This time last week I was sitting with a group of people on the lawn outside a house in Darwin, Minnesota, enjoying the last throws of an unusually warm streak of weather. The late afternoon sun cast long shadows on the grass. Trees waved in the gentle breeze, and newly plowed fields waited expectantly for the coming snow. Conversation was muted as befit the gentle surroundings, with laughter and the bleating of baby goats occasionally breaking through. Laurence and Mel* talked about fishing while Cathy snapped photos. Bill debated how he could get back to Cokaeto, and George wanted to know what highways were around the town. Jen watched the group with a bemused expression and Joe slept on. If I closed my eyes, I could imagine that I was at a family gathering or a bbq with good friends. It was a lazy Monday afternoon on the ranch.
Except that this is no ordinary ranch. This is
Lakeview Ranch, a magical place and home to 30 residents with dementia. I was there with the documentary photographer and author of
Alive with Alzheimer's Cathy Greenblat and Laurence and Kathy Harmon, owners of
GreatPlaces. The occasion was a pet therapy session, held on the lawn to take advantage of the warm weather. Mel, Bill, George, Joe and Jen have dementia, and yes, Bill was asking for the sixth time how he could get back to the town of Cokato, and George was worried about getting back to his farm and wanted to know the best route. But the staff expected these questions and worked to avert any stress that might be caused by non-answers.
Lakeview provides specialized dementia care for people who are at high risk for repeated hospitalizations due to challenging and often violent behaviours resulting from their dementia. Prior to relocating to Lakeview, most of the 30 Lakeview residents had been moved repeatedly from care facility to hospital to care facility, causing untold stress on the resident and anguish for the families. In addition, the residents had experienced restraints and behaviour-controlling medications. For these residents, a move to Lakeview means a move to a permanent loving home, where they can live a peaceful, active, and restraint-free existence with minimal use of psychotropic drugs. For families, it means seeing their loved ones treated as humans, and seeing their loved ones acting as humans as a result.
How does Lakeview do it? By showing respect and love, and taking care of emotional, spiritual and physical needs. I asked two of the staff members, both RNs, what they considered the philosophy of Lakeview, or the main operating principle. One answered that they do not want the families to worry about their loved ones, that their family members with dementia are loved and well cared for. The other nurse concurred and added the principle of respect for the person with dementia.
Lakeview staff know that most often there is a reason for a challenging behaviour in a resident, and that if you fix the cause, you fix the outcome. A great example of how Lakeview staff handle challenging behaviours such as agitation that presents itself at the same time each day, is the story of the resident and the cows. One resident would become agitated at approximately 3:30 a.m. each morning. In reviewing the man's life, work and habits, the staff discovered that he was a dairy farmer who milked his cows at that time each day for untold years. He continued to be concerned about his cows. Staff were able to assure him that the cows were being milked and not to worry -- problem solved. The fact that they are willing to repeat this action every day rather than turning to behaviour-modifying meds to control his agitation is what differentiates Lakeview from many other facilities.
Lakeview Ranch is the passion of Judy Berry. When Judy first started working towards establishing her vision of a better place for people with dementia, she had no experience other than the knowledge that there had to be a better way to care for people like her mother. Her mother had Alzheimer's disease and during the last seven years of her life was "bounced around" from one facility to the next due to her somewhat challenging behaviours before her death in 1996. According to Judy, her mother spent the last year of her life strapped in a chair and drugged to make her behaviour "compliant." Judy was determined that no other person with dementia have the same experience.
Judy spent those years with her mother in frustration, anger and heartbreak as she searched fruitlessly for help and appropriate loving care for her mother. She already had a vision of the type of care she would like to find for her mother, but was told by nursing home administrators that the care of her dreams was exactly that: a dream. It was not possible, it wouldn't work and it was too expensive. As a result, at age 55, Judy decided to use her life savings to start Lakeview Ranch.
The first facility opened in Darwin, Minnesota and Judy later built another facility a few miles away in Dassel. Between the two locations, Lakeview Ranch now has a total of 30 residents (15 in each) and 85 staff. Judy's staff to resident ratio is 1:3: that's 3 residents for each staff member, plus RN's and activity directors. The high staff to resident ratio -- in addition to
ongoing specialized training, mentoring of support staff, and in house RN coverage -- allows Lakeview to provide the specialized care for which they are becoming famous.
Let me tell you what I saw as evidence of how the Lakeview model of care plays out. What does this model really mean to the residents?
First, each of the facilities looks like a house, albeit a house with two kitchens and two wings of bedrooms. There is a huge living room with couches and a TV (it's not turned on very often, but some of the residents like to watch Wheel of Fortune). In the corner of the living room is a stack of bright homemade quilts threatening to topple over. The equally large common room is bright and airy, with large windows and skylights allowing the natural light and sunshine to stream in. Judy felt that darkness contributed to depression in the elderly, and so wanted to ensure that the interior of her homes were as bright as they could be. Indeed, all of the bedrooms have large windows allowing in a lot of natural light.
Besides the brightness, I was struck by the fact that all rooms were carpeted, with the exception of the common room and kitchens, lending to the home-like (non-hospital) feel of the place. I was also struck by the sheer quantity of common space. The living room and common rooms were true gathering spaces for residents, staff, family and friends.
There are two twin beds per room, in the belief that people in the later stages of dementia find it disorienting to wake up alone. The staff make provisions for people who object to sharing a room at first, such as putting up a moveable screen between the beds. However, the sheer size of the rooms ensure that residents will not be tripping over each other in the middle of the night. Furnishings are simple and all beds are festooned with homemade quilts and/or favourite quilts and pillows from home. Large bulletin boards on the walls are used to display photos, homemade cards from grandchildren and reminder notes.
Bathrooms are shared, and each wing has a large bathroom with bathing/showering facilities. Each location has a state-of-the-art bathtub that lowers and raises for accessibility, has a door that drops down... well, it looked like a space ship. At Lakeview, residents can choose whether they would like a bath or a shower. As a side note, staff at one of the homes raised the money for one of the special tubs.
The kitchens are large, functional, and each contains a table and chairs so that residents can eat family-style rather than restaurant-style. Here in Minnesota, coffee is drunk with every meal and in between as well, and so, the coffee is always on!
When staff interact with the residents, they always look them in the eye even if that means getting down on the knees to do so. They don't "schlepp" people around like inanimate objects, sending them off to one activity or another or rolling them over to the dining room for meals. I also realized that staff always moved residents themselves rather than with the assistance of a mechanized lift. I remembered that the home in which my mother resided had a policy about lifting residents: if a resident required lifting and more than one person was needed for assistance in lifting, then a mechanized lift had to be used to lift the resident (note that this does not necessarily translate into a safer lifting experience for the resident!). My mother, because she could not support herself with her legs, was deemed a "two-person lift" and so was always hauled out of bed and into her wheelchair with a big lifting machine. She never had the benefit of someone's arms around her to lift her up, and she wasn't a large woman.
Lakeview staff also know when and how to intercede before an event can take place. For example "Jen" didn't like having "Bart" close to her at dinner. Before things could escalate, a staff member dropped down between Jen and Bart and brightly said to Jen, "See, I told you I'd sit next to you at dinner!" Problem solved.
Judy believes in appropriate, frequent and engaging activities and doesn't hesitate to take a chance on something new. While we were there, and at the insistence of Cathy Greenblat, some of the residents took part in what we think might be the very first "Laughter Yoga" session ever held with people with dementia. It was a total success and the subject of a future blog. In the summer, Judy takes residents out fishing in a boat on the lake outside of the Dassel home. They have been known to go ice fishing in the winter. Residents also help out with the animals in the barn at the Darwin home, a boon to residents who used to farm. In addition, Lakeview recently acquired a bus, which they use to take residents on frequent outings to parades, local events and DQ.
But what struck me most was the overwhelming sense of peace, tranquility and positive energy that flowed all around. There was none of the noise of people in distress that one hears in many dementia care facilities. Staff speak normally and respectfully to residents, without shouting or speaking in simplified words as if the resident can't hear or understand. The decor is best described as comfortable "shabby chic," with china stacked up in china cabinets, overstuffed couches inviting people to snuggle under homemade quilts, and magazines, books and newspapers strewn around, waiting for a reader. There is always a bustle going on somewhere, and residents are welcomed to get involved. The food is homecooked and rib-sticking. Family visits are encouraged at any time, and family involvement is taken seriously at Lakeview rather than given lip service. And when family do come, they can expect their loved one to be happy, alert (unless they're asleep or in the final stages of the disease) and not demonstrating the behaviours that families find so distressing to see in their parents.
I felt as if I was in someone's home, and I was tempted to flop down in a chair and put my feet up on the coffee table as if I was at my parent's house. I've never felt that way in a dementia care facility before.
Of course, specialized dementia care costs money. Lakeview's per day cost is higher than most facilities, but the resident (and the family) get SO much more for their money. And, Judy will never turn away a potential resident because of inability to pay.
The 2009 Alzheimer's Facts and Figures report that Medicaid payments for this population (elderly with dementia and significant behavior) are nine times higher than for elderly without dementia, and that healthcare costs for seniors with dementia are three times as high as for those without dementia. The Lakeview model focuses on
pro-active disease management and prevention. St. Cloud State University research has shown this model has proven to reduce behavioral hospitalizations by 93.3% while reducing psychotropic medication use by 36.1% in this high risk population. This high success rate translates into less money for Judy. According to an excerpt from a recent article by Judy:
Our current healthcare system funders and case managers doing assessments for Medical Assistance clients do not recognize this added value approach or fund -- Pro-active Disease Management and Prevention as an effective way to enhance quality of care while significantly reducing healthcare costs. In fact, Lakeview Ranch endures repeated cuts to low income residents Medicaid payments simply because they manage to do a better job, and are successful in reducing the aggressive behavior of their residents. Significantly higher payments are available for residents with ongoing aggressive behavior. In a nutshell, under our current Healthcare Delivery System, the better care you provide, using appropriate higher staff ratios of specially trained staff, and the more pro-actively you manage disease and "prevent" other acute medical emergencies that require high cost hospitalizations, ER visits and unnecessary testing, THE LESS YOU GET PAID.
To try and shore up the gap between revenue (from private pay residents and Medicaid) and expenses, Judy started the
Dementia Care Foundation. She relies heavily on donations to the fund to provide "scholarships" for residents who cannot afford the care at Lakeview. Once again, note that Judy will never turn away a resident who cannot pay. With the downturn in the economy this past year, donations are way down and Judy is uncertain as to how she will close the gap. However, Judy takes it a day at a time, keeping her eye on the goal of providing quality specialized dementia care, and trusts that things will work out.
Help make sure that more people and families with dementia can experience the magic of Lakeview Ranch and that that magic is never extinguished.
Make a donation to the Dementia Care Foundation.
*Names have been changed to protect the privacy of Lakeview residents.
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