January 20, 2011 | by I Advance Senior Care

Homeward bound

For many people, one of the joys of retiring from work is not having to wake up on someone else’s schedule. That benefit shouldn’t end just because someone needs nursing care. About four years ago, Garden Spot Village, a non-profit continuing care retirement community in New Holland, Pennsylvania, successfully moved to a person-centered, household model of skilled care. It was only natural that we would transition to that model at Maple Farm, a skilled nursing community in Akron, Pennsylvania, that we acquired in September 2009. We are in the process of replicating the culture change.
We started working toward person-centered care at Maple Farm as soon as we took responsibility for the community. We started by giving team members greater freedom to resolve issues for themselves. Most often, they know what’s best because they work directly with the residents. We adopted the concept of learning circles to solicit staff comments and feedback, particularly in relation to decision making and problem solving. This technique allows us to get input from anyone with a stake in the topic at hand. The learning circles, which meet as needed, and the equivalent community circles with residents, ultimately give each household a unique character, shaped by the individuality of its members.
Operationally, our initial changes were simple, yet profound. For example, in the main dining room, cafeteria-style trays and clothing protectors stopped being standard operating procedure. Instead, we put place settings on the tables, started taking residents’ meal orders, and began offering linen napkins—or clothing protectors, if residents prefer. More recently we moved to an open breakfast, served from about 7 a.m. until about 10:30 a.m. We set up a steam table with waffles, eggs made to order, or a breakfast entrée of the day. Eventually, the open kitchen will be staffed 12 hours a day, with some menu items always available. At Garden Spot Village, household residents can always get a sandwich or a fruit plate, and residents and their families have “rights to the refrigerator” 24/7.

Open country kitchens in the households at Garden Spot Village help create an environment similar to residents’ previous homes. Similar plans are in place at Maple Farm, which has already instituted an open breakfast schedule.
Along with open meals, the Maple Farm nursing staff is transitioning toward medications on waking, rather than on our schedule. We have already implemented the change with insulin, which insulin-dependent residents receive before breakfast. As the staff gains experience, it should be easy to transition to this approach for all medications. A slight modification to our existing tracking sheet will enable nurses to document time of administration of first dose, first dose plus four, etc.
Over time, staff roles will evolve. Some household models call for a “universal worker—a certified nursing assistant (CNA) who acts as a housekeeper, prepares and serves meals, and runs activities in addition to nursing duties. We are adopting the hybrid model that Garden Spot Village follows, under which CNAs help with serving meals and household activities, etc., but these tasks are not their primary responsibility. Clinical team members will report to the director of nursing. Our homemakers will be primarily responsible for housecleaning and preparing and serving meals, although they will also be involved in visiting with residents and participating in household activities. They will report to a household coordinator, who might be a social worker, an activity director, or another homemaker. Still, the roles, duties, and reporting are not strictly siloed. For example, if a household coordinator notices that a CNA has some available time, the coordinator might suggest that a CNA facilitate an activity. The ultimate goal is to get everyone to pitch in and help do whatever needs to be done. This fluidity also enables team members to get to know residents’ likes and interests well enough to keep residents actively engaged in household life.
Facilitating change
Change—even change for the better—can be challenging. Many of our team members have worked here for five years, 10 years, or longer and were comfortable with the traditional model. We find that open lines of communication between management, staff, and residents help. Out of a team of about 100, including per diem workers, we established a committee of about 15 individuals to help lead the changes. It meets at least monthly. At least one CNA from each shift, two LPNs (a floater and a day shift nurse), a nursing supervisor, the director of nursing, a representative from environmental services, a dining services assistant and the manager of dining services, an activities director, and a social worker are included on the committee. To get a wide range of perspectives and broad buy-in, we made sure to include individuals who may have had reservations in addition to those who were ready to champion the concept. Members of this core team work directly with their coworkers to explain and implement changes.
Martha Areiza, a nursing assistant who is now a member of the advisory committee that is helping drive the transition, initially had doubts about the concept—until she saw the changes play out.
“Change can be scary. It helps that we are taking it slowly and not making all the changes tomorrow,” Areiza says. When they did start to implement changes, “we saw a huge difference. A lot of residents feel better. After the first day, everybody was happier about it.”

With shared duties and a person-centered focus, the household model supports a relaxed atmosphere where staff has more time for social interaction with household residents.
“As the changes progress and they see the good effects, people are starting to get really excited about it,” agrees Pam Capliner, LPN, a charge nurse who is also a member of the advisory committee. “It’s so rewarding to see the impact on the residents as we create a more homelike environment. It works around them, rather than around us.”
We also include an update in the monthly employee newsletter and post educational materials in the break room to promote new concepts. All staff members help explain and demonstrate changes to residents, talking to them one on one about the benefits. We have also sent team members for outside training by professional organizations, including ActionPact, the Pioneer Network, and the Pennsylvania Culture Change Coalition.
We were also fortunate that Garden Spot Village has had the household model in place and running smoothly for the last four years. This gave us an opportunity to have most staff members “shadow” their counterparts in one of the Garden Spot Village households. This has been a tremendous help in a couple of ways. First, it gives the individual a clear, concrete picture of what it is like to work in a household. She or he is able to get a feel for the process, ask specific questions, and get answers from someone who has been doing the job. Perhaps more important, he or she can get a feel for the more relaxed atmosphere of a household, where there is no rush to distribute meal trays on a schedule and residents are less grumpy in the morning because they’ve been able to awaken naturally. So far, everyone who has shadowed a counterpart at Garden Spot Village has come back to Maple Farm with renewed enthusiasm for the changes being made.
As we move forward with the process of creating households, the results of the changes we have already made seem to be our strongest selling point. If one resident isn’t ready to wake up yet, a CNA can spend more time with another. All staff members have more opportunities to spend quality time with residents. Members of the dining services staff look forward to the opportunity to assist residents with their meals, which they will be able to do after they have completed a dining assistance class. The residents seem to be adjusting well to the change, too. Although some still prefer that a tray be brought to their room, more and more are coming down to the dining room for breakfast. Some are eating more or are more willing to try new foods. Once they realize they have choices, it begins to click for them.
Building the house
The next major step at Maple Farm will be renovating the building, creating two households over a period of about 15 months. Each will have a residential-style front door, an open country kitchen with a breakfast bar, a living room, parlors, private bedrooms, and other features that will make the environment more homelike. Although what we have achieved to date at Maple Farm proves that it is possible to provide person-centered care regardless of floor plan, without major building renovations, the team at Garden Spot Village has found that the homelike environment serves as a strong reminder of the driving principles behind the household model and makes it less likely that we will slip back into old behaviors and processes. As it has at Garden Spot Village, we do anticipate that the new physical environment will continue to inspire changes. The transition to the household model is never truly complete, because it continues to evolve. As issues arise, we ask ourselves: “How would we do it at home, and how can we reproduce that here?”
Lora Gomboc is the Executive Director of Maple Farm in Akron, Pennsylvania. She is a recent graduate of Leadership AAHSA, a program created by the American Association of Homes and Services for the Aging to develop transformation leaders in the field of aging. She can be reached at LGomboc@maplefarm.org.

Becky Weber is Director of Health Care Services at Garden Spot Village in New Holland, Pennsylvania. She is a member of the team that led the original culture change initiative there in 2006. She is a member of the board of the Pennsylvania Culture Change Coalition. Contact her at Weber@gardenspotvillage.org.

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