Linda Moreno heads the life enrichment department for two long term and post-acute care “sister” facilities in Northwest Washington, D.C. One is Forest Side, a six-year-old memory care provider. Not far away sits Forest Hills of DC, a skilled nursing and assisted living operation that started out as the Methodist Home some 130 years ago.
In total, the two campuses have 132 beds amongst skilled rooms and assisted living apartments. Moreno and her staff of seven are responsible for the activities, recreation, and life enrichment programs for the residents.
In modern parlance, she is in reality the chief of a multi-pronged, technology-laden, bus-driving, hand-holding, therapeutic-providing, entertainment-fused catch-all of a department that works under the heading of life enrichment but does so much more.
All around the country there are people like Moreno and her staff working at an especially interesting time for life enrichment, considering the indisputable fact that the legal emphasis on person-centered care in the long term and post-acute (LT/PAC) sector has really hit home for them and for what they do.
New Look for Activities
With innovative technology, a focus on the individual needs of a resident within a community setting, and the progression to a new generation of elders coming to facilities, the old methods of motivating, exercising, and soothing residents is yesterday’s news.
Today, Moreno says, the arts and crafts session in a large group has given way to smaller gatherings or the individualized personal touch, with programming complemented oftentimes by smart TVs, iPads, and the like. “I think the trend shifted when we finally started talking person-centered care and asking what does that mean? And, it is exactly what it says, person-centered care,” she says.
How that looks to residents and their families can be as simple as staff listening and writing down in their normal documenting of the day’s activities some tidbit, some personal anecdote from a resident’s life and turning that into an enriching experience.
For example, at Forest Hills, a resident recently mentioned that she missed getting Starbucks, and that turned into a fun experience when staff did a run to the popular coffee shop and brought back the goods of coffee and very berry refreshers for those interested residents. And it doesn’t stop at coffee either, Moreno says.
“In fact, we are ordering Subway next week for six of the residents who said it’s been a long time since they had that … and it started with one resident who said they used to regularly order a tuna sandwich on wheat there,” she says.
This little give and take will now be a mini-group activity with residents gathering to have their Subway sandwiches. “That is an example of person-centered care … that is what it is,” Moreno says.
Social Means Social
Another focus at Forest Hills and Forest Side is not to pass up chances to socialize, she says. There are times when a resident does not want to leave her room and staff pay a visit to see if she needs assistance in finding a TV program or other interest, be it on the Internet or some other means. But when socializing with the others, it is about being social.
“No one sits around and just listens to music or just eats ice cream. We are sitting around in a living room,
socialized, listening to music, laughing, and telling jokes.”
Moreno says technology in this regard also plays a great new role, like the fact on her iPhone she has a corny jokes app that she keeps open to josh with certain residents and ignite conversation.
“It is about finding out what residents enjoy. Of course we still have a lot of structured group programs, but we also have a lot of one-on-one opportunities, like going outdoors for a stroll and the telling of corny jokes,” she says.
One resident loved to play golf in his younger years, so staff make sure to sit and watch parts of the latest tournament with him on TV. One woman has the same affection for tennis, and when a big event like Wimbledon arrives, an activities assistant will also arrive to tune her TV to the right channel.
Not Just Technology
But, Moreno says, the difference in delivering life enrichment to residents is not just a matter of plugging in the right device in the wall. There is also the fact that the resident has changed as well.
“Our program is different today than it was 10 years ago not because of technology alone, but also because of the mental capacity of the residents coming in,” she says.
When working with residents outdoors, for instance, on a watercolor painting activity, the interest level is very low to nonexistent for most. Instead, residents mostly want to hear from an expert Moreno brings in to talk about the artists, to present PowerPoint slides on surrealism or other genres, rather than do art themselves.
“When she [the expert] presents to Forest Side to the residents with dementia, it is not about talking technique but more about talking about the color and how it makes you feel,” she says.
Many Activities at Once
Having a recognition of what works and what does not for each individual is a major point of emphasis, Moreno says. This leads to facilities deploying multiple activities at once as they consider which subset of their population will want to undertake which part of that day’s programming.
“Not everybody goes to all programs. We have three or four going at one time, because this is about their interest and not so much about their capability,” she says. “You have to know your residents and offer a variety of programs so they can have a choice, and see which one is appropriate. We can have eight or nine activities a day.”
There is even a twist in Moreno’s program on technology itself, with residents given the chance to do armchair travel through videos shown on a larger screen. “We also do virtual tours like for real estate, and residents talk about the houses they once had and the prices now and how beautiful the homes are,” she says.
This can lead to discussions about technology itself, with residents comparing how things have changed while at the same using iPads and Amazon’s voice assist aide Alexa to make their lives easier. “Some have Alexa, and others know it is out there, and now we see residents who come in with their smart devices,” Moreno says.
Signature Sees Quality Life as Key
For another provider, the person-directed care mantra is part and parcel of the activities program, and has been for some years now, says Angie McAllister, director of quality of life and culture change, Signature HealthCARE.
She tells Provider that her group’s “main thrust” right now is to shift from traditional activities that improve quality of life to exploring the value of engagement and to mentor creativity. “We are working to bring person-directed care to everything we do,” McAllister says.
At the end of the day, she explains, the programming is really about offering a new vision of what elders do with their time in a care community and how to let them express their talents, interests, and needs.
McAllister says the expectation for Signature now is to “flip the script” on how people view residents, with the hope of being able to nurture them and help people reach their ultimate level of well-being.
“This can come through the use of technology in some cases, but it is all very different in different parts of the country with different cultures. It is up to the provider to identify what works best,” she says.
The previous mindset that limited the potential for activities and recreation in skilled nursing and assisted living communities is not easy to shake, McAllister admits. Old-style games for people with dementia where they were asked to locate letters or numbers were not a good idea, and not gratifying for those with memory issues, she says.
“It used to be about entertainment, and that has gone through so many evolutions since then,” she says. Time fillers have morphed over the years into truly therapeutic programs to allow residents to get in touch with who they are.
Passion in the Programming
Signature programming now seeks to put passion behind traditional arts activities, McAllister says. This has resulted in some stunning revelations for not only residents, but staff and the families of residents as well.
“We had a play performed by our residents with dementia,” she says. “They wrote the script and put together that performance, which really allowed them to get in touch with their creativity.”
This type of activity is also part of shattering the myth that everything in this realm of life enrichment has to have a therapeutic value, McAllister says.
“Sometimes it is just about wanting to do this today because it is joyful, like it was in their past lives, or for anyone who wants to go to a lake, read a book, this gives me joy personally, and it is not for some clinical outcome,” she says.
Signature, in the end, wants to make this whole area of its care program not about limitations only. “Too often in our industry it is about the limitation of the resident, and very rarely about what people can do.
When [residents] have limitations, they are very conscious of it, but if we can engage them in new ways then they can see themselves differently,” McAllister says.
Focusing on Body and Mind
In Laredo, Texas, the recently opened Las Alturas Nursing & Transitional Care, a Touchstone Communities property, has the total resident in mind when devising activities and recreation, says Nicole Blanco, activities director and recreational therapist.
“As a recreational therapist, I focus on activities that are going to be more beneficial mentally, physically, emotionally, spiritually … so that’s what I do,” she says. “I plan out all the activities for every single day and month.”
In doing so, Blanco says she makes sure programs are going to benefit residents’ bodies through exercise, as well as to ensure their spiritual beliefs are taken care of, providing religious services. Cognitively, the focus is on talking about history, the past, where residents came from, and with a continuous emphasis on taking care of their minds and having them active.
“I provide activities in the morning, in the afternoon, and at night they often will do their own leisure activity,” she says.
The broader goal is to focus on what activities can help to improve residents’ lives and quality of life through focusing on all the dimensions of a person’s health.
Class is in Session
One recent effort to fulfill her mission came when the Las Alturas administrator let Blanco know there were two desktop computers in the activities room for use.
“I thought it would be a good idea to teach the residents how to use them, she says. “Most of them haven’t had any experience with a computer before. The Laredo residents come from farming and outside work, and so computers are so different for them and most have never had an experience with one.”
This effort led to a partnership with the local public library in which the librarian comes to the facility and teaches the basics. Blanco also does some instructing since she has experience with computers, and this experience has led to some education of her own on how removed many of her residents were from modern technology in their lives before coming to Las Alturas.
“To me, grabbing the mouse and clicking things was normal. But, when I was teaching one of the residents I realized that she didn’t know how to move the mouse,” she says. “We knew then that we needed to implement a class about how to turn on the computer, how to move the mouse, how to click, how to use the keyboard, etc. We decided that was important before we started teaching them the Internet and social media.”
Taking on Many Roles
In an example of how the activities leader in a facility has to wear many hats, as well as the staff under the director, Blanco says she also focuses on the social aspect of a resident’s health and ties that to education efforts when possible.
Touchstone prefers to be referred to as a community. “It is a community,” she says. “I help create a community with the residents. They come and may be afraid that they may not know anyone, and classes like these help because they see others learning and taking part.”
There is also the need to work well with staff in other departments to help improve the quality of life for a resident.
“The nursing staff and CNAs [certified nurse assistants]—their job is to take care of their residents’ health in terms of medications, for example, and CNAs will help them get dressed,” Blanco says. “But, sometimes those staff will lean on me to provide residents an activity that improves their mood.”
An example of this cross-department teamwork came when a resident woke up in a terrible mood, and everyone was tiptoeing around him to prevent a conflict. The nursing staff “told me about it so that I could provide a good activity for the resident [to put him] in a good, positive frame of mind,” she says.
This checking up on residents is a routine part of the job. Every day at 9 a.m., Blanco says there is a morning meeting after which each staff member visits a room and talks to residents to make sure they are okay.
“A majority of the day I am able to see changes in the residents physically or cognitively, and I express that to the nursing staff and the director of nursing to make sure they are not declining or have an infection, for example,” she says.
100 Years Old and Teaching
Blanco says the best part of her work is the connection she has with residents. One such story she tells is about an “amazing connection I had with a 100-year-old lady at another facility. We still talk.”
While at the other community, Blanco says she learned that the woman didn’t like to participate in activities because she was partially blind and hard of hearing. “One time she told me she really enjoyed cooking and loved making desserts. She told me about a fruit salad she used to make. I told her she could teach us,” she says.
This offer thrilled the resident and brought her happiness in a way that neither she nor the staff working with her could have imagined.
“She had been independent all her life, and when she moved into the center, life was hard because she could no longer do anything by herself. And, so her teaching something to someone was a joy. She was so excited, she showed everyone how to do it, and she gave everyone a taste,” Blanco says.
Offering Residents a Full Slate
For Luciana “Luci” Loureiro, director, therapeutic recreation, Miami Jewish Health, one of the top considerations that guides her work in the sprawling 20-acre campus that includes some 412 beds is the importance of the task at hand.
“Depression is the No. 1 killer in this population, so recreation therapy programs really are one of the top three most important things in a nursing home. I like to say, first comes dietary, the food, then nursing, and then therapy,” Loureiro says.
To accomplish the goals of her department she has many different programs happening at the same time, with each of the 11 nursing stations holding activities simultaneously.
Of the new and trending activities at Miami Jewish that has struck a chord with many residents is something called Silent Disco. This entails putting headphones on a resident, so they can hear music being played. This can even be done from their bedrooms if that works best, but the purpose is to initiate engagement, Loureiro says.
“You don’t have to have any cognitive ability to like music, so a lot of patients with dementia and Alzheimer’s can enjoy this,” she says.
After stating how successful the disco idea has been, Loureiro says the way for her to gauge what works and what does not with residents when it comes to therapies is attendance first and foremost.
“You learn very quickly about things, like in this population of 70 years or plus, most of these folks really don’t want to do any exercise,” she says. “So, I have to be really creative to get them to exercise without them knowing they are exercising. This can be something that makes them move their hands say, which helps with circulation and all of that.”
Connections Are Strong
Loureiro, like many in her profession, taps her own brain to come up with many of the programs she tries out for residents. One that she originated that has also proved popular is called I Connect.
“There is a huge need of residents to connect with loved ones not able to visit. A lot of our elderly have family that are overseas or in New York and can only see Mom once a month if that,” she says.
Enter I Connect, which allows family members to have a standing appointment with residents at Miami Jewish via Skype. “We give them directions to open their own Skype and get their preferred time to meet with Mom or Dad,” Loureiro says.
Since starting a few years back, the rather simple and inexpensive program has lifted many spirits, often from far distances.
One such occurrence came when an 85-year-old resident finally could see her daughter who lives in Australia. “Daughter started crying and Mom, and we all did,” she says.
Families in the Know
One part of the job, Loureiro says, is to make sure families are told of new initiatives that they may have concerns about or at least just to let them know what is happening on a regular basis.
“If we are just playing a Bingo game, then no, obviously you don’t have to talk to families. But if we’re taking a resident to Disney on Ice or out of the facility in general, then yes. We have, for example, a botanical group and do planting outside the facility,” she says.
The calendar is kept busy, and at times there are requests for family involvement, but these occasions often yield just the same few participants each time, she says.
Five Senses Get Attention
An exciting addition that any resident or family likes at Miami Jewish is a rarity among any health care community. “I believe we are the only clinical operation or hospital in the country that has two multi-sensory environment rooms,” Loureiro says.
These rooms can tap into any and all of the five senses. “These are my babies,” she jokes. “They really are used to arouse or to calm patients. If they are agitated we have the lavender scent and classical music playing and nice soft materials to feel, a lava lamp.”
On the opposite end, the room can arouse a resident who is overly sleepy, like via drumming music and citrus aromas, she adds. “The room is awesome given that we are able to change it around according to the behavior we are trying to achieve.”
Essential Oil as Activity, Therapy
The use of aroma therapy is a recent project at another LT/PAC provider, says Susan Kane, director of memory and dementia care for Opis Senior Services Group, which operates 10 skilled nursing facilities and one assisted living community in Florida.
She tells
Provider that five of the centers are called Caring Way units, which are dedicated to residents with Alzheimer’s disease and other forms of dementia. It is there that a new aroma therapy program has debuted, which was actually introduced to Opis by Kane.
“In my role I work directly with recreation directors at Opis centers, since it is so highly important to have a good slate of recreational activities with residents who are displaying a lot of behaviors,” she says.
This effort is built on assisting customers to achieve a better quality of life, which again leads to the need for a robust calendar of activities.
“One thing we did not have in place, and which has been shown through research to really affect those with dementia, is aroma therapy and essential oils to improve those conditions,” Kane says.
So, late in 2018 Opis started an aroma therapy program, which has proved to be a great benefit for residents and something that has led to improved sleep and reduced stress. Team members love it, she says, and some have been trained to conduct the sessions, which are offered at least three times a week for 30-minute durations.
Oils for Different Goals
Kane says the various oils to choose from were narrowed to five, with each chosen for assigned goals:
- Lavender: Calming, increases sleep;
- Peppermint: Decreases pain, increases attention;
- Cedar wood: General wellness, uplifting;
- Citrus fresh: Increase appetite, increases alertness; and
- Bergamot: Improves mood/depression, decreases stress.
“[The last one] is for customers here for the short term, basically there to have rehab and be discharged home. It is their first foray possibly into serious medical issues, and some suffer from some depression,” she says.
As part of the selection process to find residents who may benefit from the aroma therapy and oils, Kane says recreation directors work with the nursing department and social services staff to make the decisions. Those picked are then carefully screened to make sure there are no medical complications.
“The program is very, very safe, but there are some medical conditions that could be exacerbated tied to cardiac and respiratory issues,” she says.
Once selected and approvals made, the customers are put into small groups. The two modes of delivery are to inhale via an electric diffuser that is plugged into the wall and spreads aroma throughout the space.
“This is the best way because the sense of smell is the most powerful of the senses, and when you inhale it goes straight to the brain, which research shows triggers memory,” Kane says.
There is also a second way to deliver, a topical application, where staff take oils and mix with vegetable or sunflower oil to dilute and then apply a hand or arm massage.
“We have now tracked behaviors before and after the aroma therapy and oils, and in most cases we have seen a reduction in behaviors or the behaviors remaining the same,” she says.