“Where there is no vision, there is no hope.” George Washington Carver

Vision: noun

1. The act or power of anticipating that which will or may come to be: prophetic vision; the vision of an entrepreneur.

2. A vivid, imaginative conception or anticipation:

verb (used with object)

1. To envision, or picture mentally: They tried to vision themselves in an institution at the end of their life.

People living in long-term care settings have been frequently left out of the conversation about how they think long-term care should be set up, changed or managed on a day-to-day basis. There have been many ideas on how to capture residents’ voice on assessments, surveys or care plan meetings.

The idea of person-centered or person-directed care has been an emerging vision in the long-term care field. This emerging vision is changing the way we “measure” quality.

This change has not just been the vision of older adults, but of young people who hope to change the way we set up health care concepts. One thought that is common to all the generations is innovation is the key to excellence. All over the news people are talking about innovation. There are a lot of questions about what innovation means in the long-term care industry.

One definition of innovation is that it is a process of finding novel solutions to important problems.  See more at  http://www.innovationexcellence.com/blog/2013/04/14/what-is-innovation-2/#sthash.LxvyiCZR.dpuf

The problems facing long-term care are very important. Everyone has heard of the vast number of baby boomers coming in to the health system. Many articles are being written about the increasing number of people with a cognitive disease process. In the above mentioned blog, the author talks about the models of innovation. Several are mentioned including disruption, sustaining and break-through innovation.

In Arkansas we are using all these innovation models to change the long-term care setting. Music and memory projects using the latest research on music and its link to the brain is one model. We’re also seeing pets in our homes and the amazing way residents respond to them. Another is the idea of sleep being the basis for healing and how if we do not get the quality of sleep we need, we may have poor outcomes in our homes. And we’re looking at how in an effort to prevent falls, we may be causing more harm than good with use of our alarms. This list goes on and on.

If you would like to hear about these wonderful visionary ideas and the people who are finding novel solutions to important problems, check out AIPP’s 2nd Annual Culture Symposium scheduled for June 23.


You, too, can “boldly go … and change the world of long term care.”

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“You know, food is such – it’s a hug for people.” Rachael Ray

Proper nutrition is important to keep you healthy. Many people with memory disorders or cognitive function decline cannot maintain the same nutritional intake over the progression of their life.

Providing meals is an important part of a care partner’s routine. Often the meal time is a busy, stressful time for the care partner and the resident. How can we as care providers provide that “hug” for our residents? Many of our homes have used educational programs to give care providers the knowledge they need to assist our residents to have a wonderful meal experience.

Several websites have excellence sources for information:

The Alzheimer’s Association provides excellent tips and education on the Alzheimer’s and Dementia Caregiver Center page for care providers on why the resident may have a poor appetite.  The person may no longer recognize the foods you put on his or her plate to the decreasing senses of smell and taste. This site also provides excellent ideas to de-stress the dining room.

Another useful website is the National Institute on Aging’s Alzheimer’s Disease Education and Referral Center, where you can find simple ideas for implementation for a plan of care for residents.

All the research and tips have a common theme: change the culture of your dining experience by knowing the resident. Encourage staff to provide food that is adapted to each resident’s individual need and stage of cognitive loss.

Many of our homes in Arkansas have changed from large dining areas to smaller home-like environments for their memory units. The nursing homes and their food suppliers often plan together for the special needs of their home. The presentation of meals and the successful addition of new dining experiences are implemented with a team approach.

As more and more research points to the evidence of food, music and activities being the key to a quality of life for all of us, more education will be needed to assist staff.

Continue to follow us at www.afmc.org  for events related to food, dementia and the quality of life.


Wednesday, May 20 9 a.m.–4 p.m.

Conway Expo Center and Fairgrounds

2505 E. Oak St. Conway

Registration begins 30 minutes prior to the start of the session. Lunch will be provided by Sysco.

A free workshop presented by the Arkansas Innovative Performance Program

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“Sometimes Ya Gotta Laugh” Karen Stobbe

Person-centered care has become a common term in the long-term care field.  CMS regulations and guidelines more and more mention the importance of person-centered care. It is often the topic of lectures at most senior living conferences. Many providers say they are doing person-centered care. Many use it as a platform for advertising.

At a recent conference in Louisiana, person-centered care was on everyone’s mind and the major topic of conversation.  

Researchershealth care workers, social and activity directors gathered to discuss current topics in senior care. Person-centered care was the major topic at the LEADER conference this year.

Leader (Louisiana Enhancing Aging with Dignity through Empowerment and Respect) is an organization “committed to helping providers, consumers, regulators and policymakers move toward providing person-center care to Louisiana elders in every healthcare setting.”

Every year members come together to share ideas. This year the conference’s main speaker was Karen Stobbe. Karen speaks about caring for dementia and assisted with the development of the training material series “Hand in Hand.” We have had the great fortune to hear Karen speak at our culture change symposium in 2014. Each time Karen speaks, everyone hears the message of person-centered care.

What does person-centered care mean to us? Are we getting close to having our nursing homes provide true person-centered care? These are questions that are being asked all over the United States. Now that we are focused on dementia and medication, and as our population becomes older, these are very important questions to continue asking ourselves.

Now more and more regulatory agencies and senior advocate groups are looking at other areas in our nursing homes, not just nursing care. Activity and socialization are now seen as important factors in the quality of life.  We ask, “Are these areas being addressed?”

Activities that are offered in our senior living homes are being scrutinized for meaning. Do we know what our residents really like? We know we try to return our residents to a maximum level of health, but do we try to return their social, activity level to a maximum level of participation?

Do we look at who likes to read in his or her room, and who truly is the social butterfly? Or is this information just gathered for documenting a plan of care – a piece of paper for compliance.

Enhanced activities and the reduction of anti-psychotics took prominent place on the leader agenda this year. For many of the attendees, person-centered care was about activities, socialization and dementia care based on new knowledge.   There are many resources for information on how to bring person-centered care to our senior living homes. Homes that are making changes are often the best resource. Take a look at some of the information and contacts from around the country:

www.in-themoment.com/  Karen Stobbe




And at home in Arkansas:




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“A failure is not always a mistake, it may simply be the best one can do under the circumstances. The real mistake is to stop trying.” B. F. Skinner

In 1987, the federal Nursing Home Reform Law (OBRA 87) set forth certain standards of care for nursing homes receiving Medicare and Medicaid funding.

Under the regulations two of the standards are listed as:

  • Promote each resident’s quality of life. (42 CFR §483.15)
  • Maintain dignity and respect of each resident. (42 CFR §483.15)

These standards are listed first in the regulations and are some of the areas that we struggle with every day in the nursing home. As our culture changes, so should the way we meet these regulations. Part of our struggle is the fact that each of us defines “quality of life” differently. Each of us has different definitions of respect.

We often have a gap between the caretakers and the residents of our nursing home based on age, culture and knowledge base. Our goal in our nursing homes is again, to promote each resident’s quality of life and maintain dignity and respect for each resident. This sounds like a simple goal, but is often lost in our daily struggle to get “things done.”

We make mistakes, often when we start new programs. Does this mean we have to scrap that program?  No, especially if we are implementing a program that has been shown through research to enhance “the quality of life” for many residents. We have to go back and look again at some of our basic elements.

  1. Who are our residents?
  2. Who are our staff?
  3. Do we have staff buy-in to our programs?
  4. Do we have staff?
  5. Does everyone understand the program?
  6. Have we really done the proper training/education?

As more and more “memory units’ are opening in our nursing home, it is very important that we continue to try to meet the needs of our residents.  As more research is done and different programs are shown to enhance the quality of life of our residents, we need to continue to try.

Many of our homes working for change in our nursing homes continue to do just that, try again and again. Look at where we can change. Maybe more community involvement. Maybe more education. Obtain grants for new programs. Work with a national program.

We like to help our homes with change and promoting “quality of life,” so take a look at our upcoming event.


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“It is what we know already that often prevents us from learning.” Claude Bernard

In the Last blog we talked about “are we ready to change the way we our caring for our residents?”

Are we as healthcare providers ready to take on care driven by a new culture of education?

Are we ready to provide education and resources to our staff to engage and understand our residents with dementia?

These are some of the questions that we asked ourselves, as we prepared to start a new year.

We talked about what we would be doing in Arkansas, how we would be using many resources to help us provide quality care to our residents.  We were going to try to unlearn some of our behaviors that have become so ingrained in Long Term Care.  Many of our homes will be using special tools for training and sending staff to specialized training.  Some of our homes continue to use music and memory programs, computer programs and special in-service programs to lower the use of medication in our residents

It is working, data is showing a gradual decrease in the use of anti-psychotic medication in Arkansas long term care homes.  More and more people are talking about going to a local home for rehabilitation and how we are encouraging them to return to community. Letting them know that the home is there for them, if they need to come back at a later date.  This mindset change is helping homes, like General Baptist of Piggott, change the way we see our elderly residents. This thought that we can help others to grow and change through the aging process, makes employees feel good.

Next month a direct staff training will be available around the state to help us change our mindset and behaviors.  The thought that we can change our behavior to improve our residents’ quality of life, is a true culture change idea.

See the schedule for training at http://events.afmc.org/Home.aspx

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“What we have, first and foremost, is a crisis in care.” Dr. Al Power

In his blog highlighted in, www.changingaging.org, Dr. Power talks about it is time to get serious with real culture change.  Healthcare workers need to change the way we view behaviors in dementia residents.  He goes on to point out that as we reduce medications with side effects that produce sedation, we will have to start changing our organizational structures.

The crisis he talks about is not the increase in behaviors of residents, but in us, are we ready to change the way we our caring for our residents. Are we as healthcare providers ready to take on true person- centered care, person-directed care or care driven by a new culture of education?

Are we ready to provide education and resources to our staff to engage and understand our residents with dementia?

Dr. Power asks if we have the courage to change our way of care, to meet the crisis by steady shifts in change, slowly turning down the fire under our crisis.

In Arkansas, we are going to try! With assistance from many resources, including Dr. Power.  Many of our homes are opening memory units, using special tools for training and sending staff to training.  Some of our homes are using music and memory programs, flexible staffing and activity programs.  We have many links and tools on our website.  If you would like to read Dr. Power’s blog and see some of the innovators in care, visit his page at,       Time to Get Serious

Many of our homes are joining with community providers to help raise money and awareness for disease process that may cause dementia and behaviors. Joining with other’s to encourage education for staff.  Together we can meet this crisis with courage and not blame.

As always we are thankful for the pioneers of change, like Dr. Power and Dr. Thomas who’s courage to promote innovative ideas have inspired other’s to slowly reach for low-hanging fruit, then move on to the next level.


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“It’s never too late to try something new.” Dr. Bill Thomas

In a recent article written on what’s trending in nursing homes, research on enhanced activities was highlighted by the Annals of Long Term Care. The research highlighted that nursing home staff tended to emphasize a person’s disabilities in their interactions with their aging residents. The article describes how men were affected by the interactions of staff. The article explains how research shows the importance of activity directors and their unique positions to promote personhood in residents. What was very interesting about this article and the highlighted research is that it took place in Arkansas. The results of this research can be reviewed at http://www.annalsoflongtermcare.com/article/promoting-personhood-men-nursing-home-activity-directors,

In spite of the small population of respondents to the questionnaire and other drawbacks to the study, there are many interesting remarks from activity directors. Remarks included the wish-list of being able to take more outings for fishing, golfing, etc. We have talked on our blog page about some of our homes that offer fishing, going for outings to casinos, and man-caves. This is a reachable goal for homes to increase the personhood of residents.

The article mentions the study addressed the education level of activity directors. We have educational opportunities for activity directors to increase their knowledge and obtain certification. Hopefully this will increase as more and more articles are written about nursing home engagement. This will help in our need to change the mindset of our communities about what residents in nursing homes are doing in Arkansas.

Health and wellness were also mentioned in the article with specific types of exercise highlighted by activity directors. We talked about out-of-the-box type exercises (tai-chi, yoga) in a previous blog that would help with residents’ balance and fall prevention. Falls are a major occurrence in our nursing homes and communities. Fall prevention has always been relegated to the medical field, but research is showing more and more how a well-rounded exercise and a therapy program can help a resident maintain a quality lifestyle in the nursing home. Some of our homes are offering these exercises and many work closely with their therapy department to provide fall-directed activity.

We would like to invite everyone to join us in the upcoming months for a falls education regional training. Visit us at http://www.afmc.org/ for a calendar of upcoming events. We all want our residents to have the highest quality of life in our nursing homes and increase their feeling of personhood, so … hope to see you there!

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“Nobody grows old merely by living a number of years. We grow old by deserting our ideals. Years may wrinkle the skin, but to give up enthusiasm wrinkles the soul.” –Samuel Ullman

Dementia Care Mapping (DCM) was originally developed as a clinical tool but now is being looked at as a way of measuring the quality of life and well-being of long-term care residents with dementia. You know us in healthcare, we’ve got to have our tools for measuring quality. Some of the issues and problems identified with the DCM tool are:
1. Complex scoring algorithms.
2 Time burden.
3. The ability to compare results across study settings.

Does this sound familiar? Isn’t this what we hear in the trenches from our people working in the field of long-term care? Please do not give me another complicated tool or form to fill out.

Despite these problems, the DCM tool has shown promise as a research measure. However, we are told the promise lies in the manner in which it is applied and if the people using the tool understand what we are trying to measure. Does this sound familiar? Remember in the early days of data entry…”garbage in / garbage out”?

This tool has been in use over many years in memory units. What the researchers have found is that still, the tool is only as good as the staff’s use of the tool. Do you see a pattern?

We struggle in healthcare to continue to change our methods of treatment to fit new research. We have new toolkits, new technology and new ideas. What we have not done is put into place the fundamental idea that each person is different, an individual’s needs are different, and as a result, treatment should be different for each person.

Maybe as healthcare workers, we should just pass out blank pieces of paper (or i-pads) to the residents to write down what they consider quality of life or have staff write what they know about the resident, or what the family knows about the resident’s life.
Wow … hold on a minute! How do you score that? Where is the quality of life measurement?

Here’s a thought … We could place at the bottom of the blank page a measurement indicator. What about a picture? A picture says a lot!

How would you score these pictures? What is the quality indicator? Does this seem to fall in the “life is good” range? If so, keep on keeping on!

sarah_rowan_picture    wedpic     spread

arkansas           cook1  cook



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“The secret of change is to focus all of your energy, not on fighting the old, but on building the new,” according to Socrates, a gas-station attendant and character in a book by Dan Millman.

Regular visitors to ArkansasCultureChange.com blog may have noticed that there was no post in June. That is because we “posted-in-person” at AIPP’s first Culture Change Symposium, June 18 at the Heifer International Village in Little Rock.

Karen Stobbe, of “In the Moment” and co-developer of the CMS hand-in-hand training videos, was the symposium headliner. Stobbe was assisted with her educational headliner by her husband “Mondy.” Watch them on YouTube.


The headliner, usually the final act in a music, theatre or comedy performance, is preceded by the opening act. The symposium’s opening act featured Lisa Thomas, state training coordinator for the Arkansas Office of Long Term Care, and staff from the Oak Haven Community Care Center in Center Point, Louisiana. Their presentations focused on building a new long-term care. Both Thomas and our guests from Oak Haven are very familiar with new ideas in culture change. For a glimpse of Oak Haven’s commitment to change , you can download files from the Louisiana symposium.  http://www.cvent.com/events/let-s-get-cookin-with-person-centered-care/custom-20-f0e148689a9641dc9f30998ac6897d80.aspx


The “Dog Days of Culture Change” video premiered at the symposium. There was also a showcase gallery of Arkansas nursing homes that are building a new culture of long-term care. Visit our website for more information from the symposium and gallery. (Click on Arkansas Innovative Performance Program on the far left.)

As we build a new long-term care culture, it is important to remember why we are doing it. Culture change efforts should start with the needs and life circumstances of residents. This is why we say “person-centered” or “resident-directed care.” The core principles of culture change include knowing, understanding and listening to residents, and honoring their experiences. As we learned at the symposium, our actions must be guided by our residents’ perspectives.

Many of you may remember Dr. Richard Taylor’s 2008 visit to Arkansas. Taylor, who has Alzheimer’s disease, shared his unique wisdom from the perspective of a dementia patient:
“We are told we must now resign ourselves to allowing others to take care of us …
We are told by many professionals, and even our own loved ones, sign away all our rights …
We are expected to trust professionals who have not experienced our cognitive environment, and who were trained by others who have not experienced our cognitive environment …
They believe they know not only what is best, but that they know all there is to know about how best to take care of us …”

Even if your home does not want to change its environment or its operational model, you can make simple and individualized person-centered changes. For example: when a research group asked residents to investigate their nursing home, here’s what they noticed that was not resident-oriented:

• Residents said bulletin boards were placed too high on the wall to be seen clearly by residents in wheelchairs.
• The print size of posted materials was too small to be read by those with visual impairment.
• Positive news and artifacts representing residents’ accomplishments were rarely shared on bulletin boards.
• Read about more ideas at web site below.


It does not take a lot of policy and procedure changes or money to correct these things. Change is about focusing on the new, not fighting the old.

DSC_0989        DSC_0977

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“Education is the most powerful weapon which you can use to change the world.” ― Nelson Mandela

Knowledge Will Improve Care

Despite a nationwide push by the Centers for Medicare & Medicaid Services (CMS), we are still not seeing the reduction in antipsychotic medications in older adults with dementia.
The Interim Report from the National Partnership to Improve Dementia Care in Nursing Homes: Q4 2011 – Q1 2014 was recently released by CMS. It outlines the history and current use of antipsychotic medication in older adults with dementia living in nursing homes. It concludes that “alternative, non-pharmacological approaches to optimize care for people with dementia living in nursing homes have not been widely implemented to date.”

Over the past two years, CMS and its partners have developed numerous resources and made them available in the public domain.
One of these resources is the “Hand-in-Hand Toolkit,” a series of six training DVDs. This toolkit is available at http://www.cms-handinhandtoolkit.info/Index.aspx

The toolkit was distributed free to every nursing home in the country and many facilities in Arkansas are using it. In June, one of the creators of this toolkit will be coming to Arkansas to speak. Watch for more information about this learning opportunity on our web site: http://aipp.afmc.org

“Toolbox for Improving Behavioral Health in Nursing Homes” is another toolkit for healthcare partners that is available to download at http://www.nursinghometoolkit.com

Another learning opportunity is to read the Minutes from the monthly conference call, held on April 8, 2014.       They have been posted to our website http://aipp.afmc.org/AIPPResourceCenter/MonthlyConferenceCalls.aspx
The topic was “Antipsychotic therapy…then and now,” presented by Anthony M. Hughes, BS, PD, FASCP.

The recent and very successful AIPP Culture Change Workshop “Demystifying Resistance-Addressing Unmet Needs,” was presented by Teepa Snow on May 1. Handouts from the workshop will soon be available in the AIPP Resource Center at aipp.afmc.org

Many other free tools are available to download at www.afmc.org.    These tools were developed to help care partners and families improve the quality of life for nursing home residents living with dementia.

We have the tools, so why is it taking so long to make the changes that CMS wants us to report? The answer may lie in an article entitled “Slow Change,” by Atul Gawande, a surgeon and a public-health researcher. The article explains how and why some innovations spread fast in the medical community, and others are slower to be implemented by healthcare workers. He says part of the problem with the spread of innovative ideas may be “the technical complexity.” Read the article at http://www.newyorker.com/reporting/2013/07/29/130729fa_fact_gawande?currentPage=all

“Slow change” is definitely part of the problem with attempts to reduce the use of antipsychotic medications in nursing homes and in the community. Dementia has a complicated disease process. The care of dementia patients can be a very complicated process, often exhausting for caregivers and facility staff.

With education and support, Arkansas care partners will continue to implement new ideas and innovative programs to improve the quality of life for nursing home residents.

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