CategoryHealth Systems

Executive Summary on Alzheimer’s Disease and Related Senile Dementia

In 2002, the Indiana Alzheimer’s Association convened a Working Group of consumers, long- term care professionals, and state agencies to complete a study of aggressive and potentially harmful behavior among long-term care residents pursuant to Senate Concurrent Resolution 18.

A summary of findings presented by the Group to the Governor’s Task Force on Alzheimer’s Disease and Related Senile Dementia follows:

Data is limited on the incidence and degree of harm caused by resident aggression. Indiana may wish to participate in more detailed studies if they are undertaken and funded by the federal government or private sources.

While the Working Group initially focused on aggressive behavior among nursing home residents toward other residents – as charged – it found in literature and practice at least equal concern about aggressive behavior of residents toward staff and family members in a variety of settings including home care, assisted living, adult daycare, and so on.

The problem of aggressive behavior concerns not only family members of victims, but also family members caring for aggressive loved ones, direct care staff, and administrators subject to liability and occupational health and safety (OSHA) issues.

Moreover, while the Working Group initially focused on aggressive behavior among nursing home residents with Alzheimer’s disease and other forms of dementia — as charged — it eventually recognized that aggressive behavior is a problem among a larger pool of nursing home residents, including residents with mental illness, co-occurring mental illness and dementia, physical health problems such as urinary tract infections, pain, and a history of violent or criminal behavior.

Indeed the aggressive Evansville nursing home resident that prompted this study had a violent criminal history as well as alcohol-related dementia.

Consequently when estimating the scope of the problem, the Working Group included information on behaviors as well as diagnoses of dementia. Demographic trends imply that these problems will grow over time as the Indiana population ages. Dementia is more prevalent with age.

The Indiana State Department of Health (ISDH) conducts annual surveys of the 600+ Indiana long-term care facilities and investigates complaints from the public. ISDH reports that:

  • During the most recent six-month period (12-1-01 to 5-16-02) ISDH received 11 complaints from the public of resident-to-resident abuse; if annualized this would equal about 22 complaints of resident-to-resident abuse per year.
  • During the same six-month period long-term care facilities reported to ISDH 571 incidents of resident-to-resident abuse (of about 5,000 incidents reported by long term care facilities); if annualized this would equal about 1,142 incidents (of about 10,000 incidents reported by facilities per year).

The Office of Medicaid Policy and Planning (OMPP) provided very useful data from the Minimum Data Set (MDS), an assessment tool used by long-term care facilities pursuant to federal guidelines.

It shows that aggressive behavior is an important problem but it is not widespread. While 29% of the nursing home population displayed one or more behavioral symptoms (wandering, verbal abuse, physical abuse, inappropriate/disruptive behavior, or resisting care), only 5% (n=2,134) displayed physically aggressive behavior and a lesser proportion displayed physically abusive behavior that was difficult to change (3%)(n=1,276).

Studies in other states indicate that an even smaller portion actually cause harm to others.

MDS data indicate that only a portion of physically aggressive residents are cognitively impaired (60-94% depending on the degree of cognitive impairment counted) and only a portion of these have Alzheimer’s disease.

Studies indicate that aggressive behavior is associated with a variety of factors, including but not limited to dementia:

Factors related to residents include:

  • Previous history of violence/criminal record
  • Untreated pain or other discomfort
  • Medical conditions, such as urinary tract infections
  • Depression, other mental illness, co-occurring disorders
  • Males
  • Mid to late stage Alzheimer’s disease
  • Other forms of dementia not related to Alzheimer’s, such as head injury and alcoholism (younger and stronger residents with other dementias sometimes are placed in special care units for behavior management)
  • Provocation by other residents and caregivers, often during assistance with Activities of Daily Living (ADLs)

Factors related to facilities and the overall delivery system include:

  • Insufficient training on dementia and behavior management for professionals caring for geriatric population (physicians, nurses, aides, etc); insufficient use of behavior management techniques (environmental changes, acceptance)
  • Inadequate use and training in proper use of medications
  • Inadequate supply of caregivers specially trained in geriatrics, ranging from aides to nurses to social workers to physicians; not enough staff
  • Beyond dementia, large numbers of nursing home residents with mental health needs contributing to aggressive behavior
  • Insufficient early assessment and treatment of behavioral and mental health conditions, especially for residents excluded from pre admission screening & resident review (PASRR) due to the federal dementia exclusion
  • Lack of awareness of reimbursement options available in Indiana for mental health services
  • Shortage of geriatric mental health professionals in nursing homes, in private practice, and in community mental health centers
  • Lack of highly specialized “Facilities of Last Resort” for treating behavioral disorders
  • Limitations in reimbursement and regulation of dementia care in special care units
  • Limitations in criminal justice and adult protective service systems

Although several states have implemented models that could be considered in Indiana, generally resident aggression has not been studied in depth or addressed systematically throughout the U.S. National advisors indicated that Indiana may be in the forefront in tackling this issue.

Many of the factors contributing to aggressive behavior can be addressed in order to prevent and minimize aggression. The Indiana Working Group recommends strategies including the following:

  • Make greater use of behavior management techniques to minimize the majority of behavioral symptoms, including physical aggression
  • Provide more training for caregivers (ranging from aides to physicians) in use of behavior management techniques
  • Provide more training in proper treatment protocols including drug treatment
  • Ensure that appropriate medications/protocols are included on the preferred drug list under development by the Drug Utilization Review Board
  • Increase the supply of health professionals with geriatric training, including aides, LPNs, RNs, nurse practitioners, advanced practice nurses, social workers, mental health practitioners, and physicians.
  • Refer human resource needs to the Governor’s Commission on Caregivers for the Continuum, a group already working on human resource issues.
  • Ensure early assessment and treatment of mental health conditions, notably co- occurring dementia and depression; help facilities locate mental health providers.
  • Educate families and providers about the availability of Medicaid, Medicare and other reimbursement for delivering mental health services to long term care residents
  • Expand the pool of mental health professionals, especially those cross trained to provide geriatric services
  • Encourage community mental health centers to provide geriatric services; market centers that currently offer such services
  • Bring care on site rather than move or transfer patients
  • Involve regulators, such as the Indiana State Department of Health, in collaborating on solutions, with ongoing training on dementia, behavior management, documentation needs, treatment/drug protocols, mental health screening, etc.
  • Create several highly specialized nursing “facilities of last resort” to treat the most difficult behaviors (less than 1,000 people) and to provide technical assistance to other care providers.
  • Consider findings from a previous FSSA study acknowledging the need for additional reimbursement of special care units under certain conditions; consider a similar study for all residents with behavior symptoms, with and without dementia.
  • Consider other criminal justice and adult protective services system changes to address violent behavior among elderly persons supervised and not supervised by the courts.

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5 Essential Qualities of an Effective Board Member

5 Essential Qualities of an Effective Board Member
A solid board consists of great and qualified board members. It is the qualities of each individual board member that determines whether or not a board can operate successfully.  But what makes a person fit to sit as a member of a healthcare organization’s board of directors?

Here are the critical qualities of an effective board member:

1. Dedicated and Committed

Being a board member requires a high level of dedication and commitment to responsibilities that extends beyond attending board meetings regularly. Effective board members bring a lot to the table and maintain and unwavering interest to the achieve the goals of the organization.

2. Able to lead and influence others

An excellent member of the board has the ability to lead and influence others to pursue the goals of the organization. He or she has the spirit and drive to set direction in order to fulfill the institution’s business goals.

3. Straightforward and impartial

An effective board member brings candor to board meetings. He is able to engage other board members in discussions and debates without being arrogant or disrespectful. He is objective and impartial and has the ability to the effectively drive a point across without making things personal. A good member of the board will not hesitate to ask the hard questions for the constituents that the board servess

4. Knowledgeable and an insatiable learner

A member of the board should be knowledgeable about the organization and its culture, operations, mission, and vision, the roles and responsibilities of the board as well as the principles of good governance. Aside from that, he or she has an insatiable desire to learn and seek personal and professional development.

5. Values discretion and confidentiality

Trustworthiness is an essential trait of a board member. Board discussions and meetings are confidential and each member should be able to manifest discretion at all times. He or she should always support the decision of the board when speaking in behalf of the organization.

Principles and Best Practices for Effective Governance

  • Governance principles provide an objective basis to establish a board’s role, structure, composition and working processes.
  • Nine sample principles provide a basis for your board to customize its principles.
  • By implementing best practices associated with each principle, a board can improve its effectiveness.

The trustees of one health system were divided over how to structure the board. Some favored proportional representation from its acute care, nursing home, and elder services divisions; others wanted all at-large members with no interests to promote.

CEO leads everyone by exampleThe CEO of another health system had restructured, so facility executives were directly accountable to corporate management for finances and operations. He wanted local boards to focus on strategic direction and oversight of quality, but local boards continued monthly monitoring of finances as they’d always done. Some trustees wondered what their role was.

At a third health system, a new trustee was surprised to learn the organization had no strategic plan — at least not one that identified major initiatives and set measurable performance goals, the kind he’d developed as a successful corporate executive.

So, he interviewed the vice president for planning, drafted a strategic plan and brought it to the planning committee — to the CEO’s surprise. The CEO was upset the new trustee was meddling in management. These situations share a common cause: unclear expectations of the board’s role.

Developing Governance Principles

No team can operate at optimal effectiveness unless each member knows his or her job and all members share common expectations of how they should work together. To build shared expectations, boards can discuss and adopt a written set of governance principles that define the roles, structures, composition and processes that enable the board to add value to the organization through its work.

A governance principle is a statement of the desired governance attribute or behavior that guides board work and decisions. Governance principles can help a board resolve differences and improve performance.

Governance principles aren’t one size fits all. Individual boards will benefit from developing their principles through a participative process that is enlightening and unifying. The principles also provide a basis for a board to agree on practices that apply the principles to the board’s roles, structure, composition, and work.

Nine Sample Principles

As a starting point for discussion, here are nine governance principles that are associated with effective board performance. Each principle is followed by illustrative practices.

1. Accountability

The board understands its accountability to see that the organization acts in the best interests of the “stakeholders” who it serves such as patients and the community. Board members bring perspectives and knowledge from outside endeavors, but they don’t “represent” single constituencies. The board acts with diligence & objectivity on behalf of the stakeholders as a whole.

 

Sample Best Practices

  • Written governance principles
  • Periodic discussion of primary stakeholders and their needs

2. Responsibility

To govern (and not manage, which is the CEO’s job), the board focuses its work on six major responsibilities:

  • Define the ends, policies, and goals of the organizations, beginning with the mission, vision, values and strategic plan
  • Make and support decisions that advance the ends • Select the CEO, establish goals & expectations for the CEO and organization, evaluate his or her performance and establish appropriate compensation
  • Monitor organizational performance and exercise accountability for results, especially in the areas of mission effectiveness, financial stewardship, strategic direction, quality of care and customer service
  • Use influence with key internal and external constituencies to advance the mission and vision
  • Take responsibility for the board’s effectiveness.

 

Sample Best Practices

  • Written position descriptions for trustees, board chairperson and committee chairpersons
  • Explicit process for CEO goal-setting, evaluation and compensation review

 

3. Exemplary Conduct

Directors exhibit trust and respect toward colleagues and management, honor the confidentiality of sensitive information and scrupulously observe the conflict of interest policy.

 

Sample Best Practices

  • Periodic board education and discussion of conflict of interest
  • Confidentiality policy
  • Code of conduct

 

4. Mission- and Vision-Driven

Board composition, structure, and work are designed to enhance the mission, vision, values and strategic direction of the organization.

 

Sample Best Practices

  • Board and committee meeting agendas that focus on major initiatives in the strategic plan
  • Measurable goals to track strategic plan implementation and organizational effectiveness
  • Performance reports presented in a dashboard format
  • Meeting evaluation form to assess incorporation of mission and values

 

5. Streamlined

The board’s size and committee structure are as lean as possible to facilitate communication, participative discussion, and efficient decision-making.

Sample Best Practices

  • Straight-forward structure
  • Optimal size (11-17) to balance the diversity of competencies with the need for timely decision making
  • Sunset provision for committees
  • Committee charters, annual goals, and work plans
  • Task forces for short-term needs

 

6. Competency-Based Composition

Board members are chosen to bring specific competencies and personal characteristics that will enhance the mission, vision, and work of the board. Competencies are developed further through orientation and ongoing education.

 

Sample Best Practices

  • Written board competencies
  • All trustees participate in the recruitment of prospective members
  • Term limits promote connectedness with stakeholders, fresh thinking and objectivity
  • Rotation of members on committees
  • Members are evaluated and reelected based on satisfactory performance
  • Succession planning for board leaders

 

7. Education and Development

Competencies are enhanced through education and ongoing board development.

 

Sample Best Practices

  • New trustee orientation and mentoring
  • Board manual, including written board policies
  • Education at all meetings
  • Participation in outside seminars
  • Annual board retreat
  • Board education budget

 

8. Value-Added Work

The board focuses on meetings and all work on activities that add value to the organization, with an emphasis on high level, strategic matters and critical issues affecting the future of the organization.

 

Sample Best Practices

  • Annual board goals and work plan
  • Formal and open agenda planning process
  • Consent agendas

 

9. Continuous Self-Renewal

The board regularly evaluates its performance and uses the results to improve. The board also evaluates the performance of the board as a whole as well as the performance of the chairperson and individual trustees.

 

Sample Best Practices

  • Regular self-evaluation
  • Evaluations of chairperson and individual trustees
  • Governance Committee

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