Assessment is at the heart of it all

Nursing Homes, June, 2004

You really can't overemphasize the importance of resident assessment in managing long-term care communities. The delivery of services in the field of seniors housing and care begins with, and will always be critically dependent upon, the underlying resident assessment. It is the first of the four basic functions required in any long-term care setting, the others being planning, implementation, and follow-up. Assessment is number one not only chronologically but as an essential prerequisite to the others. Absent an assessment of the customer's condition, preferences, and needs, there can be little in the way of effective planning or service delivery.

And yet its implementation, particularly in assisted living, has been problematic at best. And that's really a shame.

I spent a year, as president of the Assisted Living Federation of America, doing battle with consumer colleagues on the Assisted Living Workgroup, established by the Senate's Special Committee on Aging. As you may have read in Richard Peck's report in the April issue ("The Assisted Living Workgroup--One Year Later," p. 28), its ostensible function was to develop guidelines for the 50 states in their regulation of assisted living. What a shame we ever got to that point! Had assisted living been doing its job--if assisted living had been even elementally focused on the essential prerequisites of long-term care--such a task force might not have been necessary. Now, given that group's process-oriented recommendations, assisted living is that much closer to being saddled with the same regulatory framework that has so bedeviled nursing facilities over the years.

Assisted living's failure to come to grips with the basics of assessment is a good example of ignoring the fundamentals. Assessment is, after all, more than a clinical tool. The assessment process will, for example, determine the degree to which the facility is adhering to its business model--the "niche" it is attempting to carve out in the marketplace. It will serve as the basis for pricing decisions. It will prove essential to cost-control efforts within the community. It can serve as a vital component of human resources management. In short, resident assessment is ignored (or performed badly) only at a community's peril.

The assessment process must start with a basic understanding of the unique nature of the customer. While less the case for independent living, some congregate care, and more youth-oriented skilled nursing, the resident in a seniors housing and care community is elderly (by federal definition, at least, over 65 years of age). Seniors, unlike their younger cohorts, are characterized by an array of problems--not just medical or even primarily physical. While perhaps physically frail, they are also beset by mental, psychological, social, and environmental challenges, all of which require a holistic approach to determining their needs and developing a plan of care and/or services designed to meet them.

This is what is referred to as the "geriatric" model of healthcare. It is distinguished by the fact that it can (and usually does) reflect interrelated domains of care, some of which are "health-related" only in the broadest sense of the word. Conventional internal medicine, focusing on organ systems and single diseases, is not well suited to the typical older patient, who may suffer from multiple chronic diseases, exhibit uncommon symptoms, and have functional problems with consequent psychosocial stresses. In the same vein, "geriatric" treatment emphasizes relieving symptoms and improving function, rather than curing the underlying pathology.

Therefore, the primary tool for determining the needs of a resident in a seniors care community must be holistic in nature. It begins where the conventional routine history and physical examination for the younger patient leaves off. The areas focused on in the resident assessment must reflect the multiple issues facing the resident, be they physical, mental, psychosocial, and/or environmental.

Interestingly, one finds this emphasis on joint care and service management to be one of the four standards promulgated by the National Association of Social Workers (NASW). NASW's standards begin with an emphasis on one of the overriding concerns of professionals in long-term care: the maintenance (if not, indeed, the enhancement) of customer self-determination. That, in turn, is buttressed by the recognition that the client's interest, as perceived by the client, is paramount. Finally, confidentiality and privacy are recognized as sacrosanct, to be preserved at all costs.

Isn't all this, after all, what assisted living is all about?

The "who" of assessment is as important as the "what." Here is where the concept of team assessment becomes critical. One of the management challenges facing all seniors housing communities is the tendency to foster "silo" mentalities, the compulsion of workers to concentrate on their own responsibilities and overlook the activities of others on the staff. The results can be disastrous for the customer and, consequently, for the community as a whole. As noted in my April column ("Leadership Is More Than Giving Orders," p. 24), only a caregiving team that is as holistic as the services and care they are to provide can successfully conduct a resident assessment.