Community

Leadership

Resident-Directed Care

Grancare

Meadowood

Meadowlark Hills

Leelenau Memorial

Liberal Good Samaritan

Lyngblomsten Care Center

Chandler Hall

A legacy begun more than 150 years ago in the battlefield hospitals of the Crimean War today drives efforts to change the culture of long-term care in High Point, NC. Frances "Fanny" Taylor worked as a volunteer with Florence Nightingale in the mid-1850s to improve conditions for thousands of war wounded languishing in rat and flea-infested hospitals in Turkey. "She asked, 'Why can't things be better?' That is our inspiration too," says Sister Lucy Hennessey, Chairman of the Board for Pennybyrn at Maryfield's continuing care retirement community (CCRC).

Sister Hennessey is one of the Poor Servants of the Mother of God, a Roman Catholic Order founded by Fanny "Mother Mary Magdalene" Taylor in England in 1869. Arriving in High Point from Ireland 90 years later, the Order established the Maryfield convent and convalescence home. Sister Hennessey, also from Ireland, became the Administrator in 1987 of what had evolved into the 125-bed Maryfield Nursing Home. "I knew the Sisters left a great heritage... and I asked myself, 'What could we do better today than what the Sisters did 40 or 50 years ago?'".

She had begun to see how "almost cruel" it is for residents subjected to the systems of institutionalized nursing homes. So after meeting Action Pact and seeing the Household Model in action at Meadowlark Hills, KS, she and fellow stakeholders scrapped plans for a modest facelift in favor of new construction and renovation of their 40 year-old skilled nursing building. "Once we saw what was possible, it (creating households) really became an issue of right and wrong," says Rich Newman, Executive Leader.

As of this writing, the first of six permanent households is occupied and the next three are about ready for move-in. Already, residents are making decisions for themselves and becoming more engaged. Some who once were wheeled to the dining room are now walking, says Vonda Hollingsworth, current Administrator and former Director of Human Resources.

Word of the transformation has spread beyond High Point, attracting greater numbers of job applicants for nurse and nurse aid positions. A local community college has discontinued its contract with another nursing home to instead partner with Pennybyrn to train nursing students within the household model.

Once completed, each new household will accommodate 17-23 residents. The gospel values of compassion, kindness, dignity and respect for all are more easily lived out in smaller groupings, says Sister Hennessey: "You get to know the residents more intimately." Just as the first Sisters did 60 years ago after converting a 14-room, country mansion/former nightclub into a convent and convalescent home. About 20 residents lived downstairs. Their five caregivers, the SMG Sisters of Maryfield, lived upstairs. "The desires of the person were met," says Sister Hennessey. "If they prefer, say, scrambled eggs versus oatmeal, they got what they liked."

Residents' lives became more regimented after 1965 when Maryfield moved from a single household into a more institutionalized environment with a new building, new rules and a much larger staff no longer made up entirely of nuns. "I can't condemn it, the caregivers did an excellent job... but now we're back into the individual again," says Sister Hennessey. "We've come full circle."

She and other leaders began laying the foundation for households after learning about the model at an Eden Alternative training in 2001. By then, the organization had become a CCRC with a new name, "Pennybyrn at Maryfield." They sought to expand its independent and assisted-living components and maybe splash some new paint on the old nursing home building.

"We met Susan Dean [Eden Alternative Regional Coordinator] who introduced us to LaVrene Norton [Action Pact], who introduced us to Steve Shields [Meadowlark Hills], and we began to see there was something different out there," says Hollingsworth.

Their quest for change began in earnest in 2002 when Maryfield began partnering with Norton. Soon afterward, Newman, the Executive Leader, began visiting Meadowlark Hills to receive tutoring from Shields while Norton went to Maryfield to guide staff in, among other things, building a culture change leadership team.

The interdisciplinary team members (including not just department heads but also positions throughout the nursing home) received training in communication, conflict resolution, leadership and other essential team skills. From there, "we worked toward making decisions in a team environment versus the administrator making all the decisions," says Hollingsworth.

Next, interdisciplinary leadership teams were organized for each of the four hallways, and specialty teams tackled specific issues like dining. "Through these (leadership teams) came changes and decisions that gave residents more control before we ever began physical innovation," says Hollingsworth.

Construction began in March 2006, bringing miraculous transformation to Pennybyrn's typical 1960s era nursing home. Despite regulatory and other "surprises" resulting in construction delays, five households are nearing completion following removal of the central nurses' station and renovation of the building's four long, L-shaped corridors. A sixth household, already completed, was built from the ground up. It has private bathrooms in all resident rooms (the renovated households will not).

All households will have a fully-functional, commercial-grade kitchen, living and dining rooms, a parlor, pantry, sunroom, laundry and a porch. The five households from renovated hallways will surround an indoor "town square" complete with a beauty shop, cafe and therapy room. "It will have an exterior feel to it... where residents can come out and visit with those from other households," says Hollingsworth.

Noting that about half their resident population is covered by Medicaid, Newman expects the households to operate at about the same cost as the old model. A capital campaign, that so far has raised more than $6 million, is paying for renovation and construction. "The community has really come forward and supported this effort in a big way," says a grateful Newman.

Pennybyrn at Maryfield staff, like the five nuns who were Maryfield's first caregivers, is permanently assigned to a specific household where they come to know residents on a personal level. They work in self-directed caregiver teams with blended roles for most positions that include:

• Life Enhancement: combines social-worker and activity-director duties.
• Homemaker: blends dietary and housekeeping. With a full kitchen in each household and no more tray service or huge dining halls, dietary staff is free to help cook and clean. The morning homemaker coordinates breakfast and lunch; the afternoon counterpart helps clean house and prepare dinner.
• Certified Nursing Assistants (CNAs): help with light housekeeping and laundry.
• Nurse Supervisor/MDS (Minimum Data Set) Coordinator: roles are combined. It was felt nurse supervisors within the households should do the MDS because they know the residents best.

Several staff members have studied to become Certified Dietary Managers (one for each household) and several dietary, housekeeping and administrative staff, including Hollingsworth, have taken CNA training. "Seeing people grow within the organization, that's extremely rewarding," adds Newman.

With growth comes challenge (and vice versa), and Pennybyrn at Maryfield is experiencing plenty of both.

Combining the Nurse Supervisor and MDS Coordinator roles "was one of the toughest decisions we've made and still struggle with," says Hollingsworth. The two positions typically call for different mindsets, she explains. Required for government reimbursements, collecting the MDS is a necessary but cumbersome process. MDS Coordinators usually are detail oriented, seldom interact with residents and don't like to be interrupted. In contrast, nurse supervisors multi-task and are highly engaged with residents. As a result, "we had a lot of resistance from both Nurse Supervisors and MDS Coordinators," says Hollingsworth. She still believes the MDS should be done by someone from the household, but how they chose to do so may be an example of the organization going too far in the decision making without sufficient staff input. "There may have been a different way to do it... change is very difficult," she says.

Learning to share and accept responsibility was also challenging. For those in traditional leadership roles, making all the decisions is a hard habit to kick. "And some folks are all too glad for you to make the decisions, they don't really want to be part of it," says Hollingsworth. "We struggled from both sides of that."

Perceptions have to be overcome. The Executive Leader's opinion is often perceived as carrying more weight than others, when "really you're just trying to have a discussion where everyone has equal power," she adds.

And not all decisions are on the table. Culture change organizations must find the balance between decisions that still must be made at the executive level, and those that are appropriate for households to decide, Hollingsworth adds.

Overcoming years of conditioning was necessary before either Newman or Sister Hennessey felt at home with the household-team approach to decision making. Before becoming Pennybyrn at Maryfield's Executive Leader, Newman was a Certified Public Accountant in auditing, "a very controlling environment... making sure everything was right before moving forward," he recalls.

Sister Hennessey's image of leadership was molded by her training as an Administrator, an image reinforced by the standard operating procedures of long-term care institutions. She became Pennybyrn at Maryfield's Administrator in 1987. "Suddenly I was responsible for it all... it was difficult to think that others could do it," she says.

The weight of accountability makes it difficult to accept that "it's not irresponsible to give up the responsibility of decision making," adds Newman. He credits the "wonderful degree of honesty" his mentors at Action Pact and Meadowlark Hills gave in helping him see "where my style would cripple the team-driven empowered approach we need for the residents to be in control."

Now, he says, "It's a lot easier managing in this way... allowing the teams to do their work rather than having to control everything."

"I've realized," adds Sister Hennessey, "when you spread it out among people you get a better result because there is more energy to do it."

Meanwhile, care-givers are growing more confident and skilled in decision-making, says Newman. CNAs are becoming household coordinators and working on leadership teams together with nurses, homemakers, life enhancement staff and former department heads.

Nuns no longer make up a large proportion of Pennybyrn at Maryfield's caregivers, but the legacy of service established by Fanny Taylor continues in an ecumenical, non-denominational fashion, says Sister Hennessey. "Our staff has built-in (human-kindness) values, and we try to encourage those values in them," she says. Encourage them she adds, by constantly putting before them the example of how it was done by Taylor and other caregivers who practiced their religion by serving society's most vulnerable.

One need not be Catholic to fit in at Pennybyrn at Maryfield, she stresses. "It's just however the Lord is drawing you. You live out your faith as you see it from where you are when you're working here and caring for your residents." Long-term care is a "gospel value," she adds. "It's constantly knowing that the person you're serving is very important, you're doing it for a reason bigger than yourself."

That's why the transformation to households is so important, says Newman. "Whatever it takes is what we need to accomplish because it is the right thing to do," he concludes.