1. Rhythms of Daily Living Rhythms of Daily Living © Liberating Care & Navigating Change A Culture of Choice Dining as a Catalyst Aligning Experiences – Expectations – Resources – Outcomes

2. October 20. 2005 Scripps/SAGE Conference 2 Session Objectives  Review Changing Factors of Environment & Constituencies  Review Demographics  Define Assumptions  Introduce Choice Dining Concept  Discuss Culture of Service, Leadership, Choice  Fixed & Variable Navigation  Technology Applications

3. October 20. 2005 Scripps/SAGE Conference 3 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

4. October 20. 2005 Scripps/SAGE Conference 4 Must Rising Acuity Levels Mean Lower Dining Quality ? ©

5. October 20. 2005 Scripps/SAGE Conference 5 Why Do 65% Of NH Residents Eat Less Than 75% Of Most Meals* ?  Primary Factors That Contribute To Malnutrition In Nursing Homes 1. An Inappropriate Dining Experience For The Resident. 2. Meal Delivery Methodology and Systems Not Conducive To Eating. 3. Good Nutrition is of no value if it is not consumed *Excerpted 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

6. October 20. 2005 Scripps/SAGE Conference 6 Skilled Care Dining Today Restricted Service Times, Too Short For Quality & Assistance < 20 Minutes For Dining The Quality Gap

7. October 20. 2005 Scripps/SAGE Conference 7 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

8. October 20. 2005 Scripps/SAGE Conference 8 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

9. October 20. 2005 Scripps/SAGE Conference 9 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?

10. October 20. 2005 Scripps/SAGE Conference 10 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.

11. October 20. 2005 Scripps/SAGE Conference 11 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.

12. October 20. 2005 Scripps/SAGE Conference 12 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 2000. [i]  [ii] Chou, S., Boldy, D., and Lee, A. “Resident Satisfaction and Its Components in Residential Aged Care.” The Gerontologist 42:188-198, 2002. [ii]  [iii] Kane, R. “Long-Term Care and a Good Quality of Life” The Gerontologist 41:293-304, 2001. [iii]

13. October 20. 2005 Scripps/SAGE Conference 13 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

14. October 20. 2005 Scripps/SAGE Conference 14  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

15. October 20. 2005 Scripps/SAGE Conference 15 STAGES of RDL 1. Readiness GAP Analysis  Establish clear understanding among all constituents (residents, staff and administration) as to the program impact on 6 principle areas. 2. Culinary Capacity  Establish a servery on the resident floor where all meals can be finished, plated and served. 3. Individualized Service  Establish a service program without the tray system. Meals are plated in the servery when the resident is in the dining room. Choice is based on pre-ordered menu items, however time of service is not flexible. 4. Point of Service Menu Choice  Establish the opportunity for the resident to choose alternate items from a menu during meal service. 5. 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. 6. 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.

16. October 20. 2005 Scripps/SAGE Conference 16 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

17. October 20. 2005 Scripps/SAGE Conference 17 Outcomes  No complaints  Socialization  Weight stabilization  Improved I/O’s  Less plate waste  Smiles  Reduced staff turnover  Improved skin integrity  Reduced use of supplements  Congenial and pleasant environment – warm & inviting

18. October 20. 2005 Scripps/SAGE Conference 18 Benefits  Better interaction with staff & residents  Freedom of choice  Residents more social amongst themselves  Better presentation  Food is hot/cold  Better texture  POS selection for menu items  Better I/o’s  Resident choice of time to eat/when hungry What Are Your Experiences?

19. October 20. 2005 Scripps/SAGE Conference 19 What Are Your Experiences? Obstacles  Structure of ordering  Staff resistance to change  Inadequate staffing  Training of staff to new tasks  Management of change (fair process)  Need to educate the staff in the process of change  Clear explanations of the reasons/outcomes of changes  How changes will impact staff security and knowledge of job tasks and resident served

20. October 20. 2005 Scripps/SAGE Conference 20 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

21. October 20. 2005 Scripps/SAGE Conference 21 Culture CULTURE OF CURECULTURE OF CARE LEADERSHIPHIERARCHIALSERVANT ENVIRONMENTOUTCOMERSIDENT FOCUSQUALITY OF CUREQUALITY OF LIFE PROCESSSTRUCTUREDSPONTANEOUS WORKMANSHIPCERTAINTYRISK MEASUREOBJECTIVESUBJECTIVE REGULATIONPROCESSENVIRONMENT PRIMARY SKILL/PERSONALITYSCIENCEART

22. October 20. 2005 Scripps/SAGE Conference 22 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.

23. October 20. 2005 Scripps/SAGE Conference 23 Culture of Servant Leadership “Servant leadership is a long-term, transformational approach to life and work, in essence, a way of being—that has potential for creating positive change within our society...” Ron Ortiz Dinkel “Servant leaders put other people’s needs, aspirations and interests above their own.” Robert Greenleaf

24. October 20. 2005 Scripps/SAGE Conference 24 Need for Change?! Do you think so? Insanity – to continue to do the same things and expect different outcomes It is increasingly clear that we need to change the environment, practices and culture of caring for and with residents. What we have been doing is not as effective as necessary or possible.

25. October 20. 2005 Scripps/SAGE Conference 25 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

26. October 20. 2005 Scripps/SAGE Conference 26 SERVICE INITIATIVE 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 process from concept to implementation. The following are the task requirements for this process: 1) Identify Service Initiatives 2) Define Their Contribution To Strategic Objectives 3) Define Appropriate Measurements Of Successful Experience Outcomes 4) Identification Of Resource And Operational Intersects 5) Identification Of Intersects And Roles Of Other Contributing Departments 6) Structure Of The Process For Resource Allocation To Develop The Defined Initiative 7) Sequencing Of The Tasks 8) Implementation of The Initiative.

27. October 20. 2005 Scripps/SAGE Conference 27 Community Strategic Objectives 1)Community of Distinction 2)Financial Enhancement 3)Quality of Living / Quality of Work 4)Operational Effectiveness

28. October 20. 2005 Scripps/SAGE Conference 28 Program Intersects Grid Strategic Objectives Community of Distinction Financial Enhancement Quality of Living Quality of Work Operational Effectiveness Step #1 Strategic Objective Benefit Step #2 Benefit Measure Measurement Tool Step #3AdministrationRegulatoryOperationsPersonnelPP&ECommunity Operational Resource Requirements Budget Impact $/FTE’s

29. October 20. 2005 Scripps/SAGE Conference 29 Program Intersects Grid Strategic Objectives Community of Distinction Financial Enhancement Quality of Living Quality of Work Operational Effectiveness Step #4 Collaborating Departments NursingResident Services Therapies Pastoral HousekeepingMaintenanceActivities Task Step #5 Task Implementation NursingResident Services Therapies Pastoral HousekeepingMaintenanceActivities Procedure Policy Resource Requirement Inform/Train Measure

30. October 20. 2005 Scripps/SAGE Conference 30 Project Management

31. October 20. 2005 Scripps/SAGE Conference 31 Alignment  The appropriate positioning of systems and resources to attain a defined goal, mission, outcome or culture

32. October 20. 2005 Scripps/SAGE Conference 32 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

33. October 20. 2005 Scripps/SAGE Conference 33 Technology Applications  Excel Budget & Cost Management Worksheets  Microsoft Project Manager  Visio Flow Management Software  POS  Resident Data Management  Satisfaction Survey Documents  Leadership Effectiveness Survey Documents  Operational & Compliance Gap Analysis

34. October 20. 2005 Scripps/SAGE Conference 34 POS Systems  Horizon Software  http://www.horizon-boss.com/default.htm http://www.horizon-boss.com/default.htm  Micros  http://www.micros.com/ http://www.micros.com/

35. October 20. 2005 Scripps/SAGE Conference 35 Additional Culture Change Organizations  Culture Change Now! http://www.culturechangenow.com/index.html http://www.culturechangenow.com/index.html  The Eden Alternative http://www.edenalt.com/  The Pioneer Network http://www.pioneernetwork.org/ http://www.pioneernetwork.org/  Providence Mount Saint Vincent http://www.providence.org/Long_Term_Care/Mount_St_Vincent/default.ht m

36. October 20. 2005 Scripps/SAGE Conference 36 Contact Information  Dan Look  3605 Sandy Plains Road  Suite 240-269  Marietta, GA 30066  dcl@dm-resources.com dcl@dm-resources.com  www.dm-resources.com www.dm-resources.com  770-565-4006  Irene Dennis 989-275-8936

37. October 20. 2005 Scripps/SAGE Conference 37 "For every complex, difficult problem, There is a simple solution. And, it is probably wrong!" H.L. Mencken