The term “providers” is a general title for all of the staff involved in direct care in a long-term care facility. Several reasons exist for encountering providers and various ways to make the encounter a positive and care-enhancing experience. We’ll run down the list of all of the staff categories, from administration to social services, at a long-term care facility.
Every facility has at least one administrator identified as the supervisor of the facility. Most have some
licensing status, such as nursing home administrator and assisted living administrator. These licenses
require classroom hours and testing and must be renewed periodically. Administrators would generally
like to meet every resident and family and are the people to address at any time with any issue if
other avenues have not been successful.
Administrators usually make the final decision whether a resident is admitted to the facility. They
look at the information from the hospital chart, at their own staffing availability, and at the acuity of
their residents. The latter term describes the amount of care that the current resident census requires.
A facility may have unoccupied beds but if the residents in the occupied beds require an unusually high level of care, the administrator may choose to keep an empty bed rather than admit another resident
with high care needs. Administrators in nursing facilities make these decisions in collaboration
with admissions staff, often located in social services. In assisted or residential care facilities, and in
foster homes, admission decisions are usually made by one person.
If the resident is receiving specialized rehabilitative treatment, such as physical therapy, other disciplines should seek to support a positive outcome from that treatment.
Nursing will attempt to stabilize the resident medically and provide effective pain control in order to maximize rehabilitative efforts that require focus and energy. Dietary staff will focus on sufficient nutrition to promote healing, skin health, and energy for rehabilitation. Activities or recreation staff will introduce diversions for promoting focus, socialization, gentle use of all muscle groups, skill building and relaxation, all of which will maximize the quality of the time spent in rehabilitation. Social services staff will follow up with the discharge plan that will reflect goals met and challenges to overcome in order to move to a lower level of care. The latter are not necessarily for the residents and families to address. Challenges may include staff tasks, such as equipment to purchase and home health services to arrange.
A resident who is expected to remain at the current level of care for a time will receive the same attention to care planning but without the time pressures for change to a lower level of care. Instead, the focus will be on positive adjustment to the facility with meaningful relationships and activities developed to match the resident’s personality, history, and expectations.
Care conferences are usually arranged within a week or two of a skilled-nursing admission and within the first month of a longer-term admission. The first conference is likely to last about 30 minutes. Regular quarterly conferences are held for long-term residents and these can last from 15 to 30 minutes. Quarterly conferences are usually held on a schedule and families and residents receive formal notice.
After a period of adjustment, some families stop attending care conferences, perhaps content that staff will provide the expected care. This is not necessarily a signal that families do not care, since most do visit and provide for needs as requested. However, the care conference is a special opportunity for some staff to interact more directly than usual with families. It can be disappointing to consistently report only to other staff and for the record with no input from families to enrich the care plan.
All care facilities that meet minimum standards offer residents and family members opportunities to meet with facility staff to discuss the status, progress, and care or service plan for the resident. The care or service plan is the basic document which addresses all care, including treatments and medication, that the resident will receive in the facility. The meeting is usually described as a care conference and some form of it is legally required in nursing and assisted living settings.
If the resident is able to direct her own care and wishes to do so, she may invite whomever she chooses to attend the conference with or for her. Such conferences are unique to each facility and reflect the culture of that facility. However, some facets are likely to be present in all settings.
The issues discussed will include the resident’s current health status, with reports about any incidents, medical tests, illnesses, injuries, physician orders, or other events that occurred during the period covered. Each discipline involved in care will have an opportunity to report on the status of the resident. These disciplines include nursing, culinary or dietary, recreation or activities, rehabilitation, and social work. The goals and objectives of care are discussed. Any challenges to the goals and objectives are raised together with opportunities for problem-solving. If the resident is expected to discharge to another level of care, steps required for a safe and effective discharge are discussed at that time.
The resident is at the center of the care conference and, if she directs her own care, she should have all of her information needs addressed during its course. Her input is also valuable to the staff for improving care at the facility. With the information she receives at the conference she should be able to continue effectively directing her course of treatment to meet her goals.
When a placement is long-term or the resident is physically or cognitively impaired beyond being able to participate in care planning, a family member usually represents her at the care conference. Those family members who attend conferences regularly become more effective partners in the care team. They arrive with lists of issues, concerns, questions, and suggestions to make the best use of the time. When unable to attend they call a staff person, usually a nurse or social services staff, to introduce issues for the conference and then to receive a report of the issues discussed at the conference.
Staff from most disciplines will attend all care conferences, but because time conflicts may arise other disciplines may read some reports from notes provided by those absent. Each discipline will focus on the strengths exhibited by the resident and the challenges remaining to reach stated goals. The presentation of staff information should be holistic with the interdependence of the various disciplines being evident by the close of the conference.
Culture describes the norms, actions, attitudes, behaviors, beliefs, and values of groups of people who live, work, or even just play together. The norms of cultures change as people enter or leave the group and as crises arise. The illness of a beloved parent is a crisis to a family group and affects its culture. The culture in crisis will be in contact with other cultures which are not in crisis—the hospital, the clinic, the nursing facility, the assisted living facility. The cultures have to interact with one another and clashes can occur.
Aside from the culture that develops with any group of people working together, some medical and long-term care facilities are identified with another distinct culture—faith-based, fraternal lodge, ethnicity—as opposed to a private facility. Some staff and many residents and families may be drawn to a facility by the familiarity of the culture. Other families may be drawn to that facility for other reasons and disregard the impact of the cultural identity of the facility environment, only to come into conflict with it at a later time.
Hospitals, clinics and nursing facilities operate on a medical model where care is directed by physicians and implemented by nurses and other licensed and certified staff. Residential, assisted living, and foster care facilities operate on a more social model and informal input from families can shape the care plan accordingly. The formality of the medical model and the informality of the social model can both lead to cultural clashes among family and staff. Medical staff are required by training and regulation to be task and detail oriented. This is exactly what patients need and want related to such areas as surgery, wound care, distribution of medication, and diagnosis. However, in long-term care facilities, families and residents may want more control over their care and the option of creating a more holistic environment where social and cultural needs have equal priority. Even in the most acute medical setting, families demand and can achieve some status in providing care or at least being present to oversee care.
With effective communication, a balance can be achieved and consensus built among the resident, family, and staff. Supervisory or social work staff can intervene to help with communication. If families or residents feel that they need the intervention of mediators or representatives outside of the facility, all states have a long-term care ombudsman program through which professional staff and trained volunteers visit facilities and assist them in finding a voice for their concerns. In addition all states have aging services staff who are assigned to specific facilities. Their responsibilities are mainly for residents who receive Medicaid (or welfare) benefits but they can also provide some representation for other residents and families if it is requested. All states also have some form of adult protective services which can provide access to intervention by residents, families, and facility staff.
Some families find that family history is too negative and communication too complex to manage long-term care effectively. They hire private case managers to formally direct care and focus on emotional and social connections with the resident. It is very rare for facilities and families to become entangled in conflict to the point of requiring attorneys but if this does occur, it is important for the family to choose an attorney with elder law experience.
Cedar Sinai Park, in collaboration with Jewish Family and Child Service, invites you to the workshop
Understanding Elder Care Options
What are the various levels of care for your loved one? What determines changes in levels of care? What can you do to remain effectively involved in your loved one’s care? How do you have that difficult conversation with your loved one about changing the level of care?
Join us for this workshop, a part of the new Elder’s Family Learning Initiative series at Cedar Sinai Park, to discuss answers to these and other tough caregiving challenges.
Family members can visit their loved one in an elder-care facility as caregivers and as casual visitors.
Primary Caregiver Visits
Some visitors, usually spouses and adult children, spend hours, if not the entire day, at the facility. They were and remain the primary caregiver and will resume the role formally if and when the resident discharges. Staff can rely on them to be alert to needs and to provide some casual care such as assistance with eating, set up for grooming, and getting fluids and snacks as appropriate. Facility staff are accustomed to this attention and value these visitors. Rarely does conflict arise over staff retaining the ability to provide appropriate care related to privacy or caregiver insistence on providing care in a manner that conflicts with facility protocols. Equally rare is the situation where staff are concerned about the health and welfare of a caregiver, usually a spouse, who is sacrificing her own well-being to be in attendance at the bedside at all times.
Facility staff can help familiarize caregiver visitors with routines and schedules, alert them to special activities, and provide support. These routines actually are of most value when the home routine, prior to admission, is recreated as closely as possible to make the resident comfortable and hopeful.
Most visitors, even some spouses and children, visit for defined time periods. If a resident is weak and ill, short frequent visits, daily for no more than an hour or less are most effective. If the resident is interactive, note interests and energy and provide a glimpse of the world she is missing and to which she is likely to return. If she is not responsive, or just too weak to hold up the usual interactions, bring a book to read, magazines, tapes or read letters, cards and e-mails from home.
Begin visits with a greeting, stating your name and some identifier to residents who cannot see well or have poor short term memory. Bring gifts, small but pleasant—flowers, books, magazines, cards, or food for those who are not on restricted diets. On the trip to the facility, try to review some positive topics of conversation to present—a phone call, another visit made, a religious service or community event, a joke heard, an incident witnessed. Pets and children make good topics of conversation and can even make good visitors if plans are made ahead of the visit. Neither the visiting pets nor children need to do anything—their presence alone brightens the area. Both should be rested, clean, and in good health for a visit. Check with the facility for protocols.
Visitors may note that some residents at the facility have few or any visitors of their own. Staff can confirm this and would be delighted to facilitate appropriate relationships with other residents. Such visits may be convenient when one’s own family member is receiving care, therapy, or is asleep. Such networks help to turn facilities into communities. One universal element of visits throughout the continuum of long-term care is that any facility which generally discourages visits at reasonable times from involved family members and friends should be avoided as a potential placement and reported to the local aging services system.