Welcome to Eden.

They're injecting nursing homes with life - in all its forms

Being the sole physician and medical director of an 80-bed nursing home in rural New York State wasn't exactly Dr. William Thomas' dream job. He had, in fact, always done his best to avoid nursing homes. Nevertheless, Dr. Thomas rolled up his sleeves and started doing what was expected of him - taking care of residents' medical problems. Before long, though, he realized that "all the Lasix in the world wasn't going to touch what was really ailing those people" - the loneliness, helplessness and boredom that Dr. Thomas now refers to as "the three plagues of nursing homes."

He decided to find a "cure."

He believes he found one. Four years later, the mortality rate at Chase Memorial Nursing Home is down by more than 15%, medication use has declined significantly, nurse aide turnover has dropped by 26%, and residents' loneliness, helplessness and boredom have yielded to companionship, self-sufficiency and (many will tell you) a sense of joy.

Dr. Thomas' "cure" is a holistic approach to care known as the Eden Alternative. He describes it as "the creation of a 'human habitat' where people thrive, grow and flourish, rather than wither, decay and die." To create this habitat, "edenized" facilities are literally infused with life, in the form of plants, animals and children.

Bringing animals and children into nursing homes is not a new idea, it's how one thinks about it. Dr. Thomas cautions against "taking parts of a life well lived and turning them into therapy: affectionate touch becomes touch therapy, contact with animals becomes animal therapy." Instead, plants, animals and children are part of the day-to-day lives of the residents and staff of edenized facilities; they are not "therapeutic activities."

Plants are placed where people actually live, rather than just in the lobby for show. Rather than being part of a structured "pet therapy" program, animals in these facilities are considered therapeutic simply by virtue of being there, providing close and continuing contact. This is companionship, says Dr. Thomas, and "companionship is the only antidote for loneliness."

Ongoing school programs ensure that the same children return to the edenized facilities each day, giving them a chance to build relationships with the residents. "If nursing homes are truly medical treatment facilities," says Dr. Thomas, "children have no place there. If, however, they are genuine homes, children belong there everyday."

With this infusion of life comes the unexpected and, at times, even the chaotic. To the Eden Alternative, that is as it should be. It is this break in routine and monotony that makes life interesting and enjoyable. It is the ultimate enemy of boredom.

Change, especially of such a fundamental nature, is never easy in the nursing home, and facilities that commit to the Eden Alternative undergo nothing less than a total transformation. This requires, not surprisingly, a complete attitudinal shift from everyone involved. Dr. Thomas stresses that none of this is possible unless the people "at the top" are leaders, rather than simply managers.

Today, more than 100 skilled nursing facilities in Missouri, Texas, Alabama, North Carolina and New York have undertaken that challenge, and facilities in Minnesota, Michigan and Nebraska are preparing to do so. Dr. Thomas acknowledges that the process is a difficult, time-consuming one. But, he maintains, "none of those who have met the challenge would ever want to go back."

Initial resistance at Chase - and, believe it, there was quite a bit - came in the form of questions: "You're buying parakeets? Why not give us a raise instead?" "Do you really think I'm going to clean up after a dog? That's not my job." And so on, as one might imagine. Then there were the logistical problems - like the arrival of 120 birds and their cages (unassembled in flat cardboard boxes). "We stumbled and fell at times," Dr. Thomas recalls, "but we kept pushing. In the end, resistance became tolerance and, finally, acceptance as the vision began to materialize."

Of course, state surveyors would have serious problems with this - wouldn't they? Quite the contrary, says Dr. Thomas. Sanitary concerns are, of course, of primary importance, but are easily allayed by conscientious - and enthusiastic - staff. Beyond that, OBRA regulations focus on creating a "home" for facility residents, and surveyors have recognized this in the Eden Alternative (see "The Bureaucrat's Eye-View," p. 33).

For some providers, though, Dr. Thomas' message seems to compete with the unrelenting pressures of overregulation and underreimbursement. "I know I'll never reach the providers who feel that all obligation for change is on the 'outside,'" he says, "but they have been the minority in my experience. Most I know are adopting a proactive approach to change, rather than simply waiting for it to occur and then reacting. For these providers, the message is getting through loud and clear."

The Eden Alternative In Action

Three short years ago, Tioga Nursing Facility in Waverly, NY was very much the conventional facility. "We were always considered innovative, says administrator Maria Landy, NHA, "but we were still a nursing home: staid, sterile, quiet and boring."

To say that Tioga has changed is the consummate understatement. Now home to six dogs, six cats, 350+ birds, one chinchilla, 1,000 plants and, on Mondays through Fridays, 97 kindergartners, the quiet has yielded to the giggles of six-year-olds and the chirping of birds, and the sterility and boredom to the purring of cats and the wags of dogs' tails.

In short, Tioga has become a home.

It all began when Tioga agreed to become one of three New York State facilities to attempt to replicate the pilot study conducted by Dr. Thomas at Chase. "There was no question that it would greatly enhance the quality of life here, but as a 211-bed, not-for-profit SNF with eight staff physicians and a family practice residency program, we wondered about replicating what was done in an 80-bed, one-physician facility. We also decided that all the needed funds would have to come from grants and in-kind donations, without impacting Tioga's operational budget."

Nonetheless, Landy and her administrative staff decided that the Eden Alternative was right for Tioga. The department heads and front-line staff, while a bit concerned about logistics and the residents' reactions, were excited by the prospect. Tioga's community-based board of directors was a bit surprised at Landy's willingness to embrace such a dramatic change, but never discouraged her from doing so.

A program to educate staff on the Eden Alternative philosophy was developed and implemented while Tioga was braced for change. "We were ready to literally turn the environment upside down and inside out," Landy recalls. "There was no turning back."

The Animals

When it came to bringing in the animals, says Landy, "we knew that if we didn't do it quickly, we wouldn't do it all. So we decided to bring the animals in, let things calm down, and then deal with the fallout."

With the residents delighted at the prospect of having their own birds in their rooms, Landy then spent weeks calling closed bird colonies to find birds certified free of disease - the first evidence that her job as an administrator would never be the same.

Selecting the dogs and cats was a group endeavor. The residents boarded buses and went to the local animal shelter, where they adopted six of each. The immediate favorite was a nondescript little white dog named Bandit. "Bandit had been abused and I wasn't sure how he'd do in the nursing home," says Landy, "but our residents made it very clear that they weren't leaving the shelter without him."

The dogs and cats then spent several weeks with veterinarian William Corbett, DVM, who made sure they were all healthy and had appropriate temperaments for the nursing home, and the birds were quarenteened on the Tioga campus for two weeks prior to being placed in residents' rooms.

Landy recalls being greeted by 60+ residents when she and the activities staff arrived from the animal hospital with the cats. Each cat was given a name and "assigned" a specific floor as its "home base."

The next morning, one of the male residents approached her with a rather unusual question: "Guess who I slept with last night?" Just as Landy began to think "incident report," the resident told her that at 2:30 AM, Rusty the cat had climbed into his bed and snuggled up next to him under the covers. "When he asked if I knew how long it had been since he'd had a warm body next to him - well, I knew we were doing something right."

This was just the first of countless testimonies to the relationships between the residents and the animals, especially the dogs - some of whom have actually learned to operate the elevators to visit their "favorite people." Of course, there were a few issues that needed to be dealt with. "The animals weren't allowed in the dining room during meals," Landy explains, "but that didn't stop the residents from smuggling food to them and, for a while, we had some of the fattest dogs and cats you've ever seen."

All in all, these animals, all former strays, "think they've died and gone to heaven. They have the run of the place; this is their home, and no animals on earth get more love and affection."

And more of the animals "on earth" were involved than one might expect. When one of the two people hired specifically to care for the animals offered to bring in her miniature Shetland pony, Landy agreed. "At that point, a pony in a nursing home sounded almost normal."

Thus, "Nutmeg" became a regular fixture at Tioga. The pony was befriended by a 92-year-old woman who had grown up on a farm. "She needed to strengthen her 'arm and shoulder muscles, but she hated physical therapy," says Landy. The solution: Nutmeg (and her owner) began taking the elevator to the resident's floor, where she brushed the pony's mane with delight - and got more physical therapy then she ever would have tolerated by lifting weights.

When the task of caring for the animals became too large for just two people, the activities department was restructured to assume most of these responsibilities - with the help of Tioga's residents, who are eager and able to help care for "their" pets.

True to administration's word, Tioga's operational budget has never been impacted by all this - quite an accomplishment when you consider just the basic monthly expenses: 550 lbs of bird seed, 100 lbs of dry dog food and a case of canned dog food, 40 lbs of cat food and 250 lbs of litter (not to mention plant food for 1,000+ plants). "We've had tremendous community support all along," explains Landy. "An 18-month supply of pet food was donated, and Dr. Corbett bends over backwards to help by providing medical care for nominal fees."

The Children

While Tioga already had a relationship with the local school district through a program called Share (Students Helping And Relating with the Elderly), what the facility wanted was a full-time arrangement. What began as an after-school program evolved into a full-time kindergarten program with four classes and 97 students.

The timing was fortuitous. The district had run out of classroom space and the new kindergartners were faced with beginning school in the small, windowless basement classroom of a K-6 school. With $150,000 in grant monies, as well as donated computers, Tioga built large, bright, state-of-the-art classrooms in an adjacent, connected building, made the dining room available for gym classes, and donated playground equipment for an enclosed courtyard.

While some parents viewed this as an innovative learning opportunity, others were understandably uneasy. One parent even called the Departments of Education and Health to complain about putting her child "in a place filled with rats, mice and AIDS patients." Ultimately, even this parent came around when she saw the classrooms and Landy addressed her misconceptions.

While most of the contact between the residents and children is by chance, as the children become more comfortable, they can be seen visiting, reading and playing games with specific residents. "On the first day of gym class, you could have heard a pin drop as the residents sat listening to the giggles and commotion," says Landy, "and watching the children play in the courtyard has become a favorite pastime."

During the first few months of the original after-school program, Landy used to watch as the children got off the bus, lined up and quietly walked into their classrooms. Now, she makes it a point to be in her office when the children arrive. "It's not often that you see 97 people making a mad dash into a nursing home."

The Rewards

"The rewards we've reaped from this transformation are too numerous to mention," says Landy. "Seniors have so much to give and, too often, no one to give to. Now, rather than being constantly cared for, they have something and someone to care about."

The staff, even those who were skeptical at first, have fully embraced the transformation. "They now know that their raises won't be 'going to birdseed' and they see the change in our residents."

Staff morale is consistently high with respect to the Eden Alternative, says Landy. "While it's usually noisy, and sometimes chaotic, the atmosphere is paradoxically calming. Even after a rotten day, it's hard to feel down with a purring cat in your lap while you're doing your charting."

Landy, like Dr. Thomas, observes that the state surveyors are very pleased with what they see and are consistently supportive. There have, of course, been a few "causes for discussion" - such as the cat who chose the day of the state survey to jump into the drinking fountain and wait for a drink. During the exit interview, the surveyor politely suggested that since they probably wouldn't have a cat in their sink at home, they probably shouldn't have one in the nursing home drinking fountain. The staff now watches more closely for this.

To Landy, "edenization" has come to this: "When a resident feels lonely and has only to reach for a dog for something soft and warm to cuddle, we know that Tioga isn't a place where people come to die, but rather a place where people come for help with living."

For more information, call the Eden Alternative at 607-674-5232.

Dr. Thomas' book, Life Worth Living. How Someone You Love Can Still Enjoy Life in a Nursing Home: The Eden Alternative in Action, is available through VanderWyk & Burnham Publishing, PO Box 2789, Acton, Mass. 01720. Phone: [phone].

RELATED ARTICLE: The Bureaucrat's Eye-View

What goes through the mind of an area administrator who walks into a nursing home and is greeted by six dogs, six cats, 300+ birds and several kindergartners? If that administrator is Norm Andrzejewski, what goes through his mind is the word "amazing."

Mr. Andrzejewski, Syracuse Area Administrator and a sixteen-year "veteran bureaucrat," still clearly recalls his first visit to Chase Memorial Home, where the Eden Alternative concept was born. "It was exciting, striking, noisy and - above all - different."

As a pet owner himself, the idea of animals in a nursing home seemed reasonable enough to him. He was, however, a bit taken aback by Chase's resident greyhound, a former racing dog rescued from the racetrack, who stood waist-high on all fours. After being formally "introduced," however, Andrzejewski found that this was "the most gentle, docile dog" he'd ever seen.

"Having been rescued himself, he now considers it his job to 'rescue' others," says Andrzezewski, "by standing next to a wheechair-bound resident to be petted, and then moving on to the next for more of the same" - a job for which he happens to be the perfect height.

Acknowledging the need for staff training and preparation before bringing animals into an environment with frail elderly, Andrzejewski stresses that, to make the concept work, tasks need to transcend job description. In the words of one Eden Alternative facility administrator: "If something drops, you reach for the Dustbuster, no matter what your job title happens to be."

As someone who admittedly 'wrestles' with the sterility of the nursing home environment, Andrzejewski is "seized with the Eden Alternative concept," as he says are most of the 15 surveyors in the Syracuse office. Some wonder if the same results could be achieved by the Maria Landys of the world, without the animals, "but if you polled our surveyors today," says Andrzejewski, "they'd vote to edenize all 93 facilities in the region. In fact, that's what we're looking to do."

Not only is there nothing in OBRA that precludes a nursing home from taking this direction, he says, but "as I read OBRA, the concept fits right in with the mandates for enhanced quality of life and home-like environments.

"Time and time again, residents who appear completely devoid of affect, and are totally unresponsive to me, literally light up at the sight of a child or an animal. The resident with a bird in her room may or may not be cleaning the cage and filling the seed cup herself, but she knows that this is her pet, to care for and nurture. It's hard to feel lonely, helpless and bored when someone or something needs you."

Especially impressive to Andrzejewski is the way in which the Eden Alternative brings the community back into the nursing home - not only the schools, the veterinarians and the garden clubs, but the residents' families as well. "The parking lots are filled to capacity: children and grandchildren actually look forward to 'visiting grandma in the nursing home.'

"The nursing home of yesterday, the poorhouse built on an out-of-the-way site where 'undesirables' could be housed out of sight and out of mind, is a vivid reminder of how far we've come," Andrzejewski reflects. "You need only to look into the faces of the residents of these very special places."

Laura Bruck