Creating “Choice” Environments

At Chicago-based Lancaster Health Group, which operates seven nursing home facilities, we started the C.H.O.I.C.E. program (Choosing How Our Individualized Care Evolves) in January 2003 to allay these concerns. Families (typically baby boomers) were generally unhappy about placing their loved ones in nursing homes. The biggest problem we saw had to do with life and the perceived quality of life in a nursing home setting. It is very apparent that when a resident adjusts well to a new environment, the family becomes happier and fewer problems or issues are encountered. We wanted to create an environment that made that adjustment quicker. We wanted our homes to be a pleasant surprise for the resident and an enjoyable place for the family to visit.

Planning for C.H.O.I.C.E.
We explored specialty programs such as the Eden Alternative, Wellspring, and the Pioneer Movement. We planned a two-day trip to the nursing home in Missouri that started the Pioneer Movement to observe what the administration was doing and how it was doing it. We took our administrators, directors of nursing, activity directors, social service directors, dietary manager, some nurses and certified nursing assistants, and the owners to Missouri.

After spending two days in Missouri, we believed we had a starting point from which we could develop a new and different program based on increasing the quality of life in a nursing home. On the way back, we brainstormed about what we wanted to do and in what order. Our goal was to create an environment where we would be proud to have our own parents reside. Putting ourselves in our parents’ place, we started with the things most important to us.

All agreed that fine dining was going to be the first project tackled.

Dining Services
Food was a universal issue. Everyone disliked tray service because the aroma of the food is never present before delivery. We felt the need to smell and see the food before ordering to help increase appetite. With tray service, ever-present condensation on the lids of the plate covers further lessens the appetizing appearance of the food. Also, the concept of choices was significant. Besides the substitution of the day, we wanted two choices of everything: meat, vegetables, and desserts. We also wanted soup and salad at every lunch and dinner. Since we were excited about getting started and the steam tables we ordered would take time to arrive, we began by taking tureens of soup from table to table. One facility used hot plates and began making omelets in the morning. Just these minor changes created a stir among the residents and families, and we could already see the impact this program was going to have on everyone.

Before our steam tables arrived, we created a questionnaire to find out what the residents wanted; e.g., what time they wanted to get up in the morning, what day and time they wanted their bath, and whether they wanted a bath or shower. Once data were compiled, we knew we had to provide more time for dining. A two-hour window would be needed for dining since everyone got up at different times and more people wanted to eat in the main dining room. The first steam table arrived in May 2003, and all our facilities had initiated their fine-dining programs by July. We also began using china plates, glasses, and cloth napkins. The cloth napkins were used as clothing protectors so we could eliminate the word “bib” from our vocabulary.

The residents gave a unanimous “thumbs-up,” and by October we were seeing that food was a large part of the residents’ quality of life. By then:

• We began asking our physicians for more liberal diets-the more liberal the diets, the more the residents enjoy mealtime. Weight loss was no longer the problem it once had been; however, now weight gain needed to be monitored more closely. We observed, from looking over data from 2004 through 2005, that residents either were maintaining their weight or were decreasing the percentage of weight loss during this period.
• We realized just how much food and dining were a part of visiting. We allowed family members one free meal per day (more for special situations) if they came to eat with their loved one. Dining became a much more social event than before. After all, none of us eat in front of visitors without asking them to join us.
• We were able to eliminate seat assignments. After all, those assignments were for the staff’s convenience of getting everyone served at the same time when operating a tray line. Now people sat where they wanted, made new friends, and even began new romantic relationships. This was possibly our biggest surprise! As you might expect, this socialization dramatically increased not only resident satisfaction, but family satisfaction, as well.

Dementia/Alzheimer’s Care
At one home, staff started their fine-dining program in their separate dementia/Alzheimer’s unit. The first thing they noticed was that residents who previously were fed now started feeding themselves. It took three or four revisions on exactly how the dining program worked, but once they had it the dining program for the general population was a snap. And because of the success with dining, they began to really look at other factors related to dementia/Alzheimer’s, such as the type of activities they were doing and making them a “routine.” We also began to realize that many of the behaviors of the dementia/Alzheimer’s resident could be stemming from unaddressed pain, for example. A trial began of decreasing psychotropic medication while starting or increasing pain medication, and we discovered that not only could we significantly decrease psychotropic medication, but also in some instances eliminated it altogether! Today, 11 of our 48 dementia/Alzheimer’s residents are not on any antipsychotic medication whatsoever.

Enhancing Activities
Each of the facilities began to look at different aspects of the ongoing C.H.O.I.C.E. program, including activities. Facilities began to take residents on more outings, even in the dead of winter. As an organization, we determined that a minimum of two outings per month would be mandatory. Some of our homes do as many as five per month. The trips are both fun and educational and have encompassed such places and activities as botanical gardens, Major League Baseball games, the circus, boat tours, the casino, dog races, a Christmas lights tour, the movies, and senior fairs. All members of the activity department are now certified nursing assistants to make outings easier and safer for everyone.

Our in-house activities were upgraded to include more educational programs such as documentary films, horticulture classes, and learning about the facility pets. Bathing the dog, taking the dog for grooming, and feeding the ducks, for example, have become part of the activities program.

The administration at one home gave staff a list of all the former occupations of its residents to recommend tasks that might help the residents feel useful. A former beautician took a corner of the beauty shop to do nails two days a week, and a former security guard was in charge of checking to make sure all the doors were locked at night. Some residents fold laundry, place the silverware in our cloth napkins, help with parties, take other residents to the dining room, and answer the phone for the receptionist when she takes her break. The residents provide extra hands during busy times, and they feel valued and have a sense of purpose.

To make it easier for residents to communicate with families, many of our facilities are now providing cell phones to alert residents. All our homes now have computers, and residents are learning how to e-mail grandchildren and use the Internet.

Elm Brook HealthCare
Connie Sherman, Administrator
Emmie Manalac, Director of Nursing
Nilda Fabular, Assistant Director of Nursing

Fairmont Care Centre
Nenette Angelio, Administrator
Nilda Burgos, Director of Nursing

Norridge HealthCare
Sandy Bernett, Administrator
Cathy Nerja, Director of Nursing

Lake Shore HealthCare
Jim Farlee, Administrator
Dorothy McDonald, Director of Nursing

Oak Brook HealthCare
Joanne Bedrosian, Administrator
Rusty Prades, Director of Nursing

Wauconda HealthCare
Jodi Borck, Administrator

Lancaster Health Group
Cheryl Morris, Vice-President of Operations
Laurence Zung, Executive Director
Christopher Vicere, Vice-President-Finance
Leonor Salvador, Nursing Consultant
Branka Keljalic, MDS Coordinator
Gayle Aquino, MDS Coordinator
Butch Saluta, Nursing Consultant

More than 60% of our resident rooms have now been remodeled to offer nicer furniture, resulting in more personalized space and more secluded sleeping areas. We also created “town squares” in our common areas that are inviting to all residents and increase resident involvement significantly. Once we knocked down walls and created large flowing spaces, the “room” belonged to no one person but to everyone. These spaces include a jukebox with ’40s and ’50s music, ice cream fountain, magazine area, gift shop, bistro, and movie theater. There are game tables, cooking areas, and barbecue grills on the patios for families to use. Washers and dryers are available for residents who want to do their own laundry. No longer do friends and family sit in a resident room to visit; instead they actively enjoy the surroundings, activities, food, and pets.

One aspect of creating a homelike environment was looking at how many times during the night residents were awakened for medications. None of us sets an alarm clock to take medications, and we wanted to give the same respect and consideration to our residents. After addressing this issue with physicians, we were able to decrease the percentage of medications given between the hours of 10 p.m. and 7 a.m., from 75% down to 15%, and on occasion, down to 0%! The better a person sleeps, the better he or she feels and behaves, as we discovered with dementia/Alzheimer’s residents.

Expanding and Improving Hospice
Another area that has been enhanced by one facility and shared with the others for implementation in 2006 is the private hospice room. The first hospice room was created in one home to provide privacy during the dying process. The room is furnished with a couch and rollaway bed for relatives who choose to spend the night. A table and chairs allow families to work on memory boards, photo albums, or just eat or play cards. A CD player is provided with soothing music or special music the resident enjoys, and aromatherapy candles enhance the aesthetics of the entire room. Meals, snacks, coffee, and juice are provided throughout the day. Other residents are encouraged to visit and share with the family members their experiences with the resident.

The entire experience has been overwhelmingly successful. Families are able to grieve in private, and the other residents in the home feel respected at the most private and vulnerable time of their life. Since few residents are able to attend funerals, they are now able to go to this room and pay their respects as a part of their community. One family member was so impressed that she wrote an article about her dying mother for a magazine and mentioned how positive her experience had been with our organization.

Measuring Success
In 2005, our organization was chosen to participate in a project sponsored by the Illinois Foundation for Quality Health Care. Funded by the Centers for Medicare & Medicaid Services, the program demonstrates quality outcomes in hospitals, home health, nursing homes, and physician offices. Only 10% of the 900 nursing homes were selected to participate. We were the only for-profit organization that had all of its homes chosen. Our homes will be studying depression and ways to decrease depression in the nursing home resident. Although we have just begun this process, we are already seeing the excitement and imaginative ideas of the staff emerging. We believe we can not only increase the residents’ quality of life, but help families to feel less guilt over placing their loved one in the nursing home setting.

This is not a program that can be implemented without cost, but it is a program that does not have to cost as much as we spent. The cost, $15.00/per day/per resident, relates to operating cost per day and does not include any capital expenditures. While the cost per day of operating the program is significant, the increase in our Medicare census has made this program cost-effective; we have experienced a significant increase in our Medicare census since starting the C.H.O.I.C.E. program. Although we have enjoyed this significant increase, we have set our sights to achieve a much higher reimbursement rate through a better payer mix. This truly has been our vision: to be the facility of choice in every community we serve-and to do so in a cost-effective manner.

Conclusion
Many aspects of this program are changing the way we do things. For example, reducing medication pass at night meant using fewer staff on the 11 p.m. to 7 a.m. shift but more on 7 a.m. to 3 p.m. shift when there is more activity. There are creative ways to make this work-we shifted some of the paperwork that was done on the day shift to the night shift. Creativity was not just about what needed to be done, but how to do it cost-effectively. As with any new program, the initial start-up cost is higher than what will be the eventual cost. It always takes more people and more time to make a change, but once that change becomes routine the cost levels out. This program cannot be successful without the total commitment and buy-in from the owners and financial executives. We believe we have succeeded so far. But the C.H.O.I.C.E. program is ongoing-it will never be complete.

For more information, contact Cheryl Morris, Vice-President of Operations, Lancaster Health Group, at (773) 509-1400. To send your comments to the editors, contact us.