Developing Scheduled &
routines that Work
Creating a
Culture of Change
for People Living
with Cognitive Changes
Its not a Nursing Home or Facility
It’s a HOME where nursing care is given
Design Each Day
Offer a variety
of activities
every day
Make a
schedule and
follow it
Leisure, work,
rest, self-care,
groups and 1:1,
passive and
active
Be structured
BUT allow
flexibility
Create Group
schedules
BUT
also build
individual
schedules
Not everything
is for everybody!
8 am – coffee circle
8:30 – songs of joy
9 am – time to ‘go’
9:15 – take a hike – walk’n’roll
10 am – cool down & stretch
10:30 – watering hole
11 am - ‘use your brains’ games
11:30 - time to ‘go’ – wash up
11:45 – ‘set-‘em up’ crew
12 noon – let’s eat
12:30 – clean up crew
1 pm – music and meditation
1:30 – coupons clipping
2 pm – time to ‘go’
2:15 – let’s dance
Create a FLOW
for the day
Build up and
then slow down
Circadian
rhythms
Build a Foundation
of Familiar and Favorite
Activities
Add a few
special events and something
different
Understand Activities
What type of activity is it???
Self-care, leisure, work, rest…
Spiritual, social, physical, cognitive,
passive, active, solitary
Analyze the
Activity…
What is the
activity all
about?
What do you
need to do
it?
What skills,
abilities,
interests?
Doing
something
or
making
something?
Modify and Structure the Activity for
Success
Change the materials, the complexity, the
setting, the help offered, the task demands, or
the purpose of the activity
Enough Supplies
& Materials
Good quality
lighting
Good work
surfaces
Enough help for
each person
The right
equipment for
clients’ needs
Skilled
leadership for
the activity
Seating that
works
A BACK-UP
Plan
Traditional Facility Care
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Run by administrators & nurses
Organized around staffing
Work shared among 3 shifts of staff
Safety and health care issues TOP
PRIORITY
Medical model
Organized by departments – task specific
You are sick – you need care for your
diagnosis
Father knows best!
What’s Wrong with this Model?
• Who wants to live in a hospital?
• Who wants to do everything you are
supposed to?
• Who wants to have someone else
telling what to do and when to do it?
• Who wants to have to talk to three
different people to get something
done?
• Who wants to live in a nursing home?
For People with Changes in
Health and Abilities
Need for help
Need for equipment
Need for changes in routines & habits
Need to match needs with availability
of help
• Need to ‘anticipate’ when and where
you will do things, need things
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Cognitive Changes with
Aging
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slowed processing
less flexibility
more difficulty with new learning
more rehearsals needed
benign forgetfulness – immediate
recall goes first
Emotional Changes with Aging
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increased incidence of depression
increased incidence of anxiety
with stress – mood swings
with some drugs – emotional side
effects
What Does Having Cognitive
Abilities Do To This Whole
System of Care?
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Changes in memory & thinking
Changes in understanding & speaking
Changes in impulsivity & initiation
Changes in abilities & processing
So Let’s Figure YOU Out…
• What time do you wake
up?
• How do you wake up?
• What do you do when
you wake up?
• When do you eat
breakfast?
• What do you eat for
breakfast?
• How do you get ‘clean’?
• When do you get clean?
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When do you toilet?
What do you do for work?
What do you do for fun?
What do you do when you
are stressed?
ID two people you love…
Where are you from?
What is your favorite food?
What do you HATE to eat?
Questions
• How would you DO
living in your
community?
• What would it be
like if you had
physical changes?
• What about
cognitive
impairments?
• How would you do
on someone else
schedule?
• What would NOT be
OK?
• What if it was the
rest of your life?
• What would you
want?
What is Veteran-Centered Care?
Combination of…
• Person’s wants
• Person’s needs
• Still can do
• Can’t do
• Can do with support
• Individual good
• Common good
• Family needs
• Family wants
Balanced with…
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Staff skills
Staff availability
Private space
Public space
People resources
Equipment resources
Safety & Security
Rules & regulations
Others needs and wants
Personal Preferences & Values
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Who have you been?
What did you value?
Who are you now?
What do you value now?
Why does it matter?
Who gets a ‘say’?
Who gets to set the priorities?
Who Matters?
All of Us
Each of Us
What Matters – When
Illnesses Are Present?
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Safety – Environmental modifications
Access - Availability
Timeliness of help
Flexibility in timing
Structure & predictability
Privacy and respect
Preservation of SELF
Key Steps
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Connect
Gather Information
Share Information
Use Information
Review Information
Make Changes
What About Medical Conditions?
What is essential?
• Good care is delivered
• The person is receiving
the care they need and
want
• Conditions are
assessed
• Decisions are made
based on good info
• There is agreement on
what to do and what
NOT to do…
What is optional?
• When it is done
• Where it is done
• Who does it
• How often it is done
• How strictly it is
followed
• It depends on the
person & their situation
What are the Different Care
Approaches to Consider?
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Health Promotion
Curative
Restorative - Rehabilitative
Maintenance
Compensatory
Palliative
Health Promotion
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Check Ups
Annual vaccinations
Lower the numbers
Increase activity level
Eat well – moderately
Monitor all conditions for careful control
DO WHAT YOU SHOULD to be the BEST
YOU CAN BE!
Curative
• Fix what is wrong
• Test to figure out what is happening
then DO SOMETHING ABOUT IT:
– Surgery
– Medications
– Treatment
• Full recovery of function – GOOD as
NEW!
Restorative
• Recovery of SOME degree of function
or ability
• Focuses on the PERSON regaining
skills and abilities with help
– Rehab personnel
– Special equipment
– New techniques
• Not perfect, but BACK to a Higher level
of Function
Maintenance
• Maintaining the Status Quo – Keepin’ ON
• Not losing ground
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Physical environment not changing
Caregiver consistency
Sustained abilities of the person
All other things staying the same
• It’s HARD WORK … SO…
– ‘IS what I have worth keeping???’
Compensatory
• Providing what the person can’t do to ‘fill in
the gaps so that LIFE GOES ON….
• Supportive
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Physical environment changes
Caregiver cueing and helping changes
Expectations change
Schedules and routines change to
accommodate
• End Point is the Same –
– How we get there Changes
Palliative
• Comfort Care
• TOP PRIORITY –
– Honor personal preferences and choices
– Manage Pain, Distress, Anxiety, Fear,
Discomfort
• Identify & seek to meet social,
physical, psychological, and spiritual
needs
• Let go of FIXING and MOVE ON to
Comforting
The GOAL?
• Build a schedule and care routine that
helps the person:
– Be the way they want to
– Do what they are able
– Feel good about themselves
– Feel OK about where they are
– Enjoy the people who are there to help them
– Get what they need
Who Needs to Buy In?
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Residents
Families
Front line staff
Managers
Community leader
Regulators
Public
Reimbursors
So… What Do We Need from
Staff & Families?
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Awareness of the process
Participation in planning
Sharing about the past
Time to learn & try something new
Willingness to listen
Willingness to advocate AND negotiate
Flexibility as we figure this out