Podcast, Season 2 -

Adrienne Alford – Person Directed Care

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Adrienne Alford is executive director of The Village Langley, a dementia friendly community in Vancouver, Canada. And her experience in working with older adults extends through a lengthy career working in Canada’s Office of Veteran’s Affairs.

From this work, she explains, Adrienne learned the importance of standardisation and consistency – and has brought this to her new position in aged care. In this conversation she shares with us the importance of marrying standards with a personal touch, and she clarifies how this fluid approach is key to providing world class care.

It’s this personalisation that Adrienne holds to be the key for maintaining a “person directed approach”. Which goes beyond simply centering a care recipient at the heart of the activities, it also ensures that their wishes and directions are the basis of all action undertaken for them. Much like the human rights approach promoted by Daniella Greenwood, Adrienne’s person directed approach does away with the paternalism that is so prevalent in residential aged care.

Transcript

Ash de Neef: Adrienne thank you so much for joining us today on the podcast.

Adrienne Alford: Thank you for having me.

Ash de Neef: Can we start with a little bit about your story and the work that you do?

Adrienne Alford: Sure. So I’m the executive director of the Village Langley. So my role is to lead the day-to-day operations of a dementia enabled community in Langley, British Columbia.

Ash de Neef: Fantastic. And you have quite a history in aged care and working with the elderly, right?

Adrienne Alford: I do. I do. So I’ve worked in health and social services for about 25 years now in all different aspects of supporting older people.
So everything from mental health and addictions to supporting veterans, and aged care and the ageing process in that aspect. And then moving specifically into residential care, assisted living and long-term care in the publicly-funded sector. And now in the privately funded.

Ash de Neef: The jobs that you were doing, those were within the government, the Canadian government?

Adrienne Alford: Yes, for a long time I worked with the federal government with veterans.
So I worked with the veterans for about 15 years. So I actually started there as a case manager, working with veterans from world war II. And the Canadian veterans who fought in the Korean war. And then I moved into policy work and project management work, and that became tricky working on the front lines and hearing some of those stories and dealing directly with individuals who were really affected by war service and military service.
So I moved into the senior leadership and for almost 10 years, I led operations responsible for the British Columbia mainland and the Yukon territory.

Ash de Neef: How did that experience prepare you for the work you’re doing now?

Adrienne Alford: I loved it. I absolutely loved it. And I think the way that it prepared me for the work I did now or I’m doing now was for me, it really helped narrow down the fact that I really liked working specifically with older adults.
So with veteran’s affairs in the Canadian context, the definition of veterans that we worked with and continue to work with are individuals who served the Canadian armed forces, as well as the Royal Canadian Mounted Police.
So that profile as veterans aged, we were also picking up a younger veteran clientele, younger service members who for all intents and purposes could be 18, 19, 20, 21. And so what it demonstrated to me was that I really did prefer working with older adults as opposed to younger adults. But on the mental and emotional health bit, I really began to draw parallels between people with acute mental illness and the ageing process, as it related to dementia. You do tend to see a lot of parallels.
And as people who experience mental illness and cognitive impairment related to mental illness and cognitive impairment related to long-term substance abuse and substance misuse. And then the impacts of ageing and the impacts of dementia on top of that, those conditions become very compounded and very profoundly impactful on the individuals and on their families.
And it just became extremely fascinating to me that the brain is a very fascinating beast and it really stood out to me that this was a very specific field that I wanted to become involved in. And that was actually what prompted me to exit the veterans affairs portfolio and moved specifically into residential care and long-term care.

Ash de Neef: When you transitioned into more of the aged care sector, were there things that you thought could be taken from the veterans affairs work into aged care more successfully?

Adrienne Alford: That’s a really good question. I think that there were things from a policy perspective that certainly could have been borrowed from and applied practically to aged care in a practical sense. Most definitely.
I think when we look at things like program architecture and in a practical sense, so how we frame the practical aspects of how we deliver care. Yes, there definitely were things that could have been put into place. And I tried to put into place and I still do try to put into place. And there are other things that I think in a federal sense are too high level to put in place in a practical sense.
Like where the rubber meets the road sometimes are a little too high level and miss the boat a little bit in a practical sense too. We have to be cautious sometimes I think, in a high level sense, we think if only everybody did it this way, or if everybody understood politically that this is the solution for everything on the national health scale, all of the problems would be solved.
And it actually doesn’t work that way because not everybody actually has the same shared experience. But if everybody did have the same shared experience, I think that some of those policy solutions probably would work very well, but not everybody does have that same shared experience. So we can borrow from some of those policy platforms, but not across the board for everybody.

Ash de Neef: Are you speaking to cultural and regional differences there?

Adrienne Alford: Yes, for sure. Definitely cultural, regional differences, family differences, socioeconomic differences, expectations for ageing differences.
How people expect to age, who are in their nineties or in their eighties are quite different from how people expect to be supported as they age, when they’re in their sixties.

Ash de Neef: Absolutely. What were some of those structural things that you were trying to implement or that you have implemented from veterans affairs?

Adrienne Alford: Some of the things were around consistency, in terms of application of policy. So that staff understand what is done with one particular family needs to be applied consistently with other families so that people understand how people are treated.
I think it stands well for things like, management of reputation, professional reputation, professionalism. I think that it’s good for ethos of an organisation. Those things are really important for retention of staff, for building a team, especially for building a new team. When you don’t have consistency in leadership, when you don’t have consistency in your staff training, when you don’t have consistency in your policy instruments.
That sounds really boring to say, but those are the really foundational instruments that let people know, how to do their role – the foundational pieces of their role. It lets your clients and their families know what they can expect from your organisation. It builds trust. It builds trust within your team.
It builds trust within your residential base, it builds trust within the community. It builds trust within the people who afford you your operating licenses. And those were the things that keep your organisation afloat and running. And when your organisation has those things in place, you produce a sustainable service and you produce a consistent service, and those are the core foundational elements that then allow you to get better with time.
And then as you get better with time, you have those foundational elements, but also then allow you to experiment. And when you can experiment with different models, those are the things that I like to try. Things that are different and allow you to try out things that might then challenge the status quo and start challenging things that we have always accepted to be the norm in aged care.
And if you don’t have those things, then you’re never going to get to the point where you can do things that are in fact different. We’re just going to keep doing the things that we’ve always thought are normal. And we’re just going to keep doing the same old, boring, traditional things for our elders and we’re never going to be able to do anything different or better or more.
We’re just going to keep repeating the same things over and over again.

Ash de Neef: What I’m hearing is you’re talking about the culture of the organisation and how to establish some standards of practice that extend across all elements of the business, and of the care process as well. In Australia, a lot of the frontline workers are not, they’re casuals or they’re moving around between different institutions.
How do you apply consistent standards and create a culture when people are rotating in and out of care facilities?

Adrienne Alford: So COVID is not a nice thing. But one of the things that it has done that I am actually thankful for is that in order to prevent COVID infection spread, one of the things that we chose to do early on at the Village Langley before we were actually mandated to by our health authority, was to introduce single-site staffing.
We did that in early March. And then we were, everybody was mandated to do it in April. And in doing so we eliminated people moving about, and that actually allowed us to build consistency and commitment early on. And that was a blessing for us too, because we really, we had just opened our doors in August of 2019.
The other thing too, because we apply a household model of support and a social relational model of support. One of the foundational elements there is that you do use a dedicated staffing model, which does, in it’s essence require dedicated staffing – one-on-one, ideally you are working at one site.
And so the expectation was always set for staff that if you can, you work at one site and at the very least, when you do work here, you only ever work in one household. So that you get to know your resident or as we call them your villager and they get to know you. And maybe they don’t remember your name per se, or maybe they do it depends on the person. But they will remember your face.
They’ll remember your voice or your tone or your mannerisms or your gestures. And they’ll build a trust and a bond with you. So that’s another way to build consistency with your team members. That’s one of the ways too. But the whole COVID realisation for us has been a bit of a blessing in that sense, because that in and of itself has allowed us to build consistency.
We simply don’t have people that are working at other sites and I’m hopeful that when COVID settles down, if it ever does, that people will have come to the realisation that only working one job is actually nice. It certainly isn’t as lucrative financially. It’s not. And healthcare is typically, it’s not a well-paid industry.
It’s usually under-recognised, it’s underfunded, it’s feminised labor. And typically as such it is underpaid, but ideally people will stick to that one employer and we don’t have a lot of turnover. Anyway, we, we didn’t prior and hopefully we can maintain that.

Ash de Neef: Can we talk about the Village Langley and a bit about the ethos behind the organisation? What’s what sets the Village Langley apart? Why is this a different approach to aged care?

Adrienne Alford: So a few different ways. I think for us, the difference is that, a lot of organisations do apply a social relational model of care. And so by that, i mean we don’t prescribe to any particular model.
We don’t say that we apply an Eden philosophy or, the butterfly approach or the evergreen approach. We take a combination of several of those models and that we believe in forming the relationship first and that the relationship forms the foundation of care and support that we provide.
We believe in an enriched living model of support. We believe that every person should have a good day, every day. And that a good day is defined by that person, by the person receiving care. It’s not defined by me. It’s not defined by my task list. Or by how I define a successful day for the staff. It’s not up to me to say if you got everything done on your checklist today as a nurse or as a healthcare aid, that means that everybody had a great day.
If you didn’t get everything done on your task list done today, but most of the people in the community are smiling. And it looks like they had a great day and they were out singing and had this fantastic picnic – I think that’s great. I think that means everybody had a great day. That’s a good day for us.
The main thing is that people have control over their day and that they have a choice and that they have freedom of movement and that they control the activities that take place within their space, within their bedrooms and over their bodies.
So the main thing that I’ve aspired to teach the staff is that we don’t provide person centered care. I don’t quite know what the buzz terms are in Australia, but in North America, we always hear, we should aspire to provide person centered care. And I always maintain that, that is a really outdated model. And I don’t think there’s anything wrong with person centered care, but I think the goal of providing person centered care is very outdated.
And I say that, and that we don’t provide person centered care. Person centered care is an outcome. What we provide is person directed care and that in order to provide person directed care, it’s our job to make sure that we receive permission from the person who is within our care, we have accountability for.
And that the care that we provide also is serving a purpose that is meaningful to that person. So they’ve given us consent to touch them or to do something with them or to them. And that it serves a meaningful purpose to them in that moment.” Ash, is it all right if I touch you? Is it all right if I offer to help you bathe today?”
And you say yes or no. And if you say yes, Then that’s great. “And would you like to have a bath today?” So you may have given me permission to, but then I have to say, would you also like to have a bath today? And then if you say “no, I actually don’t want to have a bath today, but I’d like to get dressed.”
Okay, then that’s fine then. So we’re not going to have a bath, but you’ve given me permission to touch you to help you get dressed for the day. And that’s fine. And so if we establish those things and then you get dressed and you feel fine, then what we have done is we have provided a person directed care and the outcome is a person centered outcome.
And if your mother shows up and says, “you know what, Ash is dressed really nicely today, but I can tell he didn’t have a bath.” Then I would tell your mother, “you know what, you’re right. He didn’t have a bath, but he’s really happy about it. And he thinks he looks great.” Big deal. And so that’s where the community differs in a person directed approach.
You as the person receiving care are telling us what you want done, and we are respecting your decision. If you were to be delivering care from a person centered approach. You would be at the center of the provision of care, but we might be providing the care based on what we think is best for you. So that’s the difference in what we do.

Ash de Neef: It seems the norm that frontline care workers are often put in a position where they feel like they are fighting the recipient of care to do something that’s on their task list. And it’s evident that the recipient doesn’t want that done at the moment. For example, in the case of a shower or a bath, but that it needs to be done and it’s positioned as something that is a necessary requirement of care.
Would you say there’s a fallacy in this idea that these care actions need to be taken?

Adrienne Alford: Very good question. I think that there is a belief that we have failed as caregivers if within the first 36 hours of being admitted or moved in, that a move-in checklist that somebody created 15 years ago, doesn’t have all of the boxes checked off.
I also believe that if something is critically important to get done for somebody’s welfare and wellbeing, there is 98 percent of the time. If you ask somebody in a creative way, after taking the time to get to know them before they move in, you will be successful in having those move in checklist boxes. If they are actually important and many of them are, checked off.
We had a woman move in this winter. Who had not physically submerged in a bath for two years. And one of our nurses, Christina had her in the tub within two days without any problems. We had a woman who moved in just before COVID hit. She hadn’t washed her hair in three months, and I washed her hair myself on the second day and her family was stunned.
“How did you wash her hair.? How did you get her to…?” We have a salon on the property, a hair salon on the property, and they asked her, would you like to get your hair done at the salon? And she was really excited to go to the hair salon.
So she came to the salon and the staff asked, “Adrienne, would you be willing to wash this lady’s hair? She saw you walking around. She thought you looked like a really lovely person and she wants you to wash your hair. She thinks you work in the salon will you wash her hair and put it in rollers.” I’m like, “okay, sure.” So I washed her hair. I put it in rollers and during the whole COVID, that initial COVID lockdown she came to see me every Friday and I did her hair in the salon on Fridays.
It was great for me because it got me away from email. I loved it. There’s always a creative way. You just have to be willing to do it when it’s not necessarily your job.

Ash de Neef: It’s interesting that we talked about standards and about standardisation before, because it’s very hard to standardise these sorts of approaches to be creative and how you respond to the desires and the wishes of the individual. How do you marry those two things?

Adrienne Alford: You don’t, it’s just shades of grey and it’s, it’s odd. It is odd. So you have to live in a world of shades of grey. So we talk about – and actually it’s funny, cause we talked to the staff about this a lot, about trying to reconcile these things. We talk out of both sides of our mouth. And so when we recruit staff members, we actually one of the things that we asked them is “how do you feel about ambiguity? “
Because we are so black and white about being clear, being consistent, being professional, being consistent with policy application when it comes to regulation. When it comes to care standards, when it comes to professionalism, when it comes to infection prevention and control standard.
But then we are very grey when it comes to boundaries. We never want to hear, “that’s not my job.” We never want to hear “I’m off in five minutes.” Like those things just don’t exist for us. We all do things that obviously they have to be clinically within your scope and professionally within your scope, but everybody picks up garbage.
Everybody sweeps, everybody vacuums. Everybody is capable of washing hair. Everybody’s capable of giving somebody a bath, not everyone’s capable of using a mechanical lift to get a person in a bath, but anybody’s capable of giving somebody a bath.
And so if there’s a particular villager who will only have a bath with, or for somebody guess what? It’s fair game, if you’re asked to help that person.
So there are things that are difficult to reconcile and we’re cautious when we hire people that we hire people who are able to accept that and are able to bounce between those two extremes. And it’s difficult to do because traditionally in healthcare a lot of people are black and white.
And especially nurses because they are very they’re scientifically minded people. And they do tend to be fairly, I don’t want to say rigid because they’re not rigid. They’re problem solving oriented people. And they’re very like go, go, go, which is great. That’s good. But they struggle with shades of grey sometimes.
And so it can be tricky to retain people because they tend to be a little bit uncomfortable with that.

Ash de Neef: Because it’s such an intensive model for the care workers. What kind of training do you provide? How does the preparation of staff differ?

Adrienne Alford: So when we recruit, when we book them to come in, we let them know that we’re inviting them for an interview. But we’re also going to have them write a test and we usually will give them a test, but right away, people respond back that they’re not going to be able to come. We actually do that as part of a screener, because that tells us right then whether or not, they’re comfortable with doing something different.
Because how many employers are actually going to make you come in and write a test? And we tell them it’s like multiple choice based on knowledge, plus a little small essay, which is really just a couple of paragraphs around, tell me why you want to work here. But it tells us a little bit about the person’s ability to do something different or outside of their comfort zone.
So we start screening that way and that they’re not really hard things like if you work in health, and your test is what’s a normal temperature? What’s the normal blood pressure? What are foods to avoid if you’re diabetic? Those kinds of things. They’re not difficult tasks, but they tell us more about you as a person.
Those are initial screening elements that we use. And if you make it through those stages, when you’re hired, we do have everybody complete a basic dementia education program. And then we use consistent professional development plan throughout with our staff, once they’re on board, we have regular education.
So some of it’s very clinically based like we have coming up nutrition education for staff related to therapeutic diets, specific to dementia. So a lot of persons with dementia, as the dementia progresses they’ll experience problems with choking and dysphasia. Difficulty swallowing they’ll experience difficulties with a taste sensation changes.
We’ll do education related to sensory changes again that are specific to dementia. So a lot of people, as they age, the spatial visual fields will narrow. As we age, we’ll probably narrow to about 30 to 35 degrees. Whereas persons with dementia, their visual spatial range narrows to about 10 degrees.
Color perception for persons with dementia tends to change. So things on like the purple-blue-green spectrum tend to dissipate completely. So we do specific education for people along the way, and then we do refreshers for people, but then we tend to repeat some of that same education for new staff.
And then if there’s anything new, because we don’t know everything, and we learn something new all of the time in the field of dementia and there’s lots of new experts coming out in the field. So that’s something to stay on top of.

Ash de Neef: Can we pivot away from the Village Langley now and talk about your experiences in aged care within Canada?
What do you think is some of the biggest challenges being faced throughout the aged care industry in Canada at the moment?

Adrienne Alford: I think in a Canadian context, its interesting. Inter-provincial differences are quite interesting. So our federal government funds the provinces and the territories for healthcare, but then each province manages its own healthcare portfolio.
And the federal government will set national priorities, but doesn’t actually maintain mandates over provincial spend. So it’s tricky to get consistency over how each province, prioritises aged care, what is important between the provinces in terms of the aged portfolios. So you’ll see differences from province to province in terms of what is available.
So what is available in a publicly funded sense between British Columbia and our neighbor province Alberta is very different. And what is available between provinces with some financial means and provinces that are less economically viable is vastly different. And that ranges from things like just funded medical care, to go see a general practitioner, to things like funded home care programs and care homes, nursing care homes type of a thing are very different.
Let alone, care in northern communities, and first nations communities are very grossly underfunded, and there’s a large lack of available aged care in rural communities. So people who are living in rural communities often have very limited if any access to any type of formalised home care support, or aged care support within congregate or group settings.
And so then are either forced to go into care like in a hospital setting or are forced to then leave their home community and go to larger metropolitan centers. So there’s those pieces, there’s language barriers. We’ve got our two official languages, English and French. We’ve got a Western-Eastern divide and we’re similar to Australia.
We’re a migrant country with large immigrant and refugee groups. And so we also have issues with language barriers, with large populations where neither English nor French is their mother language, is the mother tongue. And so then trying to receive language appropriate and language sensitive medical care, and culturally appropriate aged care is also becoming a larger and larger challenge.
There are myriad issues with it right now, and it’s just getting larger with the baby boomers now, right on that cusp and entering the system as they’re starting to need aged care. It really, our system is grossly under capacity to deliver either at home, in their home or in a group or congregate living, setting for that population.
And we’re all just waiting to see what’s going to happen here. We don’t have the facilities in terms of buildings, nor do we have the staff in terms of the infrastructure. To support that population. So we look at my age group, we look at our parents and think, where are these people going to go?
Because they’re not coming to my house. Like, where are my parents going to go? What’s going to happen here. And we all just sit and wonder what’s gonna happen here? I think that, Australia and New Zealand, or the world is facing something similar because here we look to you for a comparable model.
And Ireland, we look to Ireland as well to see, okay, what are these countries doing? And we’re waiting for you guys to come up with something smart that we can borrow from. And. We haven’t seen it yet.

Ash de Neef: The pressure’s on!

Adrienne Alford: The pressure’s on. Yeah.

Ash de Neef: With the, when the baby boomer generation moves into more aged care settings, do you think it’s just the number of people moving into that environment is going to be a lot larger or are the requirements for care different as well?

Adrienne Alford: I think both. I think the number is going to be very high. And I think that the disease representation is going to be very different. I think that we’re dealing with a portion of the population where modern disease manifestation is very different than it was when my grandparents were needing care.
I think we’re dealing with a much higher volume, or at least we’re dealing with a much higher awareness of volume of diseases like cancer, Alzheimer’s disease, various dementia’s. I also think that their expectations for ageing and lifestyle support are very different.
I also think, and I hate to say it,the children of the boomers are pretty bossy bunch. And I think I look at the people who are operating care communities, and I think they’re going to be dealing with families of boomers who also have very high expectations. I think, if my parents tomorrow moved into a care community where they live – my parents live on Vancouver island and they’re in their mid seventies.
And so they’ll be mad at me for announcing their age, but I thought if they moved into a care setting right now, and I know some of the settings that they might move into and those care community operators. If I wasn’t pleased with the quality of care that they were receiving, you can bet I’m going to show up on their doorstep. And they’re not going to be pleased to see me. And I’m the nice sister. I can only imagine if my sister showed up, they wouldn’t be pleased to see her at all. She’s a lawyer.
I think it’s going to be a whole other ballpark. It’s a whole other ballpark. And I think the states is facing the same thing. And they’ve got a whole other issue with funding and with insurance with the way that their funding model works as well too.
Just from the north American context, their model is very interesting. So again, as Canadians, we watch that setting very closely too.

Ash de Neef: We’ve covered so much today. Adrienne, thank you so much for your time. Where can people find out more about your work or the Village Langley?

Adrienne Alford: The best places on our website. So www.thevillagelangley.com. And we’re on Facebook, LinkedIn. We’re on Instagram and then I’m on, I have my own LinkedIn page as well, too. We’re quite easy to find.

Ash de Neef: Excellent. Thank you so much for your time today.

Adrienne Alford: Thank you.

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