PHI has recently completed a project to refine and strengthen the way we present our consulting services to the eldercare and disability services community. As a result, I am proud to announce our new team name and tagline:

PHI Coaching & Consulting Services
Building Skills. Strengthening Teams. Managing Change.

The new name captures both what we do (consulting services) and how we do it (using the PHI Coaching Approach^SM). And the tagline succinctly states the heart of our approach:

• Building skills amongst all staff in the organization to provide exceptional person-directed care
• Strengthening teams so that staff are able to communicate and collaborate effectively in achieving organizational and client goals
• Helping provider organizations manage the rapid changes in today’s long-term care and disability service markets

Our website has also been updated and new resources are now available including case studies, client stories, and video clips of coaching in action. Please stop by and check them out.

I would like to thank the Taproot Foundation, a nonprofit that provides pro bono consultants to organizations working to improve society, for leading us through this process and providing a top-notch team of marketing and branding experts to work with. PHI is fortunate to have had their assistance and strongly recommends their services.

Please visit our website often, as new content will be added regularly. If you would like to contribute a story or content, contact me at smisiorski@phinational.org.

Kathy McCollett

By Kathy McCollett

Kathy is a Change Management Consultant with PHI’s Coaching and Consulting Services team.

In order to create the feeling of “home,” many nursing homes are changing the look and feel of their facilities, removing the objects and other artifacts that scream “institutional.” Perhaps taking their culture change efforts a step further, they have implemented consistent assignment, with the same staff supporting and caring for a specific group of elders. Having made these initial changes, these organizations want to know what to do next.

Culture change is not a task that lends itself to checklists. If we think of it that way, we will be waiting to check each aspect of the change process off our list. Rather, it is a process of making the needs and desires of each person living and working there more important than what has been dictated by institutional history. It’s about creating communities of people in relationship with each other, those who live there as well as those who work there.

Many providers have made changes to their physical environments and operational procedures that support culture change, but these changes aren’t always enough to have actually changed the culture. It is not uncommon to hear, “We did everything we thought we were supposed to do, but the culture still feels the same.” That’s because a culture doesn’t change by moving through a series of tasks.

Cultures change when our way of being with other people is altered from one that focuses on staff or organizational needs first to one that focuses on the needs of the elders first. According to Webster’s, changing a culture means making “the sum total of ways of living built up by a group of people and transmitted from one generation to another something different from what it is or from what it would be if left alone.” This takes an intentional process that is applied consistently and persistently.

Let’s take changing dining services as an example. If a home decides to eliminate tray service and go to family-style dining, that home is often intending this change to shift the culture. However, if staff and elders are “told” this is what they will now be doing — rather than being involved in the decision making — the result may fall short of the goal. Tensions between dietary and nursing may escalate, and staff may even plate the food without asking the elders what they want to eat.

In this instance the home could “check off” that they implemented family-style dining, but they would not have moved decision-making to the elders and those working most closely with them and, therefore, would not have shifted cultural norms.

If you are looking for more information on how to move beyond tasks to a relationship-centered culture, check out Getting Started, a guide to implementing culture change available through the Pioneer Network. In addition to providing guidance on the change process, this handbook includes multiple staff education tools that invite involvement in thinking about the why, what, and how of culture change.

Mark de Roo, Culture Change Coach for Resthaven Care Communities shares the following story:

On Saturday afternoon, I was in our backyard when I noticed a butterfly in the neighbor’s yard. I thought the frost of last week might have been the demise of all insects, but not this hardy soul. In fact, the butterfly was a Monarch.

You may or may not know that, similar to birds, Monarchs migrate to a particular forest in Mexico for the winter. Sensing that I was rather fascinated by the fact that he/she was still “alive and kickin’,” the butterfly flew right to me to verify its existence—and I think to show off. It was kinda cool.

Seeing the butterfly, reminded me of a story about MIT meteorologist, Edward Lorenz. In 1960, he made an accidental discovery while trying to develop a computer program to simulate weather conditions. Being in a hurry and instead of entering .506137 into his computer simulation, he rounded the number to .506, figuring such a rounding to the nearest thousandth would be inconsequential. He left the lab and later returned, observing that the simulation had revealed dramatically different weather conditions—all due to his actions in rounding the number. He estimated that the numerical difference was equivalent to a puff of wind created by a butterfly’s wings.

If it’s true in science, it’s equally profound in life and in our relationships with residents, co-workers, family and friends. Seemingly insignificant actions—a positive or negative word, using “but” instead of “and”, one’s body language—all can become magnified over time and have major consequences.

Too often, we fail to connect the dots between choices we make and consequences. Every choice—even the smallest—has a domino effect that can alter a relationship….even a destiny.

This profound impact of seemingly small actions played out recently at Resthaven Care Center in a story shared by Aubrey Meunier, Activity Director:

The State arrived for our annual survey and for lack of a better description, things were not going well. It was a very stressful time at the Care Center for all staff members, and especially for management.

Throughout the challenging weeks that followed, our Administrator, Mike Jalacki, and DON, Pat Dowd, always kept positive; they took every opportunity to reassure staff and tell any and all staff how great they were and how much they were appreciated and not to worry about the survey, because we know that we do a wonderful job. They stood up for our company and for us – never conceding to the notion of failure.

In the end, we cleared all the citations from the State not only due to our hard work, but also because we had leaders who believed in us and our work and helped us believe in ourselves. I feel so blessed to be a part of such a wonderful organization where any and all work is appreciated.

A few heartfelt words, a positive outlook and sustained belief in people can be the puff of wind from the butterfly’s wings that supports an organization to realize it fullest potential.

Renya is an Organizational Change Consultant with PHI’s Training and Organizational Development team.

Long-term care organizations are facing unprecedented challenges today. They are coping with an austere fiscal environment as well as seismic changes to the models of care delivery. How can those of us who work in this field find the positive energy we need to keep moving forward in the face of so many obstacles?

At PHI, we have been thinking about these questions a great deal in recent months. We have talked with employees at some of our client sites, and we have been inspired by their stories.

We have learned that the leaders we support are indeed sometimes worried or overwhelmed— how could they not be?—but they have been able to avoid the downward pull of those feelings by maintaining a clear sense of vision and purpose. In other words, they talk about not only surviving this challenging time, but thriving despite it.

“Generative Hope”

In a recent retreat with the senior leadership team at Isabella Geriatric Center, CEO Mark Kator shared this story with us:

“Last week, an early snow storm caused a great deal of damage in the community where I live. Many trees snapped under the weight of the snow and most of our neighbors lost power. Even days after the storm, the streets were still littered with branches. It was an impressive sight – a reminder of the power of nature to destroy. But I found myself thinking that this kind of destruction is just part of the natural cycle. Out of destruction, new cycles of life begin. It reminded me that challenging times can be times of great creativity and regeneration.”

Sara Joffe, PHI’s Organizational Executive Coach, has coined the term “generative hope” to describe what we heard from Mr. Kator at Isabella. “Generative hope is an appreciation of the possibilities that still exist for the future,” Sara says. “It has the power to inspire.” This kind of hope can generate a great deal of energy and motivation, and must be nurtured and tenaciously maintained.

One way to do this is to make a conscious effort to notice organizational strengths that remain despite current challenges. At Isabella, for example, senior leaders have told us about how their direct-care staff members continue to be compassionate and dedicated, despite the fact that they are working harder with fewer resources. Recently, many of these staff volunteered their own time to throw a Halloween party for residents.

In sharing this story with us, Isabella’s leaders were planting a “seed of hope.” They were making a conscious effort to notice their own sources of strength and inspiration. Sharing stories like this is one way to identify your own organization’s strengths. Once you’ve identified these strengths, the next step is to do whatever you can to protect them and nourish them so that they can grow.

“Degenerative Hope”

There is another kind of hope that may paradoxically be “degenerative.” One form this can take is hoping for too little. For example, we may find ourselves hoping for nothing more than organizational survival. This kind of hope is motivated by fear. Instead of inspiring us and motivating us, fear-based hope can sap energy and even lead to emotional paralysis. It may also lead us to take actions that are inconsistent with our vision and purpose. When we hope for too little, we become blind to the possibilities that may still exist for the future. We shut ourselves off from our own rich inner resources: our capacity for strength, resilience, creativity.

Another form that degenerative hope can take is hoping for too much. “This is essentially the same thing as ‘wishful thinking,’” Sara says. “This kind of hope may lead us to deny current realities. Usually, these realities catch up with us, and when they do, we may end up feeling enormous frustration or even despair.” In the current environment, long-term care organizations may find that some of their specific goals are no longer realistically feasible. It may be necessary to delay or even abandon these goals in order to avoid the dangers of “degenerative hope.”

When an organizational goal is delayed or abandoned, it can raise strong feelings of disappointment, loss, or frustration. We know that most of our consulting clients have experienced at least some of these feelings over the past several years. If you find yourself experiencing any of these feelings, you are not alone! These feelings are part of a normal response to the current macro environment—an environment in which all of us are facing very real limits.

A New Cycle of Growth

Nonetheless, despite these limits, we can all develop a “generative” relationship with hope. This means staying focused on the real strengths and possibilities that still exist. It also means finding ways to continue to fulfill our vision and purpose—even if the specific ways in which we do so need to change. Finally, a “generative” relationship with hope means sharing our stories with each other. In this way, we can inspire and support each other, and work together to begin a new cycle of growth.

[Read also Part 1 of Navigating Hard Times in Long-Term Care]

Kate is an Organizational Change Consultant with PHI’s Training and Organizational Development team.

“Person-directed care” allows nursing home residents and home care clients to be fully themselves by providing supports based on individual needs, rather than institutional formulas.

Creating an inclusive environment for elders that identify as lesbian, gay, bisexual and/or transgender (LGBT) is one important step in honoring individuality and creating a space in which no one has to give up parts of themselves in order to receive necessary assistance. For many long-term care and disability services providers, LGBT inclusion is a goal, but there is a lack of clarity as to how to achieve it.

In response to this need, highly skilled representatives from multiple stake holders within aging services and LGBT organizations traveled from all across the country to participate in the National Resource Center (NRC) on LGBT Aging’s second “train-the-trainer” event.

The three-day training took place in St. Louis, Missouri, and was delivered by PHI’s Kate Waldo-Fillion. It prepared the NRC ambassadors to facilitate four separate 4-hour trainings: two for aging services providers and two for LGBT organizations.

These trainings assist organizations in creating an inclusive and welcoming environment for their elders who are LGBT. It provides best practices and knowledge of LGBT elder issues, concerns, and fears.

Our LGBT elders have lived in an era when it was scary and often dangerous to be open about their sexual orientation or gender identity. They have become professionals at reading people and cues to know if they can truly be themselves and not face harsh or unequal treatment. LGBT elders are not asking to be treated differently, but the same as we would treat elders who are not LGBT. They want to be able to share stories of their lives, families, and friends without fear of judgment or discrimination. They want to be able to have their visitors feel welcomed and a part of their new home. They want to celebrate special occasions and events that are important to them. They want to be accepted and welcomed as valued members of their new communities.

If your organization is interested in having one of your members participate in the federally sponsored training, you can request training through the NRC website. After this request is made you will be paired with a certified NRC trainer in your area. If you are interested in building your internal capacity to teach the training within your organization, you should contact the NRC directly to make arrangements at 212-741-2247.

“The Innovation Challenge is an exciting opportunity to design creative care models that expand the role of direct-care workers in an array of long-term care settings,” said Steve Edelstein, PHI national policy director. “It also signals the importance of HHS’s commitment to models that integrate these frontline workers into the care team to improve the care outcomes for elders and people living with disabilities.”

Grants ranging from approximately $1 million to $30 million for a three-year period will be awarded to applicants proposing the most compelling new ideas to deliver better health, improve care, and lower costs for people enrolled in Medicare, Medicaid, and CHIP — particularly those with the highest health care needs.

New Models of Workforce Development and Deployment

The Innovation Center will give preference to proposals that include “development and/or deployment of health care workers in new, innovative ways.” For example:

• new roles and skills for an existing workforce,
• new types of workers to support core transformation of the health care delivery system, and
• team-based models as better methods to serve a particular population.

Successful proposals, according to the grant guidelines, must include an innovative, explicit workforce development plan, one that requires new roles for all staff engaged in the new models of care and new skills to manage team building and care coordination.

“Training and educational experiences will be needed” to develop the skills required for the “health care workforce of the future,” states the announcement, which also notes that “preference will be given to projects that implement their care improvement activities faster than six months.”

The Innovation Center was created under the Affordable Care Act as part of the Centers for Medicare and Medicaid Services (CMS).

More information on the Health Care Innovation Challenge is available on the CMS website.

Important Health Care Innovation Challenge Dates

• Letter of intent: due December 19, 2011
• Applications: due January 27, 2012
• Awards Granted: March 2012

– by Deane Beebe

Kathy and Sue are members of PHI’s Training and Organizational Development team.

In these challenging economic times, with the eldercare and disability services industry under scrutiny and funding becoming increasingly scarce, we are looking for ways to maximize our resources while still providing for the needs of those we support.

The most obvious ways to address this have already been fairly exhausted. We have all tried to reduce our expenses to the point that we’re not just working lean, we’re practically emaciated! Someone coined the phrase several years ago that we “need to work smarter, not harder.” While it sounds good, how do we do this when we feel like we are in survival mode and working as smart as we know how?

Relationships: A life boat during hard economic times

When the culture of an organization is one that must focus on surviving, it has a tendency to be in crisis mode, adopting a “strictly business” mentality.

Those who have been working on developing a culture of strong teams, relationship-building and community connection may be told that they need to refocus on “what’s really important,” meaning the bottom line.

The problem with this strategy is that those teams, relationships and connections are what provide the life boat for successfully navigating these treacherous waters.

In working with organizations facing hard times, what often emerges is a decision-making style that focuses on the present rather than the future. Rather than continuing to move toward or maintain team participation and staff inclusion to achieve a vision, there is a tendency to revert to a top-down management style. This is certainly an understandable attempt for executive leaders to gain control at a time when the political and economic health care climate seems anything but controllable!

A hierarchy of needs

To understand this on a deeper level, it is helpful to apply Maslow’s hierarchy of needs to the organization. The very base level of the hierarchy is about survival. In long-term care, survival mode causes us to focus on issues such as having enough staff to cover shifts, being able to make payroll, and providing an “acceptable” level of care while avoiding the sting of deficiencies.

While it is true that each of these basic elements must be in place, focusing 100 percent of attention on survival is likely to keep your organization right where it is: At the bottom of Maslow’s hierarchy.

Stepping back from crisis mode

When applying Maslow’s theory to the workplace, it is helpful to think of the organization or workplace as a community of relationships. When employees are exposed to a workplace culture stuck at the bottom rungs of Maslow’s hierarchy, there is often a palpable level of stress and tension that yields dissatisfaction and ultimately interferes with customer service. Getting through this requires that executive leaders are able to step back –away from crisis mode–and find ways to bring people together to unleash their creativity.

Here are some steps to help you get started:

• Communicate openly and transparently. Honesty builds trust, even if the news is bad news.
• Invite involvement and give employees time to participate in teams to generate new ideas.
• With employee input, identify and implement quick, cost effective wins.
• Maintain a vigilant focus on core strengths, and build on those strengths rather than focusing on deficits.
• Set aside time for self-reflection. Think about ways to influence the organization without reverting to traditional positional authority afforded through your role.

Check back next month for Part II of Getting Through Hard Times.

While most people can imagine how difficult it may be for someone to move into a nursing home for the first time, less understood is how hard it can be for someone to relocate from one unit to another in the same nursing home.

Room changes have become much more common over the past few years due to several factors. For instance, there are always a number of people who come to a nursing home for short-term rehab (as “patients”), and then for a variety of reasons must move to long-term beds on other units (as “residents”). Such a move can be particularly upsetting (for both patients and their families) because this usually means having to accept that they will never return home.

Making the Adjustment

Regardless of the reason for the move, it is extremely important to examine the impact of any move on the resident. These changes can obviously be very distressing to residents and to their families, and challenging for staff.

Moving to a new unit may seem simple, but in fact it usually means an entirely new set of caregivers, including nursing assistants on three shifts, nurses and nursing supervisors, social workers, recreation workers, dietitians, physicians and housekeepers. It means a new roommate. It means leaving roommates, their family members, and staff on the old unit to whom the patient may have become attached. Routines from one unit to another vary (meal times, bathing times, recreation schedules).

For residents with dementia, and for their families, these adjustments can be even more difficult. Because these residents are often not able to say what is troubling them, it can be especially hard for staff to respond to their needs and to make them comfortable. As a family member noted:

“It was a huge change, very difficult. The Rehab floor had a different look, and on the new long term unit there were uncomfortable things to get used to. We tried to ease things by finding someone from the new unit who could get to know her before the move, so she’d have someone she knew and recognized when she arrived, so she wouldn’t feel alienated. It meant so much when one of the new Nursing Assistants knew she liked oatmeal, and made sure she got it. They (Nursing Assistants) are so crucial, and the littlest things can make such a big difference in helping to build a relationship.”

Working with other New York City health care providers as part of the United Hospital Fund’s Transitions in Care Quality Improvement Collaborative (TC-QulC), Jewish Home Lifecare in Manhattan (New York) made a number of improvements in how they approach moves for residents within their facility, including: calls to family members to explain the moving process itself; training for housekeeping staff regarding how stressful these moves can be for residents and families and how to help the process go more smoothly for them, changed working hours for some staff to better meet the needs of residents by providing coverage for later hours and weekends, and support groups for residents following their move.

More information: www.alznyc.org/LTC.
Read the expanded article

Susan Misioriski

Susan is the National Director of PHI’s Training and Organizational Development team.

PHI is pleased to announce the final results of the PHI Center for Coaching Supervision and Leadership (CCSL)! The CCSL yielded important quantitative and qualitative outcomes for employers, employees and residents/clients according to a just-released PHI evaluation summary of the program.

The four-year CCSL, funded by the John A. Hartford Foundation and The Atlantic Philanthropies, was designed to refine and field test the PHI Coaching Approach℠ to Supervision– a training program that teaches long-term care supervisors the core communication skills necessary to effectively engage and support their teams.

The CCSL created a learning collaborative among 31 providers in 14 states, including both nursing homes and home health agencies. Among these, 11 organizations were selected to participate in a comprehensive training, consultation, and evaluation process supported by PHI specialists.

During the four years of the project, PHI facilitated the training of 98 new coaching supervision trainers who in turn facilitated trainings of 2,000 supervisors within their own workplaces. Combined, these supervisors supported 3,000 additional staff, including direct-care workers, in growing their critical-thinking and problem-solving skills.

Participants in the CCSL reported improvements in quality of care, quality of jobs, and improvements in job satisfaction among all staff.

PHI’s evaluation of the CCSL program—which focused on the 11 comprehensive sites– found that:

• Trained supervisors retain the lessons of PHI Coaching Supervision℠. One year after their training, more than three-fourths (77 percent) of supervisors involved in CCSL said they “often” or “always” used the communication skills they were taught. In other words, PHI Coaching Supervision resulted in behavior change in 77 percent of supervisors—this behavior change was sustained a full year after the training.
• Job satisfaction increased. Direct-care workers surveyed showed significant improvements in job satisfaction following the CCSL intervention.
• Managers spend less time solving daily problems. Coach supervisors engage employees in solving daily operational problems themselves. Moving problem solving to into the hands of those closest to the issue resulted in a total of 75 hours saved per week among a cohort of supervisors.
• Care quality improved. Downward trends in fall prevalence, urinary tract infections, pressure ulcers, and other quality indicators were recorded.

More information about the PHI Coaching Approach is available at the PHI Training & Organizational Development Services website.

More information about the evaluation of PHI initiatives and services is available at the PHI Evaluation page.

Susan Misioriski

Susan is the National Director of PHI’s Training and Organizational Development team.

An August 12 memorandum from CMS to State Survey Agency Directors announced resources for enhanced nurse aide training. Section 6121 of the Patient Protection and Affordable Care Act (ACA) mandates the inclusion of training for nurse aides working in nursing homes on abuse prevention and care of persons with dementia.

Adult Abuse and Neglect Prevention Training Program

One of the recommended resources is Michigan’s Adult Abuse and Neglect Prevention Training Program developed in collaboration with BEAM (Bringing Eden Alternative to Michigan), Michigan State University, and PHI.

“The Michigan abuse and neglect prevention training program was designed to prevent adult abuse and neglect by building skills among all the staff working in an organization. It includes highly interactive trainings that focus on actively building person-centeredness and self-management skills within individuals and organizations,” explained Maureen Sheahan, PHI’s training and organizational development specialist who supported the curriculum design.

“MSU’s evaluation of the training found that almost every staff person who used the skills reported that it helped to prevent abuse or neglect. We are thrilled that Michigan’s training program was included by CMS as a resource to the nation’s nursing homes,” says Kari Sederburg, director of the Michigan Offices of Services to the Aging.

Interpretive guidelines for tag F497 (in-service training tag) have been revised to mandate training on abuse prevention and care of persons with dementia in each nurse aide’s yearly in-service training program. CMS has awarded a contract for the analysis of current training programs and for the development of additional materials for nursing homes to use in training nurse aide staff on these topics.

Care Coach Curriculum

PHI is also pleased to announce a new product that is an excellent resource to improve services to residents living with dementia. PHI’s Care Coach teaches all staff the core communication skills necessary to communicate effectively with individuals living with the symptoms of dementia. Staff learn techniques that create meaningful engagement, build relationship, and prevent and de-escalate emotionally charged situations.

PHI’s Care Coach was first launched with Genesis Health Care in Massachusetts and was recently updated and field tested with nursing homes in Vermont through a grant from the Department of Aging and Independent Living. For more information about Care Coach, contact PHI at 617-319-9820.