Engaged and transformed

Caregiver Laura Spain is able to spend one-on-one time with a resident while two other residents enjoy viewing a DVD together.

Step inside the 600 Hall at St. Leonard Franciscan Living Community in Dayton, Ohio, and you’ll witness a scene like no other. The hall, which is dedicated to the care of 18 residents with Alzheimer’s and dementia, is often quiet and the demeanor of its residents is rather calm. All around the community sit residents actively engaged in their own individualized activity: One is wearing headphones and listening to music reminiscent of his or her past while another is flipping through a worn hobby book with a visiting family member.

This wasn’t always the picture. Just a year ago St. Leonard was faced with the same challenges that all continuing care retirement communities have when it comes to Alzheimer’s and dementia care. The disease’s unpredictable patterns were causing patients to become easily agitated and caregivers mentally and physically exhausted.

Sisters Cindy Copas and Fran Schlegel visit with their father Eugene Miller, a former pilot. A book about airplanes helps create a way of communication.

At the time, resident engagement activities were carried out in group settings, and when caregivers did offer something one-on-one it was often with a magazine or game that was chosen with no specific personality in mind. As a result, residents would become disengaged and bored, creating opportunities for unhealthy behaviors such as anger, roaming, rummaging, and increased falls.

Those familiar scenarios, however, quickly changed when Dayton’s Wright State University Professor Dr. Govind Bharwani and his daughter Meena combined their knowledge of ergonomics with their healthcare experience to create the first Behavior-Based Ergonomics Therapy (BBET) program. This special program prevents the two main causes of behavioral problems in residents with Alzheimer’s or dementia-boredom and disengagement-and gives caregivers the tools they need to proactively stop them from happening.

The BBET program has transformed the way St. Leonard residents spend their days and the way their caregivers and family members are able to communicate with them. In less than a year, the community’s 600 Hall has seen incredible results from the program including a 35% reduction in falls, a 70% decrease in anti-anxiety medication usage, and increased quality of one-on-one time between residents and caregivers.

“It is a unique approach to healthcare that came from somebody looking at our industry from a new perspective,” says Tim Dressman, executive director of St. Leonard. “Now our staff is happier than I have ever seen them before because they’re able to spend more time interacting with residents in a way that is individually meaningful.”


Ergonomics is synonymous with workplace safety and each year companies employ consultants in an effort to create environments that prevent injuries and avoid long-term disabilities. This was the mind-set when Dr. Bharwani was first employed at St. Leonard.

“Therapy Library”: Meena and Govind Bharwani in the new resource area created for St. Leonard’s Adult Day Services program, Day Away.
Music CDs are cataloged and labeled for easy access by caregivers.
Stimulating activities are coded and then cataloged on a shelf in the BBET resource room.
“St. Leonard Knitting”: BBET DVDs in the resource room in 600 Hall are carefully cataloged.

As an independent ergonomics consultant and co-director of ergonomics at the College of Engineering at Wright State University, Dr. Bharwani had worked with more than 100 companies on improving their workplace environments. However, his passion for long-term care-and his position as director of Nursing Ergonomics and Alzheimer Care at Nursing Institute of West Central Ohio-caused him to look at St. Leonard’s Alzheimer’s and dementia care in a whole new light.

He knew the issues facing the Alzheimer’s and dementia unit were unique to the community’s other areas. With St. Leonard’s blessing, Dr. Bharwani and Meena began researching how they could employ the core principle of ergonomics-the reduction of stress-in the 600 Hall.

The Bharwanis visited various Alzheimer’s care units across Ohio and found one common thread: Caregivers lacked the right resources needed to calm and soothe residents according to their specific needs. Most centers only knew how to engage residents in group settings, which often met the need of only 20% of the participants.

After months of research, Dr. Bharwani and Meena created BBET. The goal of this systematic program is to help reduce cognitive (mental) stress on residents with Alzheimer’s and dementia by using customized comforting and stimulating interventions. The Bharwanis created a resource center in 600 Hall to provide caregivers with the tools required to meet the needs of each resident according to his or her individual learning style, personality, and behavior profile, as well as cognitive skill level.

The specialized center contains portable CD and DVD players, individual headphones, and four types of libraries including resident memory prop boxes, a DVD library, music library, and a cognitive-stimulating library of games and puzzles tailored to residents with Alzheimer’s. Each library item is carefully coded and a BBET action plan is created for each resident by listing the appropriate codes.

Each resident also has a memory prop box that contains comforting items from his or her past such as family photo albums, hobby magazines, and other memorabilia. The DVD library contains documentaries, sports, and hobbies that fit the individual resident’s personality profile. The CD library is intended to do the same through music intervention.

Music and movies are tools caregivers have tried in Alzheimer’s and dementia units, but what makes the Bharwanis’ method unique is the way in which it is organized. In a matter of minutes, caregivers can identify a resident need, walk into the resource center, read the resident’s BBET action codes, and select the appropriate intervention at that particular time.

Unlike scheduled group activities, the BBET is available to caregivers 24 hours a day and can be used by family members when they visit. In that way, residents’ needs are met when and how they need it. Most importantly, interventions can take place in a timely manner, curbing certain behaviors that cause stress on the individual or the unit as a whole.


The initial plan was to roll out the BBET over a six-week period, adding three residents to the program each week. However, the caregivers were so amazed at the results that they pushed to have all the residents in the program just 11 days after its implementation.

Within six months, the caregivers had reached their goal of providing 1,000 interventions and 600 hours of BBET contact time with the 18 residents. That number has only increased each month since, totaling 3,000 interventions and 2,000 hours of contact over the past year. “There’s a greater story behind those numbers,” says Meena Bharwani, consultant and graduate of MIT and Cornell University. “It means 2,000 less hours that a resident may be roaming a hall or sitting alone in his or her room. It also means 2,000 more hours that caregivers are providing emotional care instead of trying to control common behavioral issues.”

Tim Dressman
Govind Bharwani
Meena Bharwani

Perhaps the best part of BBET is its low start-up cost. The program was implemented using existing staff, space, and supplies. Most items added to the resource room and libraries were donated by staff or families. Nursing assistants were placed into four different roles-focused on caregiver training, education, data, and inventory coordination-to help implement and carry out the program in a seamless manner.

All caregivers undergo four hours of training and at the end are empowered with the tools they need to ease agitated residents and aid those often withdrawn. “I have a resident who goes down for a nap in the afternoon and used to just stare at the ceiling,” says Laura Spain, a nursing assistant who has worked in the unit for 10 years. “Now, I can put headphones on her (with music she likes) and she is asleep in 10 minutes.”

The BBET program has also changed the way family members are able to relate to their loved ones. A grandson, who used to resist his mom’s suggestions to visit his grandfather, now comes on his own because, he said, the BBET tools make it less intimidating.

The uses of BBET are limitless. St. Leonard is in the process of implementing it into several other areas of its community including its skilled nursing, assisted living, adult day services program, and its new memory support center. The BBET is also gaining national attention. In the past two months, it has received two national awards and Dr. Bharwani has been approached by other healthcare institutions that want to use it.

Meanwhile, Dr. Bharwani has established a research team at Wright State University in collaboration with the university’s Department of Geriatrics in the School of Medicine and the College of Engineering, the Nursing Institute of West Central Ohio, and the Alzheimer Association (Miami Valley Chapter).

“Facilities often focus their efforts on regulations, but St. Leonard was willing to think outside the box and allow us to find an innovative way to improve the quality of care and life of their residents,” Dr. Bharwani says. “Because of that, they have set the stage for how I believe Alzheimer’s care and therapy will soon be done throughout the nation.” LTL

Julie Thompson is a freelance writer based in Dayton, Ohio. Long-Term Living 2011 March;60(3):49-51

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