Developing Scheduled &

routines that WorkCreating a

Culture of Change for People Living

with Cognitive ChangesIts not a Nursing Home or FacilityIt’s a HOME where nursing care is

given

Design Each Day

8 am – coffee circle 8:30 – songs of joy9 am – time to ‘go’9:15 – take a hike – walk’n’roll10 am – cool down & stretch10:30 – watering hole 11 am - ‘use your brains’ games11:30 - time to ‘go’ – wash up11:45 – ‘set-‘em up’ crew12 noon – let’s eat12:30 – clean up crew1 pm – music and meditation1:30 – coupons clipping2 pm – time to ‘go’2:15 – let’s dance

Make a schedule and follow it

Be structured BUT allow flexibility

Create a FLOW for the day

Build up and then slow down

Circadian rhythms

Offer a variety of activities every day

Leisure, work, rest, self-care,

groups and 1:1, passive and

active

Create Group schedules

BUT also build individual schedules

Not everything is for everybody!

Build a Foundation of Familiar and Favorite

Activities

Add a fewspecial events and something

different

Understand Activities

Modify and Structure the Activity for Success

Change the materials, the complexity, the setting, the help offered, the task demands, or

the purpose of the activity

Analyze the Activity…

What do you need to do

it?What skills,

abilities, interests?

What is the activity all

about?

Doing something

or making

something?

What type of activity is it???Self-care, leisure, work, rest…

Spiritual, social, physical, cognitive, passive, active, solitary

Enough Supplies & Materials

The right equipment for clients’ needs

Good quality lighting

Skilled leadership for

the activity

Good work surfaces

Seating that works

Enough help for each person

A BACK-UP Plan

Traditional Facility Care

• Run by administrators & nurses• Organized around staffing • Work shared among 3 shifts of staff• Safety and health care issues TOP

PRIORITY• Medical model • Organized by departments – task specific• You are sick – you need care for your

diagnosis• Father knows best!

What’s Wrong with this Model?

• Who wants to live in a hospital?• Who wants to do everything you are

supposed to?• Who wants to have someone else

telling what to do and when to do it?• Who wants to have to talk to three

different people to get something done?

• Who wants to live in a nursing home?

For People with Changes in Health and Abilities

• Need for help• Need for equipment• Need for changes in routines & habits• Need to match needs with availability

of help• Need to ‘anticipate’ when and where

you will do things, need things

Cognitive Changes with Aging

• slowed processing • less flexibility• more difficulty with new learning• more rehearsals needed• benign forgetfulness – immediate

recall goes first

Emotional Changes with Aging

• increased incidence of depression• increased incidence of anxiety• with stress – mood swings• with some drugs – emotional side

effects

What Does Having Cognitive Abilities Do To This Whole

System of Care?

• Changes in memory & thinking• Changes in understanding &

speaking• Changes in impulsivity & initiation• Changes in abilities & processing

So Let’s Figure YOU Out…

• What time do you wake up?

• How do you wake up?• What do you do when

you wake up?• When do you eat

breakfast? • What do you eat for

breakfast?• How do you get ‘clean’?• When do you get clean?

• When do you toilet?• What do you do for work?• What do you do for fun?• What do you do when

you are stressed?• ID two people you love…• Where are you from?• What is your favorite

food?• What do you HATE to

eat?

Questions

• How would you DO living in your community?

• What would it be like if you had physical changes?

• What about cognitive impairments?

• How would you do on someone else schedule?

• What would NOT be OK?

• What if it was the rest of your life?

• What would you want?

What is Veteran-Centered Care?

Combination of…• Person’s wants• Person’s needs• Still can do• Can’t do• Can do with support• Individual good• Common good• Family needs• Family wants

Balanced with…• Staff skills• Staff availability• Private space• Public space• People resources• Equipment resources• Safety & Security• Rules & regulations• Others needs and wants

Personal Preferences & Values

• Who have you been?• What did you value?• Who are you now?• What do you value now?• Why does it matter?• Who gets a ‘say’?• Who gets to set the priorities?

Who Matters?

All of UsEach of Us

What Matters – When Illnesses Are Present?

• Safety – Environmental modifications• Access - Availability• Timeliness of help• Flexibility in timing• Structure & predictability• Privacy and respect• Preservation of SELF

Key Steps

• Connect• Gather Information• Share Information• Use Information• Review Information• Make Changes

What About Medical Conditions?

What is essential?• Good care is delivered• The person is

receiving the care they need and want

• Conditions are assessed

• Decisions are made based on good info

• There is agreement on what to do and what NOT to do…

What is optional?• When it is done• Where it is done• Who does it• How often it is done• How strictly it is

followed• It depends on the

person & their situation

What are the Different Care Approaches to Consider?

• Health Promotion• Curative• Restorative - Rehabilitative• Maintenance• Compensatory• Palliative

Health Promotion

• Check Ups• Annual vaccinations• Lower the numbers• Increase activity level• Eat well – moderately• Monitor all conditions for careful control• DO WHAT YOU SHOULD to be the BEST

YOU CAN BE!

Curative

• Fix what is wrong• Test to figure out what is happening

then DO SOMETHING ABOUT IT:– Surgery– Medications– Treatment

• Full recovery of function – GOOD as NEW!

Restorative

• Recovery of SOME degree of function or ability

• Focuses on the PERSON regaining skills and abilities with help– Rehab personnel– Special equipment– New techniques

• Not perfect, but BACK to a Higher level of Function

Maintenance

• Maintaining the Status Quo – Keepin’ ON

• Not losing ground• Depends on:

– Physical environment not changing– Caregiver consistency– Sustained abilities of the person– All other things staying the same

• It’s HARD WORK … SO…– ‘IS what I have worth keeping???’

Compensatory

• Providing what the person can’t do to ‘fill in the gaps so that LIFE GOES ON….

• Supportive – Physical environment changes– Caregiver cueing and helping changes– Expectations change– Schedules and routines change to

accommodate

• End Point is the Same – – How we get there Changes

Palliative• Comfort Care• TOP PRIORITY –

– Honor personal preferences and choices– Manage Pain, Distress, Anxiety, Fear,

Discomfort

• Identify & seek to meet social, physical, psychological, and spiritual needs

• Let go of FIXING and MOVE ON to Comforting

The GOAL?

• Build a schedule and care routine that helps the person:– Be the way they want to– Do what they are able– Feel good about themselves– Feel OK about where they are– Enjoy the people who are there to help

them– Get what they need

Who Needs to Buy In?

• Residents• Families• Front line staff• Managers• Community leader• Regulators• Public• Reimbursors

So… What Do We Need from Staff & Families?

• Awareness of the process• Participation in planning• Sharing about the past• Time to learn & try something new• Willingness to listen• Willingness to advocate AND negotiate• Flexibility as we figure this out