The music of St. Anne's.

The St. Anne Home is a not-for-profit long-term care facility located in Greensburg, Pa., and run by the Felician Sisters. St. Anne's cares for 125 residents of varying cognitive and physical abilities. A large percentage of St. Anne's residents have some sort of cognitive impairment, ranging from mild dementia to Alzheimer's disease, but the facility is also home to a number of higher-functioning residents.

When music therapist Laurie Jones, MMT, MTBC, began working at St. Anne's five years ago, she used her 15 hours per week to develop and implement music therapy programming primarily for residents with dementia. Her music sessions featured different activities each week: theme-centered singalongs with the guitar, movement to music, rhythm band activities, reminiscence through music, and so on. One-on-one sessions were held for terminally ill residents, and for those who were unable or reluctant to join in group activities.

It was when the higher-functioning residents began to desire more music programming that Jones petitioned for, and received, additional hours at the facility. Today, Jones spends four half-days and one full day at St. Anne's each week. She continues to provide group and one-on-one programming for all residents who want to participate, but the additional time has allowed her to develop a number of innovative programs tailored to the interests and needs of the higher-functioning residents - programs that would also be appropriate for use in assisted living settings, if providers were so inclined.

One of the most unique of these programs is St. Anne's bell choir. The bell choir consists of a core group of 8 to 10 residents, but Jones, who is always on the lookout for additional participants, has had as many as 22 residents come to the practices. She is especially pleased that a number of men - a minority at the facility - participate in the bell choir.

The group uses 10 hand bells - lighter in weight and easier to manipulate than the heavy hand bells used in churches - to accompany themselves while they sing and Jones conducts. The choir meets a few times each month for 45- to 60-minute practices during the regular Friday afternoon music club sessions. Additional practice sessions are added before performances, each of which requires several months of preparation. The bell choir gives at least four concerts each year; most are holiday performances, but the group also performs for National Nursing Home Week and has been asked to play for board members and other visiting groups.

Jones considers the bell choir "therapeutic music" rather than music therapy, per se, but the benefits reaped by the residents are evident. "Most of the participants have never tried anything like this before," she says, "and it gives them a sense of accomplishment to know that they can still learn something new - and succeed at it." She adds that this sense of accomplishment is reinforced by the overwhelmingly positive feedback received at the bell choir's performances.

In addition, "doing it all" - playing the bells, singing, learning the music, working as an ensemble and taking direction - enhances independence and feelings of self-worth. Jones notes that the bell choir activity is also therapeutic for the participants' families, who are given the opportunity to see what their loved ones are still capable of accomplishing and enjoying. "It does the families good just to see the smiles on the faces of their relatives."

Higher-functioning St. Anne's residents also participate in song writing activities, which consist primarily of what Jones calls "lyric substitution" - writing new, theme-centered words to familiar songs. The lyric substitution activity evolved through a process of trial and error involving both the participants and the nature of the activity itself. Jones notes that some lower-functioning residents have participated from time to time, but because the sessions often involve brainstorming before the actual music begins, it is often difficult to hold their attention. She has also attempted to lead the groups in writing their own music in addition to their own words. Although Jones still leads these music writing activities from time to time, she has found that, in general, it has proved too confusing for lower-functioning residents; they have difficulty grasping the concept and remembering what they have written. "A challenge is a good thing," Jones says, "but it's important that music therapy activities be success-oriented."

Jones hopes to develop additional programming for the facility's stroke survivors who, she explains, are often difficult to motivate to participate in group activities. "Our residents who have had strokes are generally higher functioning and are younger than the other residents. They need a group of their own in which they can interact with their peers through music from their own era."

Jones works for St. Anne's as an independent contractor paid by the facility. Today, she is spearheading an effort for the facility to receive reimbursement for her music therapy services. She explains that many music therapists have been receiving reimbursement since 1985, primarily from smaller insurance companies, similar to that obtained for occupational therapists. She adds, however, that the process requires a great deal of paper- and legwork. Among the crimps still to be ironed out are the reimbursement codes which, according to Jones, tend to be somewhat contradictory. For example, music therapists are instructed by insurers to submit reimbursement requests using their own codes, but are told to do so in an occupational therapy format.

As Jones continues to research reimbursement resources, she plans to add more quantitative evaluations to the anecdotal progress notes and assessments she carries out today. She also plans to conduct in-services for third-party payer representatives and potential referral sources - internists, psychologists, nurses, etc. The in-services will be aimed at educating personnel about the potential benefits of music therapy in a long-term care setting.

Jones is optimistic about her reimbursement efforts, primarily because of the support she receives from the staff at St. Anne's, who understand the value of music therapy. She explains that this support often comes in the form of nurses and nurses' aides joining in the music making during the sessions held in open areas on the units. "It's wonderful to see the staff join in and encourage the residents in this way, giving them some one-on-one attention in a group setting."

Laura Bruck is a contributing editor for Nursing Homes/Long Term Care Management.