With our aging population poised to change the shape of long-term care, providing a person-centered approach to care and services is more important than ever.

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ur society faces many challenges when considering the long-term care needs of our elders. The face of our aging population is changing. The entrance of Baby Boomers into the eldercare market will bring numerous challenges to the current providers of long-term care. We need only look at the responses of Boomers to historic events throughout their lives to get a glimpse of how they might react to the realities of their own declining functioning and health, not to mention how they might react to being institutionalized.
       Today we know that individuals enter long-term care with great reluctance. Typically, all options for care at home are exhausted before the decision is made to go into long-term care. The inability to juggle family caregiving with paid caregivers, personal safety with needed supervision, and autonomy with the need for personal care end in the decision to choose a long-term care facility.

The Need to Change

       Long-term care is changing. Many of the journals you read, like this one, have articles on why organizations are changing, what they are doing to transform their homes into places where persons want to receive care and services, and how they are sustaining these changes.
       Recently, the CEO of a large organization was making a presentation to his board of directors on the need to change the things it did in its long-term care facility. The chair of the board looked at him and said, “Why do we need to change? We have an excellent reputation in the community, our staff turnover is the lowest in the region, our surveys are among the best in the state, our occupancy is above average for the state, and our quality measures are excellent. Why do we need to make these changes you are suggesting?”
       The CEO looked the chair of his board in the eye, paused, and simply said, “Because you wouldn’t live here!” Perhaps this is the question we in long-term care should ask ourselves: Would we live in the home where we work or provide services? If you would not, what makes you think Boomers will?
We know there is a better way to provide care, and we must not ignore it. Maya Angelou summarizes the situation for us: “We did the best we could with what we knew; and when we knew better, we did better.”
       We know better, so we must do better.

Quality for the Future

       If we strive to create places where persons will want to live, we should know what they want. From our experience as well as anecdotal evidence in this area, we do know that 2 of the key markers of quality for those who live and those who work in long-term care are the relationship with the caregiver and the ability to choose. When asked to choose a measure of quality, the choice will almost always be in the area of quality of life rather than quality of care.
       While there can be excellent quality of care but little quality of life, there cannot be a quality of life unless there is quality care. For example, a person with a pressure sore or restraint or who is experiencing unrelieved pain cannot experience a quality life, even though the quality of care can be remarkable.

Establishing a Quality Framework

       There is considerable literature about quality in long-term care. It is known by many names, including: total quality management (TQM), continuous quality improvement (CQI), performance improvement (PI), and performance management (PM). There are many structures in which the journey to quality can be framed, including the Baldrige National Quality Program (BNQP), Six Sigma^®, and the International Organization of Standardization (ISO).
       The remainder of this article will speak to a framework for establishing a quality home where residents want to live, where personnel want to work, and where both choose to stay. This framework supports the Commission on Accreditation of Rehabilitation Facilities (CARF) standards for a Person-Centered Long-Term Care Community (PCLTCC). These standards are based on what has been proven to be effective and beneficial in producing the types of outcomes that residents, families, and caregivers want in long-term care.

What is a Person-Centered Long-Term Care Community (PCLTCC)?

       A PCLTCC fosters a culture that supports autonomy, diversity, and individual choice. Leadership, along with the community, cultivates relationships among residents, families/support systems, and personnel. They commit to responsiveness, spontaneity, and continuous learning and growth. Residents and personnel celebrate the life cycle and connect to the local community to continue relationships that nurture the quality of everyday life.
       In PCLTCCs, residents are the experts regarding life in their home. Residents participate in deciding about the rhythm of their day, the services provided to them, and the issues that are important to them in their home. Their families/support systems are welcomed. In partnership with residents and their families/support systems, personnel understand what services residents want, how the services should be delivered, and how they can help in their home. A PCLTCC is a place where residents want to live, where personnel want to work, and where both choose to stay.

Developing the Standards

       The PCLTCC standards are the first set of standards that address the transformational change occurring in long-term care. By developing these, CARF has literally set the standard for person-centered care. When implementing these standards, the organization has the quality framework to provide person-centered care.
       The standards themselves are international consensus standards, as opposed to being derived from a research base. Using this as a framework, the standards define which systems are needed for person-centered care, including the expected input, processes, and outcomes of programs. To develop the standards for PCLTCCs, CARF convened an International Advisory Committee (IAC) in August 2005. Members of the IAC who were invited to participate were all experts in the field of person-centered care.
       After the standards were developed by the IAC, they were reviewed by the field. Nearly 300 individuals studied and commented on the standards. The comments from the field review were incorporated into revisions of the standards, and they were published in January in the 2006 Aging Services Standards Manual (a CARF publication).

The CARF Framework for Quality

       The CARF standards clearly present the systems and processes PCLTCCs should have in place to be able to provide quality person-centered long-term care. We will look at this framework from the standpoint of 2 megasystems: care processes and business practices. Care processes provide the main framework for those involved in PCLTCCs, while the business practices standards support the organizational systems needed to support this care. The PCLTCC care processes and program standards follow.
       1. Building relationships. As we have discussed earlier in this article, building relationships with caregivers is a key component of the quality of life for residents in long-term care. We build these relationships through:
• Consistent assignments for front-line caregivers
• Flexible visitation hours for families and friends
• Opportunities for intergenerational relationships
• Relationships with pets
• The establishment and maintenance of social contacts both within home and with the external community.
       2. Maximizing choice. From rising in the morning to retiring in the evening, residents determine their daily routines. A resident’s daily schedule reflects his/her rhythm of life and is not based on staff members’ convenience or institutional efficiency. The organization offers services that reflect the residents’:
• Choice of services
• Choice of timing of services
• Choices related to food, including types and eating time
• Choice of lifestyle.
       The organization is prepared to negotiate risks with resident choices when applicable.
       3. Helping to achieve personal goals.
• Personal goals can be met through learning and developing or simply by supporting the residents’ desires for how to spend their day
• Activities embrace the individuality of each resident by offering diverse programming that tries to meet the wellness needs of each resident. The goal is proactive in nature, intending to try and prevent greater loss
• Activities are those things persons do during the day to remain active and engaged. They create meaning and purpose in the life of each resident and assist them to achieve their personal goals.
       4. Involving residents in the external community.
       There are opportunities for residents to continue their activities in the community in which they lived. Whether they are active in the League of Women Voters or their church, their new home identifies ways in which they can continue to remain connected to their previous community(ies).
       5. Celebrating lifecycle events and respecting life-closure desires.
• Opportunities are provided so events important to residents are honored and/or celebrated
• Each resident’s end-of-life wishes are solicited and honored
• All personnel, residents, and families are provided opportunities to grieve when a member of the community passes away.
       6. Moving into the home.
       Individuals interested in moving into the home are provided information from the outcomes management system about the outcomes of care and the characteristics of persons living in the home. Individuals receive information about the scope of services provided by the organization to make an informed choice about living in a home. Information is also available about:
• All health and related services
• The processes involved in developing, implementing, and monitoring the plan of care and services.
       7. Transitioning within and moving out of the home.
As much notice as possible is provided to persons and their families when they are to leave the home or transition to another program. The organization is responsible for preparing a summary that is provided when a resident leaves the home or transitions to another part of the home.
       8. A collaborative team.
       The resident is the focal point of the team and is involved as a member along with his or her family/support system when desired. The organization ensures that the team has the necessary competencies so residents can meet their goals.
       9. Caregivers.
       Personnel and residents should be treated the same. In a culture that values the relationship of the resident and the caregiver, the systems surrounding personnel are key. At the heart of person-centered care is an organization that provides:
• Proper orientation
• Ongoing training and education
• Competent supervisors
• Opportunities to participate in decisions that impact their work.
       10. Safe and secure environment.
       The home should promote the dignity and self-worth of each person living and working there. The environment is safe for both the residents and the caregivers. Residents feel safe, and their possessions are secure. In short, they feel at home.
       11. Business practices.
• The key ingredient to creating an environment that is person-centered is to solicit, collect, analyze, and use input from all stakeholders. Focusing on the expectations of persons served is essential to creating and providing services that meet their needs. A person-centered environment should be free of barriers. Leadership has knowledge of what is needed and plans to provide an environment that is accessible for all persons.
• All quality frameworks have a component whereby data are collected, and the information is used to manage and improve the delivery of care and services. Information management and performance improvement are systems that set accredited organizations apart from others on the journey to person-centered care.
• Listening to complaints and resolving issues of both residents and their families are important in protecting the rights of persons served. The maintenance of a healthy and safe environment forms the backdrop of person-centered care.
• If the top measure of quality is the relationship with the caregiver, then human resources might be one of the most important functions in a person-centered home. Standards support the value of personnel and their involvement and engagement in the practices of the home.
• Leadership is identified as a key component of success by members of the IAC. Movement toward person-centered care can be successful with committed and involved leaders.
• Many questions arise about the financial feasibility of person-centered care. The systems required by the financial planning and management standards support fiscal responsibility and ensure the sustainability of the transformed culture.

Conclusion

       Over the years, long-term care employees have seen a shift in the way we care for our residents. Residents and families tell us that we must move to a person-centered approach to care and services. Based on our experience and what residents and families tell us, CARF convened an expert panel that established the first set of standards for person-centered long-term care. We invite you to look at them, implement them, and be among the first to be accredited as a PCLTCC.
       You might ask, “Why?” We will close as we began with a quote from Maya Angelou:
       “We did the best we could with what we knew; and when we knew better, we did better.
We know there is a better way to care for those living in long-term care facilities. To ignore that moral imperative is wrong.