Resident-centered care

Health Progress, Nov/Dec 2001 by Gould, Marianne Osborn

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.