This growing population of people needing memory care services presents a challenge for operators in balancing the freedom they promise with the security they need. Fortunately, technology advancements now allow facilities to keep residents safe without making them feel like they are being held hostage, security experts say.

“In many respects, the key concerns have remained consistent over the years — personal or medical emergencies, duress, wandering, falls and general facility security,” says Steve Elder, senior marketing manager for
STANLEY Healthcare. “What’s changing is a greater focus on the individual situation of each resident. Facilities are looking for technology that will allow them to better understand and meet the needs of each resident.”

Wandering and fall prevention are the biggest growth areas of the security market overall, Elder says, as more assisted living facilities investigate potential systems that are affordable, unobtrusive and effective.

“Fortunately, the technology has been moving in this direction, with systems offering far more integration options than in the past,” Elder says. “For example, ‘emergency call’ solutions can now be extended to cover wander and fall management so that assisted living facilities don’t need to invest in three separate systems.”

Discretion paramount

To preserve each resident’s dignity, security systems need to be practically invisible around the facility. Nothing screams “institution” like overtly placed cameras and alarms.

In today’s security climate, there is no need to have devices out in the open for all to see, Elder says. It is now possible to conceal them without sacrificing safety.

“It is preferable to keep infrastructure like door monitors and readers as discreet as possible or hidden altogether behind drop ceilings,” he says. “Some facilities are becoming very creative with this, using wall sconces instead of traditional dome lights for their nurse call system.”

Reducing audible alarms is another major trend, Elder says, because there are many options to send alerts directly to caregivers via hand-held and wearable devices.

RF Technologies’ CodeWatch transmitter is such a device. Using radio frequency identification technology, the tracking device is worn by residents deemed to be at risk for “elopement.” Worn around the wrist, the device resembles a wrist watch and sports decorative faces like the American flag and forget-me-not flower. 

When a resident wearing a transmitter comes within range of a monitored exit, near-door antennas register the transmitter’s presence and communicate with a door controller to secure the exit.

“The addition of colorful CodeWatch transmitters and banding is not only a wonderful way to increase acceptance by memory care residents, but they’re something our customers have been asking for,” says Michelle Dalton, marketing director for RF Technologies. “We’re committed to providing our customers with discreet solutions that help them keep those under their care safe. Communities can also let their residents choose which transmitter and banding color they prefer, helping residents embrace the security measure.”

Smart sensors

Another clandestine security device is the QuietCare system from GE-Intel Care Innovations. About the size of a quarter, the motion sensor technology is programmed to study resident lifestyle routines and detect variations from the patterns it establishes.

“Any changes in resident patterns are transmitted to caregivers, who can respond and intervene if necessary,” says Bryce Porter, the company’s Americas sales manager. “This system allows for a more proactive, preventative level of care that reduces risks of falls or injury.”

By giving caregivers a window into each resident’s routines, the QuietCare system improves upon the conventional reactive method of responding when something has already happened.

“The name of the game has always been about how fast staff members can respond,” Porter says. “This system detects anomalies before they can turn into an emergency.”

For instance, if there is a significant increase in bathroom frequency at night, the system detects that and notifies staff. This intervention could preclude serious injury or illness, Porter says.

‘Peace of mind’

A concealed, unobtrusive security system can be a major selling point for prospective residents and their families on how the facility values the dignity and security of its population, Elder says.

“It is essential to demonstrate the benefits to residents and their families, showing how technology can actually empower residents, giving them more choice,” he says. 

Porter adds: “The main pitch is that a sound security system enhances the lifestyle that assisted living offers. Because the clientele coming into today’s assisted living facility has more medical and personal needs, it gives them peace of mind knowing that they can have proper care and safety while preserving their dignity and independence.”

Investigators found that middle-aged people engaged in physical activity at least twice a week had a lower risk of dementia than those who were less active. The protective effects of an active lifestyle were especially pronounced among overweight individuals. Even people who became more physically active after midlife appeared less likely to experience dementia.

Full findings appear in the journal Alzheimer’s & Dementia.

Several modifiable risk factors for dementia were suggested, but further refinement of this information is essential for effective preventive interventions targeted at high-risk groups, experts agree. 

Leisure-time physical activity (LTPA) is a particularly important due to its broader effects on health in general and cardiovascular health in particular. Previous research has yielded inconsistent evidence on the association between LTPA and dementia, possibly because of short follow-up time, intensity of physical activity or population characteristics such as sex, body mass index, age or genetic risk factors of dementia.

Recent findings from the Cardiovascular Risk Factors, Aging and Incidence of Dementia (CAIDE) Study demonstrated that those who engaged in LTPA two times or more each week had a relatively lower risk of dementia. 

The findings were not explained by socioeconomic background, age, sex, genetic risk factors, obesity, weight loss, general health status or work-related physical activity.

These results suggest that the window of opportunity for physical activity interventions to prevent dementia may extend from midlife to older ages. Results from currently ongoing trials, such as the Finnish multi-center trial FINGER, may give more detailed information about the type, intensity, and duration of physical activity interventions.

In an unrelated study released last year, British investigators at Cardiff University found that regular exercise is the most effective single lifestyle choice people can make to reduce their risk of dementia.

KEY QUESTIONS

This may be a good time to ask yourself three important questions about your property:

1. How market-responsive is my property, really?
2. Do I compete effectively on product, price, services and value?
3. Will I really be able to compete this year and beyond? 

Capital investment planning must deal with difficult issues involving both individual units and common/public spaces. Are the needed investments really worth the dollars you would have to commit? How much would you have to raise monthly fees in order to break even on funding the added costs, assuming borrowed and invested funds at today’s typical cost of capital of approximately 5%?

Answering these questions involves a four-step common sense analysis. First, determine the amount that should be invested in each individual living unit. Let’s use $20,000 as an average cost per unit. Some operators are actually upgrading their older units at a cost exceeding $40,000 per unit. Let’s assume you would like to break even on the added cost to spend $20,000 with a 5% cost of capital. The total principle and interest is called the “debt service constant.” We’ll use a 30-year loan term or amortization. Now we must adjust for a debt service coverage ratio (DSCR). That’s because your friendly lender wants you to have at least $1.30 in available cash (after operating expenses) for every dollar you owe in debt payments. This analysis would yield a new annual debt service obligation for a $20,000 investment in each improved unit of approximately $150 per month. 

The concept works for both independent living and assisted living. For an older independent living community with a typical monthly service fee of $2,700 per month, the total added cost of the $20,000 investment of $150 per month represents an increase of approximately 5.6%. For assisted living, with a monthly service fee of $3,400 per month, that $150 per month cost represents about a 4.4% increase. The increase may appear modest, but these are obviously additional out-of-pocket dollars for the senior consumer. 

Does the increased perceived value in your significantly improved unit justify the increase in monthly service fees? Some existing residents might experience mild sticker shock. However, a new prospect might see considerable value in the improved vacant unit. Many owner/operators are implementing the strategy exclusively for currently vacant units where the price vs. value rationale is clearly favorable.

The analysis for investment in common area improvements is essentially the same as that of a typical unit . . . with one big difference. With a common area investment, you can spread the capital cost recovery across all of your occupied units. For example, a $200,000 common space investment in an 80-unit assisted living community at 93% occupancy and a 5% cost of capital would require each resident’s monthly service fee to be increased by only about $19 per month. 

TWO PHASES

Consider implementing a capital improvement plan in two phases:

1. First, the common/public spaces — this offers the biggest bang for the buck at a very nominal monthly cost per resident.

Then . . .

      2. Upgrade selected living units — at least on a unit turnover/attrition basis.

Aging physical plants and property improvements may present short-run challenges, but in the long run, benefits can be permanent and significant. 

About 47% of elderly people had completed a living will as of 2000, and that increased to 72% by 2010, according to data from the Health and Retirement Study. This is a national survey done by the University of Michigan Institute for Social Research, on behalf of the National Institute of Aging.

However, during that same period, hospitalization rates increased in the last two years of life, the investigators found. 

The proportion of people dying in the hospital decreased from 45% to 35%, but the researchers determined this had little to do with advance directives. This could be because directives focus more on the type of care rather than the setting where it is provided, they surmised. 

“These are really devices that ensure people’s preferences get respected, not devices that can control whether a person chooses to be hospitalized before death,” said Maria Silveira, M.D., MA, MPH.

Among those who have completed a living will, most have both explained their treatment preferences and appointed a surrogate to make care decisions for them, according to the findings in the Journal of the American Geriatrics Society.

Diabetes-wound link

Diabetes is the co-morbid condition most strongly associated with the development of pressure ulcers in senior living residents, according to an analysis of existing research.

Investigator Yuta Kurashige, M.D., Ph.D., identified seven studies that have been done on this topic. The smallest involved 827 residents in the United Kingdom, and the largest involved more than 14,600 in the United States.

Six of the seven studies found that diabetes mellitus is associated with pressure ulcer development, according to Kurashige, of the Hachioji Medical Center at Tokyo Medical University. 

Some of the studies found that Parkinson’s disease, hip fracture and peripheral vascular disease also are correlated with pressure ulcer development, but other studies indicated that these conditions are not associated with PUs, Kurashige found. His findings are published in the International Journal of Clinical Dermatology & Research.

Alzheimer’s test

A new blood test reveals with 90% accuracy which people will develop Alzheimer’s disease or mild dementia within three years, according to study results in Nature Medicine.

The study involved 525 seniors. An analysis of 10 lipids predicted the cognitive conditions, the researchers discovered. They say this could improve interventions and drug development.

Further testing is needed before the test could be offered to the public. Without any proven preventive therapy, screening for dementia might be pointless, prior research has suggested. 

Enhance care

Stroke survivors have “enormous” palliative care needs, and healthcare providers should ensure they can provide these services, according to a scientific statement released by the American Heart Association/American Stroke Association.

In the first statement outlining palliative care guidelines for stroke survivors in the United States, members of the writing group emphasized the need for care coordination among different types of providers and clinicians. Nurses and therapists are two members of a care team that also should include primary care providers, neurologists and other specialists, families and the patients themselves, according to the statement.

High-quality palliative care should be patient- and family-focused to aid in the complex decision-making that characterizes stroke care, the guidance states. 

Specifically, the care should involve “effective, sensitive discussions” about physical and mental losses and, potentially, dying. 

In an age where personal information is increasingly at risk of being exposed and stolen, protecting that data from brazen interlopers has become a monumental challenge.

Many senior living operators are bound by HIPAA privacy and security rules to guard their residents’ information and should have a risk assessment system in place to ensure compliance.

To that end, the HHS Office of National Coordinator for Health Information Technology and Office for Civil Rights are making a new security risk assessment tool available to help small- to mid-sized providers conduct their own risk assessments. 

The ONC application, available for downloading at www.HealthIT.gov/security-risk-assessment also produces a report that can be provided to auditors. The tool is available for both Windows operating systems and iOS iPads.

“The new tool we are releasing will help operators assess the security of their organizations,” says Karen DeSalvo, M.D., national coordinator for health information technology.

Tech snafu victim?

HHS Secretary Kathleen Sebelius announced she was stepping down in April. Many linked her departure to a disastrous rollout of the Healthcare.gov website. 

Her departure coincided with an announcement that more than 7 million people had signed up for insurance cover under the new federal healthcare law. 

President Barack Obama is set to nominate Sylvia Mathews Burwell, director of the White House Office of Management and Budget, to take over at HHS. 

She faces congressional confirmation — where, according to pundits, she is likely to face resistance from Republican senators who continue to oppose the Affordable Care Act.

HIPAA data secure?

Thousands of people receiving senior living services in Michigan have had their personal information compromised due to a laptop and flash drive theft, the state’s Department of Community Health (MDCH) has announced. 

The computer and flash drive belonged to an employee of the state’s Long-Term Care Ombudsman’s Office, and were stolen on Jan. 30 or 31, according to MDCH. 

The unencrypted flash drive contained personal information of more than 2,500 living and deceased individuals, and more than 1,500 records contained a Social Security or Medicaid identification number.

The data on the laptop was encrypted, MDCH said in an April 3 press release.

After being alerted to the Health Insurance Portability and Accountability Act breach on Feb. 3, investigators reconstructed the stolen data and notified affected parties, according to the community health department.

Poor back-ups?

MSS Analytics alleged that too many providers rely on outdated and inefficient practices to back up and archive resident-related information. The organization surveyed 150 senior IT professionals nationwide. They found that processes tend to be inconsistent when it comes to safeguarding data and meeting long-term compliance requirements.

New IT funds

A proposed White House budget for the 2015 fiscal year seeks $1.8 billion to bolster health information technology incentive payments — the same as last year. The proposal also calls on the Department of Health and Human Services to use funds to upgrade technology tools related to Medicare and Medicaid in ways “that encourage high-quality and efficient delivery of health care, improve program integrity, and preserve the fundamental compact with seniors, individuals with disabilities, and low-income Americans.”

Good on balance

A RAND Corporation study finds that the overall benefits of health IT outweigh negative or neutral effects of their use, but challenges remain. Almost 20% of the studies yielded negative results, and only 45% saw overwhelmingly positive outcomes. 

Blast program

The Government Accountability Office released a report that chastises the Meaningful Use EHR Incentive Program. The initiative is not guided by a clear strategy that outlines goals — or how to achieve them, the GAO claimed. One improvement would be to mandate the use of clinical quality measures. Outcome-specific performance measures also should be put in place, authors noted.

Hospice mandate

Operators will have to report certain hospice quality measures to the federal government starting July 1, the Centers for Medicare & Medicaid Services formally announced in a recent Federal Register notice. The Hospice Item Set has been designed to track seven quality measures endorsed by the National Quality Forum, according to the notice. These are pain screening, pain assessment, dyspnea screening, dyspnea treatment, patients on an opioid given a bowel regimen, and patient treatment preferences and beliefs/values. Hospice providers will be required to submit records for each patient at admission and discharge, the Federal Register entry states. These records will include some administrative information related to patient identification, as well as items related to the quality measures.

Assessment update

Lawmakers in both houses of Congress have unveiled a draft bill calling for senior living providers to furnish standard assessment data, with the goals of enabling better quality oversight and driving Medicare payment reform. 

The Senate Finance and House Ways and Means committees on Tuesday introduced companion versions of the “Improving Medicare Post-Acute Care Transformation Act of 2014” (IMPACT Act). 

Should the bill become law, the Minimum Data Set and other assessment instruments would be modified to enable different types of post-acute providers to submit standard data related to patient assessment, quality measures and resource use measures. 

The patient assessment data would include such items as functional status, cognitive function and medical condition, according to the draft. Quality measures would include changes in skin integrity and incidence of major falls. Resource use measures would include total Medicare spending per beneficiary. Risk-adjusted rates of potentially preventable hospital admissions and readmissions also would be tracked as a resource use measure. 

Why are some therapists so good at motivating residents while others have a history of flat-out refusals or a lack of participation?  

According to American Physical Therapy Association Spokeswoman Alice Bell, the most important component of establishing success in rehab therapy is getting to know your clients and understanding what makes them tick.

“I don’t believe there is an unmotivated person — it’s just a matter of figuring out what they’re motivated toward or away from,” says Bell, vice president of clinical services and director of physical therapy for Genesis Rehabilitation Services. “The reality is that if we don’t take the time up front to talk to and listen to our patients and build a good foundation, then nothing else we do has value.”

Medical limitations

Most therapists can usually pick up on patients who might need more help engaging in therapy through the initial evaluation process. In doing so, they take into account a patient’s social and medical history, says Neely Sullivan, education director at Select Rehabilitation.

“If a patient hasn’t engaged in physical activity their whole life, they’re probably not going to be eager to participate in physical activity later in life, either,” Sullivan says. Michael Biel, CScD, agrees, noting that being ill often affects motivation as well.

“If I’m seeing a person who has multiple medical problems, their speech behavior may not be at the top of the list of things weighing heavily on their mind right now,” says Biel, a professor of Communication Disorders and Sciences at California State University-Northridge. “Sometimes, people simply aren’t ready to engage in our treatment until they’ve made headway on some other medical issue.”

In addition, some patients can’t help but display a demotivated state during therapy sessions, as a result of changes in their central nervous systems due to dementia or neurodegenerative diseases such as Parkinson’s, Biel says. Rather than convincing these patients to become motivated to participate, therapists have to understand that they don’t have as many goal-directed thoughts as other people do, and therefore don’t experience the same kind of reward sensations.

Whether or not a patient takes an active role in rehabilitation therapy can also often depend on his or her diagnosis, says Kristy Brown, CEO and founder of Centrex Rehab in Minnesota.  

“Someone who has just received a terminal diagnosis is not as likely to be motivated to participate in therapy unless it means that they just have to do enough to get home to a more comfortable setting,” Brown says. “On the other hand, therapists typically cannot work fast enough to get people with elective joint replacements home, as they are extremely motivated to get back to their day-to-day functioning.” 

Goal setting

One way to engage clients is to dig deep in understanding the patient as an individual, says Mark Besch, vice president of Clinical Operations for Aegis Therapies. 

“Ask them about their family and their grandchildren, what kinds of activities they enjoy, and pick one or two nuggets to use as an aspirational goal,” Besch says.

Therapists also might consider using functional-based assessment tools to help develop goal-directed therapy, Sullivan says. 

“This way you’re not just focusing on what the patient can’t do anymore, but instead on what they want to get back to doing,” she says. For example, if a patient used to be a great cook in her home, perhaps there are opportunities for her to get involved in a cooking club, or to cook small meals for other residents.

“Just figuring out what’s meaningful to that patient, and planning out the small steps they can take to incorporate that into therapy can really help a patient get back to doing the things they love,” she says.

It’s also important to focus on goals that are achievable in a relatively short period of time and have some value and meaning to the patient, particularly at the onset of treatment, say Bell and Biel.

“A lot of this is about self-efficacy — this sense of our ability to achieve goals,” Bell says. “Part of being a therapeutic agent is making sure that we instill in our patients a confidence in their ability to achieve things, which means we have to have realistic goals.” 

It’s also important for therapists to communicate compassion and empathy in every patient interaction, says Holli Benthusen, regional director of business development and client relations at Select Medical Rehabilitation Services Inc. When patients feel that the therapist really understands how they’re feeling, it can help address common problems therapists may encounter with patients during a therapy session, including anxiety, anger, confusion or pain.

“As a therapist, I find these to be some of the biggest barriers to reaching patient goals, and when I can work through them, I feel more empowered and more successful, which reduces my own anxiety and helps me to enjoy my job more,” Benthusen says.

Making therapy fun

Forget orange cones and resistance bands. Today’s physical and occupational therapy sessions are more likely to use Google Earth to have patients take a virtual walk on the beach or make use of giant touch-screens to task patients with putting together a life-size jigsaw puzzle — all while practicing standing balance, endurance, coordination, range of motion and dual tracking. The list  could go on and on. 

“Once you bring technology into the picture, it opens up a new world of ways to find different connections with different residents,” says Christopher Krause, director of the therapy business unit for It’s Never 2 Late. “If you’re at all creative as a therapist and committed to getting to know your patient, you can use a smartphone, a tablet, a laptop — any computer system — and basically start riffing on what’s of interest to that individual.” 

Incorporating gaming systems such as the Nintendo Wii Fit or Wii Sports into therapy sessions can keep people engaged while also adding in a competitive component.

In speech and occupational therapy, patients often easily tire of doing traditional paper and pen activities, which undermines the therapy’s effectiveness, says Dan Michel, CEO of Dakim BrainFitness. To address this issue, many therapists are now using computer-based “brain fitness” software, which incorporates graphics, music and videos to keep patients stimulated and engaged in their cognitive exercises.

Steve Sarns, vice president of sales and marketing for NuStep, notes how much the environment — and whether or not it makes people feel alive — can play a role in motivation.

“We need to move away from the more clinical environments and make the therapy rooms a more motivating place to be,” he says.

Facilities that are committed to providing updated, bright, spacious, comfortable gym areas, along with adequate equipment and updated technology, also often inspire therapists to infuse their approach with more positive energy when initiating a treatment with a patient, says Tammy Begler, director of Clinical Services at Synertx.

“Walking into a facility that values and supports therapy motivates the therapist and therefore motivates the patient,” she says.

When to take a break

Krause says it can be easy to look at patients who, for all intents and purposes, appear fairly old and frail and to want to give them a break. But when it comes to building strength, endurance and coordination, the only way to really do that is to push them beyond their comfort zone.

But it’s also important to know your patient’s limits and when to push and when to hold them back, he says. This is a skill that just comes with on-the-job experience, Begler says. By monitoring vitals during activities and exercise, assessing the quality of a patient’s movement and effort, over time therapists get to know when to take a break and when to push the patient to the next level of capabilities.

“This can be as simple as noting breathing rate and effectiveness of deep breathing versus shallow breathing during a gait activity,” Begler says.

Paying attention to these vitals is important, because one downside of pushing too hard and too soon is that it may actually delay recovery, explains Laszlo Bayer, vice president of sales and marketing at Therapeutic Industries Inc. 

“The key is developing a relationship of trust with the patient, and there are many products and technologies available that greatly reduce the risk of injury for both patient and clinician, and provide greater productivity,” Bayer says.

For medical or therapeutic equipment to be effective, it must be operating properly, and inspected, tested and calibrated on a timely basis by a company that has experience with physical therapy equipment, says Morton Beckman, director of operations at GDC Medical Electronics. Some PT equipment, for example, imparts some type of energy, such as transcutaneous electrical nerve stimulation (TENS) therapy or low-volt therapy. The right tests can prevent burns or shocks.

“Testing and inspection of that equipment should be important to the therapist for safety reasons and for proper treatment of the patient,” Beckman says.

While tight funds can prove challenging when revamping outdated or dilapidated spaces, beautiful assisted living communities can be had on even shoestring budgets. The secret to making facilities the toast of the town? Advanced planning, effective prioritizing and a cache of creativity, experts say. 

“Today’s assisted living owners and designers are under continual pressure to do more with less. Every dollar spent needs to work even harder to show a favorable return on investment,” says Jim McLain, general manager, C/S Eldercare Interiors. “Achieving the desired look and finding products that can stand the test of time is critical.”

Pinpointing priorities

Operators often question whether they should focus their attention on common areas or residences. Each facility is unique and certain areas will understandably command a larger portion of the budget. If a facility caters to rehab residents, for example, operators may want to make residents’ private spaces a priority, for example. In memory care units where resident socialization is actively promoted, it may be more important to focus attention on common areas. Either way, though, designers stress that neither residences nor common areas should be neglected. 

Before earmarking design dollars — and especially before making any purchases — attaining feedback from all stakeholders is essential. “Getting this input is valuable for prioritizing where and how the design budget will be [allocated]. Without that, you can easily lose focus and your budget can spin out of control,” says interior designer Ebonee Bachman of Moonlight Interiors. Safety and code issues should always be addressed first, she reasons. “From there, you can assess which areas would benefit most from an updated look or new features to better meet residents’ needs.”

Paying more for contract-grade seating almost always saves operators big money in the end, design experts agree. Many operators are enticed by consumer-grade furnishings’ lower price, but if seating is placed in well-used common areas, premature replacement will be a near certainty. “High quality, healthcare-grade furniture will have reinforced frames that can stand up to heavy use,” notes Sherry Gaumond, director of design for Larson & Darby Group. “I’ve seen facilities make the mistake of skimping on their seating budget, only to find the frames racking and a complete replacement needed after a year-and-a-half.”

Sofas, love seats and chairs should feature dense foam, raised seat height, and durable, washable fabric that holds up against stains and moisture. As long as furniture frames are well constructed and durable, facilities can get many years out of them by simply swapping out fabric styles and patterns, Bachman says. 

When budgeting for resident rooms, beds should take center stage. Gaumond sees value in standardizing beds. Aside from driving down purchase price, this can make furniture rearranging easier. “You don’t have to get a bed with all the bells and whistles, but you do need to make sure it’s a quality model that will last,” adds Bachman. “It will likely be used by more residents than just the person using it today.”

Most resident beds come with headboards and footboards integrated with frames, and many are offered in various faux wood finishes to match surrounding furnishings. 

‘Lux’ looks for less

Although quality furnishings should always be sought, that doesn’t mean luxurious-looking accessories should fall by the wayside when budgets are slim. On the contrary, creative layering of accessories — many of which can be purchased at discount consumer stores — is one of the easiest and most cost-effective ways to punch up a space. 

“Little details matter and, typically, there’s nothing about accessories that makes them contract,” says Catherine Richardson, design consultant for Direct Supply Aptura. This means facilities can take advantage of inexpensive or mid-range finds for artwork, lamps, lampshades, and other decorative pieces. Facilities looking to create a more updated, trendy and welcoming lobby can get good attention from installing a coffee bar. It’s a relatively inexpensive way to make a big impact, adds Chris Morgan, healthcare renovations national account manager for HD Supply Facilities Maintenance. 

Murals make attractive artwork and can now be inexpensively purchased at home goods stores, such as Pottery Barn, says Richardson, adding that they can also be easily removed. Commissioning local art students for artwork — or design students for building shelves or other accessories — can be a low- or no-cost solution for low-budget facilities. “You can also ask children to provide artwork and then frame it,” notes Bachman. “This really incorporates community and makes a space more personal.”

Window dressings don’t have to cost a bundle, either. Although Bachman urges facilities to pick premium functional coverings, such as blinds and shutters, she says residential-grade soft accents and decorative panels can work well for facilities with limited budgets. “These are there for looks, so they don’t have to be made of custom-made fabrics.”

A big effect can be made with simple wall covering changes, too. Designers see paint as one of the least expensive, yet high-impact products available, allowing facilities to instantly update a look with the stroke of a brush. One easy way to save, according to Morgan, is to “remove wallpaper, skim coat walls with a light texture and then paint with a semi-gloss or eggshell finish.” If designer wallcoverings are preferred, Richardson suggests limiting it to a focal wall. 

Look out below

Don’t forget the flooring, either. Gaumond says one of the most high-impact, budget-conscious changes she witnessed was when a facility swapped its high-maintenance, high-glare VCT flooring with homey, durable and low-maintenance wood grain sheet vinyl. “This was a county facility, so we really had to be careful with money. That meant we also had to factor in maintenance expenses,” she says. High-impact, wood grain wall protection with integrated handrails further added to the warm design aesthetics, while maximizing safety.

Dining areas deserve design attention, too, but they can chew up a budget if operators aren’t careful. Again, quality seating and fabrics are critical, but operators can opt for value-priced table bases. “They’re often hidden by tablecloths or chairs,” Richardson reminds. 

Rooms with a view

Resident bedrooms can get a quick and inexpensive update with decorative headwalls. “We’re finding many designers are incorporating matching full- or wainscot-height wall systems that improve design aesthetics and offer protection of wall surfaces,” McLain explained. 

Some facilities, he adds, are choosing headwall options that create a high-end hospitality look, while others are opting for warmer, more residential appearances. Either way, it’s a look that doesn’t cost much and can be installed even by do-it-yourselfers. “These systems surprise owners by how easy they are to install and how affordable they can be to design and specify,” McLain explains. “We’ve seen many resident rooms transformed into beautiful, comfortable living spaces with just a few dollars spent.”

 Bedding can offer a budget-friendly boost, but only if key factors aren’t overlooked. Facilities don’t need $300 bedspreads. Non-quilted options can cost about one-third less, according to Richardson. Still, she warns that any bedding chosen must be able to withstand high washing temperatures. “Very inexpensive bedding may not hold up, and having to replace it quickly winds up costing much more in the end.”

Bathrooms can offer big bang for the buck. Sources agree that the key is sticking with more timeless and durable designs, like easy-to-maintain subway tile to accent walls, and porcelain floor tiles that are color-through, so white glazing won’t be seen when chipped. Many experts are seeing a steady push for spa-like bathing areas complete with inviting décor and soothing lighting, such as wall sconces on dimmer switches instead of fluorescent ceiling lights.

“Today, it’s not just about taking a bath or shower. Residents want a true bathing experience,” says Lee Penner, owner of Penner Manufacturing.

Bathing areas should be spacious — or, in the very least, carefully laid out to allow for safe access and mobility by residents and staff. If done right, revamped bathing areas will be money well spent because they’ll serve as an effective marketing tool for drawing in prospective residents, designers note. 

With proper planning and careful execution, the same can be said of virtually every reworked space. “You can definitely create a ‘wow’ space with relatively little investment. It’s just knowing where to invest and where you might be able to safely cut some corners without sacrificing quality,” Bachman reasons. “Marrying those two is what brings success.” 

This safety-first approach is prudent, especially considering more injuries occur during lifting, handling and transferring than any other resident care activity. According to Bureau of Labor statistics, heavy lifting contributes to more than 200,000 occupational injuries each year, most of which affect nursing aides, orderlies and other frontline caregivers. When lifts and transfers are combined with bathing — and the slick, wet surfaces that accompany it — the risks become even greater. In fact, bathing areas are where most musculoskeletal and head injuries typically occur in every home environment, the Centers for Disease Control and Prevention reports.    

A growing array of innovative equipment and solutions is helping assisted living operators better manage those risks, while significantly improving the overall lifting, transferring and bathing experience for residents and staff alike. 

“Quite simply, the technology is better and the market has demanded that bathing and lift systems evolve with the times,” says David Anderson, national sales manager for Apollo Bath. 

Lighten the load

As more assisted living residents require assistance before, during and after bathing, having the right equipment available (and readily accessible) is imperative. More than ever, safety lies in the details, notes Derek Newbould, associate business manager for Invacare Continuing Care.

With lifts, new-and-improved features are making facilities take notice. “New lift safety features include anti-entrapment sensors, which automatically stop the lift if it meets any resistance while it’s being lowered,” Newbould says. Emergency up-and-down functions are another added safety feature, he adds, as are wider base openings that accommodate wider wheelchairs and make lifts more versatile. 

Whenever possible, the best way to minimize risks is to avoid transfers altogether. In assisted living, where some residents prefer a beauty shop approach to shampooing, adjustable sinks can allow many non-ambulatory residents to stay in their wheelchairs while their hair is washed. “Because the number of transfers is reduced, the opportunity for transfer- and lifting-related work injuries for facility staff is also reduced,” says Dave Shusterich, president of Accessible Systems LLC, referring to the benefits of the company’s Adjust-a-Sink adjustable height shampoo bowl.

Adjustability extends to other bathing fixtures, as well. With bathing areas often cramped, especially when wheelchairs or lift equipment are present, having sinks and other bathroom fixtures that can be adjusted for each resident’s needs can make maneuvering and bathing simpler and safer, says Gary Nowitz, president, North America, of Pressalit Care Inc. 

“Adjustability allows you to cost-effectively customize a bathroom set-up to each resident’s unique needs,” Nowitz says. Pressalit Care’s flexible bathroom design system is built upon a system of horizontal and vertical aluminum wall tracks that allow bathroom fixtures to be easily height-adjusted and repositioned. They also allow support arms, shower chairs and other aids to be added or removed without the need for tools.  Not only does fixture flexibility enhance resident independence and simplify care processes for staff, it allows bathing areas to be adapted in connection with progressive illness or for different users.

To further enhance resident independence, Pressalit Care’s Matrix line of sinks and washbasins can be raised or lowered to standing- or wheelchair-height, and moved side to side, as needed. “They also have integrated grab bar, so a person can easily grab on and steady themselves with one hand, while washing with the other,” Nowitz continues. For European-style wet room spaces, residents can be placed on shower seats attached to the wall track and then safely moved directly to the shower area. Adjustable shower seats feature high shower chair backs and independently adjustable arm rests that can be safely lifted out of the way when not in use. 

 Some facilities are installing ceiling lifts in bathing areas, which can reduce transfer and overall bathing times. They also eliminate the need for hunting down mobile lifts — a headache that sometimes leads caregivers to cut corners and attempt the dangerous task of manually lifting and transferring residents. 

Some resident care products also can pull double-duty, making them more cost-effective and user-friendly. The EHOB WAFFLE Mattress Overlay, for example, is a pressure redistribution product with built-in hand wells that make it easier for staff to transfer and position residents who need more assistance. The product, which costs a healthcare facility roughly $30 and is designed to be discharged with the resident to and from other care settings, allows staff members to grab the hand wells to safely “log roll” the resident on his or her side if a bed bath is needed. Once the resident is positioned on the side, a wedge can be placed to lend additional support while bathing takes place. 

Caregivers may also use the WAFFLE product to safely pull up residents and transfer them to a wheelchair or bedside chair. “This mattress lives under the patient, so there’s no need to go looking for lifting equipment that’s located down the hallway in another part of the facility,” says Kurt Vetters, VP of corporate accounts for EHOB Inc. The resident can be transferred with their own WAFFLE to the bathing area. When accompanied by a gait belt and an appropriate shower chair, this process allows for easier positioning and transferring during and after the bath or shower. “The material can be dried easily and the WAFFLE then goes with the patient back to their room,” Vetters explains.  

Baths get a boost

Today, assisted living operators have access to innovative, feature-rich bathing units that emphasize resident and employee safety. Easy access, side-entry baths with built-in transfer devices are just one example. In the past, getting residents into the bath required a separate piece of equipment that lifted them up and over the sides of the bathing unit. 

“Today, we offer spas with integrated transfer systems that [negate the need] for independent transfers,” says Lee Penner, owner of Penner Patient Care. To further enhance resident and staff safety, the integrated transfer systems on Penner Manufacturing’s bathing units transfer residents in and out of the spa at wheelchair-height.

Temperature control is easier than ever, too. “Virtually every bathing system on the market comes equipped with thermoscopic/thermostatic mixing valves to ensure residents will not be subjected to water that’s too hot,” assures Anderson of Apollo Bath. 

Enhanced infection control and prevention is another key benefit of many bathing systems today. Backflow preventers that reduce the likelihood of water entering the air line when the air blower is turned off aid the process, as do smaller-diameter air lines that allow disinfectants, fresh water and air to do their job better by making greater contact with the surfaces of the lines, Penner explains. 

Pipeless baths powered by pipeless jets also make disinfection a snap, Newbould says. Invacare’s TheraPure tubs meet demanding hospital-grade requirements of NSF International’s Protocol P182, allowing removal of up to 99.9% of bacteria after each bath, he says. For added safety, TheraPure tub seats “are positioned at wheelchair height to make transfers easy from both wheelchairs and lifts.” 

Integrated cleaning and disinfection systems that automatically flush whirlpool and air spa lines also are prevalent.  Apollo offers a germicidal ultraviolet system with its whirlpool bathing systems, exposing cycling bath water to UV light. [Editor’s note: Even with the presence of a UV system, bathing units must be thoroughly cleaned and disinfected after each use.]

Comfort and convenience count, too. Units with autofill features and water reservoirs that keep water warm and ready for the next resident can further shave valuable minutes off each bath, assures Penner.  “This is all part of making the bathing areas more comfortable and homelike, and less institutional,” he says. “When bathing is something that residents look forward to, that makes giving a bath more positive and efficient for the caregiver.”

Eli is living the good life now because he’s in a place where he never has to be alone again – he has people around him day and night. And he is always happy to see new faces as they enter the facility.

Such is life at Silverado — providing care to residents and animals alike. In fact, it is not unusual to see dogs and cats on the premises serving as companions for residents. At Orchard Park, where all residents have memory care needs, there also are guinea pigs, a fish tank, a rabbit and several species of birds to round out the menagerie.

While it’s true that pets aren’t really germane to a facility’s design, the Silverado model incorporates animals as part of its physical environment. They are as much as part of a property as walls, furnishings and décor. Why? Because all of these elements are intended to improve the quality of residents’ lives and pets have proven to be a huge positive at Orchard Park, says Administrator Samantha Johnson.

“We want to treat residents as adults and having animals and children here helps them with blood pressure,” Johnson says, adding children also are welcome at the facility. “Having a rabbit on your lap can help you relax. I’ve seen this firsthand.”

Besides Eli the resident dog, Silverado-Orchard Park has three other dogs that are part of the environment: Maggie, a Jack Russell terrier mix; Bella, a Cavalier King Charles Spaniel; and Mobley, a Cocker Spaniel. They make up Johnson’s dog “pack” and accompany her to work every day. It is not uncommon to see them sitting on furniture or riding the elevators from floor to floor. Two felines – Gladys and Betty Boop – also have become residents of the second floor, after being adopted from a nearby animal shelter. 

Letting animals roam free in a facility where vulnerable elderly people are living may seem like a risky situation, setting up instances where residents could fall or sustain pet-related injuries, and Johnson acknowledges that the risk does exist. Even so, the Silverado philosophy is that the benefits brought by animals far outweigh the risks.

“We believe that love is greater than fear,” she says about a tenet that extends throughout the corporation. “Worry about something negative happening comes from the fear side. But from the love side, it is about how residents light up when they see a dog, cat or a child. Having animals around makes their experience here more normal. Many of these people had animals in their homes before they came here.”

Silverado-Orchard Park has four floors and 56 residents in various stages of Alzheimer’s and dementia. Silverado purchased the facility in July 2013 as part of a three-property acquisition in the northern Illinois-southern Wisconsin region.

He was trying to honor her wish, expressed many years before her final illness. But family members are frequently torn between what they believe to be their loved ones’ wishes and — in the days and hours before and after death, in the midst of terrible emotional turmoil — what is the right thing to do. 

Today, this conflict is exacerbated by families and providers all too often avoiding the hard conversations that need to take place if a patient’s wishes are to be thoroughly understood and if the care offered by providers is to align with what the patient and their family really want. 

Advance end-of-life planning can spare patients unwanted, aggressive treatments and it can help physicians calibrate care in a more reasonable manner.  

However, the conversations that provide the foundation for effective end-of-life plans are difficult for everyone.

Caregivers have been trained to view death as the ultimate enemy, to be fought with all the weapons at their command — and those weapons get better every day. For many doctors, discussing death with patients and their families can sound like surrender. Relying on their training, and retreating behind the protective ethical walls of their profession, doctors often pursue treatments they know to be futile, or of little value, rather than sit down with the patient and family to raise issues related to the inevitable. 

Consequently, beyond the simple DNR order that almost all LTC facilities require incoming patients to address (a document that is effectively trumped by any care directive a family member gives in a clinical setting), a rich conversation is rarely conducted addressing the patients’ wishes and options with physicians, other care team members, and family members all participating.

Up to providers

Therefore, as families frequently don’t know what questions to ask, are unfamiliar with their options, and are wrestling with grief, guilt, and fear, it is up to care-giving facilities — hospitals, hospice or senior living — to make sure that these conversations take place in a consistent, repeatable, and structured way. 

Indeed, having a written process for end-of-life planning makes the conversation so much easier to have. 

If rich, end-of-life advance care planning conversations are conducted, and documented, early enough so that patients can be fully informed and engaged, a recent Dartmouth-Atlas study has shown that they tend to take greater advantage of palliative and hospice care. Thus, they avoid the more aggressive interventions associated with what the Atlas-Dartmouth study termed “poor quality of life and death, as well as higher costs and, in some cases, reduced survival.”

And when a patient’s true wishes are explored, aired and documented in the presence of providers and family members, death arrives with less confusion and uncertainty about what the patient wants, and what’s the right thing to do. 

That spares physicians the job of attempting to do the impossible, and can help spare survivors some portion of the guilt with which my friend is still wrestling. 

Kerry Shannon is the Senior Managing Director, Health Solutions, at FTI Consulting.