1. Humanizing the Care of Residents Long Term Peter A. Lichtenberg, Ph.D., ABPP Director, Institute of Gerontology Professor of Psychology Wayne State University p.lichtenberg@wayne.edu

2. Thirty Years of Enhancing Personhood Look back at behavioral approaches Examine Eden and Greenhouse models Examine Personhood models Understand organizational influences on care Three C’s of everyday care Tie it all together and discuss

3. OLD AGE IS ALWAYS 15 YEARS OLDER THAN I AM BERNARD BARUCH AGE 84 UNITED NATIONS DIPLOMAT

4. 1 st cohort to Grow old and be Visible in U.S. Changes from 100 years ago: Life Expectancy Number of elders Idea of com- Pressed morbidity Dementia after 90

5. My early Experiences in a 180 LTC bed unit Referral: “Man throwing himself on the floor due to manipulative tendencies” What I observed 1.Often lost balance and fell to floor (22 times per 6 hour period) 2.Tearful 3.Stopped eating—losing considerable weight 4.Poor verbal communication skills

6. What we did Got neurology referral—he had untreated PD Got speech language referral—voc-aid and taught him to use Increased his social interactions with staff and depression remitted WHY HAD HE BEEN VIEWED IN SUCH A DEPERSONALIZED WAY?

7. 78 year old man with Schizophrenia In state hospital since his early 20’s Seclusive Spent entire day lying in bed Behavioral Modification techniques used Used a shaping technique to increase physical activity In one year improved from walking a total of 10 feet to one mile each day

8. PREVAILING VIEW OF FRAIL ELDERS Medical v Community/Social model of care: Deficit model Passive Sedentary Close minded Lost too much cognitive ability Results De- individuation Fostering of dependency

9. RODIN AND LANGER (1976) Gave more control to residents over day to day events and compared them to control group Outcomes—group with choice engaged in more activity, reported more happiness, were rated as more alert

10. MARQUETTE COUNTY MEDICAL CARE CENTER PROJECT Depression Treatment and Prevention in Persons With Alzheimer’s Disease Peter A. Lichtenberg, Ph.D., Principal Investigator

11. MARQUETTE STUDY DETAILS New home-like setting created for persons with Alzheimer’s Disease Unit de-emphasizes “institutional” behavior and emphasizes individual, client-centered approach to care

12. MARQUETTE STUDY DETAILS CONT. Baseline: Neuropsychologist blinded to intervention assessed 23 residents from the 2 new AD units Geriatric Depression Scale Cornell Scale for Depression in Dementia Behave-AD Clinical Interview & DSM IV Diagnoses

13. MARQUETTE STUDY DETAILS CONT. Marquette County Medical Care designated ½ time person for further baseline work intervention. Pleasant Events Mood Monitoring Relaxation Tx. ongoing for 3 months Reduced behavioral disruption in pleasant events vs control group

14. ACTIVITIES ENGAGED IN Pampering –massage, aroma therapy, hair care 27% Reminiscence-old photos, verbal discussion 22% Social activity—one to one visiting, small group 18% Physical activity—walking, fixing, gardening 16% Quiet activity—watch birds, reading 11% Correspondence—holiday letters, cards 6%

15. CONCLUSION Personal choice, 1:1 relationships enhanced well being Model not practical for broad implementation

16. Nursing Homes and the Medical Model: Bill Thomas Staff Hierarchy much like hospital 3 Plagues of Long Term Care: 1.Loneliness 2.Helplessness 3.Boredom Challenge—creating the Eden team concept in a LTC facility

17. Creation of the Eden Alternative 1991 By Dr. William H Thomas and wife Judy Chase Thomas Chase Memorial: reduced medications, infections, staff turnover and mortality rate after Eden was put into place What makes the Alternative come to Life?

18. EDEN ALTERNATIVE COMES TO LIFE:

19. From Parking Lot to Activity Room Gardens/landscaping Children Animals Person Centered activities

20. GREENHOUSE MODEL OF LONG TERM CARE Goal is to rethink: Philosophy of care Architecture Organizational Structure of care

21. WHAT IS IT? Independent housing unit for 6-12 people with dementia CNAs are called Universal Workers UW’s organize day in collaboration with residents Other staff are wrap-around support services 2006 RWJ awarded $10M across country to increase number of Greenhouses HOWEVER policies and funding models do not provide support for Greenhouse model to expand even more

22. Greenhouse in Action

23. CURRENT STATUS OF GREENHOUSE 1700 in existence across the U.S. Staff do more but for fewer people “Get to know resident as a real person” Less rigid schedule; meals, bathing To date: studies show that care is similar to that found in larger nursing home

24. Expressions of Personhood Pia Kontos and Gary Naglie—U of Toronto “Expressions” of personhood “discourse” over-utilized by us all in defining personhood Artistic expression under-utilized and appreciated Current model--- as cognition declines so does self- hood Negative views of those with more severe dementia in long term care and less caregiver engagement

25. Expression of Personhood Cont. Kontos’ ethnographic study claims that selfhood continues even after cognition declines Key challenge in LTC: Maintenance of Personhood Kontos: Selfhood taps into “pre-reflective” levels of consciousness Examples: 1.Importance of gesture in communicating 2.Body and facial expression 3.Items hold unique and personal meanings to residents

26. Artistic Expression as Performance

27. SUMMARY AND QUESTION Choice, personhood is important Wonderful models created across past 40 years Why is personhood still the exception rather than the norm in care?

28. REFRAMING ORGANIZATIONS: BOLMAN AND DEAL 4 frames needed to understand organizations and most people only look at 2 1. Structural 2. Human Resource

29. 1. STRUCTURAL FRAME Metaphor: Factory/Machine Dimensions Differentiated or integrated jobs Centralized or diffuse in responsibility Rigid routine/flexibility

30. 2. HUMAN RESOURCE FRAME Metaphor: Family Employees: Replaceable v Valued Fit between individual and organization LTC workers—high levels of meaning in work, low participation in team decision making Structural and HR frame are rational—ways of organizing work and treating workers

31. 3. POLITICAL FRAME Metaphor: Jungle Power—ability to make things happen Coalitions form—compete for scarce resources Conflicts—win/win v win/lose negotiators Power can be coercive and destructive if not used wisely (e.g. space shuttle Discovery; Housing crisis; Nanny cam of Abuse in the Nursing Home)

32. 4. SYMBOLIC FRAME Metaphor: Carnival, Temple, Theatre Meaning Hope Faith Core Values “Culture in Organizations” Symbols/rituals

33. REFLECT ON LTC AND YOUR PLACE OF WORK How do 4 frames influence policy, power, structure and meaning? Frail persons– weak in terms of powerful coalition; chronic under-funding of LTC Stability of administrators in LTC—poorest functioning organizations have least stability in administrators let alone direct care staff Negative stereotyping of LTC

34. PERSONAL HABITS IN DAILY WORK Steven Covey: 7 Habits of Highly Effective People Begin with the end in mind Seek to understand before being understood Put first things first Think win-win

35. 3 C’S TO PERSON CENTERED CARE Curiosity – who is this person, what was their greatest passion, what brightens them up Compassion – what is this person’s greatest fear, what causes them to suffer, what grief do they have, how lonely are they Contemporaneous– Be mindful in the present, be aware, present in the moment, come to each day ready to engage with residents and colleagues