the changing faces of LTC

Specialties Geriatric


  • Specializes in LTC,Hospice/palliative care,acute care.

Back in the day nursing homes often had residents separated into units according to their functional abilities.I remember the "trach and tube" unit, the "feeder" unit and the few that were the "showplaces" with cute and alert little mom -moms and pop- pops-suitable for touring visitors...Fast forward to CASE MIX.....In my facility all this has done is make the lower functioning residents victims of the higher functioning...There is NO dignity for them now...Years ago an alert and oriented LTC resident was something of a rarity.Now we see more and more and they are getting younger....Should they be subjected to the problem behaviors of the lower functioning residents? And how do we protect the lower functioing from verbal and sometimes physical abuse from peers? Is LTC going to move forward and recognize this problem? Will we be permitted to do something about it? It's conundrum,ain't it? (that's my word for the day-did I spell it right?))

jnette, ASN, EMT-I

4,388 Posts

Specializes in Hemodialysis, Home Health.

Intersting topic, ktwlpn.... and points well made. I noticed that here not too long ago myself, and actually wondered about many of the things you have pointed out. Humans can be cruel... at ANY age.

I do believe there should be some sort of "protections" in place. To whom might one addresse these concerns? :confused:

CoffeeRTC, BSN, RN

3,734 Posts

Good questions! Since my LTC is so small, 48 beds with two halls, I see this everytime I work.. There is very little room in our facility for separation...the lobby and dinner/activities/ church area is the only place for residents to be unless they are in their rooms. One hall is usually the higher functioning, A & O, medicare and hall two is more LTC with the demetia res. There is very little space for the residents to be. I cant tell you how many times I've heard residents (the alert and high functioning) yell at the others "Shut up" or "Can't you do something with him/her" . And don't get me started talking about the "wandering" residents. God forbid one of them would walk by the others room. Yep this is a big problem in my facility. The hardest thing I have to deal with is when they admit someone who is extremely agitated and dangerous to the about time consuming...


221 Posts

as a nursing student I worked here years ago

many changes have been made

here is the rationale

[note well the mixing of residents was part of a total concept and remodel]

>>>Resident Directed Care at The Mount


Since the 1920's, Providence Mount St. Vincent (PMSV) in West Seattle had been providing compassionate care to the elderly in a traditional medical model of care that proved to be extremely successful. Yet the Mount's leaders struggled with the fact that the traditional system in long term care is designed to foster dependence. Many residents complained that they were experiencing the loss of independence, dignity, privacy, social interaction, and physical and cognitive ability. They were bored, lonely and often felt they had no control over their lives anymore.

With this in mind, the leaders at the Mount in 1991 decided to start over. After many, many hours of discussion and numerous drafts of the Mount's strategic plan, the new vision became clear: a community directed by the residents. PMSV chose the term "resident directed care" as a means of capturing the essence of the values that are integral and consistent with the Mount's core values and mission._

The Sisters of Providence Health System's mission statement emphasizes that "....the healing ministry of Jesus in the world of today, with special concern for those who are poor and vulnerable. Working with others in a spirit of loving service, we strive to meet the health needs of people as they journey through life." This mission, combined with PMSV's core values of "community, compassion, creativity, conservation and commitment," was key to this project.

Goals and Objectives

*The goals and objectives, as outlined in a three-year strategic plan beginning in 1992, were as follows:___

*Begin a process of change to allow residents more choice and control over their care and their lives;___

*Support aging in place for the residents living in the apartments as an alternative to the nursing center;___

*Renovate the nursing center to accommodate a more home-like residential environment;___

*Expand the rehabilitation services to meet the needs of both the facility and the community;___

*Decentralize decision making in order to expedite problem solving among staff and residents as well as allowing the nurses more time to provide clinical care.___

*Implement systems to improve employee recruitment and retention.

Impact of Change

The change to resident directed care involved every resident, client, family member, staff member and manager. It was first introduced to the residents of PMSV's 111 apartments through an assisted living program called "Hand in Hand." Along with family members and staff, each resident (even the frail and those with dementia) determined how much assistance he or she needed.

"Hand in Hand" went through several evolutions --such as fee for service and a menu plan of services--until the final design was mutually agreed upon by all. Services were built into the fixed price and were negotiated for the apartment rent so that residents would not hesitate to use them because of cost concerns.

The psychological benefits of "Hand in Hand" proved to be extremely satisfying. Typically, residents were no longer asked to move to the nursing center because they were showing signs of dementia or because of incontinence. For many residents, the apartments had become their permanent homes. Home care and hospice were utilized in this model. The assisted living program allowed them to age in place and remain in their homes forever.

Concurrent to the assisted living changes, the Mount began a program offered as a benefit to many: the residents, employees and the community. In 1991, a child care center was established and housed within the building. This Intergenerational Learning Center gave residents the benefit of having more than 80 "grandchildren" close by as well as offering opportunities for the elderly and children to interact and play. In addition, an on-site child care center has proven to be a positive benefit to employee recruitment and retention.

Nursing Center Experiences Most Radical Change

The nursing center experienced the most radical change, both physically and philosophically. Prior to resident directed care, residents were assigned to floors based on their level of needed care. As they changed, they were moved to other floors, often causing transfer trauma. Resident directed care brought an end to this arrangement and a beginning of mixing the acuity levels of residents just as any community would have a diversity of residents. The neighborhoods were designed programmatically to be flexible in meeting the changing acuity levels of its residents.

Bed capacity was downsized from 215 to 173 to provide more open space for living. The long corridors were divided into separate, 20- to 23-bed units named "neighborhoods," each with its own theme and decor, such as art deco or a "ski lodge look." At the heart of each neighborhood, a large open area was built featuring a kitchen, dining room, lounge and staffing station called "care team area." In most homes, the kitchen/family room is where everyone seems to gather for meals, entertainment and conversation. It was the hope of the residents and staff that this new construction would convey this same warm environment.

Steam tables in the kitchen were installed enabling the staff to discontinue individual tray service and making it possible for residents to choose their food and portion size. This also ensured that residents were being served hot, fresh foods, and it eliminated costly food waste. In addition, new sleep and wake schedules were honored. If a resident decided to sleep in, he or she could knowing that breakfast would be prepared upon awakening. Residents' favorite snacks were made available 24 hours a day.

Personal laundry areas were added to each neighborhood, providing an additional opportunity for residents to interact with each other as well as increase their physical activity. This eliminated the problems associated with centralized laundry such as lost clothing, delays and harsh treatment of clothing.

Other physical changes in the nursing center included the addition of whirlpool baths, a common space between neighborhoods for group meetings or recreational activities (such as a library, a horticulture therapy room and an aviary), and carpeting to halls and resident rooms to reduce noise as well as providing cushioning against falls and injuries.

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