Developing Scheduled & routines that Work Creating a Culture of Change for People Living with Cognitive Changes Its not a Nursing Home or Facility It’s a HOME where nursing care is given

Design Each Day 8 am – coffee circle 8:30 – songs of joy 9 am – time to ‘go’ 9:15 – take a hike – walk’n’roll 10 am – cool down & stretch 10:30 – watering hole 11 am - ‘use your brains’ games 11:30 - time to ‘go’ – wash up 11:45 – ‘set-‘em up’ crew 12 noon – let’s eat 12:30 – clean up crew 1 pm – music and meditation 1:30 – coupons clipping 2 pm – time to ‘go’ 2:15 – let’s dance Make a schedule and follow it Be structured BUT allow flexibility Create a FLOW for the day Build up and then slow down Circadian rhythms Offer a variety of activities every day Leisure, work, rest, self-care, groups and 1:1, passive and active Create Group schedules BUT also build individual schedules Not everything is for everybody! Build a Foundation of Familiar and Favorite Activities Add a few special events and something different

Understand Activities Modify and Structure the Activity for Success Change the materials, the complexity, the setting, the help offered, the task demands, or the purpose of the activity Analyze the Activity… What do you need to do it? What skills, abilities, interests? What is the activity all about? Doing something or making something? What type of activity is it??? Self-care, leisure, work, rest… Spiritual, social, physical, cognitive, passive, active, solitary

Enough Supplies & Materials The right equipment for clients’ needs Good quality lighting Skilled leadership for the activity Good work surfaces Seating that works Enough help for each person A BACK-UP Plan

Traditional Facility Care Run by administrators & nurses Organized around staffing Work shared among 3 shifts of staff Safety and health care issues TOP PRIORITY Medical model Organized by departments – task specific You are sick – you need care for your diagnosis Father knows best!

What’s Wrong with this Model? Who wants to live in a hospital? Who wants to do everything you are supposed to? Who wants to have someone else telling what to do and when to do it? Who wants to have to talk to three different people to get something done? Who wants to live in a nursing home?

For People with Changes in Health and Abilities Need for help Need for equipment Need for changes in routines & habits Need to match needs with availability of help Need to ‘anticipate’ when and where you will do things, need things

Cognitive Changes with Aging slowed processing less flexibility more difficulty with new learning more rehearsals needed benign forgetfulness – immediate recall goes first

Emotional Changes with Aging increased incidence of depression increased incidence of anxiety with stress – mood swings with some drugs – emotional side effects

What Does Having Cognitive Abilities Do To This Whole System of Care? Changes in memory & thinking Changes in understanding & speaking Changes in impulsivity & initiation Changes in abilities & processing

So Let’s Figure YOU Out… What time do you wake up? How do you wake up? What do you do when you wake up? When do you eat breakfast? What do you eat for breakfast? How do you get ‘clean’? When do you get clean? When do you toilet? What do you do for work? What do you do for fun? What do you do when you are stressed? ID two people you love… Where are you from? What is your favorite food? What do you HATE to eat?

Questions How would you DO living in your community? What would it be like if you had physical changes? What about cognitive impairments? How would you do on someone else schedule? What would NOT be OK? What if it was the rest of your life? What would you want?

What is Veteran-Centered Care? Combination of… Person’s wants Person’s needs Still can do Can’t do Can do with support Individual good Common good Family needs Family wants Balanced with… Staff skills Staff availability Private space Public space People resources Equipment resources Safety & Security Rules & regulations Others needs and wants

Personal Preferences & Values Who have you been? What did you value? Who are you now? What do you value now? Why does it matter? Who gets a ‘say’? Who gets to set the priorities?

Who Matters? All of Us Each of Us

What Matters – When Illnesses Are Present? Safety – Environmental modifications Access - Availability Timeliness of help Flexibility in timing Structure & predictability Privacy and respect Preservation of SELF

Key Steps Connect Gather Information Share Information Use Information Review Information Make Changes

What About Medical Conditions? What is essential? Good care is delivered The person is receiving the care they need and want Conditions are assessed Decisions are made based on good info There is agreement on what to do and what NOT to do… What is optional? When it is done Where it is done Who does it How often it is done How strictly it is followed It depends on the person & their situation

What are the Different Care Approaches to Consider? Health Promotion Curative Restorative - Rehabilitative Maintenance Compensatory Palliative

Health Promotion Check Ups Annual vaccinations Lower the numbers Increase activity level Eat well – moderately Monitor all conditions for careful control DO WHAT YOU SHOULD to be the BEST YOU CAN BE!

Curative Fix what is wrong Test to figure out what is happening then DO SOMETHING ABOUT IT: – Surgery – Medications – Treatment Full recovery of function – GOOD as NEW!

Restorative Recovery of SOME degree of function or ability Focuses on the PERSON regaining skills and abilities with help – Rehab personnel – Special equipment – New techniques Not perfect, but BACK to a Higher level of Function

Maintenance Maintaining the Status Quo – Keepin’ ON Not losing ground Depends on: – Physical environment not changing – Caregiver consistency – Sustained abilities of the person – All other things staying the same It’s HARD WORK … SO… – ‘IS what I have worth keeping???’

Compensatory Providing what the person can’t do to ‘fill in the gaps so that LIFE GOES ON…. Supportive – Physical environment changes – Caregiver cueing and helping changes – Expectations change – Schedules and routines change to accommodate End Point is the Same – – How we get there Changes

Palliative Comfort Care TOP PRIORITY – – Honor personal preferences and choices – Manage Pain, Distress, Anxiety, Fear, Discomfort Identify & seek to meet social, physical, psychological, and spiritual needs Let go of FIXING and MOVE ON to Comforting

The GOAL? Build a schedule and care routine that helps the person: – Be the way they want to – Do what they are able – Feel good about themselves – Feel OK about where they are – Enjoy the people who are there to help them – Get what they need

Who Needs to Buy In? Residents Families Front line staff Managers Community leader Regulators Public Reimbursors

So… What Do We Need from Staff & Families? Awareness of the process Participation in planning Sharing about the past Time to learn & try something new Willingness to listen Willingness to advocate AND negotiate Flexibility as we figure this out