A Visionary Path to Culture Change: Pearl Merritt & Debby Burgett
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A Visionary Path to Culture Change: Pearl Merritt & Debby Burgett






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  • Pearl will speak from slides 1-10 Debby will speak from slides 11-22 Pearl will speak from slides 23-29
  • Pearl to open/speak… Complement TXCCC for their efforts and vision for the symposium. How exciting you are to see so many care givers in the room. Thank them all for being here. 20+ of years in long-term care Knew there had to be something better Went to Tupelo, smelled the fried chicken Charlie and Pearl decide to build the first Green House homes in Longview Texas to complete the continuum of care. Recruited Debby from Sears Methodist to become the Guide and Administrator Opened in January 2008 with all 20 rooms spoken for. 3 million dollar project Exceeded our expectations
  • Questions that we will answer during the next hour…
  • This home represents the look of small house homes all over the country, and is located in Taylor Texas. The definition of a small house model can vary according to the model. There are different models that appeal differently to organizations. 3 Examples of different models: 1. 10-12 Elders, The Green House® Project 2. 14-20 Elders, Household/Neighborhood model 3. I am excited to introduce today a third model of care called My House Communities, My House is “Texas born” and has been designed by PI (“Pie”) architects from Austin, Texas. Greg, Mark and Pat have created a flexible model with a solid philosophy of elder centered care. It is designed to be home to 16-24 elders and works well for assisted living and nursing care. The flexibility of the design appeals to for profits and non-profits alike and can accommodate Medicaid, Medicare and private payer mixes.
  • There are different elements to small house design and philosophy, but you will find many similarities such as Small scale in design Fewer elders living in one area Access to the outdoors Residential in look and feel You will find a full kitchen or at minimum a warming kitchen or buffet style dining Elimination of long hallways Private rooms and baths Inviting outdoor spaces The design is good for Assisted Living, dementia care and nursing care. Organizations all over the country are on a journey to create small house living and promote elder centered care. Next is an example of a retirement community here in Texas.
  • USE POINTER LASER TO HIGHLIGHT THE DIFFERENT HOMES. This community is planning for a full continuum of care and has the infrastructure currently in place to support the work of the small house. This is for profit home located here in Texas. PI Architects has redesigned the traditional home to meet the requests of the owners as well as the demand of the consumers. This traditional nursing home (highlighted in yellow) is being redesigned internally to accommodate four different small houses or also known as a “neighborhoods.” In addition, this community has been designed to accommodate 2 small house homes (My House E/F red). 16 Elders will live in each home joined by a common shared areas that include laundry, and a community room. Each home is designed to have a fully equipped kitchen and its own dining and common areas. House A will be a home for 30 elders House B will be a home for 30 elders House C will be a home for 30 elders House D will be a home for 30 elders. House E will be a My House home for 16 Elders House F will be a My House home for 16 elders.
  • The small house design is one LARGE factor in creating elder-centered care. The outcomes of small house homes have been studied by researchers for the past several years. One of the first studies of the small house home was of first Green House homes located in Tupelo began in 2003. Dr. Rosalie Kane spearheaded the research on this project and is a well known researcher of the small house design. Two of her well known publications are… Effects of Green House® Nursing Homes on Residents’ Families Terry Y. Lum , M.S.W., Ph.D., Rosalie A. Kane , M.S.W., Ph.D., Lois J. Cutle r, Ph.D., and Tzy-Chyi Yu , M.H.A., Ph.D. 2. Resident Outcomes in Small-House Nursing Homes: A Longitudinal Evaluation of the Initial Green House Program Rosalie A. Kane , PhD, Terry Y. Lum , PhD, Lois J. Cutler , PhD, Howard B. Degenholtz, PhD, and Tzy-Chyi Yu, MHA, Journal of the American Geriatrics Society, 55 (6) :832–839, 2007. Since then many other researchers have looked closely at elder centered care and the small house design. Sharkey , S. S., Hudak , S., Horn , S. D., James , B. and Howes , J. ( 2011 ), Frontline Caregiver Daily Practices: A Comparison Study of Traditional Nursing Homes and The Green House Project Sites. Journal of the American Geriatrics Society , 59: 126–131. doi: 10.1111/j.1532-5415.2010.03209.x Dr. Barbara Bowers University of Wisconsin Madison studied the relationship of the shahbazim, nurses, the models of care and communication. We are expecting her publication this fall, but have begun to learn of some the research findings. Green House ® elders to comparison group of nursing home residents. Research has shown that families are more satisfied with general amenities, meals, housekeeping, physical environment, privacy, autonomy and health care. In addition fewer elders experienced depression, being bedfast and having little or no activity. Quality of life improved for elders in areas of privacy, dignity, meaningful activity, relationships, autonomy, food enjoyment, individuality and emotional well-being. Green House ® homes relative to nursing home comparison sites. Small House staff reported higher job satisfaction and direct care staff reported less job related stress. Staff spent 23-31 minutes more per resident per day on direct care activities A fourfold increase in staff time spent engaging with elders outside of direct care activities. Additional Outcomes Due to the high level of familiarity with elders, direct care workers were able to identify very early changes in elders’ conditions and facilitate timely intervention
  • CMS has a long history of supporting culture change in long-term care that began back in the Fall of 2002 with satellite broadcast to all surveyors entitled “Innovations in Quality of Life – the Pioneer Network.” The broadcast taught surveyors about common culture change innovations that might be encountered and how compliance with federal requirements might be maintained within culture changed. This support has continued with Thomas Hamilton, Karen Schoeneman and Leslie Norwalk to just name a few. CMS funded and co-developed a well known tool called the Artifacts of Culture Change and made it available to the public April of 2006. The great State of Texas is in support of culture change and has endorsed it whole heartedly. We currently have Green House homes located in two different cities in Texas operating very successfully. In addition, TDADS just supported a very well attended Culture Change Symposium in Austin. In addition, small house design has the support of Fred Worley and he is working hard to provide this model with the support it needs to succeed.
  • Small house homes across the country are reporting… Increase in overall campus census since opening a small house home Operating a small house home is cost neutral compared to a high quality traditional home 3. It is beneficial to have an existing campus to support the work of a small house home to spread the cost
  • “How can you say we’re not behaving like a team? We’re all wearing the same color shirts, aren’t we?” Let’s take a look at “real” teamwork and how you get there.
  • The care givers in a small house home must operate as a team. They must work together each day to not only provide the needs of the elders, but maintain a home for the elders..
  • They are charged with many different tasks such as cleaning, cooking, scheduling, prioritizing, decision making, care giving and they are succeeding in homes all over the country
  • They are often host and hostesses in the home arranging family get togethers, celebrating birthdays, anniversaries and arranging for entertainment.
  • Most would conclude that their most important work is that of care givers and companions to those that have been left in the care.
  • A beautiful well designed home is certainly an added plus in developing a culture of elder centered care, but it is not the “silver bullet.” A beautiful well designed home must be led by team members who have ownership in their work, who are trustworthy, trained and talented. They are educated and understand what it means to place decision making at the level of the elder to create a home that thrives in choice, dignity and autonomy. They are guided on mentored by a professional that believes in empowerment and building trust.
  • A self-led team just doesn’t happen by chance, but through thoughtful planning, education and training you will begin to see your teams come together. Direct Care Staff, Clinical support staff, organizational leaders, other department mgrs, family members and even residents to participate in appropriate areas.
  • The method in which the information is delivered can and should be fun! Learning is about seeing, hearing and doing! The goal is for individual insecurities to decrease and for trust to begin to rise among the team.
  • Training is challenging, interactive and informative. It will challenge our current thinking, guide us to interact and learn from others and provide us with information so that we can be our very best. Participation from the VP of Operations Charlie Wilson, Executive Director, DON, Administrator, Nurses and Nurse aides.
  • Strengths, Weaknesses, Opportunities, Threats Plan, Do , Study, Act The leadership in the organization should participate in the direct care training, but it is also necessary for the leadership of the organization to review the organizations mission and vision statements to ensure that they line up with the philosophy that is being taught in the home. In addition, the leadership of the organization with input from other key stakeholders to go through a SWOT analysis to develop a strategic plan for implementation
  • When all else fails… My new approach to effective team development will take a bit longer. In my plan, we raise them from birth.”
  • Nurses working in a small house home are in an environment that is designed to allow them to be nurses and not managers or bosses or scheduling coordinators, etc… Let’s take a look at and discuss some of the nursing features in a small house home.
  • Traditional nursing stations are institutional. All three of these areas can serve the functions of a nursing station in a small house home. Point out the features that “hide” the fact that they serve as nursing stations. Use Red laser pointer Top Left: French style doors, office look. Bottom Left. This area was installed with a computer monitor that displayed the nurse call system. Every room was viewable from this location. A secondary fire alarm panel can be found on the wall to the behind the desk and to the left. Bottom Right: PI architects is using a desk area like this one to serve as ancillary nursing stations. This area can easily be utilized for charting and a nurse call system. All three of these stations can easily serve as a nurses stations meeting regulatory requirements in Texas.
  • A nurse in a small house home utilizing electronic medical records A nurse aide in a small house home showing the pharmacy consultant how she utilizes care tracker.
  • The functions of the med cart remain, but the institutional look of med carts have been removed.
  • Nursing Students from nearby college are exposed to elder-centered care in a small house home. There are opportunities for clinical training of nurses and CNA’s. Don’t forget other clinical support team members such as therapists and social work practicum work.
  • Thank the audience for their time and ask for questions.

A Visionary Path to Culture Change: Pearl Merritt & Debby Burgett A Visionary Path to Culture Change: Pearl Merritt & Debby Burgett Presentation Transcript

  • A Visionary Path to Culture Change Texas Coalition for Culture Change San Marcos, Texas September 23, 2011 Pearl Merritt, EdD., MSN, MS, RN Regional Dean Texas Tech Health Sciences and Debby Burgett, LNFA Member of Pivot Senior Living Experts
  • The Beginning of a Journey "Vision without execution is hallucination.” — Thomas Edison
    • Analyze contributions of small houses for elders
    • Propose innovative strategies for ADL’s by CNA’s
    • Critique the role of the nurse in small houses
    • Questions and Answers
  • Small House Design
    • What is the definition of a small house?
    • Do you already have an existing campus infrastructure?
    • Will the design meet with regulatory guidelines?
    • Is the design financially viable?
  • Traditional Home Repositioning
  • Outcomes
    • Opens doors for increased opportunities
      • Better clinical outcomes
      • Lower staff turnover
      • Increased staff satisfaction
      • Increased campus census
      • Increased elder and family satisfaction
      • Better survey results
    • Changes negative image of long-term care
    • Creates a brand strength for your organization
    • Increase revenue if proves to be a good financial model
  • Cultivating Relationships
    • Buy-in from federal and state surveyors
    • Educate and keep surveyors informed of your adopted philosophy and practices
    • Design approval is required from the State of Texas.
    • Connect with TAHSA, TXCCC, SAGE, Pioneer Network
    • CMS offered its contribution to the movement by stating , “It is our goal to have State agencies assist innovative providers in determining how changes they wish to make to improve the lives of their residents can be compliant with the Federal regulations that protect all residents.”
  • Financial Viability
    • Market study
    • Financial pro-forma
    • Secure financing and fundraising
    • Operating and Projected budget
    • Timeline for completion of project
  • Care Givers in a Small House Home
  • The Direct Care Staff: Flexible, Talented, Multi-Taskers, Selflessness, Adaptable, Generous, Courageous, Trustful
  • Activities, Celebrations and Meaningful Engagement
  • Care Givers and Companions
  • Self-Led Team
    • Team scheduling
    • “ Keepers” of the daily rhythm of the house
    • Work as a team with nurses, therapists and any clinical support member
    • Coordinate meals to include planning with elders, ordering, receiving and cooking of food.
    • Responsible for maintaining the house in a clean, neat and orderly.
    • They report to a coach, guide or mentor.
    • They are highly skilled with culinary talent, safe cooking practices, and CPR.
  • Time, Training and Method
    • TIME
    • Direct Care Staff, prior to opening, 2-4 weeks
    • Leadership, prior to opening, 4-12 weeks
    • Culinary Skills
    • Food Safety
    • CPR
    • Conflict Resolution
    • Communication
    • Elder Centered Care
    • Support –VS-Accountability
    • Developing Self-Led Teams
    • Team Scheduling
    • Ageism
    • Regulatory Support/Survey Readiness
  • Time, Training and Method
    • METHOD
    • Classroom Instruction
      • Role Playing
      • Lecture
      • Videos
      • Brainstorming
      • Active Participation
      • Power Points/handouts
      • Problem Solving Scenarios
      • Involvement from All
  • Leadership Development
    • Begins as soon as possible
    • Key stakeholders
      • SWOT
      • PDSA
      • Realign vision and mission statements
      • Strategic planning
      • Readiness Assessment
  • Nursing in a Traditional Home
    • Steep bureaucracy
    • Nurses control all unit activity
    • Nurses are the “boss” of the nurse aides
    • Nurses are responsible for nurse aides scheduling and finding replacements
    • Departmental
    • Regimental
    • Nurses station is the center of most units
    • Institutional feel
    • Nursing Charts and paperwork intensive
    • “ Giving nursing staff a voice in the organization’s decision making related to care practices and work process changes will influence staff retention—an integral part of maintaining quality care.”
    • – Barbara Bowers, PhD, RN, FAAN
    • Associate Dean for Research
    • Helen Denne Schulte Professor of Nursing
    • University of Wisconsin-Madison
  • Nursing in a Small House
    • Bureaucracy is flattened
    • Daily rhythm of the home is in the control of the elders
    • Nurses are not responsible for CNA scheduling or finding replacements
    • Nurses and Nurse aides work as a team; they are often described in a small house as educators.
    • The functions of the nurses station are provided, but the “look” is different
    • Home environment; the institutional look and feel is removed
    • Nurses truly are nurses and not supervisors
  • Nursing Stations
  • Technology
  • Institutional Features are Removed
  • On- Site Training
  • Conclusion
    • Research validates small house outcomes of improved quality of care and improved quality of life.
    • CNA’s through education and training maintain the home with the elders at the center of all decision making.
    • The role of a nurse in a small house home is crucial in maintaining quality of care.
    • The small house design can be financially viable.
    • State and Federal agencies are supportive of the small house model and culture change.