St. John’s Skilled Nursing: Leading and inspiring a shift in society’s view of elderhood 1.

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St. John’s Skilled Nursing:Leading and inspiring a shift

in society’s view of elderhood

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The St. John’s AdvantageLearning from the success of a small home, with

innovation to lead the trends in health care

150 Highland Avenue

Penfield

Elders, Families, and SJH Agree:• We need consistent care teams who work with the same

elders every time they are here and who are able to support each individual elder in their daily desires and needs

• We need enough care team members to accomplish this (including evenings and weekends) and they must have access to the tools and training necessary to be successful (lifts, technology, access to create fun activities, food, etc. . . .).

• We need to pay the best employees top wages and support staff teams with training to achieve excellence

• Elders individual desires and needs should set the course for how our daily decisions are made in each household.

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St. John’s Small Homes are built to better Support Elders.

The Medical Model is insufficient: Skilled nursing has been living in a medical model of care for too long. This model misses the

mark when it comes to what people requiring skilled nursing desire (meaningful lives their way). Elders who need skilled services and the staff members who work in skilled service need a different model of service delivery to increase responsiveness, quality, and cost efficiencies.

Human beings need a meaningful home where their medical support is only a vehicle for them to live a meaningful life, not their reason for existing. Employees in helping fields also need a meaningful work experience that extends beyond “giver of medical treatment” to being something deeper, something more meaningful.

Elders have the right to live their lives in a way that works for them:

Paternalism and patronization have no place in skilled services. Every operational decision should aim to serve the elder in an honest, informed, and non-judgmental way. This forces conversations to center around individuals’ desires and the ethical implications of individuals who are living in a community setting.

Elders living with both cognitive impairments (dementia) and physical impairments can and should make decisions. The skill of active listening and responding to the desires of elders with dementia is imperative in innovative skilled care communities.

(by better supporting direct staff)

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What St. John’s believesUniversally trained staff members create a better caring environment: (Shahbazim)

People are best satisfied through deep recognition. This improves quality of care and satisfaction. This recognition is fostered by spending as much time in connection with others. Indirect support (meals, housekeeping, and activities should be done as close to those who care for the elder because it expands the depth of intimacy in relationships. It also simplifies the number of connections that have to be made by elders, their families, and the employees who partner with them. Caring communities need a close and continuous generalist support infrastructure to provide access to “specialists” when needed.

Enough Universal Staff Members, paid to succeed, and invested in by the organization:

Ratios of universal staff members should be flexible enough to respond to changes in needs. These needs vary from changes in activities to care. The intimate small household has the solutions and support to adjust according to needs. Innovations in pay models and development to lessen the impact of external stress will strengthen the operation’s ability to execute our mission.

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Fran’s Story

Fran was well loved in her traditionally supported home. There

were many tears from her family and staff on the day she departed to

move into a small home model. When her daughter came to visit one day, however, and found that Fran had

gone to the grocery store with one of the shahbazim (universal workers) to pick out some snacks, her daughter was so moved by the agility that this home allowed--a staff member was

trained and able to do something that would prove to be better than any

medicine or dietary intervention. This helped to maintain Fran’s weight despite her difficulty focusing on eating full meals without many

prompts--meaningful activities to find familiar snacks!

The Medical Model is Insufficient for elders needing skilled care

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A Shahbazims' Story:

Your Name here_ is an incredible Mom of 4 boys. She works full time as a CNA and loves the people for whom she works. The elders. After several years of connecting and saying goodbye, she starts to loose steam. She is

“doing people”- a slightly different or radically different assignment each time she works and her body and mind are tired. She starts calling

in and her manager puts her on disciplinary notice. She feels pretty alone in her job. There are some people who know her, but team work is dependent on who is working, and honestly,

she doesn’t always know who is going to be working with her.

Your name here becomes a Shahbaz, because she’s looking for something more. She works

with the same elders and the same team members each day. It takes some time, but it starts to feel like a real team, a caring family of people. And, her job is so much more than “doing people.” It’s growing people and she is

growing too. She even started a girl scout troop with a co-worker and they volunteer in

the small home.

The Medical Model is Insufficient for caring staff who work in skilled homes

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A Small Home Story

Small Home If I don’t feel well in a traditional home, I

can call in to someone on my team and they will help me cover my shift.

If I have a pattern of leaving the team hanging too often, they address it with me (with help from the Practice Partner/Neighborhood manager).

My team knows who is working when, and they started on a team with shared expectations, or were hired by our team to join us with shared expectations.

If we are having additional needs we can staff to it or we can collaborate with our neighboring households for support in the moment without a third party because we care about our neighbors.

Traditional Home

If I don’t feel well in a traditional home, I call in to a scheduling entity who tries to find a replacement.

My team may or may not know I called in.

They may or may not know who they are working with when they walk in the door. This is a great cause of stress.

If we are having additional needs, we can staff to it, but often that support is “pulled” to cover for call in’s, leaving us feeling powerless and angry.

We need enough of the right staff members, compensated for the versatile role they play

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Joyce’s StoryUniversally trained care staff members

( Shahbazim) create a better caring environmentMany people know Joyce, because she’s often looking for a way to go outside for a walk. Her well-being, like many of us, depends on getting

outside for a walk each day. Because of her fragmented care system in a traditionally

structured home, one person is responsible for her physical cleanliness, another for her meals, and

still another for her medications. The person “technically” responsible for her meaningful

activities sits with a staff member who supports 40 people part time. This makes daily strolls with this “responsible party” pretty hard to come by.

While resourceful, Joyce and her team have committed to finding staff who can enjoy Joyce’s company and also could use the outdoors daily,

but this team that needs the lessons Joyce teaches the most miss out--on the stories of her

past, her garden tomatoes, and bi-annual chili con carne cooking. These are things that she misses

the most about not being home.

In a small home, with enough universally trained staff members, this daily walk becomes a time for

Joyce to share who she is with the person who helps prepare her meals, who helps her get ready for the day, and who will support her the closest if

someday she can no longer stroll. It’s vital that this person know these stories as a part of Joyce’s

whole care.

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What St. John’s believes

Growth and development are never-ending:

Every human being should be engaged in personal growth that is meaningful to them. Innovations in skilled environments propagate opportunities for elders and universal staff members to grow.

Leadership of households and technical specialists employed by the organization commit to education and development of community competencies that maintain and develop better processes, better systems, and more adaptability in meeting individualized needs.

Smaller is better to meet individualized needs.

There is something that gets lost in 455 people that can be regained in a household or neighborhood-- intimacy.

Intimacy drives relationships, especially when you are living with dementia. Close and continuous contact are a must for success.

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Lou’s Story

“They can’t do that” should never be a part of our dialogue.

“How can I support them to do that” is the question at hand.

Lou pushed this envelope daily. He did this by taking his electric wheelchair through all

terrain, choosing to ignore traditional safety queues in exchange for his basic rights of

freedom and self-determination.

Lou was stymied in a home where he was “safe,” but unable to participate in the things he loved most about life: hunting, meeting

neighbors, and exploring wildlife.

Our job as care partners is to identify what makes elders tick and then figure out how to

support them to achieve it.

Without struggle, there is no growth.

Growth and development are never-ending

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Don’s Story- Smaller is better

A wonderful traditional home unit struggled to meet Don’s needs. He prefers to be alone, watches very specific TV shows, and his wife and he enjoy sharing meals. However, 24 other elders and anywhere from 15-17 staff supporting him during a given day shift (dining, laundry, social work activities, 1-2 environmental service, 4 CNAs, 2-3 nurses, dietician, unit secretary, MDS nurse) and 6+ evening and weekend staff made knowing people, learning his specific way of communicating, and meeting his specific routine very difficult.

After moving to a team where universal workers (Shahbazim) supported his day, consistency became the norm, and Don’s needs were met in a way that renewed his desire to visit his cabin on the lake and the same 6 primary care givers met Don’s needs all 7 days of the week during days and evenings.

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George’s Story “

“Once a wanderer always a risk.”

George moved in right before Christmas. He made quite an impression on the staff when he

realized that he wasn’t just helping his wife stay, he was here because he needed some help too.

He loved to threaten to leave. His family and the staff adored him, and were so worried that he

would “up and leave one day.”

He wore a watch for safety, and every time he would leave to go out with a friend, he’d ask the person with him when they were going to take

that darn watch off.

A month or so into his time with us, his daughter was staying with him. She and the team

brainstormed how to trial time without the watch because it was such a drain on his psyche.

After some trials, George got that watch cut off, and started signing himself out and back in with

some help from the staff members who loved and knew him.

Had he been in a smaller place, the fear would be much less, because less variables would have been involved, and George would have had his

individual needs met far sooner.

Smaller is better to meet individualized needs

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What St. John’s BelievesLoretta’s Story

Physical environment matters

The surroundings, colors, size, smells, and accessibility of a physical environment prompt the intimacy and connection needed for wellness in both elders and employees.

Innovations in environment involve adaptability, personalization, and familiarity, which are not found in traditional care environments.

“In the traditional home, Loretta was placed in a merry walker as soon as the team saw how mobile she was and how hard it would

be to keep her safe. She tried to get everywhere that wasn’t meant for her--

behind the desk, in the dining room which was closed, in others rooms, etc..

When she moved into a small home, she had universally trained staff members who supported her with her walker. She got

comfortable in the living room in a recliner much like the one she sat in at her home. She walked the household distances to the

dinner table, to her bedroom, and to the den when she needed some space.

She walks less now, but she still transfers to a dining rom chair at meals, and uses her wheel chair for the distances she can no

longer do, even with help.

Mary stopped walking after a fall, but recently , after almost a year of using her

wheelchair exclusively, she has been pushing to use her walker again.

Familiarity and accessible goals, with staff expectation of creating a real

home, shows improved function again and again.

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The Structure of ResponseYesterday, Today, and Tomorrow in a Small Home

Yesterday

N=455 Elders

“Whole house” efforts needed to respond to elders desires

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The Structure of ResponseYesterday, Today, Tomorrow in a Small Home

Today

CST and leadership from Two Households/ (one neighborhood) needed to respond to an elders desires

N=67-80 Elders

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The Structure of ResponseYesterday, Today, Tomorrow in a Small Home

House Nurse

<23 Elders

Shahbazim

1:5

Tomorrow:Small Home

A nurse or/and a Shahbazim are needed to respond to an elders desires

N=< 23 Elders

Shahbaz:

A specialized care partner who is trained in caring for a whole

person on an accountable team by ensuring an

individualized experience for meaningful meals, light

housekeeping, physical care, and meaningful activities

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St. John’s Small Homes Building on successes of first small homes

Successful Employees Elders Growth and Well-Being

Financial Stability

Current Home issues

• Staff retention (leaving between 6-12 months)

• Call off at >100 shifts/week• Staffing “short,” often evenings and

weekends, due to insufficient coverage for call offs

• Staff satisfaction at < 50% good/excellent

• 75% good/excellent satisfaction of families and elders

• Consistency in staffing assignments sporadic: impacts notice of change in condition

• 14% re-hospitalization

Strong after a tough couple of years

Penfield “Small Home”

• Staff retention at 100%• Penfield call off at <1 shift/week• Penfield “staffing short” at <1%• Staff satisfaction at 100% good and

excellent

• 100% satisfaction of elders and families

• Consistent staff; Investment in early identification of change in condition notification

• Successful survey• <1% re-hospitalization

Strong after tough start

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Changes for Rose

Two houses on the floor, 1 house on 6S– All Private Rooms

16 or 17 elders in a house on Res 6 22 Elders in a house on South 6 We will not kick people out of their rooms, but will offer

alternative rooms and will not fill doubles as they become available.

– Each house has its own living room and own kitchen. House specific staff members will be trained as

shahbazim and household nurses.– Changes in duties, scheduling, quality assurance process,

pay– Captain role will be transferred to other neighborhoods if

a shahbazim role is not desired

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Rose Time Line April May June July August

Action Start 6R 2nd Kitchen in the current TR room

Finalize ability to open 1S for a small home to focus on long term rehab

Post for positions for shahbazim

Start renovations on 2nd living room and full room renovations for 1st wave of resident rooms

Start work on current dining room--convert to a hearth room/multi-purpose room

Household Training for Shahbazim (5 days, each household trains together)

Finalize major common area spaces for each of the three houses (6S, etc.)

Impact on floor/ org

TR room will be out of use for 3-4 weeks

Open up LTC rooms by moving long-term rehab to 1S when staffing established

Hire / firm up internal staff fill for Small Homes

-8-9 resident rooms will be out of use for 3-4 weeks- We will address with the elders in those rooms what they desire (share a room on the floor/ go to a temp space for time takes to renovations/move to a new permanent floor

Current dining room will be out of commission. Alternative dining in one of three spaces--TR room or one of the two living rooms.

Some float staff to cover for training time

Begin operationalizing household team meetings, elder council in each house, etc.

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Review and Build on lessons

Sept-Nov: review elder/family and staff satisfaction; staffing impact; and clinical outcomes

Evaluate financial impact of small home conversion

Finalize timeline and room modeling for next neighborhood

All floors will be converted to small homes, minimally 2 more in 2016 Dahlia, Apple Blossom