BY: MARIANNE OSBORN GOULD, RN, BSN
Ms. Gould is coordinator of health services, Teresian House,
Albany, NY.
Teresian House Takes a Team-Based Approach to Care of the Elderly
The concept of resident-centered care is rooted in the
philosophy of the Carmelite Sisters for the Aged and Infirm, founded by Mother
Angeline Teresa McCrory in 1929, who said,
At the time I was called a revolutionary, but I went ahead with my plans
for creating new, home-like residences for the elderly, where they would have
full freedom and privacy and would be encouraged to retain their independence.
It would provide living quarters for elderly couples and recreational facilities,
as well as medical care.1
As stated by Mother Angeline, the philosophy and mission of the
Carmelite Sisters for the Aged and Infirm has always centered on the individuality
of the resident. The Carmelite order has also always recognized the individuality
of caregivers. Like the women who first worked with Mother Angeline, the Carmelite
Sisters for the Aged and Infirm of today represent myriad professions and talents.
In addition to administrators and nurses, Carmelites also include social workers,
chaplains, dietitians, nurses' aides, musicians, housekeepers, and accountants.
Because of the interdisciplinary composition of the order, the Carmelites are
particularly well suited to a team-based approach to care of the elderly that
draws on the different strengths, talents, training, and expertise of its members.
A History of Care
The first Carmelite home for the elderly, St. Patrick's, opened
in Bronx, NY, in 1931. In 1974, the Carmelite Sisters for the Aged and Infirm
opened Teresian House, a 300-bed facility located in Albany, NY. In the years
since 1974, Teresian House has embarked on a journey through physical, organizational,
psychological, social, and spiritual changes. This article will highlight only
a few of the challenges encountered during the journey that ultimately shaped
the Teresian House of today.
As originally built, the structure of Teresian House featured
hospital-like corridors of private and semiprivate rooms. The nurses' station,
a separate room, was located in the center of the building and was always the
center of activity. Places where residents could gather, such as the chapel,
therapy rooms, beauty parlor, and the "country store," were located on the first
floor — far from the actual living areas.
Limitations included a very small chapel, with fixed pews seating
about 50 people and little room for wheelchairs. To accommodate more residents,
Sunday Mass was said in St. Joseph's Hall, the official community gathering
space. Although pleasant enough, that room was not conducive to contemplation.
Meals were served in the main dining room, also located on the first floor.
This physical environment worked well at the time because most
of the residents were what was then considered the "well elderly," and services
provided followed a social model. As the residents became more frail over the
years, two of the five floors were certified as skilled nursing units. Residents
with more complex medical needs were housed on those floors. Staffing levels
were adjusted according to the residents' care needs. Having different levels
of care within the same facility allowed changes in staffing to improve flexibility.
The shift away from a social model was gradual. As the residents
continued to need more assistance with activities of daily living (such as bathing,
eating, and transferring from chair to bed), each succeeding sister administrator
did her part to improve the physical space and the services offered. In this
manner, Teresian House developed and maintained its reputation as a model for
care of the elderly in Albany.
By the 1980s, Teresian House had shifted away from the social
model of services and was considered a medical model. As in other "good" nursing
homes, some residents were restrained (according to New York State Health Department
guidelines), feeding tubes were inserted in some critically ill patients (after
ethics committee meetings and recommendations), and residents' lives were governed
by what physicians ordered and by established routines of the nursing home.
The organizational structure at that time was traditional in nature, with top-down
decision making. Nursing unit managers directed the care on each floor.
Movement Toward Fundamental Change
In 1991, Teresian House undertook a detailed study of its strategic
plan. The study outlined Teresian House's strengths, weaknesses, opportunities,
and threats. The areas examined included:
- Physical and architectural features
- Policies and programs
- Residents and staff
- Social and environmental features
- Priority setting and planning
Teresian House surveyed residents, families, and staff to determine
their opinions of the facility and its services. Results showed the need for
work in several areas. First and foremost, a resident satisfaction survey indicated
that residents wanted more control over their care. Surveys concerning the physical
environment revealed the lack of adequate space in both resident rooms and offices.
Additionally, total quality improvement teams had made several suggestions for
changing our approach to care, but the physical environment at the time hampered
the implementation of these suggestions.
Teresian House made all levels of staff aware of the findings.
Our administrator, Sr. Pauline Brecanier, wrote her own vision statement and
challenged all staff members to write their own vision statements and set their
own goals. Leadership then convened meetings to consolidate and prioritize goals.
The formation of a specialized, interdisciplinary steering committee
to study the care and treatment of our residents with dementia was high on the
priority list. The purpose of this steering committee was threefold:
- To address the needs of residents with early dementia
- To demonstrate the feasibility of providing specialized dementia care in
an existing unit without disturbing the organization and placement of residents
- To demonstrate whether progression of dementia can be stabilized or slowed
Over the course of the next several years, the Dementia Program
Project was implemented. The first challenge was to create separate, smaller
dining areas where residents with dementia could eat in a pleasant environment
with minimal distractions. A third-floor lounge was considered suitable because
an adjoining closet could be modified to serve as a kitchen serving area, and
restrooms were nearby. We also decided to serve the residents with dementia
one course at a time. (This deceptively simple approach was immediately successful.
Rather than being distracted by the soup and salad available at the same time
and eating neither one, the residents in the special dining program began to
eat or drink all their soup before approaching the next course!)
Although our emphasis was on the dining experience, we also planned
to train staff to interact with residents with dementia around the clock and
in all situations. To provide continuity of approaches, profiles were completed
for each resident accepted into the special program unit. These profiles listed
the physical needs of the residents as well as descriptions of their interests
and individualized hints for staff on how to avoid confrontations, which, in
those with dementia, are so often merely the result of an inappropriate approach.
Because our plan included specialized training of staff to conduct
programs, we posted notices asking for a show of interest. Twenty-six aides
representing all three shifts applied for the course. After being interviewed
and ranked, 12 applicants were selected for the 12-hour course. An interdisciplinary
team consisting of the administration, nursing services, social services, activities,
occupational therapy, and staff development departments developed and taught
the curriculum.
The Dementia Program Project was successful on a number of levels:
- We developed criteria for identifying needs in a population incapable of
communicating in "ordinary" ways.
- By recognizing the individuality of caregivers, and matching their
strengths to the needs of residents with dementia, we proved that a team pulling
together can accomplish more than any individual could, no matter how highly
motivated.
- The project forced us to consider unconventional approaches, not only toward
dementia, but also toward all behavioral challenges.
- We broke down virtually all care practices into their smallest delivery
unit. This "cluster concept" became the cornerstone of care delivery at Teresian
House.
The Dementia Program Project and its individualized approach
to environmental, organizational, psychological, social, and spiritual concerns
fundamentally altered the methods of care delivery at Teresian House and reinforced
our belief in the benefits of resident-centered care.
Current Environment
By the late 1990s, administration and staff realized that even
specialized programs could not meet all the residents' needs given the existing
physical structure. With a renewed awareness of the resident-centered model
of care, the entire facility embarked on a series of changes in all the environments.
We held regular meetings with residents, families, and physicians
to keep them updated on the developing changes. Weekly meetings for all staff
in all departments, and on all three shifts, resulted in many innovative ideas
as well as a sense of everyone being involved in the decision-making process.
Teresian House underwent physical changes both in its original
facility and in the newly constructed, adjoining facility. Resident-centered
care was a key design feature in the Bishop Howard H. Hubbard Pavilion, our
new building. A team of architects specializing in long-term care designed this
two-story addition. Its configuration of two squares joined in a "bow-tie" shape
allowed for clusters of 12 or 13 resident rooms arranged around two courtyards.
The upper floor, named Mount Carmel, is home for residents who
are still quite independent and alert. The lower floor, Carmel Garden, is our
dementia unit, where the practices of the Dementia Program Project continue
in a structurally enhanced environment. Because it surrounds two courtyards,
the lower floor provides protected walking paths both inside and outside the
unit. Both these floors have four small dining areas, one on each side of two
kitchens. Many recreational spaces are available on both floors, such as living
rooms, garden rooms, and game rooms. All Pavilion resident rooms have dutch
doors (divided horizontally so that either the top or bottom can be closed),
allowing the residents different degrees of privacy.
One hundred residents transferred to the new facility. Fifty
independent residents moved to Mount Carmel, and 50 residents with middle-stage
dementia moved to Carmel Garden. Major renovations then began in the old building.
The cluster concept, as developed in the Dementia Program Project, was evident
in the physical changes made to the old building. These changes consisted of
converting all residents' rooms to private rooms with private baths, reducing
the number of residents cared for on each floor from 60 to 40, and constructing
kitchen/dining areas (serving 20 residents) in each wing. Staff refer to each
wing as a "neighborhood."
A large living/family room is central to each neighborhood and
furnished much as any private residence would be, with comfortable, upholstered
furniture as well as televisions, videocassette recorders, and pianos or organs.
Bathing and showering rooms were enlarged, and washers and dryers (for personal
clothes) are available on each floor.
Planners carefully considered the use and placement of nurses'
stations in both the new and old buildings. To keep the staff involved and physically
present in the activities of the residents, their work spaces were incorporated
into the living areas of the units. In the Pavilion, cabinets adjacent to the
residents' family rooms function as staff workstations. In the old building,
the old nurses' station was eliminated and cabinets in each family room now
function as staff work space.
Surprisingly, constructing the new building was the easy part
of the renovation. The real challenge for Teresian House staff was adjusting
to their new work space amid the residents as well as to their place in the
new organizational structure, which now centers on a team-based approach.
The concept of a leader directing a team of staff representing
all departments replaced the idea of an RN manager of a floor with supplemental
help from various departments. In keeping with our vision, this leader is called
the resident-centered care coordinator (RCC). He or she is trained as a mini-administrator
and has overall responsibility for a 40- to 50-resident unit. The RCC leads
a team consisting of an RN, an LPN, nurses' aides, resident assistants, a social
worker, an activities coordinator, and housekeepers. This team performs all
the tasks necessary to address resident needs on an assigned floor.
Each team reviews all the tasks performed for residents and collaborates
on a list of global duties, defined as tasks that can be performed by any team
member as long as the task does not exceed the scope of his or her job description.
The scenario of a resident turning on a call light is a good example of these
global duties. Any member of the unit team can answer a call light. The
person answering the light may not be qualified to bring the resident to the
bathroom or to administer medication, but that person may move a box of tissues
closer, pull a shade down, or alert the nurse to a request for pain medication.
In addition to lowering the noise level on the floor, the prompt answering of
call lights illustrates one advantage of the team approach, which is quick and
efficient response to resident requests.
To prepare the team to care for individual resident needs, a
preadmission assessment form is used. Completed by the resident and family before
admission, this form lists items such as medications the prospective resident
receives, preferences for meal and bath times, placement of bed, and interest
in church and other outside activities. By reviewing the information on this
assessment, the unit team can form a picture of the resident's life in the community
and use it as a basis for an individualized care plan.
The preadmission assessment form also reflects our shift in focus
from the medical model — requiring the resident to fit into the established routines
of the facility — to a focus on the facility accommodating, as much as possible,
the routines of the resident.
The physical and organizational changes implemented by Teresian
House have resulted in profound psychological, social, and spiritual benefits
for the residents. The cluster concept enables the different personalities and
interests of each resident to blossom. Large parties and gatherings still happen
occasionally, but the day-to-day activities center in a homelike group. With
few exceptions, residents are now allowed to age in one place, eliminating the
fear of being sent to another floor when physical capabilities diminish. Replacing
the institutional aura with the more homelike environment allows for more family-oriented
gatherings. Residents are now more relaxed and interact more with staff and
other residents. Each floor can cite numerous anecdotes of the positive effects
of this new environment.
Of course, not every change was met with wholehearted enthusiasm,
and not every change succeeded. Some staff members left because they did not
agree with performing global duties that they believed were beneath their educational
level. In some instances, prepared budget line items (especially food) went
beyond set parameters and had to be brought back in line by careful monitoring.
Nevertheless, our fundamental belief that benefits for the residents would result
from the practice of resident-centered care was a beacon for our journey and
remains our hope for the future.
NOTES
- Lorretta Pastva, The Carmelite Sisters for the Aged and Infirm, Editions
du Signe, Strasbourg, France, 2000, p. 4.
Copyright © 2001 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.