Top 10 clinical innovations in LTC
Clinical innovations in long-term care might bring to mind invasive procedures and/or pharmaceutical interventions. At least that’s how it used to be. According to the experts, innovations in the now second decade of the 2000s, by and large, lean more toward non-invasive means and a “person-centered” model.
The term person-centered is tossed about quite a bit, but a closer look reveals that the phrase has emergent significance. “An overarching philosophy of person-centered care has been around for a while, but is now being implemented in more creative ways,” says Elizabeth Gould, MSW, project director at the Alzheimer’s Association. “There is a mind shift from managing the behavior to understanding the behavior.”
As you’ll see, person-centered care is involved in just about every entry on this list. And most-though certainly not all-are fairly low-tech, leading one to believe that in some cases, “the more things change, the more they stay the same.”
“Developments in dementia care are driven by increasing public awareness of the enormous increase in the numbers of persons with dementia in the coming years,” says Susan D. Gilster, PhD, Fellow, and co-developer of the Alois Alzheimer Center, the nation’s first freestanding dementia care facility located in Cincinnati. “However, in relationship to the daily care of individuals with dementia in long-term and acute care, we have not made near enough progress. Despite research in the early 1990s regarding the clinical care and enriching environments for enhancing dementia care in all settings, many have not yet embraced that knowledge.”
Segregating individuals with dementia from the rest of the population, Gilster says, is just not enough. “Resident choice, living a ‘normal’ life in the confines of a residential environment, reduces issues. Decisions should be driven by ‘person before task,’ and ‘person before convenience,’ recognizing and appreciating that this [the long-term care facility] is their home.”
Here are a couple examples of innovations being integrated into contemporary dementia care settings:
TimeSlips. “Forget memory. Try imagination.” So says the t-shirt that represents TimeSlips, a storytelling program developed by the Center on Age & Community of the University of Wisconsin-Milwaukee. First implemented in 1998, it is finally hitting its stride. TimeSlips moves away from the emphasis on memory and factual reminiscence and steers residents toward creative expression via storytelling. And when the pressure’s off, the fun begins.
PARO Therapeutic Robots. Dovetailing the high and low-tech worlds is Illinois-based Passages Hospice, which is using PARO therapeutic robots for patient memory disorders. “We started with one and it worked so well we just received our fourth,” says Kaitlyn Henderson, media and communications manager of Passages Hospice, the only hospice in the country to use PARO. At first glance, PARO looks like a stuffed animal from the toy store. But it’s actually a soft, sweet-faced plush baby seal wrapped around intricate mechanics that simulate the sounds and movements of a companion animal. It even coos and purrs when a patient pets it and has been shown to help stem depression and enhance communication. Since Passages introduced PARO to its patients in August 2010, the robot is being successfully used in skilled nursing facilities throughout Illinois and Michigan. You may have even seen it featured in the Idea House at LeadingAge’s annual conference.
Telemedicine reduces travel costs related to transporting residents to and from medical appointments, but more importantly, it increases resident access to doctors and specialists. A particularly innovative example of telemedicine comes from the University of Iowa Hospitals & Clinics’ Department of Family Medicine, which embarked on a research project using a rollabout system that is outfitted with an electronic stethoscope, otoscope, dermascope, dental scope and EKG machine. Although no longer in use at the university, it is being used at a number of skilled nursing facilities in Spain where the rollabouts move from bedside to bedside allowing residents access to medical assessment easily and more comfortably. A computer is housed in the system, as is a videoconferencing unit and a monitor on a moveable arm so doctors, nurses and family can be part of the virtual examination.
Although the use of restraints in long-term care has been reduced considerably over the years, Beryl Goldman, director for Kendal Outreach, notes that there’s a long way to go when it comes to advancements. Kendal Outreach is a nonprofit organization offering creative solutions in healthcare. It is a subsidiary of The Kendal Corporation, which operates older adult communities in the Quaker tradition in eight states, clustered mostly in the eastern United States.
Goldman co-wrote a chapter of the book “Rights, Risks and Restraint-Free Care of Older People,” published in 2009 in both London and Philadelphia by Jessica Kingsley Publishers. The book details how to provide safer long-term care by putting older people at the center of decision making about their own well-being.
From a general perspective, “The primary lesson learned is that one size does not fit all,” says Goldman. “Only person-centered assessments and interventions can achieve sustained positive outcomes.” Goldman also emphasizes that careful assessment and meticulous follow-through are of utmost importance.
In addition, the newest research shows a possible reduction in falls-a primary reason for restraints-as a result of a combination of vitamin D therapy and exercise. An evidence review published in the December 21, 2010, issue of Annals of Internal Medicine was commissioned by the U.S. Preventive Services Task Force to help the agency update its recommendation for preventing falls in the elderly. According to the review authors, exercise and physical therapy reduced participants’ risk of falling by about 13 percent and even more impressively, researchers found that those who received vitamin D supplements were 17 percent less likely to fall than those who did not.
With advancements in sprays, gels and living bi-layered skin substitutes the rage these days, a hospital in Florida has developed a low-tech, low-cost program for wound care.
St. Vincent’s Medical Center in Jacksonville was chosen as an innovator by the U.S. Department of Health and Human Services’ Agency for Healthcare Research and Quality for the development of a comprehensive, interdisciplinary set of preventive guidelines known as SKIN. The interventions can be implemented for the prevention of pressure ulcers in all patients with a Braden score of 18 or less. The acronym stands for:
Surface (type of mattress, etc.)
Nutrition and hydration management
SKIN was shown to reduce the incidence of pressure ulcers by more than 90 percent (from 5.7 to less than 0.5 percent), and completely eliminated stage 3 and 4 facility-acquired pressure ulcers for a significant period of time. And though its roots are based in acute care, this is a program that could be replicated in an LTC setting.
Pain in nursing home residents presents its own constellation of challenges, in many cases because it is underreported. Some elders believe it is a normal part of aging. Others prefer not to take medication because of the side effects or because of their fear of dependency. Still others-those suffering from dementia-may have trouble communicating their pain and its intensity. But pain can negatively impact quality of life by causing problems with performance of activities of daily living, which could result in depression.
Barbara Resnick, PhD, president of the American Geriatrics Society, suggests that a familiar over-the-counter remedy combined with other noninvasive treatment could be the key. “Given a focus on patient-centered care, we are starting to be a bit more innovative in terms of combining behavioral and medication management interventions to treat pain,” she says. “We encourage physical activity-which is the best treatment for musculoskeletal and joint pain and stiffness-combined with acetaminophen, for example, or heat or ice prior to an activity.
“The other innovation comes in the area of dissemination with more time and resources put into disseminating guidelines for pain management, plus assessment of pain and integration of pain protocols into routine care.”
Back in October 2008, the Centers for Medicare & Medicaid Services stopped paying hospitals for eight conditions that have evidence-based prevention guidelines. Pressure sores and infections associated with catheters and coronary artery bypass grafts are among the eight. Can long-term care facilities be far behind?
This is just one small reason why infection preventionists are an increasing part of the LTC landscape. Deb Patterson Burdsall, MSN, RN-BC, CIC, is a member of the editorial review board for the Association for Professionals in Infection Control’s quarterly publication, Infection Connection focusing on long-term care. She is also the corporate infection preventionist at Lutheran Life Communities in Arlington Heights, Ill. She describes one especially important advancement in LTC infection control practices. “Private rooms in long-term care are a great innovation,” she says. “Research indicates that the infection rates for private rooms are lower. With unknown levels of persistent colonization in long-term care, it is not difficult to consider applying this research across the healthcare continuum.
“Multidrug resistant infections and persistent colonizations of MRSA, clostridium difficile or multidrug resistant gram negative rods are expensive [to eradicate]. Private rooms in long-term care may not only decrease the rates of infection and colonization, they also increase dignity and autonomy. Private rooms are possible. I have worked in a faith-based not-for-profit care community that has been providing all levels of care, and it has had private rooms since 1953.”
As the medical needs of LTC residents rise in complexity, the result will likely be more medication per resident, placing increased emphasis on medication management.
Lynne Batshon, director of policy and advocacy for the American Society of Consultant Pharmacists, explains that by 2020, those over the age of 65 will comprise 16 percent of the population, yet will consume 49 percent of all prescriptions in the United States. “And since older adults are four times more likely to be hospitalized by a medication-related problem-more than 75 percent of which are preventable-LTC managers are expanding the role that pharmacists have traditionally held in nursing homes,” she says. “They are now incorporating a senior care pharmacist or consultant pharmacist, skilled in medication-related problems associated with the older adult, into their facility’s transition of care program to help eliminate medication problems as a source for unnecessary hospital readmission.” She explains that the pharmacist can perform medication reconciliation, looking for possible errors and omissions in prescribed medications that are transferred between the hospital and LTC facility.
“A pharmacist can also identify medications that are highly associated with falls and other debilitating problems and work with facility staff to proactively develop a treatment approach that will minimize the risks for the nursing home senior,” Batshon says.
NON-PHARMACOLOGICAL SLEEP INTERVENTIONS
Rita LaReau, MSN, GNP-BC, clinical nurse specialist at Bronson Methodist Hospital in Kalamazoo, Mich., is an author, educator and public speaker whose research focuses on methodologies in nursing to improve care for the elderly. She says that a good night’s sleep begins during the day with the implementation of “sleep hygiene” practices. “These include daytime bright light exposure, adequate activity, avoiding caffeine and nicotine after noon and avoiding long naps,” she says. “Many patients also require consistent times for awakening and bedtime, as well.” LaReau adds that if patients have excessive daytime sleepiness, chronic conditions such as insomnia, restless leg syndrome and obstructive sleep apnea need to be ruled out.
Supporting LaReau’s research is Melodee Harris, PhD, APN, GNP-BC, associate professor at Harding University’s Carr College of Nursing in Arkansas. Harris conducted a pilot randomized controlled trial in 2010 that used actigraphy to test the effects of back massage on nursing home residents with dementia and sleep disturbance. She explains, “Participants were randomized to an intervention group that received a three-minute slow-stroke back massage or a usual care control condition at night. The results showed no statistically significant differences between the groups on sleep variables. However, the clinical significance of the study is that slow-stroke back massage may be an effective nursing intervention to improve sleep without the side effects of pharmacological interventions.”
Harris adds that large randomized controlled trials are needed to further test the effectiveness of slow-stroke back massage on nursing home residents with dementia.
J. Donald Schumacher, president and CEO of the National Hospice and Palliative Care Organization (NHPCO), believes that palliative care has an important place even in non-hospice environments. “Having high-quality hospice and palliative care services in long-term care settings brings a particular set of skills that people nearing the end of life desperately need,” he says. “One of them is pain management. Research has shown that the presence of the hospice interdisciplinary team in nursing homes contributes to quality throughout the facility.”
Following this trend is a cutting-edge approach implemented at the Hebrew Home of Greater Washington. It is based on a group of volunteer doulas. Often thought of as assistants in the birthing process, the nonprofit nursing home has found another way to make use of these compassionate individuals. Following the guidelines of the NHPCO, administration at the Hebrew Home has chosen
not to have a separate palliative care program. They trust that the high caliber of care the doulas provide is intrinsically palliative.
The volunteer doulas visit their patients at least once a week for up to two hours and attend regular continuing education and support meetings. They visit with their patients even during periods of hospitalization, providing important continuity of care.
We’ve talked about robotic plush seals and rollabout carts equipped with videoconferencing capability and electronic stethoscopes, but a list of innovations would be lacking if we did not include robotic nurses. With a full understanding that 76 million Baby Boomers are speeding toward old age-and that current low birthrate figures point toward a looming shortage of healthcare workers-Toyota has taken matters into hand. The car company runs Toyota Memorial Hospital in Toyota City, Japan (where they, too, have a large population of aging Baby Boomers), and is performing field trials on mobility robots to help move residents around the facility. The plan is for the bots to become a core business by 2020. Toyota took its lead from Honda, whose famous ASIMO robot has served tea and conducted the Detroit Symphony Orchestra. Toyota’s humanoids have played violin and trumpet. But all of this money-saving, workforce-boosting, staff injury-reducing technology begs the question: Would
you want to wake up from a nice afternoon nap with an automaton staring down at you? Tobi Schwartz-Cassell is the founder and editor-in-chief of
Girlfriendz Magazine, which is devoted to Baby Boomer women in southern New Jersey. She is also the co-author of “Adding Value to Long-Term Care: An Administrator’s Guide to Improving Staff Performance, Patient Experience, and Financial Health.” Email her at
Tobi@GirlfriendzMag.com. Long-Term Living 2011 September;60(9):46-56
Topics: Articles , Clinical