The COVID-19 pandemic was devastating for nursing homes. The close quarters, challenging infection control protocols, and medical complexity of many residents left this population extremely vulnerable. However, the pandemic also magnified the impact of non-medical factors on residents’ wellbeing. Residents were dying not just of physical illness, but of social isolation, loss of connection, and lack of engagement.
Nursing homes serve an important role for older adults in need of round-the-clock care. At least 1.3 million Americans currently reside in these facilities; yet, over 50% of Americans say they would rather die than spend their final years in a nursing home.
In June of 2020, a team at Ariadne Labs began investigating an important gap: We know that things like having a sense of purpose or forming meaningful social connections matter for quality of life and even improved clinical outcomes. So, how can we put them at the center of nursing home care?
Defining Wellbeing
The team set out to define this concept of wellbeing, or quality of life, and how it can remain intact despite medical illness and frailty. Then, they created solutions to systematically integrate it into care.
“Life in a nursing home isn’t just about medical treatments. These are people’s homes, their communities,” said Rachel Broudy, MD, who leads the Eldercare work at Ariadne Labs. “We wanted to take a more holistic look at how the treatments and interventions we’re enacting contribute to a resident’s overall sense of wellbeing. For nursing home residents to lead fulfilling lives, we need to integrate who they are into their care.”
The team first developed a Wellbeing Framework to concretely identify and prioritize four key areas of wellbeing: meaning, social connection, autonomy, and security. For residents of long-term care, these core components can get lost in the day-to-day routine and medicalized paradigm of nursing home care. Cognitive or physical limitations can make it difficult for residents to connect with friends or family. Residents may have to stop activities that brought purpose and meaning, or they may have fewer opportunities to make choices about their living space, meals, or personal care.
Putting Wellbeing into Action
From there, the team used a human-centered design process to create tools that would help staff put these concepts into action in day-to-day care. The result was the Wellbeing Toolkit. which, in addition to the Framework, includes:
- A Conversation Guide to help staff guide residents in conversations about what matters most to them in their care
- Implementation Support resources, including tips for introducing the Toolkit to staff, guidance on how and when to have conversations with residents, and considerations for having conversations with residents with cognitive impairment
- A Putting it into Practice tool to bring the Framework’s domains to life with real-world examples of what may come up during conversations and how to integrate what comes up in conversations into a resident’s care
“There is room in the everyday processes of nursing home care to allow for more of what brings meaning and purpose to an individual. Our goal with these tools is to help residents and staff identify and implement changes that will contribute to a greater sense of wellbeing,” said Dr. Broudy.
Testing the Toolkit
So far, the Toolkit has been piloted in a small nursing home and a skilled nursing facility, both in Mississippi, and has received overwhelmingly positive feedback. Staff have reported that using the guide helps them feel more connected to residents, more positive about their work, and better able to support residents’ needs.
“If every family knew that this tool was being used, it would instill confidence in them that we cared,” one staff member said. Another noted using the Toolkit “helped us slow down for a minute. It’s not all about taking care of their medical needs. I think it just invigorated the staff and made them excited and more connected with the elders.”
Staff posited that this increased understanding would help them better anticipate resident needs and challenges sooner, potentially reducing the need for antipsychotics in some cases. Research on other nursing home models that have a more home-like feel, such as the small house model, have shown that this type of focus on quality of life, meaningful engagement, and connection can also lead to improved clinical outcomes.
In total, staff involved in the pilot implemented more than 25 interventions after using the Toolkit. Some changes were simple, like adding a birdfeeder outside a window for a resident who loved watching birds, allowing a resident to use her favorite kind of lavender soap, or introducing resident-led prayer at mealtimes. Others, such as ensuring trauma-informed care, or expanding residents’ ability to have time outdoors, took more systemic changes, but overall contributed to a more trusting, fulfilling environment for both residents and staff.
Scaling for Impact
The team is now hoping to continue to spread the Toolkit, with plans for a larger trial to study its impact on residents’ quality of life and staff job satisfaction. The team also aims to adapt the Toolkit to be used to address staff wellbeing in the efforts to address the staffing crisis in nursing homes across the country.
“This work has shown us that it is possible to change the culture in nursing homes by changing the practices we use in our daily routines. Asking about the wellbeing of each resident reminds us that this matters, and that even when we can’t cure illness, we can attend to and improve the wellbeing of our residents and our nursing home communities,” said Dr. Broudy. “So many older adults live out their final years in a long-term care facility. Each one deserves to be seen fully and with dignity, and to receive care that values what’s most important to them.”