Enhance Community Involvement "We got trouble, right here in River City," ...and that stands for pool! One son knew his employer would not let him off work to spend the afternoon at a local pub playing pool with his father and the other father-son duos from the nursing home where his father lived. Since he refused to miss this chance to continue to enjoy a favorite pastime with his father, the son asked the administrator to write a note to his employer saying he needed to come to meetings on the dates when the immensely popular father-son pool outings were scheduled. The dictionary defines community as "a body of people living near one another and in social relationship, a body of people with a faith, profession, or way of life in common." (New Webster's Dictionary & Thesaurus, 1992, p. 198) Most individuals belong to a number of communities their neighborhood community, their town or city community, possibly a church, synagogue, or other religious community, a professional community or ethnic community. Rituals are associated with each of these communities. Visits with people from the outside community may help residents to preserve their identity (Duncan & Morgan, 1994). Staff's ability to meet residents' emotional needs may be dependent on these links to the outside, especially with family. It is difficult to leave a community because of a move, especially when one has established many rituals. Even simple things such as waving to the neighbor when the newspaper is picked up, nodding at the postman, laughing with a favorite check-out person at the grocery or telling the regular van driver, "I'm going to my sister's" without needing to give the address can be important rituals. This sense of belonging in a community must be continued or recreated. If it is lost for any of the communities to which an elder belongs, with it goes a piece of self- identity. When some of these rituals are recreated in the nursing home it can help a new resident connect with that particular community. Equally important are those other communities outside the nursing home. What about morning coffee and conversation at the caf‚, the regular Wednesday trip to the grocery, weekly religious services, the Friday lunches in that favorite restaurant with a friend, the symphony or theater performances, the outings to the zoo or ice cream parlor with the grandchildren and the annual spring trips to the garden center? How many of these can be continued or recreated? The more that are continued the easier the transition. York and Calsyn (1977) found that families want to maintain contacts with their family member living in the nursing home but that they need help to make their visits more productive. Cornell University (2000) designed and tested "Simple Gifts." The hypothesis posed was that behavior problems in dementia care units would decrease if the residents were given opportunities for self-initiated activities. Thirty sensorimotor items were created and tested. The study showed declines in behavior problems but an unexpected benefit was that family and volunteer interactions with residents increased as they were engaging in productive activities. Instructions for ordering the "Simple Gifts" program can be found in the Resources section. Through a grant funded by the Mt. Sinai Health Care Foundation, the IDEAS Institute (2003b) has developed a booklet to help family and friends have enjoyable visits with residents. The booklet covers topics such as how to deal with hearing, vision, memory, or speaking difficulties, conversation starters, going out, bringing children, and maintaining connections when living at a distance. (See Resources section for more information.) Some facilities have found that creating a museum area with objects and photographs dating from times when residents were children and young adults can provide an enjoyable stimulus for visitor/resident conversations. Objectives relating to enhancing community involvement include: strengthen formalized volunteer programs, provide intergenerational programs and provide opportunities to participate in community activities. Strengthen Formalized Volunteer Programs A strong volunteer program increases the likelihood that residents will get the individualized attention that is necessary to provide an optimal quality of life. Volunteers offer friendship and support that can enhance self-esteem. One of our staff members attending a conference overheard a comment that the best return on the dollars the organization had invested in culture change was their volunteer coordinator. It has been suggested that if an organization does not have enough resources to hire one for themselves, they should partner with another organization in the area (which need not necessarily be a long-term care organization). Many organizations have discovered that food and fellowship go hand in hand. For many years, volunteers who were home economics teachers have led Thursday morning cooking classes at Friendly Acres in Newton. These sessions give residents the opportunity to share favorite recipes (and the stories about them) as well as learn about new ones. Inexpensive computer cookbook programs can generate nutritional information for any recipe, if this information is needed for dietary reasons. Kansas Masonic Home's philosophy is that everyone needs to look good to feel good and that includes having attractively styled hair. Their very active volunteer organization makes this happen, regardless of residents' abilities to pay. Every Tuesday 8 to 10 volunteers "do hair." Nearly sixty residents took advantage of this service on a recent Tuesday, receiving everything from sets and comb-outs to perms. Paid staff working in institutions cannot be expected to provide residents with "primary care," or the type of care that is provided by family members (Litwak, 1990). Even when the staff have the best intentions in mind, they may not have the time or resources to provide more than basic tasks for residents. Because of staff limitations, organizations need to look to the community. Volunteers have valuable experiences and knowledge to share and are able to do this in a highly personalized and non-professional relationship. Volunteers can be links for the nursing home, residents and the community. Community organizations often welcome ideas for service pursuits. At Windsor Place, the Coffeyville Boys and Girls Club comes weekly for intergenerational activities. Students from the horticulture department at Coffeyville Community College volunteer time to work with residents on indoor as well as outside projects. Practical support may be provided by volunteers in many areas. In some Kansas homes volunteers lend a hand with life-story writing, taking walks with residents, providing music, assisting with senior Olympics practice and gardening. Volunteers can also help residents personalize the decorating of their rooms. Some homes have used the Retired and Senior Volunteer Program (RSVP) to bring volunteers in to visit with residents and engage in activities. RSVP matches people age 55 and older who are willing to help with local community needs (see Resources). Volunteering also extends to residents. Residents can act as role models reading to and tutoring young people, teaching them to crochet, knit or build something. In an example from another state, residents helped at the school with after hours programs. An ideal exchange can include a young person teaching a resident how to use the computer while the resident teaches the youngster correct English usage or social skills. Mennonite Manor Photo by Gayle Doll Provide Intergenerational Programs Brightly colored playground equipment adorns the grounds of Friendly Acres, Newton. On warm sunny days when the children are out playing, residents often come or are wheeled out to watch. A pre-school has been housed at Friendly Acres since the beginning of September 2002. The administration had been discussing the possibilities of a day-care when an existing school in a church basement was destroyed by fire. They offered to house the school and did some creative thinking about space issues. The maintenance department did most of the work replacing a conference room with the school. The school has 48 children who attend, 11 or 12 at a time, a couple of hours a day. Older children are also engaged with residents at Friendly Acres. Students from an elementary school visit throughout the school year and a Boy Scouts troop has started having annual campouts in the yard. Hesston Community Child Care began bringing preschool children to Schowalter Villa for intergenerational activities more than 13 years ago. As a result of this relationship a corporation called Hesston Intergenerational Child Development Center, Inc. has been formed. A new 8,000 square-foot child care center is being built between the assisted living and health care centers. It is planned to promote healthy interaction between young and old and features a library, an area for visual arts activities, and a bake shop in addition to the classrooms. Since there are a number of different requirements and ways to license a child care center (and some options are more intergenerational-friendly than others) it is advisable to contact Kansas Department of Health and Environment, Bureau of Child Care Licensing and Regulation well in advance of starting a project. Determining the type of license needed will assure appropriate space and equipment to support effective intergenerational programming as well as spontaneous intergenerational activities. Friendly Acres Photo by Gayle Doll Several resources are available to assist in intergenerational programming. The Kansas Intergenerational Network (KIN) is a coalition of people from all generations who are members of schools, churches, colleges, government agencies, volunteer programs, community service organizations, statewide associations, and service providers. Its members collaborate and exchange information, resources, and expertise to build interaction and cooperation among the generations. For information on the organization and resources available, as well as national organizations such as Generations United, and Generations Together (University of Pittsburgh), please see the Resources Section. The Galichia Center on Aging web site also has some resource and training materials posted from an intergenerational service-learning project for which KIN was a partner. Finally, the Retired and Senior Volunteer Program (RSVP) often teams seniors and youth together in intergenerational service projects. Contacts for RSVP can be found in the Resources as well. Benefits of Intergenerational Programs For Older Adults Increased satisfaction and purpose in their lives Enhanced self-esteem Increased learning and knowledge New, positive, meaningful relationships with children, youth, and professionals in their communities Understanding and acceptance of today's children and youth Opportunities to transfer culture, knowledge, skills, and values to the next generation Continued involvement in their communities For Children and Youth Increased self-esteem Increased learning, knowledge, and skills Better understanding of aging and older persons New, positive, meaningful relationships with older persons Special acceptance, nurturing, and support Supportive, positive role models Increased motivation to learn Improved leadership and communication skills Kansas Intergenerational Network Provide Opportunities to Participate in Community Activities One day at a garage sale Brenda Thornton, administrator at Parsons Presbyterian Manor, noticed a van with a state license tag. She shook her head and thought to herself a state employee in a state vehicle is attending the sale on state time! Later when Gary Daniels, superintendent of Parsons State Hospital and Training Center, was consulting with her about bringing person-centered support to her nursing home she learned that staff at the state hospital often take residents to garage sales in Parsons to help them find items they need or things to personalize their rooms. Now she is encouraging her staff to take residents out where they like to go even to garage sales. Trips to Walmart, dining out, driving by old neighborhoods and surrounding countryside are just a few places homes are regularly taking residents. Since every resident's dealings in the broader community are so individual, most trips out will likely be one-on-one or in pairs. Since some residents are too frail to make trips out into the community, it helps to bring familiar forms of community structure into the home itself. A mayor and deputy mayor are elected in each neighborhood at Plaza West in Topeka. These "officials" run the neighborhood meetings. They encourage their residents who have been active in Topeka organizations before moving to Plaza West to continue these connections with the broader community. Residents invite individuals they know through these associations to come and attend their neighborhood meetings. Staff can also strengthen the nursing home's associations to community activities. For example, Rossville Valley Manor took responsibility for the concession serving a Mexican meal at the local high school basketball game as a fund raiser to purchase a DVD player and several chairs for residents. Photo courtesy of Windsor Place Windsor Place has made interfacing with the greater Coffeyville community one of their priorities. By inviting the citizens into their home for events and offering room for community organizations to meet they strive to be a friendly neighbor. For example, the Ministerial Alliance comes monthly, both for lunch and their business meeting. Residents regularly attend home football and basketball games and the nursing home also hosts pre-game pep rallies for the high school on their front lawn so that residents can continue to cheer for their local team. Community members who need dialysis treatments know that they can call for the Windsor Place van to take them for their therapy. Rossville Valley Manor also has reached out to the town and surrounding communities by becoming very visible - literally! At Christmas, two Topeka television stations featured the Manor's display of outdoor Christmas lights and invited families to drive by and enjoy the decor. Their inside decorations were open for all to visit on the Rossville Holiday Homes Tour. Each neighborhood was given a budget to use for decorations, which led to good-natured competition between the neighborhoods as they prepared for their friends in the community coming to tour. Giving is as important as receiving, and community activities at the holiday season provide other ways for residents to reach out as well. For example, one neighborhood at Plaza West 'adopted a family' through a charitable organization and provided Christmas for them. Instead of looking to the heroic efforts of outstanding individuals for successful work, create systems that routinely allow excellent work to result from the ordinary efforts of ordinary people. (Scholtes, 1998) Taking on the Dragons Leading the Charge Cultures within organizations will naturally evolve and grow because they are open systems that exist in multiple environments (Schein, 1990). Changes will produce strains and stresses that force new learning and adaptations. One of the tasks of organization leaders is to initiate and help guide the direction of and responses to change, enhancing elements that are viewed as maintaining identity and promoting changes in those that are viewed as dysfunctional. Changing policies, procedures and behaviors to provide a significantly better living environment for residents and working environment for staff requires a tremendous amount of persistence and commitment. The kind of transformational learning curve needed to implement a new philosophy and model of care is much lengthier and more erratic than the more familiar conventional learning curves (Scholtes, 1998). Many leaders believe that long-range commitment to a single organization is essential to build the trust that is critical for the sustained success of major culture change initiatives. A number of the long-term care professionals who serve on our advisory group are insistent that the importance of leadership be addressed prior to any other information about culture change, and that committed leadership must be the first step in the process. This leadership is spoken of in two contexts. The most traditional viewpoint is that the administrators and department heads are seen as the leaders. Newer lines of thinking and models of care focus on developing leadership skills at every staff level and among residents. These skills are essential because new models of care require that decision-making happens at the level closest to the resident. Staff who have been skills- and task-focused in the past have found that these new models require them to have judgement skills and other leadership abilities. One of those abilities may be assertiveness, so that caregivers can become good advocates for the residents they serve. Many of these skills can be taught, but not without a commitment to a continuous learning environment and to supporting an organizational climate that recognizes and prizes leadership at all levels. Leadership must be seriously addressed before the organization initiates a culture change journey. Do organization leaders have the commitment to see the journey through? Does the organization have a commitment to seeing that staff get the training they need to provide care in a person-centered model? Are there resources to support the commitment? See Resources for some materials suggested by the PEAK-ED advisory group. Additional information and resources on leadership will be included in the educational materials to be developed by PEAK-ED in the near future. Conventional Learning Curve A. Slight loss of productivity while adjusting to new way B. Rapid rise in effectiveness and efficiency as new way mastered C. Plateau at a higher level of effectiveness and efficiency Transformational Learning Curve A. Illusion of learning w Mastering the rhetoric w Grafting programs onto the old organization w Knowing enough to be dangerous B. Sufficient understanding to see that 'we don't know much' w 'A-ha!' experience w Beginning of integration of knowledge and know-how C. Real learning begins (Scholtes, 1998) "Effective leaders attend first to the basic conditions that foster team effectiveness" (p. 204) w Leaders make sure that teams have some stability over time. w Leaders provide teams with compelling direction. w Leaders make sure teams' structures foster, not impede, teamwork. w Leaders make sure organizational structures and systems provide teams with ample support and resources. w Leaders arrange for or provide expert coaching to help teams, not forgetting to take advantage of opportunities at beginnings, midpoints and ends of task cycles. w Leaders move quickly and decisively when there are opportunities for action, but never intervene unless the time is right. "Effective leaders do these things in their own way using the idiosyncratic behavioral styles and strategies that they have found to work best for them." (p. 205) (Hackman, 2002). Don't Make Regulations into Dragons A common question asked of providers who have made dramatic changes in care delivery within their homes has been "How were these changes modified because of regulations?" They always replied, "Very little." There seems to be a perception on the part of many nursing home organizations that a harsh regulatory environment inhibits creative new forms of care and building design. This is untrue. Those who have successfully made changes and at the same time maintained good performances on the survey process have found that working collaboratively with the survey agency in the planning stages has been helpful in their progress. The interpretation of the regulations can be quite flexible when addressed in a pro-active way, and providers are frequently surprised by how much they "can" do rather than how much they cannot. The Centers for Medicare and Medicaid Services and Pioneer Network released a video in 2002, explaining the culture change phenomenon to state surveyors. One segment is devoted to analyzing federal regulations that have been perceived as road blocks to change. Each of these regulations is dissected to show how providers can re-interpret them to make allowances that enable change. Information about the video is available in the Resources section of this booklet. Don't Forget... Culture change means a new way of doing business, a new philosophy of leadership, and a new, more effective way of working. One's management style has been forming since childhood and has been shaped by parents and all of one's associations, therefore change for leaders is extremely difficult even change that is intently pursued and genuinely desired. (Scholtes, 1998) How to Know When You've Been Successful: The Importance of Assessment and Evaluation We live in a world that holds us increasingly accountable for our actions. Knowing what to change and how to change becomes easier when you know what might happen when you do. One of the goals of this booklet has been to provide some helpful information about the 'outcomes', or the potentially wide-ranging effects of culture change that have been identified for residents, families, staff, and organizations. The process of systematically and objectively obtaining and analyzing this kind of information is called evaluation. Currently culture change for nursing homes does not have much of the "what might happen when you do" information available. That makes it important that each of the organizations committed to making changes also commit to evaluating those changes to document their anticipated and unanticipated impacts. All nursing homes are already collecting all or most of the data that they might possibly need. Often, cost-benefit analyses are already being completed to assist with some kinds of administrative decisions. With a little help, the data already maintained in different parts of your organization can be used to determine how new procedures and policies or even design changes are working, and whether they are helpful or not. For example, in addition to financial and personnel records, organizations maintain extensive records for each resident which include clinical measures that can be used. This knowledge can then be passed on to other organizations, making changing the culture of care more efficient and more likely. Examples of good data collection and evaluation are listed within the booklet. For example, Rossville Valley Manor documented the cost of implementing a new buffet dining program and the savings from reduced plate waste and reduced use of nutritional supplements. These are examples of some types of quantitative measures, but other organizations implementing new dining programs have chosen to measure changes in resident and family satisfaction. Often there is more than one way to systematically assess an outcome; for example, satisfaction with dining can be measured by noting changes in the number of complaints, surveys, or even facial expressions of residents while dining. Since this booklet focuses on the what and why of culture change, space does not permit a detailed description of how to do assessment and evaluation here. PEAK-ED is developing a module on culture change evaluation and may also be able to assist you in planning an evaluation strategy. In addition, there are many good resources available for nursing home organizations to use when planning evaluation. There are many excellent books on the subject, and searching the internet for "program evaluation" will provide additional sources. Another good resource is your local university or college. The remaining sections of this booklet provide a variety of resources to help you change the ways in which we provide long-term care to older Kansans. In addition to contact information for the organizations cited in this booklet, there is a summary of the resources that will be available through PEAK-ED, a variety of useful resources, including contact information for organizations, literature, videotapes, and web sites, the list of references used in the preparation of the booklet, and information about the PEAK recognition program sponsored by the Kansas Department on Aging. Changing the way we care...Photos courtesy of Windsor Place, Gayle Doll Where to Start Website. PEAK-ED also provides information on our web page located at http://www.ksu.edu/peak . l This booklet is available in pdf format. l Photographs of many of the initiatives described in this booklet are available as well. l Links to web sites mentioned in this booklet are provided, as well as other potential resources. Putting Research to Work. This section of the PEAK web site provides summaries of current research and professional articles and how the information can be adapted for use in nursing homes. Educational Presentations. Through May, 2004, PEAK-ED staff will be available to provide educational presentations for nursing home staff and conferences. Culture Change Conference. The Kansas Department on Aging hopes to hold a conference on culture change in Fall, 2003, for long-term care organizations already engaged in or interested in beginning this journey. Educational Modules. Over the next year, PEAK-ED will be developing additional educational and resource materials to support nursing homes as they engage in changing their cultures. Nursing homes partnering with PEAK-ED to implement specific projects using these materials will have access to: l A series of educational modules l A companion web site l A list-serv for participating organizations l A resource team of consultants in different disciplines to provide technical advice for specific projects. University Coursework. KSU plans to offer a distance-based, project-focused course on implementing culture change in long-term care in the future. Web-based Distance Education Master's Degree and Certificate Program. Although not part of the PEAK-ED initiative, KSU will begin offering both a master's degree in Family Studies and Human Services with a Specialization in Gerontology and a stand-alone Certificate in Gerontology in Fall, 2003, through the Great Plains Interactive Distance Education Alliance (GP-IDEA).These educational opportunities complement those available through PEAK-ED.