ALTERNATIVE SOLUTIONS
By Sandra Stimson ADC, CALA, CDP Executive Director,
Alternative Solutions in Long Term Care

ABOUT SANDRA

Sandra Stimson has experience as a
corporate consultant, Corporate Trainer
and National Speaker. Her experience is
in long term care, as Activity Director,
Director of Alzheimer's Units and
Assistant Administrator of a 550 bed long
term care county home.  She is
Co-founder of Pet Express Pet Therapy
Club, is a Life Replay Specialist.  
Sandra implements dementia units
nationwide.  Sandra has written several
books, Volunteer Management
Essentials for Long Term Care and Pet
Express Pet Therapy Program. Sandra
has been a facilitator for Alzheimer's
support groups and is the Awards Chair
for the NJ Association of Activity
Professionals.  Sandra is the Executive
Director of
National Council of Certified
Dementia Practitioners
http://www.nccdp.org  

Alternative Solutions in Long Term
Care offers resources for health care
professionals in many areas of dementia
care, care plans, Snoezelen products,
dementia activity calendars, adult day
care calendars, sensory calendars,
reminisce videos for dementia, activity
books, and dates to remember, party
supplies,
resources and links.
Each Norman Rockwell print is
paired with a national standards of
Resident Rights and is
illustrated by a picture depicting
the "Resident Right."

click here to purchase resident
rights prints
THE ACTIVITY DIRECTOR
for Activity Professionals
in Long Term Care Settings
admin@theactivitydirectorsoffice.com

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The Activity Director's Office
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Disclaimer
ACTIVITY DIRECTOR TODAY
Sandra Stimson
Dementia Units and the Importance of Admission
and Discharge Criteria Agreements


Fifteen years ago, dementia units were almost unheard of. Now more and more nursing homes and
assisted living facilities are offering secure units to keep their wandering residents safe. Many of the
secure units offer specialized dementia activities, individualized meal options and trained staff in the area
of dementia care. One problem that dementia units are having is discharging residents from the unit to
another more appropriate unit, once the resident has declined and no longer benefits from the unit.
Frequently, family members are refusing to move their loved one. Not only is the resident not appropriate
for that unit, the slot is not utilized by a resident who could benefit from the dementia program.

The family member must understand the admission and discharge criteria agreement and sign it at the
time of admission. Family members must clearly know in advance and understand at what point their loved
one will be transferred to the step down unit.

The admission / discharge criteria cannot be vague and open to interpretation. It must clearly state the
criteria for admission on to the unit. Such as: ambulatory, able to participate in daily activities, able to
participate in their ADL’s, not be violent to themselves or others, able to feed themselves and have a
diagnosis of dementia. In addition, it should also state that they score lower than a 6 (3-5) on the testing
forms you are using, such as Global Deterioration Scale, Brief Cognitive Rating Scale, Functional
Assessment Testing, Geriatric Depression Scale, etc. The Mini Mental Test should not be the only test
conducted for Dementia residents.

These tests should be conducted as a baseline upon entering the facility and then at minimum on an
annual basis. This will give a baseline and track decline. The test should be administered in a quiet place,
allowing an adequate environment and enough time for the resident to respond. Staff should be trained to
administer the test and utilize only the explanations accompanying the test to score the results. It is
recommended that only the staff psychiatrist provide this test, as the answers residents give can be very
subjective. Not everyone performs well when being tested. The resident may not be in the mood, tired, sick
and a host of other reasons that could affect their score. The test scores would also be used as part of
criteria for admission and discharge. The test should not be the only criteria for admission or discharge. It
is a part of the whole picture to determine your criteria for admission and or discharge.

On the flip side, the discharge criteria agreement also needs to spell out clearly the criteria for discharge
from the unit. The criteria should include at minimum, the resident is: unable to participate in activities,
unable to feed himself, requires total care, be at risk to harm themselves or others, etc. The discharge
determination must involve the team and the family or responsible party.

The team will gather all the facts  and in a team meeting discuss the possibility of discharge. Families
must be kept in the loop each time the resident has a change or declines. The family member or
responsible party must be told in advance that the change in condition is leaning towards discharge
because the resident is no longer benefiting from the services provided on the dementia unit. At each
meeting review the discharge criteria with the family member.

These meetings must clearly be documented in your care meeting notes and family member or
responsible party should be signing the care plan note.

Facilities that do not have admission / discharge criteria agreements with families / responsible party face
problems when it is time to discharge. Families may refuse to move their loved ones to another unit. Some
are in denial and don’t want to face that their loved one has declined. But most families are refusing to
move because they were never told that they would have to transfer when the loved one declined or they did
not understand the criteria. The facility may have a discharge policy and the policy is so vague that it makes
it hard to determine when to discharge. If, families clearly understand the discharge criteria and are kept in
the loop as the resident’s condition changes, they may not be happy about moving their loved one but at
least it should not be a shock or surprise when the time comes to discharge. The other reason making it
difficult to transfer, is that the facility is not following their own discharge criteria. They are not consistent.
Every resident who no longer fits your criteria has to be moved. Families will not move their loved one if they
see other residents who have not been moved off the unit.

Additionally, the staff that work on the unit need to be educated about the discharge criteria. The staff
become attached to the dementia resident and may not want to discharge a resident to another unit. They
can sabotage management’s efforts to discharge by reporting to the family members their personal
feelings about discharge.

Prior to admission, the facility should be interviewing family and resident for suitability for the unit, review
medical records and medications to determine if the resident is appropriate, complete preadmission
screening (cognitive and function tests, physical exam, blood work (Metabolic Screen), Thyroid test, B12
and test for Syphilis, as well as a psychiatric evaluation and neurology evaluation. The Admission team
should also complete a wandering assessment form. The form would include information about places a
resident may have wandered to in the past, triggers for wandering, description of the resident, words he
may answer to, etc. Finally, explore resident’s use of common words and their meanings, so that staff may
anticipate his needs. For example, a repetitive word used by a resident may be, “TA TA”, which to this
resident may mean, “toilet”. All of this combined would determine eligibility to the dementia unit as well as
a truly comprehensive assessment.

When facilities do not follow their discharge criteria they then encounter all kinds of problems. Families will
refuse to move their loved ones because they see other residents who may be more debilitated than their
family member who have not moved from the unit. They may refuse to move their loved one based on
“resident rights”.

When you are unsuccessful in moving clients, your resident demographics will soon look like all the other
units. Everyone is now low functioning! Now your premier unit is no longer unique or more special than any
of your other units. This will affect your future admissions. Prospective resident families who are touring do
not see higher functioning residents. The hardest part of running a successful unit is discharging. Other
departments are competing for the same beds on other units, such as new admissions, rehab residents
who now qualify for long term care placement, room changes and dementia residents moving off the unit. It’
s a challenge for all facilities. If you follow your admission / discharge criteria you will have a smoother
transition when the time comes for discharge. Every department knows in advance that there is a transfer
pending from the dementia unit.

Facilities have put a lot of time and energy to develop premier units that offer extra services, but facilities
need to give a reason for family members to cooperate. The units that their loved ones are transferring to
must be just as beautiful and home like. Recreation departments must be offering activities that fit the
needs of the lower functioning populations, such as sensory rooms, music program, pet therapy, aviaries,
activity pillow/aprons, mobiles over beds, aroma therapy, touch therapy, doll therapy, etc. As long as
families see that even though their loved one is moving to another unit, they will be offered the same
amount of services that your premier unit provides, they will be more apt to move. Your dementia unit offers
special services that will benefit the dementia client and your step down units should also provide palliative
nursing and sensory activities to fit their current function levels.   -  END
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