walkitout (walkitout) wrote,

_Old Age in a New Age_, Beth Baker

Subtitled: The Promise of Transformative Nursing Homes

Beth Baker is a journalist and former hospital worker. This is a very up-to-the-minute book, published in 2007. Baker traveled the country talking to people who are working to reinvent nursing homes and, to a lesser degree, assisted living facilities, retirement communities, places where those with chronic health problems live, generally but not always expected not to leave other than via the final exit.

There are Buzz Words: transformative nursing homes, culture change. Green Houses. The Eden Alternative. These are pretty useful words to learn about; Baker does a good job not just defining them but showing you what they are in action. She even goes so far as to locate Bad Examples -- people who use the buzz words, use the jargon, kinda _look_ like they're fighting the good fight, but somehow missing a crucial element -- like, maybe, the whole point.

Not so very long ago, dementia wings in particular, and nursing homes in general used a lot of restraints on a lot of residents. Scandal erupted. Some thought leaders (notably a chain of nursing homes run by Quakers) took a principled stance against restraints and demonstrated that this could be made to work with equal-or-better "health" outcomes by anything anyone bothered to measure. As a result, there's been a sea change in the use of physical restraints. Unfortunately, drugs are still very widely used, as are alarms on beds, chairs etc. followed up by someone coming over and physically stopping (hand on the shoulder is all it takes, typically) the resident from getting up or whatever.

Staff turnover (which I've already seen in the memoir and the history) is a huge problem in this industry: the aides are underpaid, overworked, have no say in how they go about their work, the management tends to be highly punitive and the work itself is kinda soul destroying. It doesn't _have_ to be that way. Baker's profiles of several innovative homes shows that clearly.

Bill Thomas is, of course, one of the big names, creator of the Eden Alternative (think pets, plants and better food) and Green Houses (same, but add in a flattened, far more autonomous hierarchy of staff who all cross-train, and very small group homes -- 10 rooms each -- in a campus setting). Kendal (the Quakers) has facilities more along the traditional continuing care retirement community lines, but policies that show that facilities aren't everything. The Mount in West Seattle, Meadowlark Hills, Oatfield Estates -- there seems to be no clear pattern of faith-based or not, for-profit or non-profit. The thread running through all these new and different and BETTER places is leadership that decided the same-old same-old wasn't good enough and went looking for -- and found -- new ways of solving the old problem of keeping people with cognitive losses and other major, chronic health problems safe and relatively healthy.

Idealistic? Boy, howdy. Worth reading? Of all three, if I were actually trying to solve this knotty little problem for someone I cared about, this is the book I'd be using to generate google searches and base interview questions on when I toured homes. It's easy to read. It's up to date. It points out a wide range of possible solutions. If I were a discouraged aide or nurse working in the industry, I'd use this to direct my job search. If I were a policy maker or regulator, I'd need to read this to do my job well.

Surprisingly fun stuff, but in some ways, the most depressing of the books. First, there's just the sad reality that even if this movement (these movements) really take hold, it's quite clear it will be in an approximate and pale imitation of the ones profiled here (there will be outstanding future examples, but this is _clearly_ a best practice thing, not a minimum bar thing). Second, and from the reading-project perspective, more saddening to me, is the pervasive emphasis on how-can-we-make-these-people-live-longer. Sure, the outrage at feeding tubes, restraints and unconscious old guy taken to the ER so the death goes on the hospital's tab, rather than the home's. The obviously pointless extensions of the dying process are decried, but I'd take that set of ideas considerably further. It might be Baker's tilt; she, after all, is the one picking quotes from aides and so forth to include or not include.

I really liked that Baker spent so much time on dementia and other residents with cognitive issues. Eddy's inspirational chapter on his mother is a depiction of a woman in full possession of her mental faculties whose life has become unbearable because of physical decline. Her case makes me wonder a lot about why go on. OTOH, perhaps Eddy's mother would not have so feared giving up her own home in her own town if the alternative had been something like one of the Tupelo Green Houses. Baker talks more about hospice than either of the other two books, but still, it is only in passing. Perhaps I should read a book about hospice at some point. Altho looking at the references to _Dementia Reconsidered_, that's also looking pretty tempting.

The best thing about this book is the insight it provides into why people who, in younger days, were so sure they would make sure they were dead rather than end up in a nursing home (skilled nursing facility, whatever) -- to the point of joining the Hemlock Society, back in the day -- nevertheless end up in one. At least for some people, on some paths, life is more worth living with chronic health problems than they believed before they had those health problems. It's easy to glide over this with a pithy "will to live" remark, but the details deserve all of our attention. If there _is_ some environment that makes life worth living, even in severe and irreversible physical and cognitive decline, we probably should be making an effort to provide it to those in need.

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