Resident Directed Care
Since the 1920’s, Providence Mount St. Vincent (PMSV) in West Seattle had been providing compassionate care to the elderly in a traditional medical model of care that proved to be extremely successful. Yet the Mount’s leaders struggled with the fact that the traditional system in long term care is designed to foster dependence. Many residents complained that they were experiencing the loss of independence, dignity, privacy, social interaction, and physical and cognitive ability. They were bored, lonely and often felt they had no control over their lives anymore.
With this in mind, the leaders at the Mount in 1991 decided to start over. After many, many hours of discussion and numerous drafts of the Mount’s strategic plan, the new vision became clear: a community directed by the residents. PMSV chose the term "resident directed care" as a means of capturing the essence of the values that are integral and consistent with the Mount’s core values and mission.
The Sisters of Providence Health System’s mission statement emphasizes that "....the healing ministry of Jesus in the world of today, with special concern for those who are poor and vulnerable. Working with others in a spirit of loving service, we strive to meet the health needs of people as they journey through life." This mission, combined with PMSV’s core values of "community, compassion, creativity, conservation and commitment," was key to this project.
Goals and Objectives
- The goals and objectives, as outlined in a three-year strategic plan beginning in 1992, were as follows:
- Begin a process of change to allow residents more choice and control over their care and their lives;
- Support aging in place for the residents living in the apartments as an alternative to the nursing center;
- Renovate the nursing center to accommodate a more home-like residential environment;
- Expand the rehabilitation services to meet the needs of both the facility and the community;
- Decentralize decision making in order to expedite problem solving among staff and residents as well as allowing the nurses more time to provide clinical care.
- Implement systems to improve employee recruitment and retention.
Impact of Change
The change to resident directed care involved every resident, client, family member, staff member and manager. It was first introduced to the residents of PMSV’s 111 apartments through an assisted living program called "Hand in Hand." Along with family members and staff, each resident (even the frail and those with dementia) determined how much assistance he or she needed.
"Hand in Hand" went through several evolutions --such as fee for service and a menu plan of services--until the final design was mutually agreed upon by all. Services were built into the fixed price and were negotiated for the apartment rent so that residents would not hesitate to use them because of cost concerns.
The psychological benefits of "Hand in Hand" proved to be extremely satisfying. Typically, residents were no longer asked to move to the nursing center because they were showing signs of dementia or because of incontinence. For many residents, the apartments had become their permanent homes. Home care and hospice were utilized in this model. The assisted living program allowed them to age in place and remain in their homes forever.
Concurrent to the assisted living changes, the Mount began a program offered as a benefit to many: the residents, employees and the community. In 1991, a child care center was established and housed within the building. This Intergenerational Learning Center gave residents the benefit of having more than 80 "grandchildren" close by as well as offering opportunities for the elderly and children to interact and play. In addition, an on-site child care center has proven to be a positive benefit to employee recruitment and retention.
Nursing Center Experiences Most Radical Change
The nursing center experienced the most radical change, both physically and philosophically. Prior to resident directed care, residents were assigned to floors based on their level of needed care. As they changed, they were moved to other floors, often causing transfer trauma. Resident directed care brought an end to this arrangement and a beginning of mixing the acuity levels of residents just as any community would have a diversity of residents. The neighborhoods were designed programmatically to be flexible in meeting the changing acuity levels of its residents.
Bed capacity was downsized from 215 to 173 to provide more open space for living. The long corridors were divided into separate, 20- to 23-bed units named "neighborhoods," each with its own theme and decor, such as art deco or a "ski lodge look." At the heart of each neighborhood, a large open area was built featuring a kitchen, dining room, lounge and staffing station called "care team area." In most homes, the kitchen/family room is where everyone seems to gather for meals, entertainment and conversation. It was the hope of the residents and staff that this new construction would convey this same warm environment.
Steam tables in the kitchen were installed enabling the staff to discontinue individual tray service and making it possible for residents to choose their food and portion size. This also ensured that residents were being served hot, fresh foods, and it eliminated costly food waste. In addition, new sleep and wake schedules were honored. If a resident decided to sleep in, he or she could knowing that breakfast would be prepared upon awakening. Residents’ favorite snacks were made available 24 hours a day.
Personal laundry areas were added to each neighborhood, providing an additional opportunity for residents to interact with each other as well as increase their physical activity. This eliminated the problems associated with centralized laundry such as lost clothing, delays and harsh treatment of clothing.
Other physical changes in the nursing center included the addition of whirlpool baths, a common space between neighborhoods for group meetings or recreational activities (such as a library, a horticulture therapy room and an aviary), and carpeting to halls and resident rooms to reduce noise as well as providing cushioning against falls and injuries.
Rehabilitation Services and Adult Day Health Program
The Mount’s rehab services were increased to offer enhanced services to residents and to the community. One nursing floor was divided into two separate programs: a 20-bed subacute, or transitional care, unit and a rehab wing that provided rehab services for residents and the community. In addition, the Adult Day Health Services, a day program for individuals from the community, was expanded to offer services for stroke survivors and others in need of respite care services.
While the physical changes were taking place, major organizational and program changes with the staff were implemented. A number of middle management positions were eliminated in order to provide additional resources for new staffing. Many employees were moved from management to direct service jobs. All floor staff received cross training in all household "chores" such as food service, laundry and housekeeping. Managers worked on the floors to teach by example and show employees that it was okay to accept risks: when a resident wanted to sleep in, he or she could; when a resident wanted ice cream in the middle of the night, it was served.
The neighborhood teams discovered they needed to become flexible, share responsibility and function like a family. Everyone pitched in when something needed to be done. Nurses served food or cleaned up in the kitchens as well as administering treatments and medications. Resident assistants (NAC’s) were hired to assist in all areas such as serving meals, leading activities or folding laundry with residents. Recreation therapists helped with rehab as well as other areas. All task-oriented positions were eliminated in order to provide more holistic care. A position called "neighborhood coordinator" was created to serve as a "mini administrator" in every neighborhood. Available 24 hours a day, neighborhood coordinators were hired to have full authority over daily operations. They were responsible for staffing, budgets, hiring, and firing--all aspects of management and operations. Staff schedules overlapped depending on resident needs, thus ending traditional "shifts." Decisions were made by the team and careful consideration was given to communication among the staff as well as the residents.
It has been demonstrated that a measurable link between changes in the physical environment coupled with staff training has increased social interaction among residents. For example, before the new model was implemented, more than 25 percent of the population ate in their rooms. That figure dropped to less than 10 percent after the remodeling.
- Residents were able to age in place, thus eliminating "transfer trauma" of moving to different floors.
- Each nursing center neighborhood was designed to become flexible in order to meet the change acuity levels of its residents.
- Activities in the new neighborhoods changed to reflect the preferences of the residents of that particular neighborhood. The number of activities in each neighborhood increased significantly.
- There was a decrease in resident and family complaints to the administrator, due to empowered staff (neighborhood coordinators) and residents and their participation in problem solving.
- The remodeled bathing and dressing areas offered more privacy and dignity to residents.
- Interaction with toddlers and children in the Intergenerational Learning Center, an on-site child care center, resulted in increased levels of interaction and reduced agitation levels when residents focused their attention on the children.
- Resident and family council meetings changed to become neighborhood based rather than facility-wide.
- Staff satisfaction became evident. Despite the industry average of 50 to 60 percent for staff turnover, PMSV began to experience a much lower percentage. In 1994, the rate at PMSV was 54 percent; in 1995, it was 39 percent; and in 1996, it was 37 percent.
- The use of float staff was greatly reduced and use of contract/agency labor disappeared.
- Staff cross training allowed greater pay and career ladder possibilities.
- Decentralized decision making resulted in the creation of neighborhood coordinators who became fully responsible for all management tasks. This allowed more time for nurses to provide clinical care.
- Holistic care was held in high esteem among residents, family members, volunteers and staff.
- Resident engagement, interaction and agitation were defined and a structured tool for evaluation was developed. Substantial improvement in resident interaction and a decline in agitation were observed following the implementation of resident directed care through a study conducted by the University of Washington Health Services Administration. A customer satisfaction survey was performed in all program areas with the Mount receiving an overall score of 4.11 out of a possible 5.
- Providence Mount St. Vincent provided more than $148,000 throughout 1996 in social accountability--consultations and meetings with other long term care facilities and professionals regarding resident directed care, assisted living, intergenerational learning center program development, program design, and in all areas affiliated with the Mount’s services.
- The Mount has received several awards for its innovative thinking including a National Best Practices award presented by the American Society on Aging and the Brookdale Center on Aging. PMSV was nominated by the Washington State Ombudsman’s office to receive this award.
In addition, Providence Mount St. Vincent has received the following recognition:
- Nursing Homes Magazine selected PMSV as "Best in Category for Remodeling and/or Renovation Projects";
- Featured on the front pages of The New York Times, The Seattle Times, and the Christian Science Monitor as one of the best nursing homes in the country;
- American Association of Homes and Services for the Aging (1997 Excellence in Practice Award);
- Washington Association of Homes for the Aging (1997 Innovator of the Year Award);
- Contemporary Long Term Care Magazine’s 1997 Order of Excellence Award for renovation; and
- Recognized in a U.S. Senate Special Committee on Aging as an example of a "best practice" facility.
Providence Mount St. Vincent is a vibrant and innovative facility serving nearly 400 individuals in a home-like atmosphere that emphasizes resident choice and capability. The management philosophy is customer-focused and emphasizes decentralized decision-making. Using the organization’s core values of compassion, community, creativity, conservation and commitment, we have created a new model for long term care.
A change in systems enables staff to put people before tasks and residents in control of much of their daily life. It provides a rich environment and help residents move back to a life in which they were accustomed. This approach builds on the strengths of people, both those who live and work in long term care. We believe this unique design will serve as a catalyst to create a more holistic approach to the residents in long term care facilities.
Because we believe that these changes can take place programmatically--not totally dependent on physical changes--our wish is to offer our experiences to other long term care facilities considering this model. We feel we are creating an environment for individuals which is as free from traditional limits as possible, and visionary in its autonomy, setting and plain, simple normalcy. Our goal is to continue to provide something our residents want--a home and a family.