"Risk Management": Heeding the New Mantra.

Assisted living providers are discovering that one of the unexpected side effects of rapid growth is the intense scrutiny they are suddenly receiving from legislators, regulators, consumers and insurance underwriters. With this increased visibility, many providers are also discovering that they are not immune from liability suits. In fact, over the past two years, the number of suits brought against long-term care providers has escalated dramatically. Insurance underwriters, unsettled by the number of suits and settlements, have chosen either to walk away from the industry or to dramatically escalate its insurance premium costs.

Accordingly, the new mantra of the assisted living provider is "risk management." There is one basic fact to realize, however: Just as we can't always eradicate disease and must therefore rely on prevention, the assisted living industry will never be able to eradicate the risks inherent in caring for an elderly and often frail population. That said, there is much that can be done to manage risk by preventing problems before they occur and minimizing the chances of unwanted litigation and liability suits.

The provider seeking to improve outcomes and minimize unwanted liability suits must effectively manage three types of risk:

* the risk of unrealistic expectations held by the family and resident

* the risk of resident injury caused by lack of staff training that identifies and minimizes risk through on-going assessment

* the risk of resident injury caused by failure to establish and enforce appropriate safety measures 

Risk Management Starts With the First Meeting

Early meetings with the family, resident and marketing staff are a "getting to know you" period that allows everyone to clarify their concerns and expectations. The marketing director might be tempted to "oversell" the services the assisted living community can provide--a temptation to be firmly resisted. Family members wanting to safeguard their loved ones' well-being often interpret "round-the-clock supervision," "we'll make sure she doesn't fall" and "she'll do so much better here" as ironclad guarantees. Worse still is the promise that "she'll always have a home here." When their loved one later experiences some of the inevitable results of aging or needs to be transferred to a nursing home, the family can feel betrayed and misled.

The assisted living community, resident and family members are much better served when an honest dialogue occurs that clearly addresses sometimes uncomfortable realities. For example:

* Life is terminal. Many families can expect to see deterioration in their loved ones' condition. Your assisted living community cannot prevent aging, but it can help residents maintain dignity and choice, while aging as comfortably as possible.

* Accidents do happen. You can commit to trying to make the environment as safe as possible through design and training, but you cannot guarantee a risk-free environment.

* A good way to prevent accidents is for families to communicate everything they know about residents' condition and preferences. This enables the assisted living provider to work with them to design appropriate care plans.

* It is critical to explain and document agreements regarding negotiated risk. For example, if Mother really shouldn't have sugar but insists on having hot chocolate each night, the family and caregiver need to work together to decide how to address this situation and not leave the situation to chance.

* It is important to be clear about the costs of additional services. While such services might not be necessary immediately, take time to explain what they are and what the incremental charges would be.

* There might be a time when the assisted living community can no longer provide the level of care necessary for a resident's well-being and would then need to transfer him or her to a skilled care facility. Families need to understand the conditions that can trigger this eventuality.

All of this is intended to convey the importance of establishing a good foundation of communication with the family, as a component of risk management. If you establish a relationship of trust and open dialogue with families, the likelihood of getting the information you need to best serve residents increases exponentially. This foundation also helps you and the families weather difficulties and challenges without resorting to accusations and lawsuits.

Train for Ongoing Assessment and Reporting

Training all caregivers and staff from orientation through skills in observation and assistance with daily activities is a critical component of any successful risk management program. Caregivers need to understand the aging process and be trained to observe and report any changes. For instance, specific training to handle the challenges of wandering and falls should be a component of risk management.

Equally important as skill-based training is communicating to caregivers the importance of their role. While one cannot guarantee that falls, wandering and other problems won't continue to occur, the number of incidents is likely to be greatly reduced when your caregivers understand the impact of continuous assessment and their role in preventive care.

Maintain a Safe Physical Environment

When a long-term care residence is designed and constructed, great care is devoted to maximizing the features that protect future residents from harm. Handrails, wider hallways, good lighting and flat walking surfaces are just a few of the design features incorporated to minimize the risk of resident injury. It is essential, however, to train staff to maintain the residence's physical safety and to report any problems they find, whether it's a loose piece of carpet or a burned-out light bulb. The ongoing role of staff in identifying physical risks to residents cannot be overemphasized.

Along similar lines, caregivers' intimate knowledge of each resident's habits and patterns make them invaluable observers of the impact of environmental change on a resident.

Risk Management Is Easy

Risk management is not very complex. It is simply the steps an administrator takes to build a strong foundation of communication and understanding with all parties involved. The time it takes to develop a good relationship with residents and families, plus the effective training of caregivers, is well worth the investment. Aside from reducing risk, this process helps to protect your facility from poor resident outcomes and to avoid the expensive and painful "cure" of lawsuits.

Resources Are Available

In response to the increased costs of insurance and lawsuits brought against the assisted living industry, the Assisted Living Federation of America (ALFA) has introduced a comprehensive Risk Reduction program that offers training, competency testing and consultation for providers through the services of ALFA University and TAGWEB, a risk management consulting firm.

David Peete is president of ALFA University.