What makes better care?

If you were trying to decide the best place for an elderly relative to live, would you choose an assisted-living setting or a nursing home? The smaller mom-and-pop alternatives provide a homier feel but have limited resources. Large nursing homes are often better equipped, but ringing telephones, long corridors, and drab decor may mean a rather bleak atmosphere.

Largely because of federal law, nursing homes are often highly regulated and tend to be somewhat similar. State law regulates assisted-living settings, resulting in more variation. “There’s no reason to assume that one type of facility is inherently worse than another,” says Sheryl Zimmerman, associate professor of social work. Rather, she and Philip Sloane, professor of family medicine, intend to identify what characteristics have a positive effect on residents. “We are not comparing one to another but looking at how facility characteristics influence outcomes,” Zimmerman says.

Zimmerman and Sloane, codirectors of the Program on Aging, Disablement, and Long-Term Care at the Cecil G. Sheps Center for Health Services Research, are conducting more than 10 interrelated studies on the quality of care provided to the elderly. The largest project involves nurses, graduate students, and research assistants going out across four states to 250 facilities and collecting data through direct observation, interviews, and telephone follow-up. Another study involves videotaping activities at 15 facilities. The locations range from small, personal-care homes with as few as four residents to large facilities with hundreds of beds. By studying 3,000 individuals over two years in a wide range of facility types, they can determine the relationship between facility characteristics and such outcomes as injuries, infections, mortality, and other quality-of-life issues.

Already Sloane and Zimmerman have found that, whether in nursing homes or assisted-living settings, residents with Alzheimer’s disease appear to have similar risks of death and of developing new or worsening medical conditions. That shows that residents are not increasing their chances of death or illness by choosing less-medicalized settings, Zimmerman says.

Sloane and Zimmerman are also attempting to quantify some of the more difficult concepts by going beyond what is written in a resident’s chart. Does she look sad or happy? Was it good that he stumbled because he had been provided with some freedom or bad because the safety measures were inadequate? For several of the studies, the researchers have refined existing measures that evaluate mood by categorizing facial expressions. “Ideally, we will be able to say ‘this woman, who can no longer speak, appears to be happy and is doing well,’” Zimmerman says, “Whereas this one, in another facility, appears unhappy and to be doing poorly.” They can then evaluate how the facility is run to determine why that might be.

We are developing structured ways of seeing, then training people to do that efficiently,” Sloane says. When one of Sloane’s students returned from a visit to a facility, he had a hard time putting into words what made that facility a good one. “I tried to get at what it was that he saw,” Sloane says. “Was there a lot of touching going on? What were people’s facial expressions? Were people milling around interacting or were they by themselves?”

Another issue is that the number of workers in the field does not nearly meet the demand. Not enough people on the job means more staff injuries—often from trying to lift residents. Sloane says that one-third of nursing home patients with Alzheimer’s disease act out physically—hit, bite, scratch, kick, spit—during bathing or dressing. “And the pay that care workers receive is no better than flipping burgers at McDonald’s,” Zimmerman says. Much of the care depends on the frontline worker, so one goal is to figure out how to improve the performance of nursing assistants by increasing skills and providing better professional support. Having a clinical psychologist or nurse specialist work directly with nursing assistants resulted in a 50 percent decrease in violence against staff, Sloane says.

Sloane and Zimmerman hope their findings will help inform administrators what they should be doing and what they are doing well. “We are trying to identify what is important in quality of care; we’re not in a position to change the way the system is financed or run,” Sloane says.

But with Zimmerman as a member and Sloane on the support staff of North Carolina’s Long-Term Care Task Force, they may be in a position to influence those capable of enacting change. The task force recently issued 47 recommendations to the N.C. legislature, focusing on access and financing, the quality of care, the structure of the facility, and the adequacy of the workforce. Their intention is to help older people and their families obtain appropriate, high-quality, cost-efficient care in the least restrictive setting.

Thinking back to feel better

An 83-year old woman comes to Carolina’s Geriatric Assessment Clinic; she is depressed, has been losing weight, and is having more and more trouble walking. Her appointment is at 9 a.m. Before noon, she will see a gerontologist, an occupational therapist, a physical therapist and a psychiatrist; give a blood sample; try out different kinds of walkers; and show how well she can stand and tap her toes.

Then Florence Soltys sits down beside her. She pats the woman’s arm and asks how she’s been feeling, what she likes to do during the day, how she met her husband.

When examining the physical body, it’s easy to forget about the person inside. But not if Soltys is around. Soltys, associate clinical professor of social work and associate clinical professor of medicine, spends her days listening to people, whether it’s at the geriatric clinic or a local senior center or retirement community.

Soltys doesn’t like to distract a patient by taking notes during a conversation, but she listens so closely that, from an hour-long talk, she remembers most details. When the clinic’s team meets, Soltys can often give insight into what’s going on with the patient’s family or add details that the patient didn’t reveal to the others. With the 83-year-old woman, most of the doctors get the impression that her weight loss is mysterious because she has been eating a normal amount. But after talking with Soltys for half an hour, the family tells her that their mother eats “not enough for a bird.” The team decides to have her keep a calorie record for a few days, so they can find out how much she’s truly eating.

Listening comes naturally to Soltys, but it’s a skill that can be learned, she says. So Soltys and LaRue Coats, formerly of the School of Nursing, developed the SolCos Reminiscence Model to facilitate reminiscence therapy. “As far as we know from the literature, we were the first to actually define reminiscence therapy and formalize it in a model,” Soltys says.

Talking about the past has often been considered taboo by caregivers who believed that it was imperative for elderly people to stay in the present, Soltys says. “Nursing-home staff were saying, ‘you must know what today is, you must know that it’s cloudy outside and that the next holiday is Christmas.’ I think people in Britain were the first to say, ‘This doesn’t matter. We need to make sure these people have a perspective on their lives.”

When training certified nurse assistants, who often give nursing-home patients their daily care, Soltys encourages them to use reminiscing, even if only for five minutes. “I say to them, ‘this was somebody’s mother, this may have been your first grade teacher, this may have been a university president.’ What you’re seeing is a person who looks frail and sick. But that person once was strong.”

Soltys’ model reminds caregivers to consider the patient’s health status, ethnic background, education, and historical perspective. For example, in these days when master’s degrees are increasingly common, it’s easy to forget that many older people did not have the chance to finish high school. “It wasn’t until 1956 that North Carolina had twelve grades in school,” Soltys says. “This state was agrarian and very poor. People worked really hard in the tobacco fields or picking cotton. These are the people who built this state.”

Soltys also emphasizes the importance of touch, which can be scarce for some elderly people. “In the clinic, I often hug the patient, or they’ll take my hand and hold it while we talk,” Soltys says. “Some people might scorn that. But I’ve never let that be a concern to me.”

The most important thing, Soltys says, is “giving people permission to go where they want to go. I don’t have a form, and my questions are open ended. It’s helping them look at themselves in a way maybe they haven’t before.”

Reminiscing can be especially important when coping with an illness. People with dementia, for example, have short-term memory loss, but their long-term memory is often intact. “If they still have some thought processes, they’re aware of the losses in function they have experienced, and so their self-esteem is probably pretty low,” Soltys says. “You can help them go back in their lives and see when they were healthy, what they’ve achieved.” Many of Soltys’ master’s of social work students have conducted reminiscing groups at Orange County senior centers and hospitals. For one group, the students tested the seniors before and after the 10-week group and found that the participants’ self-esteem had increased markedly.

Soltys also uses reminiscence when people are nearing the ends of their lives. Soltys first met Bettie Carter, for example, when Carter came to the geriatric clinic because she had been diagnosed with Alzheimer’s. “She wouldn’t make eye contact; she just looked down,” Soltys says. At first, Carter answered Soltys’ questions with just one or two words. But with encouragement, Carter began to tell of raising her brothers and sisters after their mother had died when Carter was only nine. When she was 17, she married a tobacco farmer.

Then she told Soltys that she had been having visions of scenes from the Bible. “Right away, I thought, ‘that’s why she was diagnosed as having dementia,’” Soltys says. Otherwise, “She was very clear, she could make judgements, she made complete sentences, and she responded appropriately with me.” But it did seem to Soltys that Carter was depressed.

Carter then revealed that she’d been sculpting these Bible scenes out of red clay that she found in her backyard. She’d been rendering her “visions” for almost 40 years. “She said to me, ‘before I die, I’d like to know are they worth anything,” Soltys says. So Soltys called Roger Manly, then curator of the North Carolina State Folk Art Museum, and the next day he drove to Carter’s house. Excited, he brought back a roomful of sculptures. Carter decided to leave them to two North Carolina museums. They now exhibit parts of the Bettie Carter Collection.

Soltys continued to see Carter and made a couple visits to her home. “We continued reminiscing about her work and her life, and with that and antidepressants, she improved steadily,” Soltys says. “She was able to see what she had achieved. She raised four children, all of them college graduates. Given the resources that she had, she used them well.”

Carter died three years after Soltys met her. “I spent more and more time with her as she was dying,” Soltys says. “It was a great pleasure for me to be with her when she died. Every individual you work with leaves a little bit of themselves with you.”

Jill Aitoro was a student who formerly contributed to Endeavors.

In 1996, Soltys helped form the International Reminiscence and Life Review Society, of which she’s still a board member. She chairs the Orange County Advisory Board for Aging and the Orange County Master Aging Plan and recently received a 2001 Distinguished Teaching Award for Post Baccalaureate Instruction.