A setting for severe Alzheimer's.

MANAGING SEVERE ALZHEIMER'S DISEASE IS WHERE ASSISTED LIVING FELL SHORT - UNTIL RECENTLY

In the early 1990s, when the assisted living concept was relatively new, it became obvious that a segment of the population was still being forgotten. Alzheimer's patients, particularly those in the advanced stages of the disease, had no environment truly designed to meet their needs. Nursing homes could care for their medical needs, but those with dementia have very specific social and behavioral management needs. The assisted living model offered an option, but facilities were being designed more to care for the frail elderly and those who needed daily assistance. Without 24-hour, licensed nursing care, assisted living residences couldn't meet the needs of those in the late stages of dementia.

I knew the industry could be serving those people better. I had a long history in the care industry, having served as president and COO of a worldwide company specializing in psychiatric centers. I grew up on the grounds of a family-run behavioral health facility with what I realize now was, at the time, a state-of-the-art dementia wing. But to design an improved concept in Alzheimer's care was going to take a team of the industry's best. Once I had the initial members of that team, all experts in their fields, we set forth to create Silverado Senior Living.

Before we developed the first Silverado community, the management team wrote out the company's core values and ideologies. We wanted our facility to recognize value and build the human spirit in all we do. Our residents needed to feel useful and important. We knew even those in the advanced stages of the disease could feel the thrill of daily accomplishments. It was our theory that if we could reestablish a sense of dignity and life-purpose within this population, we could reduce behavioral problems, cut back on psychotropic medications and improve physical and mental well-being in a restraint-free environment. We were right.

In June 1997, we purchased an underperforming, 90-bed assisted living facility in Escondido, Calif. Within a year and a half, we have achieved solid, measurable results showing that our model works. Twenty-one residents who came to us unable to feed themselves now do so with minimal or no assistance. Thirty-one of those who arrived nonambulatory are now walking. Some residents have even regained the ability to remain continent. Meanwhile, we have cut the use of most psychotropic medication in half, with one in four residents receiving none at all.

Our clinical outcomes are more impressive when you consider our population. We have become the last stop for many families whose loved ones are considered "problem" residents, the kinds of residents often hard to place because they are disruptive, combative, uncooperative or have special medical needs. At Silverado Senior Living, we call these "miracle residents" because, with the proper care, almost all see some improvement in their condition. More often, families are amazed at how much improvement is possible.

How have we done it? It is a combination of many factors. The facilities are uniquely developed for this population and decorated in a fashion more homelike than I've seen elsewhere. We even did away with the nurse's stations, which can seem fortress-like and pose as barriers to residents. Instead, we have medications hidden away in locked supply closets, and staff complete their paperwork in a country kitchen while still interacting with residents. This might be intrusive on our staff at times, but we want to create a family atmosphere, and family life inherently involves unpredictable interruptions.

We have walking trails specially designed with various textures to create the feeling of covering greater distances. There are attractive diversionary gadgets on the walls, pleasant furnishings and plenty of age-appropriate activities. Yet, none of this would mean any-

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Each type of remedy has more specific criteria for imposition - for example, when imposing state monitoring, the state must consider whether "the situation in the facility has the potential to worsen." When determining the amount of a civil monetary penalty, the state must consider such factors as the "facility's financial condition" and the "likelihood that the CMP will achieve correction and continued compliance."

So, let's assume that the GAO report will conclude that many more enforcement remedies are proposed than are actually imposed. Does this mean that the federal enforcement system is ineffective? Not necessarily. It could mean that the threat of imposing enforcement remedies has the desired effect: encouraging nursing facilities to "achieve and sustain compliance." It could also mean that some deficiencies were inaccurate, resulting in a withdrawal of the associated enforcement remedy. It could mean that in 1995, states weren't very well organized yet, since the regulation only took effect July 1, 1995, midway through the calendar year. It could mean that the four states studied used state enforcement systems more effectively than the federal enforcement system, which was in its infancy.

One thing I am certain of: It will take more detailed, carefully designed studies, spanning several years and using a random sampling process, rather than a politically targeted one, to evaluate whether the states and HCFA have "achieved and sustained" the use of a fair and appropriate enforcement system. Everyone should carefully review the findings of the GAO study before leaping to conclusions.

Beth A. Klitch, FACHCA, is president of Survey Solutions, Inc., Columbus, OH. For further information, phone [phone]; write c/o Nursing Homes/Long Term Care Management, or fax [phone].