Gerotalk : Nursing Home

Frontal-Temporal Dementia

Brian Garavaglia — Wed, 24 Nov 2010 13:32:00 GMT

In the November/December edition of Scientific American-Mind, one of the feature articles discusses an often misdiagnosed illness called Frontal-Temporal Dementia (FTD). Formerly called Pick's Disease, a disease that has been known about for a number of years but not often diagnosed, it is a form of dementia that obliterates the personality of individuals. Although the study of dementia is still underfunded and in its incipient stages, FTD is a neurodegenerative disease that is less funded with a lower quantity of research done than other more prominently known neurodegenerative diseases such as Alzheimer's and Parkinson's disease. Although Alzheimer's disease is still far more common, many middle aged and older adults may actually be misdiagnosed and be manifesting the effects of FTD than Alzheimer's disease.

Understanding the implications of FTD may be important for those that service older adults, especially in long-term care environments. There are a few reasons for this. First, individuals that acquire FTD often are younger, with many patients suffering from this disease first manifesting their symptoms in middle age. Therefore, many individuals that end up in long-term care facilities will potentially need a different level of accommodation of needs than would be provided to an older adult with Alzheimer's disease. Second, this disease targets the personality of the individual, slowing destroying many of the acquired social skills that are so important for human functioning. Therefore, these individuals frequently demonstrate behavioral problems that alter their personality, often to a diametric point of opposition from what their personality on a premorbid level was prior to their illness. Many of these individuals will become combative and demonstrate markedly inappropriate social behavior, features that are not typically a part of the profile of those that suffer from Alzheimer's disease.

FTD strikes different parts of the brain as compared to its more commonly known relative, Alzheimer's disease. With FTD, the destruction of critical brain areas in the frontal region and temporal regions is marked, which differentiates it from Alzheimer's. By insinuating its influence especially in the frontal areas of the brain, especially within the prefrontal cortex, an area that is responsible for appropriate social behavior and personality, the progressive unraveling of the basic core of humanity is slowly eroded. This subsequently creates a different profile than that which is found with Alzheimer's disease, a disease that more prominently targets memory yet does not demonstrate the level of personality degeneration as is found in FTD.

Since FTD creates an incredible debilitating influence on the social behaviors of the person, this in itself can be very important for correct diagnoses and treatment. Although the disease cannot be cured, and it is progressive and ultimately fatal, incorrectly diagnosing the disease can lead to treatment interventions that are better suited for those with Alzheimer's. Since inappropriate social behaviors from even a single individual that suffers from FTD can ultimately be destructive to the milieu of the long-term care environment and other residents that interact with this individual, accurately diagnosing and tailoring a particular treatment intervention that addresses the potentially unwieldy and inappropriate behavior of those that suffer from this terrible disorder is necessary.

Because FTD is often a social disorder, the aberrant social behaviors that gradually surface as the person's personality degenerates, needs to be controlled to maintain a productive and therapeutic milieu within the long-term care facility. Although no form of therapy will reverse the progression of the disorder, sensitive clinical intervention is often needed to appropriately target the symptoms and reduce the severity of their manifestation.

As many who work in long-term care are well aware, it only takes one resident that fails to have proper control over their behavior that can cause a reign of terror and lead to total disruption of the environment. Subsequently, this can also lead to excessive paperwork, reports being made and submitted due to resident altercations, as well as heightened labor costs due to the need for one to one care being rendered for the disruptive resident. One has to wonder how often individuals with FTD, due to being misdiagnosed and given inappropriate treatment, are found in long-term care settings. Furthermore, one has to wonder how much calmer many of these facilities could be if individuals with this disorder were appropriately addressed.

Ultimately it is up to the staff to become more educated on the types of dementias that exist, their distinctive forms and manifestations, and subsequently the appropriate forms of treatment that need to be targeted toward addressing the symptoms of various forms of dementia. Although this may seem a daunting task, it nevertheless is increasingly necessary to provide appropriate therapeutic intervention that will lead to a less stressful environment for residents and workers alike.

Reference

Chen, I. When character crumbles. Scientific American-Mind Nov/Dec 2010;30-37.

Integrating a Person-Environment Perspective

Brian Garavaglia — Thu, 28 Jan 2010 16:32:00 GMT

Nursing facilities have come a long way from the custodial environments that were dominant in many care settings some years ago. With recent regulations averring the need for nursing facilities to be more homelike environments, many nursing facilities today have invested in state of the art environments that are esthetically pleasing. Yet, esthetically pleasing environments that have been modernized and pleasant to the eye still fail to meet the needs of many residents.

Regardless of many of the modern facilities that shine in high gloss, giving the impression that tremendous advancements have been made in the nursing home industry, this might actually be specious. At best it provides a primacy effect that often allows many seeing the facility at first blush to be excited by the new, attractive and picturesque nature of the facility, leaving a handsome marketing impression upon consumers. However, how far have we come in tailoring a proper environment to meet the needs of the residents that we service? The question may not be one that many would like to hear. In reality, tailoring the environment to the needs of the residents still has not been successfully implemented in long-term care.

If at First You Don't Succeed, Regulate!

Many at CMS probably would look in agape at this comment. Many would say with all the rules and regulatory requirements that exist, we must be sufficiently meeting the environmental needs of the residents. Many of the quality of life requirements often dictate the need to meet these requirements. Furthermore, surveyors are mandated to look for, and enforce, these federal requirements. With all this said, how can it be said that most nursing care facilities still fail to have a sound person-centered environment?

With all the regulatory requirements that exist, individuals in long-term care regulatory offices often think that they have covered all areas, including the person-environmental fit, on a blanket level. Regulations in and of themselves do not always bring about sufficient change, however we have come to think that if we have enough regulations, we will eventually be able to cover everything. However, more regulations often bring about enforcement strategies that are often quite diffuse in nature.

Establishing a proper person-environment fit is based on more than just regulatory requirements, but knowledge of older adults, the environment that leads to their optimal level of functioning, and having a level of expertise in both resident care and environmental processes. Therefore, to establish a proper understanding of this area, it cannot be done just by regulatory requirements, but through sensitizing long-term professionals to understand and be vigilant in developing a "best-fit" environment. Inculcating this through establishing a mindset rather than adding a litany of regulatory requirements is the most fruitful way of establishing the "best-fit" environment.

Environmental Press

So what is the "best fit" environment that needs to be considered for nursing care facilities? What continues to exist is a "one size fits all" view of nursing care environments. Regardless of regulatory requirements that assert a need to a more personalized environment to accommodate the needs or residents, nursing home environments have continued to maintain a level of homogeneity as it relates to establishing an environment of "best fit." The reason for this is difficult to understand since in the gerontology literature, consideration of the person-environment perspective has been researched for some time. Although most of the research has been directed toward non-institutional environments, a considerable level of applicability exists.

One theory well-known in the area of gerontology is the "environmental press" theory (Lawton & Nahemow, 1973). This theory looks at two things, a person's personal competence and the environmental press. Personal competence is rated from low to high and it deals with the level of personal ability the older adult has. It encompasses their social, physical, psychological, and intellectual abilities. It is evident that individuals differ considerably on these skill levels and residents within nursing home environments also differ quite dramatically in these areas as well. Environmental press on the other hand deals with the demands, levels of stimulation and challenges that the environment possesses. Environmental press is also rated on a scale from low to high levels. Here again, long-term care environments often maintain a level of homogeneity on the construct of environmental press.

The above model recognizes that individuals have different levels of competencies. This is not just found outside of the nursing home environment, but within the nursing home environment as well. To maintain an optimal level of challenge that continues to stimulate the older adult, the environment has to be adjusted to each individual's level of competency. This model assumes that there is an optimal level of adaptation that needs to exist to nurture the personal competencies of each individual. When an environment holds too view challenges for the individual that has higher levels of personal competencies, negative or maladaptive behaviors are the result. Conversely, on the other extreme, when an individual has too few competencies and exists in an environment that has too many challenges, the result also is negative or maladaptive behaviors. In essence, what is needed is a very close calibration of each resident's competencies and continuous attention being paid to matching each resident's competencies to the correct level of environment stimulation and challenges.

Organizationally here is the problem. It entails much work. Each individual has to be matched to the appropriate type of environmental challenges that will optimize their lives. This in particular would require major changes in the area of social services and recreational therapy, where the true individualizing of treatment plans would have to exist, not like the current titular process that exists, but a more thorough process that, to this point, has not be found in long-term care facilities. This would eliminate many individuals of varying levels of skills sitting through many forms of activities that for some, may provide proper stimulation, but for many others, provide too little or too many challenges for the individual.

All too frequently, as one wanders down the hallways of many nursing care facilities, one is able to witness the homogeneity of environmental press that exists, untailored and unvarying in its ability to properly sensitize the environment to the varying capabilities of the residents that the nursing home services. Although one of the paramount tenets of federal regulations to is prevent a regression in the skills and abilities of residents if possible, this cannot be fully brought to fruition unless the culture of nursing homes realize the need to continue to match the person to the environment. If this continues to not be addressed, many individuals will continue to desocialize, unnecessarily losing many of their skills and abilities due to failing to address the proper person-environment fit for each resident.

Currently, tailoring the environment to the resident is spoken about, addressed loosely, but really not carried out to any significant level. Because of this a continuation of many unnecessary losses in skills and abilities among nursing home residents will continue to exist. Will it change in the future?

One would hope but since the level of work to carry out such a program is great, and since the number of staff may actually have to increase, these become two formidable barriers that may preclude any changes in the near future. Nevertheless, one can still hope that as we eventually move to the next stage of nursing home change, this will be an important cultural focus. As mentioned earlier in the paper, it is questionable whether this could be achieved through continuous additions of more federal and state regulations. Stateways often cannot change folkways, and in this instance change in this area has to be recognized within the mindset of long-term care professionals and inculcated into the customs and habits of the long-term care culture.

Reference

Lawton, M. P., & Nahemow, L. (1973). Ecology and the aging process. In C. Eisdorfer and M. P. Lawton (Eds.), Psychology of Adult Development and Aging. Washington, D. C., American Psychological Association.

The Social and Psychological Process of Dying

Brian Garavaglia — Tue, 17 Nov 2009 20:24:00 GMT

Those who work in long-term care are all too familiar with death. Death is very much a part of life, but those who work in the long-term care environment become quite acquainted with the death and dying process as part of an endemic feature of this type of environment. It is not a pleasant aspect of life, but it is a very real feature of all our lives.

Yet, we often lose sight that death in itself is a complex experience. Not only does it often present an ineffable topic that many do not want to discuss, but when it is discussed, it is often viewed as the cessation of a biological process. However, death and dying face a complexity that is very profound, which extends beyond the cessation of the body's biological functions, and its depth is encountered on the social, psychological, emotional and spiritual levels.

If we examine the process of death and dying, the terms of bereavement, grief and mourning are often mentioned. However, what do these terms mean? In discussing the meaning of these terms, the complexity of the death and dying experience will become evident. Furthermore, far from being a unitary moment at which the body ceases to function, it will also become evident that death and dying is a process that extends beyond the biological realm.

Bereavement Process

What is bereavement? Bereavement signifies a process in which a person(s) have experienced a significant loss. The bereavement process does not necessarily have to involve just death, but for this article this is what will be emphasized. Bereavement involves two other components that will be discussed next, grief and mourning, but before moving to these two essential components, one must understand that bereavement is a process that often starts even before the person has died and extends beyond the death of the person.

The impeding loss of something, or in this case, someone who is cherished, often provides apprehension and evinces a complex set of emotions that the person(s) have to attempt to deal with prior to the death of the person, as well as after the person has passed away. Bereavement, being a process, is more than a process of anticipating and confronting the death of a loved one. It is a process of social, psychological, emotional and spiritual adaptation. As a process of adaptation, it is similar to other periods of adjustment that human beings have to confront and adjust or adapt to, however in this case human beings have to deal with possibly the most stressful of all stressors, the death of a loved one, which is something that is seen quite frequently within long-term care environments.

Furthermore, bereavement as a process cannot be easily quantified in which a person can attach a specific period of time to and say this is where normal bereavement starts and ends. Health care workers have to be aware that they may often have to work in the capacity of ad hoc bereavement counselors. Therefore they need to understand the process of bereavement and the complexity that it entails.

Moreover, those who work within the long-term care environment have to also be aware that they may experience bereavement as well, especially due to their attachment to many of those residents whom they have worked with in their provision of care. Therefore, experiencing multiple deaths of many of those residents that long-term care workers care for can be a serious adaptive challenge that leads to the stressful nature of their work. However, having a better understanding of the process of bereavement can help these workers achieve successful adjustment.

Grief

Grief or grieving is the complex set of emotions that we experience through the loss of someone who is close to us. It is difficult to anticipate the types of emotions that a person will experience when confronted with such a loss. The magnitude of the experience often defies a prediction of how a person will respond based on an intellectual and reasoned calculation.

The existential nature of the experience often transcends our ability to use a calculated, reasoned approach, and since death often brings with it so many questions that are not often amenable to empirical evaluation, the response is often a uniquely personal response. Nevertheless, what we do know is that the person(s) have to allow for an appropriate period of grieving, in which they are allowed to work through these difficult emotions, a process often referred to as grief-work.

Mourning

Mourning refers to the cultural ways of expressing our grief. Long-term care workers need to understand that mourning rituals will often vary based on the culture of the group involved. The culture of those that are involved in the grieving experience often will dictate how those involved in grief-work will experience their grieving.

Not only are their major cultural differences in mourning, but in our own culture we have many subcultures and they also experiences differences in how they grieve. Some may attempt to intellectualize the process, some may spiritualize it, some will engage in highly emotional responses, while some may retreat into their own private phenomenological reality to deal with their mourning. Regardless of the type of mourning, long-term care professionals need to be trained in the diversity they may find in this area and how to respect such diversity.

Hopefully, after reading this, the complexity of the death and dying process has become evident. It holds some important social psychological challenges that are faced not just for those family members of the deceased, but also for long-term care workers who have established relationships with residents that have now come to an end.

Hopefully you'll come away with a better understanding of how death and dying is a complex process, a process through which being more informed will aid their psychological adjustment to this difficult stressor. However, regardless of the knowledge that one gains, it will still continue to pose life's most difficult challenge for all of us.

Mind and Body

Brian Garavaglia — Mon, 02 Nov 2009 21:30:00 GMT

The nursing home, being predominately a medical environment, relies overwhelming on pharmacology for addressing issues of pain management. However, as I have mentioned in previous articles, pain is more than just a biological issue. The subjective nature of the pain response, and the psychology of the individual, too often fails to be adequately considered in pain management.

More can be done to assist with pain management in health care, especially within the nursing home environment. Many non-drug issues can not only enhance the emotional and psychological wellbeing of the nursing home resident, but can also help the person gain a sense of control over their lives, something that pharmacological remedies often fail to provide.

The feeling of control is a necessary part of human existence. Human beings need to feel a sense of control over their lives. Pain, especially when it is chronic in nature, confers feelings of helplessness and a loss of control. Furthermore, although pharmacological intervention helps with pain, many individuals often feel powerless to control their pain and become totally and exclusively reliant on pain medication.

There is nothing wrong with using pain medication to control pain, but for many, pain relief can happen through other means or can also be enhanced through using medication with other nondrug complementary mind-body interventions. Many of these interventions can not only help control pain, but also psychologically empower the resident to feel that they have a sense of control over their lives, something that pain often robs them of.

Even though there is greater acceptance of complementary nondrug treatments for pain, the dearth of such types of intervention within long-term care environments is quite conspicuous. Although there has been a continuing emphasis for proper pain evaluation and management in nursing homes, the overwhelming level of intervention is pharmacological, driven by the extant medical model that continues to dominant within the nursing home environment.

This subsequently raises the question, "Are we truly doing everything that we can do to manage and control pain among nursing home residents?" From my perspective the answer would be no. Although we have become much better at evaluating and managing pain through the use of medications, we still have a number of strategies available that are never employed in the nursing home environment. Furthermore, many of these strategies often hold a greater psychological potential for removing the helplessness and powerlessness that many residents feel about their pain.

So What Are Some of These Complementary Treatments?

Two very common types of mind-body complementary treatments are distraction and meditation. Distraction allows a person to move their attention from the pain that they are feeling. Getting involved in activities of any type, in which the nursing home resident focuses their attention on something other than their pain, can be a productive method of assisting in pain management.

However, all too often nursing home residents fail to obtain the necessary level of activity that focuses their attention outward. Since many older adults with pain live in nursing home settings that fail to provide an optimal level of activity that can distract the resident from their pain, most residents are left focusing on their body, ruminating about the pain that they feel and sensitizing themselves toward noticing other forms of somatic complaints.

Meditation is another means that can help the older adult feel a sense of empowerment and help to reduce the experience of pain. Meditation frequently works by calming the sympathetic nervous system that, when activated, can produce feelings of anxiety as well as possibly lead to the release of neuropeptides such as endorphins that act as the body's natural painkillers and can also enhance the mood of a person. Meditation however is a technique that often relies on practice to achieve effective results. Therefore it can be a harder technique to use among many older adults in nursing care facilities. However, this technique should not be excluded from being used on long-term care residents as part of a pain management regimen.

Imagery and visualization are similar to meditation. However, typically they are easier to employ, especially when using guided imagery. The basic principle of imagery and visualization is to help the resident imagine or visualize, typically with their eyes closed, an image. The image is usually pleasant and nonthreatening and it often confers a feeling of relaxation.

For instance, visualizing walking on a sanding ocean beach, with warm ocean waves splashing against your feet, whiling also seeing a calm, deep blue ocean, can be a very relaxing as well as a pleasant image for many people. The goal is for the visualization to become so vivid that one can feel the grains of sand on your feet, the sun warming your skin, the water splashing your ankles, and even smell the ocean water through your visualization. This further leads to a type of distraction and relieves the person of many of the ruminating features that locks the on their pain experience. It further can also induce those endogenous opioids to be released naturally in the body, providing further natural pain reduction.

Also important with imagery and visualization as well as with meditation is proper breathing. Breathing is very important for achieving a sense of calm and relaxation. Breathing by itself can be used as an effective relaxation technique. Slow rhythmic breathing and even visualizing one's breathing as one inhales and exhales can be one of the best means for total body relaxation as well as helping to address pain management issues. Breathing from the diaphragm and not the chest allows for the person to achieve a greater relaxation response.

Unfortunately, pain often leads to anxiety and anxiety leads to shallow chest breathing. This chain of events further accentuates the anxiety a person feels and the pain that they experience. Frequently, when individuals learn to breathe diaphragmatically, the anxiety-pain cycle is short circuited.

One of the most common responses to pain is to move away from activity. However, as many rheumatologists will tell you, conditions such as arthritis often benefit from exercise. Rheumatic pain conditions are among the most common found in the elderly.

Here again, many nursing care facilities often fail to use an optimal level of exercise to assist with pain management. Often, after many residents come out of physical therapy, they will experience little, if any, regular exercise. However, one of the best ways to address many issues of pain is through regular exercise. In fact, many forms of pain are often the result of a lack of movement and regular exercise, where through disuse we see contracting of muscle groups, tightening of ligaments and tendons, or even injuries that lead to pain after atrophied muscles groups contributed to falls and fractures. Therefore, instituting some form of regular exercise among all nursing home residents can prevent many forms of pain due to stiffening, tightening and contracting of muscles, tendons and ligaments.

How many nursing care facilities use humor or music therapy as part of their pain management approach? Again, there are very few that use these approaches even though they have been found to be effective is assisting with pain management. Music has been found to be very productive in its therapeutic impact, and humor has been found to help assist with pain relief. In fact, Norman Vincent Peale championed the use of humor therapy and credited its use for helping him with his recovery from cancer.

With the growing body of work that is being done in mind-body medicine many hospitals have started to adopt many of the techniques that have been discussed, as well as others such as biofeedback, acupuncture, hypnosis, skin stimulation, yoga, and even spirituality and prayer. However, nursing care facilities are still lagging far behind in this area.

In fact, many of these types of intervention are practically nonexistent in nursing care centers, especially as part of a pain management program. One has to ask why this is so? Pain and pain management is one of the key indicators that is often examined as part of quality found in nursing home care. Yet, pain management continues to frequently exist on a single dimension, with continuous emphasis on the pharmacological management of pain with very little attention given to other mind-body complementary treatments.

Even though the benefits of complementary mind-body approaches hold not only the benefit for improving pain management, but also augmenting the psychological and emotional status of the resident, they still are not frequently found as part of standard nursing home pain management intervention. When an awakening happens among nursing care facilities, realizing the benefits that these complementary approaches hold, we will then be able to say that the nursing home environments are not only addressing the quality of care as it relates to resident pain management, but the quality of life as well.

Click here for an archive of Brian's Gerotalk columns.

Additional Staff Training Must Accompany the Increasing Complexity of Care

Brian Garavaglia — Mon, 22 Jun 2009 13:48:00 GMT

Click here to read Brian's column "Gerotalk" on the ADVANCE for Long-Term Care Management Web site.

According to AHCA, many long-term care organizations are increasing the levels of services they provide:

More than 36 companies are adding rehabilitation suites or units."
16 are planning to add new services such as Alzheimer's care, secured units, and respite rooms.
23 providers will start offering ventilator services.

At first blush this shows the increasingly progressive nature of many long-term care environments. It also demonstrates the need for many companies to attempt to capture higher reimbursement rates that these services potentially hold. However, although these services provide a greater potential for increased revenue as well as heighten the level of professional services offered, they do not come without a cost.

There is a monetary cost based on the capital expenditures that definitely needs to be considered. Equipment such as respirators, special safety devices for Alzheimer's residents, rehabilitation equipment that is purchased, as well as the construction costs all incur hefty capital outlays.

This is during a period of time when state and federal reimbursement is facing potential declines. State governments are looking to make cuts during these difficult economic times in numerous areas that will affect Medicaid reimbursement and the Centers for Medicare and Medicaid are also looking for possible reduction in funding for skilled nursing care centers.

So even as the skilled nursing care environment becomes increasingly competitive, with many companies looking to gain an edge on their competitors by adding more skilled services, the financial cost in doing so will be considerable. As mentioned, in an era where many decisions to reduce reimbursement have been made, many companies have to make sure and be cautious in approaching this type of expansion. A good example of this can be found in the hospital industry, where many hospitals that also are part of a highly competitive environment, have actually put out incredibly great capital outlays, just to find out that they often have poorly calculated payback periods.

However, there are other costs that will need to be examined as well. The staff that needs to carry out many of these services will definitely need to be upgraded as well. For instance, introducing a ventilator unit in a facility will entail hiring an optimal number of respiratory therapists that are on staff for 24 hours, seven day a week. Furthermore, many of the nurses that nursing care facilities rely on are typically licensed practical or vocational nurses. With ventilator units, often you need more nurses that are registered nurses and also specially trained with advanced cardiopulmonary training. Many facilities that decide to add neurological units will in turn need advanced nursing care and training among their nursing staff.

Upgrading training will not only be important for nursing staff, but it will also be necessary among social workers, activity professionals, rehabilitation staff, and in particular among certified nurse assistants. Since most clinical care is provided by certified nurse assistants or CNA's, this group of workers will need greater periods of training. Most certified nurse assistant training is short and generalized, being focused on the traditional nursing care issues that are often found among the frail clientele of nursing care centers, such as providing basic care and assistance with the activities of daily living.

With the provision of more complex clinical services, this group, which is often recipients of a very short period of training, will need to obtain greater levels of specialized training to address many of the more complex clinical needs that they will face. There are many that currently think that certified nurse assistant training is too short as it is. Therefore, with the introduction of specialized Alzheimer's services, ventilator care services, or neurological care services, certified nurse assistants will definitely need greater training to support the needs of the higher complexity of residents they will be working with daily.

With increased training and the level of work that many of the specialized areas will lead to, remunerating workers so that their wages are commensurate with their training and workload with also enhance the cost for a facility. Again, one has to be mindful of the current economic climate in which government subsidization for services are being lessened rather than increased. Furthermore, one has to also be aware of the potential for increased liability, which will definitely increase as resident acuity increases. Therefore, to minimize the risk, proper training and education of workers in these new specialized areas will be mandated, all escalating the cost to the nursing care center and for nursing services that will be provided to residents.

As the culture of nursing homes continues to change, moving toward acceptance of a higher acuity clientele, and concomitantly more complex services, it will lead to not only greater costs for the long-term care industry, but much greater levels of training that many companies may not have totally envisioned. As nursing care centers will address the needs of residents with greater clinical complexities than has been traditionally seen in long-term care, it will become imperative that many of the frontline individuals involved in the provision of clinical care will obtain greater levels of training.

Long-term care companies that envision enhancing the clinical complexity of its nursing care environment, as well as enhancing their revenue base through increasingly specialized services, will need to realize that the core element of these services, its professional staff, will also need to be part of these changes.

The Effects of Pseudopositive Attitudes

Brian Garavaglia — Tue, 02 Jun 2009 16:52:00 GMT

Click here to read Brian's column "Gerotalk" on the ADVANCE for Long-Term Care Management Web site.

All too often care provided to many older adults is offered in a manner that may be viewed as positive. In many long-term care facilities those that provide care are often taught to assist older adults to an extreme. After all, nursing care centers are established for the provision of care, frequently to an elderly or frail clientele that needs considerable assistance with their activities for daily living. In fact, one of the major tenets that individuals often think is essential for quality care is engaging in paternalistic intervention. A common misconception is that there can never be enough care provided. Although many of use are aware that there is numerous long-term care facilities that have failed in providing sound quality care at an optimal level, more care does not always mean better care.

I have to be careful in advancing this argument because some many take this out of context. I am not saying that nursing care facilities do not need high quality care at an optimal level. In fact, throughout the United States, most facilities still need considerably more improvement in the area. However, excessive and paternalistic intervention can be detrimental to the elderly, much like a smothering and overly protective parent who fails to allow their child to develop secure attachments and independency. Furthermore, just like a smothering parent who fails to let their child foster a level of emancipation necessary for optimal growth, a smothering caregiver can thwart the development of the elderly as well.

One of the major regulatory requirements that are found in long-term care deals with quality of care. The quality of care requirement states that,

"Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing, in accordance with the comprehensive assessment and plan of care."

This requirement is the hallmark for providing optimal care with the intent to enhance the wellbeing of the individual and prevent nursing care residents from avoidable regression in their physical, mental and psychosocial wellbeing. Although the word optimal is not found in the regulation, the intent for optimal care is nevertheless implicit in the regulatory requirement. Therefore, one has to understand that optimal care is also the provision of care that fosters a personal independence and avoids feelings of learned helplessness and feelings of inefficacy.

So what does all of this mean? Paramount in our understanding of providing necessary care is that intervention should be tailored to appropriately target the needs of the residents. Just as too little care can be detrimental to the wellbeing of the individual, so can too much care. It has been found that providing excessive intervention can lead to elderly regression. Providing too much assistance actually can lead to the reduction in the nursing home resident's ability to remain independence as well as establishing feelings of learned helplessness, where the resident feels that they fail to have full control over their lives. Furthermore, it has also been found that many individuals who are provided with excessive levels of care actually have lower levels of self-esteem, frequently due to lower levels of self-efficacy.

Not only is excessive physical intervention potentially problematic, but also the all to common verbal paternalism that is found in many nursing care facilities is a problem as well. Two types of verbal paternalism called "overaccommodation" and "baby talk" are frequently found in nursing care facilities. Overaccommodation happens when caretakers will speak louder or even slower, attempting to over accommodate for what are viewed as perceived deficits found among the elderly. Baby talk is a simplistic speech pattern that is often used toward the elderly, similar to that which is found when parents speak to their young children. Both types of speech often fail to take into account the concerns of the elderly and often inculcate into the older adult a feeling of inefficacy. Furthermore, these speech patterns are driven by stereotypes that are held by caregivers, viewing the elderly as being unable to understand what is best for them and therefore in need of paternalistic oversight.

These problems fall under what can be conceived as the caregiver's pseudopositive attitudes toward elderly care. What this means is that although many caregivers actually view this type of excessive intervention or paternalistic speech patterns as positive, in reality they may be doing more harm than good. However, this pseudopositive attitude is not only found among caregivers, but the public in general, and it reflects the endemic ageism that is found among the elderly in our society. Most individuals would fail to see anything wrong with excessive care and paternalistic speech, viewing it as properties of perceived "good care." Moreover, most would agree that given the amount of negative exposure that nursing care centers have received for substandard care, excessive care and intervention should be lauded. However, as was mentioned, extremes on both sides of what is optimum is potentially problematic and can have negative consequences for the quality of care that is rendered to the elderly resident.

Therefore, it is necessary to look at the provision of optimal care. Care that is optimal should not only focus its support to fulfill the needs that elderly cannot provide for themselves, but also nurture the independence and control that currently exists in their lives. Furthermore, caregivers have to be aware of their pseudopositive attitudes toward caring. They have to be aware that what they perceive as being positive may in fact hold negative consequences for the elderly. Although paternalistic attitudes and interventions are often viewed by caregivers and society as positive, being sensitive toward the negative consequences that these behaviors and attitudes may hold, as well as being sensitive to how ageism drives many of the perceived positive attributions of pseudopositive care will enhance quality care in the future.

The Need for Preventative Health Care Practices in Long-Term Care

Brian Garavaglia — Wed, 22 Apr 2009 12:57:00 GMT

Although nursing care facilities have made considerable advancements in the quality of life offered, there still is substantial room for improvement. One of the areas that need to be focused on is creating a culture that nurtures greater activity and promotes health. In many facilities the esthetic improvements that have been made are great, but overall most nursing care facilities are still environments focused on tertiary care. It may sound counterintuitive, but nursing care facilities have to invest more of their resources in preventative care! You may be saying this sounds crazy. Since most individuals found in nursing care facilities often suffer from considerable levels of chronic illnesses, what importance can be gained from offering more preventative care services. Moreover, what other types of preventative services can be offered other than those normally offered, such as the influenza and pneumonia vaccines. Let me briefly address this matter in further detail.

Although there are many areas that I can address, the one that I am going to focus on here, albeit briefly, is the need for increasing the levels of physical and mental activity in the elderly. Even with advancements in the quality of living that we have witnessed in nursing homes in our country, today we still see most individuals in these setting relegated to a static and sedentary existence. Increasing the level of physical activity has tremendous benefits for advancing the health of the elderly, preventing unplanned hospitalizations, maintaining a stable census, reducing nursing home costs, and ultimately enhancing the quality of life of older adults residing in these facilities. Although nursing care facilities typically have physical, occupational and activity programs, many do not receive any physical and occupational therapy after they have exhausted their Medicare benefits and activity therapy is often too infrequent and frequently not targeted at preventative health care. Also, the care staff is often focused on the secondary and tertiary care needs of the residents and often have little training in providing preventative health care services for the elderly.

So what are these preventative services that I am mentioning in this paper. Most of them involve exercise, both physical and mental, which enhance the wellbeing of the older adult's daily functioning. Take for instance the problem of falls in nursing care facilities. This is an epidemic problem in long-term care and one that has continued to plague even the best nursing care facilities. One of the major problems is muscle weakness in the legs. The leg muscles are one of the largest groups of muscles in the human body and they are responsible for providing support and balance. In younger individuals who are active, walking frequently often will keep these muscles toned to prevent injury. However, as we age and engage in more sedentary activity, which is especially found in many nursing care facilities, muscles atrophy. First, greater levels of walking will help strengthen leg muscles, enhance balance, and prevent many unnecessary falls that often have the negative consequence of a fractured femur or hip. Staff has to be trained in encouraging more leg strengthening activity and walking is probably the best exercise to enhance leg strength and general health. However, what about leg squats! You may be saying that this exercise is only used by younger individuals that go to the gym, but this is not true. Think about moving up and done in a chair. Many falls happen when the elderly are getting up or setting done in chairs. One way to enhance leg strength is to encourage elderly, during the breakfast, lunch or dinner setting to sit up and down in a chair a few times. During your post meal cleaning of residents this can be part of nursing intervention.

What about something like arm strength? Older adults in nursing care settings loss a considerable amount of their upper body strength through disuse and sedentary lifestyles. Here again, simple clinical interventions frequently throughout the day, such as having them lift small weights or involving residents in other forms of frequent isometric or isotonic exercise can help strengthen the arms that often support movements that are frequently done in their daily activity.

Providing appropriate mental stimulation is important as well. Frequently many within the nursing home environment think that playing pleasant music or playing bingo is adequate for mental stimulation. However, here again, one has to wonder how much cognitive impairment happens in these types of environments due to not having adequate, challenging stimulation. The key word here is challenging. It is becoming evident that neurogenesis is often incumbent upon challenging the mind and that neurogenesis can happen throughout life. Providing clinical education to have nurses and nurse assistants use reminiscence therapy, pose challenging questions for residents to think about, ponder and answer, and having activities that challenge the cognitive abilities of older adults is critical for proper mental stimulation.

Many of these changes will provide a better quality of life through preventing injuries and illnesses that will happen through a static existence. Our bodies are built for movement and this axiom does not just apply to those who are younger, but it applies to those of all ages. Regardless of age, inactivity leads to weakness, frailty and preventable illnesses. For older adults the acceleration in the reduction of functionality is even more of a problem that has to be guarded against. This is an endemic issue in nursing care facilities. All too often many residents will demonstrate precipitous declines that are quite preventable with the appropriate active intervention. One has to wonder how many falls leading to fractures, slips leading to injury, illnesses due to compromised immune systems, confusion and delirium that is often attributed to age, and reduced ability in movement could be abated, forestalled or even prevented if greater levels of physical and mental activity would become part of the preventative culture of nursing homes. All too frequently many nursing home residents end up with preventable physical and cognitive declines as well as end up being discharged to hospitals from nursing homes, also frequently preventable, due to succumbing to the ill effects of inactivity. Turning our attention to not only treating disease, but also enhancing the health of the community is an important paradigmatic shift that needs to exist in nursing homes across the nation.

What Can Long-Term Care Learn From Enron?

Brian Garavaglia — Mon, 30 Mar 2009 17:01:00 GMT

Today, most people are familiar with the story of Enron. A company that was once looked at as one of the exemplary companies in the United States became a buzzword for corruption and mismanagement. Although the problems that came to eventually destroy Enron were monumental, as mentioned it was once viewed as an exemplary company. What happened at Enron is a lesson for those in business and this lesson is transferrable to the health care sector as well.

Enron as mentioned was once viewed as an exemplary company, which was growing and had sound leadership driving its corporate culture. Under Richard Kinder, the president of the company, the company flourished, and a corporate culture of trust was established. Kinder was viewed as a person that was quite meticulous and held others accountable for their behavior and for their roles in the company. Although strict, he did build a culture of trust that many felt comfortable with. They understood their roles and their expectations and although Kinder drew a line in the sand, establishing his area and what his expectations where for others, many felt that he did so without equivocation.

With the movement of Richard Kinder out of the company and Jeffrey Skilling into the role of Chief Executive, things started to change. Skilling had a Machiavellian temperament for control and an unbridled hubris. Skilling introduced evaluation systems that would be made available to others in the company. He also created an environment that found frequent turnover, fostering hegemony and fear throughout the corporate environment. This left many looking over their shoulder wondering if they would be the next person to be cut from the workforce. The environment that had previously been based on a level of trust and stability was now being replaced by a culture of paranoia based on Skilling's capricious and fear-inducing tactics.

Skilling appeared to feel that introducing fear and fostering a sense of insecurity among the workforce culture was a positive management strategy. As the new culture and management style became set in place at Enron, it was almost inevitable that the organizational features that Skilling put into play would led to the formerly successful company to witness a destabilization of their cultural environment. We now know that it did and the stability and trust that was established by Kinder was destroyed by Skilling within a very short period of time. This for sure in not the only problems that Enron faced, which ultimately led to their demise, but the establishment of a "social Darwinism," with a cutthroat mentality and a lack of care for those in their work culture was significantly related to the downward spiral of this company.

So what type of lesson does this hold for those in long-term care? The lesson is significant. In a health care environment, the importance of trust and collaboration is very important. Prior to Skilling's arrival at Enron there was a feeling of consistency and trust. The company flourished under leadership that encouraged a firm management style that emphasized a collaborative and trusting team approach. People were viewed as resources that needed to be tapped. However, when the culture moved to a dog-eat-dog environment, trust waned, collaboration waned and the workers came to view themselves as disposable cogs that occupied positions on a day-to-day basis. How often do we witness this type of style within long-term care?

Think of how often we feel that we need to manage in secrecy, behind closed doors. For sure, there is need for this type of management. But all too often this type of management comes to dominate the administrator or other manager's styles, providing for a less than transparent environment. Workers come to feel that the culture is veiled in secrecy, with workers becoming paranoid about what is being discussed behind those closed doors. This in turn often erodes feelings of trust that are needed for a sound and efficient work environment. Furthermore, a level of hypocrisy often results where managers state they have an open door policy, yet spend most of their days is clandestine discussions or meetings. Workers pick up on these subtle clues that are provided by those in authority.

As we witnessed with Enron, when trust started to erode and when capricious policies were set, the breakdown of trust as well as the breakdown in the cultural environment as being a stable and predictable place eventually led to the downfall of the company. Workers became anxious about their jobs and they also became weary of working in such a strenuous and draining environment. The social Darwinist philosophy of "survival of the fittest," promoted distrust and continuously made workers view others in askance. Moreover, it ultimately led to workers viewing themselves as disposable commodities without any attention being paid to the person's self-worth. All too frequently we provide little attention to developing an environment or organizational culture based on trust. As those at Enron did, letting their profit and loss be the all determining factor that a worker's worth was measured by, many in long-term care fail to nurture the important factors of trust, stability, and security in the organizational environment.

Health care is a business, and long-term care is no exception. Yet, failing to recognize the importance of our human capital, those people that we depend on to carry out the important duties found in long-term care on a daily basis, is critical. If we fail to build a culture based on trust and respect, and fail to recognize that these needs are paramount for those that we manage, we too could face the same type of problems as an Enron. Therefore, rather than look at a company such as Enron and say it could not happen to us, we need to learn and understand how we can obviate such problems from occurring in the environments that we oversee and manage. History does not need to repeat itself if we can learn the lessons that it teaches us.

The Nursing Home Rating System Revisited

Brian Garavaglia — Mon, 19 Jan 2009 15:55:00 GMT

In my June 30, 2008 blog post "Can Apples and Oranges be Compared?" I wrote about the anticipated implementation of the nursing home rating system that the federal government was going to introduce. Since that time the Centers for Medicare and Medicaid (CMS) have introduced this system, leading to a system of ranking that has produced controversy and outrage among many long-term care professionals. Nursing homes are rated on three major measures: health inspections, nursing home staffing and quality measures. Out of these data CMS produces a ranking system based on stars with a one star ranking being the lowest and a five star ranking being the highest. Each of the three categories is ranked on one to five stars and each nursing home obtains an overall ranking of one to five stars based on these three criteria.

In my previous article I mentioned that you cannot compare apples and oranges and yet, this is apparently what the federal government has attempted to do in their ranking system. When you look at this system I am very puzzled on how many of the overall ranks are finally attained. I see many facilities that appear to average three or four stars yet receive an overall ranking of two or three stars. Conversely, I also see many that appear to average three or four stars in the areas that are examined, yet they come away with an overall ranking of two or three stars.

This is interesting. I then wonder how they weigh the respective areas. Is one of the three areas weighted differently, or are they all weighted the same, which in turn in some way should lead to the overall rankings that are found. However, I am not sure how they come away with these rankings. Looking at this system reminds me of going into a college course with the professor not providing any information on how grading takes place. Intuitively the system looks quite appealing. We like simplistic systems that do not require much thought. When we hear that a hotel or restaurant is five stars, we automatically assume that it is a quality hotel or restaurant. We often fail to question how the rankings were put together. With the nursing home ranking system it appears to be another consumer friendly ranking system, but what does it really mean, and how are the overall star rankings attained.

A major question that I have to raise is how do individuals at the federal level put together an overall ranking of every nursing facility in the United States by looking at 1) health inspection surveys; 2) nursing home staffing; and 3) quality indicator measures. Of the three variables that are examined, nursing home staffing is the only highly objective and highly empirical variable that can be found. You can count and average out this variable with high levels of objectivity. However, the other two variables, health inspection surveys and quality indicator measures have tremendous variability. Health survey inspection teams have great variability. Some teams provide more citations than others.

In addition, states vary considerably in the survey team's provision of health citations, with some states differing quite dramatically in the average number of citations given. Furthermore, the quality indicator reports provide information on how nursing homes rate in certain areas as compared to other nursing homes, but it fails to take acuity into consideration. For instance, a nursing home can rank very high in pressures sores but it may also have a terribly high acuity of clientele as compared to another nursing home that does not admit residents that are as severely ill or infirm. These are just a few of the major problems that can be found in comparing data of this nature.

So how do those that conduct the analysis to provide these rankings create a common benchmark to compare all nursing care facilities equally? With all these confounding factors that can work to influence the results what type of statistical control exists, if any. It would be naïve to assume that the data that is being used is not compromised in any way. However, it appears that those at the government level that are conducting this rating are assuming that no variability or biases in the data exist and take the data at full face validity. This assumption is an important methodological flaw. Furthermore, how do they measure the data? When things are examined in the scientific community the methodology is always made public to assure that others can examine it as well. However, in this case, what types of measuring tools where used and how the measurements lead to this ranking system that in turn achieved the results are for the most part a mystery.

So where does that leave us. It leaves us with an apparent system that is suppose to rank nursing homes objectively. However, what type of objectivity really exists in this measure? Do nursing homes that take a higher level of severe residents get penalized unfairly in this ranking system? Do nursing homes within lower socioeconomic regions that fail to obtain the funding that other nursing care facilities obtain get penalized by this system unfairly? Can those who do the rating, not knowing if the data that they are using is compromised in some way, say that they are doing a totally objective analysis? These are important questions that this new rating system brings up and needs to answer.

Unfortunately, when people here that a rating system has been done, they often view it as a totally reliable system that one must take unquestionable heed of as if it is the final word. But as I have mentioned, this supposed ranking system poses too many questions. It is interesting to note that as I have mentioned in my previous article, it is very difficult, if not impossible, to say that hotels, restaurants, and nursing care facilities can be ranked on the basis of stars. In an industry that deals with people's lives, with a byzantine complexity, it is interesting that we now feel that we can rank this complexity on a system of stars.

Changing Brains

Brian Garavaglia — Wed, 31 Dec 2008 15:46:00 GMT

Are you paying enough attention to your residents' cognitive wellness? Read my latest column on the ADVANCE Web site.

We Still Have A long Way To Go

Brian Garavaglia — Wed, 19 Nov 2008 18:24:00 GMT

With all the changes that nursing homes have undergone during the last 20 years, we still have a considerable way to go. Even with nursing home reform that started slightly over 20 years ago, especially the movement to make the nursing home environment more homelike, the changes that have been introduced still have not eliminated the institutional setting that exists in nursing homes in the United States.

As I enter many nursing homes I have noticed different levels of accommodations. I have noticed nursing homes in communities that have higher socioeconomic levels having more resources and coming closer to many of the goals that the industry has set for the nursing home industry. However, at the other extreme, as I have toured nursing homes in lower socioeconomic level communities, and I have witnessed not only deprivation within the community but also within the nursing homes that are found in these communities. During our election year it sometimes makes me wonder that although we espouse democracy and equality, we still face considerable obstacles in perfecting these major concepts found outside as well as inside long-term care environments.

As I walk through many of these nursing care facilities I often wonder why there is so much inequality in resources and care found in these health care facilities. Sociologically, I have to say it intrigues me that the provision of care that exists in many long-term care facilities is predicated upon the deferential level of resources that is found from one long-term care facility to another. This interests me because it reflects many of the same inequalities that are found in our larger society. However, at the same time that it interests me as a researcher, it also saddens me to think that this type of inequality continues to exist at a time when it should not.

An interesting sidebar that exists is that we attempt to monitor and engage in regulatory oversight using the same standards for all nursing homes. However, how can we apply a universal regulatory standard to all nursing homes when there is such disparate features found among nursing care facilities in the United States. How can we apply the same standards to a long-term care facility that may have abundant levels of financial resources and say that the same standards should be applied and exist among nursing care facilities that have very few resources.

Often we attempt to delude ourselves so we fail to realize the harsh realities that continue to exist in our world. We do so at times to distance ourselves from the true reality and pain that we would come to feel if we were to let ourselves comprehend the complexity and less than humane circumstances we face in daily life. As we continue to deal with the harsh inequalities that are found in society, we have to come to realize that health care facilities, as institutions of society, face the same endemic problem.

Therefore, it should not come to surprise me, or anyone else for that matter, that the disparity that is found in long-term care facilities continue to exist. It should not surprise us that the ideals for a homelike environment are more closely found among certain facilities and far from it in others. Moreover, it should not surprise us that there is differentials in the type of care that is provided among nursing care facilities based on a large differential in the resources that they have available.

What should come to surprise, if not astonish us however, is that we continue to delude ourselves by thinking that many of these differences fail to exist. Furthermore, what should surprise us is that we as a society can employ the same standards for all nursing facilities, deluding ourselves into believing that they are all playing on a level playing field.

Not only do we have to recognize that the inequality of long-term care facilities mimics that found in larger society in general, but we also have to recognize that we cannot continue to employ universal regulatory standards to all nursing care facilities as if they were all equal. If we fail to recognize the great disparity in resources that is found in long-term care, or bury our heads in the sand and say that it is not financial resources that matter, but the personnel that exist in the facility, or say that oversight needs to be equal when that entities that are being overseen are not, we will fail to be able to further enhance our industry. As one can see we still have a long way to go.

Matching Residents to Facility Resources

Brian Garavaglia — Fri, 29 Aug 2008 14:41:00 GMT

It is no surprise to anyone who works in health care that census is always a critical issue for long-term care facilities. This especially is an important focus for many skilled nursing care facilities. As more assisted living facilities are now taking many residents that at one time was the purview of nursing facilities, many nursing facilities today are in competition for residents that are being more difficult to get to help bolster their census numbers. However, because census is such a driving force for nursing facilities, and since many facilities are in competition with many other nursing care facilities for the same residents, a common error often happens: Many facilities attempt to take anyone they can obtain in the referral process. This is a critical error than can come back to haunt the nursing facility.

A few principles need to be adhered to regardless of whether the facility is a for-profit or a not-for-profit facility. First, the facility must remember that they are there to service the resident to the best of their ability. The ethical principle of beneficence has to be always followed here. Although census is a key driving force for the sustenance of the facility, so to is following this important ethical principle of doing no harm to help further the resident and their health status. Taking residents that you cannot support with the skill level of your facility is unethical and inappropriate.

Another major principle that follows from this is that the administrator and other administrative personnel such as the director of nursing, have to know their staff, the knowledge capital that is found in their facility, and the supplies and other supportive factors that will enhance their ability to provide the appropriate level of care. For instance, if a person comes in with a significant level of wound care that is needed as well as a wound vac, and your facility fails to have a sound wound care personnel that can address this issue, your facility can face great liability in this area. When you admit a resident it is implied understanding that you have reviewed the case and feel comfortable with the ability to care for the resident's needs.

Revenue is very important on the business or administrative level in long-term care. However, this often is at variance with sound clinical judgment on taking a resident. Another important principle that needs to exist is never let your bottom line business mentality become so myopic that it clouds your ability to see the larger context of the resident care environment. Many individuals will often try to close the sale of a resident, similar to that of a car sales person. A sales or marketing plan in long-term care is always dealing with human beings and not inanimate widgets.

Making sure the proper people, skills, accoutrements and such are in place all need to be considered. Admissions decisions are too often driven from a purely business point of view-how can we increase our census and with it, our revenue. Administrators and other nursing home administrative personnel who manage on this level often fail to understand that management happens within a larger context, both internal to the facility and external to the facility, and both factors have to be considered in the larger context of appropriate resident to facility fit.

Quality care and resident population stability is driven by making sure that the resident to facility fit is appropriate and conducive for not only the resident, but also the staff. If the resident has care issues that exceed the facilities resources it can be quite problematic. On one level it may actually be so expensive to care for such residents that the bed that they are occupying, nevertheless, is causing the facility to incur a tremendous financial hardship. Furthermore, the clinical complexity of the resident may actually outstrip the knowledge capital and resources in the facility.

However, more often than not, the staff feels the pressure and stresses of not having the appropriate skills to care for residents that are not a proper fit with the skill level of the facility. Take for instance a nursing facility that chooses to admit more residents with psychiatric issues that many nurses, or physicians, may not feel comfortable with in treating since they have not worked with this type of clientele before, or very sparingly. Can nurses and certified nurse assistants be trained to address the unique concerns that some of these residents have? Yes, but remember there is a learning curve. Is it fair to say to improve our census we will take more individuals with behavior problems even though our staff is not comfortably trained with this type of resident. Definitely not! Not only is it not serving the resident well, but having staff work in apprehension because they know their skills are not appropriate to care for these types of residents on a wider scale will often lead to errors and poorer levels of care.

Furthermore, it is a hardship for many residents. They need to feel comfortable with the facility and skill level of those that take care of them. Residents and family members often become cognizant of a facility and staff that lack the skills to appropriately address the resident care issues. Not only does this taint the reputation of the facility, but the legal liability that exists here can be quite costly.

A final principle that needs to be stated is that quality is the driving force for nursing care facilities. Although everyone is looking for a quick fix to their census problems, quality drives census in a number of areas. Understanding your facility's capabilities shapes quality. Tailoring your residents to the fit of your facility shapes quality. These in turn lead to a facility having a strong reputation in the community. The reputation of the facility leads to census development. However, the leaders of the facility have to be realistic about what their capabilities are and where their strengths lie. Exploiting the strengths of the facility will lead to better quality of care, which subsequently leads to a strong reputation and better census growth and stability. Conversely, one has to also understand their weaknesses. All facilities have weaknesses, yet attempting to enhance their census be admitting residents that fall into these areas of weakness is a recipe for disaster.

It is a categorical imperative that nursing care facilities understand the importance of matching residents to the facility's strengths and therefore proper facility fit. If you find yourself saying that "I think we can take care of this resident," this often is a sign of attempting to place a round block in a square peg. If the fit fails to exist and you are not able to knowingly and adequately address the resident's needs, then you need to be conscious of this and let that resident be admitted to a facility that is more able to do so. Just because many skilled nursing home are called ‘skilled," does not mean the same skill level exists in all facilities. Skill is not a constant, but is a variable that has to be closely monitored to provide appropriate and quality resident care. Continuing to view census myopically, viewing just the numbers and failing to understand the larger qualitative context of the resident to facility fit is often a major error that is learned by many the hard way.

Depression and Pseudo-Dementia in the Long-Term Care Population

Brian Garavaglia — Tue, 12 Aug 2008 17:30:00 GMT

What interests me is how often stereotypes dedicate care. In society, individuals still assume older adults should be depressed and that it is part of normal aging. Furthermore, in long-term care this stereotype is even further consolidated. It is often assumed that older adults in long-term care settings, even more so than their same age counterparts in mainstream society, should be depressed, especially due to their presence in a long-term care setting. It becomes an interesting phenomenon, where behaviors that are abnormal, which depression definitely is, now become "normalized" for long-term care residents because of their age and the social context that they live in.

Therefore, it is important to address the issue of depression in long-term care settings. Furthermore, it is important to address how many individuals with depression also get misdiagnosed with dementia, a condition that is called pseudo-dementia. In the upcoming paragraphs I will briefly discuss this problematic issue that is often found in long-term care residents. Moreover, I will discuss how this problem can be addressed by changing our stereotypic views of older adults in long-term care settings.

The elderly in long-term care often face two stereotypic misconceptions: It is normal to be old and depressed and it is normal to be old and cognitively impaired. Therefore when an older adult is found to be depressed or to be impaired on a cognitive level, this behavior has often become "normalized" in long-term care settings. Furthermore, it is often falsely assumed that both conditions are intractable. Yet, there are many instances when cognitive impairment that is being experienced by older adults can be improved and even eliminated. One of these circumstances happens when elderly individuals become depressed. When individuals become depressed they will often have memory issues. When younger adults become depressed and have memory problems it often becomes a symptom of their depression. However, when many older adults become depressed and develop memory issues, especially in long-term care settings, the attribution that is often made is the person has an inevitable level of dementia.

Depression among older adults in long-term care is quite prevalent. Furthermore, it often goes untreated and unnoticed. Frequently, one of the characteristic symptoms of depression is memory impairment. As stated above, when it is manifested by those who are younger it becomes a prominent feature of their depressive illness. However, what about the older adult in the long-term care setting that starts to forget and has other cognitive issues? How can one determine if it is depression or dementia? After all, it is quite commonplace to see dementia among many long-term care older adults?

What even complicates the issue further is that the elderly pose a complicated clinical profile. Especially in the long-term care environment, the elderly often have a myriad of clinical issues that can complicate the diagnosis of depression and make it very difficult to rule out dementia. However, a diagnosis of dementia often becomes an easier grab bag diagnosis. This is influenced by the stereotypes that we hold about the elderly in general, and the elderly in long-term care in particular, which regards this age group as inevitably destined to be demented to varying levels.

Another confounding factor is that depression in many older adults is often atypically manifested. The sad affective presentation and loss of pleasure that is found among many with major depressive disorders can actually be masked in different symptoms such as anxiety, behavioral outbursts and the inability to sleep, which coupled with confusion and memory loss, may be taken as the so-called "sundowners" features of those with dementia. The atypical nature of many depressive disorder in older adults, coupled with prevailing cognitive symptoms, often lead many to overlook depression as being the cause of these memory issues.

Another important issue is that although many long-term care professionals are quite dedicated toward the provision of care, many come to the profession having very little training in this area. Most physicians who work in long-term care were not trained as geriatricians, and often work in long-term care facilities in addition to their other practice. Many nurses have completed much of their training in acute care health care facilities. Also, most social workers, psychologists and psychiatrists have spent most of their training addressing the problems of a more youthful population.

Therefore, many of these professionals are not as uniquely sensitized toward the special needs of the older adult populations in long-term care as those who have special training in this area. Furthermore, many of these professionals bring stereotypes that they have learned about old age and the elderly to the clinical setting, which in turn fails to allow them to see beyond this misconceptions and leads them toward missing a diagnosis of depression.

Many fail to understand the overlapping significance between depression and dementia in the older adults. Therefore it is often assumed that these two disorders exist in exclusivity. However, in reality, depression in older adults can lead to memory disturbances and other cognitive issues that mimic dementia (see diagrams below). Although most forms of dementia cannot be eradicated, pseudo-dementia caused by depression is quite treatable once the underlying depression is lifted.

Therefore, very important in addressing the complicated issue of targeting depression in those elderly is overcoming many of those harmful stereotypes that can make us loss sight of this important underlying problem. Furthermore, hopefully one will come away without automatically assuming that memory issues found to exist among older adults are not just inevitable consequences of their age or of being a resident in a long-term care environment. Hopefully, after reading this brief article, the reader and long-term care professional will come away with an increasingly sensitized eye for understanding the implications of depression among elderly in long-term care and how many memory problems may be corrected with the appropriate diagnosis and treatment of depression.

The Importance of Creating Workplace Spirituality in Long-Term Care Environments

Brian Garavaglia — Mon, 28 Jul 2008 16:16:00 GMT

When someone hears the word spirituality, along with a statement of attempting to introduce it into the workplace, what immediately comes to mind is someone attempting to interject their religious beliefs into the workplace environment. Although this may be one interpretation of workplace spirituality, in this case the theistic nature of such a definition is not the focus. The emphasis that will be part of this discussion will be more secular in nature. Workplace spirituality as a secular rather than a sacred phenomenon is a topic that has recently been spoken about, and even though there is not a great deal of empirical research on this topic, its introduction into a long-term care environment does make some intuitive sense.

Workplace spirituality or organizations that foster such spirituality look to nurture the worker and the needs they bring to the organization. Spiritual organizations that foster individual needs in these areas often garner reciprocal benefits in their own right. At the basis of workplace spirituality is an understanding that people have spiritual needs, needs within the individual that are not necessarily religious, but are based on an inner need for meaning. People need to achieve a sense of meaning. They also have a humanistic need to potentiate themselves as human beings, to develop to their full human potential.

Sense human beings spend a great deal of their lives in work environments, spiritual organizations look to tap the inner resources of individuals. This in turn applies to long-term care environments, which as organizational environments can also become spiritual organizations that tap the often untapped resources of their workers. Since individuals spend a considerable portion of their lives in work environments, nourishing the spiritual needs of individuals, helping them find meaning through their work, is critical in organizations that nurture an organizational spirituality.

Why is this important for long-term care? Many individuals who work in long-term care environments have done so for many years and continue to dedicate a considerable portion of their lives to this type of work and work environment. In fact, many of us, when asked who we are, come to provide answers such as nurse, administrator, caregiver, physical therapist, etc. Generally speaking a key factor in shaping all human beings' identities is the work that they do. Spiritual organizations come to understand this and attempt to help the individual with their inner needs through shaping the organizational culture and environment to target many of their inner, spiritual features. Organizations that help foster this also obtain reciprocal benefits in that workers that are more fulfilled also can work more productively for the organization itself.

This is important for many long-term care facilities. Nursing care facilities that have successfully achieved a spiritual organizational environment not only enhance worker productivity through satisfaction with their work, but also have lower worker turnover and increased levels of trust. This latter quality is extremely important. Successful organizations depend upon successful teamwork. Moreover, for successful teamwork to exist a sense of trust has to exist as well among the team players. In a healthcare environment that is predicated on the care that it provides frail and sick individuals, teamwork not only on the administrative levels, but also on the line levels is extremely important for the success of the organization and for the lives of those that they serve. Therefore, organizational spirituality not only helps foster the needs that individuals have, but also fosters the growth and development of the organization itself.

Another important need that helps foster the growth of the individual in spiritual organizational environments is enhancing their sense of security, but here again the need is reciprocal. Human beings need to feel secure and that includes feelings of security in their work environment. But this need is not just unilateral. Spiritual organizations recognize the importance of their workers and in these types of long-term care environments the benefit of fostering a sense of worker security helps reduce worker-management conflict, turnover, and enhances the care, morale, and the general well-being felt about the environment. Therefore, spiritual organizations do not just provide inner levels of personal growth on a psychological level for the workers, but they also derive the benefits from their worker's personal growth as well.

Key to human development is establishing a sense of purpose and meaning and possibly no other factor in our lives provides use with this sense of purpose than the work that we do. Work in all areas of society has to nurture more than just the base needs for people, but they have to nurture many of those higher level needs that provide us with a sense of meaning and purpose in our lives. Health care workers, especially due to the close interaction with other human beings that they serve, have a special affinity with the customers they service. Their sense or purpose is tied to more than just the production of widgets, but to the nurturance of other human lives.

However, this type of work is also very difficult and emotionally draining at times. Therefore, it is important for long-term care organizations to recognize the purposeful importance that long-term care workers derive from their work, yet spiritual organizations also recognize that they need to help promote their worker's feelings of purpose and help guard against those destructive forces that may lead to burnout or stagnation of human growth.

A long-term care organization that invests in the development of a spiritual organization helps to nurture the fundamental needs that human beings have, which is for personal growth. Workers in all walks of life often identify with the work that they do. It often provides them with a very important piece of their personal identity.

Long-term care workers are no different. Many individuals who work in long-term care often do so for more than a casual passing. Many workers in long-term care have worked in this area for numerous years and identify with the work that they do as a critical part of their identity. It is because of this that long-term care organizations have to pay greater attention to stroking the important spiritual foundation that helps to provide purpose and meaning for them in their daily lives. Furthermore, as was mentioned, the benefits of developing a culture based on a spiritual organization that targets the internal needs of the worker are not unilateral, but reciprocally come to hold benefits for the organization as well.

Organizations that infuse their culture with the beliefs in a spiritual workplace come to find that the benefits they sow ultimately lead to greater team cohesion, less turnover, higher levels of morale, less tension between different work groups, a more enjoyable work environment, and workers that have a greater ethic toward the provision of care. Because of this the investment toward achieving a spiritual organization will ultimately lead to a work environment that is more productive and workers that are more satisfied. Such a win-win situation for the organization and the individual need to be further investigated for possible implementation in many of our long-term care facilities.

Can Apples & Oranges Be Compared?

Brian Garavaglia — Mon, 30 Jun 2008 14:20:00 GMT

The Bush administration advocated the need to rate nursing homes on a similar ranking system to that found in the hotel and restaurant industry. At first blush this seems an intuitively simple and consumer friendly system. Why not have consumers that are looking to place their loved ones in nursing homes have a simple system of one through five stars to help with their search. It appears to be a completely simple and adequate system that can be put in place quickly to assist the public with nursing home quality. However, remember when your algebra teacher said you cannot add apples and oranges? Can the rules be overlooked here? Can nursing homes be ranked similarly to hotels and restaurants? I think this question begs further consideration.

Currently there are a number of tools that are used to rank nursing homes. Probably the best known is the Medicare site that compares nursing homes on the basis of their number and type of citations. The information for this site is compiled from surveys of nursing homes conducted by surveyors. Yet, what is known about the system as it exists is it is far from perfect. In fact, there is a considerable level of subjectivity that is found in the survey process. Surveyors often make judgments about facilities prior to entering the facility. Furthermore, there is considerable variation from one surveyor to another as well as from one survey team as compared to another. In addition, states demonstrate a considerable level of variation among their surveyors. Surveys and the level of stringency found to exist in the survey process from one state to another differ considerably. Therefore, the system as a whole is filled with considerable variability that often is difficult to account for and would dramatically influence a supposed standardized rating system.

Another problem that exists is that hotels and restaurants do not have to rely on Medicare and Medicaid funding, or other third party funding, as do most nursing care facilities. Consumers in these other industries often pay up front with a fee set by the establishments. This allows hotels and restaurants to know their revenues and cash flows up front. However, in the nursing home industry, state and federal entities and third party insurance regulations place great restrictions on what earnings are actually realized. Most nursing homes operate on very small margins and therefore, many fail to have the funds to engage in extensive renovations as well as have the comfort to pay out large amounts of money for extensive and specialized staffing. In fact, there is also considerable statistical variability between nursing homes and the companies that own them, with larger companies often able to incur much greater capital expenditures to achieve the homelike environment that many seek.

So you may ask, what does all of this have to do with ranking nursing homes? As I hope has been illustrated so far, the complexity for a simple rating system is simply, not that simple. Even with hotels and restaurants, this simple five star system is not so simple. First, how many of us have been in supposed five star restaurants and hotels, only to come away quite disappointed in the food or service we encountered. Also, how many of us have come away saying that I wish I would have went instead to the smaller community restaurant or hotel where I get better quality and more food to eat for the money or better and higher quality customer service.

Yet, these hotels and restaurants, which are smaller and less spacious, are often viewed as the red-headed stepchild of the hotel and restaurant industry, especially when compared with their four and five star competitors. The same holds true for the nursing home industry, where the commodious environment of new, modernized, and large-scale facilities hold a primacy effect on those that rate these facilities.

For a true nursing home rating system to work, the rating system must be multifaceted and use many different indices for measurement. If the rating system is only going to be based on facility survey results, a less than true picture of the facilities that are being rated will result. This is not to say survey results should not be used. For sure survey results are an important indicator of the health of a nursing home facility. However, as was mentioned above, it does have its flaws and our current survey system, which has improved over the pre-OBRA years, is still predominately a subjective system. So with the subjective nature of the survey process, coupled with considerable differences found among state survey agencies as it relates to the level of nursing home survey stringency, other factors have to be considered in ranking nursing homes.

One important consideration is the type of people working in the facility and not just the number. Often, facilities are examined for having an adequate number of staff to residents. However, the quality of the staff is also important. What is the level of training, years experience, education, and level of specialization found among nursing home staff. Just as hospitals are viewed as progressive environments, predicated on the quality of their staff, so to should nursing care facilities be examined in the same manner.

In addition, how does acuity play a role in rating nursing homes? For instance, a facility that provides more extensive and intensive services such as bariatric care, dialysis, or ventilator care often have more critical residents with concerns that are more easily targeted during the survey process. However, they also typically have a clinical skill base that is higher as well. This also needs to be factored into the rating system of any nursing facility.

Moreover, is the nursing care facility a learning, teaching and training environment? Is it a place for training physicians, nurses or other long-term care professionals? Is research conducted among individuals within the long-term care environment? Is it a progressive environment that explores new strategies and techniques, especially toward advancing the care of long-term care residents? Many at this point may be saying you have to be kidding; these are nursing homes and not hospitals. However, many long-term care environments are now involved in many of these areas as well.

There can be more that can be targeted in creating a nursing home rating system with greater levels of legitimacy to help assist consumer knowledge in this area. However, just using survey results is not enough and I hope I was able to emphasize the importance in creating a multifaceted rating scale for nursing homes. Furthermore, I hope I was able to demonstrate that creating a rating system for nursing homes, based on and similar to the one used in the hotel and restaurant industry, would be very difficult. These industries are apples and oranges, and as your elementary algebra teacher explained to you early on, apples and oranges cannot be added together.

That being said, a system of rating nursing homes can be created, however in doing so one cannot create a valid system that is overly simplistic and based on a one-dimensional scale of measurement. It must be a system that adequately captures and reflects the complexity of the long-term care environment. Because of the complexity of the systemic nature of long-term care environments, capturing the complexity in creating a valid rating instrument for measuring nursing homes will be more difficult than for rating hotels and restaurants.

For more information: New Rating System in the Works for Nursing Homes