“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.

https://www.youtube.com/watch?v=xeU8q7-Z3IQ

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

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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.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3140257/

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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“You can design and create, and build the most wonderful place in the world. But it takes people to make the dream a reality.” Walt Disney

Create the Culture Around You
Training helps us move toward creating a better health care environment for our elders and for ourselves. “Defining and Creating the Culture Around You” is the title of our latest regional training that will be completed this month. The response has been very positive.
Our speakers have encouraged audiences all over the state to build a dream and then make it a reality. Speaker C.W. Miller made us think and respond to ideas on how we can change our culture. He reminded us that the health care industry is similar to other organizations. In order to change an environment you must have a vision and create, not stay the same and stagnate.
The message from our training flyer says it all: “We hear the terms ‘culture change’ and ‘person-directed care’ used so frequently. Do we embrace these ideas with a full understanding of their true meaning, or do we view them as merely the latest catchy phrases?”
Speakers Melinda Davis, OTR/L, CEE director of Rehabilitation, Arkansas Health Center; and Shelley Muscovalley, RN, CEE Eden mentor, Department of Human Services, Division of Medical Services, Office of Long Term Care, encouraged us to continue on our journey with support from others in Arkansas.
As we networked, we also learned about new research that shows changing our culture is making good business sense.
These links provide information that was discussed during our networking sessions. See our calendar for time and location of the final training on “Defining and Creating the Culture Around You.”

http://events.afmc.org/

The following will link you to data on change research to start your own discussion:
http://www.pioneernetwork.net/Latest/Detail.aspx?id=388
http://gerontologist.oxfordjournals.org/content/54/Suppl_1.toc
http://changingaging.org/

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“Come on Steve, we’ve got diem to carpe.” ― Flint Lockwood in “Cloudy with a Chance of Meatballs”

The big myth about nursing homes is that Bingo is the only activity. Bingo is important to many of our residents, but most homes have varied and creative activities.
In some homes there’s often a few residents who want Bingo seven days a week. This often poses a problem for activity directors. Several activity directors have solved this by having Bingo on the activity calendar on certain days and, on other days, the residents have bingo parties. Bingo parties or resident-directed-bingo is a way to have Bingo any day of the week. Residents have access to Bingo equipment and a Bingo room at any time.

Resident-guided activities are important and generally popular with most residents. Not only do they provide more activity opportunities, residents become involved in daily life. These activities use their leadership skills, decision-making and diplomatic skills to enhance residents’ independence, self-confidence and acceptance of this stage in their lives.

What about seizing the day? What about activities that make you catch your breath, make you laugh until you cry, or make you remember you are still alive? We are seizing the day in Arkansas nursing homes with these creative activities.
A balloon ride was part of a “bucket list” request from a resident living at Southern Trace Rehabilitation and Care Center in Bryant. It was something she had always wanted to do. What a wonderful experience.

“The wheels on the bus go ‘round and ‘round,” is an enhancement of the nursing home’s weekly ride. The residents get to map out the journey and set the destinations. It may be a ride to all the old home places or a trip to a casino. We’ve been to the horse races, the movies, gone swimming and horseback riding.

Laughter IS the best medicine and laughter was flowing at the Annual Snowball Fight at Craighead Nursing Center in Jonesboro. Who knew that throwing large marshmallows, as Christmas carols played in the background, could be such fun.
Residents laughed, staff laughed and the marshmallows flew.  A resident told me, “I’ve laughed until I’ve about died.” Then she hit her friend with a huge marshmallow, as she peeped out from behind a wall. Somehow I got stuck in the crossfire and my shoe got covered. The memory is stuck on my shoe–I mean,… mind.

Kathy Caskey from Woodruff County Nursing makes everyone glad to be having another birthday. Kathy knows all about seizing the day but she’s not the activity director. Kathy is the dietary manager and is also known as the “hat lady.” Kathy started wearing crazy hats on Fridays, just because residents’ loved it. From there it has grown to a birthday hat day that has the residents excited about having another birthday. On their birthday, every resident gets a visit from Kathy with her singing birthday hat and a cake.
Even providers have gotten into the act. The home’s food supplier brought her a chef’s hat to wear. The dietary staff joined in the fun by adding an apron. Now Kathy is a life-size version of the Pillsbury Dough “girl.” Residents rush to the dining room to see what hat will be on Kathy’s head! hathat1

Enhancing our resident’s lives, as Kathy has shown, is not just the activity director’s job.

Come on Arkansas, we have a day to seize.
For our residents who are “walking with forgetfulness,” this link includes ideas to help them seize the day too.
http://www.alz.org/care/alzheimers-dementia-activities.asp

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“Everything has beauty, but not everyone sees it” Confucius

This gallery contains 12 photos.

“A nursing home is a place for people who don’t need to be in a hospital but can’t be cared for at home. Most nursing homes have nursing aides and skilled nurses on hand 24 hours a day. Some nursing … Continue reading

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“Good management is the art of making problems so interesting and their solutions so constructive that everyone wants to get to work and deal with them. “ — Paul Hawken

A nursing home is a place resident’s  call “home.” It is also a place where residents at times receive complex medical care. It can be hard for caregivers to blend these two ideas. We have difficulty speaking the language of home and the language of medicine in the same conversation.
Some of this language is slowly changing through education, team mentoring and new workers coming into the long-term care environment. We welcome these changes and we welcome new ideas to help with some of the problems we face in long-term care.

For example, compare the medical model of language and the natural culture change model for these terms:
Medical model language                       Natural language
Wing, unit                                                       Household,street, neighborhood,lane
Allow                                                                Encourage,welcome
Patient                                                              Resident, individual, elder
A feeder/the feeders, feeder table              Person who needs assistance \dining

One of our best change ideas is to use teamwork to find solutions to safety issues, falls and quality of life questions. Many of our change homes are actively seeking out employees at health fairs, schools and community events. They are developing ideas and encouraging employees to help invest in the home. They are doing this by providing direct care staff with access to education and by encouraging the trained staff to be the educators for new programs and ideas. Change teams, behavior teams and quality teams are formed with all levels of staff participating in finding solutions for their home.

At our next training, we will be discussing teamwork, leadership and how to make it exciting to find solutions to problems in our homes.

Join us at : National Park Community College in Hot Springs on Tuesday, Nov. 12 for a culture change workshop.   http://aipp.afmc.org/

We will have several leaders, including Melinda Davis, who was in our first-year project and serves as a mentor for our new project homes. She is an Eden Educator and has recently participated in a training project with Dr. Al Power, author of Dementia Beyond Drugs.

C.W. Miller will begin our day with new teamwork ideas and activities. Mr. Miller has been creating high performance teams in a variety of industries for more than 25 years. He has lectured to executives nationwide on such topics as quality assurance, cost containment, time management and customer satisfaction. Mr. Miller understands that our people in long-term care are Arkansas true diamonds.

“From the backroom to the boardroom, one principle prevails. People are our most important asset and success is dependent on the human interaction skills of those people. Therein lies our opportunity and our challenge.” — C.W. Miller

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“Everything that can be counted does not necessarily count; everything that counts cannot necessarily be counted.” — Albert Einstein

Nursing home quality measures have four intended purposes, according to the Centers for Medicare & Medicaid Services (CMS):
1. To give you information about the quality of care at nursing homes in order to help you choose a nursing home for yourself or others
2. To give you information about the care at nursing homes where you or family members already live
3. To give you information to facilitate your discussions with the nursing home staff regarding the quality of care
4. To give data to the nursing home to help them in their quality improvement efforts
And according to CMS, these ”measures assess the resident’s physical and clinical conditions and abilities, as well as preferences and life care wishes. This assessment data has been converted to develop quality measures that give consumers another source of information that shows how well nursing homes are caring for their residents’ physical and clinical needs.”
The current quality measures are listed at http://www.cms.gov/Medpicare/Quality-Initiatives-Patient-Assessment-Instruments/NursingHomeQualityInits/NHQIQualityMeasures.html.
Where are the measures for preferences and life care wishes?
The nursing home quality measures come from resident assessment data that nursing homes routinely collect on the residents at specified intervals during their stay. CMS also says, “The current quality measures have been chosen because they can be measured and don’t require nursing homes to prepare additional reports. They are valid and reliable. However, they are not benchmarks, thresholds, guidelines, or standards of care. The quality measures are based on care provided to the population of residents in a facility, not to any individual resident, and are not appropriate for use in a litigation action.”
This assessment data is from the MDS 3.0 (Minimum Data Set), which has been recently updated to allow more resident involvement in the assessment. Sounds like a good idea when the quality measures want to reflect preferences and life care wishes.

But what do consumers really want to know about a nursing home? Glad you asked!
According to surveys done by some leading organizations and advocacy groups in long-term care, the people they survey want very simple things in a nursing home.
1. They want the staff and the residents to be happy. They feel that if the staff is happy the residents will be happy.
2. They want an active lifestyle to continue in the nursing home.
They want books and computers available for resident use, and where the home stands in culture change areas.
3. They want the kitchen to prepare food the residents want and like to eat.
4. They want the wheelchairs and mobility products to fit the individual.

Sounds like they want quality meaures for living.

That is just what many of our Arkansas homes are offering: quality measures for living. If you look back over the earlier blogs entries on this site, you will see homes making changes to promote individualized care. You will hear of many positive changes made by staff and residents in Arkansas — changes like…
Westwood Health and Rehabilitation provides empowerment and education of staff through special programs. Staff is paid for a voluntary four-hour “resident experience,” a program in which staff members are given a diagnosis and a list of limitations. They then live out that life for four hours. The CNAs also self-schedule. Education on changes coming to long-term care — we bring them by the busload. Staff members come from St. Johns Place to hear Richard Taylor and Dr. Power speak on changing the way we look at dementia. (We won’t mention the parking garage incident.)(We will laugh and be happy.) Springcreek Health provides special education for memory enhancement of residents with the Spark of Life program. The direct care staff leads the training and helps grow other staff with education.
The CMS Hand in Hand educational series is off to a great start in Arkansas, in part due to the team approach for training modules. Many of our homes have the involvement of all staff in training. Leadership teams to promote involvement of staff in developing motivation systems in the nursing home — what measure is this under?

Hey, and remember the blog about Salem’s Place, the pool table and book club? The community involvement, the man cave… What about the wedding at St. Andrews? Fishing and cooking at River Ridge in the backyard by the gardens.
Computer labs and wireless internet are in many of our homes.
And what about that food! We have many homes now with restaurant style dining; you get what you want, sometimes all day. Chefs like those at St. Andrews and Whitehall cook to order. Greenhurst tells you on its web page about the dining there.
What about those cafes in our nursing homes? The Rusty Bucket at Ozark Health, the Bistro Café at Broadway Health, Café 720 at The Crossing at Malvern — they all provide special areas for food and socialization. Many cafes like the one at Brookridge Cove are on the memory unit, decorated in a style for special memory appeal. Apple Ridge has family-style dining on its memory unit. Many of our memory units cook and bake on the neighborhood. Many of these cafes are named by the residents and decorated according to resident choices. Many have internet and fresh baked items. Some have different coffees available like Starbuck’s.
Many of our homes are taking out the central nursing station and placing a living area in the middle of the units, excuse me, neighborhoods.
Oh and what about that — neighborhood, street name, home address, lane? What’s in a name? Where would you rather live, on Unit 3 or Hummingbird Lane? We even will help you make the change. At Katherine’s Place, you can get a book written by staff on how to develop a neighborhood.
What about the big changes, such as Greenbrier changing medication times to promote resident satisfaction. Wake up at noon, sleep in (don’t wake me at night) or stay up late. Our homes reflect the changing mindset, not to just maintain the resident, but encourage the resident to continue to grow. To not just have the right wheelchair, but provide learning programs and adaptive equipment. Hillcrest Home has the Never2Late to Learn series along with adaptive equipment. Many of our homes have this program. With the changes occurring in the nursing home population, the adaptive equipment must be ever changing. Therapy departments are jumping in with the nursing home team to provide holistic plans of care.
Teamwork — what a concept! What a measure!
Increasing involvement of teams, like at Arkansas Health, Ozark Health and Eaglecrest, are growing in Arkansas —teams made up of all departments to promote reduction of falls, reduction of restraints and reduction of alarms. These teams use measures like learning circles, huddles and communication connections. Measurement tools like the Home Thermostat Tool are being developed in Arkansas. This tool, developed by our state ombudsman and available on our website, measures, “What is our home like to our residents”?
Now that’s a quality measurement! All I can say is, Way to go Arkansas!

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“How you treat the one reveals how you regard the many, because everyone is ultimately a one.” ― Stephen R. Covey

Changing the way we care for people in the long-term care setting, or changing the “culture” in long-term care, has been a hot topic in the recent news. The Pioneer Network , the Eden Alternative Program and the Arkansas Innovative Performance Program are just a few of the organizations that provide resources for those who want to change the way we provide care to our residents in long-term care. The goal is to move our mindset as a nation to a person-centered approach to health care. One of the first big changes in long-term care is the need to look at things in a positive way. We need to document the positive things we are doing, we need to involve the community in our homes, and we need to gather teams that work for positive changes. We need to provide the positive to the media — film our own stories. We are doing incredible things in long-term care.

Let’s look at some of the negative thoughts we hear in team meetings about change.
What we hear: “We’ve always done it this way.” “It ain’t broken — why fix it?” Or the all-important, “We have always done it this way and no one has complained…not got a tag.” “What if?”
What they are really saying: We know it works and we are afraid of a new routine. What if the survey team does not understand the changes we are making? Why should we get a tag? We hear the same complaints from the same people; they do not understand how it works in long-term care.

Ideas and technology change and so does the delivery of health care, thus changing regulatory guidance. So just because it works now under the same regulation does not mean it will be the standard of practice forever. Our population in nursing homes is changing, just like the population in the world around us is changing. We can bring about positive change if we keep up with education, technology and resident surveys, and if we document the positive results of our change process, not just the negative issues of our investigations. We can look at all the what-ifs and determine if a problem is really a problem.

What we hear: “We cannot, because the money is not there … our company won’t give … our staff is strained…”
What they are really saying: My staff will not want to do extra. (Have they been asked to do something fun?) We are a medical organization, not a social organization. (New studies suggest that quality is not just skin care.) Money is tight and we do not get reimbursed for social programs.

For some programs to begin and continue, money must be spent at the beginning for things like educational training, environmental changes, activity expense, staff expense, etc. Many owners and managers looking at cost vs. return on investment ask, “If a change occurs and the environment is improved, is the reimbursement better?” Usually, the answer is no. Will it change in the future? Maybe, as our mindset changes as a nation. Will it help bring new residents to our home? Many of our homes are marketing their changes. Quality of life — does it have a price tag?

Many free educational opportunities are available to our staff members. Just look at the events calendar at http://www.afmc.org. Many homes have tapped into community help, grants and volunteers to start projects of enhanced activity, childcare for staff, and individualized therapy plans for residents. Try using employees creatively. Bring different disciplines together to solve problems. Involve residents’ families in projects. We need to look at what we can do to make people want to work in long-term care. What do we as health care providers offer to our workers? Is it a negative image or one of flexibility, creativity and engagement? We spend a lot of money on staff turnover — money that could be spent on enhanced activities for our residents.

“The thing that lies at the foundation of positive change, the way I see it, is service to a fellow human being. “ — Lee Iacocca

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