Sailing to Success
In the mid-1990s, 2000, and 2004, a series of decline points in the overall market share of guests needing rehabilitation services and, specifically, those requiring services related to orthopedic conditions served as a call to action for Ballard Healthcare, in Des Plaines, Illinois. In response, we developed new and distinctive clinical service lines in post-acute care for complex conditions while augmenting existing clinical services and exiting others. We also deinstitutionalized the physical environment to make it more comfortable and homelike. All of these efforts were made to continually improve outcomes and attract clients.
Yet, with the market’s continued shift toward lifestyle-driven decisions, we desired a broader, holistic approach to address the needs of active adults requiring care. Our goal was to dispel the popular notion that skilled nursing facilities were only for the chronically ill or dying. A leadership conference in April 2005 presented the cruise ship “experience” as a method of delivering high-value, high-touch customer-focused service.
Immediately, this was seen as being adaptable as a clinical therapeutic intervention—one that focuses on mobility, activity, fitness, and well-being to improve the restoration/recovery of function and community reintegration, and/or minimize the rate of decline/loss of function (see figure on page 28). In incorporating all of these elements, the experience would address all of a guest’s physical, social, cognitive, and emotional needs to enhance function, independence, and quality of life.
Consequently, in summer 2005, Ballard launched its initiative, Passage to Discovery, to enhance its guests’ (patients’) rehabilitation outcomes and quality of life by offering virtual land and sea cruises to destinations around the country and around the world.
Passengers and “Crew”
We designed this “travel” initiative with a twofold purpose: (1) to improve rehabilitation and quality of life for our guests and (2) to educate our staff about the “soft” non-clinical mechanism of the service culture.
Passengers. Cruises consistently average nearly 50 guests, starting with 45 guests aboard the maiden “voyage” down the Mississippi from St. Louis to Memphis and on to New Orleans, and peaking with 65 on a trip to the Congo seven months into the initiative. Participants are active adults (active in that they are generally ambulatory, although most are still in need of wheelchairs or other assistance) who are cared for on either a short- or long-stay basis. Short-stay (SS) guests are those who reside in the building for less than two consecutive quarters. Overall, the average length of stay for SS guests is 22 days, with more than 20% having less than 14-day stays. Long-stay (LS) guests have called Ballard home for an extended period. Throughout their stay, SS guests typically have fewer than 10 opportunities to take a cruise. Obviously, LS guests have more opportunities to “travel.”
Crew. Ballard staff at all levels and in all areas are involved with the Passage to Discovery program. We expect managers to participate regularly, along with a cross section of staff—51% of staff (representing approximately 125 staff members) have been involved with at least one cruise in the past year.
Each event is organized and coordinated by the “cruise director,” activity director, and their supervisor, the assistant administrator. The “captain” of every cruise is Ballard’s executive director, who sets the tone by exemplifying how staff members are to serve guests at all times. To demonstrate that no one is too important to participate as an actor, all senior leaders don costumes as the ship’s officers or act as servers, transporters, dining room hosts, or photographer assistants. No role is viewed as higher or lower in importance; achieving the desired guest experience is the focus. Other cruise roles include tour guide, photographer, server, bartender, and safety officer. Because this is such an enjoyable and rewarding program for both guests and staff, many staff members invite their families and friends to join the cast. When we featured Nigeria, for example, staff members and their friends replicated a tribal wedding, complete with a native village, traditional clothing, authentic ceremonial dances, and drumming and instrumentation.
Before Setting Sail
Our cruise experience is evocative of The Love Boat TV series, where guests have a fun, lighthearted, socially engaging vacation, shaped by the help of a friendly, attentive crew.
Guests and their family/friends board the ship every other Thursday. We chose this day so weekend visitors would not distract the staff’s focus of providing our SS and LS guests a full cruise experience.
The days before the cruise are filled with a variety of activities reflecting the culture, cuisine, and customs of the featured destination. These include arts and crafts projects or, as when we went to Italy, a day sampling regional foods and listening to Italian operas.
Before beginning the adventure, cruise staff review all aspects of the day’s activities and assignments, and are briefed on any necessary guest precautions.
The Cruise Experience
All cruises start with a guest’s picture with the captain. Visiting family members are included, too. When embarking on the virtual excursion, guests travel to an area(s) of the building where a “stage set” depicts one or more points of interest in the geographical area visited. As the guests arrive, they are greeted by a tour guide who explains the country’s history, topography, culture, economy, and more.
The first Passage to Discovery sailed to Gdansk, Poland, and comprised management staff only as a training exercise to demonstrate what was intended and, if possible, the use of this concept as a clinical intervention. When participants arrived “onstage,” they smelled the salty sea air and enjoyed local beverages and herring. They heard about the city’s importance as a seaport and the historical impact of the worker’s strike at the Gdansk shipyards. Elsewhere in the city, guests could shop for jewelry and art representing the style of Polish artisans.
The rollout cruise for guests—the trip down the Mississippi to the French Quarter in New Orleans—included stops at the St. Louis Arch and Graceland in Memphis for a tour, a virtual Elvis concert, and shopping for Elvis’s “super souvenirs.”
The grand finale of this and every cruise features the food (and aromas), beverages, and music of the destination. In this case, guests visited restaurant storefronts for food from three world-famous French Quarter eateries, including Café du Monde, where guests enjoyed chicory coffee and deep-fried beignets as they listened to Dixieland jazz. While enjoying native food and drink, guests can join in the singing and move to the music. Some guests even get up and dance. Ballard works with local talent and staff (when possible) to provide the entertainment.
When the guests return “home,” they share memories and photographs of their fun-filled, educational, active trip. Since that first voyage, Passage to Discovery has transported its guests to nearly 50 locations across every continent except Antarctica.
While the majority of the Passage to Discovery program cost represents additional incremental expense, much of it is non-variable recurring expense (specifically new labor). Cruise day costs include set construction, decorations, and entertainment. Other associated costs include staff expense for room setup, guest transportation (moving large numbers of guests at varying functional levels around the building in a short time frame), table service at dinner, and the extra staff needed to handle a large party event.
Our goal in implementing Passage to Discovery is to improve rehabilitation and quality of life—specifically, measurable therapy and community reintegration outcomes, along with measures indicating that guests are able to enjoy an enhanced quality of life.
We weighed rehabilitation and quality of life for our population before and after the initiative launch against the nationally published and comparable Quality Indicators/Quality Measures (QIs/QMs) score derived from Minimum Data Set (MDS) survey data and activities of daily living (ADL) scores—a standard accepted measure to evaluate rehabilitation progress.
Originally, performance measurement focused on operational execution. Now, the process combines operational performance and clinical outcomes. Working with our partner eHealth Data Solutions (eHDS) for data compilation/reporting and statistical analysis, we extracted data from our MDS survey database (and comparable regional and national data) using the company’s CareWatch tool to measure clinical outcomes. The MDS data are collected as part of the federally mandated process for clinical assessment of all residents in Medicare- or Medicaid-certified nursing homes. This process provides a comprehensive assessment of each resident’s functional capabilities and helps nursing home staff identify health problems.
Theresa Schmidt from eHDS developed the indices below, among others, from the MDS tool to indicate outcomes improvement related to rehab function, community reintegration, and quality of life of residents experiencing the “tours.” We measured:
Social engagement. We constructed a Social Engagement Index (SEI) from section F1a–f of the MDS 2.0. The SEI is an accepted indicator of time spent in social activities, as described by interRAI (https://www.interrai.org). It includes sense of initiative/involvement with others, planned activities, self-initiated activities, establishes personal goals, facility life, and accepts invitations. Social engagement is measured from 0–6, with 6 being the most socially engaged.
Depression. We constructed a Depression Index based on the Depression Rating Scale, which consists of items from section E1 of the MDS. This scale is associated with the DSM-IV major and minor depression diagnoses. Suggested items are: made negative statements; persistent anger with self or others; expressions (including nonverbal) of what appear to be unrealistic fears; repetitive health complaints; repetitive complaints/concerns unrelated to health; sad, pained, or worried facial expressions; and crying and tearfulness. Because of the social nature of the cruise experience, we added reduced social interaction. Depression Index scores range from 0–18, with 18 being the most depressed.
Cognition. The Cognitive Performance Scale (CPS) “…combines information on memory impairment, level of consciousness, and executive function.” Scores range from 0 (intact) to 6 (very serious impairment).
In sum, data were collected for 631 guests in 2006 (625 assessments), 147 SS guests in 2005, and 140 guests present in both 2005 and 2006 (this number is included within the 631 total).
On the Monday following the cruise, the planning team meets in a rapid-cycle PDCA (Plan-Do-Check-Act) quality management process to assess the operational, safety, and experiential aspects of the activity. Data for each cruise are obtained from or reported by the cruise director and others at the PDCA session. Notes from these meetings capture information, and adjustments are made for future progress.
In the PDCA sessions, opening discussions center on team members’ observations of the event. Analysis then focuses on three key topic areas—operational execution, guest safety, and the overall experience. In each area, the team analyzes the success of previously implemented changes and plans the implementation of new refinements. All discussions and decisions are measured by key indicators: Will the change drive participation by guests at all risk levels? Will these changes enhance the “experience” to improve engagement and socialization? Do the changes promote guests’ function and independence?
In relation to the analysis of MDS data, we observed significant findings facility-wide and in the SS and LS populations.
While overall resident acuity (as measured by RUG-44 case mix) has continued to increase in this same period because of the specific business focus on caring for significantly more complex conditions, such as dialysis and ventilator cases, meaningful improvements in clinical condition were experienced. Among the findings:
QI/QM 1.2 Falls have diminished
7.1 Weight Loss has decreased for four consecutive quarters
9.4 Range of Motion and 11.2 Little or No Physical Activity have moved in positive directions similar to the weight loss findings
9.3 Mobility Worse and 13.2 SS Pain also saw improvement in 2006
Passage to Discovery has had a palpable impact on SS guests, who are often discharged and readmitted, because it encourages their integration into facility life. Other guests, because of their conditions, may only be in the facility for a short period and purposely try to remain disengaged. Among the findings:
SS guests attended, on average, 13% of cruise opportunities. The average number of opportunities available to all SS guests was 1.8.
SS guests who participated more than 50% of the time had greater levels of Social Engagement and Engagement in the Life of the Facility.
The average ADL score for High Participators (those who took advantage of 50% or more opportunities to participate) was 9.74 (out of 18), while the score for Low Participators was 11.94, a difference that is statistically significant (F = 10.51, p < 0 .01).
77% of Low Participators triggered QI/QM 9+ Medications versus 58% of High Participators, also significant.
Compared with 2005 data, use of Antipsychotic, Antianxiety, and Frequent Hypnotic fell to lower levels than in 2006. While the results were not statistically significant, they indicate a causal relationship between the 2006 cruises and the significantly lower levels of 9+ Medications for High Participators.
Because of the greater opportunity for participation in Passage to Discovery, LS guests experienced greater benefit from the program than SS guests. LS guests who attended more cruises had lower ADL scores, fewer QIs/QMs, and higher levels of social engagement. Among the findings:
On average, LS guests had 17.41 opportunities to attend cruises.
From 2005 to 2006, Low Participators increased their ADL scores, while High Participators decreased their ADL scores.
High Participators were also significantly less likely to trigger QI/QM 7.1 Weight Loss.
Antianxiety medication use was also significantly lower for High Participants.
Improvements for the program are planned in PDCA sessions. Often a pilot will be tested with one group on a cruise and then analyzed for its benefits or the need for refinements before widespread implementation. Some key recent adaptations were:
Costumes are mandatory for all cast members.
Staff offer varied beverages and more diabetic choices.
The cruise director holds a pre-cruise meeting to review “crew” assignments.
Staff are recruited and encouraged to help plan trips to their ancestral homelands.
The dining room host seats guests with respiratory concerns in a more staff- accessible place.
A guest name tag system helps identify dietary needs, allowing non-clinical personnel to assist in serving meals.
A final measure of the program’s impact: During the time frame of the MDS data study, the only major organizational change other than the planned increase in acuity of SS guests was the Passage to Discovery initiative. In that the evidence that High Participators did better than Low Participators in the same time frame as the increase in acuity, we believe this strongly supports the relationship between the program improvements and observed changes in the data. We have formed a steering team that includes physicians to suggest further enhancements that might improve scores for all participants and further engage nonparticipants. The work of this group will be enhanced by the recent awarding of an Illinois Department of Public Health Innovations in Long Term Care grant to further analyze and promulgate the results of the program, as well as to support other organizations’ efforts to replicate the model.
That the changes in MDS scores are relevant to resident care goals—improved function, independence, and quality of life—is easily witnessed. This is most concretely seen in qualitative ways—increases in hairstyling, makeup, and “dressing up” for the event, the obvious social bonding experiences of guests, and other positive and clinically significant behaviors, such as increased appetite on cruise day.
PDCA sessions remain an integral part of the initiative. However, the MDS measures will become the key indicator of success because of their ability to demonstrate specific, clear clinical impacts, and these assessments will become an element of quarterly reporting and monitoring at monthly medical advisories/organizational leadership meetings.
Overall Results (and Surprises)
The immersion cruise experience Passage to Discovery has clearly met our goals and exceeded our expectations. We expected to see greater socialization, but not at the level displayed in some groups, in which SS and LS guests began eating and relaxing together throughout the SS guests’ stays. This socially, economically, and culturally diverse group went beyond “roommate” and “tablemate” associations.
The other surprise revolved around staff. As we discussed the destinations, staff suggested outings to their various homelands and were eager to participate. We did not anticipate the level of staff enthusiasm and excitement. The real surprise, however, was the change in attitude and feelings about those from other cultures. For example, when sharing wedding experiences in Nigeria and India, guests and staff began to relate to each other not as those from a foreign land who speak an unfamiliar language and are difficult to understand, but simply as people. Barriers are broken down. Fundamentally, the demystifying of foreign cultures increases trust between staff and guests, yielding better outcomes as guests feel better about their situations, their surroundings, and the people there to help them.
Guests show strong and growing behaviors from being engaged in the cruises instead of becoming bored with them. These behaviors include attending pre-cruise activities. In an interview, one resident’s visiting family member noted that “…[Mom] especially enjoyed the lesson on using chopsticks. She said everyone kept dropping their food on the floor and they were all laughing so hard they were crying.”
While seemingly a quaint qualitative story, this is of great significance and a reason for further study through the Illinois Department of Public Health grant and a reason for replication by others. The importance lies in the fact that the MDS only captures crying as representing sad or negative feelings, whereas this program demonstrates that positive social and emotional elements have a positive effect on guests and improve their health status. This reveals public policy implications related to MDS design and potential bias toward capturing only negative indicators.
Helping Others Move Forward
The principles of Ballard’s Passage to Discovery initiative are easily replicated. The benefits are rooted in the substance of the initiative, not the form it takes. Although we have chosen a cruise ship experience, this idea can be adapted to any vehicle that incorporates the following elements that yield the outcomes desired, as long as they are delivered consistently over time:
Movement and activity must increase function and/or retard decline, and social interaction should revolve around a common experience (cruise, railroad trip, visiting museums around the world, etc.) that is stimulating, festive, and thought-provoking. Include uniforms, costumes, and stage sets to add realism while allowing the imagination to fill the gaps.
The theme must be outside the realm of routine experience within the facility. It can be urban or rural, elaborate or simple in style and approach, yet it must be within the realm of possibility so it is not trivialized as fantasy and becomes ineffective.
Establish a rhythm to the event. Cruises every other week allow time for guests to prepare for the next event and share their experience afterward.
Events should safeguard for various risks factors and functional limitations, such as choking, aspiration, and visual impairment. Yet, of prime importance, the guest’s experience should not be compromised. Guests should be served in a manner that appears the same for everyone else to avoid embarrassment or discomfort.
Normalize the guests’ experience by ensuring that individual function/clinical implications are accommodated seamlessly and in a way unnoticed by others.
By incorporating the principles on which Passage to Discovery is designed, any organization can replicate the outcomes and achieve a high level of excitement, along with clinical, social, and psychological benefits.
For more information, contact Christopher Looby, Marketing Director, or Eli Pick, Executive Director, Ballard Healthcare, at (847) 294-2300. To send your comments to the editors, please e-mail firstname.lastname@example.org.
Passage to Discovery Development Team
Andrew Rzaca, Cruise Director
Eli Pick, Executive Director
Nancy Rodriguez, Assistant Administrator, Operations
Sue Ahlgren, RN, MSN, Clinical Administrator
Teresa Arcos, Manager, Culinary Services
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