Tom Rinkoski is a caregiver coach for the Florida state agency Elder Options
Ed Youngblood – Special to the Chronicle
In the early 19th century, practically all medical care took place in the home. In an agrarian society, the next farm house might be several miles away, and a doctor even farther than that. The idea of taking someone to a separate place — such as a hospital — for care was not practical, and by most considered not desirable.
The Industrial Revolution, brought people from farms to urban centers, and applied the theories of industrial efficiency to many sectors of society, including the medical community. The “skilled care” model meant moving care from friends and relatives to professionals trained for the task. This was expected to make medical care better and more efficient.
What the new model of “industrial” care found it difficult to provide was the personal touch. Of course, there were good and conscientious practitioners who cared for their patients as individuals, but now the system provided shifts of nurses around the clock. One might be attended by a nurse and never know her name. For procedures like an appendectomy or a broken bone, this model might be just fine. Get them in, fix the problem, get them out. Who needs to know the nurses’ name? Or for that matter, sometimes even the doctor’s.
Nursing Homes were created that were based on this same model. The frail and elderly were moved into these facilities for a variety of reasons, and soon this became an industry in and of itself. But people began to notice that the industrial medicine model is not so good for elderly people — especially those with Alzheimer’s and other forms of dementia — who are facing months and even the final years of their lives in a hospital-type environment.
These morphed into Assisted Living Facilities and Memory Care Units, but they were still based on the hospital model. Staff turnover in these facilities is often chronic, and levels of skill and training vary. Tom Rinkoski, a caregiver coach for the Florida state agency Elder Options, sees modern care as a kind of a three-legged stool, which cannot be optimum without consideration of all of its legs, “We cannot base care on efficiency only. We must evaluate the quality of care from three points of view; the provider, the person with dementia, and the family of the person with dementia.”
With a new emphasis on the importance of quality of care, the idea of “person-centered” care has re-emerged among leading practitioners. One such person is Dr. William H. Thompson, whose Eden Alternative promotes the de-institutionalization of nursing homes.
Others have expanded this, going so far as to create a radically new approach where nursing homes are replaced by small, home-like environments where social contact is encouraged and people can live a full and interactive life to the extent of their abilities.
Along with experiments with a better person-centered environment, new and more compassionate, personalized philosophies and techniques of care are being developed. Teepa Snow, one of the leading theoreticians, practitioners and teachers of person-centered care in the United States, has developed new theories and a new body of techniques of care that utilize tone of voice, body language, appropriate touch and rules of verbal interaction that bring clearly more positive results to dementia care. Every aspect of her work is grounded in the understanding that we are treating a person; not just a disease.
This work by Snow has led to an approach she calls the Positive Approach to Care. Under this philosophy, emphasis is placed on a better understanding of a patient’s remaining interests, skills and abilities. Instead of always lamenting what the Alzheimer’s patient is losing, Snow believes we need to focus on and cater to their remaining abilities.
This belief has led to breakthroughs in caring for people with dementia. For example, it has been long recognized that dementia patients will respond positively to music after they appear to have lost any other means of communication. Dan Cohen concluded that this ability could be enhanced with a person-centered approach. Using modern digital technology, Cohen is able to identify the specific songs that delight a person with dementia, then he installs them into their personalized device.
Out of Cohen’s work has emerged Music and Memory, an organization through which his methods can be adopted by assisted living facilities to deploy personalized music therapy to all of their residents who can benefit from it. His work has been documented in an inspirational film entitled “Alive Inside.”
It has also been long observed that in addition to music, art and poetry touch a chord in people who seem to be shut off from fact-based and logic-based communication. Taking the phenomenon to an individual and person-based level, Gary Glazer has created the Alzheimer’s Poetry Project where the arts are used not just to entertain, but to stimulate and enrich the lives of individuals with dementia, assisting them in finding new ways to express themselves.
Citrus County proponent of person-centered care Debbie Selsavage points out, “Until we can discover how to reverse or cure dementia, the only thing we can offer these individuals is dignity and a better quality of life through personalized and compassionate care. They need be treated like the unique individuals they are, who have their unique histories and accomplishments, with worth and meaning.”
While researchers continue to seek a cure for this devastating disease, advocates of person-centered care have learned and demonstrated that we have viable and far more humane options than just “warehousing” our rapidly-growing dementia community. By necessity, investment still seems to be on the side of building mega-facilities to meet the impending demand, but even these are experimenting with breaking up their floor plans into “communities” where personalized attention is easier to practice.
We probably have not returned to personalized care more rapidly because the old industrial model brought with it industrial methods of measuring success, which focuses on bottom lines, efficiency, and reduced cost. Fortunately, today we see the medical community moving toward the idea of achieving “evidence-based” results with each incremental part of the process of care. With this approach, much more than the bottom line is taken into account, and ironically, when additional investment is made in new evidence-based policies and procedures, often the bottom line is unexpectedly moved in a positive direction.
In a study published by the Stanford University Center for Compassion and Altruism Research and Education, researchers Lloyd Dean and James Doty concluded, “Compassionate Care is not just the right thing to do. It is the smart thing to do because it is good business, a claim now backed up by sound scientific research.” Results revealed in the Stanford Study include improved efficiency, greater staff satisfaction with reduced turnover, reduced medication, and faster healing; all factors which can contribute to lower costs.
Demographers and health care specialists warn of the coming tsunami of Alzheimer’s and dementia in America as our population ages. They also point out that our national health system is unprepared for the coming storm, both in resources and infrastructure. Improved efficiency must be one of the key components as we try to deliver more and better dementia care, and it appears that concepts of person-based care can offer both better efficiency and better results.
With Citrus and surrounding counties possessing a well-above average aging population, we are already experiencing the leading edge of the storm. It is why we are seeing new, large, and modern assisted living and memory care facilities popping up throughout the region.
These, depending on the extent to which they choose to adopt the new theories of person-centered and compassionate care, have the opportunity to make the Nature Coast and Central Florida a national model for the future of efficient and effective memory care.