Be a Noticer. Questions to ask Assisted Living Providers, and What to Note. Part 3 of 5
By David Hahklotubbe, gerontologist
Brilliant! Great to see you’re back. I hope this series is paying dividend for you as you perform due diligence on behalf of your loved one. As kamikaze as this gesture may seem, I am willing to entertain 1:1 questions, so if you should feel the need, please don’t hesitate to reach out us. My passion is improving the quality of life of humanity, any opportunity I get is a blessing.
All right…. Let’s get back into this. We left off drilling down on the provider’s approach, the qualifications of the team and the method of delivering care by staffing. To further these very important aspects, I offer the following line of questioning:
1. Who will be conducting the comprehensive geriatric assessment? And, can I get a copy of it?
WHY: You are making sure that someone with clinical skills, or at the very least, knowledge of the elderly is performing the assessment. Under NO circumstances should the assessment be performed by the Sales or Marketing Directors. While it’s rare, I’ve seen it done and it is an obvious and clear conflict of interest. The Director of Health Services, RN, LVN, Assisted Living Director, or, if qualified, the Executive Director should perform it. It should take NO LESS than an hour if it is to be done correctly, and you, should be invited to participate. To distill this down, the purpose of this assessment is to gather every minute detail relevant to your elder’s quality of life – I’m talking all the way down to favorite color of nail polish. Some providers only capture the overarching items like the needs and services and is less about ensuring the quality of life but rather the bare necessities and it’s often rushed to speed up the move-in process. Your presence is important to fill in the blanks. Assessing your loved one directly may be fruitful for some items but if there is denial, unawareness or cognitive disruption, they will not get an accurate picture of what is necessary to build a care plan. Additionally, you being there ensures that you have delivered all the minor details that would ordinarily be left out. My STRONG suggestion is to write a biography that is no less than 5 pages. This exercise can also be cathartic to the author. This biography should include: What the person is most proud of in their life, Their greatest accolades or accomplishments, How they would like to be seen (which may differ from how they would be seen without cues), a list of favorites things in their life, topics of discussion that will bring pride and joy, and conversely, topics of discussion that should be avoided (maybe a recent passing of a spouse, an estranged family member, combat or significant loss of any kind). It should include fun facts about the person and perhaps some struggles that they were able to overcome. A list of hobbies might be beneficial, but you should bare in mind that as people decline cognitively and physically, older hobbies may be a source of frustration since they may no longer be able to perform them adequately. I recall a family member who insisted that Dad get his daily newspaper, but they when we gave it to him, he’d open it, attempt to make sense of it, crumple it, toss it on the floor in the corner and remain agitated for an hour after. His beloved routine that once gave him comfort and a sense of stability was now an agitator, be thinking about this story as you create your biography. Also, remember that, especially with dementia, past behaviors are not accurate predictors of the future. That will be expanded upon in a future BLOG. Lastly, make sure that you get a copy of the assessment tool, if for no other reason, to have an understanding of what services are being performed for your loved one. It’s also good to use as a foundation so you can backfill all the missing pieces. The goal here is not just to create a higher quality of life, but to maintain a level of consistency for a smooth transition. Speaking of consistency…..
2. Are you currently fully staffed?
WHY: This one seems super-obvious, and it is. You want to make sure that your loved one will get the care they are paying for and deserve. Staffing shortages are a direct threat to this. It is no secret that caregiving, while considered “essential”, is not highly valued in our culture. If it were, the pay would be more commensurate with what they do. As a result, it is not uncommon for providers to be short-handed at any given time. This not only means that your loved one may not get the highest level of attention and care, but it also speaks to the attitude of the staff who are stretched thin, rushed and burdened with the stress of understaffing. Burnout is the number one killer of morale and morale cannot be teased apart from productivity. Our product is quality of life. To compound this issue, burnout spreads like wildfire and impacts all staff which only perpetuates more turnover. If the cycle is not broken, it can prove disastrous. To be blunt, I, as an expert witness provider in court cases for the past decade, can tell you that the catastrophic accidents that precipitate a lawsuit are almost always rooted in either understaffing or poor (or absence of) training. And, commonly, the poor training is directly related to the provider hemorrhaging money because they are constantly training new staff, so to save money, they pare it down or skip it all together, opening the door to liability and accidents. Therefore, being understaffed is a red flag that should not be ignored. One last comment on this – don’t necessarily take the person’s word for their current staffing status to be true. Am I suggesting that people sometimes lie? Yes, people sometimes lie, especially when their commission is in the balance. This is where you put your sleuthing skills to good use – walk the property and ask a caregiver directly if they feel that they are appropriately staffed. I think you’ll be surprised how generous they will be with their perspective! And, keep that in mind, perception is reality, if the staff feel they are understaffed, they are understaffed and the attitudes that come along with that perspective will prevail.
3. How many of your staff are less than 6 months on the job?
WHY: This is a clever way of asking what the turnover is like. If you just came out and asked how the turnover is, the standard answer will be, “fine” or “average for an Assisted Living” which is a way of lulling you into complacency. If you ask directly, how many of the hands-on staff are 6 months or less in tenure, it speaks to the morale, leadership and most of all, consistency and continuity of care, which, as we discussed earlier, is essential. The field of long-term care is notorious for turnover, especially among the hands-on staff. The workloads are intense, the emotional strain is immense, the pay is low, the schedules are not commonly attractive and the leadership is often unappreciative and autocratic. What you want to hear is that the teams are comprised of veterans of 5 years or more, that turnover is minimal and that those who are employed feel valued and morale is high. While it is difficult to quantify this, it can be seen on the faces of the employees. You will see major differences when you tour a number of communities. There is an unmistakable energy difference when you enter a community who has their act together with an engaged team and one that does not. The community who builds and fosters morale will feel light, upbeat and welcoming, the community who has chronic issues will feel heavy, dark and you’ll feel an innate impulse to leave. There is no masking this – the staff will give this away in how they approach you and interact with the residents. TOP SECRED INSIDER REVEAL: Sales and Marketing personnel are keenly aware of this as it directly effects their pocket book and they will alter their tour path to avoid trouble areas where they know you might be exposed to less than impressive behavior by the staff (especially around a break room). In fact, communities have spent big bucks on consultants to try and resolve this issue and efforts have been made to mask it – it is tradition in the morning meeting for the Sales and Marketing folks to reveal to the team what time their tour is that day and where they will be. If it feels like the staff are magically at the right place at the right time to greet you, you now know why, they are getting rewarded (often monetarily) to be there with a smile and a warm greeting. Sad and pathetic, but effective for the uninformed. When you return without a tour scheduled, you’ll see the real deal, not the Disney version. What you want to see is an organically happy and spirited staff who are always happy to be at work and are engaging. Does this exist? Of course, but it’s terribly rare. Looks like we have time for one more key question.
4. What does your community do to address caregiver burnout? Is there an employee appreciation program?
WHY: Ok, you are getting two questions for the price of one… First, just the mere fact that you are aware, as a consumer, to ask about how burnout is prevented, will be impressive. Let’s hope they respond with an equally impressive answer. Many communities simply ignore caregiver burnout and accept the churn and burn method. I can tell you as a consultant for the past 20 years, I can draw a straight line between the community’s efforts to decrease burnout and their worker’s compensation claims, their labor board disputes, their turnover, their overtime, their licensing citations, their census and their overall NOI, not to mention morale. So, is this a reasonable question to ask? Is it relevant? 100%. If they give a half-baked answer, it’s easily assumed that it is not being addressed. If they have a comprehensive answer with solid examples of team-building, retreats or exercises they perform to alleviate stress and burnout, you may want to drill down. A dovetail question would be right at the heart of the matter, is there a budget for employee appreciation? This literally puts their money where their mouth is and shows the forethought and proactiveness of keeping a healthy and happy workforce. It’s not rocket science – if the staff are happy, the residents are happy, if the residents are happy, the families and decision-makers are happy, if they are happy, licensing and the labor board are happy and if everyone is happy, the business thrives and the ownership is happy. Why is this not common practice? Poor leadership and shortsightedness. That said, if its confirmed that there is a line item for employee appreciation, it’s not offensive to ask how it’s spent. Are there incentives for good performance? Is this for holiday parties? Is there room for the staff to have a say in how it’s spent? Is it large or just token? Is it spent appropriately? This last question is stimulated by a recent event I witnessed. In support of our brothers and sisters in the field during the time of the Corona Virus, we stood allied and donated meals and marched in support of the teams who had boots on the ground. I was impressed by the level of support and by one of the teams who had printed special t-shirts that had “I AM ESSENTIAL” on it with a massive logo of the company on the back. Normally, companies do not go to this extent to outwardly support their teams and rarely allow staff to break from the uniformed dress code. But before I got overly excited to see companies doing the right thing, I later learned that the cost of the t-shirts was taken out of the employee appreciation fund. I immediately got nauseous. The translation is that the staff wound up buying their own shirts. This clearly should have been taken out of the Sales and Marketing budget, not the staff appreciation. So, just when I started to have faith in corporations, it came crashing down in classic fashion. So, asking these types of questions will reveal how the parent company views their staff. I’ve been outspoken for 20+ years and challenged by many when I say, “the most important people in any assisted living, are the personnel”. It’s a fact. So, it’s your responsibility to vet this out and see if that is being put to practice. I think you will find this exercise interesting and very informative. I’m always curious to hear what people find… circle back to me and let me know, if you would be so kind.