When it comes to caring for those with advanced dementia, changing to a person-centered approach that focuses on resident comfort can be difficult for entrenched professional caregivers and family members. Skilled nursing facilities and their staff members—and, most importantly, residents and their families—can reap satisfaction and many other rewards from doing so, however.
That’s been the experience of Tena Alonzo, and she shared the knowledge she has gained as executive vice president for education and research at the Beatitudes Campus, a non-profit continuing care retirement community in Phoenix, in a presentation at a Sept. 8 Institute of Medicine (IOM) workshop in Washington, DC, that brought together dementia experts, federal agency staff members and others to discuss innovative care practices. Alonzo discussed Comfort Matters (formerly Comfort First), an initiative for those with Alzheimer’s disease and other dementias that Beatitudes started developing in 1998. Alonzo directs the program at Beatitudes, and use of the model has since spread throughout the United States and to other countries, although widespread implementation challenges remain.
Comfort Matters, Alonzo said, starts with the beliefs that comfort benefits people with dementia, that those with dementia are experts on their own personal comfort, that people with dementia communicate comfort and discomfort through their actions, that everyone who has dementia can be comfortable, and that the goal of comfort should not be reserved for end-of-life circumstances. The model allows residents to sleep as they wish; to eat what they enjoy when they want to eat, regardless of dietary concerns; to perform activities of daily living on their own terms; and to be engaged as they like.
The model, she added, “recogniz[es] that this is a terminal condition, and of course this is a time when you really should enjoy whatever piece of life gives you pleasure.”
Beatitudes tested Comfort Matters in its Vermilion Cliffs area, a secure neighborhood for those with advanced dementia located in its center for skilled nursing, rehabilitation and post-acute care. The backbone of the approach is “deceptively simple,” Alonzo said: “We must anticipate needs; we need to know who the person is; we need to practice person-directedness, which means we need to listen as they respond to us in whatever way that they can, to identify whether or not something suits them; and we must do it within the framework of an empowered team that can, at the moment, change direction and do something different to create comfort for any particular individual.”
Those empowered teams are key to changing a community’s culture to one that embraces a “comfort as primary goal” philosophy, she added. Such interdisciplinary teams, led by a nurse and a social worker, can meet weekly to discuss what needs to be modified and how to do so. Policies and procedures related to activities, bathing, bowel and bladder management, call light use, comfort care, dining, dressing and grooming, healthcare decisions, mobility and safety, pain management and self-protectedness/rejection of care should support individuality, capitalize on residents’ strengths and minimize their challenges, Alonzo said.
The process, she notes, is based on quality assurance and performance improvement (QAPI). Comfort Matters has identified about 120 competencies to help staff members operationalize the approach, some of which apply to several disciplines of the interdisciplinary team. Collectively, the competencies affect every role in the nursing home—for instance, physicians and those working in the housekeeping, maintenance and dietary areas—not just nursing staff and aides.
“We have to help staff understand that comfort does not just matter at the end of life. It matters all the time and in everything, from how we would help someone rise in the morning to how we help them go to bed at night,” Alonzo said.
She detailed “impactful” improvements in quality of life for residents and their families, quality of work life for staff members and financial benefits for the Beatitudes Campus stemming from the implementation of Comfort Matters. Specifically, she said, the focus on mind, body and spirit rather than just medical needs now means that physical restraints, therapeutic diets and supplements no longer are used; antipsychotic and anxiolytic medication use is minimal (see chart, “Medication Use Rates, August 2014,” by clicking on photo, upper left); weight loss among residents is rare; and residents do not exhibit sundown symptoms and are less likely to resist care. (See table, “Beatitudes Campus – Evolution of Care Models,” here or by clicking on photo, upper left.)
Additional program outcomes: