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Putting the resident first.

It's their home, make it their "ideal"

Shirley Gannon still sleeps in her own antique bed, surrounded by familiar objects. The walls of her room are covered with photographs. On a shelf sits an aquarium, on others houseplants. If the 74-year-old wants a cold drink or snack, she can get it herself from a small refrigerator just a few steps from her bed.

More important is Gannon's freedom to make choices each day. She's a "farm girl" who likes to get up at dawn. She helps out in the kitchen, proudly wearing her nametag that describes her as "cutlery specialist." She brags about catching fish on a recent trip to a nearby lake.

Doesn't exactly sound like life in a nursing home. But that's exactly what life is like at Crestview Nursing Home in Bethany, Mo., a town of 3,000 just off interstate 35 halfway between Kansas City, Mo., and Des Moines, Iowa. Once notorious as "the county home," the 130-bed not-for-profit skilled nursing facility, along with 24 assisted living apartments, has launched a groundbreaking program known as "The Ideal Nursing Home." It's drawing raves from residents, family members, government officials, and long term care advocates, and it's being done for $79 a day ($76.05 Medicaid reimbursement) without any tax assistance.

The results are almost unbelievable: The facility is not only full while 30 percent of beds in the area's other four nursing homes go begging, but there's a waiting list with more than 50 names. Not one of Crestview's residents had a bedsore or suffered from impaction or dehydration in recent months. The facility is actually "overstaffed in a county with 1.9 percent unemployment," says Administrator Eric Haider. And he's managed to save $500,000 a year in Medicaid costs.

"This is the way a nursing home ought to be," says Marilyn Rantz, R.N., Ph.D., professor in the Sinclair School of Nursing at the University of Missouri-Columbia, who's collecting data of Crestview's results as part of a National Institute of Nursing Research study of how staff deliver care.

Changes in attitude

Several years ago, Eric Haider watched an aide console an elderly resident in a nursing home. "This is your home now," the aide told her. But the resident wanted to eat. Glancing at her watch, the aide replied, "It's quarter to twelve. Lunch isn't served for another fifteen minutes."

The scene irritated Haider. "If this were really her home, she could eat when she wanted." It's been incidents like that that have inspired him to make changes over the years. In 1991 at a Kansas facility, he instituted restaurant-style dining, had an outdoor fishing pond built, brought in plants and animals, and opened a daycare center for the children of his employees. In 1992 he took the job at Crestview and saw "there was lots of catch-up" needed.

By the mid-1990s, he bought steam tables and offered a buffet for each meal, extending serving times over several hours. An enclosed courtyard provides a home to the pet rabbits and roosters; cats wander the indoor hallways.

At a September 1998 seminar, Haider heard Myron Reinke, mental health consultant for Region VII of the Health Care Financing Administration (HCFA), speak. Reinke wondered why the concept of person-centered planning, common in mental health residential facilities like the state mental hospital in Parsons, Kan., couldn't be applied to a nursing home.

"We cant solve the quality-o-life and care problems that plague America's health care facilities through governmental action or political means alone," Reinke says. Haider agreed for Crestview to become a pilot project. No grant or funding was involved; HCFA and representatives from Parsons have provided training and guidance.

Person-centered planning

In November 1998, "person-centered planning" took root at Crestview and eventually became known as The Ideal Nursing Home program. Residents were encouraged to set their own schedules and activities. Direct-care staff members on the 7 to 3 shift were assigned to teams, led by a CNA or CMT, for each of the four units, or neighborhoods (divided by care levels and including a 22-bed Alzheimer's unit). Finally, a mission statement was written: "To change the way long term care is perceived and to achieve the best quality of life for our residents. To boldly go where no long term care has gone before!"

Haider's wife, Margie Haider, R.N., is the facility's director of nursing. At first, the nursing staff felt threatened by the empowerment of the nurse's aides to make frontline care decisions, she says. She herself worried whether the aides' decisions would be in the patients' best interests. The number of falls increased because residents were more active, although no serious injuries occurred. Paperwork increased, too, as care plans required modification.

In December, residents started "working"--doing tasks like folding laundry and peeling potatoes. By February 1999, teams had started on all three shifts and soon other departments like housekeeping and maintenance were included.

In October 1999, the state surveyors gave the facility a standing ovation at a deficiency-free visit. Haider was named state administrator of the year by the Missouri League of Nursing Home Administrators and appointed to the Missouri Governor's Caregivers Workforce Task Force. The director of Missouri's Division of Aging, long term care advocates from surrounding states, and representatives from more than 30 nursing homes have visited Crestview to see how it's done. The Haiders have been invited to speak at numerous conferences and to participate in The Pioneer Network's August 2000 meeting in St. Louis.

"People say a nursing home is a place to die," Haider says. "I want to change that. A nursing home is a place to live and enjoy the rest of your life."

Satisfied staff

At the heart of the program are the permanently assigned teams who know the habits and schedules of the residents in their "neighborhood" and the residents who know their caregivers. Call-light use has been reduced 49 percent because staff members anticipate residents' needs. "It's written down in the care plan and the CNA knows that 'Mr. Smith has a bowel movement every day at 1:30,'" Margie Haider explains. "The CNA can toilet him in time."

With 160 employees at a 130-bed facility, Crestview enjoys a daytime direct-care staffing ratio of 1 to 4.5, on the evening shift of 1 to 7, and on the night shift 1 to 10.

Haider is blunt on how to afford that many staff members: "Eliminate the high-dollar people like the assistant administrator and the assistant director of nursing, the marketing director, the public relations director, and the personnel director and replace with hands-on, direct-care nurse's aides." He has a CNA who serves as a staffing coordinator and has no need of marketing or PR personnel.

The pay isn't high at Crestview. Nurse's aides start at $6 an hour. Competition for employees includes fast-food joints, which pay $6.50 to $7 an hour, and the corporate hog farms, which pay $9 an hour. Haider screens potential aides with a written exam that requires a 90 percent or higher score, yet he still has a waiting list of employee applicants.

"He's a good manager and he's providing a very satisfying work environment, "Rantz says of Haider. "He has people who want to work there."

"Hard work has been turned into hard work and a lot of fun," says Charles Turpin, CNA, staffing coordinator.

Staff productivity has doubled while turnover is down to 9.4 percent (retention on the night shift remains the toughest). Job descriptions are history. "You don't know what you'll do when you come to work," Margie Haider says. "You may be taking residents to Dairy Queen or hanging a wallpaper border in someone's room."

Give residents what they want

Giving residents what they want is the basis of The Ideal Nursing Home program. "It's such a simple concept," says Tish Thomas, coordinator of Project LIFE at the University of Missouri-Columbia. "That's the beauty of it and that's why it works."

Residents get up and go to bed when they want. The buffet and menus in the dining room broaden their choices of when and what to eat. They can have refrigerators and microwaves in their rooms. One couple eats hot dogs every night around 1:30 a.m.

Bathing is dictated by the resident's personal preference. Bath or shower? Morning or night? How often?

"The daily routines are individualized as much as possible," says Melissa Bennett, ombudsman manager for Region IV in the Missouri Long Term Care Ombudsman Program, whose office has received no complaints about Crestview. Bennett thought so highly of the facility after visiting that she had her own grandmother, a resident in another nursing home, put on the waiting list. "It's definitely a model nursing home."

But The Ideal Nursing Home program goes beyond choices in daily routines by finding out what residents need and want to make them more satisfied. "If someone's not eating well, the staff will ask why. Maybe the answer is the person wants Burger King for lunch, so we'll get him Burger King for lunch until he gets tired of it," Haider explains. "If three activities are going on and someone's in his room looking unhappy, we'll find out why. Maybe he says he doesn't like Bingo or dominoes; he wants to go to the casino. So we'll arrange a trip to the casino."

Anytime any staff member hears a request from a resident, it's written down in a special record book at the nurse's station, where the result is also noted. The goal: Meet all requests within 24 hours if possible.

Around 80 percent of the requests are very simple, such as a clock or shelf in the room, a bird feeder, plants, or some material to make a quilt. Many requests deal with food: grape pop at meals, a root beer float, non-pitted prunes every day, hot chocolate at 4:30 a.m. Others are more complicated. A former bank president wished he could work at the bank again, so Haider arranged for him to do just that for a day. A 78-year-old woman wanted to learn how to read, so a teacher was found, and now the resident is proud to read the menu each day in the dining room.

The number of activities at Crestwood has increased from one to an average of six a day since the implementation of The Ideal Nursing Home. Many of those are spontaneous, resulting from residents' requests. And while the facility employs three full-time and two part-time activities directors, frontline staff get involved as well. In fact, several have chauffeur's licenses so they can take the home's van and residents on jaunts that can include an impromptu trip to Wal-Mart or Dairy Queen or planned excursions to the casino in nearby St. Joseph or fishing at Bethany Lake. Activities have included a Valentine's Day dance (residents requested rock n' roll instead of big band music), a watergun fight, and taking "glamour" photos of residents after having their makeup and hair done.

In addition, Crestview has two full-time and two part-time beauticians on staff whose on-site beauty shop is free. An exercise room, complete with treadmill, stair stepper, stationary bike, and other equipment is available to staff and residents.

The bottom line

"Everywhere we go, the question is, 'Where does the money come from?'" Haider says. "It's cheaper to do things this way than not." He lists the savings: $20,000 in food expenditures the first year, $6,553 savings in briefs and $1,164 in oral supplements. Joanne Polowy, volunteer executive director of Missouri Coalition for Quality Care is struck by what Crestview has accomplished with one of the lowest Medicaid rates in the state of Missouri.

Haider wants to spread the word that changing the culture in nursing homes is affordable. So far, Foxwood Springs, a not-for-profit home owned by the National Benevolent Association in Raymore, Mo., just south of Kansas City, started implementation of The Ideal Nursing Home in early July 2000. Deanne Lenhart, executive director of Kansas Advocates for Better Care, is working to encourage the start of a pilot program in Kansas.

But perhaps the real bottom line is what the people who live and work in the nursing home think of it. Wilbur Swartz, a 72-year-old resident who owns another nursing home, would rather live in Crestview. Gannon looks around her room and says, "If you can't be in your own home, there's no place any better."


Residents decorate their rooms, choosing carpet or linoleum, wallpaper or paint, drapes or blinds. Eric Haider's philosophy of letting residents make their own choices has extended to the design of 38 new rooms. Everybody wants their own window. One wants the air conditioning cold, the other hot. One wants to watch the religion channel and the other a movie," he says. The Y-shaped rooms give each resident a bay window, a separate AC/heating unit and cable TV. "It gives privacy but they still have someone to call if they need help."
 The Haiders have meticulously documented
 their results with The Ideal Nursing
 Home program.
 Sept. '98 July '00
Residents suffering from significant 38 10
 weight loss
Number of dietary supplements prescribed 72 14
 by physician
Pressure sores 11 0
Psychotropic medications prescribed [*] 27 20
Sleep medications prescribed 11 2
Anti-anxiety medications prescribed 40 14
Use of soft restraints 21 10
Patients using briefs 53 3
Patients with Foley catheters 16 7
Call light response time (in minutes) 6.33 3.24
(*.)These medications are prescribed
only to residents with a long-standing
diagnosis of a mental disorder.
COPYRIGHT 2001 Non Profit Times Publishing Group
No portion of this article can be reproduced without the express written permission from the copyright holder.
Copyright 2001, Gale Group. All rights reserved. Gale Group is a Thomson Corporation Company.

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Publication:Contemporary Long Term Care
Date:May 1, 2001
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