Humanizing the Care of Residents Long Term

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Humanizing the Care of Residents Long Term

• Peter A. Lichtenberg, Ph.D., ABPP
• Director, Institute of Gerontology
• Professor of Psychology
• Wayne State University
• p.lichtenberg_at_wayne.edu

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Thirty Years of Enhancing Personhood

• Look back at behavioral approaches
• Examine Eden and Greenhouse models
• Examine Personhood models
• Understand organizational influences on care
• Three Cs of everyday care
• Tie it all together and discuss

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OLD AGE IS ALWAYS 15 YEARS OLDER THAN I
AMBernard Baruch Age 84United Nations Diplomat
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1st cohort to Grow old and be Visible in U.S.
Changes from 100 years ago Life
Expectancy Number of elders Idea of com- Pressed
morbidity Dementia after 90
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My early Experiences in a 180 LTC bed unit

• Referral Man throwing himself on the floor due
  to manipulative tendencies
• What I observed
• Often lost balance and fell to floor (22 times
  per 6 hour period)
• Tearful
• Stopped eatinglosing considerable weight
• Poor verbal communication skills

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What we did

• Got neurology referralhe had untreated PD
• Got speech language referralvoc-aid and taught
  him to use
• Increased his social interactions with staff and
  depression remitted
• WHY HAD HE BEEN VIEWED IN SUCH A DEPERSONALIZED
  WAY?

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78 year old man with Schizophrenia

• In state hospital since his early 20s
• Seclusive
• Spent entire day lying in bed
• Behavioral Modification techniques used
• Used a shaping technique to increase physical
  activity
• In one year improved from walking a total of 10
  feet to one mile each day

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Prevailing view of frail elders

• Medical v Community/Social model of care Deficit
  model
• Passive
• Sedentary
• Close minded
• Lost too much cognitive ability
• Results
• De- individuation
• Fostering of dependency

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Rodin and Langer (1976)

• Gave more control to residents over day to day
  events and compared them to control group
• Outcomesgroup with choice engaged in more
  activity, reported more happiness, were rated as
  more alert

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Marquette County Medical Care Center Project

• Depression Treatment and Prevention in Persons
  With Alzheimers Disease
• Peter A. Lichtenberg, Ph.D., Principal
  Investigator

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Marquette Study Details

• New home-like setting created for persons with
  Alzheimers Disease
• Unit de-emphasizes institutional behavior and
  emphasizes individual, client-centered approach
  to care

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Marquette Study Details cont.

• Baseline
• Neuropsychologist blinded to intervention
  assessed 23 residents from the 2 new AD units
• Geriatric Depression Scale
• Cornell Scale for Depression in Dementia
• Behave-AD
• Clinical Interview DSM IV Diagnoses

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Marquette Study Details cont.

• Marquette County Medical Care designated ½ time
  person for further baseline work intervention.
• Pleasant Events
• Mood Monitoring
• Relaxation
• Tx. ongoing for 3 months
• Reduced behavioral disruption in pleasant events
  vs control group

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Activities engaged in

• Pampering massage, aroma therapy, hair care 27
• Reminiscence-old photos, verbal discussion 22
• Social activityone to one visiting, small group
  18
• Physical activitywalking, fixing, gardening 16
• Quiet activitywatch birds, reading 11
• Correspondenceholiday letters, cards 6

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Conclusion

• Personal choice, 11 relationships enhanced well
  being
• Model not practical for broad implementation

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Nursing Homes and the Medical Model Bill Thomas

• Staff Hierarchy much like hospital
• 3 Plagues of Long Term Care
• Loneliness
• Helplessness
• Boredom
• Challengecreating the Eden team concept in a LTC
  facility

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Creation of the Eden Alternative

• 1991 By Dr. William H Thomas and wife Judy Chase
  Thomas
• Chase Memorial reduced medications, infections,
  staff turnover and mortality rate after Eden was
  put into place
• What makes the Alternative come to Life?

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Eden Alternative Comes to Life
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From Parking Lot to Activity Room

• Gardens/landscaping
• Children
• Animals
• Person Centered activities

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Greenhouse Model of Long Term Care

• Goal is to rethink
• Philosophy of care
• Architecture
• Organizational Structure of care

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What is it?

• Independent housing unit for 6-12 people with
  dementia
• CNAs are called Universal Workers
• UWs organize day in collaboration with residents
• Other staff are wrap-around support services
• 2006 RWJ awarded 10M across country to increase
  number of Greenhouses
• HOWEVER policies and funding models do not
  provide support for Greenhouse model to expand
  even more

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Greenhouse in Action
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Current status of greenhouse

• 1700 in existence across the U.S.
• Staff do more but for fewer people
• Get to know resident as a real person
• Less rigid schedule meals, bathing
• To date studies show that care is similar to
  that found in larger nursing home

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Expressions of Personhood

• Pia Kontos and Gary NaglieU of Toronto
• Expressions of personhood
• discourse over-utilized by us all in defining
  personhood
• Artistic expression under-utilized and
  appreciated
• Current model--- as cognition declines so does
  self-hood
• Negative views of those with more severe dementia
  in long term care and less caregiver engagement

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Expression of Personhood Cont.

• Kontos ethnographic study claims that selfhood
  continues even after cognition declines
• Key challenge in LTC Maintenance of Personhood
• Kontos Selfhood taps into pre-reflective
  levels of consciousness
• Examples
• Importance of gesture in communicating
• Body and facial expression
• Items hold unique and personal meanings to
  residents

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Artistic Expression as Performance
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Summary and Question

• Choice, personhood is important
• Wonderful models created across past 40 years
• Why is personhood still the exception rather than
  the norm in care?

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Reframing Organizations bolman and deal

• 4 frames needed to understand organizations and
  most people only look at 2
• 1. Structural
• 2. Human Resource

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1. Structural Frame

• Metaphor Factory/Machine
• Dimensions
• Differentiated or integrated jobs
• Centralized or diffuse in responsibility
• Rigid routine/flexibility

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2. Human Resource frame

• Metaphor Family
• Employees Replaceable v Valued
• Fit between individual and organization
• LTC workershigh levels of meaning in work, low
  participation in team decision making
• Structural and HR frame are rationalways of
  organizing work and treating workers

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3. Political Frame

• Metaphor Jungle
• Powerability to make things happen
• Coalitions formcompete for scarce resources
• Conflictswin/win v win/lose negotiators
• Power can be coercive and destructive if not used
  wisely
• (e.g. space shuttle Discovery Housing crisis
  Nanny cam of Abuse in the Nursing Home)

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4. Symbolic frame

• Metaphor Carnival, Temple, Theatre
• Meaning
• Hope
• Faith
• Core Values
• Culture in Organizations
• Symbols/rituals

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Reflect on ltc and your place of work

• How do 4 frames influence policy, power,
  structure and meaning?
• Frail persons weak in terms of powerful
  coalition chronic under-funding of LTC
• Stability of administrators in LTCpoorest
  functioning organizations have least stability in
  administrators let alone direct care staff
• Negative stereotyping of LTC

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Personal habits in daily work

• Steven Covey 7 Habits of Highly Effective People
• Begin with the end in mind
• Seek to understand before being understood
• Put first things first
• Think win-win

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3 Cs to Person centered care

• Curiosity who is this person, what was their
  greatest passion, what brightens them up
• Compassion what is this persons greatest fear,
  what causes them to suffer, what grief do they
  have, how lonely are they
• Contemporaneous Be mindful in the present, be
  aware, present in the moment, come to each day
  ready to engage with residents and colleagues