Assisted living for Alzheimer's patients.

Is this the "missing link" in the continuum of care?

Because of the progressive nature of Alzheimer's disease, patients require a range of services from one end of the health care continuum to the other. While patients in most communities have access to home-based assistance when their needs are minimal and institutional skilled nursing care in later stages of the disease, there are few, if any, alternatives for patients in the middle of the spectrum - those who are unable to live independently, yet don't require skilled nursing care.

It is easy to see how this "void in the continuum" can lead to premature nursing home admissions. This was evident in many of Manor HealthCare's Alzheimer's special care units. Rather than the more impaired population we were expecting, we were admitting large numbers of patients in the early-to-middle stages of the disease - patients whose needs were more psychosocial than medical.

That was our impetus for thinking about a residential setting for Alzheimer's patients - one that provided a safe, supportive, supervised setting involving psychosocial services, programming and structure. Last November, we opened the first of five residences called Arden Courts: Alzheimer's Assisted Living. This differs from the nursing home and SCU settings in a number of ways. One primary difference: Because assisted living residences are not bound by the same regulations that govern nursing homes, we have the opportunity to be more flexible and creative with respect to physical environment and delivery of services.

To begin with, each Arden Courts facility houses 50 to 60 residents, yet has a cozy, informal environment that is as home-like as possible. The building is divided into four self-contained houses, each of which accommodates up to 14 residents. Each house has its own living and dining room, kitchen, laundry room, private bedrooms and baths and an enclosed back yard. A simple architectural layout and visual cues (symbols, photographs, colors) help keep our residents oriented and independent as long as possible. The facility also offers a secured backyard for gardening and enjoying the outdoors - a feature that gives residents a sense of normality that comes from being able to move freely inside and out, simply leaving the house at will, as they would at home.

Staffing

When fully occupied, each Arden Courts complex will be staffed by approximately 35 caregivers, programming personnel, service coordinators and assistants. At the core of our team are Resident Caregivers who serve as "houseparents" and assist with all daily activities. Resident Caregivers are assigned to a house, working with the residents on a daily basis and getting to know their individual needs. Coverage is provided in three shifts - but that is where the similarity to nursing home staffing ends.

The staff-to-resident ratio in each of the houses is one-to-six, although in the facility at-large, that ratio is closer to one-to-four, considering all staff members who have direct contact with residents on any given day. Our hiring policies are also quite different from those of nursing homes. While some of our caregivers have experience as certified nursing assistants, personality is a key credential - we look for people with patience, compassion, energy and creativity.

The programming staff is responsible for planning and conducting activities. Again, rather than requiring certification in occupational or recreational therapy, we select people who have the traits for and experience in working with people with Alzheimer's. All of our service coordinators (department heads) are also involved in programming at a variety of levels. For instance, our food service coordinator conducts cooking activities and our facility services coordinator might "do rounds" with a resident who enjoyed fixing things around the house.

Medical support for Arden Courts residents is provided by a full-time, on-site RN, a medical director and medical consultants. Some of our residents are still followed by their private physicians, with family members or staff providing transportation for routine appointments.

Regardless of their prior experience, everyone on the Arden Courts staff goes through an intensive training program before coming into contact With residents, and attends ongoing inservices thereafter. In addition to specific job requirements, the training covers a range of topics related to dementia, with an emphasis on communication and behavior management issues involving these patients.

Programming with Choices

Perhaps the greatest distinction between the Arden Courts and nursing home models is, in fact, our programming. Because Arden Courts was created exclusively for individuals in the early-to-middle stages of Alzheimer's disease, we are able to concentrate on the programs and life skills that best meet residents' special needs - promoting their independence and individuality, their health and spiritual well-being.

Our residents can choose from multiple, simultaneous activities at different sites throughout the facility. These generally include continuing activities in the common area and concurrent small- and large-group activities in the individual houses. The activities even cut across houses, allowing residents from one house to go to another to participate in, for example, cooking or a card game.

All of this ties in with our commitment to honor residents' personal preferences and provide them with choices, giving them some control over the way in which they spend their time. To this end, our residents' social histories contain detailed information about their interests, leisure activities and daily routines, all of which helps us develop a truly customized activity plan for each resident.

Because this concept is central to all the programming that goes on at Arden Courts, it requires a certain amount of flexibility on the part of our programming staff with respect to their definition of a "meaningful" activity. If a resident has been watching Oprah every day for the past five years, we're going to make sure he or she can continue to do so. Watching television may not be listed in the official "book of meaningful activities," but it is the resident's perception of the activity, not the staff's, that makes it meaningful. We have enough flexibility to allow our residents the freedom to spend one-on-one time with a staff member or another resident, to engage in a solitary activity, or simply do nothing at all from time to time.

Our programming also includes special social and educational events for family members, as well as a family support group that is also open to home caregivers in the community. We maintain ongoing communication with our residents' families and encourage their participation in care planning. Family members are viewed as integral partners in care who can provide unique insights into their relative's needs, wishes and behavior.

Since the first of our facilities opened, we've been very impressed with the degree of ongoing family involvement. In addition to the emotional support they provide, families also volunteer to help with programming, and frequently take their relatives on outings or to medical appointments.

Early Observations

With two facilities operating in Maryland and three more just recently opened in Pennsylvania, the Arden Courts model is still in its infancy. Our hope is that the program's innovative features, along with our experience in Alzheimer's care, will help to maintain our residents' dignity and independence in a setting that is as much like home as it can be. Even at this early stage, however, we already know that it has helped to fill that void in the continuum, directing these residents toward a more appropriate level of care.

Tal Widdes, MPH, developed Manor HealthCare's Arden Courts program and serves as its Director of Program Development. She is a leading specialist in the development of programs and services for people with Alzheimer's Disease and related memory disorders.