Person-centered is the “new” terminology for care in skilled nursing facilities. That seems almost like an oxymoron. Wouldn’t the care for people always have been person-centered? The truthful answer is no.
While the Nursing Home Reform Law of 1987 states that each individual should be able to achieve their highest practicable level of function, the delivery of care in skilled nursing facilities did not always seem to have completely understood the full meaning of the phrase. Individualized care plans were put in place to address resident’s individual needs, but did the system really provide a means to meet those needs and does it still?
The Centers for Medicare and Medicaid Services, also recognizing the fact that overall the nursing home industry became a payment- driven culture based on volume and quantity of services delivered, has taken steps to redirect the focus to the person and modify their reimbursement structure to reflect more of a person-centered approach. The Patient Driven Payment Model, known by the acronym PDPM, reflects this refocus away from the volume driven RUG reimbursement system to one based on the functional outcomes of the individual. The shift has been a gradual one, occurring over a period of time. Now that it is here, is it fully reflected at all levels of care delivery, and if not,what are some of the ways it can get there?
What does person-centered care really mean and what are the factors that affect or impede care delivery?
Is it just a matter of reimbursement and having therapists and nursing staff understand that in order to receive maximum reimbursement they need to carefully look at the care needs of the individual for billing purposes in terms of therapy, skilled nursing needs, etc.? Reimbursement is not a dirty word. The reality is the provider is paid based on the services provided. The greater the number of services provided as it relates to outcomes, the higher the level of reimbursement. The logic is obvious. The provider can then pay the staff who provide services. The money has to be generated from somewhere and in some fashion.
However, too often the person is lost in the process. When the resident is viewed for generating revenue, the person can become lost in the process. The resident is a whole individual, with needs beyond care needs and in ways that can contribute to the skilled nursing facility community. The skilled nursing facility environment can and should become one of community, no different than the community in which people live outside of the facility.
The writings and work of Dr. William Thomas and the concept of the Eden Alternative, The Green House Project and The Pioneer Network hopefully have strongly influenced this shift.
On a personal note, it is an unfortunate fact that many people I know in the industry, from the very top to line staff, are not aware of Dr. Thomas, his writings, work, The Eden Alternative, The Green House Project or The Pioneer Network.
Understand the whole person
Person-centered care must take into account the whole person, considering their emotional, psychosocial and psychological needs.
We all have basic human needs; they are universal. Here they are in alphabetical order, not necessarily in order of importance: appreciation, autonomy, contribution, compassion, effectiveness, freedom, inclusion, love, purpose, security, to name a few. Are the needs of the resident really viewed from this vantage point? Is thought given or an environment created where these needs are truly met? Are facility staff members given the tools to understand and meet these needs? I have seen many staff who understand and intuitively attempt to fulfill some of these needs for “their residents,” especially love and compassion. But what about the needs in the other aforementioned areas?
All too often, little or no money is allocated for the programs that would provide greater opportunities for engagement, for activities that reduce boredom, depression, loneliness, isolation, loss and grief. What methods or departments can be developed to address these needs?
Recreation is one which is too often considered something that is necessary and is low down on the totem pole of financial importance. All too often I have heard directors of recreation departments complain of the little or no money that has been allotted to them for programming. All too often the extras associated with programs (i.e., food, and who doesn’t love attending programs where food is served?) is tied up with the kitchen budget and therefore is little or nothing, creating antagonistic department relationships.
How often have I heard dedicated professionals using their private funds to buy materials for programs or for individual residents because it’s not in the facility budget? How can directors of recreation become more creative in their program ideas to address the needs of the residents in their facilities in ways that are cost effective? Some of the most valuable resources in a building are the residents themselves, our wisdom keepers, who can become an integral part of programming. This more appropriately reflects a person-centered care environment. This would be superior to a director or recreation staff developing and organizing programs and putting them on a calendar and then attempting to encourage residents to attend.
There is a critical component that goes into person-centered care that is often overlooked. In order to provide a skilled nursing facility as a community with a true person-centered approach to care from all departments, the staff person must be viewed as an individual, not just an employee who is hired to deliver the care that is needed for the facility to receive reimbursement. All too often, staff is viewed along the same lines as capital investment: to serve the needs of the organization in order to make a profit.
How can this be developed? Everything is systemic and starts at the top.
I have retold this story over many years and wrote about it in my book “OVERDUE Quality Care for Our Elder Citizens.”
At the time, I was working in a facility as a speech pathologist. One day a gentleman wearing a suit approached me in the hallway. He introduced himself as the owner of the building. He asked my name and what role I fulfilled in the building. I was immediately struck by this as I had never been approached in this way, and certainly not by an owner. After a brief conversation, I watched him as he continued down the hallway. He stopped and greeted staff members at every level, addressed them by name and asked pertinent questions related to their life or their position, i.e., how they enjoyed their vacation, about their son’s graduation, how their parent was feeling, were they having any difficulties they wanted to discuss, etc. He also stopped and spoke with residents. He knew their names as well and seemed genuinely interested in how they were feeling, their families or a particular issue they wanted to discuss.
I continued to take note. This owner did rounds with the administrator on every unit four days/week. He provided preferred food items to residents at a time when person-centered care wasn’t a “buzz word.” Needless to say, the staff was incredibly loyal to this owner and to providing the same level of care to the residents as they received from him.
I have recently been retained to provide communication/empathy programs for another nursing home now owned by this same gentleman. What struck me was that he wanted everyone in the facility to participate, including people who work in the kitchen, the receptionist, porters and the administrator. Everyone was in it together. This went a long way in having the staff feel the owner was investing in them as people, cared about how they related to their fellow coworkers, the environment of the workplace itself, and it created a sense of belonging and community. This level of feeling of improved communication, relatedness and empathy for each other obvious translates into viewing the residents in their building as people, how they relate to and care for them, rather than care delivery which is interpreted as a revenue driven reimbursement model.
Person-centered care is more than a buzz word and is achievable. It is systemic and starts at the top with the mind-set of viewing people and creating an environment to meet the needs of individuals, both those who work in the nursing home as well as the residents that live there. They are all contribute to the energy of the nursing home environment and go a long way to creating a feeling of community. This is reflected in staff morale, staff retention and resident satisfaction.
Phyllis Ayman, MS/SLP, is principal of PMA Speech Solutions LLP in Greenwich, CT.