An Insider's View

I love a good story. I particularly love those stories that make me think, over and over, for a good, long time.

Celia Berdes, a researcher and author, reviewed the new book "Dancing with Rose" with such enthusiasm that I'm going directly to Amazon and ordering it:

Dancing with Rose: Finding Life in the Land of Alzheimer's (York: Viking, 2007), a new book by Lauren Kessler, is the best book yet written on the lives of old people in residential care and the people who care for them,

Celia writes in today's Quality Jobs/Quality Care e-newsletter.

Here's more of her review:

Dancing with Rose leads us to this inescapable conclusion: that caring aptitudes and attitudes of skilled direct care workers are the most important components of high quality care. In a call for systemic reform, Kessler asks us to think about our own aging: ''If I do need help when I get older, if it becomes impossible for me to live independently, how do I want to live? Do I want to be cared for by an overworked, underpaid woman with so many chores to accomplish on her shift that she can barely spare a minute to talk to me? The important question is whether I--whether any of us--have the gumption, foresight, creativity, fearlessness, imagination, whatever it takes to do something about eldercare before it's our turn.''

Let me echo this. My theme, and I'll repeat it every chance I get, is to simply say that this is a personal issue for all of us. Who will care for my mother - for yours - when the day comes? Who will, eventually, be caring for you and me?

That's about as personal as it gets.

For Caregivers, It's All About the People

I shared with you earlier my memories of my first job as a nursing home caregiver. I was just 17, living away from home at a distant college, needing a job I could fit around my class schedule. Working swing shift seemed perfect – except for one small problem: my supervisor never once, during the entire semester I worked there, gave me a Friday night off – my one and only request when I started work.

I was trained by following an experienced caregiver for one shift. After that, I was responsible for feeding, bathing and assisting to bed 10-12 residents each evening.

Here’s the part that actually surprises me when I think about those days: I still remember the people. I remember the two young women with severe cerebral palsy, for whom we provided total care, including peri-care during their menstrual cycles. I remember the gentleman who became one of my favorites. I remember the people who really needed a two person assist, but whom I usually had to assist by myself.

This was over 30 years ago, and I still remember the people.

This reflects a lot of what we now know about caregivers in general: they’re in it for the people in their care. They’re not in it for the money, the respect or the leadership shown to them. It’s the people.

Imagine if we could enhance the money, increase the respect, offer multiple training opportunities and provide strong leadership?

What kind of a powerful workforce could we build?

Given the tools to excel, caregivers will be able to focus even more on the part of the job that defines them: genuinely caring for people.

Don't be a Technology Dinosaur

Let’s face it: most of us running companies providing care to seniors today didn’t grow up with a PDA or a mouse in our hands.

We probably don’t have Facebook or MySpace accounts, let alone thousands and thousands of “friends.”

If you’re like me, you may not even know how to load a video onto YouTube, although you have watched one or two.

But please don’t call us technology dinosaurs! We like to think we’ll adopt technology as soon as it’s tested and can be demonstrated to be of benefit – that very minute, we’ll be on board.

But just listen to what U.S. Senator Whitehouse (D-R.I.) said about us just recently at the Senate “idea exchange” sponsored by Sen. Harry Reid and Sen. Debbie Stabenow: “"the use of technology is worse in this industry [long term care] than any other industry except mining."[1]

Yikes! That’s not a flattering review of our profession.

Just to show you that I know how to do some cool things using technology, here’s a YouTube video of what one company, Ecumen, is doing to utilize technology:



Pretty cool stuff – and great press that gets the attention of seniors today whose number one concern is losing their mental functioning and consequently their independence.

But what about technology as it relates to training? What’s wrong with the old “stand-up-in-front-of-the-entire-staff-on-payday” approach?

Just a few things: using the same schpele for everyone, regardless if they are a week one or year 10 employee, missing those folks who are sick, sleeping or simply don’t show up, and checking how well your training worked by using a sign-in sheet for verification.

Why not dip your toes into the murky water of technology and check out online training? Like other aspects of technology, the cost is increasingly affordable, the implementation is quick and simple. And the results? One independent study found that game-based online learning was over 7 times more effective than traditional forms of training.

That’s something to think about when you’re ready to make the move away from the old way – the dinosaur way – to the new, modern way of providing senior care!
[1] As reported by Larry Minnix, AAHSA President and CEO in his message dated 9/13/07.

Choices

Here's one advantage to our jumbled system of senior care: we have a lot more choices now. Less than 50 years ago seniors either moved in with family or moved into a nursing home. There were no other options available.

Today, in-home care is readily available in almost every community in the US. Assisted Living has added another level of care to the mix, allowing seniors to live in an independent, residential environment while accessing support services. Granted, the level and type of support varies widely - from state to state and even from building to building - but no longer does a person needing care have to move into a skilled nursing community to receive assistance.

Barbara Quirk, a geriatric nurse practitioner, writes about yet another option that boomers may well choose in the future: shared housing arrangements.

The fact is that it is not a bad idea to consider moving in together with lifelong friends and hire whom you choose for your helpers. This may be a far better option than the traditional assisted living. For starters, you would be with people you know and enjoy, rather than strangers.

My immediate response is, "Yes, but then I'd still have to cook and clean!" I like the idea of someday moving into a senior living community where I simply show up at the dining room when I wish, and leave the day-to-day worries to someone else.

My mom has been living in a cottage in a retirement village now for over 6 months. She was sharing her experience with friends who had come to visit her for the first time - and who were speechless at how friendly everyone there was to them.

"We were just walking down the sidewalk and people would stop to talk. Come to find out, we have friends in common with more than one person living here!"

My mom is happy, has tons of new friends, and says she truly feels like this is now "home" for her.

My friend, on the other hand, receives calls daily from her mom who, recently widowed, is alone and lonely on her countryside home.

“I lied to my mom for the first time yesterday when I told her I was busy and couldn’t go with her on an errand,” she said. “I was simply worn out from daily calls for help – but mostly for companionship.”

Caregiver stress and the medical ramifications are well documented today. This stress affects families who are trying to balance it all, as well as paid caregivers who don’t have access to the training or support that they need to do a demanding, often thankless job.

I like what Barbara Quirk says in her comments about shared housing and other options we have now:

With all of the housing options available today, plus a few that haven't even been thought of, it pays to at least consider what would be acceptable to you.

And, perhaps even more importantly, consider – and discuss - what would be acceptable to your loved ones. Giving that some attention now may take some of the stress off all of us when needs arise in the future.

Working Together for Change

This Sunday is the annual Race for the Cure event in my home town (Portland, Oregon). It’s an event I’ve been participating in for several years, and one I’ve encouraged my daughters to attend with me year after year.

The first time I attended the Race I spent the entire time in tears – what an emotional experience to see so many women, moving together with a force that only comes from joining together for one purpose and one goal. At the time, I wondered what incredible things we could achieve if we put that kind of effort into other needed changes in society.

I often reflect on this experience as I work with senior care providers, training the next generation of senior care administrators, managers and caregivers. What a force we can be when we join together to achieve a goal!

Too often in this profession, however, we tend to want to protect our turf, and focus only inward. Instead of tapping into each others’ skills and services, we try to “reinvent the wheel” by doing everything in house. We miss the tremendous benefits we can gain by going outside our own circle and sharing our expertise, asking advice, or standing together for a cause.

The folks in Hendersonville, NC know the power of joining together to solve a problem. Instead of protecting turf and hording resources, they’re joining forces to reach out to impoverished seniors who cannot afford to purchase medical equipment – equipment that may make the difference, for many, between the ability to live independent lives or becoming dependant, increasingly frail seniors.

Carillon Assisted Living (1550 Charles Rd Shelby, NC 28152) is at the head of the pack, collecting donated items 7 days a week and working together with the Salvation Army and other area non-profit organizations.

Associations like the American Association of Homes and Services for the Aging and the American Health Care Association provide a vehicle for providers to join forces for change on a national scale, and in that manner those organizations have achieved amazing things.

As those of us who are both senior care professionals and aging boomers know, however, change starts right here at home, in my town, in our state. Working to improve the quality of care provided to seniors right here is a cause we can support – together.

A New Message for Senior Care Communities

The other day I had to stop by my physician’s office for a few inoculations before I take off on our upcoming trip to Indonesia. My plan was to run in, get my shots and run back out. My plan, as often happens, got waylaid – but this time for a very good reason.

Occupying a good share of the sidewalk in front of the clinic was a table loaded with fresh fruits and vegetables. A banner above the stand identified it as being from a local produce farm. The fruits and veggies looked fresh and fabulous. So I stopped – and I shopped. I brought home fresh corn on the cob, salad greens and nectarines – the best I’ve eaten all summer.

Since that day, the idea of stopping at the doctor’s office and picking up some fresh, wholesome produce on my way out has stuck with me. What an incredibly creative way to live your point: eat healthy, take care of yourself and you’ll need to see less of us! This was Kaiser Permanente, who is clearly living their new motto, “Thrive!”

Last week in Dodge City, Kansas, Kathy Greenlee, the Secretary of the Kansas Department on Aging spoke to a group of seniors about healthy aging. As reported in the Dodge City Daily Globe, the first question Ms. Greenlee asked the seniors in attendance was, “How many of you plan to go to a nursing home?”

Not surprisingly, no hand was raised. Ms. Greenlee went on to talk about the importance of taking responsibility of our own health, and eating well – lots of fresh fruits and vegetables being a key component of that advice – as one of the best ways to avoid needing long term care services.

Researchers have found that we can prevent many of the disease processes that cause long term disabilities and dependencies. The two most important things we can do to live long, healthy lives are getting regular exercise and good nutrition.

I have been wondering, as I reflect on the best produce I’ve had all summer, how we can incorporate this message in a meaningful way in our senior care communities.

What about sponsoring a walking club for residents, and inviting seniors in the general public to join in?

How about offering space inside our spacious lobbies or activity areas for local farmers to sell their produce?

What other ways can we creatively say to the public, “We’re here to help when you need us, but in the meantime, we’ll help you stay healthy, active and independent”?

This may be a message that helps move senior care from the dreaded place (“I’d rather die than move there”) to the mainstream (“I’m sure glad they were there when I needed them!”). It’s a message we need to be giving today, as we prepare for the needs – and the options – of tomorrow.

Honoring Those who Share Their Talents

Last evening I had the pleasure to share stories with John Wakeman, the Administrator of the Life Care Center of McMinnville, a skilled nursing center operated by Life Care Centers of America.

John and I talked about how managing a nursing home is a challenge, while being at the same time an honor and a privilege. I shared with John a beautiful story I had read earlier that day about one woman’s experience in the Alzheimer’s center where her mother lived: how her young daughter, experiencing the boredom common to kids visiting grandparents in a care setting, had wandered over to the piano and started playing the few songs she knew. Shortly she was joined by a group of residents who started singing along, over and over, the familiar songs the young girl was playing.

John shared how he played the guitar and enjoyed singing with his residents as well. He and I talked about how music seems to be such a universal, deeply rooted language, and how residents who can’t remember how to perform simple daily care functions could remember every word to a beloved song.

John also shared with me his upcoming weekend plan to hold a barbeque and picnic, and invited me to attend. John says he’ll be participating in all the activities – maybe even wearing a clown suit and sitting in the dunk tank.

As I was driving home I reflected that nursing homes are a lot like hospitals: places we all hope never to have to stay, but places we’re incredibly thankful exist if we need them. I also was thankful that people like John have chosen, as their profession, the challenging and often thankless job of running these centers, and daily put their hearts, souls and talent – from guitar playing and hamburger flipping to managing staff and dreaming up new ways to better serve the community – into their jobs.

Oh, and if you’re in the small, rural town of McMinnville, Oregon, nestled in the heart of Oregon’s great wine country, stop by the Life Care Center this Saturday afternoon for a little heartwarming fun.

Honoring the PROFESSIONAL Caregiver

Yesterday I shared some of my memories on the last time the staffing shortage in senior care was truly a crisis. Looking ahead, the aging of our society – and all of us boomers approaching our senior years – means that the shortage of the early 90’s could be a fond memory of times that really weren’t all that bad.

The other area that, I believe, ties in directly with this issue is our need to elevate the caregiver perception in the eyes of the general public to that of a profession, not just a lowly minimum wage job.

In practical terms this means not only talking about the profession of caregiver in our daily conversations with other professionals, but it also means honoring those individuals with the kinds of perks – and requirements – associated with other professionals.

Training, for example. Physicians have CMEs; nurses, attorneys and teachers have professional continuing education requirements. Many states have continuing education requirements for caregivers, but some of those requirements are so loosely enforced that simply reading a posting and signing that you’ve read it counts. Other states don’t address continuing education at all. Initial caregiver certification varies widely from state to state as well, with many states requiring no certification or licensure at all.

When I talk with owners and operators I often mention the need to offer extra training opportunities for all staff, especially caregivers, to give them the tools to become the best at their profession that they can be.

After all, for the most dedicated among them this is not simply a job, it’s their profession. It’s our duty - and our privilege - to begin to raise the respect for these individuals to a new level.

Caregiver Crisis Memories

I've been talking to a lot of people lately about two issues that are on my mind: The coming caregiver workforce crisis and the need for caregiver respect as a profession.

The projections on the coming caregiver crisis are dire; they make the shortage we experienced in the 1990s seem insignificant. I recall only too clearly what those days were actually like for an owner and operator of several senior care communities, which was my work at that time.

Before that time we had policies against hiring multiple persons from one family. During the shortage, we began asking every employee if he or she had a brother, sister, aunt or mother who would be interested in this work.

Before that time, we could keep our staff roster full with only periodic advertising. During that time, we put sandwich boards on the sidewalks that said “Now Hiring Caring People” – and left them there week after week.

Before that time we’d put two-line ads in the local newspaper and actually have applicants to interview and choose from. During the shortage, we got creative in our descriptions (“seeking people with a sense of humor only”) and ran ads in everything from the daily paper to the Nickel Ad sheets.

While we were trying everything we could to find people to fill positions, we were working every staff member overtime – lots of overtime. I worried constantly about fatigue and the results on the quality of care that a caregiver provided, not to mention the increase in abuse potential when a caregiver was exhausted.

And I have to admit we hired a few doozies, too. I remember a couple of people with tattoos from head to toe - neatly covered during the interview - that had colorful language and questionable motives for applying in the first place. Some got hired, and almost always we regretted the hiring choice.

Our managers worked night shifts, then came in the next day to do their own jobs bleary eyed and fatigued. We had residents who simply needed 24 hour care, and we had committed to providing that care to them, whatever it took.

Looking at the demographics, that experience was nothing compared to what is coming just ahead. Better Jobs Better Care reports:

Shortages of qualified, committed paraprofessionals are likely to worsen. In the coming years, the U.S. will experience a tremendous increase in the size of its­ elderly population as baby boomers age. At the same time, the number of middle-aged women who have traditionally filled these jobs is not growing fast enough to meet the increased demand for services. The result of these demographic shifts is an emerging "care gap" that could severely curtail our nation's ability to provide long-term care.

Tomorrow I’ll address the second part of my recent conversations: how to enhance the role of caregivers as professional. I can’t help thinking that these two subjects are directly linked, and are essential to our understanding if we’re going to make a real difference in the care we provide – and the care we receive.

Needed: Bold Leadership

Thanks, Larry Wenger (Workforce Performance Group) for your feedback on yesterday’s blog about the crisis of staff turnover.

Larry says, “In my 40 years of experience as a human services exec., I have come to believe that a large % of turnover is due to inadequate and poorly focused supervision...'people don’t leave jobs, they leave supervisors'.”

I agree, Larry. What’s needed in senior care today is true leadership.

Leaders who will make reduction in turnover – and the improvements in quality care – a priority.

Leaders who will be bold, and will make leadership decisions in implementing whatever technology is available to achieve bigger goals.

Leaders who won’t say, “I can’t require my staff to do anything – they’ll just quit” – but who will set up requirements along with incentives and rewards, and create a culture of going above and beyond the minimums.

Larry’s latest newsletter contains a quote that I needed today, as it’s the end of a week that held some frustrations and challenges for our team:

“We are all faced with a series of great opportunities brilliantly described as impossible situations.” - Charles R. Swindoll

Today, reducing staff turnover in senior care feels like an impossible situation. Perhaps, in reality, it is simply a great opportunity.

Caregiver Turnover - an Expense We Cannot Ignore

Do you realize that the turnover rate for CNAs in nursing homes today stands at over 70%? That means in a given year 7 out of 10 caregivers will leave their jobs – and the people in their care. That’s incredible – and an issue none of us can afford to ignore.

During my mother’s stay in a nursing home following her auto accident last fall she came to know her caregivers well. She listened as they told her stories about their kids and personal lives, and she shared her own stories with them. They got to know her as a person, and got to know her individual care needs and wishes.

My mother, mind you, is not only a lactose intolerant vegetarian but she is also a retired RN who worked her entire career in long term care. Meeting her needs in a way that met her standards was challenging, to say the least. Imagine the increased challenge to discover, just when she had one trained, he/she left only to be replaced by a “caregiver in training.”

Families rely on caregivers to notice when something changes in their loved one; when something seems a little “off” or when behaviors can signal a problem.

To the brand new caregiver, agitation might mean the doctor gets called and an order for an anti-anxiety medication gets added. For the experienced caregiver, this may simply have been an alert to a medical problem like a bladder infection that needs diagnosed and treated.

In fact, reduced caregiver turnover is directly tied to the quality of resident care and to client/resident satisfaction, according to Better Jobs Better Care, an organization focuses on improving the turnover rate among direct care staff and “contribut[ing] to improved workforce quality.”

BJBC found that, among other things, turnover costs the organization an average of $2,500 per person, racking up millions of dollars of costs that get passed to the consumer either directly, as a portion of the cost of care, or indirectly, as governmental programs reimburse care services.

In a recent article published in FutureAge (“The Business Case for Investing in Staff Retention”, March/April, 2007) David Farrell of Medical Hill Rehabilitation Center shared what happened when his community began to seriously invest in proven staff retention strategies (things like increased staff training – near to my heart – seniority wage increases, peer mentoring and more): “Over the past six months, as staffing stabilized, the results have been dramatic: Our annualized CNA turnover rate has dropped from 94 percent to 29 percent, representing significant savings.”

As the result of this savings, Medical Hill was able to increase staff wages (one significant factor in high turnover) without adding to overall expenses.

Investing in improved staff training and other turnover-reducing measures pays off financially, but it also pays off in a more significant way to those of us who need the services of a care community: it pays off in better care for our loved ones. And that’s a payoff we all have a stake in.

Challenges In Training Staff for Today's Caregiving Needs

My friend and colleague Keren Brown Wilson and I were recently discussing some of the most challenging aspects of preparing a work force to meet the caregiving needs of seniors today and into the future. As Keren pointed out, it's not like we're training people to do highly repetitive, step by step assembly-line tasks.

We're actually teaching people "complex judgment and decision-making skills", as Keren phrased it. Each task that involves another person, especially an elder adult, must be respectful of that person and responsive to his or her needs and rights.

That's why teaching someone to help give a shower isn't simply a "Step 1 - Step 2" process. I like to say that as soon as we complete the "Here's how to assist with a shower" lesson and send a new caregiver off to do just that, he or she will encounter something we never covered in this lesson.

What happens if the person refuses to shower? Prefers a bath? Wants a helper of another gender? Finds the experience frightening or overwhelming? As often is the case, the person sent to assist with the shower and the person being helped may have entirely different needs and agendas.

Clearly, we need to teach caregivers some more basic skills before we begin the lesson on bathing assistance.

We need to teach about basic resident rights - but more importantly, we need to give caregivers the tools to understand those rights. Although it may seem simple from the outside, when you're actually in caregiving situations there are many shades of gray; rarely is anything simply black and white.

The person who is being assisted with bathing has a right to refuse to bathe - but what about the rights of the other people who must share a table with him/her at mealtime? Do we then have the right to make the person who will not bathe regularly sit at a table all by him/herself, essentially isolating him/her from social interaction? How do we meet the health care needs of the person who is refusing to bathe, resulting in skin breakdowns or other problems? When does the person no longer have the right to refuse to bathe?

Trying to boil down caregiving training to simple assembly-line-style procedures results in some of the abuse situations currently making news, situations where the person did what he/she was taught, but didn't take into account the unique individual needs of the resident. (Here's an example where the caregiver may have simply been doing what she was taught - and now is facing the next 6 years in prison.)

How do we teach complex judgment and decision-making skills? Join us as we continue to explore that question, using all of the incredible tools we now have available. Through our team, we're using stories (helping caregivers understand the PEOPLE behind the tasks), situational decision making and games. We're exploring approaches using interactive multi-generational games to allow people to experience, in a safe but realistic environment, the options and choices that come with every task related to caregiving.

It's an exciting challenge - but such a necessary one if we're going to prepare the next wave of caregivers to provide the kind of care that we'd want for our loved ones - or for that matter, for ourselves!

Caregiver's Language of Caring

Clearly the topic of the words we use in talking about caregiving is a concern to many. Roy G. Gedat wrote,

This came up as a priority at the recent Direct Care Alliance national convention of direct care worker associations. 18 states were represented and our goal is "to help determine universal terms for DCW issues."

The words we use do reflect how we feel about people and about tasks. One of the words I've struggled with in the past is "resident" to reflect people who live in our care communities.

Although moving to "resident" is an improvement from "patient", I used to teach my staff to refer to the folks living in our assisted living communities as "the people who call this their home." It helped remind us that this WAS their home, and to communicate that to others, especially guests and prospective families.

The problem, of course, is that we've replaced one short word with 7 words - not an easy solution. As I look at many word suggestions for replacing other words that don't reflect our current view on caregiving, I see the same pattern. A challenge, clearly, if we are to replace words with new terms that gain broad usage.

I have to chuckle, speaking of words, at the creative language people use to talk about their experiences as members of the "sandwich generation." Colorful language - all in an effort to help communicate how truly challenging this role is for many of us.

Some have referred to feeling like an open-faced salami sandwich, lying face-down on the sidewalk. Others have talked about feeling like a smushed flat PB&J. Judy Steininger describes the feelings of living your life when, out of the blue, you get a phone call that a parent has suffered a serious mishap. Meanwhile, you're busy balancing your kid's soccer game and dinner for the family.

Just like that, you’ve become the newest member of the Sandwich Generation. If you’ve always liked your lunch served on wheat or rye, in the months or years ahead, you’ll learn to appreciate sourdough.

I think this generation is perfectly equipped to handle the task of creating a new language of caregiving. We're talking the Baby Boomers, Sandwich Generation - or whatever term you want to use - but we're talking about people who are all about creating a new language!