Category: Communication

Opening the door for ombudsmen

Here’s my latest article on McKnight’s Long-Term Care News:

Opening the door for ombudsmen

Last week during a talk at the Pennsylvania Department of Aging 2017 Ombudsman Conference, audience members told me that they’re having difficulty speaking to administrators and other senior staff when they visit the facilities. In fact, some people reported that the administrators close their office doors when they find out the ombudsman is in the building!

While I can imagine from an administrator’s point of view that an unexpected interruption from someone complaining about problems is not exactly a welcome visit, perhaps there’s a way to shift the relationship to mutual advantage.

In fact, ombudsmen may be able to use their resources to help you solve problems within your facility.

Their role

Long-term care ombudsmen act as advocates for residents to address problems and to facilitate quality care. According to The National Long-Term Care Ombudsman Resource Center, ombudsmen promote “the development of citizen organizations, family councils and resident councils.” Ombudsmen and the councils can identify areas of potential improvement and, if properly guided, can offer solutions and assistance.

Local ombudsman’s offices have, for example, sponsored training programs on culture change and invited facility staff free of charge. Ombudsmen have arranged trips for staff to visit nearby Green Houses and provided free staff training on various resident care matters.

Pennsylvania’s Ombudsman Program is very active in promoting resident participation. Their ombudsman-trained PEERs (Pennsylvania’s Empowered Expert Residents) focus on improving the quality of life for residents. PEER efforts include initiating activities in which elders have the opportunity to assist others, such as a program making blankets for the homeless. That would make a nice mention during the prospective resident tour, don’t you think?

Ombudsman contact tips

While it’s likely that your ombudsman will be sharing resident complaints with you, it’s better to hear about these problems from them than from a state surveyor. Consider the following methods to improve your working relationship and to enhance resident care:

For the entire article, visit:

Opening the door for ombudsmen

On power, teamwork and communication

Here’s my latest article on McKnight’s Long-Term Care News:

On power, teamwork and communication

Having enough of it at work, I tend to avoid drama in my entertainment choices unless it involves aliens or post-apocalyptic nonsense. My family and I are currently enjoying the creative spectacle of Project Runway “Teams” version from a few seasons ago. In it, the judges of the clothing design competition repeatedly make the point that “teams are only as strong as their weakest link.”

A significant part of the Project Runway teamwork challenges involve communication. Collaborators who take over the project and those don’t speak up can both get penalized by the judges. Similarly, teamwork within the long-term care setting heavily relies on communication. For the best healthcare outcomes, it’s essential for all team members to contribute their expertise.

An article in the American Psychological Association Monitor, however, suggests that people who feel powerful are more likely than those who don’t feel powerful to share “opinions that differed from the norm,” a important element of team interactions.

Further, the authors cite research that describes how “people who feel powerless are more likely to…behave in inhibited ways. People in positions of greater power, on the other hand, are more likely to…act in uninhibited ways.” A care team member who feels inhibited is less likely to speak up and contribute to a group discussion.

In the hierarchical world of LTC, administrators, nursing directors and medical directors have more perceived power than, say, charge nurses or recreation therapists, despite whatever layers of upper management and accountability exist.

In my conversations with aides and residents, there is consistent disagreement among them regarding who has the power. Aides will argue that the “Resident’s Bill of Rights” gives the residents control, while residents, waiting on aides for intimate care, feel that the aides are in charge. Both struggle to deal with the moods and behaviors of the other.

Family members can be considered a part of the team that wields power in the form of potential phone calls to senior staff, the ability to transfer their loved one to a different facility, a negative social media review or a lawsuit. At the same time, relatives are often overwhelmed by the new and unfamiliar situation and the shifting dynamics within their families and many feel powerless in relation to the staff members upon whom they depend for good care for their loved one.

The challenge for LTC is to empower all team members to overcome their “inhibitions,” so that they offer their expertise despite the imbalance of power and in perceptions of power.

For the entire article, visit:

On power, teamwork and communication

Correcting long-term care’s image problem

Here’s my latest article on McKnight’s Long-Term Care News:

Correcting long-term care’s image problem

Long-term care has an image problem. For a variety of reasons, we aren’t associated with good times. There are things we can do to turn this around, though, starting with the perceptions of our residents.

Most people who come to live in a long-term care facility struggle with a sense of failure. This isn’t because of anything that occurred in their lives prior to placement, but because many people view living in a nursing home as a sign of a failed life.

The most common comment I’ve heard from new long-term residents over the years is, “I never thought I’d end up in a place like this.” Some add, “Where did I go wrong?”

There are good reasons for providers to address the inherent sense of failure many residents feel in LTC placement: It can increase customer satisfaction, improve morale among residents and staff, and reduce depression among residents, thereby lessening the need for antidepressants.

The role of the psychologist

Part of my job as a psychologist is to help residents recognize that living in a long-term care facility isn’t a failure. It’s not a reflection of a life poorly lived or necessarily indicative of difficulties in their relationships with their children or other loved ones.

I do this in several ways, depending on the person and the circumstances.

I start by telling residents that I regard it largely as a societal problem. We’ve made advances in healthcare that allow people to live longer with chronic illnesses, but we haven’t yet devoted the resources needed to help people manage successfully at home and to support their caregivers. Long-term care is often the best solution under the circumstances.

Sometimes offering that view is enough to make them feel better about the situation, but other times more is needed. For example, Marie was a new resident who’d worked as an aide in a psychiatric hospital. She was distressed about living in the nursing home and had become irritable and withdrawn. I took her to visit a well-adjusted resident, Linda, who’d been a coworker and a union representative at the same psych hospital. They talked about the old days for 20 minutes and never visited together again, but Marie had a new acceptance for placement — if the nursing home was good enough for Linda the union rep, it was good enough for her too.

As a neutral party, I can provide the perspective that families and facilities can’t, pointing out, for example, how hard family members have worked to keep them out of the facility for as long as they did, how their relationships can reset once someone else is in charge of hands-on caregiving, and the benefits of living in a communal environment with easy access to medical staff and activities.

Organizational component

Aside from referring residents for psychology services, facilities can address this aspect of their image problem in several ways:

For the entire article, visit:

Correcting long-term care’s image problem

Enhancing the value of LTC by making family visits more rewarding

Here’s my latest article on McKnight’s Long-Term Care News:

Enhancing the value of LTC by making family visits more rewarding

In his Dec. 6 McKnight’s Senior Living column, Editorial Director John O’Connor reported on a senior living center in Jiangsu province in China that offers cash rewards to people who visit their loved ones. Ten visits in a two-month period led to the equivalent of about $10; thirty visits brought about $29.

The result? The number of residents receiving regular visitors jumped from 10% to about half, no doubt making a huge impact on the lives of the residents and on the culture of the facility.

While this “positive reinforcement” obviously can be very valuable — and I agree with O’Connor’s alternatives to cash such as gift cards or entry into a raffle for a local restaurant — there’s a lot we can do to make family visits inherently more rewarding.

When long-term care providers accept the role of teachers, we can add great value to our services and enhance the experiences of the families who come to us for assistance.

The reality is that many relatives have no idea how to best engage with their loved one in long-term care.

Visitors often ask questions in ways that lead to frustration or embarrassment rather than the heart-to-heart they’re seeking. A television blaring in the background can make it difficult to maintain a conversation. Family members trying to do the right thing by visiting are met with disappointment and frustration rather than joyful connection. When visits don’t go as hoped, it can create what feels like punishment instead of reward.

Take a moment to listen to the comments of the visitors on the way out the door this holiday season. Look at their expressions. Do people seem satisfied with their visits or can more be done to create a pleasant experience? Astute administrators and nursing directors might overhear remarks such as, “Dad didn’t hear a thing I was saying,” or, “She couldn’t remember anything. I didn’t know what to say to her.”

Family visits can be vastly improved with some basic tools and education. Here are some ideas for this year and next:

For the entire article, visit:

Enhancing the value of LTC by making family visits more rewarding

6 steps to manage post-election reactions in LTC

Here’s my latest article on McKnight’s Long-Term Care News:

6 steps to manage post-election reactions in LTC

The 2016 presidential election has revealed a deep rift in our country, and quite possibly in our long-term care facilities as well.

While some employees and residents are pleased about the election results, it’s likely that others in your community are considerable less so.

An informal survey of my fellow geropsychologists revealed the following situations occurring in their nursing homes:

• Staff arguments regarding politics.

• Anger in residents, some of whom are misdirecting their anger.

• Residents and staff members who are dismayed, distraught or depressed regarding the election results and the direction of the country.

• Residents reporting that staff members told them they voted for Trump but asked them to keep this secret because they don’t want their Clinton-supporting coworkers to know.

• Staff who openly voted for and are discussing their Trump votes with clients as a point of pride, without recognizing the impact on their disabled clients after Trump’s mocking of a disabled person.

• Transgender residents concerned they are going to be “outed” and will be refused the medication they’ve been taking for years to maintain their health.

• Aides and other staff (housekeeping, kitchen workers) crying in staff lounges out of fear that some of their family members might be deported and that they, too, would have to return to their country of origin because they wouldn’t be able to afford to stay here on their own. As they shared their fears with their respective residents, the possibility that their beloved aide might leave them added to the anxiety the resident might have already felt about the election results.

• Staff concerned about their jobs and the future of healthcare; residents fearful they will no longer be eligible for Medicaid if the laws change.

Certainly not every facility is experiencing such reactions — a psychologist working in a VA home indicated that the veterans seemed generally positive about the prospect of President Trump.

Another psychologist reported that a Romanian Holocaust survivor was pleased with Trump’s win because he’d feared the country was moving toward a socialist model he’d unhappily lived through previously.

With our diverse population of residents and staff members, however, it’s likely there are at least some people in our communities who are experiencing distress and would benefit from reassurance and support from those in charge.

Here are 6 ways to accomplish this:

1. If you haven’t already done so, send a memo requesting that staff members refrain from discussing politics, especially in front of residents.

2. Reiterate to staff members the corporate policies regarding discrimination and express a commitment to a fair and bias-free environment.

For the entire article, visit:

6 steps to manage post-election reactions in LTC

Suicide prevention in older adults

Here’s my latest article on McKnight’s Long-Term Care News:

Suicide prevention in older adults

In preparing for a webinar on suicide prevention, I came across startling statistics about suicide rates among older adults. Despite the concern we often hear about teen suicide, the rate for elders is even higher.

While older adults make up 12% of the U.S. population, they account for 18% of all suicide deaths. In 2014, the highest suicide rate in the U.S. population (19.3 per 100,000 people) was among people 85 years or older.

In addition, elder suicide may be under reported by 40% or more. Not counted are “silent suicides,” like deaths from overdoses, self-starvation or dehydration, and “accidents.”

Training staff to assess suicide

Given its prevalence, it’s important for long-term care staff members to know how to recognize and address suicidal thinking and behaviors.

As a psychologist who’s been assessing suicidality since my teen years as a peer counselor in college, I feel comfortable with the process. Most facility staff members, however, haven’t had extensive training and are understandably anxious about an issue that’s likely to be out of their area of expertise. This can lead to over-caution, such as unnecessary one-to-one observation, or to missing signs of distress.

Staff training programs should educate team members about factors increasing the likelihood of depression and thoughts of suicide. Many of these influences are prevalent in our elderly population, such as physical illness, pain, functional impairment, losses and social disconnectedness.

Make use of consulting psychologists by referring residents for evaluation after losses and a decline in condition such as a downgrade in diet from chopped to pureed food, a limb loss, a move from a wheelchair to a reclining chair or a death in the family.

Team communication and support

Virtually all workers know it’s necessary to inform the charge nurse and other personnel about direct statements such as “I want to kill myself,” but staff members should be trained to look for other warning signs of potential suicide, which include changes in grooming, loss of interest in previously appealing activities, giving away possessions and making statements like, “I won’t be needing any more appointments.”

For the entire article, visit:

Suicide prevention in older adults

3 surprising reasons to strengthen your resident council

Here’s my latest article on McKnight’s Long-Term Care News:

3 surprising reasons to strengthen your resident council

When it comes to resident councils, it’s often thought that an active resident council might seem good in theory, but that it’s offset by the amount of staff time required to devote to the process and concern that something written in the meeting notes will trigger an inquiry by state surveyors.

This line of reasoning, while raising legitimate concerns that need to be managed, gives short shrift to the benefits of a strong resident council.

Resident councils can be awesome for your facility and here’s why:

1. Residents tell it like it is: You know those things your staff members see but don’t mention because they don’t want to rock the boat? Residents are far more likely to speak up than the average staff member because they’re not worried about losing their jobs.

Some of them are like my Aunt Bevy, who used to tell me, “Eleanor, I can say what I want. I’m an old lady.” Tap into this important source of info and find out what’s really working, and not, in your facility.

Residents will tell you what you need to know to make your facility shine enough to attract more residents.

2. Free labor: I hate to be so crass about it but let’s face it: While everyone else is running around your organization like lunatics because they’re short-staffed, your residents are sitting around hoping for something interesting to do. We have a pool of diverse, experienced, motivated and often bored individuals yearning to be put to good use.

Sure, they’ll need some help to overcome their physical limitations, but working together they can effectively address many seemingly intractable problems. Maybe they could raise money to contribute toward an herb garden for the patio or start a welcoming committee to reduce the isolation of new residents. Ask them what they want to do – it might be exactly what’s needed to revitalize demoralized staff members and energize your institution.

For the entire article, visit:

3 surprising reasons to strengthen your resident council

Wisdom from elders

Here’s my latest article on McKnight’s Long-Term Care News:

Wisdom from elders

I’ve learned a lot from listening to residents over the years, but it’s rare that I request specific advice. This month, I decided to change that.

In private conversations, I told residents that I was writing an article on advice from elders about how to live life and I asked them if they had any wisdom they wanted to share with young people.

Their responses were immediate and enthusiastic, as if they’d been waiting for someone to ask. They were so pleased with the question that I decided to ask my own elder relatives for their opinions as well. One family member, inspired by the inquiry, called to contribute further advice after her initial offering.

Many of the comments focused on wellbeing and taking risks in life:

• “If there’s something you want to do, go for it. Even if it doesn’t work out, at least you tried.”

• “Do what you can while you can do it. Take a chance!”

• “Do things you enjoy and keep as busy as your health will allow.”

• “Don’t overdo it.”

Others centered on maintaining independence:

• “Do the best you can and save a dime, because now when they jump me for money, I got a little something to pull out.”

• “Try to have something of your own, not your mother’s, not your father’s.”

Several people offered relationship advice:

• “Pay attention to your spouse but be an individual too.”

For the entire article, visit:

Wisdom from elders

Racism and LTC

Here’s my latest article on McKnight’s Long-Term Care News:

Racism and LTC

A friend of mine called me this week, upset about the racial tension making headlines in the news. We discussed what we could do as individuals to improve the situation.

“I called a friend of mine of a different race,” she said. “I told him we need to stay in touch right now, even if we’re busy.”

“My column this week is about the issue,” I responded. We talked about how differences are bridged in a healthcare environment.

In long-term care, we provide services to, and work with, individuals from backgrounds different than our own. Residents share rooms and break bread with types of people they may never have encountered more than superficially in their previous 80 years of life. Barriers recede when we come to know each other as people, yet it’s not always a smooth road.

Studies of racism in LTC

I’ve observed firsthand various culturally charged interactions — both positive and negative — and I wondered what types of racial challenges are common in long-term care.

I turned to the research to see what’s been studied formally and found that racism is observed in the following ways:

• Residents refusing care based on the racial or ethnic group of the caregiver, as noted in the New England Journal of Medicine article, “Dealing with Racist Patients.”

• Unpleasant work environments due to hearing racial remarks by family members or other workers, in “Racism Reported by Direct Care Workers in Long-Term Care Settings.”

• Nursing homes in areas with high poverty being more likely to close: “Why Medicaid’s Racism Drove Historically-Black Nursing Home Bankrupt.”

• The changing demographics of nursing homes due to people from minority groups having increased entrance to that level of care, but reduced access to privately paid home and community-based care such as assisted living: MedicareAdvocacy.org, “The Changing Demographics of Nursing Home Care: Greater Minority Access…Good News, Bad News.”

Increasing inclusion

While some of these problems are beyond the scope of any one LTC organization, there are ways in which the first two points can be addressed within our communities:

For the entire article, visit:

Racism and LTC

Super-utilizers: LTC has them too

Here’s my latest article on McKnight’s Long-Term Care News:

Super-utilizers: LTC has them too

I was flying home after visiting some family elders last week (a story itself perhaps for another time) when I happened upon a Kaiser Health News article about “super-utilizers” of emergency room services.

Research on Medi-Cal, California’s state health insurance for those with limited income, found that 1% of the patient population accounted for about one-fourth of the healthcare spending.

The reason: Super-utilizers were more often homeless and had substance abuse and mental health problems.

This echoes my experience working as a case manager for a managed care organization years ago. For the particular account I was working on, the mental health managers had access to both the medical and mental health data.

My main observation was that those with the highest medical costs were also those who had been in and out of rehab for substance abuse. The problem was that because our company was a “mental health carve-out,” with HIPAA-protected information, we couldn’t share that information with the medical team.

“Ask them if they’ve been drinking!” I wanted to shout, when I saw they were getting readmitted to the medical hospital for the third time in two months.

It’s a question we might consider asking in long-term care too (along with checking on psychiatric medications). The “super-utilizer” problem affects us in ways that may be less obvious but just as costly.

The super-utilizer in long-term care

Our super-utilizer of services is a resident who exhibits behaviors due to a mental health or substance problem that results in a series of staff meetings and discussions that takes time away from other residents.

It could be someone who needs repeated psychiatric hospitalizations because of psychiatric medication changes during the transition from home to medical hospital to skilled nursing, or an individual ready to be discharged after rehab but difficult to place due to comorbid physical and mental health needs. (A problem also faced in psychiatric hospitals, by the way, when a now-stable patient has comorbid physical health needs.)

Families can be super-utilizers of services. Consider the time-consuming challenges when a substance-abusing relative is found to be taking money from a resident or a discharge home is deemed unsafe because of a mentally unstable family member. I guarantee that’s not a one-meeting decision.

Reducing expense of super-utilizers

For the entire article, visit:

Super-utilizers: LTC has them too