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

3. 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?

4. 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.

5. And the survey says …
17 total responses

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

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

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

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

10. Overall, please rate your job satisfaction

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

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

13. 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.

14. 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.

15. 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.

16. 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.

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

18. 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.

19. 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).

20. 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?

21. Breaking barriers to Person-Directed Care
Diana’s Story

22. RISK: And our aversion to it!

23. 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. 

24. 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?

25. 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)

26. 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

27. 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?

28. 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?