humanizing the care of residents long term
DESCRIPTION
Humanizing the Care of Residents Long Term. Peter A. Lichtenberg, Ph.D., ABPP Director, Institute of Gerontology Professor of Psychology Wayne State University [email protected]. Thirty Years of Enhancing Personhood. Look back at behavioral approaches - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: Humanizing the Care of Residents Long Term](https://reader036.vdocuments.us/reader036/viewer/2022062309/568152e5550346895dc10460/html5/thumbnails/1.jpg)
Humanizing the Care of Residents Long Term
Peter A. Lichtenberg, Ph.D., ABPPDirector, Institute of Gerontology
Professor of PsychologyWayne State University
![Page 2: Humanizing the Care of Residents Long Term](https://reader036.vdocuments.us/reader036/viewer/2022062309/568152e5550346895dc10460/html5/thumbnails/2.jpg)
Thirty Years of Enhancing Personhood
• Look back at behavioral approaches• Examine Eden and Greenhouse models• Examine Personhood models• Understand organizational influences on care• Three C’s of everyday care• Tie it all together and discuss
![Page 3: Humanizing the Care of Residents Long Term](https://reader036.vdocuments.us/reader036/viewer/2022062309/568152e5550346895dc10460/html5/thumbnails/3.jpg)
OLD AGE IS ALWAYS 15 YEARS OLDER THAN I AM
BERNARD BARUCH AGE 84UNITED NATIONS DIPLOMAT
![Page 4: Humanizing the Care of Residents Long Term](https://reader036.vdocuments.us/reader036/viewer/2022062309/568152e5550346895dc10460/html5/thumbnails/4.jpg)
1st cohort toGrow old and beVisible in U.S.
Changes from 100 years ago:Life ExpectancyNumber of eldersIdea of com-Pressed morbidityDementia after 90
![Page 5: Humanizing the Care of Residents Long Term](https://reader036.vdocuments.us/reader036/viewer/2022062309/568152e5550346895dc10460/html5/thumbnails/5.jpg)
My early Experiences in a 180 LTC bed unit
• Referral: “Man throwing himself on the floor due to manipulative tendencies”
• What I observed1. Often lost balance and fell to floor (22 times per
6 hour period)2. Tearful3. Stopped eating—losing considerable weight4. Poor verbal communication skills
![Page 6: Humanizing the Care of Residents Long Term](https://reader036.vdocuments.us/reader036/viewer/2022062309/568152e5550346895dc10460/html5/thumbnails/6.jpg)
What we did
• Got neurology referral—he had untreated PD• Got speech language referral—voc-aid and taught
him to use• Increased his social interactions with staff and
depression remitted
• WHY HAD HE BEEN VIEWED IN SUCH A DEPERSONALIZED WAY?
![Page 7: Humanizing the Care of Residents Long Term](https://reader036.vdocuments.us/reader036/viewer/2022062309/568152e5550346895dc10460/html5/thumbnails/7.jpg)
78 year old man with Schizophrenia
• In state hospital since his early 20’s• Seclusive• Spent entire day lying in bedBehavioral Modification techniques used• Used a shaping technique to increase physical
activity• In one year improved from walking a total of 10
feet to one mile each day
![Page 8: Humanizing the Care of Residents Long Term](https://reader036.vdocuments.us/reader036/viewer/2022062309/568152e5550346895dc10460/html5/thumbnails/8.jpg)
PREVAILING VIEW OF FRAIL ELDERS
Medical v Community/Social model of care: Deficit model
•Passive•Sedentary•Close minded•Lost too much cognitive abilityResults•De- individuation•Fostering of dependency
![Page 9: Humanizing the Care of Residents Long Term](https://reader036.vdocuments.us/reader036/viewer/2022062309/568152e5550346895dc10460/html5/thumbnails/9.jpg)
RODIN AND LANGER (1976)
• Gave more control to residents over day to day events and compared them to control group
• Outcomes—group with choice engaged in more activity, reported more happiness, were rated as more alert
![Page 10: Humanizing the Care of Residents Long Term](https://reader036.vdocuments.us/reader036/viewer/2022062309/568152e5550346895dc10460/html5/thumbnails/10.jpg)
MARQUETTE COUNTY MEDICAL CARE CENTER PROJECT
• Depression Treatment and Prevention in Persons With Alzheimer’s Disease
• Peter A. Lichtenberg, Ph.D., Principal Investigator
![Page 11: Humanizing the Care of Residents Long Term](https://reader036.vdocuments.us/reader036/viewer/2022062309/568152e5550346895dc10460/html5/thumbnails/11.jpg)
MARQUETTE STUDY DETAILS
• New home-like setting created for persons with Alzheimer’s Disease
• Unit de-emphasizes “institutional” behavior and emphasizes individual, client-centered approach to care
![Page 12: Humanizing the Care of Residents Long Term](https://reader036.vdocuments.us/reader036/viewer/2022062309/568152e5550346895dc10460/html5/thumbnails/12.jpg)
MARQUETTE STUDY DETAILS CONT.
• Baseline:• Neuropsychologist blinded to intervention
assessed 23 residents from the 2 new AD units• Geriatric Depression Scale• Cornell Scale for Depression in Dementia• Behave-AD• Clinical Interview & DSM IV Diagnoses
![Page 13: Humanizing the Care of Residents Long Term](https://reader036.vdocuments.us/reader036/viewer/2022062309/568152e5550346895dc10460/html5/thumbnails/13.jpg)
MARQUETTE STUDY DETAILS CONT.
• Marquette County Medical Care designated ½ time person for further baseline work intervention.
• Pleasant Events• Mood Monitoring• Relaxation• Tx. ongoing for 3 months• Reduced behavioral disruption in pleasant events
vs control group
![Page 14: Humanizing the Care of Residents Long Term](https://reader036.vdocuments.us/reader036/viewer/2022062309/568152e5550346895dc10460/html5/thumbnails/14.jpg)
ACTIVITIES ENGAGED IN
• Pampering –massage, aroma therapy, hair care 27%
• Reminiscence-old photos, verbal discussion 22%• Social activity—one to one visiting, small group
18%• Physical activity—walking, fixing, gardening 16%• Quiet activity—watch birds, reading 11%• Correspondence—holiday letters, cards 6%
![Page 15: Humanizing the Care of Residents Long Term](https://reader036.vdocuments.us/reader036/viewer/2022062309/568152e5550346895dc10460/html5/thumbnails/15.jpg)
CONCLUSION
• Personal choice, 1:1 relationships enhanced well being
• Model not practical for broad implementation
![Page 16: Humanizing the Care of Residents Long Term](https://reader036.vdocuments.us/reader036/viewer/2022062309/568152e5550346895dc10460/html5/thumbnails/16.jpg)
Nursing Homes and the Medical Model: Bill Thomas
• Staff Hierarchy much like hospital• 3 Plagues of Long Term Care:1. Loneliness2. Helplessness3. Boredom
Challenge—creating the Eden team concept in a LTC facility
![Page 17: Humanizing the Care of Residents Long Term](https://reader036.vdocuments.us/reader036/viewer/2022062309/568152e5550346895dc10460/html5/thumbnails/17.jpg)
Creation of the Eden Alternative
• 1991 By Dr. William H Thomas and wife Judy Chase Thomas
• Chase Memorial: reduced medications, infections, staff turnover and mortality rate after Eden was put into place
• What makes the Alternative come to Life?
![Page 18: Humanizing the Care of Residents Long Term](https://reader036.vdocuments.us/reader036/viewer/2022062309/568152e5550346895dc10460/html5/thumbnails/18.jpg)
EDEN ALTERNATIVE COMES TO LIFE:
![Page 19: Humanizing the Care of Residents Long Term](https://reader036.vdocuments.us/reader036/viewer/2022062309/568152e5550346895dc10460/html5/thumbnails/19.jpg)
From Parking Lot to Activity Room
• Gardens/landscaping• Children• Animals• Person Centered activities
![Page 20: Humanizing the Care of Residents Long Term](https://reader036.vdocuments.us/reader036/viewer/2022062309/568152e5550346895dc10460/html5/thumbnails/20.jpg)
GREENHOUSE MODEL OF LONG TERM CARE
• Goal is to rethink:• Philosophy of care• Architecture• Organizational Structure of care
![Page 21: Humanizing the Care of Residents Long Term](https://reader036.vdocuments.us/reader036/viewer/2022062309/568152e5550346895dc10460/html5/thumbnails/21.jpg)
WHAT IS IT?
• Independent housing unit for 6-12 people with dementia
• CNAs are called Universal Workers• UW’s organize day in collaboration with residents• Other staff are wrap-around support services• 2006 RWJ awarded $10M across country to
increase number of Greenhouses• HOWEVER policies and funding models do not
provide support for Greenhouse model to expand even more
![Page 22: Humanizing the Care of Residents Long Term](https://reader036.vdocuments.us/reader036/viewer/2022062309/568152e5550346895dc10460/html5/thumbnails/22.jpg)
Greenhouse in Action
![Page 23: Humanizing the Care of Residents Long Term](https://reader036.vdocuments.us/reader036/viewer/2022062309/568152e5550346895dc10460/html5/thumbnails/23.jpg)
CURRENT STATUS OF GREENHOUSE
• 1700 in existence across the U.S.• Staff do more but for fewer people• “Get to know resident as a real person”• Less rigid schedule; meals, bathing• To date: studies show that care is similar to that
found in larger nursing home
![Page 24: Humanizing the Care of Residents Long Term](https://reader036.vdocuments.us/reader036/viewer/2022062309/568152e5550346895dc10460/html5/thumbnails/24.jpg)
Expressions of Personhood
• Pia Kontos and Gary Naglie—U of Toronto• “Expressions” of personhood• “discourse” over-utilized by us all in defining
personhood• Artistic expression under-utilized and appreciated• Current model--- as cognition declines so does
self-hood• Negative views of those with more severe
dementia in long term care and less caregiver engagement
![Page 25: Humanizing the Care of Residents Long Term](https://reader036.vdocuments.us/reader036/viewer/2022062309/568152e5550346895dc10460/html5/thumbnails/25.jpg)
Expression of Personhood Cont.
• Kontos’ ethnographic study claims that selfhood continues even after cognition declines
• Key challenge in LTC: Maintenance of Personhood• Kontos: Selfhood taps into “pre-reflective” levels
of consciousness• Examples: 1. Importance of gesture in communicating2. Body and facial expression3. Items hold unique and personal meanings to
residents
![Page 26: Humanizing the Care of Residents Long Term](https://reader036.vdocuments.us/reader036/viewer/2022062309/568152e5550346895dc10460/html5/thumbnails/26.jpg)
Artistic Expression as Performance
![Page 27: Humanizing the Care of Residents Long Term](https://reader036.vdocuments.us/reader036/viewer/2022062309/568152e5550346895dc10460/html5/thumbnails/27.jpg)
SUMMARY AND QUESTION
• Choice, personhood is important• Wonderful models created across past 40 years• Why is personhood still the exception rather than
the norm in care?
![Page 28: Humanizing the Care of Residents Long Term](https://reader036.vdocuments.us/reader036/viewer/2022062309/568152e5550346895dc10460/html5/thumbnails/28.jpg)
REFRAMING ORGANIZATIONS: BOLMAN AND DEAL
• 4 frames needed to understand organizations and most people only look at 2
• 1. Structural• 2. Human Resource
![Page 29: Humanizing the Care of Residents Long Term](https://reader036.vdocuments.us/reader036/viewer/2022062309/568152e5550346895dc10460/html5/thumbnails/29.jpg)
1. STRUCTURAL FRAME
• Metaphor: Factory/MachineDimensionsDifferentiated or integrated jobsCentralized or diffuse in responsibilityRigid routine/flexibility
![Page 30: Humanizing the Care of Residents Long Term](https://reader036.vdocuments.us/reader036/viewer/2022062309/568152e5550346895dc10460/html5/thumbnails/30.jpg)
2. HUMAN RESOURCE FRAME
• Metaphor: Family• Employees: Replaceable v Valued• Fit between individual and organization
LTC workers—high levels of meaning in work, low participation in team decision making
Structural and HR frame are rational—ways of organizing work and treating workers
![Page 31: Humanizing the Care of Residents Long Term](https://reader036.vdocuments.us/reader036/viewer/2022062309/568152e5550346895dc10460/html5/thumbnails/31.jpg)
3. POLITICAL FRAME
• Metaphor: Jungle• Power—ability to make things happen• Coalitions form—compete for scarce resources• Conflicts—win/win v win/lose negotiators• Power can be coercive and destructive if not used
wisely• (e.g. space shuttle Discovery; Housing crisis;
Nanny cam of Abuse in the Nursing Home)
![Page 32: Humanizing the Care of Residents Long Term](https://reader036.vdocuments.us/reader036/viewer/2022062309/568152e5550346895dc10460/html5/thumbnails/32.jpg)
4. SYMBOLIC FRAME
• Metaphor: Carnival, Temple, Theatre• Meaning• Hope• Faith• Core Values• “Culture in Organizations”• Symbols/rituals
![Page 33: Humanizing the Care of Residents Long Term](https://reader036.vdocuments.us/reader036/viewer/2022062309/568152e5550346895dc10460/html5/thumbnails/33.jpg)
REFLECT ON LTC AND YOUR PLACE OF WORK
• How do 4 frames influence policy, power, structure and meaning?
• Frail persons– weak in terms of powerful coalition; chronic under-funding of LTC
• Stability of administrators in LTC—poorest functioning organizations have least stability in administrators let alone direct care staff
• Negative stereotyping of LTC
![Page 34: Humanizing the Care of Residents Long Term](https://reader036.vdocuments.us/reader036/viewer/2022062309/568152e5550346895dc10460/html5/thumbnails/34.jpg)
PERSONAL HABITS IN DAILY WORK
• Steven Covey: 7 Habits of Highly Effective PeopleBegin with the end in mindSeek to understand before being understoodPut first things firstThink win-win
![Page 35: Humanizing the Care of Residents Long Term](https://reader036.vdocuments.us/reader036/viewer/2022062309/568152e5550346895dc10460/html5/thumbnails/35.jpg)
3 C’S TO PERSON CENTERED CARE
• Curiosity– who is this person, what was their greatest passion, what brightens them up
• Compassion– what is this person’s greatest fear, what causes them to suffer, what grief do they have, how lonely are they
• Contemporaneous– Be mindful in the present, be aware, present in the moment, come to each day ready to engage with residents and colleagues