Modular Care From Concept to Reality

by Sister Anita Holmes

Rocmaura Nursing Home, a 150 bed, fully accredited facility located in Saint John, New Brunswick, was officially opened on December 16, 1972, and is owned and operated by the Sisters of Charity of the Immaculate Conception.

Rocmaura Nursing Home has to date proven itself as a leader in providing care for seniors in the Saint John region. In the spirit of Christian charity inspired by the tradition of the Sisters of Charity, we commit ourselves:

At Rocmaura we believe in caring for the whole person. We believe that in admitting a new resident to our Home, that we admit not just the resident but also the family. Yet our previous practices seemed to limit our effectiveness.

Rocmaura Nursing Home is not unlike any other in the resources we possess. We face the same challenges that now confront the industry - a more complex resident population. This dramatic shift in our resident population has had a profound impact on our organization. We found that we must examine whether we were still able to do what we professed given the changes we encountered.

The first challenge was to our mission statement. A mission statement has different meanings to different organizations. To some it seems only an impressive grouping of words that are framed on the wall. To others, it is lived and creates an ongoing call to action. The mission statement at Rocmaura is the latter. It is an integral part of all we do. We see Rocmaura as a community of caring people whose paramount concern is the provision of quality care for its residents and the creation of a home-like atmosphere that recognizes and respects the dignity and uniqueness of each resident, staff member, volunteer and all persons associated with Rocmaura.

It is that last line that challenges us in these changing times - How can we recognize and respect the dignity and uniqueness of all, when the physical environment, the skills sets of our staff, and the care we practiced seem to place everyone into the same melting pot. Every unit was a mix of different resident functioning abilities and needs, yet we attempted to provide individualized care. There seemed to be a paradox in place - staff was to respond to the resident’s uniqueness, but that uniqueness was not fully recognized in the care setting where they lived.

To become a leader, to be the Centre of Excellence that we professed we were, we realized that we must change from the standard nursing home practices, configuration and design to something more innovative and reflective of our changing times.

Ten years ago, the Home had a high level of homogeneous residents; therefore, where they were located within the building and our ability to provide optimum care were not significantly related. Today, our residents present very specific, individualized high-level care needs that are highly diverse and that must be addressed in a systematic, creative manner.

During the past five years we have seen the Nursing Home change - 70% of our residents suffer from some form of cognitive impairment and those who are cognitively well are older and frailer. We have moved from a homogeneous to a highly diverse population, to include:

We soon realized that our integrated environment created conflicts for the residents. We feared that to keep on the present path could result in a battle over who received staff’s time and attention. As we examined the potential impact, we projected that the following scenarios could easily occur:

These possible outcomes created serious concerns. It became obvious that our existing care practices could soon not meet the specific needs of our present residents. This was in total contradiction to what we professed and a direct assault on our mission statement. We concluded that to provide the level of individualized care we desired required a paradigm shift in our care delivery methodology.

The Modular Care Program

The decision was to implement a Modular Care Program - dividing the Home into four distinct care units or Courts, each specializing in a specific resident population based on similar care needs. Modular Care is a systematic alignment of residents into their own autonomous units where care, assessment, programming, supports and environmental design are specifically geared to the needs of the residents they serve. Each of these autonomous units has consistent staff trained specifically in the specialty in which they work.

The transition to this model of care took place over a two year period. The process included physical/structural changes, a formalized training schedule for staff, an empowerment process and decentralization of the facility, specific programming development, and a formal identity development for each unit. An outside consulting firm which specializes in the field of long term care and Alzheimer care was contracted to guide us through the process.

At the end of the process, the Home was divided into four specialized units or Courts:

It is important to note that the Modular Care Model provides a number of benefits to the organization, its staff, managers and residents. These include:

An overview of the clients these units or courts serve is as follows:

Trinity Court (Dementia Special Needs)

houses the mentally impaired, physically well, ambulatory resident demonstrating the following behaviors - wandering, elopement, vulnerability to an uncontrolled environment leading to aggressive behavior, and periodic challenging behaviors (sexually expressive, rummaging, repetitive, etc.) that can be elicited while living in an uncontrolled setting. Programming, environment, staff training, assessment tools, etc. on this unit are specifically geared to this clientele.

Garden Court (Dementia Unit)

houses higher functioning dementia residents who require support and care, who do not demonstrate challenging behaviors on a regular basis, and who do not require a secured environment. This unit is the primary unit from which transfers to the dementia special needs unit are received. Likewise, this unit houses non-ambulatory dementia residents who do not require high levels of physical care. This unit receives transfers from the Trinity Court (Dementia Special Needs) when the behavior of those residents stabilizes resulting in no further need for a secured or controlled environment, or where an individual on Trinity Court is no longer ambulatory requiring more physical support. Programming, environment, staff training and assessment tools are identical with Trinity Court, the exception being that this is an open unit and the resources on this unit would be less than those on the Dementia Special Needs Unit.

Hopewell Court (Cognitively Well Unit)

houses our cognitively well residents who require care but still demonstrate some degree of independence and control over their surroundings. The intention of this unit is to develop a living environment that has a shared governance with the residents in defining unit routines, expectations, etc.

Programming, environment, staff training, assessment tools are specifically geared to this clientele.

Terrace Court (Physical Care Unit)

this specialized unit houses both cognitively well and mentally impaired residents who require complete care. The resources available to this unit are greater than the Hopewell and Garden Courts. Staff are specialized in developing care strategies specific to the needs of this population, and considered specialists in Palliative Care.

As a result of the modular care program, residents are not simply admitted to a vacant bed. We admit this unique person to the particular court that is best suited to meet his/ her needs (physical, mental, social, spiritual, psychological, etc). The person’s individual personality, physical/mental condition, family dynamics, privacy/socialization preferences, environmental factors and the like all play an important part in determining which is the best court for each resident in question.

Rocmaura’s Process for Change

In the fall of 1997, construction began on a 24 private bed unit, along with many internal renovations to the Home. The design of the new unit, which would become our dementia special needs unit, included the following:

The renovations within the remainder of the home included:

As stated by Sister Margaret Toner, Superior General of the Sisters of Charity of the Immaculate Conception, in our promotional Capital Campaign brochure during the fund raising for this $3 million expansion/renovation, Rocmaura is committed to providing a safe place “…in caring for persons who are particularly vulnerable in our society - those who have been stripped of their independence, their mobility, their senses failing, their mind faltering, and who perhaps have no longer any sense of their identity. For most, it is the final stopping place in their journey toward God. That is why we urgently need to provide ‘a home away from home’ for those who make their home at Rocmaura.”

How do we make this difficult time in these persons’ lives more life-giving? At Rocmaura, we believed this challenge would be best met through the construction of a specialized unit and internal renovations to the existing facility in order to provide modular care for those with special needs.

During the planning stages for the shift to modular care, it was determined that the selection and the training of staff to work in the specific units must be given top priority. The Board of Directors and Senior Management were committed to the concept and it was agreed that an expert in this field be engaged. It was decided that all staff would need to avail themselves of this training and would be scheduled to attend the pertinent seminar and team building sessions. The Managers of all departments (Nursing, Dietary, Housekeeping, Pastoral Care, Recreation) put in place a procedure for staff to indicate which unit they would prefer to work in.

With respect to staffing of the Courts in this Modular Care concept, staff were invited to apply for the Court of their choice and were interviewed with respect to the following:

In order to ensure our success, empowerment of our staff has become the mandate within the home. All Rocmaura staff were given the opportunity to be a part of the development of each unit, the training seminars, the planning and team building sessions. All were asked to identify recommended structural changes, staff/ resident needs and organizational changes they felt were necessary in order to move to this modular form of care. Creating this level of ownership and providing staff every opportunity to a part of the process was the primary reason for the successes experienced. No organization can achieve the desired results without this important component.

Once the staff of each Court had completed their training and the renovations were finished, the staff and managers of each Court were required to create a mission statement for that unit that best depicted the focus of care for their specialized resident.

These mission statements dovetailed with the general mission statement for the facility. Further, at the official opening of each Court, the staff were invited to come forward to present their mission statement. These statements have become the foundation from which the staff of each unit evaluate their performance and monitor their success.

After the openings, a family information session was held to which all relatives of residents of that Court were invited. This was a time to educate family and friends about the philosophy and mission of that Court. These sessions were also attended by the Court staff who were an integral part of the teach-in.

Throughout this entire process, the Executive Director and the Assistant Executive Director/ Care Services attended all seminars and were present at all team building/planning sessions. Their presence let staff know that management very much wanted this change and would support it by their time and participation in its evolution and in the mentoring of staff throughout the process.

What has been the outcome of this adoption of modular care? Staff from all departments now exhibit true ownership for their Court. They more willingly participate in team meetings, planning sessions and celebrations. Each Court has developed its own unique identity which is quite evident when you step into the Court. Staff have a more holistic knowledge of and approach towards their residents. Staff, family and resident involvement has reached a higher degree of sophistication and mutual respect and interaction.

It is interesting to note that the opening of Trinity Court provided a unique opportunity for a longitudinal investigation of the effects of a special care unit (SCU). This study was done with the University of New Brunswick. Using a longitudinal, three-phase study design, families and staff participated in in-depth interviews to identify changes in the behaviors of 17 residents pre-transfer and at 2 months and 6 months post transfer. Analysis of family and staff interview data documented the unequivocal success of the unit. Specifically, this qualitative inquiry documented improvement in five areas of residents’ behaviors: eating, sleeping, participation, mood and directional orientation.

What now, would one ask? Learning does not stop. We now need to marry the Courts so that when a resident moves from one Court to another, the only difference that the resident should experience is the physical environment and the actual face of the staff caring for them.

In closing it is important to emphasize that this was not an easy process. We were challenged every step of the way. No organization can undergo this degree of change without encountering a multitude of blocks and frustrations. Its success was not the result of any one person. Our organization has become stronger because of the concerted efforts of our staff, managers, residents and their families. Their cooperation was tested and they came through - their patience during the renovations, construction and in particular, the admirable implementation of the modular care program, and their impressive dedication.

We are especially grateful to Len Fabiano who served as our consultant and education expert during this time. Len has become my personal mentor, supporter and encourager over the many years he has worked with us. I can only quote from him these lines which I feel sum up the feeling of our staff who have participated and contributed throughout this journey to modular care.

“You do not know who you are or what you believe in until you are challenged.”