Liberating Care & Navigating Change A Culture of Choice: Dining as a Catalyst Aligning Experiences – Expectations – Resources – Outcomes

April 20, 2005 LSNI Annual Convention Session Objectives  Review Changing Factors of Environment & Constituencies Demographics  Define Service Model  Introduce Choice Dining Concept  Discuss Culture of Service, Leadership, Choice  Discussion of Process

April 20, 2005 LSNI Annual Convention Changing Demographics  More Couples  More Choice & Selection  More Control  More Flexibility  Experience Consumers  More Knowledgeable of CCRC Living  Healthier – Wellness Important  Seamless Experience  Broader Constituencies

April 20, 2005 LSNI Annual Convention Attributes of Community Dining Program  The dining service program will provide a variety of dining venues, services and menu selection for all community constituencies.  The dining service program will expand and enhance its offerings while remaining consistent with established traditions, ministry and mission.  The program must accommodate current constituency expectations and traditions while providing for anticipated expanding community requirements.  The program will identify skill sets required for service delivery to initiate transition training and identify appropriate personnel.  The dining experience will be developed with consideration to: a seamless service regardless of level of care, a singular community service, measurable key success indicators, fully leveraged efficiencies, creation of a signature service brand for community.

April 20, 2005 LSNI Annual Convention What are the Attributes of a Quality Dining Experience?  Quality of menu item presentation  Appetizing  Taste  Variety  Atmosphere, environment  Pleasant service  Choice  Consistency  China/glassware  Timely  Appropriate temperature & consistency

April 20, 2005 LSNI Annual Convention Choice Is The Way We Live “Some facilities studied, usually the lower turn-over ones, were in the process of thinking about how to increase individualized care. For example, the researcher asked, what are you doing if anything about resident choice. ‘We are looking at it. Ideally, we want them to eat when they want. We encourage them to tell us what care they want, a shower or bath, or to get up when they want.” Page 5-49 Appropriate of Minimum Nurse Staffing Ratios in Nursing Homes, Phase II Final Report prepared by Abt Associates for the Centers for Medicare and Medicaid Services, December 2001.

April 20, 2005 LSNI Annual Convention How Do You Individualize Care? 1. What Are Strategic Objectives?  Current Strengths  Opportunities Identified For Improvement 2. What Is The Vision for Community Dining Experience?  Choice  Menu, Time and Venue? 3. What Is History of “Transformation” Projects?  What Were Expectations  How Defined and Structured  How was it trained & accepted?  What Are The Most Important Experiences?  Resident Experiences  Staff Experience  Family & Other Stakeholders?

April 20, 2005 LSNI Annual Convention Quality of Living Considerations A large proportion of nursing home residents are malnourished and up to half are substandard in body weight, leading to serious consequences including infections, hip fractures, and even death. The environment in which residents eat and the degree to which residents may choose when and what to eat can affect residents’ health (malnutrition and dehydration) and quality of life (perceived safety, enjoyment, social relationships, individuality, autonomy, choice). [i],[ii],[iii] [i][ii][iii]  [i] Burger, S.G., Kayser-Jones, J., and Bell, J. P. “Malnutrition and Dehydration in Nursing Homes: Key Issues in Prevention and Treatment.” National Coalition for Nursing Home Reform. June [i]  [ii] Chou, S., Boldy, D., and Lee, A. “Resident Satisfaction and Its Components in Residential Aged Care.” The Gerontologist 42: , [ii]  [iii] Kane, R. “Long-Term Care and a Good Quality of Life” The Gerontologist 41: , [iii]

April 20, 2005 LSNI Annual Convention Must Rising Acuity Levels Mean Lower Dining Quality ? ©

April 20, 2005 LSNI Annual Convention Skilled Care Dining Today Restricted Service Times, Too Short For Quality & Assistance < 20 Minutes For Dining The Quality Gap

April 20, 2005 LSNI Annual Convention Bridging The Quality Gap Serve The Resident, Not The System  The System – Individual Preparation, Bulk Service  Prepare Individual Menu Items For Storage  Place On A Tray For Transport To Feeding Area  Transport and Leave In Cart  Distribute and Unwrap At Scheduled Meal Time  The Alternative – Bulk Preparation, Individual Service  Prepare Menu Items In Bulk  Transport To Dining Room Servery  Plate Individually and Serve Upon Request

April 20, 2005 LSNI Annual Convention Rhythms of Daily Living The core of RDL is the opportunity to exercise choice – residents’ for how they choose to live their day and staff choice for care delivery. This creates a collaborative coalition of residents and caregivers working together in a living environment. RDL facilitates the delivery of care, the experience of living and the dignity of self-determination. RDL is a management principle that aligns the natural rhythms of residents and the support they need. The organizing principle of RDL is that people should be able to make meaningful choices in their daily lives – on their own or with assistance. RDL relies on caregivers to help define and achieve outcomes that balance individual choice and system efficiency.

April 20, 2005 LSNI Annual Convention Balancing the Natural Rhythms of Resident Living and Care Work  A “More Normal” Pattern of Living and Work  Residents Eat What And When They Want Over A Longer Meal Service  Pre-Meal Medications, Bathing and Other Activities Are Less Pressured  Staff Provides Assistance As Required  24 Minutes Is Average Optimal Feeding Assistance Time With A Range From 5 To 70 Minutes Depending On ADL Status*  48% Of Nursing Home Population Require Some Degree of Assistance*  A Dining Experience, Not A Feeding Period  Shift Dining Service Focus From Trays To Residents and Quality  Collaborative Service Support  Aroma Therapy  Course Presentation  Minimal Distraction Environment * Excerpts From Ch 14 Of Report To Congress “Appropriateness of Minimum Staffing Ratios In Nursing Homes” Authored By J. F. Schnelle et al, Borun Center For Gerontological Research

April 20, 2005 LSNI Annual Convention Independent Living Residents  Resident Choice Dining  Flexible Service Options  Café/deli  Traditional Dining  Take Out  “Mise en place” Dining  Multiple Service Venues  Wellness

April 20, 2005 LSNI Annual Convention Assisted Living  Flexible Service Options  Traditional Dining  Take Out  Multiple Service Venues

April 20, 2005 LSNI Annual Convention Skilled Nursing  RDL Dining  Flexible Schedule  Increased Menu Options with New Cooking Applications  “country kitchen”

April 20, 2005 LSNI Annual Convention Staff  Selection  Fresh Quality - not a “Leftover” Dumping Station  Home Replacement Meals

April 20, 2005 LSNI Annual Convention The ROI Of A Dining Experience Building “Experience Equity” Dining establishes the daily quality of life for all members of a senior living community. The culture defined by the dining experience resonates with and dictates that of the entire community. The dignity and joy of making self-determined choices are at the core of any good dining experience. BAD DINING EXPERIENCE GOOD DINING EXPERIENCE High Staff Turn-Over/Contract Labor = High Costs & Poor Morale/Service High Staff Retention = Lower Labor Costs High Food Waste/Use of Supplements = High Food Cost Low Food Waste/Elimination of Supplements = Lower Food Costs Low Appetite/Unanticipated Weight Loss = High Care Costs Healthy Appetite = Lower Care Costs Poor Image = Higher Marketing Costs and Lower Income Great Dining Program = Lower Conversion Costs & Higher Occupancy

April 20, 2005 LSNI Annual Convention  40% of Residents Gain Weight In The First Few Program Months  50% Reduction In The Number Of Residents Losing Weight.  Consistent Improvement In Resident Satisfaction  $0.18 – $0.21 Reduction In Food Cost Per Meal From Less waste.  85% Decrease In Use of Supplements  Higher Job Satisfaction  Improved Hydration  Outcomes Exceed Regulatory Requirements RDL Is Real Reported Results From Ten Communities That Have Implemented RDL

April 20, 2005 LSNI Annual Convention STAGES of RDL  Readiness GAP Analysis  Establish clear understanding among all constituents of program impact on 6 principle areas.  Culinary Capacity  Establish a servery on the resident floor  Individualized Service  Establish a service program without the tray system. Meals are plated when the resident is ready. Choice is based on pre-ordered menu items, however time of service is not flexible.  Point of Service Menu Choice  Establish the opportunity for the resident to choose alternate items from a menu during meal service.  Schedule Choice I[1][1]  Establish the opportunity for residents who are self-sufficient and independent to dine at a time of their choosing, within established service times.  Schedule Choice II  Establish the opportunity for residents who require assistance with dining but are able to determine when they would like to dine to do so within established service times.  7. Venue Choice (If Appropriate)  Establish the opportunity for residents to choose alternate places to dine.  [1] Schedule choice is the last and most difficult stage to implement because it affects the scheduling of all resident activities from bathing to medication and activities. [1]

April 20, 2005 LSNI Annual Convention Assessment Points for RDL Implementation Stages are defined against the requirements of:  Administration: fiscal, management and leadership considerations  Regulatory: compliance criteria (grouped by clinical and operational considerations)  Systems: software programs, forms, policy & procedures, protocols  Personnel: staffing requirements, training, HR. The impact on each care disciplines is identified by department  PP&E: Property, Plant & Equipment necessary to perform the tasks and functions  Community: Communications, Resident & Family education; community collaboration

April 20, 2005 LSNI Annual Convention Service Impact of Choice  Open Service and Schedule  Food Integrity & Safety  Service Flexibility  Decentralized Tasks to Allow for Staff Presence  Resident Centered Schedule/Flex Staff  Seamless Environment Throughout Continuum  Transparent Use by Constituencies

April 20, 2005 LSNI Annual Convention Alignment The appropriate positioning of systems and resources to attain a defined goal, mission, outcome or culture

April 20, 2005 LSNI Annual Convention Leadership Impact of Choice  Aligning Current Culture with New Expectations  Servant Leadership  Understand Nuances of Current & Evolving Cultures  Identify Conflict Points and Educate to Alleviate  Create Environment for “All Boats Rise” Experience  Leadership for Culture Transformation - #1

April 20, 2005 LSNI Annual Convention STRATEGIC OBJECTIVES – TACTICAL IMPLEMENTATION PROJECT MAPPING As dining options and program enhancements are discussed, specific initiatives are defined and envisioned by department management and staff. These new “dining experiences" require a specific definition process from concept to strategic alignment to tactical implementation. Executive and Board leadership must clearly identify specific strategic organizational considerations. Leadership must clearly define their expectation and measurement of a successful contribution to the community strategic vision.

April 20, 2005 LSNI Annual Convention Map Process #1, 2,3 Strategic Objectives Community of Distinction Financial Enhancement Quality of Living Quality of Work Operational Effectiveness Map#1 Strategic Objective Benefit Map #2 Benefit Measure Measurement Tool Map #3AdministrationRegulatoryOperationsPersonnelPP&ECommunity Operational Resource Requirements Budget Impact $/FTE’s

April 20, 2005 LSNI Annual Convention Comparison of Culture Pioneer Network Institution-Directed Culture  Staff provide standard “treatments” based on clinical  Institutional defined schedule and routines – resident comply  Work is task oriented and staff rotates assignments – interchangeable residents  Centralized decision making  Hospital environment  Structured activities  There is a sense of isolation and loneliness Choice – Directed Culture  Staff enters into a care giving relationship based upon individualized care & resident desire  Residents and staff design the schedules  Care is relationship-centered, consistent assignments  Frontline decision making  Environment reflects the comforts of home  Spontaneous activities  Sense of community and belonging

April 20, 2005 LSNI Annual Convention Culture CULTURE OF CURECULTURE OF CARE LEADERSHIPHIERARCHIALSERVANT ENVIRONMENTOUTCOMERSIDENT FOCUSQUALITY OF CUREQUALITY OF LIFE PROCESSSTRUCTUREDSPONTANEOUS WORKMANSHIPCERTAINTYRISK MEASUREOBJECTIVESUBJECTIVE REGULATIONPROCESSENVIRONMENT PRIMARY SKILL/PERSONALITYSCIENCEART

April 20, 2005 LSNI Annual Convention A Culture of Caring vs. a Culture of Curing There is a significant difference between these two cultures. A culture of curing, the medical model, requires workmanship of certainty – specific, objective, regimented procedures to achieve a specific outcome. A culture of caring, the LTC model, requires workmanship of risk – the collaborative relationship to create a quality of living experience that is subjective and defined by the resident and care provider at the moment of service.

April 20, 2005 LSNI Annual Convention Design Impact of Choice  Temperature Management & Integrity  Ware washing  Light production capacity  Resident visual & sensory engagement  Possible multiple tasks – activities & cooking classes  Dining area incorporated into the resident space usage flow

April 20, 2005 LSNI Annual Convention

April 20, 2005 LSNI Annual Convention

April 20, 2005 LSNI Annual Convention

April 20, 2005 LSNI Annual Convention

April 20, 2005 LSNI Annual Convention

April 20, 2005 LSNI Annual Convention

April 20, 2005 LSNI Annual Convention

April 20, 2005 LSNI Annual Convention

April 20, 2005 LSNI Annual Convention

April 20, 2005 LSNI Annual Convention

April 20, 2005 LSNI Annual Convention

April 20, 2005 LSNI Annual Convention Fixed & Variable Navigation Points  Fixed  Budget & Cost Management System  Schedule – Timeline – Scope of Work  Process Map  Variable  POS  Resident Preference/Therapeutic Data  Production Systems  Satisfaction & Leadership Effectiveness Survey  Project Manager

April 20, 2005 LSNI Annual Convention POS Systems  Horizon Software   Micros   Advanced Answers on Demand   Positouch

April 20, 2005 LSNI Annual Convention Contact  Dan Look –  Dining Management Resources, Inc Sandy plains Road Suite Marietta, GA  

April 20, 2005 LSNI Annual Convention "For every complex, difficult problem, There is a simple solution. And, it is probably wrong!" H.L. Mencken