2014 OPTIMA Award: An engaged journey

What if dementia care was really about keeping residents connected and engaged every day, instead of about mourning the memories that are fading away? This year’s winner of the Long-Term Living OPTIMA Award has taken dementia care programming far beyond reminiscing, brain-games and once-a-day-activities; focusing instead on challenging residents to learn and interact with each other—all day, every day.

Eleven residents, all with diagnoses of varying stages of dementia, sit around a long table, wearing food-handling gloves. The staff leaders (all CNAs) pull in a cart laden with fresh fruits, explaining that the group needs to help prepare the fruit salad for the big Hawaiian luau meal planned for later, as the culmination of “Hawaii Week.” The leaders pass out bananas while asking the residents: “What needs to happen first?” “Peel them,” one resident says. As the peels are set aside, the room fills with the fragrance of bananas, prompting some residents to pipe in with their memories of picnic banana sandwiches or eating banana cream pie. Using the (safely dull) table knives, one resident cuts thick banana chunks for the community bowl, while another resident labors over her micro-thin slices, constantly asking, “Is this OK?” Another resident chooses to eat the whole banana himself. Meanwhile, the leaders talk about the texture and smell of bananas and ask what kinds of desserts bananas can be used for. Monkeys somehow come into the conversation at one point, and that’s OK—because it’s the engagement that matters.

This is just one of the many activities the residents at The Atrium at Drum Hill take part in every day. Drum Hill, North Chelmsford, Mass., is part of the Benchmark Senior Living chain, which encompasses 50 sites across Massachusetts, Connecticut, New Hampshire, Rhode Island, Vermont and Maine. Benchmark’s memory care programming asks residents to stretch their brains all day, every day.

As an all-memory-care community, Drum Hill’s 50-bed residence has served as the advanced site for Benchmark’s dementia care programming, which began in 2012. The goal is to engage residents in meaningful activities that cross the spectrum of the brain’s processes—tapping into the intellectual, physical, social, emotional, spiritual and purposeful community interactive aspects of thought processing and communication.

| Related article: Six dimensions of engagement |

Above all, it’s about resident participation. Instead of insisting that a question must produce a certain answer or a “correct” memory, the caregivers (called associates) focus on simply having a discussion that helps residents join in. They call it “quilting a conversation.” One resident’s distant memory could prompt another resident’s current-day thoughts, which could prompt yet another resident to talk about a particular event he enjoyed back in 1975. But it’s all actual, active, daily conversation—and it’s one of the most difficult things to get residents with dementia to do on a regular basis.

Activity programming, once viewed as a single session or activity in a resident’s day, has become Benchmark’s whole purpose and vision. The logic behind it is that even as dementia progresses, residents can still continue to remain engaged people if they are given a forum that stimulates the social, emotional and intellectual parts of their minds on a constant basis.

“It’s a myth that people with dementia can’t learn new things,” says Joshua Freitas, director of memory care innovation and services. “People think it’s puzzles and games that exercise the brain, but it’s really learning new things.”

One of Benchmark’s resident “engagement boxes” is called “A Day at the Beach.” While interacting with the real-life materials in the box, residents can sink their fingers into a container of sand, rub suntan lotion on their arms and touch seashells while listening to the sounds of waves—a multiplex brain-wave orchestra that accesses multiple parts of the brain’s processes simultaneously. The box is both a process and an avenue, Freitas explains. The activity taps into various parts of the resident’s brain processes, including emotional responses, intellectual thoughts, old memories—and the formation of new ones.

Freitas, CDP, CAADCT, who also is certified by the National Certification Board for Alzheimer Care as an Alzheimer educator (CAEd), refuses to be called the “inventor” of Benchmark’s programming, citing the many progressive thinkers he has encountered during his studies as a music therapist and its dementia care applications. But his energy is contagious; he visits the Drum Hill community every week, and he knows every resident by name. Too many memory care programs ask residents only to recall the past, instead of focusing on what their brains are still capable of learning anew, Freitas says. “I want to push the standard in the industry, because I think it’s set too low.”

Resident engagement can still be activated in many other parts of the brain, says Krystee Ryiz, Benchmark’s corporate director of programs and customer engagement. Indeed, the residents often participate in activities meant to serve others, the key “community purposeful engagement” part of the programming. Drum Hill’s residents have sewn cat beds and made homemade dog biscuits for the local animal shelters, while reading about animals and watching videos about the relationship between people and pets. No one cares if some of the kitty beds turn out too small—it’s the resident participation in the project—the activation of resident brains toward a meaningful task—that matters.

“Benchmark’s program represents our memory care residents engaging in life, and the heart represents the inner person before the disease,” Ryiz says. “The four components of our program are the routine daily calendar, the daily curriculum, the engagement boxes and our signature programs. So it’s all about engaging the residents to do something new every day.”

As Hawaiian music plays from a nearby CD player, the luau fruit-cutting group has moved on to kiwis. Holding the fuzzy green fruit, one resident says, “What, a Keedee?” “No, a KeeWee,” the leader replies. The resident, suspiciously shaking her head, says, “Well, I’ve never heard of that fruit before.” “It grows in New Zealand,” the leader explains. A few seconds later, another resident giggles and whispers to his tablemate, “I thought we were talking about Hawaii!”

Benchmark’s programming concept has its roots in the combination of Benchmark’s existing assisted living mantra and Freitas’ 2012 idea for a memory care reading series, built on topics that might be of interest to people aged 65 to 80. Residents could read a large-print booklet to learn more about Frank Sinatra, a famous painter or Mexican cooking, either on their own or in a group with an associate leading a conversation.

| Related article: Reading series keeps residents with dementia learning |

“We thought we could relate Benchmark’s assisted living program of ‘Live Now, Live Well’ and apply that to memory care in a greater way,” Freitas says. “So we changed it to ‘Live Now, Live Engaged,’ since our memory care residents are coming with us to be engaged.”

The programming concept took off like wildfire. Soon, caregivers and residents’ families had ideas for more booklet topics, which Freitas readily added to the series. As of August, more than 320 booklets fill the reading series portfolio, which, thanks to funding from the Benchmark corporate level, has recently been rolled out across the entire Benchmark chain.

In the past four months, the programming concept has ballooned into the addition of engagement boxes and “journey stations” placed around the Drum Hill residence, each one focused on a specific topic (sports, childcare, music, gardening)—each meant to stimulate interaction with the touchable and readable items displayed. Each station serves as a leader-based lesson point for activities, but the exhibits remain in place for residents to interact with them on their own as well.

Each station serves as a leader-based lesson point for activities, but the exhibits remain in place for residents to interact with them on their own as well. Each station includes items that residents are encouraged to interact with, as well as a list of questions that are designed to trigger the brain to engage in specific processes.

For example, the sports display offers not only memory and current thought-provoking questions but also offers the hands-on texture of a real basketball and the scent of a well-oiled baseball glove, while offering a region-appropriate book about Fenway Park.

Each resident experiences the engagement boxes and journey stations every day, regardless of their cognitive abilities.

Benchmark captures very detailed histories of its memory care residents, which often leads to the creation of new boxes, based on site-specific resident hobbies and interests. Families also get in on the endeavor, as many find the engagement boxes to be a great icebreaker for family-visitation activities and conversation-starters, Freitas says.

Parallel programming is key for all memory care residents, says Allison Zwaschka, CDP, Drum Hill’s program coordinator. The boxes and stations are woven into the fabric of the main topic for each week. This week’s focus on Hawaii includes several videos about the Hawaiian Islands, Hawaiian foods, the cultural significance of grass skirts and colorful leis and, of course, the island music underlying it all.

“When families visit, they’re surprised to see their loved ones interacting,” Zwaschka says. “We hear, ‘My mom’s so isolated she’s never going to get involved in anything’ a lot. But our residents don’t spend much time in their rooms. A lot of our family visits turn into group activities and multigenerational activities.”

The fruit-cutting squad has gotten to the fresh strawberries, a fragrance-bursting memory trigger for the residents. “I remember picking strawberries as a girl,” one woman says. Another resident adds, “We ate most of them before we got home.” The leader uses this comment to involve others, asking, “Who else did this? Did you get in trouble when you got back home with no berries in your bucket?” Then always asking: “Think of another recipe with strawberries in it.”

Each CNA cares for the same six to eight residents daily and is involved in every part of their lives, including nutrition, exercise, activities and health needs. So each CNA has a unique viewpoint—and input—on how the programming is applied. Tweaking the timing of the programs can optimize residents’ abilities to participate, such as placing intellectual activities right after breakfast and sensory activities after lunch, explains Margaret Yeboah, who has been a Drum Hill associate for 13 years. Program placement also plays a key role in warding off “sundowning,” a period of heightened confusion and agitation that can occur late in the day. The Benchmark programming vision has affected the CNAs, too—most of the associates have been with the organization for more than 10 years, a turnover rate far lower than the national average.

Ryiz will be spending the next year gathering deeper data, analyzing how the programming has reached residents and determining how best to expand the new program across the Benchmark chain. Freitas will be busy training new associates in the memory care program, as certified by the AFA. The eventual goal, he says, is to have single Benchmark associate/caregiver trained and certified.

But at Benchmark’s Drum Hill site, associates and families have begun to weigh in with early data already: Residents who participate in the project have been 33 percent more communicative and participatory during just the past six months. Caregiver associates have reported a 78 percent decrease in challenging behaviors among residents after just 30 days of using the program, and families also have agreed (in a separate survey), reporting a 71 percent decrease in such behaviors. More than enough for Benchmark to know the program is on to something big in the future of memory care.

Today, resident Bob chooses to settle down in the chair at Drum Hill’s “sports journey station,” reading through a recent copy of Sports Illustrated. He may be reminiscing about the World Series of 1942 or thinking about today’s Red Sox box scores or connecting his own personal experiences with the magazine’s pictures of a batter at the plate—but it all matters equally to his engaged brain.

Be sure to check out the extensive photo gallery from our visit to one of Benchmark's memory care sites (click on the OPTIMA seal, above), and stay tuned for more coverage of the 2014 OPTIMA winner throughout this week.

Related content:

Six dimensions of engagement
Reading series keeps residents with dementia learning
My trip to relearn memory care [BLOG]
Morning pledge [VIDEO]

Pamela Tabar

Pamela Tabar was editor-in-chief of I Advance Senior Care from 2013-2018. She has worked as a writer and editor for healthcare business media since 1998, including as News Editor of Healthcare Informatics. She has a master’s degree in journalism from Kent State University and a master’s degree in English from the University of York, England.