Jan. 18, 2014, 2 p.m.: Molly Malone’s care conference is in progress. The family is not in attendance. Molly sits in a wheelchair that Physical Therapy has customized just for her.
She is sitting comfortably. Using the Wong Baker Face scale, nursing has confirmed that Molly is pain-free. Her weight remains stable. Just like the previous 90 days, she is brought to daily activities but does not participate. Daily weeping and outbursts disrupt the other residents. She seems to be calmer being in her room where she stares out her window. Molly remains on the antipsychotic risperidone 2 mg po QHS (by mouth every night at bedtime) for behavioral symptoms of her dementia.
Jan. 18, 1994, 2 p.m.: Molly Malone and her husband are almost through customs. Both are in agreement that this has been their best European trip to date. They also agree that they will just have to deal with the jet lag, as they have a very busy schedule over the next week: Besides work, there’s a birthday party for their grandchild, a Mahjong tournament, progressive dinner with their friends, and the list goes on and on.

Tackling Dementia Care

The Centers for Medicare & Medicaid Services (CMS) launched the Partnership to Improve Dementia Care in Nursing Homes program in 2012. The goals of this initiative included a focus on person-centered care and the reduction of unnecessary antipsychotic medication.

The American Health Care Association, in 2012, launched a quality initiative to safely reduce the off-label use of antipsychotics by 15 percent. Skilled Healthcare also embraced this quality initiative. Simply put—it is the right thing to do.

A plethora of resources and tools became readily available to address this quality initiative, including educational materials on the side effects of antipsychotic use, gradual dose reduction, and nonpharmacologic strategies.

Along with implementing these resources, in 2013 Aisha Salaam, senior vice president of Skilled Healthcare’s Professional Services Department, recommended forming a Behavior Management Task Force. She shared that improving the care for those with dementia is not only important for decreasing antipsychotic drug use but would also positively impact other areas such as weight maintenance and fall reduction.

The task force brainstormed many different areas on which to focus. One discussion item revolved around the feelings of distress and anxiety someone with dementia can experience when they move to a new home or have strangers take care of them. A decision was made that the task force’s first deliverable would be to create a tool to assist staff in getting to know their residents.

Creating A Resident’s Passport

Reviewing documents from a number of resources, including the Alzheimer’s Association and Alzheimer’s Society, the task force created “A Passport Into My Life: Understanding My Journey Will Help You Understand Me.”

Skilled Healthcare piloted Passport in a few centers, tweaking the document and procedure based on lessons learned. The task force rolled out the program in February of this year. Passport provides information about the person and paints a picture of who the person really is. Passport information includes interests, accomplishments, daily routines, familiar names, traumatic life events, and a number of expressions of needs.

There are also blank pages for staff to record their observations and updates of what techniques they used that worked and, just as important, anything that should be avoided.

Building a better understanding of who the resident is enables caregivers to provide more personalized care with an eye toward decreasing the use of antipsychotic medications. Using the Passport program in conjunction with consistent assignment enables the staff and the resident to get to know and become more comfortable with each other. The program also satisfies components of CMS’ dementia care program under quality of care and quality of life:

■ Identify, to the extent possible, factors that may underlie the resident’s expressions of distress as well as apply knowledge of lifelong patterns, preferences, and interests in activities to enhance quality of life.

■ Centers should be able to identify how they have involved residents, families, and representatives in discussions about potential approaches to address behaviors (needs expressions).

Distributing The Passport

The Social Services Department of each center participating in the program has oversight of distributing the Passport and ensuring it is returned. During the admissions process, if the center knows the resident has dementia, the admissions coordinator escorts the family to Social Services after the paperwork is completed.

The social services designee explains the purpose of the Passport and asks the family to return the completed Passport within seven days. If the resident can contribute, he or she is encouraged to be part of this information-gathering process.

When the interdisciplinary team identifies that staff would benefit from having Passport information on a resident already residing in the center, Social Services will introduce the Passport by contacting the family or coordinating with the quarterly care plan invitation.

Introducing The Passport To Staff

The rollout of the Passport program was done in a train-the-trainer format, with the task force rolling it out via conference calls. The center’s administrator, director of nursing, and social services director rolled it out to department managers during the morning stand-up meeting and to staff during general staff meetings.

Additional staff training was completed by department managers.

Other talking points pulled from guidelines include:

■ Centers should have a consistent process that focuses on a resident’s individual needs and tries to understand behavior as a form of communication. This may help to reduce behavior expressions of distress in some residents.

■ During interviews with staff, determine if staff have been trained in how to communicate with and address behaviors in residents with dementia.

Operationalizing The Passport

Through the pilot, the task force determined that designating a separate binder for the Passports would allow them to be accessible at all times to any staff member who may be involved with the residents’ care. A communication form was placed in front of the binder with a running list that highlights any new Passports or changes to existing Passports. An entry noting new additions or changes is also made in the 24-hour report.

Staff members review a resident's Passport.The Passport is now part of new employee orientation and is also brought to care plan meetings for review and updates.

During the pilot, some family members asked to take the Passport with them when their loved one was discharged or passed away, something staff had not anticipated. If the family makes that request, they are given a copy of the Passport, and the original is maintained in the closed medical records.

As for Molly Malone, she is a fictitious character created to illustrate a point for this article. If Molly were real, this is how the Passport would have helped staff with her care: The family completed A Passport Into My Life, learned about Molly, and went to work.

The activities director went to a few travel agencies and gathered free brochures about various vacation destinations. The family was asked to bring in an old Mahjong set. Through other residents’ Passports, the activities department identified others who were previous Mahjong mavens. Now, every morning Molly reviews the travel brochures, “planning” her next vacation, and every afternoon after lunch, she and four other residents gather to “play” two hours of Mahjong. Molly’s antipsychotic medication has been

Who doesn’t like happy endings?
Karen SchindlerKaren Schindler, PT, is vice president of quality initiatives at Skilled Healthcare LLC, which serves more than 95 skilled nursing and assisted living centers in eight states. Schindler, whose long term care career spans 30 years, can be reached at kschindler@skilledhc.com.
She would like to thank the task force members for contributions: Betty Cline, RN, Edwin Evangelista, Gabby Martinez, Jenny Johnston, LBSW, Kathleen Rose, Marsha Clark, Rose Brosam, RN, Terri Greaves, Theresa Rohrer, and Tonya McNemee.