Creating 'choice' environments

Nursing Homes, Sept, 2006

One of the most difficult decisions family members must make is deciding that their mother or father needs more assistance than they can provide. The overwhelming guilt of placing a loved one outside the home can often create turmoil and chaos among the family members themselves. The perceived reputation of the healthcare industry, let alone the nursing home industry, is unsettling to families, but the overall institutional atmosphere leads the way to further dissatisfaction and apprehension.

At Chicago-based Lancaster Health Group, which operates seven nursing home facilities, we started the C.H.O.I.C.E. program (Choosing How Our Individualized Care Evolves) in January 2003 to allay these concerns. Families (typically baby boomers) were generally unhappy about placing their loved ones in nursing homes. The biggest problem we saw had to do with life and the perceived quality of life in a nursing home setting. It is very apparent that when a resident adjusts well to a new environment, the family becomes happier and fewer problems or issues are encountered. We wanted to create an environment that made that adjustment quicker. We wanted our homes to be a pleasant surprise for the resident and an enjoyable place for the family to visit.

Planning for C.H.O.I.C.E.

We explored specialty programs such as the Eden Alternative, Wellspring, and the Pioneer Movement. We planned a two-day trip to the nursing home in Missouri that started the Pioneer Movement to observe what the administration was doing and how it was doing it. We took our administrators, directors of nursing, activity directors, social service directors, dietary manager, some nurses and certified nursing assistants, and the owners to Missouri.

After spending two days in Missouri, we believed we had a starting point from which we could develop a new and different program based on increasing the quality of life in a nursing home. On the way back, we brainstormed about what we wanted to do and in what order. Our goal was to create an environment where we would be proud to have our own parents reside. Putting ourselves in our parents' place, we started with the things most important to us.

All agreed that fine dining was going to be the first project tackled.

Dining Services

Food was a universal issue. Everyone disliked tray service because the aroma of the food is never present before delivery. We felt the need to smell and see the food before ordering to help increase appetite. With tray service, ever-present condensation on the lids of the plate covers further lessens the appetizing appearance of the food. Also, the concept of choices was significant. Besides the substitution of the day, we wanted two choices of every thing: meat, vegetables, and desserts. We also wanted soup and salad at every lunch and dinner. Since we were excited about getting started and the steam tables we ordered would take time to arrive, we began by taking tureens of soup from table to table. One facility used hot plates and began making omelets in the morning. Just these minor changes created a stir among the residents and families, and we could already see the impact this program was going to have on everyone.

Before our steam tables arrived, we created a questionnaire to find out what the residents wanted; e.g., what time they wanted to get up in the morning, what day and time they wanted their bath, and whether they wanted a bath or shower. Once data were compiled, we knew we had to provide more time for dining. A two-hour window would be needed for dining since everyone got up at different times and more people wanted to eat in the main dining room. The first steam table arrived in May 2003, and all our facilities had initiated their fine-dining programs by July. We also began using china plates, glasses, and cloth napkins. The cloth napkins were used as clothing protectors so we could eliminate the word "bib" from our vocabulary.

The residents gave a unanimous "thumbs-up," and by October we were seeing that food was a large part of the residents' quality of life. By then:

* We began asking our physicians for more liberal diets--the more liberal the diets, the more the residents enjoy mealtime. Weight loss was no longer the problem it once had been; however, now weight gain needed to be monitored more closely. We observed, from looking over data from 2004 through 2005, that residents either were maintaining their weight or were decreasing the percentage of weight loss during this period.

* We realized just how much food and dining were a part of visiting. We allowed family members one free meal per day (more for special situations) if they came to eat with their loved one. Dining became a much more social event than before. After all, none of us eat in front of visitors without asking them to join us.

* We were able to eliminate seat assignments. After all, those assignments were for the staff's convenience of getting everyone served at the same time when operating a tray line. Now people sat where they wanted, made new friends, and even began new romantic relationships. This was possibly our biggest surprise! As you might expect, this socialization dramatically increased not only resident satisfaction, but family satisfaction, as well.