Leader of the Pack: The Role of the DON in Green House Homes Tuesday, November 15, 2016

Introductions Share with your small group the one word that best describes the culture of your Green House homes. Does this same culture exist in your legacy home? Is this the culture you want in your organization?

Session Objectives Explore the role, and necessary competencies, of the nurse in Green House homes. Examine a process that helps determine how to honor elder choice and autonomy when risk is involved. Discover ways to equip nurse leaders to advance person-directed care. Identify strategies that help to build effective care partnerships that better support person-directed care.

And the survey says … 17 total responses

Are you the DON of both The Green House homes and the legacy home?

Rate the level of person-directed care being delivered in your legacy home

Rate the level of person-directed care being delivered in your Green House home(s)

Do you feel you have the support you need to be successful?

Overall, please rate your job satisfaction

Rate the following for your Legacy Home (if applicable) Scale: Poor Could be better Adequate Good Excellent

Rate the following for your Green House homes: Scale: Poor Could be better Adequate Good Excellent

Essential qualities of DON in GH homes Ability to listen and help staff see things from another perspective. Be able to provide direction and guidance. “Rounding” is very important. Comprehensive understanding of scope of practice for LPNs, RNs, and DOH requirements. Being able to recognize institutional creep and continue working with all team members to uphold GH core values. Good clinician and flexible. Good communication. Leadership.

What do you like most about your job? Relationships with elders. Seeing the staff proud of their accomplishments. Getting to see the elders smile and be comfortable in their own homes. Being part of an organization that supports an innovative approach to caring for this population. Homelike environment and resident- centered focus. Working with veterans and nurses, and instilling leadership skills in nurses.

What is the biggest challenge? Accepting that not all employees are capable of thinking and performing for what the GH model requires. Alignment of the GH team and continual adjustments of our sail so that nurses and SMWT work together. I function as both DON, MDS Coordinator, and staff nurse. Navigating and balancing all the roles has been challenging. Coaching supervision approach. Guides are not clinical. Conflict between nurses and SMWT.

What would make your job better? We need to start over with different teams, and we need a manager for the GH homes. More oversight from the guide and DON. Having more time with the elders, and not having the additional demands put on me by higher administration (to be present at so many meetings). Having a nurse team that fully supports the GH model. More training.

Nurse Competencies for Culture Change What’s changed from traditional paradigm? Do you agree with the stated competencies? What’s missing?

Survey Results Survey sent to 220 nurses + 25 nurses of GH homes 62 responded 22 (36%) – traditional nursing homes 40 (64%) – household, small house, or GH homes 88% -- registered nurses 54% -- employed in nursing homes > 16 years 70% agreed or strongly agreed with competency statements Higher percentage agreement for all competencies in non- traditional settings EXCEPT “Problem-solve complex medical/psychological situations related to resident choice and risk.” More than 80% of nurses in non-traditional settings agreed or strongly agreed that all five practices were used.

Person-Directed Practices Create individualized care plans that reflect the residents’ direction of their daily living experience. Administer medications at times that work best for residents rather than pre-determined times set by facility policy. Actively participate in alarm reduction or elimination. Support residents’ preferences to eat foods of their choice, at the times they choose. Ensure residents are cared for by the same caregivers each time they are scheduled to work (consistent staffing).

Small Group Work Discuss each of the 5 identified practices to determine if nurses in their GH homes are utilizing them. Where is there success, and what are the contributing factors? What are the challenges?

Breaking barriers to Person-Directed Care Diana’s Story

RISK: And our aversion to it!

Safety, Risk and Elder Choice What is risk? The outcome is different than we expected. Upside risk The probability that things will turn out better than we expect. Downside risk The probability that things will turn out worse than we expect. What’s surplus safety? The result of a culture of safety that does harm by preventing people from achieving future development that comes from taking risks and learning from the resultant success/mistakes. 

The Dignity of Risk The opportunity for all persons to exercise autonomy, control, and self-determination in decisions that impact their lives How do we find the balance between providing the best quality of care and keeping elders save, AND allowing choices that involve risk, but will enhance quality of life?

The Rothchild Person-centered Care Planning Process Identify and clarify the elder’s choice Discuss the choice and options with the elder Determine how to honor the choice Care Planning the choice Monitoring and making revisions to the plan Quality Assurance and Performance Improvement (QAPI)

Choice No Risk Honor Choice Risk Alternatives Accepted by Elder Care Plan Monitor Reassess Alternatives Not Accepted by Elder Unsafe Inadequate Resources Unable to Honor Choice Assessment The Process for Mitigating Risk and Honoring Resident Choice in Care Planning developed by Rothschild Person-Centered Care Planning Task Force

Creating a path for success What are the beliefs that must change? What are the behaviors that must change? What are the underlying systems and structures that must be in place to ensure success?

What is one thing we will do as a national initiative to advance person-directed practices? What is one thing you have learned today that YOU will do differently when you return to your community?