I had the opportunity to give a presentation on direct-care worker issues in long-term care as part of the UPMC Geriatrics Division’s weekly conference last week in Pittsburgh. The discussion afterwards was very informative, and I came away with a deeper appreciation of the challenges that medical directors face while doing their critical work in local nursing homes.
Geriatricians who work in nursing homes have a tough and often thankless job. They may recognize and attempt to rectify quality of care problems as they attend to individual residents, but their real power to change the underlying systems of care – the root cause of the problems – is limited. A medical director can make important suggestions and offer needed guidance to the administrator or director of nursing (DON), but for most geriatricians, not being on-site 24/7 makes it hard to truly lead change efforts.
Frustrated by the status quo
And even if an enlightened geriatrician is able to help begin introducing needed changes into the nursing home (e.g., individualizing medication management or involving direct care workers in decision-making), the incredibly high turnover rates among administrators and DONs in nursing homes can frustrate even the most thoughtful efforts. As one geriatrician put it, “Never mind culture change – in some nursing homes there’s so much turnover among key staff that no stable organizational culture exists to change.”
The result is geriatricians serving as the proverbial band-aids on a broken system, simply trying to prevent the phrase “doctor’s orders” from taking on a life of its own in the nursing home (with institutionally-minded nursing staff using it as a bulwark against family and/or direct-care worker suggestions to individualize care).
A new way of thinking
I came away from the discussion more convinced than ever that we need broad-based regional initiatives to invest in and grow the next generation of long-term care workers who can work with geriatricians to affect change. It may just be my eternal optimism, but I think with the right resources and accountability local exemplar organizations could come together to recruit and educate a cadre of new professionals to show what can be done to individualize care and transform the work experience of nursing assistants. Either that, or…..what’s that definition of insanity again?
The good folks at the Rhode Island Department of Health have developed a Medical Director Questionnaire (.pdf) as part of their Individualized Care Pilot for Nursing Homes. The survey asks questions about whether the medical staff adjust medication orders from routine frequencies to directions such as “on arising, before lunch, before dinner, at bedtime” in order to enable each resident to sleep as long as he/she wants and to go to bed when he/she wants. It also asks whether the medical staff talk about care and treatment with the nursing assistants.
There are a lot of great resources on that Rhode Island page, including a report by David Stevenson of Harvard Medical School on whether the regulatory process is a barrier to providing resident-centered care. Check it out.
– Joe Angelelli is PHI’s Pennsylvania State Director
