The moment you walk into Denver North Care Center, you know that you are not in a typical nursing home. Staff and residents alike are engaged in activities and conversations, and comfortable furniture is arranged to create the feel of a living room rather than reception area or office.
Extra Attention & Care
On the day we visited, a staff member was emptying bags of vegetables from his garden onto a counter. With cucumbers, squash and tomatoes arranged around him he told us how he planned to show them to the residents, to teach them a little about gardening before heading into the kitchen to cook them up something tasty and special, fresh from the garden.
This extra attention epitomizes the kind of care provided for residents at DNCC. To learn more about what makes this facility so special, we recently met with Sharon Hobbs, the dietary manager, and Candace Johnson, DNCC’s dietician. “In this industry,” Candace tells us, “there is the medical model and the social model. Here we follow the social model.” The medical model, she explains, is the traditional set of medical care standards in which physical needs are the main concern of providers. In the social model, the patient’s needs as an individual are of the utmost importance. This includes physical needs, but also social and emotional needs as well.
How does following the social model effect the kitchen operation? All operations are implemented with an eye toward empowering patients and creating a home-like environment. This results in a few basic policies.
Involving the Patients
First, Candace and Sharon work hard to involve the residents as much as possible in the daily operation of the foodservice program.
Denver North Care Center serves a unique population of residents. There are 80 beds in the facility, each of which is reserved for an individual who cannot otherwise care for him or herself. Residents come from a range of age demographics, with the average age being 55 and the oldest resident 98. They also have a variety of complications that make it impossible to take care of themselves, from psychological issues to Alzheimer’s disease, substance abuse and the complications that arise thereof.
Providing the most fulfilling foodservice experience possible serves a purpose beyond merely satisfying the dietary needs and preferences of the residents. “Food is a safe complaint,” Sharon explains. It is very important that food is not something that causes problems at DNCC, as often residents will complain about the food rather than address the truly pressing issues. By making the food program as free from criticism as possible, it is that much easier to address these issues head on.
Foodservice in a long-term care facility presents unique problems. The biggest challenge, Sharon and Candace both agree, is preventing the menu from becoming repetitive. There are some residents who have lived at DNCC for decades, eating three meals a day, every day. “In a restaurant, you have the same menu but the clients change,” Candace explains. At DNCC the menu must change, every single day. The best way to deal with this challenge is to keep the residents involved in menu-planning as much as possible.
The residents, therefore, are an integral part of the menu planning process. Sharon meets with them once a month to discuss what will go on the menu. They discuss which items the residents didn’t like from the previous month, as well as items they’d like to see added. This also provides a forum for staff and residents to communicate about regulatory and budgetary constraints that prevent the kitchen from serving any item the residents might request. For example, Sharon tells us, once a resident requested a lobster dinner. She was able to explain that while they could have one lobster dinner that month, it would eat up the entire budget and prevent them from doing any number of other, smaller-scale but still special meals. By keeping the lines of communication open in this way, residents feel empowered and get more satisfaction from the food they are served.
Meeting the Requirements
The DNCC population also presents special problems with regard to nutritional needs that you don’t find in other foodservice operations. Candace and Sharon must meet the dietary needs of every single resident, and if there is a dietary order for a patient they must find a way to fulfill it. For diabetic residents, they must monitor blood sugar. Other residents require a low-sodium diet. At the same time, they must honor residents’ preferences. There is an educational aspect to this job, as staff must make a concerted effort to fuse patients’ dietary needs with their preferences.
Candace and Sharon stress that it is important to honor patients’ preferences even if those preferences are out of the ordinary. One resident, they say, would drink five chocolate milks and two regular milks at each meal. There are other residents who wish to avoid certain colored foods. There are also residents who think that their food might be poisoned. With those residents, Sharon and Candace wrap food in special packaging and read the labels with them so that the residents know the food is safe.
In addition to getting residents involved in planning, the second basic policy that DNCC employs to maintain their social model of care is having a 24-hour foodservice operation. The full-service kitchen is open from 5:30 in the morning until 10 in the evening. Each meal has one main entrée, with a variety of snacks as well as cold cut sandwiches that are always available. In this way, the kitchen attempts to provide as many options as possible for residents.
Despite extensive planning, though, mealtime can get a bit hectic. When all the residents come down for meals at the same time, it is difficult to address everyone’s needs at once. Previously, residents lined up in front of the kitchen window to choose what they would like to eat. It had seemed like a good idea at the time, Sharon says, because they could see what the options were and therefore make more informed choices.
However, it soon became clear that this model didn’t work. “It felt like a prison,” Sharon says. So, they decided to start using guest checks to take patient orders tableside, the same as if they were in a restaurant. This system makes the residents more comfortable, preventing long lines from forming in which they would have to wait while staff frantically tried to help them move along.
At 10 p.m. the kitchen closes, and the pantry is opened up. Here the residents are able to help themselves to a number of self-serve meal options: pizza, macaroni and cheese, burritos, fruit cups, soups and more. “If you were at home,” says Candace, “you could eat whatever you wanted at 3 o’clock in the morning. We want this to be as home-like as possible. A nursing home can never be a home, no matter what you do. But it can be home-like.”
There is also a 24-hour self-service soda fountain. Staff had a number of concerns with regard to allowing patients free access to the machine. First, a number of residents have diabetes. This problem was addressed easily enough by making all soda in the fountain available only in the diet variety. Secondly, residents with polydipsia, or extreme thirst, also presented a problem. It is important that such patients do not drink too much as it can cause electrolyte imbalance as well as dilute essential medications. To ensure the soda fountain does not harm these patients, staff members monitor hydration closely so that they know ahead of time if a resident might be putting him or herself at risk.
This 24-hour service model replaced a set 3 meals-per-day model that the DNCC previously followed. When this change happened, staff soon found that the kitchen setup was no longer an effective work space. “It was very closed in,” says Sharon.
The biggest challenge was in the overall flow of the space. There were four separate rooms, which included a dish room, bathroom, pantry and cooking area. With the new setup and organization of a 24-hour kitchen, the DNCC needed one large room to increase efficiency and ease of use for the space. So, when the budget allowed they decided to tear down the walls and reorganize.
Coming to a Solution
However, remodeling the kitchen in a live-in care facility is not easy. Though the kitchen might be a disaster-zone, there are still 90 people, including staff, that need to be fed every day. The staff dealt with this by simplifying the menu and using disposable dinnerware. And in order to alleviate resident stress over the situation, they did what DNCC always does: they let residents in on the plans, giving them a piece of ownership in the process. Residents were informed of all the changes, what the new kitchen would be like. They were shown the new color scheme and the new equipment. After 30 days the remodel was complete and the residents were excited about the new facility. “There was not one complaint,” Sharon happily reported.
The remodel provided an open space and an opportunity to make much needed updates to the kitchen’s equipment. The ice machine, most importantly, needed to be replaced. “We got it used,” Sharon explains. “It was about three times too big.” The old ice machine took up much more room in the kitchen than was necessary, and by purchasing a smaller model that still met the ice production needs of the facility, they saved a lot on energy and space.
They also purchased a waffle-maker, a more powerful commercial microwave, a quesadilla maker, a 4-slice toaster and, at residents’ request, a Panini grill. The Panini grill along with the regular grill are among the most utilized pieces of equipment in the facility. These machines fit with the individual-focused approach of the DNCC, in that they allow for the restaurant-style made to order meals rather than large-batch cooking.
With a new remodel and a continuing commitment to the social model of patient care, the DNCC has proven that long-term care facilities can be made to feel as home-like as possible and individual needs can be met within a group environment.