Interview.

In October 2005, the GROW (Getting Residents Out of Wheelchairs) Coalition was born out of some complex questions: Why are so many residents in wheelchairs? Why do long-term care facilities seem to assume that all elderly belong in wheelchairs? Why can't more nursing home residents get into regular chairs?

It all started when Mary Harroun, MS, LNHA, was reading through CMS regulations. It bothered her that so many additional pages were added to F-tag #314, the guidelines for surveyors on decubitus ulcers. For her, any additional page was one too many, and CMS wasn't really attacking the problem. Harroun dug deeper and realized that the abundant and too-relied-upon use of wheelchairs was a culprit behind decubitus ulcers. She joined together with Diana Waugh, BSN, RN, to form the GROW Coalition.

CLTC recently discussed the coalition with Harroun and Waugh--how far their initial ideas have come and what needs to happen next. For more information about the coalition, go to www.growcoalition.org.

CLTC: How would you describe the GROW Coalition's mission?

Diana Waugh: There really doesn't seem to be a reason why so many people in long-term care facilities are sitting in wheelchairs. So our goal is whenever you're doing something where you would normally be sitting in a regular chair, you should be sitting in a regular chair. It's really a normalization piece that I think somehow we've forgotten. Wheelchairs are a very medical model and are very necessary in some cases; I'm afraid we're just overusing them.

CLTC: How will a resident benefit from sitting in u regular choir, end not e wheelchair?

Mary Harroun: The resident's overall health will improve. But let's look at the negative side of wheelchairs. Wheelchairs do not affect the hair follicles on the top of your head because those are basically dead material, nor your toenails, because they're dead material, too. Everything else in between, from the brain not getting enough oxygen, to even affecting the teeth because of the bone wasting, all the way down to the digestive system, is affected.

These residents are not up moving, therefore they're not eating, and their body's not receiving the nutrition it needs. The lung capacity has decreased because they're not exerting any energy; they're just sitting there. Obviously the heart muscles are going.

Every muscle and bone in the body start to deteriorate the minute somebody is put in a wheelchair. It's happening all the way through the whole system.

CLTC: Why do you believe staff rely too often on wheelchairs?

MH: Wheelchairs make it easier for staff, but, interestingly, in the regulations it says nothing shall be used for staff convenience that is not administered. The regulations are there. If the surveyors looked at them, there would be no wheelchairs in use unless residents really need them.

There are some people who need a wheelchair, and we don't advocate getting them out of one. If someone is a paraplegic or a quadriplegic, we're not going to go screaming and yelling to get them to walk--it's not possible. If anybody has a neurological disorder--Lou Gehrig's disease, Huntington's, all those kinds of things--he or she physically can't get out of a wheelchair because there is a neurological impairment. We understand that.

CLTC: Wouldn't residents just as easily fall out of a regular chair?

MH: Yes, they could. But what nursing homes need to do is give them rehabilitation, calcium, and vitamin D to rebuild their bones and muscles. Nerves are the only thing we cannot rebuild, but bones and muscles we can. Why do you think everybody is in fitness programs? They aren't doing it because their muscles will get weaker; it's because their muscles are going to get stronger.

CLTC: Is GROW facing opposition in its mission?

DW: People are just saying, "This is how it's always been done." It's a preconceived mindset. CMS is really pushing its Advancing Excellence in America's nursing homes campaign, but the brochure they use to explain it has a lady in a wheelchair on the cover. When they depict long-term care, somehow a wheelchair is just an automatic.

CLTC: How would you respond to the argument that more residents out of wheelchairs will cause more falls?

DW: I'm not hearing people say that more residents out of wheelchairs will cause more falls. What I am hearing is people saying, "Oh, they'll be so much more comfortable." When I talk to individuals, they say, "Oh yeah, that makes sense."

I speak on falls, and one of my issues was that residents are uncomfortable in wheelchairs, and they often try to stand up and relieve their poor little bodies. So your chance of them falling is greater in a wheelchair--that's why I advocate for chairs. Put them in a comfortable chair and on a comfortable couch.

People are saying that we don't have enough research. There is a ton of research out there on the negative effects of immobility, and that, to me, is what we're talking about. But what they're saying is there isn't specific research stating wheelchairs are bad. What's interesting is people are saying that we need research to undo a practice that got put into place without research. So I'm not sure exactly what they are looking for.

CLTC: How does your oroanization pertain to the Advancing Excellence campaign?

MH: There are eight goals, and of those goals, every single one of them is touched if nursing homes start getting people out of wheelchairs. I believe the first goal is decubitus ulcers. If residents are walking, they are not going to get decubitus ulcers. As for restraints, we strongly feel that wheelchairs can be considered restraints if a resident can walk. If a resident can walk down the hall with the assistance of one, yet cannot get out of a wheelchair unassisted, then the wheelchair would be considered a restraint.

Staff retention is affected by wheelchair use. The turnover of staff in nursing homes is absolutely unbelievable. If the certified nursing assistant is doing the bottom grunt work, she's going to leave her job if she has eight to 10 nonmobile residents to take care of. Her back is going to go because she has to lift those people eight to 10 times a day--lift them to put them on the toilet, lift them to get them back in the wheelchair, and so on. She's not going to stay in the job long because her physical stamina is just not there. If we have people walking, it's going to be a whole lot more fun working with them than having them sit in wheelchairs.

Pain management is another goal. If you sit around a whole lot, your pain is going to increase because you're not moving any joints or muscles. And wherever you have pain, let's manage the pain. Let's get you up walking and not leave you in a wheelchair, because it's going to get worse.

CLTC: In mid-February, you met with different associations in Washington, De, to build support and gain momentum. How did that go?

MH: We met with the American College of Health Care Administrators, the American Association of Homes and Services of the Aging (AAHSA), the American Health Care Association (AHCA), and the American Occupational Therapy Assodation (AOTA). We want them on our side, and we want them to go to CMS because it's costing American taxpayers a tremendous amount of money to keep people in wheelchairs. ACHA suggested we collect success stories around nursing homes that have been successful with getting people out of wheelchairs.

DH: AAHSA recommended that we also present our dialogue to the National Citizens Coalition for Nursing Home Reform, because we need to educate consumers.

MH: AOTA said that the negative impact of putting people into wheelchairs fits very nicely into the government's pay-for-performance initiative. AHCA suggested we speak with the technical advisory committee for Advancing Excellence in America's Nursing Home Campaign. They said we couldn't be here at a better time in the history of long-term care, because this wheelchair thing is an issue, and it has been totally ignored.

CLTC: When all is said and done, what does the GROW Coalition hope to achieve?

DW: I want consumers to say, "Does mom really need to stay in a wheelchair?" I want providers to say, "You know, you're right, mom doesn't really need to stay in a wheelchair all day long."

My simple goal is for nursing homes and family members to work together. If you look at CMS and you look at the regulations, they say you don't do anything without an assessment. Now it's just a matter of, "Maybe we're not doing as much as we could in that area because we don't see it as a potential problem."