Administrator has something extra: a nursing background.

According to this recipient of a 1998 ALFA Heroes Award, overseeing an assisted living residence takes an open-door and an open-heart policy

Bob Palma was prospering as a small business owner when, in 1986, he decided he wanted something more gratifying than a paycheck and began training as an emergency medical technician. After four years as an EMT, he became a licensed vocational nurse (LVN), applying his skills in the emergency room, in the ICU/CCU, in an open-heart surgical unit, as a nursing instructor for more than two years, and then as an assistant director of nursing for a nursing home. In April 1997 Palma's career path took another, relatively unusual turn: He accepted the position of program director at Arbor House, a 50-unit assisted living facility in Wichita Falls, Texas, part o Assisted Living Concepts Corporation, based in Portland, Oregon.

Assisted living administrators with a background in nursing are quite rare. At a conference held earlier this year, for instance, of 39 AL administrators in attendance Palina was the only licensed nurse.

The residents whose care Palma oversees - or tenants as he prefers to call them - are happy he left the business world behind 12 years ago to seek more fulfillment. He is a hands-on administrator who knows - and is known by - the people under his care.

Palma was honored by the Assisted Living Federation of America (ALFA) in April, when he was chosen to receive one of the organization's first annual ALFA Heroes Awards (given to outstanding front-line assisted living employees and volunteers in four categories: administrator, caregiver, staff member and volunteer). His success is also evidenced by the 80 to 90% occupancy rate at Arbor House - this despite the fact that the facility faces some extremely stiff competition. Five assisted living facilities (500 units total) were opened in Wichita Falls (population 100,000) about a year and a half ago; this in addition to one of the highest concentrations of nursing homes per capita in North Texas.

Arbor House Assistant Director Elizabeth Soto, who nominated Palma for the award, wrote, "We the staff and tenants of Arbor House feel Robert has made as much of an impact on our lives as assisted living has. [He] is always busy, but never too much to take the time to listen to tenants or family members, solve a problem, help someone with a task or just give a hug. As a licensed nurse, he is always on top of [tenants'] medical conditions and very helpful in any emergency situation.... Because of Robert's caring attitude, we the staff and tenants truly feel like we are home."

Nursing Homes/Long Term Care Managing Editor Linda Zinn asked Palma to discuss what prompted him to make the switch from nurse to administrator and to share some of the secrets to his success in a tight local market.

What was it about becoming an administrator of an assisted living residence that appealed to you?

Palma: The reason I moved from bedside nursing to my former position as an assistant DON was that I wanted to get some experience in long-term care - I felt it was the wave of the future. I also felt that if I could have a positive effect on people in the short time I cared for them as a nurse, I could have an even greater impact over the long run.

I realized how much effect just one person could have when I was still working as an ICU nurse several years ago. I was caring for a man who had developed an infection in his sternum after open-heart surgery and had undergone a sternectomy (removal of the sternum). I spent approximately one and a half hours each shift packing the wound in his chest. He couldn't talk or move, but I knew he was "in there." So I found out from his wife that he liked country music and tuned the radio to his favorite station whenever I was in his room. Also, even though he couldn't respond, I passed messages along to him after talking on the phone with his wife each day - letting him know his son was doing well and his farm was in good shape and his wife was praying for him and sent her love. After about a month and a half, he improved and left the ICU.

A year later a man walked up to me at the grocery store and said, "You're Bob, aren't you? I don't think you remember me. You took care of me in the ICU." With that he pulled up his shirt to show me the huge scar left by the sternectomy, and I knew it was the man who loved country music. He started crying and said, "I'll never forget how you took care of me and treated me like a person and not a piece of meat, and even played the music I liked."

The lesson I learned - that the seemingly small things we do for people can have a big impact on their lives - has never left me, and it serves me well in my responsibilities today.

What added qualities do you feel you bring to your present position as a result of your years as an EMT and a nurse?

Palma: First and foremost, it would be compassion and experience with dealing with ill people of all ages, including the elderly. Having medical knowledge also helps me in assessing tenants who have underlying health conditions influencing a behavior or other problem. In addition, I feel I can support our nurses in a way someone without a license and a medical background might not be able to, which contributes to our being able to provide better quality of care to our tenants.

What do you consider your three most important responsibilities as an administrator?

Palma: Number one is making certain tenants get the care and assistance they need - in a timely manner and from caring and concerned staff. Next is keeping the home financially solvent by adhering to budgetary standards - if you don't do that, no one has a home. Finally, it's essential to keep the home prominently involved in the community and with community affairs.

Since assisted living is new in so many areas of the country, ongoing community education is needed to let people know what it is, what its limits are and just what it involves. Even if an assisted living facility has been in a town for years, many tend to view it as a nursing home - a very nice one perhaps, but a nursing home nevertheless.

What sorts of activities do you host to encourage community involvement?

Palma: One highly successful activity was our "Trick or Treat" night for Halloween. We invited area school children and their families to come by for entertainment and refreshments and filled baskets with candy for the tenants to hand out. The tenants, with help from staff and volunteers, participated in a door-decorating contest and hung spider webs in the hallways. When all the decorations were up the place looked like a haunted house. Staff members also volunteered to walk groups of kids from apartment to apartment trick or treating. More than 175 children showed up, plus parents. It was wonderful for the tenants to have the children here, and the kids had a great time, too.

Another community outreach program we' re currently working on is getting Arbor House designated a "Safe Place," a location where children know they can come if they're in danger or frightened or need help from an adult.

In what specific ways do you encourage your residents' independence?

Palma: We urge them to try new tasks that they might not have been able to accomplish in the past. To do this, we use a team approach involving the entire staff, to facilitate choices by tenants that might increase their level of independence.

Often, people come here who previously were in nursing homes but who didn't need that level of care - perhaps, for example, they really only required medication reminders. When these people arrive they're sometimes impaired from having lived in an environment that was more structured than they needed. Once they realize they have choices here - when they can shower or when they can eat or have a snack- these individuals usually blossom and begin functioning at a higher, more independent level than when they arrived.

Is Arbor House able to accommodate residents with Alzheimer's disease? If so, are their apartments in a separate wing or area of the facility?

Palma: We fully integrate our people who have Alzheimer's with the rest of the tenants because we believe that's the best situation for all concerned. This reasoning also applies to the activities we provide - people with varying degrees of capability can help each other, thus contributing to our homelike, family atmosphere.

Getting back to the independence issue, we perform frequent assessments and carefully plan services to ensure that everyone is functioning at his or her highest possible level. Other factors that foster independence, especially for people with Alzheimer's, are our building design, which features user-friendly apartments and bathrooms; the way we extensively train our staff to deal with residents, to ensure that they achieve optimal independence; the way our units are adapted for safety; and our general safety and security measures throughout the building. All these work together to help residents with Alzheimer's to function and interact with other tenants, without jeopardizing anyone's safety or well-being.

At a recent ALFA conference, assisted living residents from several facilities were asked in a focus group if they minded sharing their common living areas with people who have Alzheimer's. Quite the contrary, they said they liked helping and feeling needed, and that these people were part of their family. Has that been your experience at Arbor House?

Palma: Most definitely. I can't tell you how many people pitch in and, for example, help Mrs. X back to her apartment after dinner because she's lost her way, or direct Mr. Z to the nearest bathroom, or whatever is needed. This does foster a nurturing relationship with the tenants who don't have Alzheimer's, and it does make tenants feel needed and productive.

What else have you found builds a family atmosphere?

Palma: On any given day here at Arbor House, you'll find children, grandchildren, great-grandchildren - and pets. In addition to our human family members, we also have three cats and two dogs living here full-time with tenants. There's always a good time going on somewhere within these walls.

When I came here I started something called Family Night, an evening set aside once a month to get tenants and their families together. Although tenants' family members can come share a meal anytime for a minimal cost, on Family Night we plan a special menu and there's no charge. We try to arrange entertainment or a speaker or some type of special activity.

An offshoot of these nights is that tenants' family members have begun to function as an extended family, and a lot of networking takes place. For instance, people find out that their mothers attend the same church and take turns driving them; or perhaps Mr. Smith's son is taking him fishing and invites Mr. Jones and Mr. Black to come along. It's been a tremendous benefit.

In addition to the family feel and homelike atmosphere of Arbor House, to what else do you attribute your high occupancy rate?

Palma: One key factor is stability. Families need to know who'll be watching over their loved one's care. I've been here since April 1997, and I oversee all our day-to-day operations and marketing; I give the facility tours; I help new tenants move in and do their assessments. And if there's a problem down the line, they're going to walk into my office and I'll be the one who will listen and try to resolve it.

Family members tell me that it's comforting to see the same face here all the time, and that this stability is an important factor to them when choosing a home for their loved ones. Our small size makes my extensive direct involvement possible, whereas at some of the larger facilities, there might be two marketing directors, an administrator and administrative assistants.

I think our occupancy rate, which generally ranges between 80 and 90%, is significant in light of the fact that we do very little advertising. Most new and prospective tenants have heard about Arbor House through word of mouth.

One concern administrators face is staff turnover. How do you minimize that?

Palma: The first step in keeping good people, obviously, is taking care to hire the right individuals to begin with. It's important to screen out applicants who are just looking for a temporary job until they can find something else or students who want a summer income. Also, although we have some wonderful young staff, I've noticed that people in their 40s and 50s generally seem to be at a more stable phase in their lives and therefore are more likely to stay on the job. Another benefit of hiring more mature workers is that tenants feel comfortable with them and feel people closer to their own age have a better understanding of and compassion for what they're going through.

Once qualified candidates are hired, keeping them boils down to a simple underlying principle: Treat them with respect. This can be shown in a number of ways, such as asking rather than telling them to do something, and providing bonuses and incentives and awards to recognize their efforts and accomplishments.

Do you have any words of advice for other assisted living administrators?

Palma: Whatever you do, no matter how busy you are or how stressed out you may become, always remember that the residents are counting on you for everything; also, be aware that what might not seem like a big deal to you can be of major significance to them. Always make time to smile at them, to touch them and to listen to them, because these small acts can mean more than anything else that you do for them. Some might say this isn't the best use of an administrator's time, but I disagree. The paperwork will always be there, and it's important to complete it on time. But people, not papers, are why we're here.