Thursday, October 10, 2013

When There’s No Family

When There’s No Family

I rarely write about advance directives and end-of-life discussions without a few readers asking, sometimes plaintively: What if you don’t have a family?
“The presumption is that everyone has someone available, someone most likely younger or in better health, and better able to carry out one’s wishes or make decisions with your guidance,” Cheryl from Westchester commentedthe last time the subject arose.
But not everyone does. Ten years ago, the American Bar Association’s Commission on Law and Aging looked into this problem and cited estimates that perhaps 4 percent of older adults are “the unbefriended elderly,” a chilling phrase referring to those who can’t make decisions for themselves, have no advance directive or surrogate decision maker, and have no family or friends able to assist.
Most of those aren’t computer-literate Times subscribers trying to plan ahead, like Cheryl. They’re primarily lifelong loners in hospitals and nursing homes, the report found.
But it’s an important question: If you don’t have relatives or close friends who can serve as your health care proxy or hold your power of attorney (which in most states involve two separate documents) are you supposed to resign yourself to whatever the emergency room physician or intensive care staff member decides to do, or not do, when you can’t direct your own care?
Even when you’ve written advance directives, someone has to bring those documents to the attention of medical personnel. That person may have to become a forceful advocate on an incapacitated patient’s behalf. If not a sibling or nephew, a friend or neighbor, who can do it?
One solution I’ve discussed before is a care committee: A senior recruits a cadre of friends and professionals, makes her values and preferences clear, and authorizes the committee to handle a variety of eventual decisions.
Steven M. Cohen, an elder law lawyer in Boston, has organized about 20 of these. “I can’t say the idea has taken off, but for the right person it can work really well,” he said.
Though most of his clients haven’t activated their committees yet — they’re still functioning well on their own — one man with Parkinson’s disease has experienced worsening symptoms. “As his illness has progressed and he’s withdrawn, the committee is taking more on,” Mr. Cohen said.
You can also turn to professionals.
You can appoint almost anyone your health care proxy; the exception is that 38 states plus the District of Columbia place some restrictions on treating health care providers or their employees. In some states, “your cardiologist can’t be your health care proxy,” said Charles Sabatino, who heads theAmerican Bar Association Commission on Law and Aging. Neither can a nurse-practitioner who works in your cardiologist’s practice, or a social worker employed by the nursing home where you live. In other states, all of the above could be.
But you can always ask an independent professional: a lawyer, especially an elder lawyer, or a geriatric care manager (generally a social worker who specializes in helping seniors manage their care).
The problem may be finding someone willing to shoulder that task. “Professionals are hesitant to get involved in this,” Mr. Cohen said. “You can’t make a more intimate choice for someone. It’s hard enough for families.” He’ll serve as a client’s decision maker occasionally, if he knows the person well, but doesn’t welcome the role.
Many elder lawyers feel that way, said Craig Reaves, former president of theNational Academy of Elder Law Attorneys. Being someone’s surrogate means being willing to drop everything when a crisis strikes, and to continue monitoring when a client is hospitalized or needs long-term care.
“This is not a job for which an attorney can ethically charge a fee that is anything near the attorney’s normal hourly rate, if any fees are charged at all,” he said in an e-mail. And, lawyers being lawyers, he worries about liability. Mr. Reaves has taken on the role at times, “but I do not seek this job out.”
Geriatric care managers seem a better fit; they’re comfortable in hospitals and nursing homes and charge lower hourly rates than lawyers. Karen Wasserman, director of Your Elder Experts, part of Jewish Family and Children’s Services in Boston, serves as surrogate for a 97-year-old Holocaust survivor with no family, and she’s starting to see healthy people in their 70s putting their paperwork together and asking her staff to take that role.
“I don’t see it as that big a leap,” Ms. Wasserman said. “Often, it’s continuing the work we do anyway, advocating for our clients,” whom the staff has often known for years. “It’s often an honor to be there for these people. It’s part of the deal.”
Yet three of the nine care managers on her staff are uneasy with the responsibility and decline to serve as health care surrogates. At LivHome, a geriatric care management chain with branches in seven states, company rules won’t permit the staff to be proxies. “Somehow, it just doesn’t feel right to me,” said Bunni Dybnis, director of professional services.
Of course, courts can appoint legal guardians or conservators for incapacitated seniors, and guardians — often attorneys or geriatric care managers — can then make decisions on their behalf. But most seniors don’t want to relinquish their autonomy in that way.
If you’re thinking this all becomes a bit of a muddle, I agree. It’s another way in which our traditional cultural expectations for aging — the Waltons-like family nearby pitching in to provide care and guidance – clash with the reality that more than a million older people may lack available family or friends. Extended life spans mean that people may have outlived their relatives, and many of them will suffer dementia.
Given that this situation will likely worsen for the baby boomers — who had fewer children, more childless marriages and more divorces — we may see the rise of professionals serving as clients’ late-life surrogates. How individuals will pay for that is another question.
Meanwhile, people trying to plan ahead for aging without family will need detailed advance directives and a P.O.L.S.T. form as they near the end of life to tell physicians what to do. Then they’re also going to need luck in finding a committee or a trustworthy professional willing to take on this daunting responsibility.
“We’re in this interim period,” Mr. Cohen said. “And we don’t have good answers for people.”

Paula Span is the author of “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.”

Till Death (or Decorating Disputes) Do Us Part

New York Times

September 18, 2013

Till Death (or Decorating Disputes) Do Us Part

Mendocino County, Calif. — Twenty years after they embarked on an experiment in communal living, the members of Cheesecake gathered for an anniversary celebration over Labor Day weekend. Nearly 100 people — the seven who live here full time, six who are here part time, and assorted children, grandchildren and friends, including Laura Hartman, one of the architects who designed the complex — spent two days barbecuing, talking, hiking through the redwoods and competing to see who could bake the best cheesecake. (The competition was in honor of the community’s name, which is derived from a loose translation of Casada, the surname of the family who owned the 20-acre property at the turn of the 19th century.)
The younger and more adventurous among them slept in tents or tepees in the meadow (Ms. Hartman brought her own pup tent), while older visitors bunked together in the residential buildings or stayed in hotels nearby.
It was a fittingly multigenerational celebration for an idea inspired by the parents of some of the original members, who became increasingly isolated with age: no one should have to grow old alone.
In 1994, The New York Times reported on how those members, or “partners,” as they called themselves, had settled into their first year of life as a community (“Retirement? For 11 Friends, It’s Off to Camp”). It was one of a number of such experiments, known as cohousing communities, that were springing up around the country at the time, based on a Danish model developed in the 1960s.
The original group of 11 included four married couples and three women, all in their 50s and 60s, each of whom agreed to pay a monthly fee for the mortgage, taxes and insurance on the 6,000-square-foot complex, as well as a small daily usage charge for utilities whenever they were in residence (food and phone bills were handled individually). Bedrooms and some bathrooms were private, but nearly everything else was shared, an arrangement that seemed feasible given the longstanding friendships of most of the members, who had started a cooperative nursery school for their children when they lived in Southern California in the 1960s. Still, there were three buildings in the complex (two that contained common areas and private apartments and one where residents could pursue their hobbies), because, as Ms. Hartman said in the 1994 article, “Everyone under one roof made people nervous.”
How did the experiment turn out? On the 20th anniversary, the consensus was generally positive.
As Helen Papke, 84, observed, it has been a lesson in patience. “When it’s good, it’s so good,” she said. “And when it’s bad, it’s so bad, the angst and argument we have with each other. But we have a conviction to work it out — and we will.”
Dick Browning, 78, whose wife, Louise, died in 2007, was more effusive. “I love it,” he said. “I love the community.”
Of the original 11 members, seven are still here, although apart from Ms. Browning, no one has died. (One couple and one woman left for personal reasons.) The community has taken on new members, so there are now 13 altogether.
No one seems lonely, but some of the residents aren’t quite as energetic as they once were. Take Daniel Myers, a retired lawyer who moved in with his wife, Jill, in 1993, when he was 60. Now, he said, “I can’t get on the roof to get the leaves off, and I can’t chop wood.”
And needless to say, there have been plenty of compromises along the way. Even something as simple as cutting down a tree or buying a new dishwasher requires a consensus, or at least the agreement of three-quarters of the residents. And getting that many people to agree on anything can take a while.
Ask Sophie Otis, a clinical psychologist who is now 77, who had to lobby for almost two decades to get rid of the tree obstructing the view from her window. In 1993, when she moved in, it was only six feet tall and she could see around it. Ten years later, at 30 feet, it was starting to block the light. But it wasn’t until January, when it was 45 feet tall and threatening to fall down, that the community agreed to remove it, Ms. Otis said.
“They finally cut it down this year, not because of my problem with the view,” she said, “but because it was blocking the light and was a hazard in lots of ways.”
In matters involving the environment, Ms. Otis said, the community is divided into two camps: “Some are Druids, those who don’t want to change anything, and some are foresters, who can cut the brush back. Jill and Gaile are the Druids.”
Gaile Wakeman, a retired pediatric physical therapist who is 76, concurred. “I don’t want a single tree to be cut,” she said. “I don’t give on this. You cannot replace a tree that’s been here 300 years.”
Or as Mr. Myers said, “When you think about taking down a tree, we’ll have a fuss over it.”
The other thing residents tend to disagree about is money. And as is true elsewhere in the country, Ms. Otis said, “conservatives are those who do not want to spend money, and liberals do.”
But while these distinctions may resemble those between Republicans and Democrats, Ms. Wakeman noted, Cheesecake members lean to the left politically. “We’re all pretty liberal,” she said. “A Tea Party person would never live here.”
Most of the rules they established at the outset remain in place. Private quarters may be decorated according to personal tastes, but in communal spaces the majority taste rules. No one can inherit a membership in Cheesecake; members’ children must apply to join the group like anyone else. And these days, buying in to the community costs about $25,000 upfront, plus a continuing $500 monthly fee and an $11 daily charge for food staples, electricity and Internet use.
But time and infirmity have altered at least one rule.
Initially, members agreed that if one of them became seriously ill, he or she would have to go elsewhere for care, because Cheesecake wasn’t designed to function as a hospital or hospice. But when Ms. Browning, a retired school administrator, had open-heart surgery in 2003 and learned she had cancer the following year, the group changed its collective mind.
During the four years she was sick, when she wasn’t in the hospital or at her son Jonathan’s home in San Francisco, she was at Cheesecake. And when Mr. Browning, a retired school principal, brought his wife back after her 2003 surgery, residents began appearing at the Brownings’ door within the hour, he said: “They asked, ‘Can I be the one to bring tea to you?’ ‘Can I bring flowers every day?’ ”
After his wife died, he said: “I’d be in my room, grieving and crying. But I wasn’t alone.”
Cheesecake was envisioned for happier times, but for some of its residents it also seems to have made the difficult ones more bearable. As Marco Heithaus, the spouse of the Brownings’ son Jonathan, said: “When you lose a person, usually you grieve for a year or two. But there was so much support, Dick came out of his shell in six months.”

90-year-old Talladega woman, daughter arrested for burglary in Panama City Beach

90-year-old Talladega woman, daughter arrested for burglary in Panama City Beach

Posted: Aug 08, 2013 3:02 PM MDTUpdated: Aug 15, 2013 3:02 PM MDT
A 90-year-old woman and her 67-year-old daughter have been arrested for burglary in Panama City Beach.
Ruth Luker, and her daughter, Pamela Luker Mitchell, of Talladega, were arrested by Panama City Beach Police for burglary of an unoccupied structure.
The women spent four days in a condo at Aqua Vista Condominiums, without the owner's knowledge or permission.
The women had vacationed at the condo in May, and apparently kept the room key.
They returned this week and made themselves at home.
When confronted by beach police, the women claimed they worked for the president and therefore had authority to use the room.

David Edward Benes Allegedly Tries To Exorcise 80-Year-Old Girlfriend

David Edward Benes Allegedly Tries To Exorcise 80-Year-Old Girlfriend

Posted:   |  Updated: 09/19/2013 3:54 pm EDT
David Edward Benes
Hey, they say it's important to exorcise at any age.
A 54-year-old Florida man has been arrested after allegedly trying to perform an exorcism on his 80-year-old girlfriend.
Police say on Monday, David Edward Benes grabbed the woman at the home they share in Holiday, holding her down and telling her he was going to "exorcise her and get the devil out of her," the Tampa Bay Times reported.
He then allegedly took her car keys and "dismantled the garage" to prevent her from leaving, according to an affidavit obtained by The Smoking Gun. The complaint also states he took the batteries out of all the phones in the residence so she couldn't call for help.
The woman said that when she fell asleep, Benes began "exorcising" her, though it's unclear from the complaint exactly what that entailed.
It's also unclear who ultimately contacted police, but according to the Times, authorities found her crying outside of the home with bruises and scratches on her arms. Benes was passed out drunk on the couch at the time and was charged with battery on a person 65 years or older and false imprisonment.
The couple has been together for three years.
Exorcisms can be dangerous, and not just for the alleged demons that ail you. In June, a Wyoming woman involved in an exorcism stopped breathing and went into cardiac arrest. She survived, though there's been no word on the condition of the poltergeist.

80-Year-Old Woman Reportedly Arrested for Selling Crack Cocaine

80-Year-Old Woman Reportedly Arrested for Selling Crack Cocaine

An 80-year-old Alabama woman has reportedly been arrested for selling crack cocaine for a second time, authorities said.
Ola Mae Robinson, of Prichard, Ala., was arrested Wednesday after officers executed a search warrant at her home and found an unspecific amount of crack cocaine and pills. Robinson, who was arrested in June on drug possession and distribution charges, denied selling the drugs, WPMI reports.
"Who? No! I don't have time for no crack cocaine," Robinson told a reporter when asked if she sold drugs from her home. "Wish I was, cause then I'd have money."
Prichard Police Chief Jimmie Gardner said it's never easy to arrest an elderly resident.

"It's tough because for all of us, we look up to the elderly community to be smarter, wiser, and responsible but unfortunately, I think she has a long history and age hasn't made a difference," he told the station. 

Virtual Clinical Day CNA class

Sunday, October 6, 2013

Dining Done Right

Dining Done Right

The kind of changes a facility makes to its dining service should depend totally on its clientele.

There are so many options when deciding what is best for an entire community. For example, determining the right type of services for the community and changing them as the population changes will be the key to whether the dining program is outstanding or just serves meals. Understanding what flexibility the community can offer will only enhance the meal service, and it can be as simple as allowing a customer the option to sleep in a little before breakfast.

Identify Facility Customer Needs

Before considering dining options, it is important to take a step back and determine what types of customers are being served by the community. The most frequent customers in senior living are independent living, assisted living, health care (nursing facility), short-term rehab, and adult day care.
Each of these groups has different needs and different expectations.
Most health care residents lived through the Great Depression, while incoming independent living residents and rehab patients are more and more likely to be baby boomers.
Knowing this can impact the service style. Start with the understanding that the more resident/patient types there are, the more certainty there is that one type of service will not provide excellent service to all.
As the process begins, first examine the existing dining system. Take a good look at whether the residents appear to like it or if they were conditioned to accept it because there was no other option.
Next, concentrate on what can be done with the current layout of the dining system and plan for the future. How can the physical design of the community support ways to meet the desires of current and future patients/residents?
This table describes service options, along with a brief description and notes to consider when deciding on additional dining venues. Any one of these can be combined with others. A chart outlining equipment that will be needed for each dining option is available.

Program Options

Changing the type of service the facility offers, or where it is offered, doesn’t mean that everything changes. The amount of food produced won’t change, nor will the number of customers. Food costs shouldn’t change.
Staffing levels usually remain the same, although staff will do their work differently. Duties may change, but each staff member will still have a group of tasks that fills his or her work day.
When considering the change to “open dining,” one recent senior living community client raised a very common question: “How do I get people to the dining room early when I have to get all my residents up by 7:00 a.m.?” The response to this was: “Why do you have such urgency to get everyone up by 7:00?” That response was: “Because they have to have breakfast early to meet the time frame for dinner.”
But when she was reminded that there were five residents sitting around at 6:30 a.m. and how, if at least beverages and cereal had been offered to those who wanted it, breakfast had really started at 6:30 a.m., thus relieving the later morning breakfast rush by accommodating early risers.
In the end, the spark lit, the client embraced the concept, and structured mealtimes are now a thing of the past in that community. This example shows how the thought process needs to change so that the benefits can be understood by all. 

Get Staff Support

The biggest change—and challenge—is how staff perceive the impact that changes will have on them. The buzzword is culture change.
An important component for dining services is nursing staff understanding that food service is a component of patient/resident care. 

Involve Everyone

Nutrition status is a component of the same care plan that addresses medical and social care. The dining aide, hospitality aide, cook, and other staff members often have difficulty seeing themselves as part of the resident/patient care team.
Changing mindsets is a culture change challenge that needs to be met. Planning changes so each group understands the full impact on them before implementation goes a long way to getting their support. This includes making as many changes as possible at the same time so staff are not always wondering, “What next?”
During the consideration of options and plan development stages, keep everyone in the loop and explain options, and then plans, to the entire community. Take advantage of the change as a reason to address issues and areas that may not have been accounted for. Turn staff into marketing ambassadors by allowing them to feel like they are part of the process.
There are many ways to provide dining service. These should be a starting place with thoughts and recommendations to help a company move toward its goals. Stay aware of how the center’s customer base is changing, and be ready with a plan of change to meet their needs.
The age-old business proverb, “What was good enough to get you there isn’t good enough to keep you there,” should be the mantra for modern-day dining services.
Wayne Toczek, chief executive officer of Innovations Services, Norwalk, Ohio, can be reached at (419) 541-7288.

Resident Choice Made Easier

Resident Choice Made Easier

A new tool enables better care planning, delivery, and quality management for older adults.

Now that person-centered care is becoming the new standard in post-acute and long term care settings, providers are increasingly shifting away from the traditional medical model toward a new focus on improving consumers’ quality of life. However, making this cultural shift—to meet individualized psychosocial and physical needs—can be challenging. Providers need practical, efficient tools to translate the vision of person-centered care into on-the-ground reality.
A team of researchers and clinicians at a senior care provider in Philadelphia developed a new assessment tool that captures the psychosocial preferences of older adults and speeds the adoption of more person-centered care practices.
Known as the Preferences for Everyday Living Inventory (PELI), this useful rubric yields vital data about older adults’ individual preferences for social contact, personal development, leisure, living environment, and daily routine.
It can also be used to assess health care access and family involvement in care and to help providers refine and customize care plans and service delivery.
Nursing homes may find PELI helpful as they shift from an institutional model of clinical efficiency toward a culture of greater responsiveness to residents’ wishes, interests, and desire for a sense of purpose and control.
It provides a useful level of specificity that can be deployed to guide staff training; measure quality improvement; and align services more closely with expectations of consumers, families, and regulatory agencies.

How PELI Works

PELI consists of 55 questions in five domains of daily life: social relationships, growth and diversionary activities, self-dominion, and enlisting others in care. Fourteen of the questions are consistent with the minimum data set (MDS) 3.0 for nursing homes but delve more deeply into residents’ preferences for everyday living.
Phrased in clear, conversational language, the questions elicit basic and in-depth insights about daily preferences, such as what time individuals like to wake up, take a shower, and get dressed, and what kinds of recreational activities they enjoy.
Professional and paraprofessional staff can administer PELI in one sitting, or over a series of conversations. Optimally, the questions are asked annually or at more frequent intervals, as well as when a person begins receiving service and experiences a significant change in status.
PELI is the first tool of its kind to pass rigorous scientific testing. In 2005, it was piloted with more than 500 home health clients enrolled in the Visiting Nurse Service of New York. The tool proved to be a reliable and valid measure of preferences and was well accepted by a wide range of older adults.
An advisory panel of long term care experts concurred that it covered the key aspects of daily life. While PELI has been tested in home health and nursing home settings, it is also designed for use in subacute, rehabilitation, and assisted living facilities. 

Residents’ Perspective On Sharing Preferences

In the pilot study, as well as at a 324-bed nursing facility, staff found that residents enjoy reflecting on what is important in their lives and appreciate the opportunity to voice their preferences to an interested listener. These kinds of focused, thorough discussions aren’t the norm in service settings. Yet they are deeply meaningful to consumers and form the foundation for comfortable, trusting relationships with staff.
Emerging research indicates that integrating preferences into care delivery for older adults is beneficial. When activities are appealing, or services are provided in a familiar way, seniors are more apt to be receptive, enjoy the experience, and feel validated. These positive feelings have a measurable effect on physical and mental well-being among people of all ages.
Data and insights elicited by PELI ensure that the consumer’s voice is heard and help the whole team—client, family, and staff—work together toward the same goals. At the nursing home, matching preferences to activities tripled resident participation in recreational activities.
PELI has also been used to assess broad-ranging outcomes. So far, its use has resulted in greater congruence between preferences and activities, leading to fewer behavior issues among residents, as well as reduced levels of depression and fewer falls.
Data are being compiled for a more comprehensive study of this dynamic.

Advantages For Providers

Direct care staff members use PELI to get to know consumers, build relationships, and devise more successful care plans. The questionnaire provides a consistent protocol to discover each client’s unique interests, passions, and priorities.
“PELI is a great tool for becoming better acquainted with new residents,” says Sarah Humes, a recreation therapy supervisor.
“It’s especially helpful for paraprofessional staff who may not have clinical training because it provides a way for them to learn more about the residents in their care and organize the information.”
The nursing home team divides up responsibility for different sections of the PELI questionnaire. Recreation therapists talk to residents about their activity preferences, and certified nurse assistants handle questions about activities of daily living. Staff implement what they learn immediately and share findings at team meetings where they collaborate to customize care plans.

A Positive Response

Humes says the process also improves job satisfaction. Findings inspire staff to stretch professionally to find ways to honor customer preferences. The tool asks seniors to talk about activities that they enjoy even if they feel that they can no longer do them. When the team understands what interests and motivates residents, they are eager to work collaboratively to prevent them from giving up treasured skills and activities prematurely.
PELI findings have also been used to assess individual practice, such as “Am I meeting Mrs. Jones’ preferences this week?” at the unit level. Recreational therapists now aggregate residents’ preferences on each 27-person unit household to plan program offerings that meet the group’s top shared priorities.
The resulting household activity board reflects residents’ authentic interests.
The nationally recognized Green House Project now uses PELI in its train-the-trainers curriculum for Green House adopters nationwide. Those selected to be educators, including nurses, social workers, and activity directors, practice using PELI with an older adult and create an engagement activity based on interview findings.
The exercise gives educators firsthand experience with deep listening and linking preference assessment to care.
“PELI provides specificity for a paradigm shift that’s key to forming deep, knowing relationships with elders,” says Susan Frazier, Green House Project chief operating officer. “It helps sensitize direct care staff so they can offer life-enriching experiences that are significant to each elder. For example, residents love being asked not just if they like to read, but what they like to read and how important reading is to them.”
A Philadelphia nursing home began using PELI this year to measure delivery of person-
centered care. Without a structured system to gauge resident preferences, activity programming reflects the recreational therapist’s best guess as to what a resident wants. Recreational options may be biased or limited by the therapists’ own interests.
PELI’s impact is being measured by examining progress on one or more areas of person-centered care in both PELI and the MDS 3.0. Although quantitative data aren’t yet available, anecdotal feedback indicates that preference-based care yields better satisfaction for families, staff members, and especially residents.
When a trusted, understanding caregiver presents activities or services in a palatable way, a resident is less likely to become frustrated, confused, or agitated and more likely to become meaningfully engaged.
Studies show that staying active and connected socially are closely linked with preventing or mitigating symptoms of depression in nursing home residents.

Looking To The Future

The Abramson Center research team continues to refine the PELI tool by testing it with diverse populations of older adults. They are also conducting studies on the impact of preference-based care on nursing home residents’ quality of life, as indicated by the presence of depression or behavioral symptoms.
The Advancing Excellence in America’s Nursing Homes campaign recently has announced new goals that focus in part on person-centered care.
According to Mary Jane Koren, MD, immediate past chair of the campaign, the initiative will include PELI as one of the resources offered to nursing homes as part of its evidence-based toolkit of interventions and educational materials. “It’s an intuitively straightforward tool that’s useful not just for the long-stay population but for the short-stay population as well, because it allows you to frame rehabilitation programs around patient preferences,” says Koren.
For More Information
Kimberly Van Haitsma, PhD, is director of Polisher Research Institute, Madlyn and Leonard Abramson Center for Jewish Life, Horsham Township, Pa. She can be reached at (215) 371-1895 or

GUEST COLUMN Daily Oral Hygiene Care Essential

 Daily Oral Hygiene Care Essential

Judith Jones, DDS
​Long term care residents with dementia deserve to have the following outcomes: comfort, dignity, safety, preserving function, and preventing new illnesses.

While every caregiver in long term care recognizes the importance of these five outcomes, their ties to good oral hygiene are not always obvious.

Among these five outcomes related to good daily oral hygiene are the following protocols:
  • Comfort: Clean, healthy tissue actually feels better. Every day everyone wakes up, has breakfast, and brushes their teeth and/or dentures. If they don’t, they have that grungy feeling. Good oral hygiene makes people feel better and more ready to face the day.
  • Dignity: Halitosis is offensive, and people with halitosis are likely to have poor oral hygiene. The anaerobic bacteria in gum disease produce offensive odors that make family members and friends want to keep their distance. Clean, healthy tissues smell better and support social relationships.
  • Safety: Broken or loose teeth and dentures or partials that don’t fit properly can be choking or safety hazards. By providing daily oral hygiene care, caregivers can identify safety issues early so that they can be remedied before becoming a serious safety issue. Thus, good daily oral hygiene promotes resident safety.
  • Preserving function: At a time when there are losses of function, preserving every capability is paramount. The ability to chew food so that it can be swallowed is one of these functions. Optimal oral health is supported by optimal oral hygiene. If the teeth, gums, and supporting structures are maintained, it is easier and more pleasant to chew.
  • Preventing new disease: Good oral hygiene helps to prevent new dental disease and the resultant pain and infection.
Residents with dementia must have an individualized daily oral care plan. If persons have natural teeth, the teeth must be cleaned twice daily for at least two minutes with a prescription fluoride gel (1.1 percent NaF gel). Prevident 5000™ is an example, but there are many others.

Flossing once each day would be a plus or use a small brush that cleans between the teeth. But brushing twice daily is essential. It is also important to concentrate on the gum line.

If the resident has dentures, dentures and oral tissues should be cleaned at least once daily.
Dentures and partials must be removed at night, cleaned, and stored in a cup of liquid. They should be rescrubbed in the morning, rinsed, and placed in the resident’s mouth.
Daily scrubbing of the dentures with an appropriate brush is what cleans the teeth. Denture cleaners added to the denture cup aid the process but don’t replace it. Denture cups need to be emptied and the water replaced daily.
Below are links to additional articles on oral health in long term care:

Perception Poses Barrier To Pain Management In Long Term Care

Perception Poses Barrier To Pain Management In Long Term Care

​Perception is key when it comes to appropriate pain management in long term care settings, according to a recent study in the United Kingdom journal, Nursing Older People.
The study, which sought to identify barriers to pain management in nursing homes, found that a patient’s inability to communicate because of sensory or cognitive impairment could lead to a significant hurdle in relieving pain.

For example, the study found that a patient who is experiencing pain, but whose behavior is commonly associated with dementia, can be misleading to caregivers.

The study utilized reports from nurses working in selected long term care homes in Ireland, who noted that patients’ attitudes, such as stoicism and the need to hide their pain from others, were a significant barrier to managing pain appropriately.

“Patient-related barriers were seen as interfering more often with optimal pain management than organizational-related or caregiver-related barriers,” the authors of the study said.

The inability to complete pain scales and communication difficulties as a result of sensory impairment were also common barriers.

“It is therefore essential that patients are encouraged to verbalize their pain to family and care staff,” the researchers said.

The solution, the authors posit, is a targeted approach to addressing the identified barriers. The authors advocate ongoing education on pain for all caregivers working in long term care settings, with particular emphasis on the practical application of observational tools, such as pain scales for patients with dementia.

Home Health, Elder Care Lead Jobs Growth

 Home Health, Elder Care Lead Jobs Growth

Home health care and “services for the elderly and persons with disabilities” were among the four fastest-growing health care sectors since 2012, according to new report from Chicago-based CareerBuilder and Economic Modeling Specialists International (EMSI).

Each has added at least 45,000 jobs nationwide in the past year.

Health care is the nation’s largest private-sector industry sector, accounting for 13 percent of the total U.S. workforce, adding more new jobs than any other industry since the start of 2012—at an estimated 365,000—the report found.

Occupations related to bedside or home care have had the biggest growth spurt, including: registered nurses (50,798 new jobs), home health aides (49,530), nurse assistants (13,097), and medical assistants (11,275).

Licensed practical and licensed vocational nurses (10,682) have also performed well, the report says.

“The health care sector makes up at least 15 percent of the total workforce in nine states and 20 of the most populous metros,” said Jason Lovelace, president of CareerBuilder Health Care, in a press release on Thursday.

Lovelace noted health care as a major source of employment across markets “that is expected to grow significantly over the next five to 10 years.”

States with the highest share of health care jobs are: Rhode Island (16.5 percent), West Virginia (16.0 percent), and Maine (15.6 percent). All three states have larger-than-average concentrations of residents 60 years or older, the report notes.

In six other states, health care accounts for 15 percent or more of all jobs: Pennsylvania (15.7 percent), New York (15.6 percent), Massachusetts (15.3 percent), Minnesota (15.2 percent), Vermont (15.1 percent), and Connecticut (15.1 percent).

Other state findings from the report: Washington, D.C., has the lowest share of health care jobs in the U.S. (8.4 percent) but by far the most health care jobs per capita (1,030 per 10,000 residents). In addition, Nevada has the second-lowest number of health care jobs (8.8 percent) but has the fastest-growing health care workforce among all states at 4 percent since 2012.

The analysis is based on EMSI’s comprehensive labor market data, a compilation of more than 90 federal and state labor market sources that tracks traditional employees and self-employed workers.
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Zeroing In On Incontinence Care Management

Zeroing In On Incontinence Care Management

To be successful, a program must have interdisciplinary involvement, including operations, clinical staff, therapy, and families.

achieving continencePost-acute care providers are functioning in a world of regulatory acronyms: QAPI, QIS survey, ZPIC, PPS, CERTs, UPICs, ACOs, and more, including programs to improve transitions of care and reduce rehospitalization rates.
Operational managers and clinical leadership in nursing homes are evaluating services, training, risks, and outcomes, as well as database content, on a daily basis to monitor outcomes for the elders they serve.
The issue of incontinence management and treatment related to incontinence is central to most of these activities and must be properly identified, treated aggressively, and monitored continuously to eliminate unnecessary cost and negative outcomes. This focus requires participation from operations, clinical staff, therapy, social services, direct caregivers, and families.

Continence Care Must-Haves

The issue of incontinence management is not new at all and has been a frequent topic of discussion for interdisciplinary team members in care conferences, team meetings, and when discussions of risk management and outcomes arise.
The current environment in post-acute care requires a more specific approach and understanding of the definitions in the minimum data set 3.0 (MDS), as well as coordination between related departments, to work to reverse levels of incontinence, when possible, and to minimize the negative outcomes for elders, including rehospitalizations and deterioration in quality of life.
Facilities are now more accountable for the data they transmit on the MDS because of the data references used by state surveyors, policy processes, and payment programs. This is a very expensive and common issue that facilities need to strive to understand, properly manage, and document, especially with regard to the impact of their interventions and programs.
When looking at the definition of continence in the resident assessment instrument (RAI) manual, May 2013 revision, it does not match the working definitions found in the majority of facilities. According to the MDS 3.0, continence is “total control of the release of urine or stool.”
This means that an elder who has stress or effort-related incontinence (urine leakage with a cough or change in position) should be coded as incontinent on the MDS.
The current Centers for Medicare & Medicaid Services (CMS) MDS frequency reports for the first quarter of 2013 show that 23.9 percent of all elders in skilled nursing facilities are totally continent.
This is a statistic that is just simply not true.
A review of F-Tag 315 uses the same definition and then goes on to explain the negative impact that any level of incontinence has on elders in the skilled nursing environment, with a focus on the identification of the type of incontinence, its cause, and treatment. Quality of life and quality of care are the goals, with an individualized approach that is undertaken by the entire team, as well as the family, when possible.

Restorative Program Required

Today, a significant number of facilities do not have active restorative programs that include toileting and retraining. Many have very little coordination between nursing and therapy for bladder and bowel retraining, while some have poor documentation of in-depth quality assessments at the time of admission to determine the true level of continence prior to hospitalization and after-hospitalization.
These are all important factors in the development of an active program to identify and reverse incontinence whenever possible. Elders must also be asked if they want to be continent and have control of their elimination.
According to an 80-year-old resident, newly admitted to a nursing home for rehab after a hip repair surgery, “I know I needed to have my hip repaired, but I did not sign up for this .... [having to wear a brief because of functional incontinence after urinary catheter removal]. I want my rehab to include help with my incontinence.”
The demographics of customers are changing, and the programs need to be there to meet their needs. These are elders who want to go back to their active, positive lives in the community—without incontinence. Nursing centers need to have excellent assessment programs and documentation at the time of admission and be open and interactive about the status of continence.
It is important to initiate retraining or scheduled toileting programs, as well as involving therapy, with strengthening and activities of daily living programs, combined with resident and family education, to support the goals and interventions in the plan.

Assessment Essentials

Careful assessment and identification of the cause(s) of incontinence are the essential first steps for appropriate and successful management. This assessment needs to involve several disciplines, including therapists, nurse practitioners, nurse assistants, nursing staff, medical directors, and dietary staff.
Assessment should be done at the time of admission to the facility and at any change in bladder and bowel status. The first step is determination and documentation of incontinence history on or before the time of admission. Staff should determine the resident’s continence status prior to admission or determine whether it occurred with the present illness, since urinary incontinence (UI) could be of several years’ duration. This requires a conversation with the elder or family
Although UI is not a normal part of aging, there are age-related changes in the lower urinary tract, such as that the greatest volume of urine is excreted at night, with two-thirds of daily fluid intake being produced by the kidneys at night. Bladder capacity is diminished with poor bladder emptying, and bladder sensations changes with age, causing a delay in desire to void, leading to bladder frequency.
Mental, functional, and environmental assessments are vital to the success of a restorative program. Cognition should be assessed to determine the ability of the resident to comprehend voiding needs. Knowing when the onset of lower urinary tract symptoms occurred, including urgency, frequency, nocturia, dysuria, post-void dribbling, and episodes of urine leakage, is important. The relationship between UI and medication use and medical diagnoses, such as diabetes, neurologic diseases, such as Parkinson’s or multiple sclerosis; prostate problems in men, such as cancer or benign prostatic hyperplasia; and chronic urinary tract infections, especially in women, should be detailed.
Facility nurses should perform a thorough bowel history of the resident to determine symptoms of constipation, fecal incontinence, and the use of laxatives, stool softeners, suppositories, and enemas. Per the MDS 3.0, an elder’s voiding and bowel pattern and frequency of incontinence should be assessed, so observation of toileting can be helpful.
In addition, nurses should perform a general examination to determine peripheral edema and gait abnormalities that may impact toileting, while an inspection of the genitalia should also be done to determine skin breakdown.
Assessments should lead to a plan of care. The classification of continence, as seen in Figure 1 (see page 63), outlines components of continence management. Centers should have well-defined policies and procedures to initiate and document toileting programs with nursing and therapy. 

Determine Staff Knowledge

Facility staff members need to address their knowledge of the topic and develop appropriate documentation skills to identify the type and frequency of incontinence at the point of admission, or before, as part of the key information they need to care for the elder.
Using the appropriate definitions for all staff and transmitting the accurate data into the MDS 3.0 database is the first step to create an accurate facility record.
Reading the facility database reports on the initial levels of continence, followed by subsequent changes in levels of continence as rehab and nursing services improve the resident’s function, gives the manager access to reportable outcomes. 

The outcomes of an active continence management program are very easy to identify and document.
If the MDS data are accurate, then tracking levels of success with toileting, ambulation, and balance programs—along with the goal of safely going to the bathroom; getting on and off the commode; control of muscles involved in elimination; and improved dignity, strength, and function—should  be straightforward.
Changes in ADL (activities of daily living) scores and symptoms of depression, as well as reduced rates of falls, can all be outcomes that are reportable and desirable in the data-driven world providers work in today. More independence decreases the stress on staff and lessens product use or the type and cost of products.
With regard to payment in case-mix states, restorative programs have a positive impact on Medicaid rates and support Part A rates with the use of the low rehab category after high- intensity rehab is completed.

Incontinence Products

Nursing homes need to evaluate their current products and the variety of sizes and types of products they use. It is essential to have incontinence products that are properly sized, with a variety of types available as the retraining program progresses. 

Staff education and training is also essential to delivering toileting programs, documenting outcomes, and elders’ responses. A toileting or retraining program should never be done to an elder, it should be done with the elder.
Scheduled toileting programs can be designed and delivered for elders with memory loss to diminish the number of incontinent episodes and develop a habit of voiding that matches the elder’s intake and activity patterns.
Proper reporting and documentation should include the outcome of a toileting program and the types and sizes of products used so that the care is consistent and connects with the plan. This will have a positive impact on survey outcomes.
Remember, the goal here is increased quality of care and quality of life for the elder, as well as a reduction of risk of falls, behavioral outbursts, moisture-associated skin damage, skin breakdown, and dignity issues. 

How To Get Started

It’s a good idea to begin with the CMS definitions and the staff’s knowledge base about continence and incontinence. Use the RAI Manual May 2013 definitions and the October 2013 updates. Assess bladder control issues at the point of admission, and inquire about the level of continence prior to taking a resident to the hospital. Focus on an accurate three-day voiding diary, and build toileting programs from that documentation. Involve the resident and family when appropriate, remembering that it is a matter of involving the resident with the program and not forcing it upon them.
Develop policies and processes for toileting programs, and include education for all clinical staff so programs can be delivered on all shifts with accurate documentation. Include the toileting program and need for muscle strength and retraining with rehab services. Analyze the data, and know what the database says about the issues and outcomes. Look for cost savings, improved outcomes, and increased customer satisfaction.
Leah Klusch RN, BSN, FACHCA, executive director, the Alliance Training Center, Alliance, Ohio, can be reached at leahklusch@sbcglobal.netDiane Newman, DNP, ANP-BC, FAAN, co-director of the Penn Center for Continence and Pelvic Health, can be reached at

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