As we know, the number of people with Alzheimer's and related dementias is dramatically rising. As a result, the number of people with dementia choosing a long-term care environment is also rising sharply.
Sadly, I have found that long-term care communities tend to be rooted in the medical model. The very nature of the name "nursing home" embodies the typical philosophy and emphasis of care—simply meeting nursing and medical needs at the expense of quality of life needs.
However, there are many changes occurring in long-term care. One of the most significant is an initiative by CMS for all nursing homes to convert to a social model of care by 2007. Surveyors are being trained to place equal emphasis on surveying on social model elements of care as they do other survey areas.
In addition, the Alzheimer's Association and other organizations have been educating consumers on how to select a long-term care living environment that facilitates quality of life. The Alzheimer's Association also supports research in quality of life issues.
I have found one of the key elements to facilitate quality of life outcomes and for implementation of a social model is for the person with dementia to be enabled to perform valued activities at their highest performance level. The feelings of "success" and "purpose" appear to have a significant impact on behavior and mood. The very act of "doing" appears to have impact on reducing common medical complications such as reducing contractures, reducing falls, reducing risk for pneumonia, reducing weight loss and skin breakdown.
The long-term care resident with dementia is by very nature complex. It is not easy for the care team to determine "best ability to function" as remaining abilities are often masked behind obvious disabilities and challenging behaviors. Therefore, a person often does not achieve their functional and emotional potential. And, therefore, it may be considered reasonable and necessary for the therapist to intervene. One of the skilled components of the intervention is to identify best ability to function, then to enable the resident to achieve this best ability through interventions such as (a) environmental modifications, (b) activity simplification, (c) maintenance program design, and (d) caregiver training.
A barrier many therapists face in this process is obtaining follow through from the care team (CNAs, nurses, and activities staff) in implementation of the maintenance program as educated. Partnership between the care team and therapist is critical for the resident's well-being and function, and overall program success. Therefore, I will review some of the key components for a successful interdisciplinary dementia model.
Key Components for Success
Getting Buy-In from Owners and Administration
A quality dementia program involves much participation from the interdisciplinary team. The most critical team members are administration/owners, therapists, nurses, CNAs, and activities staff. All of these team members must understand the goals of quality dementia care and what role they play in delivery of this care.
Owners and administrators must totally buy in and support a dementia program or it will not succeed. Their participation is important as they are the drivers of the program. They will need to provide adequate staffing numbers and hours, adequate dedicated hours for staff training, adequate training/consulting tools and resources, and constant encouragement.
A quality dementia program can make money. Often, all that is initially recognized by owners and administrators is the need to add staff or ask staff to spend more time in education programs, all of which can be looked at as a financial drain on an already slim bottom line. But, a QUALITY dementia program can facilitate a large profit.
Below are some of the many ways that a quality dementia program can infuse revenue into the facility:
- Filling empty beds: the number of people in need of quality long-term dementia care far exceeds the number of facilities CAPABLE of delivering it
- Reducing percentage of Medicaid residents while increasing private pay base
- Acuity-based fees: the greater the acuity needs of the residents, the higher level of staffing needed—however profit margins are maintained through acuity pricing
- Medicare Part A and Part B revenue increases: through improved understanding how to evaluate and treat the person with dementia
In addition, a quality dementia program can save the facility money/costs related to such issues as:
- Weight loss and supplement use
- Hospitalizations due to falls or decline
- Staff turnover
Assessment of a resident's cognitive level is of utmost importance for success.
- The nursing staff can utilize the adapted FAST (Functional Assessment Staging Tool). This will either rule out functional deficits related to cognition or define a person's general dementia stage, based upon functional performance. I recommend the adapted FAST replace the often used MMSE. The FAST is a well respected tool and was originally designed by Dr. Barry Reisberg. The adapted version I refer to is one that our team adapted to be more sensitive to abilities found in more advanced dementia. In addition, we have woven in some Allen language into the functional descriptions.
- The therapists should utilize the Allen assessment. Therapists benefit greatly from using the Allen Cognitive Level assessments, which is a more extensive assessment instrument and yields more detailed results than the FAST. These more specific results are especially important when making discharge recommendations.
- The adapted FAST and Allen assessment scores correlate well (use your course workbook and locate the comparison chart that identifies the relationship between the scales). This common approach to cognitive assessment assures all team members are talking the same language and understanding the impact that dementia stage has on functional performance and safety.
Implementation of Assessment Results into Care/Service Plans
Federal rules require a facility provides the necessary services for a resident to achieve their highest practicable level of function. Identification of a person's cognitive level through functional assessment is a critical first step. Next, the results are used to identify the person's highest level of function for ADLs and leisure activities and the appropriate care/service plan goals and approaches. Therefore, the Adapted FAST and/or Allen assessment results are directly rolled into the care/service plan.
- A person functioning at Allen level 4.2 or adapted FAST stage 5 can perform ADLs at supervision or minimum cognitive assist
- A person functioning at Allen level 3.6 or adapted FAST stage 6 can perform ADLs at limited assist or moderate cognitive assist
When determining a person's highest level of function, remember to start with administration of the cognitive assessment, then factor in any deficits in other performance components (e.g., physical, sensory, or emotional components) that may mean the person will require a greater level of assist.
I have successfully educated activity directors, nurses (restorative, MDS, DONs, and charge nurses), and others to translate the adapted FAST score into identifying highest ability to function in ADL and leisure activities. But as stated previously, sometimes it is difficult to determine a person's dementia stage because of behavioral, sensory, or physical complications. In this situation, it may be necessary for the therapist to intervene to identify highest ability to function (administration of the Allen assessment and other functional performance components) and to create a maintenance program that will integrate into the care/service plan.
The facility staff must receive extensive education for success. Education must include:
- Assessment training (adapted FAST and Allen as appropriate)
- Understanding how each dementia stage translates to best ability to function
- Understanding how to provide approaches to match each stage of dementia
- Understanding how to adapt communication for each dementia stage
- Understanding the key role the environment plays in function and maintaining safety for each dementia stage
- Understanding the relationship between dementia stage and prevalence of problem behaviors and corresponding prevention strategies
Education should be provided by the facility, and some education can be provided by the therapy team through participation in staff inservices. In any case, it is imperative that facility staff have an understanding of dementia stages in order to competently deliver therapy maintenance programs, care plans, and to be able to provide accurate feedback to help identify a resident in need of skilled therapy interventions.
Of course, we must never forget the importance of maintaining the integrity of our care program. I recommend routinely integrating aspects of the dementia care program into quality assurance meetings. Ongoing observation and analysis of the following dementia program components is very important:
- Consistency and accuracy in identifying each resident's cognitive level and highest ability to function
- CNA, nursing, and activity staff follow-through and competency in implementation of maintenance programs and care/service plans
- Skilled therapy utilization as it relates to resident need
Recently, I conducted a marketing exercise with one of my assisted living clients. We mystery shopped our competition to learn what their approach to caring for "my mom with dementia" would be.
We were TOLD about their "cookie cutter" approach to dementia care. Some seemed to share a little more knowledge than others but all talked AT us, sharing only vague and generic information about their care for the person with dementia. They never asked us anything about our "mystery mom." They never told us HOW they would individualize care for our mom because frankly, they probably don't know how.
We then called our prospects and explained to them how we would individualize care for their mom (a) integrate their loved one's life story into their daily activities and ADLs, (b) how we will adapt valued (ADL and leisure) activities to their mom's cognitive and physical level, and (c) how our therapy team has specialized dementia training to help their loved one maintain physical and cognitive health, and functional abilities, longer.
Guess what? We hit a home run! Each prospect/family we called indicated they wanted to come in and learn more about our community. This included families who initially said they already made another choice and placed their loved one somewhere else. Even though they already moved their loved one into another facility they had "hope" that we would provide a better quality of life. What a powerful marketing advantage. And, a skilled therapist is often at the heart of every successful dementia care program.