Since 1996, Long-Term Living has been honoring long-term care facilities that are proactive with programs that go “above and beyond” routine care for their residents with our prestigious OPTIMA Award. It is conferred by a jury of your long-term care peers from submitted entries. This year’s winner is Rolling Fields, a nursing and independent living facility in Conneautville, Pennsylvania. A snowstorm was the impetus to change the facility’s culture forever by instituting 24-hour dining. As the owners say, the change affected every aspect of the 181-bed facility in northwestern Pennsylvania. “We knew we had to just jump off the cliff and do it,” says co-owner Kim Moody. What resulted is truly an amazing transformation that revolves around resident choice and a dissolution of regimen. The change has improved morale among staff, residents, and their families, as well as improved the health and physical and mental well-being for residents.

Our congratulations to this year’s winner for all the hard work, inspired ideas, and commitment to make a positive change every day in every elder’s life. Information on entering next year’s OPTIMA Award competition will be in the February 2010 issue.

For Kim Moody, passing out a breakfast tray was an epiphany that changed every facet of the nursing home she owns with her sister, Cindy Godfrey, and her mother, Marlene Braham, who is now retired. It was a snowy morning in Conneautville, Pennsylvania, a rural town in the northwestern part of the state. The staff at Rolling Fields, a 181-bed nursing and independent living facility, had a hard time getting to work because of the weather. The breakfast trays were ready, but there weren’t enough employees to deliver them, so a call went out to management to help.

“I remember going into one elder’s room with a tray,” Moody, who at the time was administrator, recalls. “She was sound asleep, mouth wide open, and snoring. I thought, ‘This is crazy! I can’t wake her up to eat.’ It was an amazing revelation to me. Everything we did was revolving around meals. The answer was to get rid of our tray delivery service and offer 24-hour dining.”

As Moody says, since that decision, “our whole world has changed.” The project has gone much further than food. It has transformed the Rolling Fields’ culture change journey. Everything that is done now at Rolling Fields is based on elder choice and creating a feeling of home. “All regimen is gone,” Moody says.

The journey begins

The sisters say they had no idea at the outset of this major change, all that it would entail. “It touched absolutely every aspect of living,” Godfrey says. The first thing they did was ask for volunteers to start discussing the idea of 24-hour dining. Thirty employees signed up. On August 17, 2007, the group “jumped off the cliff” as Moody describes it. “There was no easy way. We just had to jump in and try our best.” The two-hour weekly meetings to get the project under way were dubbed “JUMP” meetings. They decided on using one of the “streets” in the home as a pilot project for two months. In October 2007, another street “jumped” and the entire house jumped in December 2008.

One of the largest changes was not with food or delivery. It was with reframing people’s jobs. “We no longer had what we called LPNs, or housekeepers, hospitality assistants, or CNAs. Everyone is now a caregiver or certified caregiver and is expected to do whatever the elders need done, whether that is to order food, help them with dining, keep their living area clean, help them choose a paint color for their room. Everyone is empowered.” These caregivers are the backbone of the program’s success. Fifteen to 20 caregivers are assigned to a street in a 24-hour period. Once the pilot project was successfully completed, the rollout continued to the other five streets with 30 elders each.

Moody and Godfrey consulted several area chefs to help them transform Rolling Field’s institutional kitchen into a restaurant kitchen. “They helped us determine what equipment we needed, what equipment we currently had that we did not need, and what the best way would be to set up the kitchen,” Godfrey says. The kitchen had to be reconfigured from an institutional kitchen to a restaurant-style kitchen. Certain appliances, like a charbroiler, are being leased. The pantries in the home were changed to include coffee, cereal, juice, and other snack items for the elders whenever they’d like to partake. New servingware was ordered and over-the-bed table linens are used for a more “room service” feel for those elders who choose to eat in their room. A POS system was specifically designed by Micros and was installed for ordering food.

Menu selection was also a lengthy process. Godfrey, along with the home’s culinary staff and dietician Allyson DeVantier, worked by interviewing elders about their likes and dislikes. Once the interviews were completed, a 24-hour menu was developed. The menu was modified at least twice during the pilot project based on likes and dislikes. When developing the 24-hour menu, ease of cooking, speed of cooking, and ease of holding were also considered, the sisters say.

Twenty-four hour dining afforded Rolling Fields an opportunity to offer its elders a more dignified dining experience. Now, caregivers can offer room service with one-on-one assistance with eating to the elders who needed it. According to Godfrey and Moody, this is where the staff transformation to caregivers really helped. “Our elders are no longer rushed [to eat their meals],” Moody says.

The culture change fueled by the 24-hour dining touched everything. Moody describes getting rid of regulatory roadblocks such as having the toilet brush next to the toilet in the resident’s room; not locked in a closet. “You keep the toilet brush in your home next to the toilet, so why not here as well?” The supply closets were left unlocked, except for the chemicals. Those are locked, but the key is accessible to anyone who needs it. “A caregiver needs to be able to wipe down an over-the-bed table, or clean up a spill on the floor.” They have bleach wipes that are antimicrobial to wipe things off.

Other nursing home “standards” were changed. There are no med carts or linen carts. Instead, the med carts look like regular furniture. Orders for medicine now read, “upon rising” instead of “8 a.m.”

Changing mindsets

The sisters agree the hardest part of Rolling Fields transition to 24-hour dining was not changes in the physical plant, although there were many, but changing firmly entrenched mindsets of “this is how we’ve always done it.” “We lost some of our staff, because they did not want to become caregivers,” Godfrey says. “Change is hard and some were not willing to do it. Now we find potential employees coming to us because they’ve heard about what we’re doing and buy into the idea.” Many of Rolling Fields’ staff have been at the home for more than 20 years.

The staff says 24-hour dining and all the changes it produced have had a huge impact on quality of life for every elder. They now may choose exactly what and when they want to eat. They can sleep in if they wish and are able to maintain the same daily routine as they had at home. Physical health has improved. The number of elders eating a puréed diet was reduced from 30 people to seven because of the selection of food available and because there is time for one-on-one interaction while dining. Pressure ulcers have also decreased due to increased food intake and ability to choose the food they like. Residents are gaining weight, pain and behavioral issues are improving, and elder satisfaction with the entire home has improved. “Our care plan meetings and elder council meetings no longer revolve around food issues,” Godfrey says. “In fact, at our annual state survey in May, there were no elder complaints about food.” The surveyors who stayed for lunch even complimented the food!

There has been such a demand for meals that sales to staff and family have gone from $2,000 per month to $6,400 per month. There has been such a demand for families to eat with their elder, Rolling Fields has hired a hostess to seat and take reservations. Some family members were even coming without their elder to eat. “This was happening so often we had to put up some parameters to limit family members to only eating when accompanied by their elder,” Moody says.

Cost

Moody says she’s very lucky that the only board of directors she has to deal with when planning improvements to Rolling Fields is her mother and sister. For this project, local contractors were used, saving on renovation costs. Godfrey was in charge of dining room renovations and Moody took on general contractor responsibilities, also saving money. “We were smart about the money,” Moody says. “When we want to make an investment in something we truly believe in, we are able to do it. To go from institutional dining to 24-hour dining cost about $200,000 total, including the renovation of four of the home’s kitchenettes. We spend about $50,000 of that leasing kitchen equipment.”

She says the return they’re getting is shown in improved census, turnover has improved, food waste is down, and elders who couldn’t eat large amounts of food can now eat small meals several times a day choosing what they want to eat and are gaining weight.

On winning OPTIMA

The sisters say they never thought their efforts to institute 24-hour dining would change the very fabric of Rolling Fields, let alone win Long-Term Living‘s OPTIMA Award. Their staff entered the competition as a surprise for the sisters. Winning was the icing on the cake for a culture change journey that started on that snowy February day in 2007 when staff couldn’t get to work to pass out breakfast trays.

“We’re very humbled and honored that Long-Term Living would recognize and appreciate what we’re doing up here in little Conneautville, Pennsylvania,” Godfrey says. “It’s important for us in winning this award that we are getting the word out to other homes. Kim and I would like to see 24-hour-dining and its resulting culture changes for every elder. It can be done and we’re just hopeful we can spread the word. We also want to thank our Leadership Team for its dedication and hard work, because without them we could never do it.”

“While it was Cindy’s and my vision, we wouldn’t have been successful without the encouragement and support of the staff. We’re very fortunate,” Moody says.