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Consistent assignment of caregivers is important for elders

by Carol Bradley Bursack, Editor-in-Chief

Think of it this way. A person comes to your door or into your room if you are living in a care facility. You've never met this person, but he or she announces that it's time for a bath. The person proceeds to help you get ready for your bath, while you remain confused and frightened. Who is this person? Why do they want to give you a bath? What would you do? Likely have the "fight or flight" response which is wired into human brains, right? The modern approach of consistent assignment, which means that the person needing care is assigned a specific caregiver, is a big step forward in this regard. A care receiver is much more likely to respond well to a person they know and like.

Wouldn't it seem logical that someone who is vulnerable enough to need a caregiver would want to get to know the person giving care, and have that person know them? One would think so. However, it's taken a long time for this logical idea to settle into many facility care plans.

A little history

Several of the elders who depended on me as a primary caregiver needed nursing home care. The staff at this facility got to know me well, as I had from one to three elders living in this home over the course of 15 years and I was there nearly every day. During this time, I saw many positive changes in care philosophies.

When my uncle, after a series of strokes left him with needs his family couldn't properly meet, first moved into this home, the administration at the time operated under the premise that every Certified Nursing Assistant (CNA) who worked in the home should have experience with every resident. That way, the theory went, if one caregiver couldn't be there for a shift, another CNA could slip into that slot, with little problem.

This home was, and is, one of the best in my community. By national standards, I'd say it was, and is, generally very good. The rotating care philosophy just happened to be ""current thought"" at the time. This nursing home was just following what was thought to be the best practices by most nursing homes.

In-home care agencies were ahead of the game

Before my uncle's last, big stroke dictated nursing home care, he'd had several years of in-home care provided by a local agency. At that time, in-home care agencies were just beginning to get a grip here in my community. I believe we had three choices. I happened to be writing a newsletter for one of them, so we chose that agency to provide my uncle's in-home care.

The people who ran this agency knew instinctively that some people ""clicked"" with certain elders better than others. My uncle, a retired military man, was a wonderful uncle. However, he was exacting in his daily life, and several strokes didn't make him much easier to please. This agency, however, managed, after some trial and error, to find three caregivers whom he liked. Among these three, he did have a favorite, but these three women happily rotated for several years. My uncle looked forward to their company as well as their care. On the rare occasion that one of these three women couldn't care for my uncle, things were not pleasant. He'd put up with this ""outrage,"" but that was all. Consistent care didn't have a name at the time, but the concept had already proven its value to me.

Nursing homes catch up

Although now most good nursing homes are at least trying to practice consistent assignment of CNAs, during most of my elder's years this wasn't the case - officially. Yet, because the nursing home we were dealing with was forward thinking, and the new owners were compassionate, the unofficial policy was often bent in that direction.

Three caregivers; three elders

For several years, I had three elders living in this nursing home. Each had a favorite CNA. Each of these caregiving women (these happened to be women, though there were several excellent male caregivers), had a very different personality. So did my elders, of course.

One CNA, we'll call her Marian, who worked on the third floor of the home where my elders all lived, was compassionate, kind and well-meaning. She also came across as quite nervous and very, very intense. Working on the same floor as Marian were Sandy and Darleen.

One of my elders, my mother-in-law, had dementia, probably of the Alzheimer's type. She often had Marian assigned to her as a primary aide, and they truly enjoyed each other. My mother, who had a different type of dementia, found Marian rather irritating because of Marian's nervousness. My dad, who suffered from severe dementia caused by failed brain surgery, tended to get agitated by Marian's quick, rather jerky movements and nervous personality. Yet, my quiet, shy mother-in-law was a perfectly matched with Marian and happily accepted her care.

My mother always wanted Darleen. Darleen spoiled Mom, bringing Mom special, in-between meal snacks, to encourage Mom to eat, and stopping by to visit, even when Mom wasn't on Darleen's list of care receivers for that day. Mom was easier for all of us to please when Darleen was Mom's special caregiver.

My dad was a very difficult case for most caregivers to understand. People couldn't just glance at his chart and think, ""Oh, Alzheimer's,"" or some other disease, and then know what to do. Dad's dementia was highly unpredictable. His anxiety could be extreme. He could be in one ""world"" mentally, or another - and it was not always easy to figure out how to ""get to him.""

I'd sit with Dad on ""bad"" days, trying to get him into a more comfortable place, mentally. But I couldn't stay with him all day. Those days, I literally thanked God when Sandy was on duty, especially when Dad was her official care receiver. Sandy was the one CNA who could reach Dad on some level. She ""got"" Dad. My knowing that someone besides me could comfort Dad when he was in a bad place mentally was worth nearly anything I could think of. Gratitude was my continuing state of mind when Sandy was on duty.

All three caregivers were wonderful people with special skills. All three were caring individuals who knew their jobs. However, since my elders had distinct personalities, as did the caregivers, there were noticeable changes in contentment when my elders had their favorite caregiver on any given day.

Everyone can't be pleased all of the time

Whether we have our loved ones cared for by caregivers from an agency or in a facility, every day isn't going to be perfect. However, when people write me a note and ask what to do because their elder ""hates"" the caregiver who is caring for them, I tell the writer to talk to the agency supervisor.

I emphasize that, in doing so, they should not indicate that the caregiver is not doing his or her job, or that there is anything negative at all about a particular caregiver (unless, of course there is some glaring shortcoming). I advise them to let the agency or facility know that it's no one's fault. The problem simply lies in a poor ""fit"" of personalities.

I let family caregivers know that they should feel free to ask for a change in agency caregivers. Once a good fit - or as good a fit as possible - can be found, then I'd ask the agency for consistent assignment as often as possible. You want this caregiver and your elder to bond with each other.

I'd ask the agency to ""try out"" a few caregivers so that there can be a rotation, such as my uncle had. No one works all day every day and never takes a vacation (though I used to tease Sandy, and tell her that she needed to do just that, so I could rest).

Having a rotation of a few caregivers who get to know your elder, and have at least some positive interaction with him or her, is important. Even though, like my elders, your elder may have a favorite caregiver, we all have to be realistic. Some change must be expected.

Consistent assignment can only be taken so far. However, with thoughtful planning and good communication on the part of the facility or agency, as well as cooperation from the family, often a good rotation can be found.

Consistent assignment is a big part of person-centered care

Person-centered care is the kind of care good nursing homes are working toward providing, and consistent assignment is a big part of that. Of course, there will be times where your elder will have to have a substitute caregiver. That is reality. However, the more we can help our elders relax and feel secure, the better off everyone will be, and that, to me, means consistent assignment should be the goal, whenever possible.