COLUMBIA — Maybe you hate Bing Crosby and “Wheel of Fortune,” or you’re sickened by mashed potatoes and contrived fun.
Maybe your ideal day would include the History Channel, surfing the Internet, liquor with dinner, and a healthy dose of alone time.
Or maybe you’d enjoy watching “Oprah,” eating Italian food, listening to lively music and playing late-night poker with friends.
And maybe someday, if you’re lucky enough to live to an age when you need assistance with these activities, you’ll realize your ideal day — the food, songs, pastimes, TV shows and people surrounding you — won’t have changed that much.
Or maybe it will, if you lose your appetite, can’t tolerate loud music anymore, or have trouble staying awake past a certain bedtime.
The point is this: You’re a unique individual, distinguished by particular habits, preferences, desires and abilities — even when you’re old.
Perhaps this is why the term “nursing homes” — and the sterile, depressing image it conjures — has been disappearing from our lexicon, making way for “care homes” and “communities.” The new terms emphasize a more personal, less hospital-like existence.
This conceptual makeover is just one reflection of an ongoing culture change in the long-term care industry. The goal is now to promote senior independence and to ensure that elders spend their final days, months and years more meaningfully.
Improvement is vital, as baby boomers are now retiring in droves, quickly becoming our next generation of the elderly. And average U.S. life expectancy has increased — from 69.6 years in 1955, to about 78 years today, which, to put it bluntly, means more time spent being old.
Elvis has left the building
Thank you. Thank you very much. Did y’all enjoy that trip to Hawaii?” asks Richard Smith, Elvis impersonator.
On this Friday afternoon in March, he is wrapping up his Blue Hawaii set for the residents of Columbia Manor Care Center, one of the smallest senior facilities in Boone County. About 25 of its 50 or so elders, primarily women, have gathered in the living room to watch the King perform.
He is wearing pointy-toed white shoes, a royal blue scarf draped over a studded, light blue jumpsuit, and a Donald Trump-like reshuffling of his own hair.
“Now we’re gonna go back to the Vegas years,” he declares.
An instrumental version of “Don’t Be Cruel” kicks up on the sound amplifier, and Smith resumes crooning into his microphone. The next set includes lesser-known songs interspersed with crowd-pleasers such as “Return to Sender,” “Viva Las Vegas” and “Fools Rush In.”
Whoops and hollers erupt from a huddle of nursing staff wearing multicolored Crocs and cartoon-print scrubs whenever Elvis shimmies or delivers a subtle foot kick on the occasional downbeat.
“Thank you!” somebody catcalls during “Suspicious Minds” after Elvis graces the crowd with a prolonged sequence of gyrations.
The residents are more tranquil. A few women have their eyes closed, and one woman is unable to hold her head up.
But the performance reaches Judith Steffenauer, 64, who remembers owning all of Elvis’ albums and seeing all of his movies, and it delights the thin, attentive woman sitting near the front, who received a peck on the cheek from Smith during a slow song and charmingly declared after his performance that she “wasn’t gonna wash her face” that evening.
There’s a palpable letdown after the show as nurses roll wheelchairs through hallways and into bedrooms for afternoon naps, push sofa chairs back into place, and flip on the TV in the living room.
Some residents stick around to watch afternoon talk shows, and one woman takes out a crossword puzzle book.
The nursing staff return to work, kindly asking residents in the hallways if they enjoyed the performance, and one nurse observes, for whoever happens to be listening, that “Elvis has left the building.”
The ‘B’ word
I think a lot of people think fun is easy,” said Tammie Henderson, who holds a bachelor’s degree in recreational therapy and now works as administrator of a Brookfield senior home. “And it’s very hard to plan fun.”
For the past seven years Henderson has led the 40-hour training session required for new long-term care activities professionals in the state of Missouri.
She is contracted by the Missouri Association of Nursing Home Administrators, which organizes the weeklong session twice yearly in Jefferson City.
Henderson reviews for her trainees the federal and state regulations, but mostly structures the week around questions like: What makes a good activity? How do you recruit volunteers from the community? How do you ensure that activities happen when you’re not there?
“Just full of ideas,” is how Henderson describes the activity-sharing sessions.
The most successful activities typically involve history (e.g. trivia), and in recent years have included dice games that call for dexterity, hand-eye coordination and mental math.
Arts and crafts also tend to be popular, especially when the staff can say, “‘We’re making these for somebody,’ and it becomes a service,” Henderson said.
But there’s one activity the trainees are prohibited from sharing:
Henderson calls it “the B-word.”
Not only does BINGO reinforce stereotypes, she thinks, but there are countless other ways to meet the residents’ needs – which is, in fact, the only explicit requirement for long-term care activities programs.
Public facilities, those accepting Medicare and Medicaid, must comply with federal regulations that each resident has a right to:
“(1) Choose activities, schedules and health care consistent with his or her interests, assessments, and plans of care; (2) Interact with members of the community both inside and outside the facility and (3) Make choices about aspects of his or her life in the facility that are significant to the resident.”
No minimum number of hours or range of planned activities are spelled out, so long as residents may choose from schedules conducive to their needs and interests.
But facilities can get cited with “automatic deficiencies” if they lack a qualified employee designated for the activities program – thanks to a rule change last year that made Missouri’s interpretive guidelines stricter.
The rule change was a boon for activities professionals, Henderson said, because planned activities had been pushed to the back burner in some instances.
“A lot of people were getting locked into ‘OK, every Tuesday we’re going to do this ...’ and the calendar would look the same every month,” she said.
And perhaps the rule change comes in time for the next generation of long-term care customers — the boomers — who have been saving for retirement and “will pick where they want to live,” Henderson said.
She also suspects boomers will demand certain things — such as livelier activities, private rooms (many facilities now have double-occupancy rooms), and happy hours for drinking (if they choose).
“They’re not gonna sit around staring at each other,” Henderson said.
Beth Simpson is director of the Central Missouri area’s Ombudsman Program, which is based out of the Central Missouri Area Agency on Aging.
The goal is to “promote senior independence,” something Simpson and two other ombudsmen accomplish by overseeing 162 senior homes in 19 counties, including Boone. Boone County has 21 establishments, which range in capacity from 12 to 132 beds. Additionally, volunteers throughout central Missouri pay weekly visits to assigned establishments to talk to residents and ensure that their needs are being met.
The program serves an important function, considering how few outside contacts elderly residents are likely to have and that many long-term care residents experience some degree of dementia. Weekly ombudsmen visits may address problems before they become larger, keeping the homes on track for annual federal and state regulatory visits.
An ombudsman for almost 12 years, Simpson has witnessed much of the ongoing culture change, recalling when nursing homes were run by nurses and operated according to a medical model.
“But not everyone there is sick,” Simpson said.
The goal of the more resident-centered approach is to involve the entire staff in facilitating meaningful activities — ones that treat residents like people instead of patients.
And according to Pioneer Network, a coalition at the forefront of the long-term care culture change, the term “residents” ought to evolve further, into something more personal like “elders,” or simply “individuals.”
Such person-centered language, according to Pioneer Network, would further specify these individuals:
- wear “incontinence garments” or “disposable briefs,” not “diapers.”
- wear “clothing protectors,” not “bibs.”
- might “need assistance with dining,” but aren’t “feeders.”
- enjoy “snacks,” not “nourishment.”
- eat “dinners,” not “trays.”
- “use” wheelchairs, but aren’t “confined” to them, and
- want “meaningful things to do” – and not merely “activities.”
By listening to and regarding individuals’ unique preferences, staff will be better equipped to offer a program of activities that adds meaning to each elder’s day.
One of the best things about senior communities, Simpson said, is the socialization they provide for seniors who might otherwise live isolated from others.
“But beyond that, life shouldn’t change too much,” Simpson said.
“You want people to do what they did while they were at home. For example, some people are night owls, and maybe want to get up late and just watch the morning shows.”
Thus, as part of her advocacy for senior independence, Simpson reminds residents that if they want to, they have the right to sleep in.
Rashawn Cason is the activities director for Columbia Manor Care Center. She’s the one who invited Elvis. She began working at the Manor two years ago as a nurse assistant, then as a certified nurse assistant, and then as activities assistant before she became the sole activities director. She is 20.
Cason arrives weekdays around 7:45 a.m., stopping by the breakfast tables to chat with her “ladies” before writing the daily agenda on a giant marker board.
“I plan my activities around the residents: What do they like to do?” she said.
One way that Cason determines this, along with the residents’ intake paperwork, is by holding monthly resident council meetings where she hears feedback on subjects such as how staff members are treating residents and what the seniors want on their monthly activities calendars. The residents also vote on a special meal, which in a recent month included fried jumbo shrimp, fries, coleslaw, and strawberry shortcake and ice cream.
With the Manor being a smaller community, Cason enjoys one-on-one time with the residents. However, there are drawbacks to this dynamic. Residents who become especially attached to Cason are unlikely to attend a particular activity unless she is running it. And Cason only works Monday through Friday, which means her planned weekend activities don’t always happen.
Planned weekday activities might also fall through. In a recent month, Cason had planned for about six volunteer and performance groups to visit the Manor (including Elvis), all of whom later canceled because of illness (Elvis was rescheduled).
Scattered on Cason’s desk are cards and photos she is preparing to send to family members of recently deceased residents: evidence that in addition to what is requested and expected of this job, those little unasked-for efforts matter, too.
For the Manor’s bedrooms (all doubles) Cason recently purchased fill-in-the-blank “Getting to Know You” posters, where residents can write down preferences such as their favorite foods, favorite colors and favorite things to do in each of the four seasons.
One of the residents’ favorite fall activities is to “sit outside and eat popcorn.”
Just a few miles away from Columbia Manor Care is Lenoir Woods Health Care Center, with a resident population of about 112 seniors and four activities professionals.
Activities Director Nancy Robertson previously served as activities coordinator on the skilled nursing floor of Boone Hospital Center. Before that, she was a church music coordinator for several years, which is how she discovered her fondness for working with older adults.
“They’re fun, they have so much wisdom, I think they’re just very neat people,” she said.
Robertson arrives around 7:30 a.m. Monday through Friday to update the daily schedule on the activities boards in each of Lenoir’s four “neighborhoods,” an alternative word for wings. Residents also have the monthly activities calendar taped up in their bedrooms.
Robertson usually plans the calendar several weeks in advance, incorporating new and holiday related activities into at least the following: spending time with the nursery children; BINGO three times weekly; open manicures twice weekly; Sunday services led by a different community church each week; weekend movies (recent selections: “The Italian Job” and “Herbie Rides Again”); a monthly joint birthday party with cake and punch; and a monthly shopping trip to Walgreens.
Robertson and the three other activities professionals on staff must also complete the activity assessments required by the state. These involve taking detailed attendance so that when residents come up for their quarterly and annual reviews, the staff can determine which sorts of activities will better serve them in the future.
For the quieter, more reserved residents, these might be smaller-scale activities — such as a small card game in someone’s room, or having a staff member spend one-on-one time with a resident while rubbing lotion on his or her hands.
For individuals with dementia, or cognitive losses, activities might require some fine-tuning. For example, instead of posing open-ended trivia questions, the staff might give residents a choice between ‘A’ and ‘B.’
Angela Jenkins, one of Lenoir’s three activities assistants, specializes in working with residents with cognitive losses. She said another appropriate activity is the “texture game,” wherein individuals wear blindfolds as they feel and describe various cloths and textures. The stroking motion seems to have a therapeutic effect.
Columbia Manor Care also uses sensory therapy — including aromatic and musical — for patients with cognitive loss.
Reminiscing is another form of therapy that Jenkins and Merri Chapman, another Lenoir activities professional, incorporate into the residents’ recreational time by playing the “Remember When” game:
“Remember when you were in school? — Who was your favorite teacher?” or
“Who was your first kiss?”
(“They’ll let you know if it’s too personal,” Chapman said.)
And for patients reluctant to share, or who perhaps can’t rattle off preferred activities on the spot, Chapman suggests entering into their conversations or overhearing things.
“The best thing you can do is just listen,” she said.
Requests for Internet access are common nowadays, but a few years ago, Chapman overheard a woman wishing she could “just do her own shopping.”
Now a favorite activity among Lenoir residents is the monthly trip to Walgreens.
One male resident enjoys spending entire visits in the chocolate aisle, Chapman said, and it’s nice for the female residents “just to be able to pick out their own color of fingernail polish.”