Arden Courts: 25 Years of Dementia Care<div><div><div>​​</div><div> <img src="/Monthly-Issue/2019/December/PublishingImages/Arden_backyard2.jpg" class="ms-rteImage-0 ms-rtePosition-1" alt="" style="margin&#58;5px 15px;" />In 1994, President Ronald Reagan penned a letter announcing to the American public that he had Alzheimer’s disease. Having a prominent statesman admit his battle with Alzheimer’s put the discussion of caring for people with memory care into the public eye. Up until that point, the 4 million Americans living with Alzheimer’s, most aged 65 and older, had very few care options other than nursing facilities and hospitals. </div><div> <br> </div><div>Today, there are 5.8 million people in the U.S. living with Alzheimer’s and other related dementias, with another person diagnosed with the disease every 65 seconds. As baby boomers reach retirement, memory care has again returned to the forefront of discussion.</div><div> <br> </div><div>Long term and post-acute care organizations are now offering a spectrum of services for patients living with memory loss who require long term care. Twenty-five years ago, HCR ManorCare was one of the first providers to address care settings to offer quality care in an engaging and social environment by creating Arden Courts Memory Care Communities.</div><h2 class="ms-rteElement-H2">At the Beginning</h2><div>The first Arden Courts Memory Care Community was built in 1994 in Potomac, Md. Five years of research and planning by dementia experts went into developing an assisted living environment that would help people living with Alzheimer’s maximize their sense of independence and increase their self-esteem by utilizing their cognitive abilities in a safe and secure environment. “Arden Courts set out to specifically design an environment that could provide a living option for persons living with Alzheimer’s disease and related forms of dementia to receive the unique care needed without sacrificing their quality of life,” says Mark McBride, vice president and general manager of Arden Courts. </div><div> <br> </div><div>Since building that first location in 1994, Arden Courts has opened 52 memory care communities located in 11 states. Originally designed for a resident population comprised of persons living in the early to middle stages of dementia, Arden Courts has adapted dementia caregiving techniques for all stages of Alzheimer’s, Parkinson’s disease, Lewy body dementia, frontotemporal degeneration, and early-onset and other forms of dementia.</div><div> <br> </div><div>Arden Courts now has increased its clinical staff and its number and types of programming, as well as changed the food and dining protocol to maximize self-function and independence for residents.</div><h2 class="ms-rteElement-H2">Experience Makes a Difference</h2><div>“Our 25 years of experience caring for over 43,500 residents not only has improved and transformed the way Arden Courts delivers care, but has also evolved how the community is designed in order to better meet the changing needs of the resident population,” says Pauline Coram, director of executive learning for Arden Courts.</div><div> <br> </div><div>“Arden Courts was among the first standalone, purposefully built memory care communities to feature a ‘house’ design that evokes a sense of home,” she says. </div><div> <br> </div><div>Each house has a living room, laundry, kitchen, and dining room. In addition, doors lead to an enclosed, protected outdoor courtyard with garden areas and landscaped walking paths and sitting areas.</div><div> <br> </div><div>The four houses at Arden Courts were designed in a homelike manner. Initially, the houses were planned as four separate living quarters, each with a porch, front door, mailbox, door knocker, foyer, and hallway leading to the common areas and bedrooms, Coram says. </div><div> <br> </div><div>“Arden Courts found its residents enjoyed exploring and purposeful wandering, so the front doors of the houses were left open to the communal areas, and residents could visit the social gathering places, such as the studio, health center, beauty salon, and shop windows, or simply sit on one of the porches for awhile,” she says. “This area also had additional access to the secured outdoor areas with guided <br></div><div>pathways, gardens, and foliage.”</div><div> <br> </div><div>The organization also retrofitted some living rooms in the houses to be able to conduct Namaste Care™ for individuals with advanced dementia. The Namaste program focuses on persons living in the latter stages of dementia with a “loving touch” in an environment that nurtures and stimulates the senses. The environment is carefully created with scents of lavender, soft music, nature scenes, hydration, and nurturing appealing to the senses of smell, touch, taste, hearing, and vision.</div><div> <br> </div><div>The soothing, slower-paced environment can help reduce agitation and anxiety in persons living with dementia by providing respite for the resident. Namaste also creates opportunities to increase hydration, which can help avoid dehydration issues and infections. Arden Courts was the first national assisted living company to embrace Namaste Care in its communities.&#160;</div><h2 class="ms-rteElement-H2">Living Spaces Evolve, Indoors and Out</h2><div>A staple for the design of Arden Courts is the courtyard, which has been beneficial physically and emotionally for the residents. Courtyards are designed with meandering paths, garden areas, and outdoor birdbaths and water features to encourage residents to explore and be involved with nature. It also provides an opportunity to exercise, while keeping residents safe. </div><div> <br> </div><div>Additionally, certain aspects of the outdoor area have been redesigned to serve more as destination opportunities, such as the installation of sitting areas and gazebos, places where families are able to interact and relax with their loved ones. The added elements of design such as gardening areas, bird-feeding stations, and flower beds also encourage the resident to explore, engage, and be involved with nature. </div><div> <br> </div><div>Connecting each of the four houses, Arden Courts features a core area that contains an art studio, porches, community center, health center, and a beauty/barber salon. Originally designed with the resident in mind, it quickly became obvious that this area is a great location where families can gather. “The core design has also evolved by enhancing the porches and common areas into destinations where families would mingle with their loved ones,” says Coram. Renovations included opening up the space between the community center and studio, which was originally designed as two separate rooms. </div><div> <br> </div><div>“Before the two spaces were separated, programming personnel recommended joining the spaces for two reasons&#58; to create a larger common area that allowed for more programming flexibility with family and themed events, and to provide an opportunity for residents to stay together with purposeful environmental movement and structured programming throughout the day,” Coram says.</div><div> <br> </div><div>Practical changes have also been necessary. Replacement finishes and furniture in the houses and the core areas were adjusted to accommodate the ever-changing needs of residents, while maintaining the residential focus of Arden Courts.</div><h2 class="ms-rteElement-H2">Design Based on Visual Cueing </h2><div>Arden Courts management knew from their original research that visual cueing is critical for persons living with dementia. Multiple and varied prompts are offered throughout the residence to help define the spaces and provide residents way-finding success, which encourages a sense of control and purpose. Each house has always featured a different color scheme and theme, as well as memory boxes outside each resident room containing personal photos and mementos to help residents recognize their house and own rooms. A name plate and bedroom room number serve as additional cueing prompts.</div><div> <br> </div><div> <img src="/Monthly-Issue/2019/December/PublishingImages/Arden_park-2.jpg" class="ms-rtePosition-2" alt="" style="margin&#58;5px 15px;" />Even in the common areas, signage offers both pictures and words, including the beauty/barber salon signage that features a picture of a brush and scissors and the art studio’s picture of a paintbrush with a palette. </div><div> <br> </div><div>“As times have changed, so has the color palette at Arden Courts to correspond with current design trends,” says Coram. “In addition to aesthetic updates, more signage was created in common areas to offer simple instructions for residents to increase engagement with their environment, both indoors and outdoors.”</div><div> <br> </div><div>Signs have been added to common areas engaging residents to comment on colors of flowers located in the garden area. Inside, signs encourage residents to help sort linens and ask them to comment on the different scenes within artwork on the walls. “Intended to be self-starters, these guided requests encourage the resident to read and partake in activities. Accomplishing these activities leads to increased engagement and self-esteem,” says Coram. </div><h2 class="ms-rteElement-H2">The Future and Changing Demographics</h2><div>When originally designed in 1994, Arden Courts worked primarily with the spouse of the resident. This has changed. As people with dementia stay home longer and come to Arden Courts reflecting differing dementias and the varying phases of the disease process, adult children now share in the decision process.</div><div> <br> </div><div>“The many health discoveries in care delivery, research, and medications have changed the way we view the world of dementia, and they are influencing the changes of the future,” says McBride.</div><div> <br> </div><div>“Despite all the change, Arden Courts continues to offer families the peace of mind they deserve, knowing their loved ones are being cared for by experienced people and in a proven environment, which is continuously evolving.” </div><div>&#160;</div><div>Brandon Smeltzer, MHA, is director of market development with HCR ManorCare, Assisted Living Division. He can be reached at <a href="mailto&#58;brandon.smeltzer@hcr-manorcare.com">brandon.smeltzer@hcr-manorcare.com</a>.</div> <span style="display&#58;inline-block;"> <span style="display&#58;inline-block;"></span></span></div></div>2019-11-01T04:00:00Z<img alt="" src="/Monthly-Issue/2019/December/PublishingImages/Arden_t.jpg" style="BORDER&#58;0px solid;" />Caregiving;ClinicalBrandon SmeltzerHaving a prominent statesman admit his battle with Alzheimer’s put the discussion of caring for people with memory care into the public eye.
Latest Data Record Progress in Reducing Antipsychotics<div>​</div> New quarterly data from the Centers for Medicare &amp; Medicaid Services (CMS) showed the continuation of a years-long trend of reduced use of antispsychotics in skilled nursing centers. <br><br><div>All 10 reporting regions across the country recorded either steady or declining use from the first quarter of 2018 to the second quarter, with some individual states like Arkansas and California marking more than 40 percent declines since the first quarterly measurements taken in the final three months of 2011, the National Partnership to Improve Dementia Care in Nursing Homes said.</div> <div><br></div> <div>In the latest quarter measured, the second quarter of 2018, the national percentage of residents in nursing care receiving antipsychotics was 14.6 percent, down from 14.8 percent in the first quarter. While the quarter-on-quarter data revealed a steady but declining trend, the effort to reduce antipsychotics in the nursing care setting has staged a dramatic and positive reduction since 2011, the partnership said.</div> <div><br></div> <div>“In 2011 Q4, 23.9 percent of long-stay nursing home residents were receiving an antipsychotic medication; since then there has been a decrease of 38.9 percent to a national prevalence of 14.6 percent in 2018 Q2,” the group said.</div> <div><br></div> <div>David Gifford, MD, senior vice president of quality and regulatory affairs, American Health Care Association (AHCA), applauded the latest data and pointed to attention to the issue by the nursing care profession as the reason for the better results. </div> <div><br></div> <div>“A concerted national effort to reduce the use of antipsychotic medications in nursing homes, particularly among residents with dementia, has been successful,” he said. “Data released today by CMS show that fewer than one in seven nursing home residents are prescribed an antipsychotic medication. In 2011, one in four nursing home residents were receiving these medications.”</div> <div><br></div> <div>Gifford said AHCA “is proud of our members’ efforts to continue to improve quality, person-centered care.”</div> <div><br></div> <div>Echoing that sentiment, the National Partnership said it is on a mission to deliver health care that is person-centered, comprehensive, and interdisciplinary, with a specific focus on protecting residents from being prescribed anti­psychotic medications unless there is a valid, clinical indication and a systematic process to evaluate each individual’s need. </div> <div><br></div> <div>For its part, CMS is tracking the progress of the National Partnership by reviewing publicly reported measures. </div> <div><br></div> <div>The group said the official measurement is the percentage of long-stay nursing facility residents who are receiving an antipsychotic medication, excluding those residents diagnosed with schizophrenia, Huntington’s disease, or Tourette’s syndrome. </div> <div><br></div> <div>A four-quarter average of this measure is posted to the Nursing Home Compare website at <a href="http&#58;//www.medicare.gov/nursinghomecompare" target="_blank">www.medicare.gov/nursing​homecompare/</a>.</div> 2019-02-01T05:00:00Z<img alt="" src="/Monthly-Issue/2019/February/PublishingImages/news1_t.jpg" style="BORDER&#58;0px solid;" />ClinicalPatrick ConnoleNew quarterly data from CMS showed the continuation of a years-long trend of reduced use of antispsychotics in skilled nursing centers.
Medical Cannabis Program Finds Success at New York SNF<div>​A new study in <em>JAMDA</em> details the success a New York skilled nursing facility (SNF) experienced when it implemented a medical cannabis program that is both compliant with federal law and approved by the state.</div> <br><div><em>JAMDA</em> is the official journal of AMDA – The Society for Post-Acute and Long-Term Care Medicine. </div> <br><div>In “Medical Cannabis in the Skilled Nursing Facility&#58; A Novel Approach to Improving Symptom Management and Quality of Life,” the authors who conducted the research at the facility outline how a medical policy and procedure they used resulted in the “safe use and administration of cannabis for residents with a qualifying diagnosis.” </div> <br><div>To meet the requirements of state and federal statutes, the SNF’s policy requires that residents purchase their own cannabis directly from a state-certified dispensary. </div> <br><div>According to the report, after the cannabis program began in 2016, the facility provided educational sessions for residents and distributed a medical cannabis fact sheet that was also made available to family members. </div> <br><div>“To date, 10 residents have participated in the program, and seven have been receiving medical cannabis for over a year,” the report said. The age range for participants runs from 62 to 100. “Of the 10 participants, six qualified for the program due to a chronic pain diagnosis, two due to Parkinson’s disease, and one due to both diagnoses. One resident is participating in the program for a seizure disorder,” the authors said.</div> <br><div>Most residents who use cannabis for pain management said that it has lessened the severity of their chronic pain. This, in turn, has resulted in opioid dosage reductions and an improved sense of well-being.</div> <br><div>“Those individuals receiving cannabis for Parkinson’s reported mild improvement with rigidity complaints.</div> <div><br></div> <div>The patient with seizure disorder has experienced a marked reduction in seizure activity with the cannabis therapy,” the report said.</div> <br><div>In reviewing the program, researchers stressed the potential for the therapeutic benefit associated with medical cannabis and said it should be viewed as an important additional tool among the clinical therapeutic options for symptom management of many common nursing facility complaints.</div> <br>They also noted that “much like every decision in medicine, the clinician must always weigh the risks and benefits of any clinical intervention.”<br>2019-02-01T05:00:00Z<img alt="" src="/Monthly-Issue/2019/February/PublishingImages/news2_t.jpg" style="BORDER&#58;0px solid;" />ClinicalPatrick ConnoleA new study in JAMDA details the success a New York SNF experienced when it implemented a medical cannabis program that is both compliant with federal law and approved by the state.
Arthritis: Listening Leads To Enhanced Outcomes<div>As the U.S. population ages, health providers and administrators in assisted living, skilled nursing, and post-acute care centers will need actionable strategies in place to manage the pain, stiffness, and limitations of activity caused by arthritis. Beyond addressing individual patient needs, the living environments of these patients and their ability to access mobility aids and <a target="_blank" href="/archives/2016_Archives/Pages/0616/Overview-Of-Arthritis-Treatments.aspx">treatments</a> will be a high priority. </div> <h2 class="ms-rteElement-H2">Just The Facts</h2> <div>There are more than 100 different kinds of arthritis, ranging from osteoarthritis (OA) caused by joint damage or wear and tear, to auto­immune forms, such as rheumatoid arthritis (RA), that are often diagnosed in young adults and require lifelong commitment to treatment and management. <br><br></div> <div>The U.S. Centers for Disease Control and Prevention (CDC) and the National Institutes of Health (NIH) estimate that nearly a quarter of all adults, 52.5 million, have self-reported doctor-diagnosed arthritis, and, of those, 22.7 million have arthritis and arthritis-attributable activity limitations.<br><br></div> <div>It’s very common for people living with arthritis to also have multiple comorbidities, such as heart disease, chronic respiratory condition, depression, or diabetes.<br><br></div> <div>In the nursing care or assisted living setting, arthritis is more common in women, but prevalence increases in both women and men as the patient ages.<br><br></div> <div>As patients get older, it’s expected that arthritis will increasingly cause disability and compromise quality of life as patients require more assistance with the tasks of everyday living, such as bathing, dressing, and getting in or out of bed, according to the Population Reference Bureau.<br><br></div> <div>The central question that health care providers need to ask of themselves is how to best understand and address the needs of this growing patient population.</div> <h2 class="ms-rteElement-H2">Listen First, Treat Second</h2> <div>Patient voices need to be heard. Physicians need to elicit information about domains important to them, such as sleep, pain, fatigue, and tolerance to medication. To this end, accumulating Patient Reported Outcomes (PRO) from the individual and the patient community are at the center of arthritis management strategies.<br><br></div> <div>In RA, particularly, assessing and collecting PRO data is integral and a common practice. The NIH Patient Reported Outcomes Measurement Information System has developed generic health measures across a range of symptoms that potentially affect the RA patient that can now be used to assess responsiveness and clinically meaningful cutoffs for treatment and management strategies. Various tools can be reviewed and selected at <a target="_blank" href="http&#58;//www.nihpromis.org/?AspxAutoDetectCookieSupport=1#2">www.nihpromis.org</a>.</div> <h2 class="ms-rteElement-H2">PRO Influence Growing</h2> <div>Widely available and in use, PRO measures provide important perspectives not evident in clinical, lab-based data, and they have the potential of better informing treatment decisions in clinical practice.<br><br></div> <div><img src="/Monthly-Issue/2016/June/PublishingImages/caregiving.gif" class="ms-rteImage-0 ms-rtePosition-1" alt="" style="margin&#58;5px 20px;" />According to a physician survey presented at the American College of Rheumatology 2014 annual meeting, the use of data in rheumatology visits is going up, and rheumatologists seem to prefer measures where patients are delivering the most information.<br><br></div> <div>According to CDC, the most commonly used PRO measures in RA are&#58;</div> <div><ul><li>Health Assessment Questionnaire—Disability Index (HAQ-DI), a 41-item questionnaire (20 items for daily activities, 13 for assistive devices, eight for assistance from others). </li></ul></div> <div><ul><li>Routine Assessment of Patient Index Data 3 (RAPID3). As explained by Orbai and Bingham, RAPID3&#160;is a composite disease activity index consisting of the three PROs included in the ACR Core Set&#58; disability, pain, and patient global assessment of disease activity. Disability is measured using the multidimensional HAQ (MD-HAQ), a 10-item questionnaire that adds two items, “over the last week were you able to walk two miles or three kilometers” and “participate in recreational activities and sports as you would like,” to the eight-item Modified Health Assessment Questionnaire. Notably, Golightly et al. recommend a tiered PRO approach for the management of OA. For example, the WOMAC (Western Ontario and McMaster Universities Arthritis Index) is commonly used to evaluate pain, stiffness, and physical function in knee and hip arthritis.</li></ul></div> <h2 class="ms-rteElement-H2">Treating The Whole Patient</h2> <div>While radiographic results and clinical lab work represent the gold standard for assessing disease activity in clinics, PRO measures are vital to understanding a patient’s experience. Listening to the patients’ responses to treatment is paramount. Medications across different classes are associated with rare, but serious, adverse events, and patients’ anxiety and overall tolerance of a medication affect their ability to maintain and benefit from treatment. Treatment adherence may be further compromised because certain medicines require additional steps, like self-administered injection or infusion in a hospital or infusion center. <br><br></div> <div>Arthritis patients, whether autoimmune or OA, also deal with complex body image issues and may develop anxiety or depression about their condition. Researchers have found that&#58;</div> <div><ul><li>In OA, structural changes impact a patient’s mobility and ability to participate in activities they enjoy, which can result in a feeling of loss.</li></ul></div> <div><ul><li>In OA and RA, patients may feel self-conscious about changes in their body caused by the disease and the treatment, for example, by weight gain caused by steroids or changes in libido.</li></ul></div> <div><ul><li>Relationships are impacted as the disease seemingly takes over other aspects of life, for example, the ability to work, exercise, or participate in other hobbies.</li></ul></div> <div>Health providers can help arthritis patients overcome real and perceived barriers to treatment by encouraging patients to be active partners in their own care. Beyond discussing personal treatment strategies, health providers can educate their patients about CDC-recommended arthritis intervention and physical activity programs (<a target="_blank" href="http&#58;//www.cdc.gov/arthritis/interventions/index.htm">www.cdc.gov/arthritis/interventions/index.htm</a>). Administrators might also review these programs to determine which could be adapted by their center to offer their local patient population access to education, joint-friendly physical activity, and support. The American College of Rheumatology also recommends early intervention for best treatment outcomes.</div> <h2 class="ms-rteElement-H2">External Forces Impact Ability To Provide Quality Care</h2> <div>Unfortunately, the business of medicine impacts patient care, specifically the high cost of specialty medications for the autoimmune arthritis patient. In the assisted living and nursing care center environment, the cost of the medications and a patient’s ability to access them, if they need to be infused elsewhere, may also impact care. Payers who require a specific clinical pathway treatment program also directly inhibit a provider’s freedom to treat a patient independent of all financial restrictions, as well. <br><br></div> <div>On the professional side, rheumatologists very likely are not the primary specialist seen by arthritis patients in the long term care setting. Rather, internists or geriatricians may be the first-line physician, but there is a severe shortage of such specialists in the United States, according to a recent report. It would be worthwhile for institutions serving older adults to encourage health professionals to seek arthritis continued medical education opportunities in order to remain engaged in best practices. <br><br></div> <div>Recall that older adults with arthritis may also have one or more comorbid conditions and be seeing several physicians, which is why a team-based, patient-centered approach to understanding how treatment and management strategies impact individual patients is so important. The team needs to keep the lines of communication open. </div> <h2 class="ms-rteElement-H2">Aging And Arthritis</h2> <div>As the baby boomer population ages, more and more patients in the extended care center setting will be impacted by arthritis. Patient-centered care relies on hearing the patient’s concerns about treatment and its impact on their quality of life in order to adjust treatment accordingly. That’s why physicians and nurses need to be active listeners and engaged conversationalists to motivate arthritis patients to be compliant with treatment and report their response to treatment to impact outcomes, particularly since arthritis is a chronic disease for which there is no cure. For example, some patients might benefit from a biologic, but if they cannot tolerate it or afford it, then a course correction will be needed.<br><br></div> <div><img class="ms-rtePosition-1" alt="Jonathan Krant, MD" src="/Monthly-Issue/2016/June/PublishingImages/JonathanKrant.jpg" style="margin&#58;5px 15px;" />Patients can and should take equal responsibility for complying with treatment recommendations, including taking prescribed medications and incorporating everyday management strategies into their day-to-day routine. Encourage arthritis patients to be equal partners in their care by tracking the symptoms and treatment via <a href="/archives/2016_Archives/Pages/0616/How-Can-Residents-Get-Involved.aspx" target="_blank">ArthritisPower</a> or reaching out for support available locally or online such as via the online support group CreakyJoints. When physicians and patients work together to treat the body and the mind, there are greater opportunities to live well. </div> <div>&#160;</div> <div><em>Jonathan Krant, MD, is medical director of CreakyJoints and section chief of rheumatology at Adirondack Health Systems, Saranac Lake, N.Y.</em></div> 2016-06-01T04:00:00Z<img alt="" src="/Monthly-Issue/2016/June/PublishingImages/caregiving_T.jpg" style="BORDER&#58;0px solid;" />Caregiving;ClinicalJonathan Krant, MDAs the U.S. population ages, health providers and administrators in assisted living, skilled nursing, and post-acute care centers will need actionable strategies in place to manage the pain, stiffness, and limitations of activity caused by arthritis.