Nursing home culture improves life quality

Changes cut drug use, improve staff performance

The name calls up images of sun-dappled walkways through groves of trees and shrubs. And though The Arboretum of San Marcos (TX) is situated among trees, it also houses 104 residents with various types of dementia, a menagerie of animals, and a professional long-term care staff.

The animals "make you forget what this place used to be like," explains Mary Kincaid, The Arboretum's activity director and life enrichment coordinator.

Complaining used to be the residents' main pastime, she remembers. Lost laundry, bad food, or impatient caregivers - anything was fair game. But the complaints were symptoms of the loneliness, boredom, and hopelessness that haunt many long-term care residents.

All of that changed two years ago when administrator Nancy Fox introduced the Eden Alternative. Eden, based in Sherburne, NY, teaches a philosophy originated by William Thomas, MD. It trains caregivers to restore a sense of community and purpose in nursing homes. Thomas says that Eden remakes institutions into human habitats. Remarking on the professional growth of the staff, as well as the differences in residents' behaviors, Fox notes, "I'm surprised how much this has impacted all our lives."

Animals, patients share quarters

Well-loved animals are an important dimension of the Eden Alternative's human habitat. The current census includes 50 birds, 12 cats, three dogs, three rabbits, and four hamsters, plus dozens of fish in three fish tanks. During the day, all but the fish roam freely. The few residents who would rather not associate with pets are given water guns to convey their wishes to the animals. At night, cockatiels and finches leave their perches on residents' shoulders or the nurses' desks and return to their cages. Cats sleep with their favorite residents.

The impact on residents is clear from the diminished incidence of "wandering," typical of dementia sufferers as they search for a person or place from their dimly remembered past. The wander-guard alarm system used to go off 15 to 20 times each shift, causing five or six staff to race off to redirect the meandering resident's focus.

With the new opportunities for patients to be stewards and companions to the animals, Fox says, "We've created a [home atmosphere] for the residents here, and they're not searching for it. The alarm doesn't go off much anymore unless a resident is waiting to greet someone at the door." When the project started, 26% of The Arboretum's residents were restrained. That number has dropped by 18%. (See graph on residents who are restrained, above.)

More telling than the statistics, however, is Kincaid's story about the woman with Alzheimer's disease who fought fiercely every time she needed a shampoo or haircut. Now it's no trouble at all. Holding a cat or dog, the lady who's incoherent most days relaxes and croons "I love you" to the animal.

"We don't reach everyone, but we do reach most of our residents," Kincaid notes. "Many of the people who once complained about everything are now running up to tell me what happened with the animals. They have a purpose. They'll fight for their animals any day."

Community supports change

A local foundation underwrote the environmental transformation with a $50,000 grant. The facility got a new coat of paint, outdoor benches, and trees and shrubs. The animals cost virtually nothing because the community donates most of them. "The community wanted this [change] to happen as much as we did, so they help us," Kincaid explains. One particularly generous gift is a local veterinarian's donation of a full year's veterinary care.

Together with volunteers, the residents themselves look after the animals' daily needs. A "birdmobile" holds the food, water, and brushes for the winged residents. Twice a month, youth groups come in to scrub down the bird cages. The rest of the time when school children come. "I don't structure their visits," Kincaid says. They might help residents care for the animals, and they might just visit. "It's the moment we're reaching for," Kincaid notes.

Not all the residents' families accepted the change without question. Afraid the animals would transmit diseases, one group reported their fears to the local social services department that pays the bills for the home's 66 Medicaid recipients.

So Kincaid invited the Medicaid inspectors to check the animals, showing a care plan for each. Finding no evidence of flees or disease, the inspectors sent the families a report to that effect. Nevertheless, Kincaid says the surest antidote to familial worries is seeing how their loved ones thrive at The Arboretum.

As The Arboretum's residents get involved with their pets, they require fewer medications. Today, for instance, the number of people who take five or more drugs daily is 39% lower than two years ago. (See medication graph, p. 113.) Additionally, Fox notes, the use of PRN (as needed) anti-psychotic drugs dropped by 90%.

As life improves at the nursing home, more families see it as a good choice when their loved ones need long-term care. From an average census of 80 people when the Eden transition began, the home now has 104 residents and a waiting list. But instead of automatically accepting every applicant, the staff reviews each one with an eye toward how - or whether - The Arboretum is the best environment for that person's needs. In the process, some are referred to other facilities.

Patients live instead of waiting to die

Here's how Fox compares The Arboretum to its more conventional counterparts: "In the medical model, people sit and wait for their meals, meds, baths. And they wait to die. Here they are living."

Any long-term caregiver will agree that nursing homes could be better, but when better care means retooling your training from the ground up, it's enough to give anyone pause. Yet that's exactly what The Arboretum's staff had to do in order to shift into the Eden paradigm.

"Nurses are trained to fix people," Kincaid notes. "It's not in their train of thought to let people go for a walk outside alone or shave themselves. But we had to give those things back if they could do them. We wouldn't change it now for the world, but when we started, we didn't know that we were in for a huge journey."

Bringing staff up to speed involved two- to four-hour orientations to the Eden Alternative. This included personality assessments and discussions of how employees' personalities blend or clash with each other. The Arboretum staff meet quarterly with staff from five to seven other long-term care homes in Texas to exchange learning and share emotional support.

Everyday "we reinforce the positive changes people make instead of criticizing the negatives," Kincaid says. The certified nursing assistants now care for the same group of residents everyday and developing abiding relationships. "The staff make their work schedules and speak up for their residents' needs," she observes. "The Eden approach empowers everybody."

For Fox, the biggest surprise of the past two years has been staff growth, both as individuals and as a team. "Our people continue to surprise me in how much they care about these residents and how much they are willing to do for them. In the past, when they had an issue with another staff person, they would get angry and stay angry until someone left. Now, they have ways to solve these things."