Functional Contentment Model: Optimizing Quality of Life for Nursing Home Residents with Dementia

The Functional Contentment Model (FCM) attains two objectives: 1) building a relationship focused plan of care for nursing home residents diagnosed with dementia; and 2) maximizing and maintaining older adults’ contentment, peace, and happiness while living in dementia care environments. There are three essential components within the FCM: 1) Person/Family Centered Care; 2) Slow Medicine; and 3) Team Care Management. The principles of “Person/Family-Centered Care” are coupled with the philosophy of “Slow Medicine,” and neither can exist without the engagement of “Team Care Management.” In short, the FCM maximizes the older adult’s potential functioning in activities of daily living, cognition, gross and fine motor skills, communication, and physical well-being, while maintaining the highest possible level of contentment, peace, and happiness. This is accomplished through dynamically utilized professional modalities adapted to the changing needs of the older adult resident—pharmacologic, physical and occupational therapies, family education and involvement, dietary, spiritual, stimulating activities, as well as any individualized modality. The lead for operationalizing the Functional Contentment Model is the nursing home medical director, whose key role is assuring a team approach to care including the older adult resident, the family, and all staff (dietary, housekeeping maintenance as well as care and administrative staff). The FCM is a culture change model that has implications in practice and policy for each nursing home.


Introduction
Residents with dementia often pose a challenge to providing person-centered care for long-term care residential environment administrators, staff, and medical directors. Historically, we have not done well in meeting this challenge, as evidenced by less than optimal resident quality of life, family satisfaction, and staff satisfaction and retention [1] [2] [3]. By utilizing a creative approach to person-centered care, built on new models of medical practice and team care, we can improve the quality of life for nursing home residents with dementia, their family care partners, and the staff. This article introduces the Functional Con- Of the total U.S. population, one in ten people (10 percent) age 65 and older has Alzheimer's dementia or related dementias [4] [5]-a predictor of eventual need for long-term care supports and services. As of 2012, more than 5 million Americans had the disease. By 2050, the prediction is this number will grow to 16 million. The percentage of people with dementia increases with age; 3 percent of people age 65 -74, 17 percent of people age 75 -84, and 32 percent of people age 85 and older have Alzheimer's or related dementia [5]. There is a direct link between disease and the need for nursing home care. Admission by age 80 is expected for 75% of people with dementia compared with only 4 percent of the general population. [6]. Overall, 50% of nursing home residents have Alzheimer's or related dementia [7]. In Maine, the oldest state (44.5 average age) in the union, the number of persons living with dementia is estimated to increase from 37,000 individuals in 2012 to over 53,000 individuals by 2020 [8]. In 2012, 58% of Maine nursing home residents had dementia and nearly half (44%) of the people receiving community and facility-based long-term services and supports (LTSS) had dementia [7]. It is essential with the rise in nursing home residential care for people with dementia that we instill sound models of care in their environments. Proper care will benefit the older adult, his/her family and nursing home staff/practitioners.  Management." In the FCM, "functional" is defined as: of or having a special activity, purpose, or task; designed to be practical and useful, rather than attractive [9]. "Contentment" is defined as: a state of happiness and satisfaction [9] [10]. 1) Person/Family Centered Care (PFCC): Person/Family Centered Care generally refers to an orientation to the delivery of health care and supportive services that considers the older adult's needs, goals, preferences, cultural traditions, family situation, and values [11]. The resident is the key member of the team with the family at the center as well. Continuous monitoring of the resident's experience of care (feelings or expressions about the care) as well as the family's experience is essential to a congruent care plan for the resident. Within person/family centered care, the care team includes the health professionals, social service professionals, direct care staff, and support staff such as housekeeping, food service, and maintenance. Services and supports are delivered from the perspective of the resident [11]. For nursing home residents with cognitive impairment, the family care partner(s) engagement is integral to achieving person/family centered care. This concept holds true even if the family is not the biologic family but a health care power of attorney (POA) or support person of choice by the resident. Family/POA involvement in the planning process helps the care team know the resident's personhood, personal needs, wants, capacity, and expression of autonomy; all factors important for creating a successful care plan. Family care partners may recognize changes that indicate a decrease in International Journal of Clinical Medicine resident function and/or contentment; both signs that can guide changes in the care plan to attain functional contentment.

Three Essential Components
To 2) Slow Medicine: Slow Medicine for care of older adults, a concept published by Dr. Dennis McCullough, geriatrician, is directed towards the protection and comfort of the older person rather than cure of an ailment [12]. According to McCullough, "Slow Medicine embraces the unsung work of daily attention that is the greatest need and firmest foundation for longevity and quality of life at the farthest reach of age" ( [12], p.xxi). It focuses attention on older persons and their specific challenges and needs; including family wishes to ensure congruent care regardless of the medical setting. Slow Medicine is an intentional plan for a) understanding the older adult's physical/cognitive/emotional needs, medical diagnoses, values, life, choices, and living circumstances; b) caring about the older person and his/her family; and c) living well as determined by the older adult, the family and the provider. Based on the belief that the best decisions about care come from a measured approach; collecting information and moving forward slowly while continually reassessing is key [12]. The philosophy and practice of Slow Medicine serves older adults well because their journey of late life is more complicated than that of middle age. Factors like the older person's stage in life, strength, and the severity of the ailment play a vital role in the practice of Slow Medicine. Dr. McCullough stated that a successful outcome in the care of an older person was based on the repeated assessment of the choices of the older person and his/her family [12]. To enrich an older person's life to the end, Dr. McCullough identified five fundamental principles to guide families, health professionals, caregivers, and other care team people: a) Understand older persons deeply-their complexity, acknowledging losses and newly revealed strengths that come with aging. b) Accept the need for interdependence while promoting mutual trust. c) Learn to communicate well and with patience. d) Make a covenant for steadfast advocacy-the doctor becomes the dedicated "agent" for the older adult and the family; although unwritten and often unspoken, she/he will be there in the time of need. e) Maintain an attitude of kindness no matter what-days of caregiving International Journal of Clinical Medicine are often long and difficult requiring patience and forbearance when there appears to be a seemingly endless cycle of chores ( [12], Excerpt pp. [3][4][5][6][7][8][9][10][11][12]. With these five principles in mind, the family, the medical director, and the nursing home staff have a responsibility to each other and the older person to provide mindful care. The Team Care Management approach is described as: "a work group that is made up of individuals who see themselves and who are seen by others, as a social entity who are interdependent because of the task they perform as members of a group, and who perform tasks that affect others" ( [13], p.308). Studies in a variety of work environments have shown that there are several potential benefits associated with team organizing, including greater job satisfaction, greater commitment, and greater effectiveness and quality [13]. However, the nursing home setting is unique as is the care for residents with dementia. In three studies conducted by Havig et al. [14] [15] [16] on team care management and workgroups, all three studies revealed that active leadership, represented by task-and relationship-oriented leadership styles, and the use of teams or workgroups, are related to higher quality of care in nursing homes [14] [15] [16]. In the last study Havig et al. [16] conducted, they found that functional teams/work groups were found to be effective when each member: 1) assumes ownership, 2) perceives an insider status, and 3) shares mental models. Active leadership is dependent on work ethic, work environment, professionalism, and organizational vision [16]. In essence, the studies have noted that enhanced success for workgroups and active leadership in a variety of long-term care settings each included engagement, feeling a sense of contribution, camaraderie, being included in care processes, exhibiting a good work ethic, and upholding the nursing home philosophy of professionalism [16]. Teamwork has an especially important meaning in a successful older adult care partner process. Including residents and their representatives into the decision-making process creates better information flow and consultation procedures to achieve a true dialogue both within the team and with the residents and family (see

Operationalizing the Functional Contentment Model
In short, the Functional Contentment Model (FCM) is a relationship building International Journal of Clinical Medicine the FCM is the nursing home medical director, whose key role is assuring a team approach to care. Every staff member in the nursing home (including maintenance, cleaning, and dietary/food service staff) as well as family and friends and of course the resident makes up the team approach to care.

Clinical Assessment Elements of the Functional Contentment Model
There are seven clinical assessment elements that are paramount to the Functional Contentment Model (see Table 1:   allowing staff to provide personal care.

Functional Contentment Case Study
The following case, a patient of the first author, illustrates how the Functional Contentment Model optimized care for Mrs. Joan Doe. Upon admission, the following was determined for Mrs. Doe. The FCM implementation is then presented further below (Section 4).

Patient Description
Joan

1) Case History
Mrs. Doe's pre-existing condition was progressive dementia over the past seven years. She is unable to care for herself independently due to cognitive decline, has urinary and bowel incontinence, and impaired communication secondary to altered mental status. At the age of 78, she was first admitted to a nursing home; but after 3 years that nursing home was unable to meet her needs as her dementia increased and her self-attentiveness decreased. She moved to the memory care environment at the current nursing home, which is located 35 miles from her home where her husband resides.

4) Daily Function
Mrs. Doe ambulates short distances with walker and one assist, but primarily is wheel chair reliant. She is essentially aphasic with occasional yelling out. She is unable to transfer without 1 -2 assist. Mrs. Doe is toileted regularly; she is incontinent of both urine and feces. The MOCA (Montreal Cognitive Assessment) score was 5 out of a possible 30. Mrs. Doe was unable to perform the PHQ 9. She shows intermittent recognition of husband (who is there daily for at least 10 hours/day), but rarely recognizes children (who are involved in care planning but visit usually once a week). She is resistant to care. Unable to perform any Activities of Daily Living (ADLs) including feeding herself.

5) End of Life Plan
Full Code without POLST (Physician Orders for Life Sustaining Treatment); husband is health care power of attorney.

Implementation of the Functional Contentment Model for Mrs. Doe
Based on the information provided in Mrs. Doe's case study, the first step is to review the seven clinical assessment elements of the Functional Contentment Model (see Table 2 for details) and adapt or adjust each according to the three components of the FCM; Person/Family Center Care, Slow Medicine, and Care Team Management.

Case Results
Mrs. Doe was a relatively uncomplicated nursing home resident except for early bouts of yelling and her resistance to assistance with her Activities of Daily Living by staff. Her dementia was severe and yet the adverse behaviors reduced as she responded well to the team effort to maximize her function and content-

Co-Morbidities
Mrs. Doe's medical history is without catastrophic events and illnesses. Her physical exam confirmed that she was a relatively healthy 81 years old. The FCM focus is her cognitive impairment, incontinence, hypothyroidism, and osteoarthritis.

Medication Evaluation
Mr. Doe (husband) agreed that essential medication should include only those that would provide her comfort (contentment). Synthroid continued for hypothyroidism to avoid the discomfort of a hypothyroid state. Lipitor, Lisinopril, Metoprolol, Vitamin D, and the Multivitamin were titrated where necessary and discontinued. Ambien was titrated and discontinued without difference in sleep patterns. Aricept and Namenda were discontinued to allow Mrs. Doe to be in a natural state. Tylenol and Senna-s are now given in the evening. After two weeks of "settling in" the Ativan was discontinued for non-use once non-pharmacologic interventions were in place, such as iPod music therapy and robotic pet (puppy) companionship. Metoprolol and Risperdal were titrated and discontinued and Mrs. Doe exhibited an increase in energy. Adhering to the Slow Medicine philosophy, nine of the previous 13 medications were discontinued over a two-week period; appearing to not adversely affect Mrs. Doe or her behaviors.

Physical Abilities
Physical Therapy, Occupational Therapy, and Speech/Language Therapy evaluated Mrs. Doe's physical abilities and each professional staff developed goals and a plan for her during her stay that matched the proposed goals for the Person/Family Centered Care plan.

Cognitive Abilities
Despite the low score on the MOCA, the increase in energy from decreasing certain medications and the implementation of the non-pharmacologic interventions, Mrs. Doe's contentment continued as did her recognition of her husband. Her "yelling out" ceased with the increase in contentment.

Clinical Implications
• The goal is to find ways to create joy and well-being with each resident with dementia. • The biggest challenge for successfully maximizing a resident's function and contentment is the dementia and its progression; therefore, challenges for FCM successful implementation is "buy in" from the family and nursing home staff-it takes a team to make this work and the more involvement by all connected with the resident the better.
• The implementation of the three components and seven FCM clinical assessment elements provides a fresh approach to resident care and well-being; focusing on the resident and family goals.
• Reframing the traditional medical model of identifying the resident "problem list" to focus on the resident's capacity, desires, and well-being within the FCM seven elements builds a quality of life network for that resident that also aids staff satisfaction.
• The Functional Contentment Model is a culture change model that has implications in practice and policy for each nursing home.
• Research on the FCM is warranted; the suggestion is to conduct qualitative case study research on individual residents and as more cases are documented, to then include pre/post survey and focus group interviews with nursing home staff and families.
• This iterative process for creating culture change is manageable, affordable,