Creating a dementia care program - from within.

Even though the prevalence of people with dementia in long-term health care continues to rise, most nursing homes were built years ago to address the needs of a different group. Research in recent years has given us insight into the special needs of this population, and start-up costs can be high. In today's world of cost containment and budget reduction, this type of funding is not readily available to nursing homes. Many cannot hire large numbers of staff to meet this growing need.

Recognizing these fiscal realities, we have developed an inexpensive alternative, utilizing our existing (albeit trained) staff and structure. The Dementia Care Program began at St. Joseph's Manor in May, 1993. It is designed to offer caring and compassionate programming that is flexible enough to meet the individual needs of residents with dementia.

St. Joseph's Manor is a 297-bed facility with over 60% of its residents diagnosed with dementia, especially dementia of the Alzheimer's type. In planning the Program, the task the facility's Steering Committee took upon itself proved to be challenging and very rewarding. The Steering Committee was comprised of disciplines that would be directly involved in developing programs for the residents -- Administration, Dietary, Recreation, Pastoral Care, Rehabilitation, Social Services and Nursing. Other departments were invited to the meetings when certain aspects of the program would be affecting them (e.g., Housekeeping, which was asked to serve on a subcommittee developing environmental changes, such as rearranging furniture in sitting areas, dining areas, etc.)

The committee focused on developing programs which would involve residents throughout the day. It also developed a 12-hour course for Nursing Assistants on techniques to be used while caring for residents with dementia. The course was taught by all the members of the Steering Committee, thus confirming the importance of using the team approach (see "Course Syllabus," p. 26).

The Steering Committee then chose 12 residents whom they felt could benefit from the pilot program. The selection guidelines they used were: 1) generally oriented to person 2) cognitively impaired; to include the need for cueing and redirection 3) short attention span 4) non-aggressive 50% of the time 5) decreased self-initiative 6) tendency to wander 7) able to attend program at least two hours

The Committee also asked Nursing Assistants to apply to take the first 12-hour class. Of the 34 nursing assistants who applied and were interviewed, 12 were chosen to pioneer the process and to help promote the concept by becoming special Care Assistants.

Since this program was new, and it was asking that some "traditional nursing-thinking, be changed from a more task-oriented to a more holistic approach, it was vital to conduct several informational meetings with the entire staff -- nursing being the most crucial. A family informational meeting was also set up for the families of the first 12 residents who were chosen to begin the pilot program.

Staffing

Realigning staff for this task proved to be the most innovative and challenging part of the process. The more we assessed our staffing, the more we realized the benefit we would reap by reassigning hours while maintaining proper staffing. Here is one example of how we worked this out: A 68-bed unit has 11 Nursing Assistants assigned to the 7 a.m.-3 p.m. shift. Each assistant is normally assigned 6-7 residents. The unit had seven residents who would be participating in the first Dementia Care Program (which by now had subdivided and acquired two names, "The Rainbow Club" and "The Sunshine Club"). The seven residents would be taken to the program by the Nursing Assistant assigned to work in the Dementia Care Program that day, therefore not shorting the floor. On the 3 p.m.-11 p.m. shift the ratios are different -- one assistant to nine residents, therefore, the assignment had to be restructured to accommodate the remaining residents for the three hours the Nursing Assistant would be in the Dementia Care Program kits hours are from 10 a.m. to 6 p.m.). We were able to reassign hours, thus assigning a Nursing Assistant from 10 a.m.-6 p.m. Monday thru Friday without increasing our budgeted hours. This assistant ensured a continuity from one shift to the other. The only position we did add, finally, was a Dementia Care Program Coordinator, who presently is an R.N.

Programs

A variety of programs are used during the 10 a.m.- 6 p.m. schedule (see "Sample Daily Schedule," p. 27). These programs are selected according to each residents capabilities, as well as the group's capabilities. The professional staffers involved teach the Special Care Assistants, who then carry out the 30-40 minute programs. Since we concentrate on each individual, it is important to remain flexible, as each day brings a new set of challenges. Furthermore, when the resident is not in the Dementia Care Program on the weekends, evenings or nights, a Nursing Assistant can engage them in a meaningful activity based on the plan developed for that particular resident.

The Dementia Care Program residents also attend and are mainstreamed at large functions, such as birthday parties, entertainments, special events, etc. We have found that the residents from the Dementia Care Program bond to one another and sit together at these functions and enjoy the familiarity of people in their group.

Documentation

A newly recommended resident is assessed and observed for a period of one week participating in the Dementia Care Program. The Dementia Care Coordinator then decides whether the resident should go into the program permanently, either as a full-time participant or part-time. The Special Care Assistants are asked to write a note daily which enables the nurses to document weekly how web the resident is doing. The Dementia Care Coordinator receives a report from each floor to gather the necessary information for scheduling the residents, such as appointments for the beauty parlor, physical therapy, occupational therapy, etc. This centralized reporting is necessary because we take the residents off our fourth and fifth floors and bring them to the room in which their Dementia Care Program is held. Our plan is eventually to have programming going on all the time on all the floors throughout the facility.

Support Group

Another aspect of the Dementia Care Program concentrates on support groups. We formed three different types of support groups: 1) for relatives and friends of someone with dementia; 2) for those residents who have to live with people who have dementia; and 3) for our family members who have a resident participating in the Dementia Care Program.

Our first support group dealt with relatives and friends of those with dementia living at St. Joseph's Manor or in the community. This group functions as a support group for 18 members who meet monthly and discuss coping mechanisms. The second support group was developed for our cognitively intact residents who find it difficult to live with people with dementia. Members meet weekly and discuss how they feel about living with people with dementia. They share some of the concerns they have arid some of the frustrations they experience. Members also engage in a monthly informational seminar explaining different aspects of Alzheimer's and dementia, helping them to understand why these residents may be acting the way they are. It allows the cognitively intact residents to understand that the resident with dementia is not causing havoc intentionally, but because of the disease. The cognitively intact residents have responded very positively to this.

The family informational meeting is conducted two to three times a year for family members who have residents in the Dementia Care Program. We are there to answer their questions concerning how their family member is doing in the Dementia Care Program and to give them information on the latest research and therapies. We share with them information on the therapies that we are using, which allows the family members to enhance what we are doing, often using our techniques while visiting their loved one.

Conclusion

At this writing we have 43 residents participating in our Dementia Care Program. The 12-hour course was taken by 103 Nursing Assistants who have now become Special Care Assistants. They are able to use the philosophy they have learned, whether they are assigned to the Dementia Care Program or to the floor. Furthermore, a two-hour inservice has been developed for non-nursing staff which teaches basic techniques to use when approaching residents with dementia.

We have been very pleased with the results. Our success is measured daily in the smiles and the eyes of our residents, their expressions acknowledging that we have given them an opportunity to continue to live their lives in an atmosphere that is supportive, affirming, removed of expectations but filled with loving acceptance.

Sample Daily Schedule

SUNSHINE

DEMENTIA CARE PROGRAM FOR DAY OF

SPECIAL CARE ASSISTANTS ____________________________

VOLUNTEERS _________________________________________

10:00-10:15 a.m. Welcome - Juice 10:15-10:45 a.m. Social Service/Pastoral Care 10:45-11:00 a.m. Toileting, Walks 11:00-11:30 a.m. Gross Motor Exercises 11:30-11:45 a.m. Lunch Prep 11:45-1:00 p.m. Lunch

1:00-1:45 p.m. Toileting, Grooming, Walks

1:45-3:15 p.m. Activities

3:15-3:30 p.m. Toileting, Walks

3:30-4:45 p.m. Games, Crafts

4:45-5:00 p.m. Prepare for Dinner

5:00-6:00 p.m. Dinner

Escort Residents Back to Rooms

Course Syllabus

1. Dementia. An Overview Inservice Coordinator Director of Compliance/Staff Development Administrative Assistant 2. Characteristics of a Carmelite Dementia Program Director of Pastoral Care/Mission 3. Compensating for the Physical Environment Director of Rehabilitation Director of Food Service 4. Involving Families Director of Social Services 5. Successful Opportunities and Programs Assistant Administrator Coordinator Dementia Care Program Director of Recreation 6. Building on Individual Strengths Coordinator Dementia Care Program Director of Nursing 7. Cognitive Perceptual Processing Occupational Therapist 8. Cognitive Perceptual Processing (continued) Occupational Therapist 9. Difficult Behaviors: Causes and Responses Assistant Administrator Director of Adult Day Care Director of Pastoral Care/Mission 10. Devising a Repertoire of Approaches Director of Social Services Assistant Administrator Director of Pastoral Care/Mission 11. Changing Staff Roles Administrative Assistant Director of Nursing Director of Pastoral Care/Mission 12. Developing a Cohesive Team Administrative Assistant Director of Nursing Assistant Administrator Director of Pastoral Care/Mission