Why it's impossible to maintain prior levels of care quality, and what to do about it

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Dr. Eleanor Barbera
Dr. Eleanor Barbera

In Editorial Director John O'Connor's April 16th column, he reported on a study from the Kaiser Family Foundation indicating that increasing numbers of new residents have dementia, are more physically ill and are more likely to be on psychoactive medications.

The study showed that there has been a shift away from long-term services and toward short-term rehab treatment. O'Connor noted the pressure that this puts upon facilities to provide high-quality care in the midst of the churn of residents.

There are many difficulties that can arise from this shift in pace and population, but I'll focus here on the mental health aspects and their effects on nursing facilities.

One problem that occurs when the length of stay decreases is that the team has a shorter period in which to get to know their residents. They are less likely to notice subtle changes in behavior and mood and they have less time to make the type of personal connection that reassures residents.

Adding to this, the fact that many facilities are operating short of staff in an environment of high employee turnover creates a “perfect storm” of emotional neglect.

Residents enter long-term care facilities in distress. When I adapted the classic Holmes-Rahe Stress Inventory to the circumstances of nursing home admission, I found that residents are experiencing a level of stress considered to be a “life crisis” that puts them at a high risk for further health breakdown. Their families also tend to be in crisis.

Residents and their family members are likely to expect that when they enter long-term care, staff members will provide compassionate medical treatment. Instead, what they frequently find are stressed out nurses and overworked aides who have just enough time to dispense medications or to make up a bed, but none to sit and talk with an understandably anxious resident and their family members about what they can expect regarding their stay and their future.

Social workers — most of whom got into the field in order to provide such counsel — are now buried under a flood of admissions and discharges. They cannot offer emotional sustenance when they need to complete the paperwork on three new admissions and order a walker for the lady whose family wants to take her home tomorrow because her insurance coverage ran out.

It is impossible for direct care staff to provide the same level of service that they did prior to this change in acuity and length of stay. In turn, distress over providing suboptimal care contributes to staff turnover, exacerbating the problem.

My main recommendations are to hire more staff, pay them fairly and train them well and continuously. Also, create an environment where people feel respected, are proud to come to work and are gratified that they're helping others through a difficult time in their lives.

The money for that can be offset by the malpractice lawsuits that didn't occur, the costs that were saved on continually hiring and training new staff, and the beds that will be filled because people who stayed in the facility recommended it to their friends and neighbors.

Consulting psychologists, meanwhile, can relieve some of the pressure that occurs in this increasingly fast-paced environment.

Psychologists are, more than ever, the only team members who are assigned to sit and speak with the residents one on one on a regular basis each week. A great deal can be accomplished with this steady, reliable contact to reassure residents and to obtain important information that can be relayed as needed to team members.

What's more, since psychologists are almost always consultants, their services are essentially free of charge to the facility.

Refer cognitively intact short-term care residents to the psychologists as early in the admissions process as possible in order to make the most of this opportunity for a degree of stability in a chaotic environment. To help establish realistic expectations on the part of residents and their families, consider putting a copy of “The Savvy Resident's Guide” in each rehab room.

Eleanor Feldman Barbera, PhD, author of The Savvy Resident's Guide, is an Award of Excellence winner in the Blog Content category of the APEX Awards for Publication Excellence program. She also is the Gold Medalist in the Blog-How To/Tips/Service category of the American Society of Business Publication Editors Midwest Regional competition. A speaker and consultant with over 20 years of experience as a psychologist in long-term care, she maintains her own award-winning website at MyBetterNursingHome.com.

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