# Evaluation of *The Club* Approach to Residential Care for Advanced Dementia

# 

# Authors 

# Jessica Heartquist Pupa, MS, OTR/L 

# Mary Ellen Riordan, LICSW 

# Ladislav Volicer, MD, PhD 

# Dementia Study Unit 

# EN Rogers Memorial Veterans Hospital 

# Bedford, MA 01730

# 

# Who Are We?

# The Geriatric Research, Education and Clinical Center (GRECC)

# Main focus of the GRECC:

## **-**Outpatient and inpatient care of patients with Alzheimer's disease or a progressive dementia 

## **-**Clinical and basic research on dementing illness

## Inpatient Program has two fifty bed units

# Admission Criteria:

## -honorably discharged from active military duty 

## -diagnosis of a progressive dementia -have to be advanced to tolerate being on an inpatient unit -family member/caregiver agree to hospice philosophy of the program, i.e., do not resuscitate; do not transfer to an acute setting; no IVs; no tube feedings, etc. 

## Admissions are from:

## - acute care settings

##  - assisted living facilities 

##  - nursing facilities 

##  - home (majority) 

**How We Began!**

-   October 2001 observed a "Lifestyle Approach" at the Vermont Soldiers
    Home's Alzheimer's Unit.

-   The Vermont Soldiers Home's consultant, Joyce Simard, MSW developed
    the "Lifestyle Approach."

-   "Life style Approach"

> \- enhances the quality of life of progressive dementia individuals
>
> \- a philosophy of care focused on easing the transition from home to
> nursing facility
>
> \- recreates a routine that is familiar and filling each resident's
> day with purpose and meaning.
>
> \- meaningful activity is provided by an interdisciplinary approach
>
> \- an activity is seen as anything a staff member does with a person.

-   Vermont Soldiers Home's Lifestyle approach was the "Vets' Club".

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-   Vet's Club provided:

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-   a full day of meaningful activities

-   interdisciplinary approach

-   one room with one staff member

-   daily schedule of staff included:

> \- nursing
>
> \- occupational and physical therapy
>
> \- social work
>
> \- support staff

# Why Did We Start the Vets' Club?

-   January of 2002

> \- Limited involvement by all veterans in activities
>
> \- All disciplines agreed a new way was needed to provide continuous
> meaningful activities
>
> \- Lifestyle Approach was agreed upon as the way to provide meaningful
> activities
>
> \- In March 2002, the Lifestyle Approach of the Vets' Club began!
>
> **Implementing the Club**

-   Staff Education

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-   Majority of staff leading group programming for *The Club* had
    little prior experience.

-   Group training sessions were lead by an occupational therapist and
    social worker.

-   Staff provided with the opportunity to co-lead group with OT to
    improve comfort level.

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-   Club schedule was implemented according to the outline (fig. 1).

-   Club model ended after the lunch hour due to the number of family
    members visiting during this time at our facility.

-   A variety of other structured activities (music performances, craft
    groups, cooking activities, games, etc.) were offered as
    alternatives for those veterans without visitors during this time.

**Vets Club Activity Schedule**

**[Time]{.underline} [Activity]{.underline}**

7:45-8:30 **Breakfast**

8:30-9:30 **Rise & Shine**

A group comprised of a variety of activities focused on morning
"wake-up" which may include greeting the veterans, the Pledge of

Allegiance, socialization, morning stretch and exercises, music, etc.

9:30-10:00 **Small group activity for veterans**

> Choose activity depending on level of veterans' function (i.e.,
> **higher level**: crafts, trivia, current events, reminiscence,
> adapted sports, sing-a-longs, etc. **lower level**: hand massage, nail
> care, sensory groups, balloon toss, ball toss!)

10-10:30 **Coffee/Snack Time**

Veteran's are offered choice of beverages and snacks as an opportunity
for

> nourishment and to unwind from the morning's events.

10:30-11:30 **Small group activity for veterans**

> Choose activity depending on level of veterans' function (i.e.,
> **higher level**: crafts, trivia, current events, reminiscence,
> adapted sports, sing-a-longs, etc. **lower level**: hand massage, nail
> care, sensory groups, balloon toss, ball toss!)

11:30-12:00 **Veteran's prepare for lunch**

**Effectiveness Measures**

-   Minimum Data Set

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-   Three quality indicators examined

> \* QI 1 Incidence of new fractures
>
> \* QI 20 Prevalence of
>
> anti-anxiety/hypnotic drug use
>
> \* QI 23 Prevalence of little or no activity
>
> \- Data collected on 68 participants in 2 groups of three months prior
> to *The Club* and every quarter thereafter.

-   Data collected regarding effectiveness of activity training sessions
    via an anonymous post-training survey.

**Positive Outcomes**

1.  Significant decrease in the number of residents involved in little
    or no activity (MDS QI 23 -- fig. 1).

2.  Decrease use of anti-anxiety/hypnotic medications (MDS QI 20 -- fig.
    2).

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3.  High family members' satisfaction (92%) regarding the quantity and
    quality of meaningful activity offered on the unit.

4.  Improved comfort level of staff leading activities in Club (86%)
    since training sessions.

5.  Decrease wandering, pacing and agitation by the veterans during Club
    activities noted by staff.

6.  Provides method to achieve JCAHO requirements regarding quality,
    meaningful activity of care and treatment of residents.

7.  Increase in veterans' attention span and willingness to participate
    in activities.

8.  Family members have become involved in the activities not just
    involving their loved one but other veterans, (i.e., singing with a
    few of the men in the afternoon).

9.  Treatment Team

> \- Patient Centered

\- Interdisciplinary (Unit secretaries are involved in leading
activities).

10. Increase in job satisfaction

> \- Using talents, interests and hobbies
>
> \- Gives purpose and meaning

11. Treatment Team Benefits:

> \- Increase interdisciplinary collaboration
>
> \- Develop confidence
>
> \- Develop trust in each other
>
> \- Better communication with family members, (i.e., monthly meeting
> was established with family members and staff).

![](media/image1.wmf)Fig. 1. Percent of residents spending less than one
third of their waking time in activities after introduction of The Club

> ![](media/image2.wmf)

Fig. 2. Percentage of residents who were treated with benzodiazepines
after introduction of The Club

> **Implications for the Future**

-   An Interdisciplinary approach for meaningful activities will meet
    the needs of older adults in nursing facilities.

-   The "Lifestyle Approach" incorporated into our Vets' Club has proven
    that recreating a routine that is familiar and filling does give
    purpose and meaning to a veteran's day.

-   Advantages:

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-   addresses shortage in staff

-   helps the staff meet the needs of the residents

-   gives staff members an opportunity to go "outside the box" of their
    job position

> uses staff's strengths to provide meaning and purpose to the
> residents.

\- can help facilities to meet JCAHO requirements.

-   This program remains successful because of the willingness of all
    Treatment Team members to remain "patient centered" and to "stretch"
    themselves beyond their "traditional roles".