< Culture Change

One’s Home is One’s Cottage at Brushy Creek

"Maude's" declining abilities seemed to put her forever out of touch with loved ones and the joys of living. Except for an occasional "yes" or "no," she had been mute for over a year and more recently quit chewing her food, subsisting instead on a spoon-fed, puree diet. So, when her daughter brought her to the Greenville Hospital System's Roger Huntington Nursing Center, she feared Maude would live only a few more weeks at best. But luckily, the Center was going through a change of culture.

"One of our first changes was to permanently assign staff to specific residents. That is the single most important change you can make," says Karen Nichols, Administrator and former Director of Nursing. Caregivers come to know and anticipate residents' individual needs and desires. "You can do more for them," adds Christy Mooney, "companion" nursing assistant.

While serving as a companion for Maude, Mooney was eating a graham cracker one day when she noticed the elder looking at her and moving her mouth.

"I asked her if she could chew and she said 'yes.' That was the first time she had spoken to me," Mooney recalls.

Knowing the cracker would dissolve in Maude's mouth whether or not she could chew, Mooney placed a piece on the woman's tongue. "She chewed and chewed and swallowed and asked for more," says Mooney, who then alerted the nurse and speech therapist and advocated on Maude's behalf until a physician was called in.

"Lo and behold," says Nichols, "we learned she didn't need to be on a puree diet. We put her on a regular diet and she lived for six more months." During that time Maude began speaking more and opening up to her daughter, who had far more quality time left with her mother than she had expected. "No amount of money can buy that," says Nichols.

Mooney doubts she would have discovered Maude could chew if she had been working in the traditional nursing home model, where "you never knew from day to day until you came on your shift which residents you were going to be assigned, or what you were going to do," she says.

But with the change to permanent assignments, "Christy was with (Maude) every day and went the extra mile," adds Nichols.

"They Feel the Difference"

Now, a few months later, the same "Companion Model" that connected Mooney and Maude is enriching life for staff and residents in homey new surroundings. In fall 2007, they moved from the 45-year-old Huntington Center into 12 newly-constructed "Cottages at Brushy Creek" on the Greenville Hospital System's medical campus near Greer, SC.

Functioning independently, each cottage has all the amenities of home and more: Private bedrooms with baths for 12 residents, full kitchen, pantry, living and dining rooms, den, laundry and beauty parlor. Visitors ring a doorbell before entering. Furnishings are residential-style rather than institutional. Like a typical neighborhood, the cottages line a circular drive and share a community center on 11 green acres. Residents choose what and when to eat, when to sleep and get out of bed and whether to have pets, even the color scheme for their personal bedroom.

The households follow a "Core and Balance" approach to resident involvement, engaging elders in "core" activities of daily living (helping in the kitchen, walking the dog, sipping coffee in your pajamas, what Action Pact calls daily pleasures) while making planned, group "balance" activities (bingo, movie night, Sunday worship) as meaningful as possible.

Residents are rising to the challenges of choice and becoming more assertive about asking for what they want, says Nichols. Some who used to be fed by staff now feed themselves, and some formerly bedridden now move about in wheelchairs. "We have five elders whose well-being has improved so much it is borderline as to whether they still need skilled nursing care," she says.

With change have come more opportunities for caregiver job applicants and potential new residents. "Some nursing homes have many empty beds, says Nichols, but we have a many people wanting to live and work here... visitors say they want their mom or dad to live with us because they feel the difference when they walk in the door."

Companions Increase Caregiver-to-Resident Hours

The project is a hybrid of the Household Model, championed by Action Pact and Meadowlark Hills, and the Green House™ developed by Dr. Bill Thomas of the Eden Alternative and first built in Tupelo by Mississippi Methodist Senior Services. "We call it the Companion Model in honor of our determination to combat residents' loneliness, helplessness and boredom as identified by the Eden Alternative," explains Nichols.

"Companions" are CNAs, housekeepers and dietary staff who have completed at least 80 hours of cross-training to assist residents in all aspects of everyday home life. They are trained in food service and cooking, cleaning, inventory, activities and more. Together with nurses and mentors, they comprise self-directed work teams permanently assigned to specific cottages. Three companions are assigned to each cottage of 12 residents on first shift, two on the second shift, and one on the third or late-night shift for a companion-to-resident ratio of 1:4, 1:6 and 1:12 respectively. "It almost doubles our (caregiver) hours per patient day because everybody working here can help take care of residents," says Nichols.

Ten of the 12 cottages are for long-term elders; the other two accommodate rehab and short-stay residents. Nurses are involved as team leaders in each, says Nichols. Nurses in the cottages for long-term residents divide their time between two households on first and second shifts, and among three cottages on the late-night shift. The two cottages for short-term residents each have an RN on site 24/7. Whether assigned to one or three cottages, nurses come to the same houses every day and get to know staff and elders well, says Nichols.

Mentors are comprised of department heads who, besides making up the facility-wide leadership team, are assigned to ensure quality of care and facilitate group discussions, learning circles and problem solving in their particular cottage. All team members carry cell phones. Nurses also carry wireless laptops so they can work anywhere in the community.

Initial concerns that accountability might break down with staff divided among houses spread over an 11-acre campus have been put to rest, says Nichols. "We're finding it was easier in the old, traditional model for staff to hide whether or not they were doing a good job," she says.

"You Can Do This"

The journey from Huntington to Brushy Creek began in earnest three years before the cottages were constructed, about the time Nichols arrived as the facility's Director of Nursing. Involved in long-term care for 10 years prior to joining GHS, she was a founder of the South Carolina Eden CARES culture change coalition and worked a while for Action Pact as an Eden Alternative Associate trainer. After several years as an advocate and trainer for culture change state-wide, she decided to accept GHS's offer for the DON position at the Huntington Center, where they were planning to replace the old building. "I felt like I needed to put my money where my mouth was and be able to tell people, 'Yes, you can do this (culture change) because I did it too,'" she recalls.

She credits former Administrator, Les Parks (who she since has replaced), as the chief motivator for the Brushy Creek Cottages. "He had the foresight to know the facility they were planning was basically just a replication of the old building, and that was just not the way to go," she says. They visited Meadowlark Hills in Kansas and the Greenhouse in Tupelo and, with Action Pact's help, began planning the Cottages at Brushy Creek.

Preparing a Smooth Transition

Nichols says there were two things they did at the onset of their culture change journey that helped ensure a successful transformation at Brushy Creek:

1. They began living the Companion Model as much as possible in their old building. "We knew if the culture didn't change at Roger Huntington, it wouldn't be any different at Brushy Creek," Nichols says.

2. They held complete, ongoing education and staff meetings with opportunities for workers to voice concerns and suggestions. ("We stopped monthly staff meetings after we moved. That was a mistake... we're going to re-institute them," she adds.)

Monthly educational gatherings are facilitated by staff from the GHS's Education Department. "A wonderful lady, Kristy Childers, has been with us throughout this whole process, working through Action Pact's Champions of Change and several other modules with staff," Nichols says. Management Team members attend the trainings as individuals, not as formal leaders. "I try to blend in... I'm there as Karen, not as the Administrator. People are free to speak their minds," she says.

To minimize stress in moving from the old building to the cottages, staff worked with elders and their families in assigning resident rooms. The objective was to enable elders to continue living close to their friends and to retain their same caregivers as much as possible, a "challenging but very successful" endeavor, says Nichols.

"You're Going to Cry Some Along The Way"

Despite the best of planning, there were and continue to be challenges in the transition. Regulatory issues (many related to fire codes) caused a 6-9 month delay in completing the cottages, the first project of its kind in South Carolina, says Nichols. Though waivers were acquired from the appropriate agencies prior to breaking ground, inspectors always seemed to find something new that needed to be fixed after construction began. "Different people interpreted the regulations differently," she explains.

Now that cottages are open, there is an ongoing need to educate surveyors about culture change. For example, "they want to walk right into our cottages without ringing the doorbell," she adds.

Her advice: "You've got to keep lines of communications open with (regulators) even after they've signed off on your plans. Let them know what you are doing, because (culture change) is just as new to them as it is to us."

She is excited for Brushy Creek's future. "People say if you do culture change you are going to cry somewhere along the way, and that is absolutely true. It's the hardest thing I've ever done, but it is one of the most worthwhile," she concludes.