In My Own Words
A collection of featured commentaries by healthcare professionals working in Long Term Care Medicine can be found in this newly added section of our website. Please check back often for more!
The Value of a Medical Director with CMD and CALTCM Training
by Claudia Alexander, RN, Director of Nursing Services, Summerfield Healthcare, Santa Rosa, CA
originally posted April 2011
I have been working in the Skilled/Long Term Care industry since 1988 and in 2002, I became a Director of Nursing for a 102-bed facility in Tucson, Arizona. This was a new acquisition for the company and we were looking for a Medical Director. My first job was to find out who was the most effective Medical Director in our community. Because I was new to the area, I started making telephone calls to other facility DONs to inquire about their experience working with their current Medical Director and why. The result of my inquiry of several DONs led me to one physician that stood out from all the rest.
What made him stand out was his vision and understanding of the challenges of Skilled/LTC. He developed a quality process program that was available to his facilities. The comprehensive integrated Quality Assurance/Quality Improvement program included the process of consistent data collection and analysis to demonstrate trends and assist in identifying projects to improve outcomes for patients. The Quality Improvement of the program directs the corrective actions of your team to decrease risk and increase satisfaction for our patients. Results were measurable and effective. We were able to see positive results and determine successes. Under his tutorage and involvement of higher education, this facility was also involved in helping with different posters and projects for AMDA in pain management and wound care. I am happy to say after five years of service together at this particular facility, we had outstanding survey results and excellent ratings. Most of all because of this program I have learned the true value of a professional Medical Director.
In my experience, a Medical Director is a physician who is responsible for overseeing, providing leadership, educating others on the delivery of quality of care. And most importantly a Medical Director is a vital part of long-term care facilities successes. My personal analogy of a Medical Director is visionary and knowing, the guiding "light" of a great ship to safe harbor. Currently I work in a 56-bed facility as a DON in Northern California and have the privilege of sharing the work force with one of the most dedicated, approachable and knowledge driven Medical Directors, Dr. Timothy Gieseke. My facility was recently honored with the “Flag” by Ensign – this is a very high achievement that allows significant facility and program upgrades. Only one other of the 85 Ensign facilities achieved this annual distinction.
I understand the ever-changing healthcare environment, on-going challenges of medical care and an effective long-term and post-acute care. Needless to say, it takes a team of professionals and to have a Medical Director that remains a stable force – setting standards and continually striving for quality. From Arizona to California, both Medical Directors specialize in caring for geriatric patients in a variety of settings and are certified by AMDA. They attend and participate in state chapter meetings such as CALTCM as well as through accessing their resources and collaborative relationships. Their knowledge, dedication, valuable ongoing education process and training is imperative to assist nurses and patients in receiving quality care especially in our ever-changing healthcare system.
An Administrator’s Perspective on the Role of a Medical Director
by Katherine Oh, Administrator, Cloisters of Mission Hills; Vice President, Kennon S. Shea & Associates
originally posted April 2011
As Administrators, we choose Medical Directors for various reasons. Often times, it’s with hope and expectation that they would influence admissions to our facilities. Sometimes, it’s their capacity to assume care of patients who are admitted without an attending physician. Then, there are those who are chosen because of their interest and desire to provide tangible clinical leadership at the facility. I think my colleagues would agree that in our perfect world, the ideal Medical Director would be all three rolled into one.
At the Cloisters of Mission Hills, in San Diego, where I’ve been the Administrator for 10 years, the role of the Medical Director continues to evolve. Serendipity at play, our current Medical Director, Dr. Daniel J. Bressler, came on board around the time F501 was revised. I’d just had an opportunity to complete a presentation with Dr. Karl Steinberg, on the role of the Medical Director. Dr. Bressler was interested in following just a few more than a handful of patients at the Cloisters, whether they were assigned or whether they were his long time patients from the community. He was not only genuinely interested in the facility processes because of way they affected the way he provided care to his patients, he understood his responsibility for providing clinical leadership and coordinating the medical care at the Cloisters.
For the first several months, I could not walk down the hallway without Dr. Bressler pointing out ways to improve our processes. He would call me and he would email me. The doctor was relentless. Our Medical Director understood his important role in providing leadership and expertise in application of our standards and practices.
Over the last 6 years, Dr. Bressler has been active in providing education to our staff, through teaching moments, as well as through formal presentations. Our monthly M&M (Morbidity and Mortality) meetings, where we review patients who’ve passed away or were transferred to the acute hospitals, unexpectedly, have been instrumental in helping us identify potential areas of exposure. Trends are discussed with subsequent studies completed through our QA Committee. We, then, use concise emails as a method of communicating changes in policies as well as best practices, with our attending physicians.
About 4 years ago, we started attending the annual CALTCM meetings, where we’ve been exposed to some of the best practices in long term care. The Director of Nursing Services and a few of our RNs are also encouraged to attend with us. Perhaps it’s his extensive practice as a physician or his experience in medical-legal work. It may just be his curious nature. Regardless, Dr. Bressler’s willingness to invest the time to continue to further his knowledge and encourage us to improve is deeply appreciated.
In order to compete and pave our way in long term care, I believe we look for all three characteristics in our Medical Directors. I understand and live the reality, each day. Medical Directors need to understand their roles, and we need to do a better job of communicating our expectations.
I encourage my Administrator colleagues and Medical Directors, to read and fully understand the expectations of the regulations outlined in §483.75(i) and F501 of the interpretive guidelines. Ultimately, the Medical Director is responsible for (i) the implementation of resident care policies; and (ii) the coordination of medical care at the facility.
Thanks, Dr. Bressler, for the studies and articles describing best practices that continue to hit my email inbox!
Depression in Nursing Home Residents During the Holidays
by Victoria Bullock, BSW, Director of Social Services at Vista Manor Nursing Center, San Jose, CA
originally posted December 2010
We all love the holiday season, and the longing to give to others does not go away as we age. Elderly people who live in Nursing Homes have all given up one thing --- independence.
I am a Nursing Home Social Worker and understand that around the holiday season, many of our residents feel sadness due to not being able to participate in the holiday traditions that they used to enjoy. Take for instance a female resident who used to have all her family over every Thanksgiving. She used to cook all day and host a wonderful meal. Her house was the center of the family for each Thanksgiving. Now for Thanksgiving she gets a turkey dinner at lunch time on a tray and hopefully her family will visit and bring her a piece of homemade pumpkin pie.
For Christmas she used to have her house decorated beautifully, shopped for everyone and wrapped the prettiest present ever. Now for Christmas she is not able to shop or give presents to her family and can only sit and look at Christmas decorations hung around the facility.
Nursing facilities and the staff do their best at providing a festive environment for their residents. Thanksgiving Candlelight Dinners are planned and family members are invited. Christmas trees are trimmed and decorations are hung. Christmas parties with gift giving are enjoyed. These activities are fun for the residents but cannot replace the memories of the past.
To help with sadness and depression around this time, we should try to make the residents feel important and have a sense of independence. Wouldn’t it be fun for a committee of residents to plan the Candlelight Dinner menu? How about each resident bringing an ornament from their family and hang it on a “resident tree?” What about a resident Secret Santa exchange?
Independence is a hard thing to give back to someone. Making someone feel important can be very empowering. Many Nursing Home Residents feel that their contributions to life are very minimal. Accepting one’s contribution, big or small, can be very uplifting. I try to help my residents draw from their past to help make each day one they will enjoy.
Happy Holidays!
The POLST is Personal
by Timothy Gieseke, MD, CMD
originally posted November 2010
My POLST journey began in November 2007 at our CALTCM Board of Directors meeting. Dr. James Mittelberger and others spoke highly of this evidence-based tool for advancing palliative care in California. I was quite familiar with the Preferred Intensity of Treatment (PIT) forms championed by the Extreme Compassion Humane Options (ECHO) guidelines of 1999. In fact, this form was instrumental in the hospital’s honoring my Dad’s No CPR preference, during his acute terminal illness in January of 2001. In retrospect, I wish we had been better prepared for the difficult decisions required by that illness. The options we were given were aggressive care, or nothing. Hospice was never mentioned. My father died the night after his first hemodialysis. Much of his care was futile, but hospice was never offered.
After this meeting, I signed up for the Leadership and Management in Geriatrics (LMG) course – sponsored by the UCLA Academic Geriatric Resource Center and California Geriatric Education Center – hoping to improve my effectiveness in advancing the care of the frail elderly in my community. As part of this course, we were instructed to select a work-related project that we would like some assistance in developing. After some consideration, I thought implementing the POLST in Sonoma County would be a simple and sustainable project. The required pre-course preparation enhanced the course experience which was complemented by an excellent curriculum and faculty. At the course, further project refinement occurred in a team-setting with a faculty mentor. My mentor was Dr. Cheryl Osborne, EdD, MSN, RN, Professor of Gerontology & Nursing at CSU Sacramento. She was of great help to me in the months to come. Please see my project which is posted on the UCLA GeroNet website.
Since that course, our state has birthed the POLST, and palliative care is starting to become mainline. We have a robust POLST implementation coalition in Sonoma County and have just completed the first training in the state for POLST in the RCFE setting. The lead organization for the POLST, the Coalition for Compassionate Care of California (www.CaPOLST.org) continues to provide the infrastructure necessary for bringing palliative care to our frail elders. I am proud to be a part of this great effort as a local and state physician champion. I am also grateful to the LMG course and team for exceeding my goal of improving effectiveness as an advocate for better care for our seniors. This course is being offered again this year on April 15-16, 2011 and is well worth your serious consideration.
For more information, please click here.
Untied Wrists & Combed Hair
by Nancy Beecham, DON of Edgemoor Hospital/DPSNF
originally posted October 2010
As a nurse in Long Term Care, post-acute nursing practice for over 40 years, when asked, “how do I define quality improvement?” I walk my mind back through the pages of the book of nursing I have lived and mental notes taken. I remember how I felt when I was working as a ward clerk, while attending college in the first associate’s degree nursing program in Harrisburg, Pennsylvania in 1969.
She was 90 years old, she was tied at the wrist to a chair placed in the hall next to the nurses’ station where I worked.
I saw nurses braid her hair into pig tails. I asked why they combed her hair like that, I was told, “it looks nice and she doesn’t care,.” I have never forgotten the image of that face, softened with time. Pale blue eyes, looking without speaking but without words asking for help, comfort, kindness and dignity. Her hair was pure white, so white you couldn’t ignore it. Hair I know that for many years would have been drawn up and back into a delicate twist or bun away from her lovely face. Now it was parted in the middle and braided into pigtails at the sides of her head and tied with rubber bands and two pieces of red yarn like a 6 year old.
I was just 20 and didn’t think I could make a difference. I learned I was wrong because the next day, I brought in silver bobby pins and a new comb. I asked her if I could do her hair and she said, “Yes.” I asked her how she wanted it, in braids or pulled back? How did she like it? “I have worn it pulled straight back in a bun mostly,” she said. She had been a teacher for years her name was Nara. Her family came to Pennsylvania in a covered wagon from Kansas. We talked as I worked on her hair.
When I finished, she asked if I could untie her wrist for a minute. Seeing no one around to ask, I untied her right wrist. She moved her hand up and touched her hair as if her fingers had eyes. She smiled and said that is how she wears it. “Thank you,” she said. I said, “No, thank you for allowing me to help”. I re-tied her wrist as the nurses came back to the station and asked me to transcribe some pre-op orders.
Now fast forward to my brand new state of the art facility: 192 rooms all private, 15” high definition personal televisions, in wall oxygen and suctions, private showers in each bathroom. Restraint- free, resident centered, individual care, neighborhoods, activities and restorative nursing programs on all 6 neighborhoods. Residents wear their own clothes, no institutional gowns or cotton dresses with ric-rack sewn around the neck with no underwear.
Residents have pizza and takeout food delivered to them here. Fold out beds where family members can sleep by residents. I don’t hear “Sweetie, Honey, Granny, Pappy." We have no pigtails, bibs or diapers.
I see and feel that quality improvement in our daily nursing care. I see respect for diversity in our daily routines. In the 40 years, there has been improvement in educational levels, higher acuity, the demand for better educated staff, and medical directors who are dedicated and involved in the delivery of care.
I see a community who is knowledgeable, and concerned with the needs of those with illness and injury. Our communities expect high levels of professionalism from our staff.
I see the delivery of better care because we can and do excel.
We have begun to untie the wrists and comb the hair and listen to the wants, wishes and stories of the Nara’s in our facility.
Monday Morning Mysteries
by Traci Clark, RN, Director of Nursing Services
Creekside Rehabilitation & Behavioral Health, Santa Rosa, CA
originally posted September 2010
Monday morning. What can this mean to Directors of Nursing in skilled nursing facilities? Too often it is valuable time spent getting up to speed on the events of a hectic weekend full of changes in condition, falls, and new orders. One finds themselves asking, “What was the reason behind the stat labs, hospice evaluations, and the unexpected transfer to an acute care hospital?”
In the morning stand up meeting, I scratch my head wondering what had happened. Everything was so calm and going so well when I left on Friday. Our active 181-bed facility was running like a well-oiled clock. I had made rounds reassuring every new patient and family that the weekend would go just as smoothly as any weekday. So, what does happen when the weekend starts? Communication fails.
I recently attended a CALTCM Pre-Conference Workshop on Interventions to Reduce Acute Care Transfers, or INTERACTII. I was so excited to hear about an entire system of communication and documentation that had been utilized and proven to be effective in a setting similar to our busy rehabilitation center, long term care facility, and mental health special treatment program. INTERACTII is a system of communication tools and documentation that we are implementing at Creekside Convalescent & Mental Health Rehabilitation. I was very impressed to see how empowering this system has been. An example of such a tool is one in which a family member, CNA, housekeeper, or any other staff member may alert others when they feel that a change has occurred with one of our frail residents. The “Stop and Watch” tool is a vital portion of this new system. Our interdisciplinary team will make this tool available to the family during an initial conference.
Like any other new documentation system, resistance from the staff is inevitable. Hopefully, as the concept of INTERACTII is assimilated, the level of support and acceptance will grow. The proven success of this system will lead to new and improved communication and documentation.
Although I am currently not an expert in the use of this system yet, I am experienced at unraveling the Monday morning mysteries. As your facility learns and implements these tools and this system, please feel free to contact me at tclark@thekkek.com to share your experiences.
For more information on INTERACTII and other helpful hints, simply visit the very user-friendly website at: www.interact2.net
My Father's Daughter
by Flora Brahmbhatt, PharmD, CGP
In many ways, long term care pharmacy is all I know. My father, Dr. Yagnesh Brahmbhatt, is a pharmacist who has worked in long term care for 30 years. My earliest memories are of him receiving calls from a nursing facility asking for medications at the oddest hours of the day. It never made sense to me why anyone would want a job that didn’t have regular hours.
In hindsight, this exposure to my father’s work has positively influenced my own career path. Today I work as a long term care consultant pharmacist and needless to say, “regular” hours are the furthest thing from what I have been able to keep. As with all consultant pharmacists, the crux of my job is to make rounds at facilities, review patient records, and submit reports. As I see it, this is where my job only begins. Read more
How to Keep the Old Folks at Home
by Diane J. Agate, FNP
Having worked in Geriatric Medicine for 13 years, I still am surprised at how much there is to learn every day. For the first nine years, I worked in long term care with the patients already placed and safely cared for. All I had to do was provide management of their health care and maintain family contact, addressing issues such as advanced directives, whether or not to hospitalize, and goals of care. Most of my patients were frail or very frail elderly. Predominantly, they were women. They were long past the time when they could consider staying at home because of severe physical infirmities, cognitive impairment, or lack of funds for full-time home care. The work was difficult and stressful, but within the context of a very supportive structure.
A year and a half ago, I moved on to home-based primary care, thinking what a wonderful background I have. I know how to take care of the elderly. How much more can there be to know? Read more