Building a Partnership in Senior Living

Liz Jensen, RN MSN Ray Miller, MSOSH

Managing Aging In Place: Preparing Staff to Respond to Rising Acuity

1 Disclaimer

The materials, comments and other information contained in this presentation are intended to provide general information but not advice about certain regulations and initiatives. This information is not and not intended as legal or other advice and each situation may vary depending on the particular facts and circumstances. You should not act upon this information without first consulting with qualified legal counsel.

Thank you. 2 Objectives

At the conclusion of this session, the participant will be able to:

1. Discuss the more common changes that occur with aging, associated risks involved with those changes and when the need for additional levels of care and service may be required.

2.Describe strategies for pro-actively evaluating staff readiness to respond to the changing service & care needs for residents as they age in place

3. Explore effective educational & management strategies to prepare staff to respond to changing service & care needs

3 Agenda Colored Paper for “Ah-ha” moments

1. Introduction

2. Demographics

3. Care Needs and Risks

4. Defining a Framework

5. Implementing Processes

6. Successful Sustainability

4 Agenda

1. Introduction

2. Demographics

3. Care Needs and Risks

4. Defining a Framework

5. Implementing Processes

6. Successful Sustainability

5 Preventative Supportive LT Care Acute

6 What Has Changed In YOUR AL World?

Self-reporting requirements Background and fingerprint check

1,000,000+ AL Residents Assisted Living vs. Hospice

Staff Training Electronic payment

WhatYou Stillhasn’t Care changed? About Culture PEOPLE. Media-Relations

Acuity Medications Threat of litigation Regulations – in 2012, aprx. 120,000 state AL-related bills Family and Resident Expectations osha submitted nation-wide

7 Agenda

1. Introduction

2. Demographics

3. Care Needs and Risks

4. Defining a Framework

5. Implementing Processes

6. Successful Sustainability

8 Who Are We Serving?

. 70% are female

. More than half are 85 or older, just 10% are younger than 65

. 74% receive assistance with ADLs, 37% have 3 or more ADL limitations

. 42% have Alzheimer’s or dementia

Assisted Living & Residential Care in the United States in 2010; accessed from www.ahcancal.org 2/1/2013 9 Quick Facts: Aides, Orderlies, and Attendants $24,010 per year 2010 Median Pay $11.54 per hour

Entry-Level Education Postsecondary non-degree award

Work Experience in a Related Occupation None

On-the-job Training None

Number of Jobs, 2010 1,505,300

Job Outlook, 2010-20 20% (Faster than average)

Employment Change, 2010-20 302,000

Bureau of Labor Statistics, U.S. Department of Labor, Occupational Outlook Handbook, 2012-13 Edition, Nursing Aides, Orderlies, and Attendants, on the Internet at http://www.bls.gov/ooh/healthcare/nursing- assistants.htm (visited February 14, 2013). http://www.bls.gov/ooh/healthcare/nursing-assistants.htm#tab-1 10 Who is Serving Our Residents?

NCAL 2011 Assisted Living Staff Vacancy, Retention, and Turnover Survey, October 2012 11 Nursing Staff

NCAL 2011 Assisted Living Staff Vacancy, Retention, and Turnover Survey, October 2012 12 Turnover of Nursing Staff

NCAL 2011 Assisted Living Staff Vacancy, Retention, and Turnover Survey, October 2012 13 Top Deficiencies % States Reporting Common Deficiencies

Deficiency % States in 2011 % States in 2012 Medication Administration 83% 86% Resident Admission Requirements 71% 76% Ongoing Resident Assessment 54% 73% Maintenance Building Code 51% 57% Staff Training 54% 51% Resident Care 20% 41% Emergency Preparedness 22% 35% Food Service 29% 35% Staff Health 27% 33% Administrative Record Keeping 34% 31%

ALFA 2012, Top 10 Deficiencies in Assisted Living 14 Top Deficiencies % States Reporting Common Deficiencies

ALFA 2012, Top 10 Deficiencies in Assisted Living 15 SIDEBAR: A new word – “Heyoka” (Heyókȟa)*

. Heyókȟa refers to the Lakota concept of a contrarian … . Exhibits extreme behaviors . Teacher … Mirror . WHY? Force you to examine your doubts, fears, (habits, processes, approaches) … and weaknesses

An Heyókȟa is also called a Sacred Clown

From Wikipedia, the free encyclopedia 16 Agenda

1. Introduction

2. Demographics

3. Care Needs and Risks

4. Defining a Framework

5. Implementing Processes

6. Successful Sustainability

17 Age Related Health Changes Can Increase Risk for:

. Arthritis . Vision problems . Hypertension . Incontinence . Heart disease . Hearing loss . Diabetes . Loss of muscle tone, flexibility and mobility . Osteoporosis . Decreased strength . Memory loss . Alzheimer’s & other dementia related disorders

Miller, C., (2012) Nursing for Wellness in Older Adults, Sixth Ed. Wolters Kluwer; Lippincott Williams & Wilkins. 18 Common Care Needs

Activity / Care Need % Residents needing assistance Bathing 64% Dressing 39% Toileting 26% Transferring 19% Eating 12% Help with meal preparation 87% Assistance with medications 81%

Data compiled from “2009 Overview of Assisted Living”. Collaborative report of American Association of Homes and Services for the Aging, Assisted Living Federation of America, American Seniors Housing Association, National Center for Assisted Living and the National Investment Center for the Seniors Housing & Care Industry. 19 Mental Health Considerations

. Study compared residents residing in a Dementia-specific AL (DSAL) vs. Traditional AL (TAL) . Similar demographics, frequency of anxiety & depression symptoms . Lack of documented dementia diagnosis to support level of impairment in both . DSAL staff were provided more specific dementia care training

Kang, H., Smith, M., Buckwalter, K.C., Ellingrod, V., & Schultz, S.K. (2010). Anxiety, depression and cognitive impairment in dementia-specific and traditional assisted living. Journal of Gerontological Nursing, 36(1), 18-30. Teri, L., McKenzie, G.L., LaFazia, D., Farran, C.J.,Beck, C., Huda, P., Pike, KC.(2009). Improving dementia care in assisted living residences: Addressing staff reactions to training. Geriatric Nursing, 30,153-163.

20 Agenda

1. Introduction

2. Demographics

3. Care Needs and Risks

4. Defining a Framework

5. Implementing Processes

6. Successful Sustainability

21 Understanding the Rules

. State regulations & licensure requirements □ Nursing Services □ Education requirements . Medication Assistance . Dementia Care

. State Nurse Practice Acts

. Business or corporation standards

. Scope of Care & Services to be provided

22 Defining Your Framework

. What is the level of care and service you are providing?

. What are the educational backgrounds, skills and experiences needed to care for your residents?

. What is the availability of the professional nursing and caregiver workforce in your community?

Defining Your Commitment

. How do you define your commitment to staff development?

. Availability of resources to support education □ NCAL Guiding Principles □ Online education services □ Community partners; NPs, Hospitals, SNF □ Vendor partners

24 Defining Structures & Processes for Resident Evaluation

. Pre-move in assessment

. Move-in assessment

. Service Plan—initial & ongoing review/updates

. Daily interactions □ INTERACT “Stop & Watch”

. Wellness checks

25 26 Agenda

1. Introduction

2. Demographics

3. Care Needs and Risks

4. Defining a Framework

5. Implementing Processes

6. Successful Sustainability

27 Supervision Expectations: Authority v. Familiarity

http://www.apbs.org/conference/denver/files/A18-Bird.ppt#369,13,Federal Regulations: Potential areas of citations 28 Supervision Expectations: Authority v. Familiarity

http://www.apbs.org/conference/denver/files/A18-Bird.ppt#369,13,Federal Regulations: Potential areas of citations 29 Defining Staff Education & Development Model

. Hiring □ Defined job descriptions, roles & responsibilities . Orientation □ Defined training for high risk, problem prone issues □ Medication Administration □ Accidents/Incidents—Drills □ Clues & Cues / Change in Condition . Mentoring . Check-in . Annual review

SIDEBAR 30 Models for Education Delivery

. Live □ In-house □ Local or National opportunities

. Online □ Self-paced □ Assigned courses Who is Your Education . Blended Coordinator?

. Workshops

31 Enhancing Education Planning

. Evaluate established educational calendars for opportunities to enhance learning

. Partnership ideas □ Nurse Practitioners □ Hospital Nurse Educators □ Local University—Student led sessions

. Certification / Specialty programs

32 Medication Assistance

. Understand state rules and regulations

. Educational preparation: □ Follow state mandated training, as applicable □ Include observation and competency demonstration by a nurse □ Include scenarios and problem solving opportunities. Focus on high risk medication issues □ Expectations for documentation and communication of variances

. Focus on medication safety 33 SIDEBAR: Clues & Cues – “Itchy Vigilance”

Opportunity to identify a change early and respond

□ Less visible in the community

□ Check for changes in meds

□ Recent trip to the physician

□ Off patterns or habits

□ Change in routines

□ Posture change

□ “Color” change

□ New cough

□ Pain

34 Let’s Apply It: Mrs. M

Moved In December 2011 January 2013 . 85 years old, widowed . 87 years old . Teacher, mother of 5, . Fell when getting out of bed grandmother of 17 to go to the bathroom. . Arthritis, osteoporosis Fractured her hip . History of heart failure . Plans to return to AL . Episodes of confusion . Takes 4 medications . Requires assistance with □ Bathing □ Dressing □ Medication management

35 Opportunity for Staff Learning

. “Learning Circles” –ask staff involved in Mrs. M’s care to meet and discuss what they observed about her over the past year.

. Consider creating a timeline from “Move-In” until the fall occurred.

. Discuss opportunities for improvement □ Staff communication □ Nursing & Physician notification □ Recognition of changes in Mrs. M’s condition

36 Mrs. M

. Episodes of confusion Root Cause Analysis . Takes 4 medications • Physician had increased her dose of diuretic medication . Requires assistance with • Daughters had made comments □ Bathing to staff that she seemed “more confused that usual” □ Dressing • Last service plan was reviewed in □ Medication management December 2012 • Communication gap between staff 37 SIDEBAR: RCA

1. WHY? Incident; Injury (Near-Misses & Prospectively) 2. What Areas Do You Focus On? a. People b. P&P&P c. Training d. Equipment e. Environment f. Management

3. Who should participate?

38 “Daily Contracting” with Residents SAFE from FALLS Toolkit -- http://www.mnhospitals.org/index/tools-app/tool.362?view=detail

1. Verbal contracting with Residents (each shift):

. Example: “Good Morning Mrs. Smith. I don’t want you fall, OK. Will you be sure to put on your slippers …”

2. Tips to share with Family Members:

. Example: “Do you understand that your Mom is at higher risk for falling? Will you reminder to her always wear her slippers?”

http://www.mnhospitals.org/index/tools-app/tool.362?view=detail39 “Daily Contracting” with Residents Sample tips:

1. Ask for help! It is OK. (weak or dizzy) 2. Wear glasses or hearing aids, use them. 3. Sit at the bed side for a few minutes before you stand up. 4. Use your walker/cane/WC. 5. Wear shoes or non-skid slippers. 6. Make sure your pathway is clear. 7. Tell us about puddles/piles/pieces. 8. Use the handrails! 9. Keep important things within easy reach.

http://www.mnhospitals.org/index/tools-app/tool.362?view=detail40 “Daily Contracting” with Family*

Sample tips:

1. Before you leave, make sure the call light and the bed stand is within reach. (Phone, Kleenex, etc,) 2. Some medications may produce weakness or dizziness. 3. Consider staying with Mom if they are at a high risk for falling or are confused. 4. Notify staff before leaving if you notice confusion or disorientation in your Dad. 5. Remind Mom to ask for help when getting up.

41 Agenda

1. Introduction

2. Demographics

3. Care Needs and Risks

4. Defining a Framework

5. Implementing Processes

6. Successful Sustainability

a. Change Management

b. Mentoring

42 Performance Improvement

43 Successful Sustainability

1. How many of you are “change managers”?

2. Have you ever thought about how you “manage change”?

3. What if I said to you that there are both “good ways” and “bad ways” of managing change?

4. Strategies for Managing Change in Nursing By Ngozi Oguejiofo, eHow Contributor, December 12, 2012

a. Choose your “Change Theory” …

(Read more: Strategies for Managing Change in Nursing | eHow.com

http://www.ehow.com/way_5870000_strategies-managing-change-nursing.html#ixzz2Oy1UeTQN) 44 400+ Available Theories of Change Management

A -0 - E - - K - - R - - U - Acquiescence Effect Ego Depletion Kin Selection see Prosocial Behavior Rationalization Trap Ultimate Attribution Error Acquired Needs Theory Elaboration Likelihood Model - L - Reactance Theory Ultimate Terms Activation Theory Empathy-Altruism Hypothesis Lake Wobegon effect Reasoned Action, see Planned Behavior Theory Uncertainty Reduction Theory Actor-Observer Difference Endowed Progress Effect Language Expectancy Theory Realistic Conflict Theory Unconscious Thought Theory Affect Infusion Model Endowment Effect Law of Attraction Recency Effect Urban-Overload Hypothesis Affect Perseverance Epistemological Weighting Hypothesis Lazarus Theory see Appraisal Theory Reciprocity Norm - V - Aggression Equity Theory Leader-Member Exchange Theory Regret Theory Valence Effect Ambiguity effect ERG Theory Learned Helplessness Theory Reinforcement-Affect Theory VIE Theory see Expectancy Theory Amplification Hypothesis Escape Theory Learned Need Theory see Acquired Needs Theory Relative Deprivation Theory - W -

Anchoring and Adjustment Heuristic Expectancy Violations Theory Least Interest Principle Relationship Dissolution, see Terminating Relationships Weak Ties Theory Anticipatory Regret see Regret Theory Expectancy Theory Linguistic Inter-group Bias Representativeness Heuristic Wishful Thinking see Valence Effect Appraisal Theory Explanatory Coherence Locus of Control Repulsion Hypothesis Worse-Than-Average Effect see Below-Average Effect Attachment Theory Extended Parallel Process Model Looking-glass Self Restraint Bias - X - Attachment Style External Justification Love Risk Preference - Y - Attitude Ethnocentric Bias see Group Attribution Error - M - Risky Shift Phenomenon Yale Attitude Change Approach Attitude-Behavior Consistency Extrinsic Motivation Matching Hypothesis Roles Attribution Theory - F - Mental Models see Schema - S - Automatic Believing False Consensus Effect Mere Exposure Theory Sapir-Whorf Hypothesis Augmenting Principle False Memory Syndrome Mere Thought Effect Satisficing Availability Heuristic Fatigue Minimum Group Theory Scapegoat Theory - B - Focalism Minority Influence Scarcity Principle Balance Theory see Consistency Theory Focusing Effect Mood-Congruent Judgment Schema Barnum Effect see Personal Validation Fallacy Forced Compliance Mood memory Selective Exposure Belief Bias Forer Effect see Personal Validation Fallacy Multi-Attribute Choice Selective Perception Belief Perseverance Four-factor Model - N - Self-Affirmation Theory Below-Average Effect Filter Theory Negative Face see Politeness Theory Self-Completion Theory Ben Franklin Effect Framing Neglect of probability bias Self-Determination Theory Bias blind spot Friendship Non-Verbal Behavior Self-Discrepancy Theory Bias Correction Frustration-Aggression Theory Normative Social Influence Self-Enhancement see Impression Management Biased sampling Fundamental Attribution Error Norms see Social Norms Self-Enhancing Bias see Self-Serving Bias Body language see Non-verbal Behavior - G - - O - Self-Evaluation Maintenance Theory Bounded Rationality Gambler's Fallacy Objectification Self-Fulfilling Prophecy Buffer effect of Social Support Goal-Setting Theory Object Relations Theory Self-Monitoring Behavior Bystander Effect God Terms see Ultimate Terms Operant Conditioning Self-Perception Theory - C - Group Attribution Error Opponent-Process Theory. Self-Protective Bias see Self-Serving Bias Cannon-Bard Theory of Emotion Group Locomotion Hypothesis Optimism Bias see Valence Effect Self-Regulation Theory Cautious Shift see Risky Shift Phenomenon Group Polarization Phenomenon Other-Enhancement see Impression Management Self-Serving Bias

Central Route see Elaboration Likelihood Model Group-serving Attributional Bias see Group Attribution Error Outcome Dependency Self-Verification Theory Certainty Effect Groupthink Out-Group Bias see In-Group Bias Side Bet Theory Charismatic Terms see Ultimate Terms - H - Out-Group Homogeneity Sleeper Effect Choice Shift see Risky Shift Phenomenon Halo Effect Overconfidence Barrier Small World Theory Choice-supportive bias Hedonic Relevance see Correspondent Inference Theory Overjustification Effect Social Comparison Theory Choice Theory see Control Theory Heuristic-Systematic Persuasion Model - P - Social Desirability Bias Classical Conditioning Hostile Media Phenomenon Perceived Behavioral Control see Planned Behavior Theory Social Exchange Theory Clustering Illusion Hot Hand Phenomenon Perceptual Contrast Effect Social Facilitation Coercion Hindsight Bias Perceptual Salience Social Identity Theory Cognitive Appraisal Theories of Emotion Hyperbolic discounting Peripheral Route see Elaboration Likelihood Model Social Impact Theory Cognitive Dissonance - I - Personal Construct Theory Social Influence Cognitive Evalution Theory Illusion of Asymmetric Insight Personal Validation Fallacy Social Judgment Theory Commitment Illusory Correlation Personalism see Correspondent Inference Theory Social Learning Theory

Communication Accommodation Theory Imagination Inflation see False Memory Syndrome Persuasion Social Loafing Compensation Imagined Memory Persuasive Arguments Theory Social Norms Confirmation Bias Impact Bias Placebo Effect Social Penetration Theory Conjunction Fallacy Implicit Personality Theory Planning Fallacy Social Proof see Informational Social Influence Consistency Theory Impression Management Planned Behavior Theory Social Representation Theory Constructivism Inattentional Blindness Plasticity Social-Role Theory Contact Hypothesis Information Bias Pluralistic Ignorance Sociobiology Theory Control Theory Information Manipulation Theory Polarization Source Credibility Conversion Information Processing Theory Politeness Theory Speech Act Theory Contagion Informational Social Influence Positive Face see Politeness Theory Spiral of Silence Theory Conversion Theory In-Group Bias Positive psychology Stage Theory Correspondence Bias In-Group Linguistic Bias see In-Group Bias Positive Test Strategy see Confirmation Bias Stereotypes Correspondent Inference Theory Inoculation Positivity Effect Stockholm Syndrome Counter-Attitudinal Advocacy (CAA) Insufficient Punishment Post-Decision Dissonance Story Model Counterfactual Thinking Interpersonal Deception Theory Power Stimulus-Value-Role Model Covariation Model Interpersonal Expectancy Effect The Pratfall Effect Strategic Contingencies Theory Credibility Interview Illusion Primacy Effect Subjective Norms see Planned Behavior Theory - D - Intrinsic motivation Priming Subliminal Messages Decisions Investment Model Private Acceptance see Informational Social Influence Sunk-Cost Effect Deindividuation Invisible Correlation see Illusory Correlation Propinquity Effect Symbolic Convergence Theory Devil Terms see Ultimate Terms Involvement Prosocial Behavior Symbolic Interaction Theory Disconfirmation bias Ironic Reversal Prospect Theory - T - Discounting - J - Pseudo-certainty effect see Certainty Effect Terminating relationships Dissonance see Cognitive Dissonance James-Lange Theory of Emotion Psychological Accounting Theory of Mind Drive Theory Justification of Effort Public Compliance see Informational Social Influence Three-factor Theory see Acquired Needs Theory Durability bias Just-world phenomenon Pygmalion Effect see Self-Fulfilling Prophecy Transtheoretical Model of Change Two-Factor Theory of Emotion

http://changingminds.org/explanations/theories/a_alphabetic.htm 45 So Which One?

http://rapidbi.com/kurt-lewin-three-step-change-theory/ 46 UNFREEZE = Decide, Plan, Strategize, use data, ENGAGE; let go of old patterns CHANGE = Engage and Communicate; Implement Your Plan: = Create AWARENESS and BUY-IN RE-FREEZE = Manage Resistance = Beat the Drum = Monitor and Modify the “Changing” Environment = Without refreezing, it is easy to backslide into the old ways.

File:Iceberg.jpg (From Wikipedia, the free encyclopedia) http://www.ehow.com/way_5870000_strategies-managing-change-nursing.html http://en.wikipedia.org/wiki/File:Iceberg.jpg Strategies for Managing Change in Nursing By Ngozi Oguejiofo, eHow Contributor47 48 Who is the “Change Leader”?

The Change Leader incorporates each step of the “chosen” change theory to bring about planned change.

DON/Nurse1 │ Corporate2 │ Administrator3 │ TEAM4

How can you apply this to today’s discussion?

http://www.ehow.com/way_5870000_strategies-managing-change-nursing.html

Strategies for Managing Change in Nursing By Ngozi Oguejiofo, eHow Contributor 49 Agenda

1. Introduction

2. Demographics

3. Care Needs and Risks

4. Defining a Framework

5. Implementing Processes

6. Successful Sustainability

a. Change Management

b. Mentoring

50 VISIT & LISTEN

EDUCATE & DEVELOP MENTORING

ENGAGE & HARVEST

1. Relationship questions VISIT ↔ LISTEN 2. Round with them 3. What went well? 4. What didn’t go well?

1. Do you have the tools, EDUCATE ↔ DEVELOP trainingMENTORING and resources to do your job? 2. What is working well?

1. How can we “fix” “this”? ENGAGE ↔ HARVEST 2. Who is doing a good job? 3. What systems can work better? HOW?

52 SIDEBAR: WHY do we “mentor” others? *

Sow a thought, reap an action. Sow an action, reap a habit. Sow a habit, reap a character. Sow a character, reap a destiny.

Here is my belief --

If you want to make QAPI, Care, Choice, Compassion or ANY OTHER important principle strong in your community, then “make” your Staff strong in those same things.

(In Bill Sands, The Seventh Step (1967), 9) 53 “Take-Away” Ideas

. Be clear on what you can and can’t provide

. Dedicated educator or education coordinator for staff

. Defined curriculum for all staff with an emphasis on identifying common changes in resident condition and expectations for communication

. Health & Wellness programs for residents with emphasis on “early identification and action”

54 “Take Away” Ideas

. Consider establishing an “Advisory Board” to discuss policies, procedures and practices to address the health and wellness needs of your residents & provide recommendations to community leadership □ Nurse □ Physician □ Nurse Practitioner □ Nurse Aides/Care Assistants □ Pharmacist

Agenda In Review – Did We Hit Them?

1. Introduction

2. Demographics

3. Care Needs and Risks

4. Defining a Framework

5. Implementing Processes

6. Successful Sustainability

Any “AH-HA’s”?

56 Thank You.