Guest post by Michelle Walch
michellewalch.com

Adult foster care home work is a 24-hour, seven day-per-week job. Care home staff not only help with resident meals, errands, bathing and medical tasks, but these staff also give very much of themselves physically and emotionally. Many find the work rewarding, but it can be physically and emotionally challenging. That said, it is important to manage your own well-being so you can provide the best care.  

What is Burnout?

“Burnout” occurs when someone is physically, mentally, and emotionally overwhelmed, according to Healthline. The rate of burnout is 53.3% for caregivers, and the rate of severe burnout is 27.1%, according to a Japanese study.

​When you live where you work, you never really have a place to take a break. You are always on duty. Many caregivers don't reach out for help and don't take a break from their work. As a result, exhaustion takes its toll.

What are the Signs/Symptoms?

Be aware of the burnout warning signs:

• anxiety 
• isolation
• depression
• lack of energy
• fatigue
• insomnia

It is important to know the difference between burnout and depression. Depression is a disorder of your state of mind. Burnout is a reaction to severe stress in your environment. The World Health Organization (WHO) calls it occupational burnout to describe work-related stress. This is different from the medical condition of depression.

An article in Psychology Today has a compassion fatigue questionnaire (similar to burnout) and suggestions on self- care if you scored high on the questionnaire.

When you live and work in the home, how do you build a break into your schedule?

Planning and Prevention

Alyssa Elting McGuire, of Oregon Care Home Consulting, recommends planning to prevent burnout. "Self-care is like being in an airplane when the oxygen mask comes down. You give yourself oxygen before you give it to someone you are caring for. When you take care of yourself, you can then take care of others."

A care provider in Washington County, Oregon, offered suggestions to prevent burnout:

• Allocate time for self-care
• Schedule breaks for both staff and yourself
• Don't over commit. Be okay with saying "no," and setting boundaries.
• Honor your personal needs
• For providers, trust your caregivers. You have well-trained caregivers. Trust them to take care of the residents while you're away.
• Pre-plan a time weekly (on say, Sunday evening) to review records and take care of what needs to be done
• Recognize the difference between what needs to be done now, and what can wait

November is National Caregiver Appreciation Month. In honor of the work adult care home providers and staff do day-in and day-out, I would like to take time to recognize and appreciate the work they do by telling their stories. Recently, I interviewed provider Vicky Barbu and her business partner and daughter Adriana Gavozdea about their experiences moving to America and starting their adult foster home in Tigard.  They shared their stories of how they came to work in the adult care home field and provided their ideas on what makes adult care home providers, and other staff, successful.

Interviews have been edited for clarity and brevity.

Interview with Adriana Gavozdea

How long have you worked in the adult foster/care home business?
 
I’ve worked in this business for eight years, since I moved here from Romania. My mom owned the adult foster home for eight years prior. I came here to start a new life, and I actually started this job two days after I landed. My mom trained me at her level because someday when she wants to retire, I can take over the home. We work together, and we’re a team.
 
What do you love most about the work you do?
 
I love that I make a difference, honestly. For example, when a resident can’t brush their teeth and you help them, it makes their day better. Recently, a client who wasn’t doing well was having trouble putting on her sandals. She asked me to do if for her, but instead I coached her and watched her closely, and she did it by herself. She was so happy at the end and thanked me so much. That’s my joy.
 
What do you believe makes someone’s work successful?
 
Compassion, and you have to be built for this. What I mean by that, is I’ve met people in this industry who didn’t have passion and they were miserable. You have to love what you do and help other people. If you do it for the money, you may succeed financially, but at the end of the day you’ll be so burned out, it won’t matter. You have to like to help people.

​Anything else you’d like us to know about you?
 
I think we’re amazing!  My mom and I were doing other things back in Romania. I never worked in healthcare before. She was an accountant and I was CEO, and we ended up in America, starting a new life from scratch. You land here and have to start all over. My mom arrived at age 45 and I arrived here when I was 30.
Since we have other skills, there is always another option, but we want to do this.

​We’re not stuck in this job, but we like this work. We got used to being at home, being home with you kids, be at home for meals. We are so family oriented. In Romania, you take care of the seniors, so we are used to being in the home with the older generations. In Romania, after I gave birth to my daughter, I went back to work. My grandmother took care of my daughter until she was four, and my grandmother was at my house all the time. It’s a cultural thing.

 Interview with Vicky Barbu
 
How long have you worked in the adult foster/care home business?
 
I opened my home in 2007, and before that, I was working as a caregiver in another adult foster home. We came to the U.S. in April of 2002, and I started as a caregiver in June. I was a bookkeeper in Romania for manufacturing, and I was also a foster mother.
 
I came to America when I was 45. It’s hard to go back to school with new culture and language. When I arrived, I could understand English, but it was hard for me to talk. I learned to speak English well with residents while working.
 
What do you love most about the work you do?
 
When you are helping residents. When residents really need help and you can give them the help they need, you get to see how happy they are and how well they are feeling. This makes you proud and think, “I did something good today.”
 
What do you believe makes someone successful?
 
I am trying to do my job the best I can do. It is very hard work, and especially working with people with disease processes. Sure, it sometimes makes you crazy, but you have to have patience and try to understand the residents’ needs, that it’s not their personality, but it’s the disease. They don’t necessarily want to do what they’re doing.
 
In this work, you need to have a lot of patience. It’s important to show residents you care about them. Much of the time, we know them very well, so we should try to be their voice (e.g. to medical staff and others).
 
With every resident, you’re learning something new. Use that new information to learn and help the next residents. I learn a lot with every resident. You have to be open to learn new things. You don’t have to know everything. Open your mind and pay attention, and then you will learn.
 
Anything else you’d like us to know about you?
 
I am trying to make everything very smooth for my business behind the scenes. I know what I have to follow, so I’m trying to follow rules and make it run smoothly. My advice is make residents happy and follow the rules, and things will work well. ​

Most hospitals and skilled nursing facilities adopted electronic medical records years ago. Now, larger community-based facilities, such as assisted living and residential care, are slowly adopting electronic health records; however, the adult care home industry has yet to jump on the electronic records bandwagon.

This lag in adoption is likely due to several factors. Adopting electronic records can be more challenging for adult care home providers without electronic record experience who may initially believe they lack the money, staffing, and infrastructure to implement this change. Fortunately, these potential barriers are not insurmountable.

As larger facilities migrate to electronic record-keeping, it is simply a matter of time before more and more providers in Oregon start implementing electronic record-keeping systems in their adult care homes.
One trailblazer in the area of electronic record use in adult care homes is Shannon Carskadon. Shannon owns and operates Silver Cloud Adult Family Homes in Forest Grove and has been in the business for 25 years. I recently had the opportunity to sit down with Shannon to talk about her experience transitioning to an electronic records system earlier this year.

The system Shannon uses is supported through Beaverton-based company Care Facility Management Systems, LLC, which works with individual adult care home providers to “cost-effectively transition their business operations from paper to electronic records.” Owners Gueipin Xi and Elaine Hartman bring over twenty years of experience providing technical support and security to health care clients.

Interview with provider Shannon Carskadon(Interview has been edited for brevity and clarity)

Have you used electronic records for your homes before?
I used Excel files, which I printed out for licensing, but I had no system set up.

What made you decide to transition to electronic records?
There were current issues [with the hard copy records]. At licensing inspections, the books would be torn apart and nothing got put back correctly. There was too much repetition and similar mistakes. There was a huge potential for medication errors.
​
Elaine [with Care Facility Management Systems, LLC] called me and asked if I’d be interested in helping build this program for use in other adult foster homes. The company takes care of online security with a private network, and provides training and support to use the system. I was all for it.

Tell me about the process of transitioning your paper records to the electronic records? How long did it take?
​Gueipin and Elaine provided me with the hardware and software, set up, and training. They also provide the system security, and ongoing technical support for the electronic records system. The support is amazing. Often, providers are isolated. For me, it feels like a professional system with support and cohesion.

At first, it was about 10-15 hours of work at the first of the month. I first started with medications only [eMAR], and it took as long as it takes to enter medication orders. The eMAR is a no fail system. For example, with a PRN, caregivers have to write the result in the record, or they cannot close the entry. Also, I can easily track narcotics using the system.

There was a learning curve, but my caregivers picked it up quickly. We worked on it piece-by-piece until they were comfortable with each section.

Elaine then came to my home with a large scanner. I scanned all resident records into the system and they’re saved in a secure folder. All the [paper] records I have left are in two binders.

What are some other benefits of the system?
​I can send and receive [electronic] faxes to the doctor, and I can have legal representatives electronically sign documents.
​
We also use the system to document resident activities and facility records, such as smoke detector testing. I can add reminders and tasks for staff. Caregivers log in with an individual login and see the reminders and tasks. I can run reports and look at tasks that were done. I can also see when caregivers read an email I sent.
My data is secure and consistently updated, and I can access the information securely and remotely. If we have a fire or earthquake, I can get into the system remotely and I don’t have to worry about losing records.

Tell me about your renewal inspection after you started using an electronic records system.
​It saved a lot of time. The inspection at my first home was in January (2019), and the renewal inspection of my second home was in March. I learned from the first inspection, and had everything ready to go for my second inspection. The licensor was in-and-out in two hours and got everything [the licensor] needed. I had no medication violations.

What advice do you have for other providers who are considering the transition to electronic records, but are concerned about either cost, the challenge of transitioning, licensing, or other issues?
​Take the time to learn the program. It’s especially beneficial for multiple homes. I can run compliance reports, and I can check on caregivers remotely and run audits to see who logged in, when, and what actions they took. The program is customized so it meets licensing requirements. If you do your due diligence, the system helps you be compliant.
​
Finally, the cost is worth it. It’s less than ink and paper, and that doesn’t include the time saved. We’ve been thrilled with this. I can’t say enough positive about it.

Today, March 8th, is International Women’s Day. March is Women’s History Month. Every day should be a day to celebrate the lives, strengths, and accomplishments of women.

It’s no secret that women make up the majority of caregivers for both seniors and children. It has been researched and written about for years. In families, of course, the care burden is primarily placed on the shoulders of female spouses and daughters. According to the Alzheimer’s Association, “Approximately two-thirds of caregivers are women…and one-third of dementia caregivers are daughters.”

If we look at the numbers for adult care homes, we can see there isn’t a significant difference between family and professional caregivers, in this regard. There are almost 1,600 adult care homes in Oregon, and based on a quick sampling of the State’s provider list, it is plain to see the majority are owned by women.
​
I think we’re starting to see a slow paradigm shift where there is less expectation that caregiving is “women’s work,” and where more men are proudly taking on caregiving roles. Anecdotally, I’ve seen a significant increase in the number of men opening adult care homes over the past few years and being the primary caregivers, or working along side their female partners. This is a good thing.

​Even with this slow shift taking place, the majority of caregivers are still women. According to a 2018 Portland State University report on adult foster homes in Oregon, 88% of providers live in the adult care home, and a third had children under 17 living at home. From this, we can conclude that many women are both providing care for residents and their children. This is both a benefit and a challenge. It really is more of a benefit, though, if we consider these women would be caring for children, or having to find care for children, regardless of where they worked.

In this regard, one significant benefit of owning an adult care home is that parents can stay home with their children while working. The adult care home business provides women with the opportunity to be their own bosses yet also care for children or aging parents while working at home and making a solid income. What other business truly provides this opportunity for women?

So, on this International Women’s Day, let’s take the opportunity to recognize and appreciate the work of women around the world, and also here at home. Let’s continue to recognize the important work of adult care home providers and support those providers who are making an important contribution to both the older generations, and the next.

Several years ago, I read an alert in the local paper I had seen many times over. Miriam*, who was 87, had wandered from her adult care home the previous day. She had fairly advanced Alzheimer’s disease. Though her memory and judgement were both strongly affected, she was physically able to maneuver with little issue, as is often the case with individuals who have Alzheimer’s disease. My stomach sank, though, as I continued reading. Miriam was still missing.

I kept an eye out for updates, but unfortunately there was no positive outcome in this case. The news updated the story soon after local law enforcement found Miriam deceased, not far from her care home.

This story highlights an extreme outcome of wandering and elopement, as most cases end with the resident safely back at home. Still, this story reinforces the importance of not becoming complacent. This situation could have happened to any care home provider. It’s an unfortunate story that illustrates the importance of managing wandering and preventing elopement in adult care homes.

Wandering vs. Elopement
The terms wandering and elopement are often used interchangeably; however, they are not exactly the same. Wandering is pacing or aimless walking. This generally takes place inside the home or facility, though it can also take place outside. These are the individuals you see who pace up and down the hallway, seemingly without direction.

Elopement, on the other hand, is the unplanned exiting of the home or facility. It commonly includes “exit-seeking behavior.” This exit-seeking behavior and elopement from the home puts residents at great risk of harm.

According to the Alzheimer’s Association, 60% of people living with dementia will wander at least once.

Who is at Risk?
According to the Alzheimer’s Association, 60% of people living with dementia will wander at least once. Individuals who have some form of dementia are at greatest risk, especially individuals who are in the middle stage of Alzheimer’s disease. Additionally, residents with cognitive limitations who recently moved to your home are at increased risk. Those who have a history of wandering or exit-seeking behavior are at great risk.

Assessing for Elopement Risk
What can you do to recognize and reduce the risk of elopement? Your screening process is the first step. It is important to conduct a thorough screening to find out if your potential resident is at risk for elopement. During your screening interviews, ask if the individual has ever displayed exit-seeking behavior or wandered outside the home or facility. Additionally, if the individual is currently in a facility, review their narratives, care plan, and any incident reports to find out if there is a concern about wandering and/or elopement.

Also consider using an elopement risk assessment tool, either during screening or after the resident has moved to the care home when their condition has changed.
​
It is important to understand, even if you’ve conducted a thorough screening, or the resident has no prior history of wandering or elopement, they could still elope from your home after admission.

Tips for Keeping Residents Safe
How do you keep residents with wandering or exit-seeking behaviors safe? Below are several tips and evidence-informed interventions for keeping residents safe. This is not an exhaustive list, as each resident’s needs and situation are unique, but it is a place to start.

• Care plan around wandering. Recognize and document when a resident is most likely to be at risk, and what possibly triggers wandering or elopement. Increase the level of observation.
• Meet the needs of the resident. If a resident is confused about where he or she is and insists he or she needs to “go home,” or “go to work,” use non-pharmacological interventions to address his or her underlying feelings and needs.
• Keep residents active during the day. Provide person-centered activities.
• Install door alarms all exterior doors of the home. Make sure to keep them turned on at all times.
• Consider using an ID bracelet, such as the Alzheimer’s Association Medic Alert + Safe Return® bracelet.
• Ask the resident’s legal representative to contact your local sheriff’s office or police precinct to find out if they have a registry for individuals at risk, like the Washington County Sheriff’s Office Help Me Home Program.
• Make changes in the home environment. Paint exterior doors a similar color as the wall, or put a dark rug in front of doors. Also consider putting a “stop,” or “do not enter” sign on doors.
• Provide a space for residents to wander safely inside. If a resident wants to walk outside, plan for a caregiver to go with him or her.
• Involve the resident’s family and/or legal representative to problem-solve around concerning, exit-seeking behavior.

Sometimes you can do everything within your power to keep residents safe, and things will still happen. It is important, then, to recognize the point at which an adult care home may no longer be the safest placement for a resident with exit-seeking behavior.

Fortunately, what happened to Miriam is a rare outcome in situations when a resident elopes from the home. In most cases, with awareness, prevention, and intervention, you can keep residents who wander safe.


*name and details have been changed