Developing Scheduled &
routines that Work
Culture of Change
for People Living
with Cognitive Changes
Its not a Nursing Home or Facility
It’s a HOME where nursing care is given
Design Each Day
Offer a variety
Make a of activities
schedule and every day
Be structured rest, self-care,
BUT allow groups and 1:1,
flexibility passive and
8 am – coffee circle
8:30 – songs of joy
9 am – time to ‘go’ Create a FLOW
Create Group 9:15 – take a hike – walk’n’roll for the day
schedules 10 am – cool down & stretch
10:30 – watering hole
Build up and
BUT 11 am - ‘use your brains’ games
11:30 - time to ‘go’ – wash up then slow down
individual 11:45 – ‘set-‘em up’ crew
12 noon – let’s eat Circadian
12:30 – clean up crew rhythms
1 pm – music and meditation
Not everything 1:30 – coupons clipping
is for everybody! 2 pm – time to ‘go’
2:15 – let’s dance
Build a Foundation
of Familiar and Favorite
Add a few
special events and something
What type of activity is it???
Self-care, leisure, work, rest…
Spiritual, social, physical, cognitive,
passive, active, solitary
What is the
What do you
need to do Doing
Modify and Structure the Activity for
Change the materials, the complexity, the
setting, the help offered, the task demands, or
the purpose of the activity
Enough Supplies The right
& Materials equipment for
Good quality leadership for
lighting the activity
Enough help for
Traditional Facility Care
• Run by administrators & nurses
• Organized around staffing
• Work shared among 3 shifts of staff
• Safety and health care issues TOP
• Medical model
• Organized by departments – task specific
• You are sick – you need care for your
• Father knows best!
What’s Wrong with this Model?
• Who wants to live in a hospital?
• Who wants to do everything you are
• Who wants to have someone else
telling what to do and when to do it?
• Who wants to have to talk to three
different people to get something
• Who wants to live in a nursing home?
For People with Changes in
Health and Abilities
• Need for help
• Need for equipment
• Need for changes in routines & habits
• Need to match needs with availability
• Need to ‘anticipate’ when and where
you will do things, need things
Cognitive Changes with
• slowed processing
• less flexibility
• more difficulty with new learning
• more rehearsals needed
• benign forgetfulness – immediate
recall goes first
Emotional Changes with Aging
• increased incidence of depression
• increased incidence of anxiety
• with stress – mood swings
• with some drugs – emotional side
What Does Having Cognitive
Abilities Do To This Whole
System of Care?
• Changes in memory & thinking
• Changes in understanding & speaking
• Changes in impulsivity & initiation
• Changes in abilities & processing
So Let’s Figure YOU Out…
• What time do you wake • When do you toilet?
up? • What do you do for work?
• How do you wake up? • What do you do for fun?
• What do you do when • What do you do when you
you wake up? are stressed?
• When do you eat • ID two people you love…
breakfast? • Where are you from?
• What do you eat for • What is your favorite food?
• What do you HATE to eat?
• How do you get ‘clean’?
• When do you get clean?
• How would you DO • How would you do
living in your on someone else
• What would it be • What would NOT be
like if you had OK?
physical changes? • What if it was the
• What about rest of your life?
cognitive • What would you
What is Veteran-Centered Care?
Combination of… Balanced with…
• Person’s wants • Staff skills
• Person’s needs • Staff availability
• Still can do • Private space
• Can’t do • Public space
• Can do with support • People resources
• Individual good • Equipment resources
• Common good • Safety & Security
• Family needs • Rules & regulations
• Family wants • Others needs and wants
Personal Preferences & Values
• Who have you been?
• What did you value?
• Who are you now?
• What do you value now?
• Why does it matter?
• Who gets a ‘say’?
• Who gets to set the priorities?
All of Us
Each of Us
What Matters – When
Illnesses Are Present?
• Safety – Environmental modifications
• Access - Availability
• Timeliness of help
• Flexibility in timing
• Structure & predictability
• Privacy and respect
• Preservation of SELF
• Gather Information
• Share Information
• Use Information
• Review Information
• Make Changes
What About Medical Conditions?
What is essential? What is optional?
• Good care is delivered • When it is done
• The person is receiving • Where it is done
the care they need and
want • Who does it
• Conditions are • How often it is done
assessed • How strictly it is
• Decisions are made followed
based on good info • It depends on the
• There is agreement on person & their situation
what to do and what
NOT to do…
What are the Different Care
Approaches to Consider?
• Health Promotion
• Restorative - Rehabilitative
• Check Ups
• Annual vaccinations
• Lower the numbers
• Increase activity level
• Eat well – moderately
• Monitor all conditions for careful control
• DO WHAT YOU SHOULD to be the BEST
YOU CAN BE!
• Fix what is wrong
• Test to figure out what is happening
then DO SOMETHING ABOUT IT:
• Full recovery of function – GOOD as
• Recovery of SOME degree of function
• Focuses on the PERSON regaining
skills and abilities with help
– Rehab personnel
– Special equipment
– New techniques
• Not perfect, but BACK to a Higher level
• Maintaining the Status Quo – Keepin’ ON
• Not losing ground
• Depends on:
– Physical environment not changing
– Caregiver consistency
– Sustained abilities of the person
– All other things staying the same
• It’s HARD WORK … SO…
– ‘IS what I have worth keeping???’
• Providing what the person can’t do to ‘fill in
the gaps so that LIFE GOES ON….
– Physical environment changes
– Caregiver cueing and helping changes
– Expectations change
– Schedules and routines change to
• End Point is the Same –
– How we get there Changes
• Comfort Care
• TOP PRIORITY –
– Honor personal preferences and choices
– Manage Pain, Distress, Anxiety, Fear,
• Identify & seek to meet social,
physical, psychological, and spiritual
• Let go of FIXING and MOVE ON to
• Build a schedule and care routine that
helps the person:
– Be the way they want to
– Do what they are able
– Feel good about themselves
– Feel OK about where they are
– Enjoy the people who are there to help them
– Get what they need
Who Needs to Buy In?
• Front line staff
• Community leader
So… What Do We Need from
Staff & Families?
• Awareness of the process
• Participation in planning
• Sharing about the past
• Time to learn & try something new
• Willingness to listen
• Willingness to advocate AND negotiate
• Flexibility as we figure this out