Working with Families: Tips for Effective Communication and

Working with Families: Tips for Effective Communication and Strategies for Challenging Situations Please call 1-866-740-1260 and use access code 3322275 to join the audio portion of today’s webinar JA N U A RY 30 , 2 01 3

Overview of Webinar Role of the LTCO when working with families Tips for effective communication Strategies for challenging situations Review scenarios Discussion questions Question and Answer Closing

LTCO Work with Family Members Who Filed Complaints with the LTCOP NHs and ALFs/B&C- 2011 NORS data 15,866 Resident 22,554 49,850 Relative/Friend Facility Admin/Staff 25,215 LTCO

LTCO Work with Family Members Other Ombudsman Activities (total state and local counts-2011 NORS data): Number of consultations to individuals (includes family members): 288,698 Number of Family Council Meetings Attended: 3,321 Number of Community Education Sessions (could include current and future family members): 12,456

Importance of Working with Families Family member may be the legal representative and/or complainant Gain information about the resident (e.g. preferences, history, routines, values) Learn about family dynamics Resident may need family support Empower family members Family members share their positive experience with the LTCOP with others

Effective Communication

Quick Tips! Use “I” Statements “Own” your statements and views and do not claim to speak for others Avoid saying “you” as people may feel they are being accused Don’t say, “When you ” instead say, “What I would like to see happen is ” Avoid emotive words that are tied to a person’s perception For example: Don’t say: “she barged into the room” Instead use a neutral, factual statement: “she came into the room suddenly”

Quick Tips! Use “open-ended” questions Helps build rapport and shows empathy You may gain more information Avoid using “why” as people may feel like they are being accused or attacked Use “how,” “tell me,” and “what” For example: Don’t say: “Why were you late this morning?” Say: “Help me understand what made you late this morning.”

Quick Tips! Use “reflective listening” Way to validate and affirm the speaker by giving them the experience of being heard and acknowledged Restate (in your own words) the content and/or feeling of what someone tells you Types: paraphrasing, reflecting feeling and summarizing For example: A family member says, “My mother has had a lot of issues regarding her meals recently. Her meals are often cold and bland. When she asks about an alternative they only offer a sandwich. We’ve addressed these concerns, but it only gets better for a week or so.”

Quick Tips! Reflective Listening Example Paraphrase: “You and your mother have addressed concerns about the food temperature, taste and lack of variety, but it is an on-going issue.” Reflect feeling: “It must be frustrating that your mother’s concerns have not been resolved and she is not enjoying her dining experience.” Summarize: “It must be frustrating that your mother is not enjoying her dining experience, especially since you have both addressed these concerns, on multiple occasions, with the staff. I would be happy to speak with your mother and see if I can provide assistance and advocacy regarding her dietary concerns.”

First Time Speaking with a Family Member Remember to: Use reflective listening Discuss the role of the LTCO Determine their motivation by asking them what outcome they are seeking Be clear about what you can and cannot do Inform them that your next step will be speaking with the resident

Communicating the Role of the LTCO Establish a clear understanding of the role of the LTCO during the first conversation “I am a resident advocate. I am here for your mother and what she needs, and hopefully we can all work together on this.” If the family member says her loved one has dementia and can’t communicate “I understand what you are saying. I will go and see her and after visiting with her we can see where we’ll go from there.”

Establishing Credibility Be clear and direct about the LTCO role Meet with family members and residents before meetings scheduled with the facility and walk in together Sit next to the resident, if possible, or the family member during meetings with facility staff When you interact with facility staff (in the facility or community) be professional and courteous, but not overly friendly (e.g. offer handshakes, not hugs) If you know a staff member (e.g. former colleague, friend from school) disclose that information

What if the resident does not give consent Points to address Emphasize what you CAN do Potential fear of retaliation Check in with the resident during When residents make choices, they regain some control Resident’s priorities may differ from their family member Despite their impairments, residents are still adults and it is important to support their rights future visits Encourage the family member to share her concerns with the resident Share observations of the resident with the family member See if other residents have a similar complaint Inform the family member of steps they can take

Communication Skills and Information for Families Barriers to Self-Advocacy Fear retaliation by facility towards their loved one or themselves Unsure how to address concerns Afraid facility will consider them a “complainer” or “difficult” and dismiss their concerns Tips Remind family members of applicable regulations (e.g. right to voice grievances without fear of reprisal) Encourage them to document all aspects of complaint process and facility’s response Share information and resources regarding the problem-solving process

Role of LTCO in Teaching Self-Advocacy Encourage family members to speak with their loved one to see if he or she shares their concern and whether the resident wants anything to be done about the matter Urge families to honor the resident’s wishes and/or preferences Explain why consulting with and being guided by their loved one is important

Resources for Family Members Family Advocacy Toolkit (Problem-Solving Process Resources) Problem-Solving Process for Families (chart) Problem-Solving Worksheet for Families Problem-Solving Worksheet for Families-EXAMPLE Documentation Tips for Family Members Strategies for Addressing Concerns in Long-Term Care Facilities

The Problem-Solving Process for Families Step 1: Identify the problem Step 2: Identify supporting information. Stage I: Defining the Problem What exactly is the problem? Describe the problem with as much specific detail as possible. What information do you have about the problem? Information can come from observation, discussion with a loved one or staff, documents, etc. Step 3: Write a statement of the problem with supporting information. Use objective, factual language (See “Documentation Tips for Family Members”) when writing your statement and include information/evidence that supports your statement. Step 4: (Optional) Identify if there are any laws or regulations that address the problem. While you should voice any concern that you believe is a problem, it can strengthen your case and increase your confidence if you know what (if any) regulations are applicable. You can look up state and federal nursing facility regulations at http://www.hpm.umn.edu/nhregsPlus/index.htm, find state regulations for assisted living facilities/board and care at http://www.alfa.org/alfa/State Regulations and Licensing Informat.asp or you can consult your local ombudsman. Step 5: Determine your goal Stage II: Analysis and Planning What does (or would) your loved one want to happen? What is an acceptable resolution? What outcome will benefit your loved one? Make sure the goal is realistic and benefits your loved one. For example, instead of setting a goal to get the charge nurse fired, determine what needs to be addressed and resolved regarding the charge nurse’s impact on your loved one’s care. Step 6: Assess what has already been done Think about the steps that you have already taken to resolve this problem. Whom did you talk to, when was the conversation, what did they say? What, if anything, happened after speaking with them? Step 7: Consider possible approaches Identify what action you could take to try to solve the problem at this point. Examples of approaches include: Find out if there is a designated person on staff to handle complaints and then speak with that person Speak with the charge nurse Speak with the Director of Nursing Speak with the Administrator Discuss the problem during a care plan conference Take the problem to the family council Step 8: Identify the pros and cons of each possible approach you came up with in Step 7. Think through the “pros” and “cons” of the approaches you identified. Step 9: Choose an approach After weighing the pros and cons, decide on the approach you think would be best given the situation and what you are comfortable doing. Step 10: Act!! Take the action you decided on in Step 9. Follow up any discussion you had with facility administration or staff by sending a note summarizing the discussion and including any specific steps the nursing home stated it would take. Step 11: Evaluate the outcome What is the result of your action? Is the problem resolved? Partially resolved? Not resolved? If the problem is resolved, thank the facility administration and staff.

Strategies for Challenging Situations

Scenario #1 A nursing home Administrator, Ms. Jones, calls you stating a family member, Ms. Daniels, is difficult to work with, complains often and is never pleased with the solution the facility offers to resolve her complaints. Ms. Jones also says the staff members are not comfortable assisting the resident (Ms. Daniels’ father), because Ms. Daniels often yells at the staff. Ms. Jones also states that the resident is pleased with his care and does not agree with the complaints of his daughter. The Administrator asks you to speak with Ms. Daniels.

Scenario #1 What are your concerns? Since the Administrator asked you to speak with the family member, what do you say and do in order to avoid being perceived as “on the facility’s side” when you speak with Ms. Daniels? Write down a few statements you would make when speaking with the facility, Ms. Daniels and the resident. Respondent: Cindy Englert, LLTCO, Centralina Council of Governments, Charlotte, NC

Scenario #2 Mr. Smith is still upset about an incident regarding the care of his mother that occurred in the past and was discussed with the staff at the time of the incident. Reminders of this incident are triggered each time Mr. Smith has a concern about the care of his mother. Mr. Smith brings up the past incident every time he speaks with facility staff (even if the past incident isn’t related to his current concern). When he refers back to the prior incident it upsets the staff – many of whom were not working at the facility at the time of the prior incident. Mr. Smith requests your assistance in addressing his current concerns about his mother’s care.

Scenario #2 What do you do? What are your concerns? Write down a few statements you would make when speaking with Mr. Smith and his mother. Respondent: Carmen Castro, LLTCO, Center on Aging at the UTHealth School of Nursing, Harris County, Houston, TX

Scenario #3 Ms. Garcia is her mother’s health care agent (per the health care power of attorney) and contacts you with concerns about her mother’s care. You visit her mother to see if she shares her daughter’s concerns and if she would like you to take any action. However, after your conversation, you are not sure about the resident’s decision-making capacity and her wishes. You are not clear whether you should be guided by the resident or her daughter since Ms. Garcia is the designated health care agent.

Scenario #3 What do you do? What are your concerns? Write down a few statements you would make when speaking with Ms. Garcia. Respondent: Lynne Person, DC SLTCO, AARP Legal Counsel for the Elderly

Discussion Question #1 When providing information to family members for selfadvocacy, what is the Ombudsman role in ensuring that the resident’s wishes are respected? Do you have a process for determining which questions or situations require providing only information and consultation versus questions or issues that trigger the need to speak with the resident to ensure that the resident’s voice is not overruled by the family member?

Discussion Question #2 A family member, who is also the President of the Family Council, is not pleased with the outcome of a complaint you assisted her with and she is telling other family members in the facility that the LTCOP is powerless and not effective in resolving complaints. What do you do?

Discussion Question #3 Avoiding actual and perceived conflict of interest is critical in order to have an effective LTCOP. Have you ever been accused of “being on the side of the facility” due to a family member’s perception of conflict of interest? If so, how did you respond? What steps do you take to prevent a perception of conflict of interest?

Application to YOUR work 1. Did you have an “a-ha moment” during this webinar with any “new” ideas or tips? How will you use this information in your work? 2. How will you share the information discussed today with family members you work with or other LTCO?

In Closing Role of the LTCO when working with families varies and depends on the resident’s capacity and situation Empowering family members does not mean that LTCO are not resident directed Look for our skills training paper and resources regarding working with families

The National Long-Term Care Ombudsman Resource Center (NORC) www.ltcombudsman.org The National Consumer Voice for Quality Long-Term Care (formerly NCCNHR) http://www.theconsumervoice.org/ This presentation was supported, in part, by a grant from the Administration on Aging, Administration for Community Living, U.S. Department of Health and Human Services.