It’s not enough to just care for patients inside our facilities. We must think bigger these days—for the good of the patient, community, and our organization. That’s where population health comes in. It has long been a buzzword, but as an industry, we have an opportunity to bring the concept to life. Skilled nursing and long term care facilities can learn from other areas of the health care industry to fully integrate population health programs into their food and nutrition services.</p><p>Population health initiatives are an important factor in caring for an entire community, but they also can have a tangible impact on a long term care or skilled nursing facility’s finances by controlling costs, improving outcomes and increasing patient satisfaction scores. Here are four key points to drive success through integrating population health within food and nutrition services.<br></p><h3>1. Invest in a sustainable supply chain.</h3><p>Where our food comes from matters. It matters from a freshness and taste perspective. It matters from a health perspective. And it certainly matters from a sustainability perspective, which recently came to light during COVID when our supply chains were strained.</p><p>Food travels an average of 1,500 miles to get from the farm to your plate. That leaves a significant carbon footprint. In all, food production is responsible for a fourth of the world’s greenhouse gas emissions. That is not sustainable.</p><p>We need to create a cleaner, greener supply chain. That journey starts with sustainability of logistics, produce sourcing, and packaging. By purchasing locally, long term care facilities can source produce that is picked and eaten at the peak of ripeness, which means it is denser in nutrients and, thus, more nutritious. This leads to a sustainable sourcing model as well as a successful business infrastructure in the community. In addition, diversifying suppliers through both number of sources and social backgrounds has proven to be a successful approach to promote sustainability.</p><p>A sustainable supply chain is more than just an environmental initiative or way to promote goodwill in the community. It is a smart business move. It is caring for the population as a whole and creating channels to get the critical resources you need to care for patients.</p><h3>2. Rethink menus.</h3><p>Creating healthier populations from a food and nutrition services perspective starts with our first touchpoint—patient dining. We need to create healthy options that foster wellness. That means no antibiotics or growth hormones, while encouraging fresh produce and low-fat proteins. All this needs to be done while maintaining delicious flavors. Menu creation can be the first step in a population health strategy.</p><p>One area where I’m seeing significant growth is with plant-based diets. Studies have shown the advantages of a diet rich with plant-based food, including lower abdominal fat, cholesterol, blood sugar, and BMI compared to study participants consuming a diet of predominantly animal protein. And 58 percent of consumers say they want to increase their plant-based protein consumption.</p><p>Rethinking our menus and taking particular care to craft dishes focused on fitness can lead to both immediate and long term improvements in patient wellness. It’s about showing them healthier options outside of their current diet. Patient dining is the first opportunity to start that conversation.</p><h3>3. Think beyond the four walls of your facility.</h3><p>We have an opportunity to impact community wellness long past a patient’s stay. That means thinking beyond the four walls of the facility and getting facts about nutrition and its impact on wellbeing to the community. The first step of this is to change patient perceptions about healthy eating, which can have a trickledown effect on others in the household. </p><p>It can be intimidating trying to cook healthy food. Facilities have an opportunity to teach the community about the benefits of healthy eating and how to bring it to life. Setting up a teaching kitchen with your onsite dietitians or culinary staff can provide confidence for in-home cooks and empower them to live healthier lives. Some hospitals have taken this to the digital space with instructional cooking videos that are featured on social media or local news.</p><p>Even armed with the right information, there are barriers to living a healthy lifestyle. Too often underserved communities do not have access to the nutritious food that is critical to establish long term healthy habits. A programmatic approach from the facility can be expensive, but it doesn’t have to entirely come out of your already thin margins. For example, I have seen facilities invest in mobile grocery stores that are funded through grants and community fundraising. These grocery stores-on-wheels provide fresh ingredients to areas that otherwise would not have access to them, helping to eliminate food deserts.</p><h3>4. Create programs to reduce waste.</h3><p>Food waste is everywhere in the U.S. with approximately 40 percent of food produced ultimately being wasted. Health care leaders sit in a prime position to make a quantifiable impact on the industry and community. Controlling food waste makes you a better steward of your resources and helps to manage your business in a sustainable way.</p><p>While we can’t eliminate food waste entirely, we can minimize it and turn waste into community benefit. Many hospitals partner with local organizations to donate excess food. They set up composting sites to better utilize the existing waste and repurpose that waste through gardens that provide produce for patients. Additionally, being mindful of ingredients and how they are prepared impacts waste. I love to see facilities adopt a “root to stem” strategy to use the entirety of their ingredients instead of throwing out large portions of useable produce. </p><p>New technology features can be used to drive waste reduction. Through enhanced analytics, we can better track and record food waste types, amounts, and ultimate destinations (e.g., donation, composting, landfill). Through this data, facilities receive valuable insights to create new strategies to address food waste at the source. Some have been able to decrease their food waste by nearly 50 percent by utilizing technology to make better, more informed decisions.</p><p>Food and nutrition services can drive a new, healthier perspective for the community because it takes more than just a clinical approach to care for a population. The foodservice team plays an important role in supporting and assisting long term care and skilled nursing facilities to establish and expand population health programs that have many far reaching and sustained benefits for patients and communities.<br><br><em>Lisa Roberson, RDN, LD, is national director of wellness & sustainability at Morrison Healthcare. She is a registered dietitian with 20 plus years of experience in nutrition leadership.</em></p> | 2022-11-15T05:00:00Z | <img alt="" src="/Articles/PublishingImages/740%20x%20740/food.jpg" style="BORDER:0px solid;" /> | Caregiving | Skilled nursing and long term care facilities can learn from other areas of the health care industry to fully integrate population health programs into their food and nutrition services. |
| 5 Ways to Reduce the Risk of Falling in Your Community | <p><img src="/Articles/Guest-Columns/PublishingImages/2022/GlenXiong.jpg" alt="Glen Xiong" class="ms-rtePosition-2" style="margin:0px;width:138px;height:138px;" />Over the last year, senior care providers have faced many new challenges and opportunities. While advances in <a href="https://www.forbes.com/sites/sarazeffgeber/2022/08/15/covid-brought-a-much-needed-tech-infusion-to-the-lives-of-older-adults-at-home-and-senior-living-communities/?sh=4cbb501368a4" target="_blank">robotics</a>, artificial intelligence, and other technologies are helping provide better care for seniors, new <a href="https://www.ahcancal.org/News-and-Communications/Fact-Sheets/FactSheets/AL-Survey-June2022.pdf" target="_blank">research by the National Center for Assisted Living</a> found that more than half of senior care providers say their overall workforce situation has worsened since January 2022. In fact, the same survey found that 63 percent of assisted living communities are experiencing staffing shortages, and a staggering 98 percent have asked staff to work overtime or extra shifts due to the staffing shortages.</p><p>Without the right support, these issues leave providers with less oversight, which makes it difficult to maintain the same quality of care. For assisted living communities, that unfortunately means more falls are likely to occur.</p><p>According to the Centers for Disease Control and Prevention, <a href="https://www.cdc.gov/injury/features/older-adult-falls/index.html" target="_blank">a person falls every second</a>, and for those living with dementia—who often need to be cared for in assisted living communities—that number doubles. Falls are truly happening all the time, and they're a source of significant concern for care providers. Even more distressing, older adults with dementia are often unable to describe how they fell, making post-fall response and prevention challenging for caregivers and distressing for family members. I know because as a doctor I've seen this firsthand. However, I have also learned that falls don't have to be inevitable. Here are five ways care providers can reduce the fall risk in their communities.</p><p><strong>1.</strong>     <strong>Keep an eye on medications that increase fall risk.</strong></p><p>One of the first steps caregivers should take to protect residents from falls is understanding their medications. That's because some pain medications—particularly narcotic medications—can cause problems with coordination, making someone more prone to falling. Similarly, psychotropic medications can also increase the risk of falls—especially antipsychotics. Anyone that is taking these kinds of medications, or is caring for someone taking them, should be aware of this heightened fall risk and make changes to their environment accordingly.</p><p><strong>2.</strong>     <strong>Stay consistent with staffing.</strong></p><p>As I mentioned earlier, providers across the US are struggling with staffing, which is likely to increase fall risk at assisted living communities. That's because for people living in a senior care community, staffing patterns can be a source of disruption or one of calmness and stability.</p><p>When we think of staffing disruptions, it could be anything from shift changes to staff members missing their rounds and disrupting a patient's usual routine. This can leave a patient feeling confused, neglected, or uncomfortable, which are emotional triggers that can easily instigate anxiety, increased movement, and ultimately, falls.</p><p>This is why our current staffing shortages are such a critical issue for assisted living communities; without the right staff, quality of care decreases.</p><p><strong>3.</strong>     <strong>Watch out for sleep disruptions.</strong></p><p>When a person's sleep cycle is disrupted, they have a greater risk of falling. In an assisted living community, it's important for caregivers to ask questions like, “What can we do to manage or fix sleep disruptions?" For instance, something as simple as monitoring the thermostat could prevent someone from waking up and falling on their way to get that extra blanket. Additionally, ensuring that a person is not sleeping excessively during the day and is engaged in meaningful activities will ensure better sleep at night. </p><p><strong>4.</strong>     <strong>Be aware of the time of day, week, and year.</strong></p><p>Keeping in mind the time of day, week, and year can help prevent falls, because we know some falls happen more often at certain times.</p><p>For instance, “sundowning" is a term we use to characterize the increased confusion or agitation that some aging people experience in the late afternoon or early evening. This can sometimes lead to more anxious and aggressive behavior, including shouting, cursing, and running around. This is a time for extreme risk of falling, and caregivers need to plan accordingly.</p><p>Based on data during the pandemic, most falls happen on Saturday. In fact, the least falls happen on Sunday and then they trend up during the week. We think this happens because of a few factors, including staffing patterns, family visits (with more happening on the weekend), and spiritual engagement (decreasing the number of falls on Sunday).</p><p>Falls occur more often during the spring and summer than during colder months. Some believe cold weather reduces fall risk because residents have slower mobility and might be more stiff. Others believe it's because the colder weather makes people less active as they stay bundled up, reducing their fall risk. Whatever the case, care champions should be aware of how these changes impact fall risk.</p><p><strong>5.</strong>     <strong>Understand patients to understand the cause of cognitive disorientation.</strong></p><p>Anyone with cognitive impairments is at greater risk of falls. Part of the reason for this is because cognitive disorientation often leads to agitation and to difficulties with balance as people get anxious, putting them at greater risk of falling.</p><p>Caregivers can help prevent falls in their patients by getting to know them. Something as simple as knowing their hobbies, family background, and personal history can help caregivers understand what's behind their cognitive disorientation—and thus, help mitigate fall risk because of it.</p><p>For example, I once took care of a mail delivery person with dementia, which meant he was used to large amounts of walking as part of his vocation before he started living in the care facility. With that in mind, he needed to be given plenty of space and time to walk the facility—just as he had walked his mail route—so that his energy was appropriately expended during the day. Then, he would naturally sleep better at night.</p><p>Similarly, it is important to avoid sedating medication during the day that would cause a person to sleep during the day but pace at night. “Agitation" often occurs if this person is not given ample opportunity for physical activity.</p><p>Between fall risks, staffing shortages, and an aging population that's constantly getting bigger, assisted living communities certainly have plenty to worry about. Falls, however, don't have to feel like an unsolvable problem for senior care providers—not when the right steps are taken to help prevent them.</p><p><em>Glen Xiong, MD</em><em>, is chief medical officer at SafelyYou. He is certified by the American Medical Directors Association in Post-Acute and Long-term Care Medicine (2006, 2016). He provides clinical care at the UC Davis Medical Center and in skilled nursing and assisted living facilities.</em></p> | 2022-11-07T05:00:00Z | <img alt="" src="/Articles/PublishingImages/740%20x%20740/fall_risk.jpg" style="BORDER:0px solid;" /> | Falls | According to the CDC, a person falls every second, and for those living with dementia—who often need to be cared for in assisted living communities—that number doubles. |
| Offsite Minimum Data Set Coordinators Are the Future | <p><img src="/Articles/Guest-Columns/PublishingImages/2022/WendyStrain.jpg" alt="Wendy Strain" class="ms-rtePosition-2" style="margin:5px;width:200px;height:200px;" />Some days it feels like up is down and right is left in long term care. Margins are razor thin, yet we face a 4.6 percent phased PDPM cut. Eighty-seven percent of communities report staffing shortages, yet federal staffing minimums are on the horizon. </p><p>However, there are glimmers of hope. Facilities are working hard to meet the moment by thinking creatively and harnessing resources outside their walls. Nothing exemplifies those two strategies better than the industry's movement to offsite and outsourced minimum data set coordinators (MDSCs). </p><h3>The State of the MDS Coordinator</h3><p>MDSCs are leaving the industry in droves, and those who remain are overstretched. We’ve all seen it or experienced it ourselves. Dining services is short-staffed, so you pull the MDSC to deliver trays. The facility is down a CNA or two, so the MDSC rolls up their sleeves to fill in.</p><p>Unfortunately, this “all hands on deck” approach has real costs. MDS assessments are months overdue or not completed accurately, which threatens the clinical reputation and financial viability of a community.</p><p>That’s where an offsite MDS coordinator comes in.</p><h3>Offsite MDS Coordinators as a True Solution</h3><p>The idea of an offsite MDSC might feel like another “up is down and right is left” situation. Doesn’t the MDSC need to be onsite with their eyes on the resident to assess? How do they collaborate with the rest of the facility team? What if facility leadership is just more comfortable having someone down the hall?</p><p>I understand these questions and the hesitancy. For a long time, I also believed an MDS coordinator needed to physically see residents and have in-person touchpoints with care providers and the business office to submit an accurate MDS assessment. Then I worked as an offsite MDS Coordinator myself.</p><h3>First-Hand Results of an Offsite MDSC</h3><p>In mid-2020, I had the opportunity to serve as an offsite MDS coordinator for a community that desperately needed to fill the vacancy but was worried about COVID-19 infections and bringing more people into the building. I was tasked with serving as the facility’s offsite MDSC, as well as with building an offsite program that could be applied to other communities. </p><p>After more than 25 years in long term care and training hundreds of MDSCs on PDPM, it’s hard to surprise me, but I was shocked by the success of our offsite approach.</p><p>For the first time in a long time, I could focus 100 percent of my energy on my MDS assessments. I could review coding with a fine-toothed comb, quickly identify gaps in assessment processes, and continuously train my team members because I wasn’t being pulled to put out other fires. I joined every morning meeting, Medicare huddle, and triple check via Zoom and was never sidetracked by a “Can I grab you for a second?” request. My facility, my residents, and my team got the very best MDSC work, and it wasn’t just because I had experience—it was because being offsite set me up for success.</p><p>The results were telling. I caught the facility up on their MDS assessments, I tracked down every dollar for care delivered, and the team became more efficient because it had airtight assessment processes and documentation. </p><h3>Is an Offsite and Outsourced MDSC Right for Your Facility?</h3><p>Since then, I’ve hired and placed dozens of MDSCs for positions across the country. Their experiences and results echo mine, and I’m more convinced than ever that offsite is the future of this role. It certainly makes sense from a quality and cost perspective, especially if you’re experiencing the following: <br></p><ul><li><strong>You have a backlog of MDS assessments, or your reimbursements are low. </strong>There’s only so much time in a day. We can’t continue to expect MDSCs to plug other staffing gaps and still submit assessments accurately and on time. We also can’t expect untrained clinical members to “fill in” on the MDS. Every time we divert time or expertise from the MDS assessment, we sacrifice dollars owed to our community and risk compliance problems. Now we have a real solution to give the MDS assessment the attention it deserves without running our team ragged. </li><li><strong>You’re struggling to find and retain qualified MDSCs.</strong> An offsite approach increases the size of your talent pool. If you’re struggling to fill open positions or find a quality candidate, making the position offsite expands your candidate options.</li><li><strong>You want to avoid interim staffing expenses</strong>. Travel and lodging for interim staffing can add up, especially if you’re experiencing turnover year over year or having trouble finding the right full-time candidate. </li><li><strong>You need help training your broader clinical team.</strong> One of the biggest benefits of a skilled offsite MDSC is that they can dedicate the time to training. Instead of offering piecemeal support on the floor, they can bolster the technical, documentation, and process knowledge of your broader team to make the MDS assessments reflect the care you provide. </li></ul><h3>Support in a New and Effective Way</h3><p>This up is down and right is left world doesn’t need to mean chaos. It can mean innovation, creativity, and a new way of thinking that still gives facilities what they need: in this case, a great MDSC achieving the best clinical and financial outcomes to support resident care.<br><br><em>Wendy Strain, RN, RAC-CT, is the Director of Consulting Services for Polaris Group. She can be reached at <a href="mailto:wendy.strain@polaris-group.com" target="_blank">wendy.strain@polaris-group.com</a>.</em></p> | 2022-10-25T04:00:00Z | <img alt="" src="/Articles/Guest-Columns/PublishingImages/2022/WendyStrain.jpg" style="BORDER:0px solid;" /> | Workforce | Facilities are working hard to meet the moment by thinking creatively and harnessing resources outside their walls. |
| A Return to the Basics of Hand Hygiene for Long Term Care Facilities | <p></p><p><img src="/Articles/Guest-Columns/PublishingImages/2022/MeganDiGiorgio.jpg" alt="Megan DiGiorgio" class="ms-rtePosition-1" style="margin:5px;width:200px;height:200px;" />The COVID-19 pandemic substantially impacted health care, particularly long term care facilities (LTCFs). Even before the pandemic, there was a need for increased focus on patient safety and infection prevention, as evidenced by the U.S. Government Accountability Office reporting that most nursing homes had infection control deficiencies before the COVID-19 pandemic and half had persistent problems.<sup>1</sup></p><p>As LTCFs emerge from the acute phase of the pandemic and navigate the new normal, it is clear that substantial changes are imperative, but many LTCFs don't always know where to begin. While improving the quality of long term care will take concerted reform efforts, there are small but impactful changes that can happen now. A targeted focus on basic infection prevention, particularly hand hygiene, is an excellent place to start.</p><p><strong>The Need to Regain Lost Ground</strong><br>Hand hygiene is the most foundational practice, yet perhaps the most difficult to improve. Nevertheless, hands are the most common mode of pathogen transmission. Further, hand hygiene is an important indicator of the safety and quality of care delivered in any health care setting.<sup>2 </sup>While studies are lacking in LTCFs due to hand hygiene being less commonly measured, studies in hospitals published since the pandemic report either there were no gains despite the situation or that hand hygiene initially improved and quickly decreased back to baseline levels or below.<sup>3,4</sup> These data suggest that for many health care facilities, including LTCFs, there's work to be done to regain lost ground.</p><p>When the <em>New England Journal of Medicine Perspective</em> was published in February 2022 calling for building more resilient health care systems,<sup>5</sup> many were seeking innovative next steps. When it comes to improving hand hygiene, however, novel, innovative approaches may not be needed. LTCFs may just need to get back to the basics.</p><p><strong>Getting Back to Basics</strong><br>The World Health Organization (WHO) hand hygiene guidelines encourage a multi-modal improvement strategy.<sup>2 </sup>Chief among the strategy has been system change, or simply put, making hand hygiene possible, easy, and convenient with readily available alcohol-based hand rub (ABHR).</p><p>LTCFs have long struggled with balancing the need for creating a home-like environment and managing the risk of ingestion of ABHR among residents while implementing these important hand hygiene requirements. However, the risk of ingestion of ABHR has likely been overly inflated at the expense of patient safety as there is a lack of data reporting on such cases. Further, the Centers for Medicare & Medicaid Services (CMS) clearly support the placement of ABHR dispensers, stating, “Facilities should ensure adequate access to ABHR since a main reason for inadequate hand hygiene adherence results from poor access."<sup>6</sup> The bottom line is that getting dispensers up on the walls is an imperative first step to getting ABHR on health care workers' (HCWs) hands.</p><p>An aspect of ABHR placement that can't be underestimated is offering a high-quality product that HCWs can have confidence in—ensuring that it is not only safe and efficacious but also maintains skin health and is aesthetically pleasing to use. Early in the pandemic, when many new manufacturers and distilleries began making ABHR for the first time, there was a lot of unpleasant ABHR in the marketplace that was runny, smelly, or sticky. (Plus, it turned out some contained dangerous impurities, inadequate levels of active ingredients, and other safety concerns that led the FDA to include more than 350 brands of hand sanitizers on their 'do-not-use' list.<sup>7</sup>)<sup> </sup>While it's unclear how much sub-par ABHR remains on the market, its impact on HCWs' overall perception of ABHR is cause for concern, and a return to products with strong research and development behind them is critical moving forward.</p><p>Setting up hand hygiene infrastructure (i.e., making hand hygiene easy and accessible) is one aspect of the bundle of interventions that is the multi-modal strategy. The abundant recommendations in the multi-modal strategy are carefully laid out for facilities looking to make changes. But, because of the complexity and opportunity in these recommendations, prioritization is critical and change takes time.</p><p><strong>From Understanding to Behavior</strong><br>For the individual HCW, the most important change they can make is performing hand hygiene before and after every resident interaction. It may seem very simple, but it's important to note that there is a difference between conceptually understanding or knowing something and following through with behavior. HCWs can know conceptually what they need to do and when they need to do it, but once inside the context of their busy and often chaotic workday, they may have difficulty following through with behaviors despite what they know.</p><p>Periodic hand hygiene education is insufficient to ensure that hand hygiene is performed at the right moment. On the other hand, proximity can have a very powerful impact on behavior in the moment. Programs designed to encourage speaking up and encouraging everyone on the front lines to provide consistent reminders for missed opportunities can help create and sustain a new set of habits and practices.<sup>8</sup> Simple and continued reinforcement by management and peers can help hand hygiene become part of a patient safety culture.</p><p>Trying to implement all of the guidelines and recommendations for hand hygiene can seem overwhelming, and for facilities regrouping post-pandemic, it may be too much at once. A focus on making access to ABHR easy and convenient and getting HCW to use the dispensers at a minimum upon room entry and exit are two good first steps in the journey. Getting back to the basics during this transition period will strengthen the promise of a safer post-pandemic future. Admittedly, this is hard work. It will take commitment, persistence, and endurance to hold fast to a journey that will span years and not months. But this is how we change hand hygiene culture.<br></p><p><span style="color:#555555;"> </span><br style="color:#555555;"><em style="color:#555555;">Megan DiGiorgio, MSN, RN, CIC, FAPIC, is a senior clinical manager at GOJO Industries—the makers of PURELL products.</em><br></p><p><br></p><p><strong class="ms-rteFontSize-1">References:</strong><br class="ms-rteFontSize-1"><span class="ms-rteFontSize-1">1.     US Government Accountability Office. Infection Control Deficiencies were widespread and persistent in nursing homes prior to COVID-19 pandemic. Published May 20, 2020. Accessed September 1, 2022. </span><a href="https://www.gao.gov/products/gao-20-576r#summary" target="_blank"><span class="ms-rteFontSize-1">Infection Control Deficiencies Were Widespread and Persistent in Nursing Homes Prior to COVID-19 Pandemic | U.S. GAO</span></a><br class="ms-rteFontSize-1"><span class="ms-rteFontSize-1">2.     World Health Organization. WHO Guidelines for hand hygiene in health care. Geneva, Switzerland: World Health Organization; 2009. </span><a href="https://apps.who.int/iris/bitstream/handle/10665/44102/9789241597906_eng.pdf;jsessionid=3337A802E44723C3B4CDC131B90B2B9C?sequence=1" target="_blank"><span class="ms-rteFontSize-1">https://apps.who.int/iris/bitstream/handle/10665/44102/9789241597906_eng.pdf;jsessionid=3337A802E44723C3B4CDC131B90B2B9C?sequence=1</span></a><br class="ms-rteFontSize-1"><span class="ms-rteFontSize-1">3.     Moore LD, Robbins G, Quinn J, Arbogast JW. The impact of COVID-19 pandemic on hand hygiene performance in hospitals. </span><em class="ms-rteFontSize-1">Am J Infect Control.</em><span class="ms-rteFontSize-1"> 2021; 49(1):30-33.</span><br class="ms-rteFontSize-1"><span class="ms-rteFontSize-1">4.     Sandbøl SG, Glassou EN, Ellermann-Eriksen S, Haagerup A. Hand hygiene compliance among health care workers before and during the COVID-19 pandemic. </span><em class="ms-rteFontSize-1">Am J Infect Control</em><span class="ms-rteFontSize-1">. 2022;50(7):719–723.</span><br class="ms-rteFontSize-1"><span class="ms-rteFontSize-1">5.     Fleisher LA, Schreiber M, Cardo D, Srinivasan A. Health Care Safety during the Pandemic and Beyond - Building a System That Ensures Resilience. </span><em class="ms-rteFontSize-1">N Engl J Med</em><span class="ms-rteFontSize-1">. 2022;386(7):609-611.</span><br class="ms-rteFontSize-1"><span class="ms-rteFontSize-1">6.     Centers for Medicare and Medicaid Services. Center for Clinical Standards and Quality/Quality, Safety & Oversight Group. Updates and initiatives to ensure safety and quality in nursing homes. November 22, 2019. </span><a href="https://www.cms.gov/files/document/qso-20-03-nh.pdf" target="_blank"><span class="ms-rteFontSize-1">QSO 20-03 Updates and initiatives to ensure safety and quality in nursing (cms.gov)</span></a><br class="ms-rteFontSize-1"><span class="ms-rteFontSize-1">7.     U.S. Food & Drug Administration. FDA updates on hand sanitizers consumers should not use. Accessed Sept. 1, 2022. </span><a href="https://www.fda.gov/drugs/drug-safety-and-availability/fda-updates-hand-sanitizers-consumers-should-not-use" target="_blank"><span class="ms-rteFontSize-1">https://www.fda.gov/drugs/drug-safety-and-availability/fda-updates-hand-sanitizers-consumers-should-not-use</span></a><br class="ms-rteFontSize-1"><span class="ms-rteFontSize-1">8.     Sickbert-Bennett EE, DiBiase LM, Teal LJ, Summerlin-Long SK, Weber DJ. The holy grail of hand hygiene compliance: Just-in-time peer coaching that leads to behavior change. </span><em class="ms-rteFontSize-1">Infect Control Hosp Epidemiol</em><span class="ms-rteFontSize-1">. 2020;41(2):229-232.</span></p><p><em></em></p><p></p> | 2022-10-18T04:00:00Z | <img alt="" src="/Articles/Guest-Columns/PublishingImages/2022/hand_wash.jpg" style="BORDER:0px solid;" /> | Infection Control | A targeted focus on basic infection prevention, particularly hand hygiene, is an excellent place to start. |
| Best Practices for Designing Memory Care Facilities | <p>Through strategic and intentional design, as well as purposeful execution, memory care facilities can reduce resident confusion, frustration, and anxiety while encouraging engagement and independence in a safe environment.</p><p>The <a href="https://montessori-ami.org/about-montessori/montessori-dementia-ageing#:~:text=The%20goal%20of%20the%20Montessori%2c%2c%20others%2c%20and%20their%20community." target="_blank">Association Montessori Internationale</a> created the first Montessori Advisory Group for Dementia and Ageing in 2014, fostering a program whose goal is “to support older adults and people living with dementia by creating a prepared environment filled with cues and memory supports that enable individuals to care for themselves, others, and their community.”</p><p><img src="/Articles/Guest-Columns/PublishingImages/2022/ScottHendrix.jpg" alt="Scott Hendrix" class="ms-rtePosition-1" style="margin:5px;width:200px;height:200px;" />To execute this person-centered philosophy, design teams must understand how people with Alzheimer’s disease and dementia interact with their environments, as well as the wide range of a resident’s abilities and limitations.</p><p>While every facility is not equipped to fully adapt to the Montessori method, it is possible to make cost-effective upgrades that enhance a resident’s life by applying best practices.</p><h3>Case Study: Evergreen House</h3><p>The Village at Summerville is one of six senior living communities operated by Presbyterian Communities of South Carolina. Evergreen House, a purpose-built memory care facility on that campus, is an example of how incorporating Montessori principles into the built environment can improve resident life.</p><p>If a facility is considering adopting Montessori methods, decision-makers are encouraged to visit an existing Montessori facility such as Evergreen House, one of the first intentionally designed buildings of its kind in the United States. Clients may witness firsthand how intentional design influences the environment and its inhabitants. From there, they can begin to think about how to incorporate the different Montessori principles into their vision for a new or revitalized facility.</p><h3>Wayfinding</h3><p>Wayfinding should be a primary design consideration in senior living facilities to reduce spatial disorientation. This is accomplished by designing surroundings that are instinctive to navigate and rich with sensory cues. For those with memory impairments, multiple layers of wayfinding methods may be implemented to compensate for cognitive decline that leads to increased spatial disorientation.</p><h3>Color</h3><p>Color can serve as a useful tool for making navigation easier. A resident with memory impairment may not be able to tell you their room number, but they may remember that they live in an orange hall. Memory care facilities can select flooring, paint, finishes, art, and signage that coordinates a defined color identity to improve wayfinding.</p><p>Each resident pod at Evergreen House leverages the interior environment to create visual cues that better orient residents as they navigate the facility. In resident rooms, bathrooms are color-coordinated to further establish color association, with the wall behind each toilet coordinating with the pod’s designated color. </p><h3>Contrast</h3><p>The color behind the toilet enhances a sense of place and provides a distinct contrast between the toilet and the wall. The use of contrasting colors for hardware such as cabinet pulls, grab bars, doorknobs, and plumbing fixtures further aids in creating spaces that promote self-reliance.</p><p>Contrast also provides cues for areas residents should and should not access. At Evergreen House, doors leading to staff areas are painted the same color as the wall and feature matching hardware to blend into the surroundings. Meanwhile, resident rooms and community spaces use black hardware and a solid, contrasting color door or wall to make them stand out to residents. </p><h3>Signage</h3><p>Signage is the next layer to incorporate into your facility’s wayfinding system. It can work in tandem with color to establish visual cues and landmarks that serve as “memory joggers” for residents. Signage can include resident room signs, back-of-house signs, and invitational cues. </p><p>At Evergreen House, bedrooms have signs located adjacent to each resident’s door. Signs include a room number and interchangeable openings where staff members insert the resident’s name and a large format photo of them from the life period they most identify with at a given time. Signage is designed to coordinate with each pod’s color palette and contrast with the wall for easy visibility.</p><p>Back-of-house, staff, and general building signage that indicate spaces not intended for resident access—such as the kitchen or utility rooms—are less colorful and more utilitarian. The intent is not to hide these areas, but rather to make them less inviting for residents.</p><p>Printed tabletop signs maintained by Evergreen House staff serve as invitation cues. These are brightly colored, high contrast, and meant to grab the attention of residents. Tabletop signs placed directly next to an activity may ask a question like, “Would you like to do a puzzle?” These signs require minimal upfront cost and planning, making them easy to adopt in existing facilities. </p><h3>Art</h3><p>Distinctive artwork should be placed throughout the building with clear, single-subject images. Owners and designers should undergo a thoughtful selection process to determine which subjects are most relatable to the residents living in their specific facilities. </p><p>Artwork and display surfaces should have a matte finish. Glare creates vision difficulties for elderly residents and may keep them from recognizing the subject of the artwork, thus minimizing its effectiveness as a wayfinding tool. </p><h3>Floor Plan</h3><p>Floor plans that encourage movement, are easy to navigate, have built-in spaces for engagement, and are designed to be adaptable to changing resident needs help residents lead fulfilling lives and provide a sense of normalcy.</p><h3>Scale</h3><p>Evergreen House is laid out in a similar manner to how a typical residence would be designed. Public spaces, such as the living room and kitchen, are centrally located with short hallways connecting to private spaces, including resident rooms and guest toilets. Support spaces are located in areas between public and private zones, allowing caregivers visual access to monitor residents and exits at all times.</p><p>Long corridors and dead ends can cause frustration for residents. The “pod” style arrangement of rooms at Evergreen House minimizes hallway length while allowing the creation of distinctive color identities for each grouping of rooms to help residents independently navigate from public to private space. In renovations, a cost-effective way to break up long corridors is to create visual stopping points using finishes, such as accent carpeting, wallcoverings, and paints.</p><h3>Resident Engagement Areas</h3><p>Facilities should have spaces intentionally designed to engage residents and encourage them to participate in stimulating activities. </p><p>Dedicated or fixed “lifestyle stations” are programmed into the built environment and provide a place for daily life activities. These may include washing machines for laundry, built-in bookcases for reading, or a piano for music therapy. Flexible stations give staff the ability to adjust areas to offer engaging activities tailored to their facility’s particular population. They may be as simple as a coin-sorting station on a table or a flower-arrangement station with artificial flowers and various vases.</p><p>Thoughtful placement of resident engagement areas creates opportunities for both personal entertainment and social interaction. Adding them along a resident’s daily path or incorporating them into common areas encourages people to interact with the space and join in on activities.</p><h3>Kitchen</h3><p>Ensuring a centralized and open location for the kitchen helps engage all of a resident’s senses. Residents can see, hear, and smell meals being prepared and can physically interact with the space to grab their own food and drink. Adding a beverage station is another great way to help residents maintain dignity and self-reliance since they can select and prepare their own beverages.</p><h3>Bedroom</h3><p>Depending on the level of care, facilities may allow residents to bring their own furniture to help them feel at home. However, there are certain elements that must not be disturbed, such as direct line of sight to the toilet. Residents at Evergreen House have two options for arranging their furniture, guided by the strategic location of power outlets, the nurse call system, and cable and telephone connections. Regardless of which arrangement individuals select, they will always be able to clearly see the door to their bathroom. </p><h3>Outdoor Space </h3><p>Providing space for residents to go outside and enjoy nature is an important component of their mental and emotional well-being. The outdoor space at Evergreen House includes multiple zones for socializing, mindful contemplation, and gardening.</p><p>Landscaping can be used strategically to establish boundaries while permitting movement and easing frustration. It can be used to disguise fences and gates, as well as inaccessible spaces outside the home. </p><h3>Design That Puts People First</h3><p>Applying Montessori for Dementia and Ageing principles into a memory care facility’s built environment can be a substantial undertaking, especially for facilities looking to do a full conversion. However, facilities don’t need to change everything to make a positive impact on their residents.</p><p>Embracing even one of these best practices may begin promoting a better sense of independence and enhancing quality of life for residents suffering from memory impairment as they interact with an environment designed with their needs in mind.<em><br></em></p><p><em>Scott Hendrix, AIA, LEED AP, is an Architect at McMillan Pazdan Smith Architecture, a regional, studio-based design firm with offices in Spartanburg, Charleston and Greenville, South Carolina; Asheville and Charlotte, North Carolina; and Atlanta, Georgia. He can be reached at <a href="mailto:shendrix@mcmillanpazdansmith.com" target="_blank">shendrix@mcmillanpazdansmith.com</a>. </em></p> | 2022-10-11T04:00:00Z | <img alt="" src="/Articles/Guest-Columns/PublishingImages/2022/ScottHendrix.jpg" style="BORDER:0px solid;" /> | Management;Design | Memory care facilities can reduce resident confusion, frustration, and anxiety while encouraging engagement and independence in a safe environment. |