2016 OPTIMA Award: An honored memory

Providing quality care for veterans who have experienced war is challenging enough for most nursing homes. But, what happens when dementia enters the picture, causing dementia-related behaviors to intersect with wartime flashbacks? How can caregivers learn to sort out what the behaviors mean and how best to intervene? Most importantly, how can providers amend their care protocols to serve veterans in the same quality-of-life way they serve other seniors?

The latest trends in dementia care are all about identifying triggers that can help with behavior modification within the realm of person-centered care and without the unnecessary use of medications. The problem for veteran residents is that being in a long-term care facility can be a major trigger in itself. Managing the behaviors of veterans with dementia—and even veterans in general—can require different intervention strategies and a very different levels of staff understanding compared to non-veteran residents.

The winner of the 2016 Long-Term Living OPTIMA Award decided to dig much deeper into such behavioral triggers and ended up learning a lot about how veterans’ minds and emotions work and how caregivers can best interact with them. Some of their findings will challenge everything you thought you knew about senior skilled nursing care.

Ted, an 82-year-old nursing home resident and veteran of the Korean War, is visiting the common room this afternoon, where he likes to watch TV. But suddenly, he hears the beating sound of rotors from oncoming helicopters. The jungle encroaches into his mind, and he’s sure he hears enemy gunfire pinging through the palm leaves. Next, there’s a crashing sound, and Ted is captured by an enemy soldier, who has grabbed him from behind. Flailing and screaming, he feels trapped and surely doomed to die as a prisoner of war.

What really happened: An aide wheeled Ted to the common room for his usual TV program watching, and then decided to turn on the ceiling fans to create a breeze against the Texas summer humidity. Next, a nearby aide dropped a metal dining tray onto the floor. Once Ted began his full-blown crisis episode, the aide approached him from behind and tried to comfort him by hugging him while he sat in his wheelchair.

Not all—or even the majority, some say—of current veterans have post-traumatic stress. But for those that do, they’ve probably lived most of their lives without assistance intervention or treatment. Ted’s care and quality of life could be greatly improved if the nursing home staff learned what his person-specific triggers are, why they happen and how they can be avoided.

The 2016 Long-Term Living OPTIMA Award winner, a senior veteran care chain in Texas, decided to learn more about what causes behavioral triggers and how to help veterans through them, and it’s not a program from the Department of Veterans Affairs (VA).

In 2014, John Berkely, deputy director of the Texas Land Board Veterans Homes (TLBVH), noticed a high rate of reported behaviors across the agency’s eight veteran nursing home sites, including unexplained outbursts and even violence against the staff. Deciding to do something about it, he hired Kathy Johanns, a seasoned assisted living administrator, to dig deeper into why such behaviors were happening and to develop a new training program that could help caregivers learn to handle behavioral situations better. “We realized the staff training needed to be different because these are not traditional nursing home residents,” Berkely says. Soon after Johanns came on board, Sara Rodriguez, RN, joined the team, adding years of skilled nursing experience to the program preparation.

What they’ve learned over the past three years has added an unprecedented chunk of knowledge and insight into senior veteran care and why it needs to be different from traditional skilled nursing care. The result is a new training program in veteran-specific education and care-change management, deliberately made available to any staff member, from the director of nursing to housekeeping.

Of course, the key differential between veteran residents and non-veteran residents is the potential for military-related post-traumatic stress disorder (PTSD). While many veterans return from combat zones without PTSD, some of them do—and many veterans from earlier wars were never diagnosed or treated. Those veterans are already among the current nursing home census, and many more will be coming behind them—who got to see Vietnam, Chechnya, Iraq and Afghanistan up close and personal.

The care teams at TLBVH have chosen to drop the “disorder” label, calling it PTS instead of PTSD. “When something is called a ‘disorder,’ people are less likely to seek a solution,” Johanns explains. Military PTS, she says, is in injury to both the brain and the soul. “It’s an anxiety illness that comes after exposure to a terrifying event or ordeal where a great physical harm was threatened. It affects the brain’s ability to handle stress, sounds, movements and memories.” And, she adds, any military situation is capable of providing “memories you don’t want to remember, yet your mind and your body will not let you forget.”

–| Is your facility ready for an influx of veterans? |–  

Veterans of past wars found their own ways to handle their emotions after returning home. Some came home blessedly free from the effects of PTS. Others would have three beers each night, or smoke to curb the shakes, or drink lots of coffee. But life in a skilled nursing facility (SNF) is a lot more structured than that, so it’s no surprise that a new veteran resident might have a tough time adjusting to the new regimens of life in a skilled nursing facility.

Kathy Johanns (L) and Sara Rodriguez

“When they move into a nursing home, we take away all those coping mechanisms,” Johanns says. “We’ll put them on a smoking schedule, allow them one beer per day and take over their pills. That’s really difficult for veterans that have lived from 1967 to 2016 self-medicating those symptoms, and it’s why we get so many behaviors in our [veteran-based] skilled nursing facilities.”

The recon mission

Once the team dove into the problem, ugly facts surfaced almost immediately. The instances of violence at TLBVH’s sites were far above national averages. Resident behaviors even affected census: “We were discharging people to behavioral health facilities because we didn’t know how to care for them,” Johanns says.

Early program development meant scrutinizing the industry’s definition of behaviors and studying the residents themselves to see what makes something a trigger. Positive changes could be made in quality of life, the team theorized, if staffers could document deep details on what happened right before and right after a behavior.

One of the first challenges was confronting what Berkely calls the elephant in the room—the excessive use of psychotropic medications. “We started looking at the medication use in our homes, and it made us wonder, ‘Is there a PEZ dispenser in here?’” he says ruefully. Finding non-pharmacological interventions for behaviors became priority one, since antipsychotic medications aren’t usually a good solution for veterans with PTS anyway. “Antipsychotics aren’t recommended for PTS,” Rodriguez explains. “You’re not treating a hallucination; it’s an actual memory. All you’re doing with antipsychotics is sedating.”

The biggest challenge was developing a program that could take into account veteran residents who had both PTS and dementia. Once dementia enters the PTS picture, the care protocols can get really muddy, Johanns says. “It’s like the chicken or the egg: Does the dementia cause the flashback, or does the PTS further the dementia?” she says. “We treat the behavior, because if you can learn what the trigger is, it doesn’t matter where it came from.”

The training program

The chosen flagship site for the new program is the Clyde W. Cosper Texas State Veterans Home, in Bonham, Texas, one hour north of Dallas. Most of its 160 beds are skilled nursing care, with 32 beds in a dedicated memory care unit.

The TLBVH’s training program interleaves awareness education for staff, resident military and life-story histories and individualized documentation on every behavior. The program borrows some of its assessment elements from the STAR-VA approach, piloted by the VA in 2014 as a behavior intervention method for veterans with dementia.

L.B. Kirby, a resident at the Bonham site, is the most-decorated veteran in Texas.

At intake, new residents and their family members are interviewed using the Military Service Information Tool developed by Johanns, which contains personalized questions about military service, from the branch and dates of service to specific duties and station locations. The tool documents the veteran’s own responses as well as the family’s input on questions about sleep difficulties, fears of crowds, panic attacks and other stress-related behaviors. The tool serves as a foundation block for caregivers to learn more about each resident, and it gives staff a structured way to capture future information on each person’s known triggers and well as positive and negative military memories.

Once the intake history is captured, all staffers are trained to use every behavioral event as an opportunity to learn more about a resident. Every staffer is trained to use a trigger-response form to record what happened immediately before and after any behavior, including details on where, when and how a behavior began, and what was successful in calming the resident—valuable knowledge that is then added to that resident’s history.

Front-line staff and aides were given a primary role in the program from the start, Rodriguez says. “Your best knowledge will come from the aides, because they’re with the residents all the time and can tell you what triggers them.” Yet, the training is offered to all, with the goal of training every person who works at the facilities in how to capture the crucial data.

–|  Behavioral intervention words that work  |–

Not surprisingly, employee engagement has skyrocketed under the program, as staff feel empowered by the historical “getting to know you” information and realize they are an intrinsic part of the ongoing data-gathering process of discovering the reasons behind the triggers and the successful interventions. In a way, it’s person-centered care at its best, since every staffer is learning exactly what drives a behavior or preference via a “living record” that is updated every time something positive or negative happens to that resident. “He doesn’t like anyone to shut his door,” says one aide, indicating a sleeping resident. “Because he was a POW,” she adds, in a whisper. Later, during an exercise activity in the memory care unit, one resident becomes agitated at being asked to participate. “No!” he yells. “I need to go see what’s going on under this table!” A nearby aide explains: “Don’t worry about him; he always goes ‘on security patrol’ in the afternoons.”

The results

In the 16 months since the program has been fully live, many residents who may have been transferred to behavioral health facilities in the past are now cared for onsite, remaining closer to their families and experiencing fewer outbursts, less violence and far fewer antipsychotic drugs. Employees are fully engaged with the process, and eager to learn more.

The team at TLBVH also has learned a lot about thinking twice—especially when it comes to activities. Planning a fun activity day with the Boy Scouts? Might not be such a good idea for the vets. The Boy Scout uniform resembles the brown-shirted uniform of the Japanese. Fireworks night? Definitely nix that one.

Even the expected event of sundowning can be very different and deeply personal for veterans, says Johanns, who is now program administrator at the TLBVH. As challenging as it can be for caregivers when residents revert back to an earlier decade in their minds, it’s far worse when the place they revert to is Iwo Jima, China Beach or Saigon. “Some like to talk about the war, and others need to be redirected,” she says. “The key for staff is to know who you’re taking care of. It all comes down to that.”

Meanwhile, the VA is watching the program’s outcomes closely, since the TLBVH program could have significant impacts on the future development of care for veterans at other state veteran care sites and across the country. From the outset, TLBVH’s program endeavors have had the strong support of Col. Mathew Elledge, Director of the Texas State Veteran Homes, and Commissioner George P. Bush, head of the Texas Land Board, both of whom are military veterans themselves.

“We’re in constant communication with the Texas VA Commission, but they can’t be everywhere,” Bush says, praising the TLBVH team for initiating the new program ideas. “If this program succeeds, the nation succeeds” in improving its veteran care, he adds.

Johanns and Rodriguez still spend most weeks traveling across the expanse of Texas to train new employees in the program. These days, about 98 percent of all TLBVH employees have received the training. Refresher training is done once a year, and new hires are trained as they arrive. The program will be part of the hiring and onboarding process once the TLBVH’s newest site opens in Houston, a city that has the third-largest population of retired veterans in the nation.

Resident Carl sits in the high-backed armchair he’s chosen in the front lobby of the Bonham home, right by the entrance door window, and adjusts his WWII veteran cap. He’s serious about his self-determined role of guardian of the front door, so he “can see what’s coming,” he says. Four of his resident comrades in arms sit outside under the shaded eaves of the front walkway, all facing the military flag poles. The flags are at half-mast today, in honor of five Dallas police officers killed in the line of duty. The men don’t converse much, but they all are bonded in a specific type of mission—a watcher mission, staying alert and ready.

Related articles:

Behavioral intervention for veterans: Words that work

Saluting service

The lost generations

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.