At our recent Activities Strong Virtual Winter Gathering, Liza Behrens, PhD, RN, an assistant professor at Penn State University, examined “surplus safety” in eldercare, in which the goal is to reduce risks at all costs. 

“This is a byproduct of regulations and institutional practice designed to eliminate all risks, including the risk of positive and meaningful experiences that make life worth living,” Behrens said. 

To protect residents’ rights to enjoy a person-directed quality of life, Behrens asserted the need for a “just” culture of safety — one that identifies and addresses behaviors that create the potential for adverse events, calls for appropriate accountability that supports disciplinary actions against individuals or organizations who engage in reckless behavior, and avoids punishing individuals for adverse events over which they have no control. 

“We need a just culture where we can do our best to honor residents and their right to make choices,” she noted, adding, “Each of us can help this change. We can’t eliminate all risk in the name of patient safety, but we can’t allow surplus safety to continue.” 

It is important to talk about the dignity of risk-taking. “No matter what we do, we impact residents’ dignity,” Behrens said. “Dignity of risk in eldercare refers to empowering an individual’s ability to make choices and remain autonomous in decision-making, which may give rise to risk taking that subsequently enhances personal growth and quality of life.”

“If we can help people engage in risk-taking, we can improve their quality of life and wellbeing,” Behrens continued.

“If we want to create meaningful moments for our residents, we need to work backwards and start with individual preferences,” said Betsy Kemeny, PhD, CTRS, FDRT, associate professor at Slippery Rock University and president of the National Academy of Recreational Therapy. 

“Part of this involves moving away from pre-designed programs and fitting the residents into it and evolving to a live calendar that incorporates individual preferences,” with an emphasis on smaller groups with common needs such as affiliate groups or clubs that provide continuity and purpose.

Kemeny added: “We want to get away from preplanned calendars and really think out of the box. To do that, we need to go beyond Section F of the MDS [Preferences for Customary Routine and Activities].” 

In other words, we need to know our residents holistically and beyond just their medical and daily care needs.

A truly person-centered model of care that improves wellbeing must be built on a deep understanding of who the person is and what their current needs and preferences are. This is key to enabling dignity of risk and empowering residents with the ability to make choices and remain as autonomous as possible. 

When we truly get to know residents in a holistic way, we can gain an understanding of how they view risk and what risks they are willing to take to enjoy the quality of life they have defined for themselves. 

As Kemeny said, “We need to be aware of risks but not limit residents from living their own lives and do things like using typical tools like bread knives or scissors.” She added, “Don’t limit access to outcomes because of your own biases related to a resident’s age and ability to engage and risk taking.”

When we have residents’ life stories and get to know them holistically, it is easier to set expectations around the dignity of risk taking. We can all start today by being champions advocating for a stand operating procedure for decision-making related to health and safety risks for residents, especially for those who are living with dementia. 

Learn more about surplus safety, dignity of risk, and getting to know residents by watching the webinar here.

Charles de Vilmorin is the CEO and co-founder of Linked Senior, creators of the Life Story product.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

Have a column idea? See our submission guidelines here.

Her name was Tiffany, and along with her infectious energy and omnipresent smile, she’d brought a satchel of intriguing goodies. After introducing herself, she commenced to unpack her trove of puzzles and games, crossword books, watercolor paints and art paper, revealing them as though they were priceless treasures stolen from the tomb of King Tutankhamun. 

Her mission was clear — to amuse, distract, engage, elevate her despondent patient by any means necessary. And under extremely difficult conditions, with the odds decidedly not in her favor, she tried her best. 

When dad showed no interest in anything she’d brought, she asked him what he’d like to do instead. “Ride horses,” he said, with a wistful look. 

“Well, unfortunately I wasn’t able to bring one of those with me,” she gamely responded. Then, undeterred, she launched into the same speech I’ve heard activity directors give so often and eloquently in long-term care settings. 

“I’m so sorry you have to be here,” she began. “But maybe all this time on your hands is an opportunity to do something you haven’t before. To explore new interests, maybe try a new hobby.” Her manner was even more persuasive than her words, communicating beyond all doubt that she knew how difficult things were for him, and wanted so much to help get him through it. 

It didn’t really work, at least not the way she intended. But I was amazed and impressed by how hard she tried. She simply wasn’t going to be dissuaded by his unwillingness, and eventually had him talking and laughing in spite of himself. Even though he never did take advantage of any activity she offered, she made his day special, which he told her sincerely, and said again once she’d gone.

I think about that a lot when I see long-term care activity directors in action. Like Tiffany, they’re masters at overcoming obstacles and getting residents involved with the sheer power of their positivity. Part of my admiration is probably rooted in knowing what it would take, were I in a similar situation to my dad’s, to get me to do anything but worry about the future and feel sorry for myself. 

Many of our residents are lying in a bed, like he was. They’re staring out the window, like he was. The fact that they’re in a facility at all means life isn’t going according to plan, that something unwelcome, probably horribly unwelcome, has happened. They’re wrestling with the discouragement, like he was, of knowing they’re on a slippery slope to the great unknown. Who can blame them for feeling like it’s all futile? When they can’t do the things they used to love to do, what’s the point of even trying something else? 

But then, that activity director walks in, flashing a huge smile and making great eye contact, energetic and engaging, never giving up, with an enthusiasm that overcomes all obstacles. 

I’ve seen the transformation activity directors achieve. I remember talking to a woman who had been reluctantly goaded into participating in an art activity designed to unlock memories and help seniors express what they’ve done and who they are. It changed her whole attitude, and she became an ardent evangelist for the program.

I’ve watched a tight-lipped World War II veteran be persuaded to create a collage on canvas of photos and text that revealed more about his repressed experiences than anything he’d ever said in the 75 years since he served. 

And I saw my dad’s defenses crumble when Tiffany worked her magic. 

Like gravity and Taylor Swift, great activity directors are unstoppable forces of nature that defy all opposition. When I find myself in that facility bed someday, I, too, will be powerless to resist, though I’ll probably try, heredity being what it is. I might even ask for a horse.   

Things I Think is written by Gary Tetz, a two-time national Silver Medalist and three-time regional Gold and Silver Medal winner in the Association of Business Press Editors (ASBPE) awards program, as well as an Award of Excellence honoree in the APEX Awards. He’s been amusing, inspiring, informing and sometimes befuddling long-term care readers worldwide since the end of a previous century. He is a writer and video producer for Consonus Healthcare Services in Portland, OR.

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

Have a column idea? See our submission guidelines here.

Job descriptions for activity directors in senior living usually read as follows: “Provide activities that meet the residents’ preferences and needs.” This generalist approach, sometimes guided by regulation and/or company best practices that lack benchmarks and standards, can lead to difficulty in the implementation and measurement of success. 

It’s understandable then that resident engagement is often viewed as “nice to have” or “fun” but not a necessity or influential when it comes to return on investment (ROI).  Do activities, or simply resident engagement, make the company money? Assisted living companies want to see a decrease in falls, longer lengths of stay, and, therefore, an increase in census that produces more revenue. Skilled nursing communities would like to stay in compliance with their regulatory requirements and, more recently, score high on their quality measures to earn a competitive 5-star rating, increase in census and improve their value-based purchasing, producing more revenue.

What if benchmarks and standards were created within resident engagement? What if quality resident engagement is shown to be correlated with better clinical and quality outcomes that foster a higher ROI? Although there have never been established benchmarks or standards within the resident engagement field, it may initially need to be optimized. But let’s try to move towards this goal in order to prove that activities are more than just “nice to have” or “fun” but “clinically necessary” and essential to the overall resident experience.

Let’s start with a familiar, yet perhaps underutilized, standard process in the activity/recreational therapy field called APIE: Assessment, Plan, Implement and Evaluate. Person-centered care is based on individuality, choice and incorporating the resident’s voice as the driver in their care. The standard of care that incorporates person-centered care looks like this: assessing your residents, planning their treatment, implementing their plan and then evaluating if that plan is working. 

Therefore, understanding our residents first takes a thorough evaluation in various areas of care. The assessment process is one of the critical steps in providing care to residents. What’s the value of the assessment process? How do your staff view this? Asking and finding out what the resident’s symptoms and diagnoses are, their physical and medical needs, cognition, psycho-social well-being, their preferences and needs, as well as their strengths and challenges within an assessment process can help the interdisciplinary team (IDT) start to formulate that understanding. 

Understanding our residents leads to improved clinical, quality and organizational outcomes. When staff have the resources to understand their residents, they feel competent and confident and residents are satisfied with their care. This leads to a lower rehospitalization rate and a longer length of stay, better clinical and satisfaction outcomes, and increased staff retention, which increases quality measures, reimbursement and revenue. 

“Long-term care as we see it is all about improving the quality of life for our residents, whether that’s improving their physical quality, mental quality, or a psycho-social quality – whatever function they still have, we want to help them attain or maintain the highest level of dignity and ensure they are living their fullest lives in any way possible in our range of care.” – AANAC, “The Value of the MDS” (October 24, 2017)

With each life enrichment or activity assessment that is completed, that data needs to be analyzed and a plan developed specific to that resident in order to deliver this person-centered approach. A consideration of the data points listed above should help the activity professional and IDT understand better what kind of engagement and programming is needed to provide the best quality of care. In other words, the information derived from the assessment process should formulate a plan that would include what and how much engagement is needed for each resident to help them get to their optimal level of functioning or at the very minimum, maintain their level of functioning.

Within your organization, how does that assessment information come alive? How is it used and implemented by all staff? Maybe it’s developing resident profiles, reviewing the care plans of the residents or sharing this information in meetings. Is this enough? Do all staff have access to and understand this assessment information? It’s important to take the information gathered and convert it into an actionable plan. 

For example, one can take the resident’s cognition level and functional status, at minimum, and determine the resident’s level of functioning. Then, a resident engagement regimen, or social prescription, can be developed based on that information and using empirical evidence that has proven better health outcomes in the aging senior. From there, staff can then use that actionable plan. 

The end goal is to create a system where the ‘social prescription’ is as important as a clinical or medical prescription in which a modality based on the psycho-social preference of the elder would be considered the first course of action before any type of clinical treatment including the use of medication.

Optimizing the assessment process empowers staff. They will be able to see what engagement works for each resident by understanding their unique abilities versus challenges. They will learn what kinds of engagement best meet a resident’s needs and preferences. They then should be able to determine the level of functioning and for how long that engagement is needed to be successful in improving quality of life, based on empirical evidence. 

They would then develop hands-on engagement and intervention techniques based on preferences and needs. In turn, the resident will feel better connected, safe and secure with the staff because this understanding brings about a familiarity and comfort for the resident with their care partners. 

Additionally, the resident will feel purposeful, hopeful and fulfilled. This can also stabilize or improve cognition and physical functioning. This connection can lead to better clinical, quality and organizational outcomes. The value of the assessment process lies in this ‘win, win’ for staff, residents, and the business. 

Learn more about the APIE process and stay tuned for future posts on the Plan, Implement and Evaluate processes by clicking here. 

Charles de Vilmorin is the CEO and co-founder of Linked Senior.

Jennifer Stelter, Psy.D., CDP, CADDCT, CCTP, is a clinical psychologist who specializes in dementia and mental health care. She is the co-owner and CEO of NeuroEssence, owner and CEO of The Oil Doctor, PsyD, Director of Product Research for Linked Senior, CEO of the Resident Engagement Institute, Staff Psychologist at Allow Wellness and Care Navigators, and an adjunct professor at Ivy Tech Community College. 

The opinions expressed in McKnight’s Long-Term Care News guest submissions are the author’s and are not necessarily those of McKnight’s Long-Term Care News or its editors.

So my question to you, my friends, is how can you and your life enrichment team gear yourselves and your residents up to go back to school?

There may be numerous answers to this. Let me provide a few suggestions.

• August provides a great opportunity for caregivers to schedule and do a little house cleaning. Activity teams, in particular, seem to collect supplies, decorations, costumes, crafts etc. that take up valuable storage space. I’m not saying anyone has any “hoarding” tendencies, but it seems we fear throwing old supplies and decorations out because we may need them for some future program.
• I would challenge you to look at your storage space. If you have not used a decoration or supply in at least three years, you may want to consider throwing them out and making some space. This theory could extend to offices, meeting rooms, files etc. Another benefit of doing this as a team-building exercise is that the team can reminisce about programs and events from the past together. You also discover supplies you forgot about, which in turn can help the creative process and spring new ideas that can brought to life.
• Do you partner with local universities, colleges and school districts for continuing education and lifelong learning? Many of these institutions and organizations offer continuing education programs for older adults. They may even come out to your campus for some of the programs. This is a great way to layer in educational programing while developing community partnerships that are sustainable and can impact your organization in numerous ways.
• Don’t forget your best resource: Your residents. Your residents have countless stories, experiences, travelogues etc. that they can share together as part of your programming.
• The local schools provide excellent opportunities to partner with and to have your residents interact with students in an intergenerational program that can impact both generations.

With a little creativity and embracing the time of year, your activity teams as well as your residents can start thinking about going back to school, furthering their own education and opportunities.

Michael McCann, MS, is the director of lifestyles for Friendship Senior Options. Readers with questions they would like answered in the blog for future articles can email him at at mike.mccann@myFSO.org.

So it is only natural that over time I have built great relationships with activity directors in long-term care. And I have encountered great ones, good ones and awful ones. You know great ones when you meet them and see them in action.

Great activity professionals had MDS 3.0 nailed before it was ever conceived — because great activity directors know that a great activities program revolves around the needs and wants of the individual. Great activity directors have been person-centered before the term was coined.

What great activity directors do is create experiences for residents, families and staff. And when experiences are great so is the word of mouth that results because of them.

So fast forward to 2007 when I wrote an article called The Chief Experience Officer suggesting that if word of mouth was a hospital’s most important marketing tool, then it all started with the experience that patients have with the hospital. I suggested that those experiences should not be left to chance and a hospital should hire a chief experience officer. It turns out the Cleveland Clinic liked that idea and became the first hospital in the country to hire a chief experience officer and start an “Office of Patient Experience.”

Long-term care has been slow in discovering and embracing the concept. Perhaps one way to start is to recognize that you have a chief experience officer in your midst in your activity director.

From my vantage point, I see that often times the activity director is low person on the totem poll in organizations and it is reflective in more than just their salaries. Yet the activity director is the lynchpin in your sales and marketing if you can see the forest through the trees and make that connection.

We need to elevate this profession. Maybe one simple way is to change our perspective and the title of the position. To me an activity director smacks of “The Love Boat.” (I do sing that song in facilities!) But you know what I mean. Let’s rename our activity directors and call them chief experience officers. Or if officer is too bold for you right now, start with chief experience director.

Names can often be looked at as fluff. But a significant title change could boost the morale of your activity staff and might even attract more people to the profession. And that in turn will elevate the profession and hopefully the tangible and intangible rewards that go along with it.

That is a Christmas present (“holiday present” for you politically correct folks) that would be welcome.

Anthony Cirillo, FACHE, ABC, president of Fast Forward Consulting, is a sought-after speaker, healthcare expert, elder advocate and blogger. He works with long-term care facilities in the area of resident experience and strategic marketing. Anthony is an expert guide for assisted living for about.com. He is the author of “Who Moved My Dentures?” In his spare time, he entertains residents in assisted living and nursing facilities. For more, go to www.4wardfast.com and www.anthonycirillo.com.