Improving Dementia Care in Nursing Homes:  Best Care Practices
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Improving Dementia Care in Nursing Homes: Best Care Practices


{music} {music} {Morris Kaplan} Hello. My name is Morris Kaplan. I am an attorney and a licensed nursing home administrator. Since 1987 I have been the Operating Partner of Gwynedd Square Nursing Center, a skilled nursing facility in Lansdale, PA, just outside Philadelphia. I have worked over the years as a presenter and resource for state and federal regulatory agencies and consumer organizations like the Alzheimer’s Association and The National Consumer Voice for Quality Long Term Care. Our goal is to improve care for residents with dementia and to reduce the inappropriate use of antipsychotics. The key to doing this is using individualized, person-centered care practices. People with dementia feel afraid and out of place, uncomfortable and lost. Often they are trying to express something, a need or a feeling or a thought, and they just can’t say or think the right words. They may get frustrated and very upset and ultimately have significant behavioral symptoms. But, when we make them feel comfortable and loved, like they’re in a familiar place and they belong, like they’re at home; When we provide level appropriate activity throughout the day where they can thrive, we make them feel happy and good about themselves. When you do that, you can reduce the incidence of significant behavioral symptoms. And when you reduce significant behavioral symptoms, you can reduce the need for antipsychotic, anti-anxiety, and hypnotic medications. When you reduce the use of these medications, you also help reduce the risk of falls, perhaps the number one threat to elders at home or in nursing homes, as well as reducing the incidence of other serious life threatening conditions. The problem is that in the late 1980s, when most facilities began to remove the variety of physical restraints that were used, they substituted them with chemical restraints like antipsychotic medications. The Office of Inspector General found that 83% of atypical antipsychotic drug claims were for elderly nursing home residents diagnosed with conditions for which the drugs’ use was not approved; they were used for off-label uses. The Inspector General found that 88% of these claims were for residents with dementia. The national average for antipsychotic use in nursing homes in this country is almost 24%. After 27 years of experience in long term care, I believe that 1 in 4 nursing home residents does not need an antipsychotic medication. At Gwynedd Square the average use is 13.8%. These numbers have remained relatively consistent for the past 15 years. I will talk today about how we are able to achieve these results. Let me first tell you a little about Gwynedd Square. Gwynedd Square is not a high private pay facility. It is 78% Medicaid. Medicaid funding is critical. Gwynedd Square has 181 beds, it is for profit, is not part of a chain, and has been family owned and operated since 1980. The basic prerequisites for good care that are responsible for our low rate of antipsychotic use are also the same essential elements that are responsible for our low rates of pressure sores, weight loss, loss of bowel and bladder control and urinary tract infections. First and foremost is leadership. The ownership and management must be active and involved. This includes the board, corporate executives, the administrator and the director of nursing. Quality improvement comes from the top down. Only the leadership can set the goals of an organization, and only the leadership can provide the tools needed to achieve these goals. Next, adequate staffing with consistent assignments. Without enough staff, care is provided in a hurried and impersonal manner, the work is difficult and leads to chronic staff turnover. While CMS does not require these staffing levels, we have found these certified nursing assistant staffing levels to be essential: On the first shift there should be 1 CNA to no more than 8 residents. On the second shift 1 CNA to no more than 9 residents, and on the third shift 1 CNA to no more than 16 residents. Consistent assignment is essential to knowing the resident, providing person-centered care and minimizing behavioral symptoms. Next, communication between the family, the nursing staff, the administrator and the Director of Nursing is vital especially whenever there is a change in condition. Residents with dementia can exhibit agitation, aggression and what can look like psychosis. The key to minimizing these behaviors is finding out what caused the behaviors. Often the resident is trying to tell us something. The staff, together with the family, must play the role of investigator and identify possible causes of the agitation and effective responses. The behavior can be due to a physical illness or condition, the effect of a medication, an infection, pain, the need to toilet or constipation. The resident can strike out, yell or hit as a means of communicating discomfort. Staff must be trained to identify symptoms and to respond appropriately. Behavioral symptoms can also be due to non-medical, non-physical causes. They can be the result of emotional distress or frustration about something that to us appears nonsensical. For example, a resident who constantly searches and frantically hollers “Where is my baby? Where is my baby?” could be someone who was a mother for most of her life and always took care of her family. Now she is confused and lost and trying to find the people she thinks she needs to take care of. Approaches that include references to the person’s life experiences can often work to redirect and calm the resident. In this case, reassuring her that the person she’s looking for is fine and possibly bringing her to a quiet place to look at photos and talk about her experiences as a mother or a favorite holiday recipe. The family and the nursing and activities staff need to communicate about what may work best to calm a resident. The key to non-pharmacologic approaches to behavioral symptoms is providing individualized, person-centered care. That means knowing the individual’s personal preferences, routine, lifetime occupations and roles, recent loss or long ago loss that may be affecting them, their likes and dislikes, and especially, things that help to distract, engage or calm them. Next, providing individualized activity programs that helps to guide residents through their day by keeping them active, engaged and monitored in level-appropriate activities. Non-pharmacologic approaches should be used as the first line in responding to behavioral symptoms, even where medication is used as a part of the treatment plan. Certainly, pharmacologic approaches can play a role. Antipsychotic medication can be appropriate when using the lowest possible dose of medication, for the shortest possible duration, helps to maintain the resident’s highest level of psychosocial & physical well being. Interdisciplinary communication is critical to insure that the resident is functioning at his or her highest level. At Gwynedd Square, we offer five, level-appropriate, activity programs that meet two times a day, one meets all day, plus there is an evening activity. We employ 11 activity staff daily for approximately 181 residents. All activity staff are also trained and work as staff are also trained and work as feeding assistants at meals. In addition, we provide three different programs for lunch and dinner based on the level of assistance provided. A resident can be kept active, engaged and monitored in level-appropriate activity and dining programs for much of the day. The programs at Gwynedd Square are: The Friendship Club – the friendship club is for residents with early stage dementia; The Sunshine Club is for residents with late stage dementia; The Rising Stars Program is for residents who are at high risk of falls, and generally have late stage dementia; Our Korean Elders Program is for our Korean residents and anyone who would like to participate; Finally, is our Alert & Oriented Group, as well as programming for the whole community. Residents are free to nap whenever they want to, and no one is required to participate. I will show clips of a few of our programs. The Friendship Club is for residents with early and middle stage dementia. These residents are generally verbal and ambulatory but are very confused. The aim is socialization through conversation. Everyone is encouraged to participate, and everyone’s answer is always right. {Activity Director}
We’re going to talk about 1920s fashion. During this era fashions changed dramatically (especially for women). Undergarments were flesh colored and one-piece. {Resident}
Oh, I didn’t have that. {Activity Director}
You didn’t have those? {Resident}
No. {Activity Director}
These replaced the griddle. {Resident}
Girdles. {Activity Director}
Girdles. Thank you.
{followed by laughter} {Activity Director}
Angela, what did you used to wear back then? {Angela}
I went to school. {Activity Director}
Yeah, what did you wear to school? {Angela}
I don’t know. What ever my mother gave me. {Activity Director}
Whatever she picked out? That’s what you wore? {Angela}
I didn’t have that much clothes. {Activity Director}
You didn’t have that much clothes? How about you, Edith? What did you used to wear? {Edith}
I didn’t have that much clothes either. {Activity Director}
No? What type of clothes did you used to wear? {Edith}
What my mother made. {Activity Director}
What your mother made? {Activity Director}
Hi Rose. {Rose}
Hi. {Activity Director}
What did you used to do on a hot day like today? {Angela}
Went swimming. {Activity Director}
When you were a younger girl? {Angela}
You had a pool near you, like we did. {Rose}
We used to go swimming. {Activity Director}
You used to go swimming? {Resident}
I didn’t get to go swimming because I lived with my grandmother, and she was poor, but she sprinkled. {Activity Director}
Sprinkling with water, yeah. {Resident}
We got wet and it felt good when you were in the sun. {Activity Director}
What else did you do, Rose? Did you ever play in the park, or play outside? {Rose}
Outside. {Activity Director}
You played outside? {Angela}
We were poor. You think we had money? {Activity Director}
Well, you can still play outside? {Angela}
Nah! {Morris Kaplan} The Sunshine Club is for residents with late stage dementia. They are usually not very verbal and are non-ambulatory. The aim is sensory stimulation using music therapy, special board or art games, aroma therapy and specialized activities. Our residents will typically progress from the Friendship Club to the Sunshine Club as their disease progresses. {music playing with activity directors encouraging residents to join in singing and playing percussion instruments} {music playing with activity directors encouraging residents to join in singing and playing percussion instruments} {music playing with activity directors encouraging residents to join in singing and playing percussion instruments} {music playing with activity directors encouraging residents to join in singing and playing percussion instruments} {music playing with activity directors encouraging residents to join in singing and playing percussion instruments} {music playing with activity directors encouraging residents to join in singing and playing percussion instruments} {Morris Kaplan} The Rising Stars Program is part of our fall prevention program. It goes from 10:15am to 7:45pm. It is in a large room with recliner chairs all around where residents can sit comfortably with their feet up if they wish. Snacks and beverages are brought throughout the day, and activities are held both inside and outside in the adjacent courtyard as you will see here… {Morris Kaplan – off camera}
Do you like it out here Jane? {Jane}
I love it. {Morris Kaplan – off camera}
That’s beautiful. {Jane}
I can go home with a much better feeling now. {Morris Kaplan – off camera}
Absolutely! It’s a nice day out. {Jane}
Yeah. {Morris Kaplan – off camera}
Oh look at Jenny. Jenny, you’re doing great! {Morris Kaplan} In addition, we have our Korean Elders Program for our Korean residents. It includes everything from Korean satellite TV, to Korean cooking, Korean crafts and board games, Korean culture and especially, Korean worship and church programs. We also have a program for our alert and oriented residents that includes a variety of social, interesting and fun activities geared toward high functioning residents. All of these programs meet twice a day, plus there is an evening activity. In addition, 2-3 times each week there is a community-wide activity for everyone. The concept of managing and guiding residents with dementia in level-appropriate activities throughout the day applies to dining as well. At Gwynedd Square, we have three different dining programs based on the level of assistance provided. Our Main Dining Room is primarily for people who eat independently. The Lunch Bunch & Supper Club Program is for people with early and middle stage dementia. We try to enable residents with memory impairment to feed themselves with the help of cueing, directing, encouragement and gentle instruction. The Lakeside Dining Program is for people with late stage dementia or strokes. These residents require total feeding assistance. As with the activity programs, residents often progress over time from one dining program to the next as their needs increase. Most importantly, the Lunch Bunch & Supper Club and the Lakeside Dining Program are set to the pace of the residents and often last as long as 90 minutes. In Closing: A resident can be kept active, engaged and monitored by using person-centered care approaches and individualized programming though out the day. Behavioral symptoms can be observed, anticipated, redirected and minimized, and the use of antipsychotic medications (for those individuals who have no clinical indication for the use of an antipsychotic medication) can be reduced or avoided. Thank you. {music} {music} {music}

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6 thoughts on “Improving Dementia Care in Nursing Homes: Best Care Practices

  1. Ms. Bernard,
    I was curious about your post. I am a professor, researcher and clinician in the School of Nursing at UNC-Charlotte. I'd love to hear more about what you think could be helpful information from this CMS video. My email address is [email protected] I work with the elderly in improving care outcomes and would love to know what you think would improve care.~ warmly, Dr. Burfield

  2. It's so important to us that information like this is available. Our mission is exactly that, to make this type of information easily available, specifically for seniors and caregivers. If you support our cause please take a second to subscribe, it will help us share our information and help more people!

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