Clonakilty Community Hospital A New Model of Care

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Clonakilty Community HospitalA New Model of Care

• John Linehan
• Doreen Lynch
• October 2009 NHI Conference

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Outline of presentation

• Background
• The New Model of Care
• Process of change
• Education
• Research
• Challenges!

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Profile of residential care for older people

• 28,000 residential care places
• 4.6 people over 65
• 65 in private or non for profit care
• 35 in public care
• (Coyle 2008)

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Projected Numbers of Older People by Gender and
Age Group 2011 to 2041 (DOHC, 2007)
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Need for change.

• There is a growing acknowledgement that the
  current model of residential care does not always
  support older people to continue to exercise self
  determination and lead a full life no matter what
  their level of dependency.
• New buildings or upgrades give an opportunity to
  develop to develop a new vision

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New Standards of Care

• Rights Based
• Person centred
• Self Determination
• Choice
• Privacy and Dignity
• Maintain contact with families and friends

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A new vision

• Create a new model of residential care which
  supports older peoples ongoing right to home and
  continued meaningful connectedness to their
  family and friends

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Objective

• To drive a change in culture from a task
  orientated institutional model to one which
  supports older people to continue to direct their
  own lives supported by consistent and valued teams

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Teaghlach

• Based on similar work in the USA
• Eden Model
• Household model
• UK My Home Life
• Model for newly developed community nursing units
  (CNUs)

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Teaghlach

• The word Teaghlach in Irish has many
  connotations. It means a family group, living
  comfortably together, cosily warm around a
  glowing fire, each person protective of the
  others.
• It suggests a respect and familiarity and a happy
  and helpful ambience of share experiences
• Small scale living

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Teaghlach Model

• An environment in which both residents and the
  staff are valued and thrive.
• Staff enter care giving relationship with the
  resident based on individual needs/desires.
• Residents continue to live their life to the
  fullest
• Residents and staff design schedules that reflect
  needs/desires.

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Teaghlach Model

• Decision-making closer to resident.
• Environment reflects comforts of home.
• Spontaneous activities available around the
  clock.
• Residents and staff share a feeling of community
  belonging
• Direct their own lives through a responsive
  highly valued and decentralised self led team
  that is supported by values driven leadership
  philosophies, practices, policies and systems

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CLONAKILTY HOSPITAL

• Clonakilty hospital is a 194 bed hospital.
• The hospital serves the West Cork Local Health
  Office area.
• Provided continuing care, respite care,
  palliative care and community support
• Dementia specific unit Saoirse

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What it was

• Block 2b was a 96 bed unit
• Long corridor
• Noisy
• Busy
• Not homely
• Element of task orientation

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Background

• Pilot site for the Teaghlach model
• Innovation funding
• New unit being developed
• Staff recruitment to work in the unit
• Staff training
• Research element
• Similar to the development of Saoirse

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Staffing

• 21 residents 15 WTEs
• 40 hours per day (24 hours) Nursing
• 44 hours per day (24 hours) Support Staff
• Nursing per day 1 Clinical Nurse Manager, and 2
  nurses 28
• Nursing per night 1 nurse 12
• Health Care Assistants per day 16 hours
• Multi-Task Attendants per day 12 hours
• Support staff per night 12 hours
• Cleaning staff per day 4 hours

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Education and development analysis

• Team building
• To develop a philosophy of care
• Person centred care
• Physiology of ageing and associated aspects
• Life stories
• Communication
• Nutrition

• Mobility and the older person
• Dementia/ behaviours that challenge
• Pharmacology
• Palliative care
• Care plans and documentation
• Activities
• Role of the family/carers

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Education and development to date

• Team building and self awareness
• Life story
• Person centred care workshop
• 1 ½ day
• Observation of care
• Discussion and very little PowerPoint!!
• Workshops, brainstorming

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Observations of care

• Workplace Culture Critical Analysis Tool
• (McCormack et al 2007)
• Staff observe the delivery of care to residents
  in a ward, document their findings using an
  agreed format, and give feedback to others
  following the period of observation.
• Areas such as the how care is organised, resident
  involvement, how the privacy and dignity of
  residents is maintained and the care environment
  are observed
• Focus on the positives and areas that need
  improvement

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Outcomes

• Clutter
• General noise
• Radio on nobody listening
• Language
• Communication
• Signage

• Gentle language
• Good level of engagement with a resident
• Sharing a joke!

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What it is now ..An Graig

• 21 bed unit.
• 20 continuing care residents and 1 respite
  patient.
• The residents profile
• 5 very high dependency
• 12 high dependency
• 4 medium dependency residents.
• 5 residents would have a diagnosis of dementia.

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A new way of being..
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Philosophy .. Some extracts

• to provide a homely, friendly and happy
  environment to live and work where people are
  treated with respect and dignity.
• to maintain a sense of continuity with the
  persons past and give them hope for the future
• Differences of opinion are respected and a true
  sense of listening is the norm
• Keeping an open mind where my way may not always
  be the right way.
• Where creative solutions and thinking are
  fostered while at all times remembering this is
  the residents home

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Feedback from Staff

• Discussion with staff
• 4 months after moving in
• Enthusiasm is still very evident
• Relationships tolerant of each other
• Prioritise now not that we must

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Feedback from staff

• Important of hearing the same message
• Relatives are more comfortable with staff
• Hidden talents of staff

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Residents

• Space residents have a sense of their own space
• Life story new learning about the lives of
  residents
• Provide areas of discussion away from the task
• Empowerment of families
• Quietness - make not suit all
• Smell
• Table is the focal point

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Residents

• Confidence about themselves
• Strong sense of home
• Residents lie in
• Less night sedation
• Continuity of staff now address staff by first
  name

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Transition

• Not an easy journey
• like everyone moving into a new house at the
  same time and wanting their choice
• May not suit everyone
• More time the rush is gone
• CNM role more challenging team and regular
  meetings
• letting go of the old ways

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Environment

• Separate entrance
• Quietness day and night
• Efficiency improved by having facilities closer
  at hand

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Some learning

• All staff need to receive the same message
• Observation of care insight
• Leadership at management and clinical level
• Research to provide evidence
• Local ownership
• Importance of public awareness

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Research

• The aim of the study is to explore the process
  of cultural change, in particular the changes in
  working practices and relationships of care,
  which result from the establishment of the
  Teaghlach Model at the study site

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Research

• Methodology
• a qualitative phenomenological approach
• Sample
• Staff
• Relatives
• Residents
• Data collection
• Focus groups
• Interviews

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Preliminary findings from the phase of the
research

• Residents
• The process of adaptation to long term care
• R1 There has to be give and take
• R7 Tis all right
• R5 We dont go out much
• R3 Nurses are good and they are all nice but I
  would prefer to be at home

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Preliminary findings from the phase of the
research

• Conforming
• R1 it isnt what I would like to do but what
  you are really left to do
• R4 I like to read every day but it doesnt
  always workbecause they mightnt bring in the
  paper
• R3 I cant read, I cant sit up

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Preliminary findings

• Enjoyment and quality of life was dependant on
  the staff
• R1 A lot depends on the staff
• I get on fine I keeps well in with the
  women
• R4 they make you feel at home
• R5 They are great staff, kind and very nice
  in every way

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Preliminary findings - relatives

• Emotional
• no body wants to put their relative in hospital
• we are very, very lucky
• it is very emotional , exceptionally emotional
  and say for us we had spent over 2 years caring
  for mother on a 24hr basis at home and it had got
  to the stage we could not mind her anymore
• you do feel a failure to them after all they
  have done for you

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Preliminary findings

• Grateful
• You can see by them that they are happy,
  comfortable, well looked after and well cared
  for
• thats it really it is peace of mind
• Open visiting gives us all a great chance also
  gives a very transparent view because staff are
  not always aware when a relative will walk in
• Priorities
• they only go from bed to chair and back again-
  but it is the simple practical things like clean
  sheets
• they are always and neat and it is no joke to
  get all that done every morning

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Preliminary findings - Staff

• Relationships
• a lot of them dont have any visitors
• sometime you and the support workers are the
  only contact and you try to make their day as
  happy as possible for them
• I suppose you get to know them and their ways
• Routine focused
• try and get as much work done as you can before
  1st break
• I do a round of patients attend to all their
  needs, toileting needs or whatever
• I suppose our day is routine really

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Preliminary findings

• Task centred approach to care
• the first thing is the drug round
• I organise my care find out who has to be
  showered
• Health and safety a priority
• as regards to patient care the priority is
  patient safety
• there is a huge emphasis now on patients
  safety making sure they are sitting safely, are
  in a safe environment are not going to slip or
  fall

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Preliminary findings

• Desired changes
• not to be against the clock, to be a little more
  flexible, team work
• to make more a family environment because they
  are not going home
• To create a homely environment
• it takes time to change the habits of a life
  time

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Johns Story (not his real name)

• John spent his days sitting in the day room. He
  was unable to interact with other patients as his
  verbal abilities are poor. It was difficult for
  staff to build up a rapport or understanding with
  John. This led to John being isolated and
  frequently would tear at objects especially the
  chair he was sitting in. One of the behaviours
  John had was to grab anyone who would pass his
  chair and this stopped people going anywhere near
  him. He had episodes of aggression
• Since moving to 2B we have found that Johns has
  a keen interest in watching the football on the
  television he likes to be taken out to the
  garden, he likes watching the television if
  there are animals or lots of colour in the
  pictures and he loves patting the dog. We found
  out through talking to his sister that he shows
  his non verbal contentment when he moves his head
  from side to side. When one of the staff picked
  him flowers one day he wouldnt let them out of
  his hand for the day. The staff found out that
  he can communicate with clear commands of yes
  and no. He doesnt grab staff anymore and when
  staff do put out a hand to him he will hold your
  hand and then relax it. There have been no
  incidents of aggression or agitation in the past
  two months. The staff have changed in their
  attitude towards him no longer fearful to pass
  his chair. His family are delighted with the
  change in him and say that he is much more like
  his old self.

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Joes (not his real name) story

• Joe, is a bachelor who lived all his life alone
  in a farm in West Cork. He was admitted five
  years ago. From time to time thoughts of his
  farm gave him reason to go outside searching,
  spent his time alone and he appeared sad. Back in
  the hospital Joe, would eat his meals alone,
  beside his bed.
• Since moving to the unit, Joe chooses to have his
  meals at the table with a couple of the men.
  They talk about the cattle and the land. He
  has a dry sense of humour, makes his opinions
  known and his so knowledgeable about so many
  subjects. His words are few but when spoken are
  well worth listening to. Joe enjoys the music
  sessions and only last week built up the courage
  to sing aloud. Joe no longer looks to go out and
  on occasions we get a smile or a comment to let
  us know he is taking it all in. We as staff feel
  that we are beginning to get to know him. He now
  calls us by our name so I suppose he is.

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Thank you for taking time to listen