Person-Centered Care for Residents with Dementia Exhibiting Aggressive Behavior Reduces Psychiatric Hospitalizations and Behavior-Related Medications
Person-Centered Care for Residents with Dementia Exhibiting Aggressive Behavior Reduces Psychiatric Hospitalizations and Behavior-Related Medications
Lakeview Ranch, Inc., a long-term residential care facility, provides a person-centered approach to caring for persons with dementia who exhibit challenging, aggressive behavior. Using many highly trained staff, this care model includes comprehensive screening and evaluation, careful management of the initial transition to the facility, daily dementia-specific activities and therapies (including animal, music, and spiritual therapy), extensive medication reviews, and ongoing monitoring of needs. The program reduced psychiatric hospitalizations and the use of behavior-related medications.
Date First Implemented
Most residential care facilities rely on psychiatric hospitalizations and behavior-related medications for residents with dementia who exhibit challenging behavioral symptoms, resulting in a greatly reduced quality of life for the individual. Person-centered approaches that include therapeutic physical activities, social programs, and behavioral programming can minimize such symptoms, improve quality of life, and reduce costs. However, few facilities employ such a model of care.
- Reliance on hospitalizations and medications: Facilities caring for residents with dementia often rely on inpatient psychiatric care and behavior-related medications to deal with challenging behavioral symptoms such as aggression, agitation, and wandering.
- Unrealized potential of person-centered approaches: Person-centered approaches to dementia care seek to manage behavior-related symptoms by addressing an individual's physical, emotional, environmental, and medical needs, with the goal of reducing external stressors that lead to challenging behaviors. This approach can reduce the need for behavior-related medications and hospitalizations, leading to better quality of life and lower costs. However, relatively few facilities follow this model of care.
Adults age 50 and over who have dementia and exhibit aggressive behavior
Description of the Innovative Activity
Lakeview Ranch provides a person-centered approach to caring for persons with dementia who exhibit challenging, aggressive behavior. Using significant numbers of highly trained staff, this care model includes comprehensive screening and evaluation, careful management of the initial transition to the facility, daily dementia-specific activities and therapies, extensive medication reviews, and ongoing monitoring and addressing of needs. Key components of the model include the following:
- Significant numbers of highly trained staff: Lakeview has one staff member for every three residents, well above the typical level of staffing in this type of facility. Registered nurses are on site 5 days a week and on call 24 hours a day, 7 days a week. Staff have extensive experience in dementia care and have received specialized training pertaining to Alzheimer's disease, Parkinson's disease, multiinfarct dementia, frontal lobe dementia, and other types of vascular dementia.
- Ongoing mentoring and staff support: All staff participate in an intensive orientation program to learn about the model of care, culture of teamwork, and the expectations staff team mentors have of each individual's position. An assigned mentor provides on-the-job training for the first 6 to 12 days of employment. Senior staff mentors serve as role models to assigned staff and provide regular feedback on their performance. Staff also participate in monthly training programs. (See the Planning and Development Process section for more information.)
- Upfront screening and at-admission evaluation: Applicants and their families undergo a comprehensive screening and medical assessment process to determine the appropriateness of placement in the facility. Upon admission, medical staff gather additional information from the family and conduct a thorough examination of the resident, including a complete medication evaluation.
- Individualized transition phase: An assigned staff member cares for a new resident during his or her first 3 to 10 days in the facility. Through one-on-one care, this person provides emotional support to the new resident, addressing any anxiety, fear, or other feelings that may result from the move to Lakeview.
- Daily, dementia-specific activities and regular outings: Each day, residents participate in exercise and other activities designed to bolster self-esteem and meet individual needs and abilities. The facility has a secure outdoor area where residents can garden, walk in the woods, and have barbecues. They also can go to the lakeside gazebo, take golf cart and boat rides, and visit the barn (see below). When possible, residents go to local parades and events, music in the park, and museums. Specific therapies offered include the following:
- Animal therapy: A specialist uses animal therapy to help diffuse challenging behaviors and encourage participation in range-of-motion exercises. The facility has a barn with farm animals that handlers frequently bring to the facility to interact with residents; animals used in therapy include alpacas, miniature donkeys, miniature horses, goats, miniature potbelly pigs, sheep, and chickens.
- Music therapy: A certified music therapist works with residents twice each week, which promotes wellness, helps manage stress, and improves communication.
- Spiritual care: Residents can participate in daily devotions and mealtime prayers. When appropriate, staff or volunteers accompany residents to local church services.
- End-of-life care: Residents and families have access to hospice and a compassionate palliative care program provided by trained staff. Staff work closely with families, explaining what to expect as life draws to an end and supporting families after a resident dies.
- Extensive medication reviews: Medical staff carefully review the list of medications residents are taking when they arrive at Lakeview for: need and appropriateness; correct dose, frequency, and duration; and for potential adverse interactions. As part of the regular charting of residents needs and behavior, medical staff consider physical or behavioral changes that might warrant a modification to medication regimens. The need for medication changes is also addressed during the monthly reviews of resident care plans.
- Ongoing monitoring and addressing of needs: Team leaders regularly chart all facets of residents' physical, emotional, and spiritual needs, noting changes that require attention. Medical staff use this information to evaluate disease progression, behavior-related issues, medication side effects, and comorbid medical conditions. As appropriate, they share this information with family members.
Context of the Innovation
Established in 1999, Lakeview Ranch, Inc. operates two residential homes in rural Minnesota for those with dementia. Judy Berry, founder, owner, and chief executive officer, developed Lakeview Ranch in reaction to her experiences trying to find appropriate care for her mother, who had vascular dementia and had been labeled as “aggressive.” Ms. Berry strongly believed that much of her mother's behavior stemmed from unmet physical, social, and emotional needs. However, she could not influence the treatment provided by the dementia care facilities where her mother resided, which tended to rely heavily on psychiatric hospitalizations and psychotropic drugs. After her mother died, Ms. Berry gathered information on best practices and developed her own model of care to better meet the physical, social, and emotional needs of persons receiving care for dementia. When Lakeview was ready to open, she enlisted the support of 15 health care professionals who fully supported her person-centered approach to care.
The Lakeview Ranch model reduced psychiatric hospitalizations and the use of behavior-related medications.
- Fewer behavior-related hospitalizations: Just under half (49.2 percent) of 122 current and former residents had at least one psychiatric hospitalization in the year before coming to Lakeview Ranch, with some having as many as five. Since coming to Lakeview, 93.3 percent of these individuals have had no additional psychiatric hospitalizations. In addition, no Lakeview Ranch resident has had more than one psychiatric hospitalization after arriving at the facility.
- Less use of behavior-related medications: Over one-third (36.1 percent) of the 122 current and former Lakeview Ranch residents experienced a decline in the use of behavior-related medications after moving to the facility.
Planning and Development Process
Key steps included the following:
- Reviewing best practices: In addition to conducting online research, Ms. Berry visited model programs to identify effective approaches to dementia care. Interviews with frontline workers at these facilities proved to be especially useful in identifying best practices.
- Designing model: Ms. Berry designed a person-centered model for dementia care based on her experience with her mother, research on dementia care models, and input from her health care team.
Developing business plan, securing funding: Ms. Berry developed a comprehensive, well-documented business plan and attempted to use it to secure funding for the facility. These efforts initially failed due to significant obstruction and resistance from the eldercare community, who viewed her efforts as unnecessary competition. However, Ms. Berry prevailed when she met a banker also struggling to find appropriate dementia care for his mother. With his assistance, she obtained a Small Business Administration loan through a local bank.
Designing and building facility: Ms. Berry designed the facility to accommodate the physical, social, and therapeutic needs of residents. Design features included an enclosed circular path for year-round walks, bathrooms with showers and tubs, and rooms without locks. Ms. Berry hired and oversaw all contractors involved in the building of the facility. As required by the state, she obtained a class F license to provide services and registered each building for Boarding & Lodging with Special Services and Housing with Services. She furnished the facility with purchases from retail, wholesale, and secondhand stores.
Hiring staff: Ms. Berry developed relationships with local nurses and other providers who supported her efforts to create Lakeview Ranch. Once the facility had been fully furnished, she hired a core staff of 15 people to start the program.
Creating training and mentoring programs: Ms. Berry worked with her core staff to design a training and mentoring program to teach existing and future employees the model of care and to help address the personal and emotional stressors associated with caring for this population.
Recruiting patients: Ms. Berry and her colleagues distributed promotional materials and made presentations to hospitals, physicians, social service agencies, houses of worship, other community-based organizations, and individual families.
Resources Used and Skills Needed
- Staffing: Lakeview Ranch has 77 staff to serve 31 residents, including registered nurses, licensed practical nurses, trained care givers, specialty therapists, and administrative staff.
- Costs: The annual cost to run a resident facility that houses 16 individuals is approximately $1.2 million.
As noted, Ms. Berry used personal savings and an Small Business Administration loan to build and staff the facility. Residents pay for their care using private insurance, personal savings, and Medicaid benefits. They also may receive scholarships from the Dementia Care Foundation to offset the gap in Medicaid payments. The foundation, a 501(c)3 public charity, was set up a year after the facility opened to ensure equal access for low-income seniors.
Tools and Resources
For more information about Lakeview Ranch Model of Specialized Dementia Care, go to: www.dementiaspecialistconsulting.com.
Getting Started with This Innovation
- Expect obstacles: Ms. Berry faced numerous obstacles in her effort to create Lakeview Ranch. Developing a person-centered, dementia care facility model requires the ability to resist opposition from other elder care providers who may not want competition, local residents who may not want a facility built, and bankers who do not believe a viable business can be built around a person-centered model of care.
- Ensure adequate labor pool: Maintaining a 3-to-1 ratio of residents to staff requires access to a relatively large labor pool, including experienced registered nurses.
- Screen for willingness to accept care model: Caring for individuals who exhibit challenging, aggressive behavior can be quite difficult. Potential employees must be willing to rethink their beliefs and feelings about dementia care, work as a team in a new model of care, and accept that they will experience job-related stress. Potential frontline staff must demonstrate sensitivity and finely tuned observation skills.
- Build customized facility: The facility design needs to allow for indoor and outdoor space for physical activity and other therapeutic modalities, along with bedrooms, bathrooms, and common living space that meet individual needs.
- Educate potential residents and family members: The general public & rsquo;s lack of knowledge and exposure to person-centered models for dementia care can be a major obstacle when recruiting residents. Therefore, materials and presentations must clearly delineate the differences between this approach and the traditional “disease” model that addresses challenging behaviors through the use of medication and psychiatric hospitalizations.
Sustaining This Innovation
- Invest in ongoing training and mentoring: Working with this population can be extremely stressful, especially for frontline caregivers. Ongoing mentoring, support, and training can reduce the potential for staff burnout and high turnover, which can exact a large emotional and financial cost on the organization.
- Consider other funding sources : In addition to startup costs, this type of facility typically requires additional funding to cover operating costs (unless leaders decide to serve only those with private insurance or other financial resources). Setting up a charitable foundation can be one strategy for obtaining additional funds to cover the costs of caring for those without adequate financial resources.
- Lobby for better reimbursement: State officials may be willing to reexamine state and private insurance coverage of person-centered dementia care once they understand the significant savings that can be realized through reductions in psychiatric hospitalizations.
Ms. Berry has not indicated whether she has financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.
Managing Challenging Aggressive Behavior in Persons with Dementia: Cost Effectiveness of Prevention versus Treatment. Available at: http://www.dementiaspecialistconsulting.com/images/prevention_Vs_treatment2008.pdf.
Caring for Persons with Dementia-Related Behaviors: A Family Perspective on an Innovative Model of Care. Available at: http://www.dementiaspecialistconsulting.com/images/research/familyperspective.pdf.
Karasik RJ, Berry J. Reimagining Care. Journal of Dementia Care. May/June 2013:121(3):28-31.
Boustani M, Zimmerman S, Williams C, et al. Characteristics associated with behavioral symptoms related to dementia in long-term care residents. Gerontologist. 2005;45(1):56-61. [PubMed]
Alzheimer's Association Web site. Aggression and Anger. Available at: http://www.alz.org/care/alzheimers-dementia-aggression-anger.asp
Managing Challenging Aggressive Behavior in Persons with Dementia: Cost Effectiveness of Prevention versus Treatment. Available at: http://www.dementiaspecialistconsulting.com/images/prevention_Vs_treatment2008.pdf