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#ActivitiesStrong 9

“Turning a Facility into a Community: Exploring Risk, Autonomy, and Independence in Senior Living”

Words such as “community,” “independence” and “choice” are used frequently in senior living, but what do they really mean? When was the last time you encouraged or supported risk in your resident’s daily life? This presentation featuring Mallory DaCosta, Vice President of Special Assets at Frontier Management, LLC, will discuss some core principles of independence and autonomy as utilized in the Montessori Method and will show how these methods can be the key to turning a facility into a community.

Listeners will:

• Explore hallmarks of a true community with specific emphasis on risk and autonomy

• Learn about specific Montessori principles and how they support and relate to autonomy

• Discuss strategies to support and mitigate risk without infringing on persons or their community

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Produced by Solinity Marketing.


Meghan (00:00):

You’re listening to the Activity Strong Executive Edition Series on the Bridge the Gap Network. The live webinar series aims to promote, engage, and empower wellness directors and senior living executives to continue the conversations surrounding health and wellness in aging adults. Powered by Linked Senior. 

Charles de Vilmorin: Welcome, everybody. Welcome to our September 7th Activity Strong Executive Edition webinar, where we are going to be talking about turning a facility into a community and how we explore risk, autonomy, and independence in senior living. I want to share with you that because of unforeseen consequences, Mallory DaCosta,  VP of Special Assets at Frontier Management, was supposed to be live with us, but could not make it. She very kindly took the time to record the presentation. I’ve had the chance to preview it and it is fantastic. I also want to share that we requested and asked for the fees to still be approved. Not to worry, all of the fees will function exactly the same way. Because this is an executive edition, I also want to share that the intention of this particular webinar today of these executive additions is for us to elevate the conversation about resident engagement. For every executive director or administrator, we want to thank you for being here. It shows that you value resident engagement. You feel like it’s important, and if you – anyone else on the call today on the webinar – feel that your executive director or administrator should be online with us today, please feel free to invite them to our further webinars. 


Activity Strong, as a reminder is a partnership led by Linked Senior with NAB and NCCAP and Activity Connection, and for these executive additions in partnership also with Bridge the Gap. Myself, like Meghan mentioned, my name is Charles de Vilmorin. I’m the CEO and co-founder of Linked Senior. At Linked Senior, there are few things that are very important in terms of value for our company. One, six years ago, we started this campaign called Old People are Cool for a number of reasons, but mostly because we do believe they’re cool like anyone else. Also, we’re not big fans of this idea of segregation based on age. 


Last year, actually more than a year ago, unfortunately now, in the wake of COVID, we started this platform called Activities Strong. Because we believe in the importance of you, activity, and life enrichment professionals. This platform is all about acknowledging the amazing work that you continue to do every single day, regardless of the challenge. But also hopefully empower you and educate you with the best things out there, including today’s presentation.


A little bit about Linked Senior because we get that question very often; what is it that we do? We provide an evidence-based, resident engagement platform for senior living. We work with fantastic organizations (that I’m sharing on my screen here). Anything from independent living, assisted living, memory care, and nursing homes. The way we help them is very simple.


We help augment. We help them do more resident engagement. That’s what I like to say, that we are a resident engagement company. We provide technology education. Obviously, you’ve seen some of these webinars, but we do a lot more with our clients. Obviously, we also like this idea of human touch. Human touch is especially important these days when we’re going through such a huge staffing crisis. 


So how can technology help you go further, help you augment the existing staff that you have? We do this in a variety of ways. One is we help you save hundreds, sometimes thousands of hours of work time. You can spend more time with your residents with better programs. We also help you manage resident engagement so you can allocate resources. Then we have a fantastic team of customer success managers that partner with you to elevate the experience you’re building for your residents.


If you have any interest in any of that, please be in touch at the end of the survey. At the end of the webinar, you’ll have a survey where you can tell us if you want us to be in touch in the form of a demo. Also, feel free to call us and email us anytime. The last thing I’ll say about our work, which we’re very passionate about obviously, is we believe in the power of measuring to manage. We’re the only platform in the industry where the work has been highlighted in a peer-reviewed journal. This is a clinical study, very proud that we did with the funding of Baycrest and in partnership with Ri Sponsivi. As you can see some of these outcomes, especially the increase of 20% in social life engagement are things that we’re very proud of. 


We work every day with our clients to help them, again, measure the impact of resident engagement. Up to today’s webinar. So today I’d like to share just one quick word as an introduction to today’s presentation, and then I’ll play the recording of Mallory. One thing just so you know, is that we will be sharing with Mallory all of the questions you might have either through the Q and A, or the chat. If you think that something’s really interesting in today’s presentation, please drop it in the chat because Mallory will be able to read it afterward. We’ll send her all the comments. If you want to thank her for such an amazing presentation, and it is, please do that. But also, if you have questions, please type in your question and perhaps your email, so she can be in touch. I’ll give you her email at the end of the presentation as well if you want to be in touch directly. But again, please as always use the chat, we know, you know what it is because you usually use it a lot and it’s very busy. Please rest assured that Mallory’s with us in spirit, and she’ll read the chat afterward. 


So the way I wanted to introduce today’s presentation is when you think about a facility, right? That’s the F word of how we talk about our communities. But what really differentiates a facility from a community?  What truly differentiates it is the idea that community rests on the idea that every agent, including our elders, our residents, has autonomy, independence, and we with them have explored just simple risks of living. Something which is really important that I often – kind of quote-unquote ‘joke’ about – which is something about person-centered care, which is true is when we see things, sometimes they simply cannot be unseen. Some of you might be familiar with this meme on the internet, it’s been going on for years. But I’d like to challenge you on this idea that what you are about to see with Mallory’s presentation is truly thought-provoking.


I hope that you have many of these moments when you see something and you won’t be able to unsee it in a good way. Where you’ll go back to work this afternoon, perhaps or tomorrow, and you’ll remember what Mallory has shared in her presentation. I will push you, your community and your team to take it one step better to the next level, in terms of thinking about the experience you’re creating for your residents. With that again, Mallory DaCosta, VP of Special Assets at Frontier Management. Unfortunately again, she couldn’t be with us today, but I’m going to start showing the presentation. Again, please use the chat and remember that she will be reading the questions that you ask.

8:39 Mallory DaCosta: Hi everyone. My name is Mallory DaCosta. I work for Frontier Management. I’ve been with them for about ten years now. I’m their vice president of special assets, and I am the author and researcher behind our SPARK program. Which is our lifestyle program, which is inspired by Montessori methods. Today I’m really excited because this is a topic that is very near and dear to my heart and something I’m very passionate about. I’m very excited to just discuss it and get an open forum going and maybe spark some ideas or thoughts in your own minds about where we stand in our own communities and what really makes a facility a community. We’re going to talk a lot about risk, autonomy, and independence in a senior living community. I will focus a lot on memory care today and folks with cognitive and physical impairments, but I hope that if you’re not in memory care, you can still apply a lot of what I’m talking about.


Because as we know, we have a lot of seniors who live in our communities who maybe have some sort of impairment regardless of where they’re actually placed. What I’d like to do is start with a story. Because the story is really to illustrate why I want to talk about this topic today. It also is sort of where I got my start on this journey. I was a memory care director in a small memory care community in Wellesley, Massachusetts. Our little memory care was on the fourth floor. It was kind of tucked away in a back corridor and there wasn’t a lot of great outdoor space. What we would do is we would usually walk downstairs and go outside and the Charles river was right next to the community. We would do a lot of picnics and a lot of seeing things through the window. Yet this community was fairly new, fairly newly opened. It was really struggling to find that feeling of community.  


The residents had a lot of exit-seeking and wandering behaviors. It was an old building, so it didn’t have a great design. I just felt like we weren’t merging. We didn’t have that harmonious feeling that I knew I wanted. One day we were on a picnic at the Charles River and we walked by a storefront that has a sign out that says “tours in a canoe of the Charles River.” Sure enough, we saw people canoeing in a real canoe. This was just a straight-up, typical two-person canoe up and down the river with a guide. Our residents thought that was pretty cool, and a couple of them joked, “Hey, yeah, maybe next time we’ll go get in a canoe.” Right? 


It sorta was a little topic of banter. But as we left, I started thinking to myself, why not? Why couldn’t we take our memory care residents on something exciting like that? I started thinking, you know, my biggest philosophy in this business is everything that I want to do, they want to do, right? There’s no difference just because you’re a senior in the things that you might find interesting. I really started thinking about it and I’m like, “you know what? I bet we could do it.” The next day at stand-up [stand-up meeting], I came in, and I had my executive director and my nurse there. This was quite a while ago, but I was just kind of growing up in the industry and I just was a little naive because I walked in and I thought, “this is a great idea. Everyone’s going to love it.” 


I said, “We are going to go on a canoe trip up the Charles River.” A couple of the people on my management team thought it was great. A couple of people didn’t think it was so great. One of our head nurses was like, “absolutely not. What are you thinking? Are you crazy?”  I was like, “well, well, why not?” “Well, they’ll jump in the water and they might drown. They don’t know how to swim and their families will get upset.” These were just 20 excuses as to why we couldn’t do it. 


Luckily I had an executive director at the time who was very open-minded and he was very quiet.  He said, “You know, I think we actually could do this. Let’s talk about it more.” We sat down and we created a plan, and we did all of the pre-work involved, and we decided to do the outing.


It was tremendously successful. I’ll show you this here. Unfortunately, it’s a scan because this was before we had some of the great technology we have now. But we got in the Boston Globe. It was quite a good spot in the Boston Globe; giant article, full-color picture. It was incredibly powerful because the article explained how all the residents on the outing were telling stories, talking to each other, sharing memories. This was what I experienced. We got back into the bus that night and I remember just feeling a sense of magic. That’s the only way I can describe it. It was like tingling in the air. They were so fulfilled and excited and happy, and they were talking to each other. And these were all memory care residents who had previously had behavioral issues, exit-seeking issues, who were not connecting.


Now they’re talking to each other, they’re connecting. It felt like a real community. After that outing, I sort of had an epiphany that I wanted more of these experiences and I was going to devote my life and my career to learning about what made that so magical. What was it about that canoeing event that was so magical, and how can we recreate it? How can we continuously make those kinds of experiences for our residents? That leads us to today and our topic of conversation. So in my quest to find the best ways to do memory care and senior living, I discovered something called the Montessori approach, which I’m not going to spend a ton of time talking about today because it is a lot of information. But I want to share with you the important bits of it because it really is the foundation for building a great community. 


And It’s going to feed into a lot of my philosophy today. Really briefly, Maria was the first female physician in Italy. She actually got her start in rehabilitation and kind of like what we think of as PT and OT today. She did work in pediatrics and she did become a teacher later in life. But we know when a lot of people think of Montessori they automatically think of just that education piece. That was a big part of it, and that’s really what she became famous for. But where she started was actually in rehabilitative medicine as a physician. Her model is based on the model of rehabilitation. That’s really just this concept of getting better or improving. She would circumvent deficits with her model. She knew that everybody that came to her was going to have a deficit of some kind, and she just built her program to support that right out of the gate. 


Her programming creates true independence. Whether you’re dealing with an adult or a child,  it’s a form of independence first. Her methods help you have success with more complex tasks. If you ever look up, there’s a TikTok channel of Montessori kids, and there are all kinds of Montessori videos on the internet of children doing very complex tasks. I was watching one the other day of a two-year-old making guacamole. It’s a Montessori setup. The teacher was explaining it. But really what the Montessori approach does is make more complex tasks easier for a person to do when they have a deficit. It’s based on life skills. It’s completely hands-on from top to bottom. And it really focuses on a prepared environment. When we took the residents on the canoe trip, we didn’t just go in blindly. 


We made sure that we had prepared the environment for them so that it would be easy for them to be successful. Maria Montessori’s work was actually piloted for memory care residents by a person named Dr. Cameron J. Camp. He’s a close personal friend and mentor of mine. I had the privilege to essentially learn from him. He was the first to apply Montessori principles. He was actually the researcher who discovered the connection and spent time working on it. Nowadays there are tons of resources and lots of people studying this, but he was the original. He created a framework for success. He calls it the twelve principles. So what he did is he took out the twelve elements of Montessori-based education that work best in our setting. He created assessment tools. Rather than determining if a person can’t do something, we often don’t have a real good assessment on that because clinical assessments rarely look at things like vision, hearing, and depth perception, et cetera. He created a lot of assessment tools. 


He also continues his applied research today. He’s a great friend at Frontier Management and we work closely with him a lot. But everything I’m going to talk about today is cited and is from his work. Ultimately the Montessori approach does a lot of amazing things, but the most important thing it does is it really creates a community. That isn’t a school setting or that isn’t an adult setting because what it does is it does that independence. It does that hands-on approach. You really get this community feeling. Above all Maria Montessori’s methods are based on ‘doing.’ Here’s a quote from her that’s very important, “everything you do for me, you take from me.” This is such a foundational tenet of the Montessori approach, whether you’re dealing with children or adults, because we have to understand that as we help someone or when we care give for someone, we do something for them, yes. 


Sometimes it’s absolutely necessary that we do that thing for them, but we have to understand the impact that’s actually taking from that person. That is really a core belief in building community. If you just do everything for someone, they don’t have the opportunity to engage in their own community. This is just a little pie chart to drive that thought home. This is from the Bureau of Labor Statistics. This is from 2010, but I imagine that it is probably similar today. This is the time used on average for a workday, employed persons ages 25 to 54 with children. If you can see that green slice there, we do more working and working-related activities than anything else. I’m sad to tell you, it’s a little depressing to hear that, but we do work more than we even sleep. 


Notice the red slice is leisure and sports. Leisure and sports are awesome and fun,  and we all love entertainment from time to time. But if you see the ratio there, it’s a very small part of our lives in comparison to how much we work. Sometimes senior living communities will have a whole calendar that’s just full of leisure, entertainment,  sports, and games. That’s not a bad thing. But we miss out on that section of work, and people do relate to work and work-related activities because it’s something they’ve done their whole lives. Ultimately to make it very simple and summarize; the best way to build a true community is to have your residents ‘doing’ more. It sounds simple, but it is that simple. A community will occur the more your residents ‘do.’ Think about the canoe trip. Sure. We had some great picnics. We would sit and we would watch people canoeing and we would have fun. But it didn’t quite have the same level of community and excitement until we did it ourselves. Until we actually got to experience the ‘doing’ of the canoe trip. That’s what unlocked that community feeling and that magical buzz in the air. Think about ‘doing.’ What does ‘doing’ look like in a senior living community? 


This gentleman on the right here is actually using a sander, an electric sander, and he’s in memory care. This is a 100% memory care in Arizona, one of our Frontier communities, and he’s sanding furniture that they’re refinishing in a club called the Seniors’ Painting and Refinishing Club. What they did is they would collect donated furniture or yard sale furniture on outings, and then they would sell it in an auction for the Alzheimer’s Association. What does ‘doing’ look like for a person with a physical or cognitive impairment? If a person has dementia or they’re in memory care, are they not allowed to try to use a power sander or do the things that maybe you and I do? That’s just a real deep question. I’m not going to tell you what’s right or wrong. I just want to make sure that we’re exploring the horizons of possibility.


What does ‘doing’ look like in your community? How much ‘doing’ do your residents do? Say you’re going to have a happy hour or a cooking club. Are your residents serving the food, or are they just partaking in it? Are they making the food or are they just enjoying it? Again, there’s nothing wrong with entertainment and a leisure activity, but we really want to think about how much ‘doing’ do our residents do? Because that’s the thing that’s going to elevate your community to that magical experience. I’m going to share a video with you of one of our first Montessori-based activities at Frontier Management. This was at a beer brewing committee.  This still, for eight years now without fail continues. Every single month this community makes a batch of beer. It has survived even through COVID. It has survived through activity director turnover, and it is still very vibrant today.


22:24  VIDEO: Being a part of the group is all by itself is wonderful because you get to know all the people, you got to know them even better, and you realize how everybody contributes. Everybody does part of this when we make the beer. This isn’t a question of one person do it, everybody gets in there and does each of the steps and we share all the things, all the steps, the procedures we have. Whether it’s bottling the beer or stirring the pot with the mead in it, or sterilizing things, or having directions from one or the other, or many, or from our guide, Allie. But it’s the togetherness of this that’s so much fun. And the product, of course. It’s to celebrate something we thought of doing, we did ourselves (we didn’t think so much as far as doing it). But we realized what fun it was to get out a product like this.  


This is unusual for a group of older people who enjoy life. You’re getting fun out of doing something different. Well, I think that what I learned was how long it takes to do it. I thought, you know, a beer… you take a cap off a bottle, but not this one. I mean, it takes a while. It takes weeks. Doing it, checking on it and being sure it’s the right temperature, and moving it back and forth and still filtering it. And then eventually the joy of seeing the product when you actually fill the bottle. You hold it up and say, “Look! We did it!” That was wonderful. That’s a great experience. It’s another thing I have done here that I’ve enjoyed so much doing. I mean, it’s probably one of at least a half a dozen different things that I do. And it’s unique. It’s different. It’s not just sitting around playing cards in the seat. You can get up and do something different here, even if it’s sterilizing pots and pans, which we did too.

24:32 Mallory: The point of that video is just to give you that sense of that’s what a community really looks like, right? So the things that he was saying, he said, “it’s the togetherness of this that’s so much fun.” He’s even indicating. He said, “I got to know some of the people” or “all the people.” He’s expressing that working with the community was so much fun. And just by the way, this is an all three: memory care, AL and IL on one campus. This is all in that, in that shot, you saw all levels, memory care all the way up to IL. So he’s saying it’s the togetherness of this that’s so much fun. He also says “doing all the steps and procedures that we share.” He talked about ‘doing’ so much through this video. He was gesturing with his hands. He was explaining stirring the pot, filling the bottle.

And then that pride of saying, “look! we did it!” And holding up that bottle at we’d completed this task. Then he made a comment about, you know, this is different. You do something different here. It’s not just sitting around and playing cards. He’s even recognizing the difference between something like this, where they’re doing all of these steps. And then the difference between that and maybe sitting in playing cards, right? The last quote is my favorite. He said, “listen, you get up and do something here, even if it’s sterilizing, pots and pans, which we did too.”  And that’s where that “everything you do for me, you take from me,” quote comes into play. The activity staff could have cleaned up that activity. The activity staff could have set up that activity and done all of the sterilizing of the pots and pans, but we would be taking that from the residents if we did it all. He’s even saying that just the sterilization of pots and pans was fun, rewarding,  and part of that entire complete process. Here’s another video of what community can look like. This is all-memory care. It is a gold-level, credentialed,  Montessori memory care. Just take a look at the different roles of the residents.

Mary/Adri: Mary Kay Shive, and I’m the tour guide. 


Once someone is diagnosed with Alzheimer’s, they’re pretty much told they’re not allowed to do anything by themselves anymore. Even though these people have lived for sixty-plus years on this planet and doing all the things we do, well as soon as they get the diagnosis, they’re restricted to very little things that they’re allowed to do. And that’s why I appreciate the Montessori-based program so much is because we give them the freedom to express themselves, to do everything they want to themselves. I mean, they come to the back of the laundry with me and then go do dishes with me. They can help cook food. They run their home in a sense, and I’m just here making sure everybody’s okay. 

You know, we were just in talk one day about what it would be like to fix meals on our own, past what the kitchen does, and the different needs that we would have for each recipe. As we gathered the information and brought up different recipes, what could we do?

Erik Doyle: From start to finish from the recipe to the ingredients, they help not only pick up the recipes, but they also help us get all that product together and then step by step they’re actually doing it. We are there to monitor them and watch them, but step-by-step, they’re actually doing it and creating it. We do not only cakes, but we do cookies. We have bread probably four or five times a week. It’s pretty amazing how intuitive they are actually, when it comes to it they really love it. It’s something they enjoy doing. But it really is hands-on for them. It’s the same thing with the gardening club. From start to finish they’re putting that soil in, they’re putting the seeds in and they’re watching something grow. And then not only are they a part of that whole process to see that finished product of which we still use in the kitchen, which is awesome. Do you know what I mean? It’s just like being at home and it’s kinda special.

Carol: It’s unbelievable because it’s turning out so beautiful. 

29:31 Mallory: So just another example of what a community can look like. And, you know, that had a couple of different things in it, but some takeaways were we had a resident leading the marketing tours, and she does do this, she leads the tour from top to bottom. We have growing vegetables to supply the kitchen. So actually utilizing all the food that’s grown. Especially in the summer months, this property has a lot of growing space so they supply the kitchen with basically all their produce. Caregivers are inviting residents to do meaningful work. You heard that caregiver say,  “Yea, I asked them to come to your laundry with me,” and “they can cook food with me.” She knows because she’s been trained in this method that going back in the laundry room with her and doing laundry is part of an activity program. Residents chopping vegetables in the kitchen with the executive chef;  not just growing the tomatoes and bringing them to the chef, but actually getting to go back there and have that hands-on process from start to finish.


We’ll dissect that video a little bit more. But what are the roadblocks? If you think about it, really, any community today could have a beer brewing program. They could have residents leading marketing tours. They could have residents in the back cutting vegetables with the chef. But what stops us from going down that path? Sometimes it can be a fear of financial risk. Maybe budgeting concerns. Sometimes marketing is concerned about what might happen if they have a memory care resident lead a tour. And sometimes it’s a safety issue. That’s what makes people fearful. But ultimately it can be boiled down to risk. To create that community that I just showed you, there’s going to be risk involved. ‘Doing’ is risky, right? So every time you step out of your house, you increase your own risk.

And the same is true with our activities program. We know that to create a true community, you have to have the residents ‘doing’ as much as possible. That is something that we have established in the first part of the presentation. But what happens when your residents start ‘doing’ more is you do have more risk. So that can often be the point where facilities get nervous or stop something is because of that fear of risk. Today’s second part of our discussion is to really explore our own feelings today about risks. Some of you are going to be very tolerant of risk, and some of you are maybe not. Maybe you all are very tolerant of risk, but perhaps someone on your team is not, or someone in your company is not. Or perhaps your caregivers don’t know what their risk threshold is. It’s really important to have that conversation.


Here’s a great quote by Atul Gawande from a book called ‘Being Mortal.’ If you haven’t read it, it is exceptional in this industry. Many of you probably have. But it’s a very, very good book about assisted living and the aging process. Here’s a quote that I share a lot with my teams. It says, “We want autonomy for ourselves and safety for those we love. That remains the main problem and the paradox for the frail. Many of the things that we want for those we care about are the things that we would adamantly oppose for ourselves because they would infringe upon our sense of self.” So it is that paradox, right? We want to protect the residents. But when it comes to us, we individually want autonomy. We want our sense of self, right? So we have to try to put ourselves in the resident’s shoes and understand that even though our choice and our desire is to protect them and to limit their risk.


We also have to understand they have a right to autonomy, and they have a right to do these things. And it does certainly create a balance. So let’s talk about that last video we saw one more time. We saw the memory care community doing a variety of different things. I’m going to share with you the spectrum of risk. And this is just based on what I have experienced as a trainer nationally and internationally. When I share that video, I often have the audience have this similar feeling about risk. Now everyone’s different like I said, and I’m not here to tell you what you should and should not do. But I just want to establish what most people feel, and just compare it to your own feelings. Garden club, you saw in that video, obviously very low risk.


This activity can be found in most senior living communities. The next level of risk is leading tours. This is very low risk to the resident, but I will tell you, I have a lot of facilities who are nervous about the impact of having a resident in memory care lead a marketing tour. That’s just one kind of risk. The next phase of risk is probably the cooking. Most of us do cooking classes, but it will vary from property to property. I have been in buildings where they let the residents do everything from top to bottom. And I’ve been to buildings where they won’t let the residents near the stove or use knives. It is variable between different communities.  But we do share cooking as part of our program in most places. Definitely, a moderate risk of burning or skin impairments when you do cooking fully. 


The next range is actually, believe it or not, the commercial laundry. When that caregiver said that she has residents go in the back and do laundry with her, I’ve shown even more video footage of something like that in the training. And people are often like, that’s usually where, even though it’s low risk, people are like, “I didn’t know the residents could go back there.” Even if managers know that the residents can go back there, staff typically feel like they’re not allowed. Obviously, check your local regulations, but I’ve operated in about fifteen states and I’ve never found, I’ve never operated in a state where there is a law against it, so really look into that. But it is a wonderful way for the residents to engage with staff. And then lastly, having a resident chop vegetables in the commercial kitchen with the chef has been the one that prickles people the most. They typically are worried about infection control and what do you do if they cut themselves? Et cetera, et cetera.


We usually explain you follow the same procedures you would for employees, as far as infection control for your state, et cetera, et cetera. It’s moderate risk, but it’s rarely considered an option for community staff. Just kind of find out where you fall on the spectrum. Some people are very tolerant of risk and some people are not. It’s just good to examine and kind of get an idea of how you feel now. Rules of risks. Risk is necessary for engagement. Right to risk is not erased by a dementia diagnosis, and assisted living is rooted in that clinical mindset. Whether we like it or not, unfortunately, it’s very hard to get away from. The clinical world is very averse to risk. The whole point of a clinical setting is to minimize risk.


So when we operate assisted living and memory care, and we have to approach risk, often it’s foreign for a lot of us. It’s something that a lot of us are uncomfortable with. And lastly, risk is more accepted in service planning rather than activities. You’ll see residents who, you know, they have the right to fall, they have the right to smoke, they have the right to drink, but then as soon as it comes to an activity for the group, we tend to be a little less tolerant. And that’s just – I don’t know, understand that phenomenon so much – but it’s definitely present. So this is Shelly on the left. She is a highly behavioral memory care resident. She was an elopement risk. She actually escaped from the hospital by putting on a doctor’s lab coat, grabbing his clipboard, and sneaking out.


So she’s very sneaky and highly, highly at risk for eloping. In this picture here, she’s giving a haircut to a caregiver. And the backstory is that she was a hairdresser for twenty years. She would tease this caregiver all the time about his shaggy hair. One day she said, “if you give me a pair of scissors, I’ll give you a haircut.” This young man being fearless and open to anything, of course, he’s like, “sure, I’ll take a haircut.” She ended up doing a really beautiful job. She had the best time of her life. She asked to do it again, so now the first Thursday of every month, they open the salon and she gives haircuts to the staff if they want one. This would stop a lot of people for a lot of reasons.


What about risks? What about her cutting herself? What about her behaviors? But it’s working and it’s working really well for this person. They haven’t tried to elope anymore. They feel like they’re part of the community now. It can really pay off when we try new things. Let’s do a gut check just to get your own feeling about risk. And I want you to think about not only your own feeling but perhaps there’s someone on your team or in your company that has a higher or lower tolerance for risk. First thing, sharp knives, right? A lot of us are probably okay with that. At this point in time in memory care or in assisted living, a cognitively impaired person, you know, as long as they have the skills and the motor skills typically can use knives and scissors.


I would also add to this alcohol and memory care. A lot of us have moved towards alcohol and memory care being accepted, but I still do hear that there are companies that restrict it. Asking yourself, what is your own personal tolerance and why is really an important step in exploring ways to add risk without mitigating, without removing safety. Next is raising chickens. What if your lifestyle director or your ED or your team member comes up and says, “I want to raise chickens on the property. We could take care of them. We could get eggs.” What would your response be? Would it be, “yahoo! That’s a great idea.” Or would it be, “Oh, who’s going to take care of them? They’re messy and they are loud. What if the families don’t like them?” What is your response?


Is your response to automatically think of reasons that it won’t work? Or is it your response to think of reasons that it will work? These are all things I’ve done by the way. So everything on this list, I have done it myself. Tried and true. How about a four-hour bus ride to take your memory care residents to the beach? You know, the four hours there and four hours back plus the time at the beach. Is your first instinct, “no, that’ll never work and there are a million reasons why it won’t work.” Or is your first instinct, “meh, maybe we could do it. Maybe let’s think about it. What could we do to make it happen?” How about taking your memory care residents to a swimming pool? What’s your first instinct on that? Some people say, “yea, let’s do it” And others will be, “oh no, that’s dangerous.”


So what’s your gut check tell you? Once you know where your own feelings lie, and then also where your teammate’s feelings lie, it helps you strategize on the next steps. What about horseback riding? Yes. I have done this with memory care residents. What’s your first thought when you think of it? Is it something bad and terrible and risky, or is it something positive, and beautiful, and magical? What is your instinct telling you? And lastly, hot air balloon ride. You know, if your residents wanted to go on a hot air balloon ride, what would your instincts be? Would it be, “oh, that’s too dangerous? We’ll just look at pictures of hot air balloon rides instead.” Or would it be, “hey, what can we do to make that happen?”


So I’m going to share a video with you. And I share this video because without fail every time I show it when I train, people have a little bit of…they raise their eyebrow with it.  So what we have here is a French community that’s Montessori-based. They make soup every day and the residents spend the day prepping the vegetables. So what they do is they have all levels of residents doing different things. This resident is breaking beans. Some of the residents are using paring knives, or they’re using peelers. Now again, you don’t actually have to eat the soup if you don’t want to. You can just do the prepping. That’s the fun part, right? They can use these vegetables every day if they’d like and do different ones all the time. We’ve got peeling, we’ve got cutting, we’ve got a paring knife. And this here on the end is where people get a little nervous. So what they’ve done is they’ve taken a cutting board and they’ve put nails up into it so that this woman who has right-sided paralysis from a stroke is able to peel carrots with one hand.  Watch how she uses this tool.


Pretty excellent. She’s very good at it. A lot of people see this as a really awesome modification. But I will have without doubt, without fail, at least two or three people raised their hands and discuss at this point, well, is that safe? What happens if she hurts herself? Right? I always usually say, you know, our residents are at risk for injury and skin tears no matter what we do every day. And I would much rather have my eyes on this person and be able to, you know, understand where her skin tear came from so I can modify it. As opposed to having somebody get a skin tear in their apartment and not knowing how. Again, I’m not going to tell you what’s right or wrong for you or your community, but I want to urge you to just think about the risk is everywhere.


Is this any riskier than her sitting alone and disengaged in her apartment? Without maybe perhaps a fall risk or maybe she gets up and trips. I mean, either way, there are some risks, but at least here it’s a modification. Clearly, she’s able to use it very well. And we’re able to have her out with a group in the community. You might watch this video and not be scared at all. You might not even find it stressful, but a lot of people will. And sometimes it’s someone on your team. Typically it might be a clinical person or a person who comes from a healthcare background specifically and they are going to look at it as a risk. Just an idea of a really great modification though, for that person.

We’ve established that having a community requires your residents ‘doing’ more, and once your residents ‘do’ more, there are going to be more risks. But, you know, we do want to be smart about it. We don’t want to just say, “alcohol for everyone” in memory care and have no plan, or “everybody gets scissors, or “everybody gets to chop fruit.” We want to have a plan to mitigate risk. And that’s where you can make these really risky programs actually really safe and very successful. There are some steps that I encourage you to take when you’re facing an activity or a group event that you feel has some risk associated with it. The first is to explore the risk tolerance of yourself, of your team, and more importantly, your care staff. If you’re all very highly – if you have a lot of risk tolerance on your team, but your care staff is unsure, then the program may not be successful.


Really understand who on your team is comfortable with risk and who isn’t. I shudder to think what would have happened if I didn’t have a great executive director who allowed us to go on that canoe trip. We would’ve missed out on that excellent opportunity, and honestly, I probably wouldn’t be where I am today working on what I work on. It was a beautiful choice and it was worth every moment of planning. But, I needed to understand who on my team was going to be the more risk-focused so that we could work through it together.


Research rules. This is probably my most important one. I will tell you, it baffles me how many rules we make up; that we impose on ourselves. The one that I hear a lot is that glass isn’t allowed in memory care. I have worked, as I said, I’ve operated in fifteen different states and I’ve never found an actual law. I’m sure there are states that it’s an actual law, but please research it. Really dig and find out, is this just something that I believe to be true? Or is it actually a law or regulation? It might also be a company policy, and that’s important to follow. But it wouldn’t hurt to ask, maybe ask a peer. Do we know where this company policy came from? Do we know when, or how, or why? Because it very well could have been that it was created under a different set of regs [regulations]or a different set of rules.


When you come across something that you believe is not allowed, find out if it’s true and valid. Because it very well may not be a true rule and just something that has been rumored. Third, solve for yes. This is one of my favorite sayings. Just imagine what would it take to make this happen, right? So say your staff comes to you and they say, “we want to go on a horseback riding trip with our residents.” Your first instinct might be “no,” but what if you said “yes?” Sometimes it’s good to sit and have a pretend session where you say, “okay, let’s imagine I was going to do this. How would I do it? What would be the steps?” And once you think it through in that framework, you will actually find that it’s probably not as difficult as you’re thinking. But we spend a lot of energy saying all the reasons something can’t happen or all the reasons something’s a bad idea.


Sometimes it’s a good exercise to just say, “let’s come up with all the ways that this is a good idea and that this is doable.” And then the last thing is to follow a framework. And I’m going to bring Maria Montessori back into this because Maria Montessori created a framework that happens to work really nicely with risk because it is based on rehabilitation. It is meant to circumvent the deficits. Maria Montessori’s model, obviously it assumes the person will have a deficit. It creates true independence in the person. It’s success with more complex tasks, so things like canoeing and chopping vegetables and all of that, we can have success with. [It] Focuses on life skills, which we know are more engaging. And it’s completely hands-on. We also focus on a prepared environment.  I’m just reviewing Montessori. You can use any framework that you like. 


You can find any methodology that you’d like, but the important thing is you just follow some sort of a system so that it is safer and that you do go through the processes and the thoughts behind mitigating that risk. We have found – I have found – in my own research and study that the Montessori approach is a great compliment to this. It follows a very good model of assessments and skills assessments, et cetera, that allow you to take more risks and allow you to do more complex things. But any framework that you want to follow would also work. It’s just about having a system. And for fun, I’m going to show you the twelve principles of Montessori. This is the framework that you would follow. Say you’re going to make chopping vegetable activity, right? And you want to follow some sort of framework.


Notice that six of these things are actually meant to mitigate risk. That idea of demonstration number, four, is actually going to help the person be more successful and thus make less mistakes. Number five, assess for and focus on abilities. How do you know that a person is appropriate to use a knife or not if we have never assessed them? The Montessori approach has some great assessment tools that’ll let you know if it’s safe or not for the person to do the activity. The slowing down of staff is really huge. We don’t realize how much faster we tend to move than our residents, both in how we talk and how we move physically. And slowing down can also mitigate risk for that person. Visual hints and cues can make them more successful, thus mitigating that risk.


And then the last three here, breaking down into steps, (or I’m sorry the last four.) Progressing from simple to complex and breaking down into steps. Now again, if we were to spend a whole presentation on Montessori, we would go into this more. But I just wanted to illustrate that six of these twelve principles actually will help you mitigate risk. And that’s why it’s so important to have a framework or a methodology because you can do a lot more things that you maybe thought were too risky by following a scientific framework for success. As we end today, I have a few takeaways for you. The first is creating a community involves residents ‘doing.’ You have a variety of residents who I’m sure do a lot of things in your community. Don’t they give it life? Don’t you all have that resident who maybe leads exercise for you?  Or who’s always checking on her neighbors? ‘Doing’ comes more naturally to certain people than others, but everyone needs to be engaged in some sort of ‘doing,’ regardless of their levels of cognition or levels of disability.


They need to be involved in “doing” things to really create a community. But in order to fully engage in “doing” more things, risk will be necessary. We have norm on the left here, he is a memory care resident. He has some pretty serious behavioral issues. He was a fireman and worked in construction. And as you can see, he can still use a drill. We know from his assessment, his Montessori assessment, what skills remain, and he’s actually helping the maintenance director turn apartments for new residents. And that’s one of his jobs. But, there are risks there. Absolutely. But there’s also risk in him becoming bored and wandering and becoming agitated, right? So, in order to fully engage in things in the community, risk will be necessary. Again, disclaimer, I’m not here to tell you what you should do or shouldn’t do, or what you should feel comfortable with.


I’m just wanting to show you examples where taking risks was successful, and it was appropriate. And I’m glad that we did them. Third, understand your own risk tolerance and others around you to ensure your opportunities are not being missed. When you have this opportunity come up, maybe it’s that you want to raise chickens. Really explore your gut instinct and become mindful about it. Because if your first instinct is to be adverse, that’s not necessarily a bad thing. It’s just something that needs to be explored and discussed as a group. Or if you have someone on your team who says no to everything, you might need to win them over with some of this information. But you’ll want to understand that to ensure you’re not missing out on opportunities. And lastly use some sort of a methodology or system to understand and manage risk.


I shared with you that I use the Montessori system because it comes with a lot of assessments and rehabilitative methods, and it’s very much supportive of an independent community environment. But really, any methodology or system would work. You could have weekly risk meetings. You could, during your safety committee meeting, you could sit and talk about upcoming events and outings that might be a little risky that you want to try. You could have a checklist of preparation and assessment plans. But really as a team, try to come up with some sort of a system. It will make you feel better about taking the risk. It’ll make you feel more confident and it will truly make it more safe and successful. That’s all I have for you today. I hope you found these experiences interesting. I hope they pushed your own boundaries of risk a little bit, or you very well may be totally comfortable with risk, and maybe it will help you to convince someone on your team, or your care staff that risk is necessary and it’s important. And just because a person has a dementia diagnosis or some sort of impairment, they don’t lose that right to autonomy, risk, and sense of self. I appreciate your time today and please reach out if you have any questions. Thank you.

53:20 Charles: Wow. What an amazing presentation. Wasn’t it? I  know that during the presentation, the chat was going on and was very, very active. I’d like to invite all of you right now. If you can, take a moment and thank Mallory in the chat. If you do this, we will be sending her the content of the chat, and I’m sure it’s going to warm her heart. And it’s just in a very nice way to thank her for this amazing presentation. Getting back to one of the things that she has been taught, telling us, teaching us is this idea of how can we explore risk? Do you know what I love about Mallory’s work? What I love about the Montessori approach is it’s not only us exploring risk. It is really about this idea of us partnering with the elders, by partnering with the residents.


And I think that this is really something that defines what we do in activities and life enrichment, is this idea of collaboration with the residents. And I’m sure that all of you love doing this. This is why you get up in the morning. This is why you show up at work. So again, think of this, and as I mentioned before in my introduction. I hope that a lot of you, and at least some of you have this, I cannot unsee that, and I’m going to do something about it. Because as always, we at Linked Senior, especially with Activity Strong, try to partner with you, help you, and provide you tools so you can enhance the experience that you’re building with residents. With that being said on these slides right now, I’m sharing with you Mallory’s email. Just so you know, during the presentation we were taking snippets of the chat.


I was texting her. She’s with us in spirit and I’m sure she would appreciate, again, you thanking her in the chat, or you sending her a note by email. So with that being said, I have a couple more announcements that are very exciting when it comes to next events going on with Activity Strong. As always we do these webinars every two weeks, so please feel free to register on our website for some of the upcoming ones. I did want to take the time to really focus on our Activity Strong for gathering, because I am so excited about the presentation. This event is a three-hour event on September 21st. Now don’t worry, you can show up just for one session, or two sessions, or the whole thing. We even have a happy hour at the end, but let’s explore this together.


The first session is at 1:00 PM eastern and is led by Julia Larimer (sorry), who is an activity director actually, and she’s also the founder of And it’s a whole discussion about enabling interdisciplinary work and creative intervention for sleep issues, which I know has always been a topic, a challenge for programming, but obviously through COVID has really emerged back and forth. And she’s going to be partnering with Melanie Bunn, who is with the Positive Approach to Care. As some of you might be familiar, Teepa Snow’s work. This is going to be an amazing presentation. The next one also is going to be amazing, obviously beyond the fact that it is led by Dr. Jennifer Stelter, who’s on the team at Linked Senior. This session is going to be done in partnership with NAAP, Alissa with NAAP.  

And they’re gonna be talking about how we use data, data-driven resident engagement to then connect to clinical and financial outcomes, which is really the future of activity and life enrichment. I really invite you to consider where you are today and how you can learn to again, do better, and build better engagement strategies, regardless of where you are. Whether you’re an activity assistant, an activity director, rec [recreational] therapist, or perhaps you’re even an administrator or an executive director. And then the last session I’m extremely excited about also. It is a discussion led by Murry Murcier, who is the General Manager in Senior Living for PointClickCare. And he is partnering with Anne Schrempp, who is the Corporate Director of Life Long Learning for Ebenezer; a society, which is one of the leading nonprofits in, I think the leading in the state of Minnesota and a very innovative provider.

And they’re gonna be talking a little bit about how we build occupancy using technology, communication, and accountability in the field of resident engagement. Please as always feel free to sign up for these events. Come and join us. Be part of the discussion. It’s an important discussion, especially as we continue unfortunately to go through these challenges and issues with COVID.  I’d like to close this again, by thanking all of you for the amazing work that you do at showing up in your communities today, yesterday, and throughout this pandemic for the well-being of your residents. With that, I will close the session today. And again, thank you for joining us. Take care. Bye-bye.

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