First, I'd like to express my appreciation to Barbara for her comments. And Joe is right; this is a thoughtful, and in my opinion, wise summary of how we should proceed when taking action to help move our organizations toward Culture Change. (It even sounds like Barbara is channeling some of the Elder's wisdom, i.e.- "slow down, and get it right the first time!")

Thanks to Barbara's message I took the trouble to read and print out the sections on Quality of Life and Quality of Care in OBRA '87 that she refers to. Upon review of these (and given that it appears these recommendations haven't been updated since the early '90s!) I would like to add a few of my own thoughts:

1) Under the "Quality of Care" section (483.25) OBRA states: "Each resident must receive and the facility must provide the necessary care and services to attain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care."

From where I stand, it seems as though we do a pretty good job (med errors and side effects withstanding) of maintaining and even improving residents' physical care. Physical care IS, after all, more easily "quantifiable" or measurable than mental or psychosocial care...and thus it is not only easier to effect both in and out of facilities, it is also obviously in the medical community and facility's interest (legally and financially) to ensure that physical care is maintained and documented. But Part "f" under this section also states:

(f) "Mental and Psychosocial functioning. Based on the comprehensive assessment of a resident, the facility must ensure that--
(1) A resident who displays mental or psychosocial adjustment difficulty, receives appropriate treatment and services to correct the assessed problem, and
(2) A resident whose assessement did not reveal a mental or psychosocial adjustment difficulty does not display a pattern of decreased social interaction and/or increased withdrawn, angry, or depressive behaviors, unless the resident's clinical condition demonstrates that such a pattern was unavoidable."

This leaves me wondering what resident DOES NOT experience at least some mental or psychosocial adjustment difficulty when moved (either voluntarily or otherwise) from their private home and all the familiarity and comfort it provided, and into a strange facility...In other words, is this really avoidable for ANYONE; never mind if their "clinical condition demonstrated that such a pattern was unavoidable"...

Given the OBRA mandate that follows (i.e.- "l" Unnecessary Drugs) to reduce psychotropic (and hopefully also anti-anxiety or tranquilizing) medications whenever possible, together with the reality that direct caregivers must usually deal with a whole group of residents' behaviors on an ongoing, full-time basis, it seems to me that effective training in psychosocial supports and "caring" for the full-time caregiver/CNA by providing adequate wages and good benefits should be a top priority for any administration that is sincerely interested in their resident's well-being.

Putting these measures into place will certainly impact the facility's financial bottom line. This is where creative problem solving comes in for the administration. Perhaps there could be an incremental shift (downward) of hours, pay, and/or benefits currently offered to doctors and RNs...especially given the mandate to reduce unnecessary drugs or other biomedical testing, paperwork, or applied procedures?

Somehow, the lead medical and administrative status quo must truly recognize that the Culture Change revolution is here to stay. If they don't, or if they are too slow to change, then the social workers, residents, families, and caregiving staff will surely show them the way!  

-Charles Macknee, MA (Oregon)
macpics11@hotmail.com