Before it was a trend or in regulatory language, the staff at the Abramson Center for Jewish Life, in Philadelphia, PA, embraced a person-centered focus on the physical, emotional and spiritual needs of each older adult. Like any transformational change, the process starts with a conversation, and at the Abramson Center, the conversation is guided by a survey tool called the Preferences for Everyday Living Inventory© (PELI). The idea is to understand the preferences of everyone served in Abramson’s adult day center, nursing home, personal care and independent living apartments, home care program, hospice or aging research program. Karen Eshraghi, project manager for Abramson, says it well: “Providers want to provide person-centered care. The challenge is how to get there.”
What is PELI?
The Abramson Center’s Polisher Research Institute (PRI) partnered with The Pennsylvania State University to allow both to expand their research on aging concerns, with a focus on person-centered care. Their collaboration led to the development of the PELI, which comes in 2 versions: one for nursing homes and the other for home and community-based services.
The participant/resident chooses if an activity is very important, somewhat important, not very important or not important. It takes considerable time to ask the 72 questions in the PELI, but as Scott Crespy, vice president of quality and innovation at the Abramson Center says, staff should not look at the use of PELI as just a task to be completed, but should embrace it as an ongoing relationship-building conversation between staff and participants.
The PELI contains nested questions that allow cultural variations in responses to be highlighted by asking, “Once you have answered how important a preference is to you, I will ask you for details about your preference.” Kimberly Van Haitsma, director of the Harry Stern Center for Innovations in Alzheimer's Care, explains the importance of this by noting that one question (“What name would you like me to use when I greet you?”) is considered rude by older adults in Germany because of a cultural and linguistic norm for how an older adult should be addressed by a younger person. A Medicaid official in Tennessee told a group of adult day services and assisted living providers at a conference that during their site visits for determining compliance with the HCBS Settings regulation, they observed that staff would address clients as “Sweetie” and “Honey” instead of by the name the client preferred to be called.
What are Clients’ Preferences?
When different staff members have a conversation with a participant about what is important to them, the relationship transforms the person who provides care into the person who cares about you as a person. Val Palmieri, chief operating officer at the Abramson Center, says before they used PELI to know their residents’ or participants’ likes, dislikes and preferences, she remembers how staff who attended the funeral of a resident reported that the eulogy included a mention that this individual had performed in a Broadway play. One staff member remorsefully said, “I wish we would have known about her Broadway performance when she was alive, we could have made her life even more rewarding.”
The Abramson Center started using PELI in its home care program, then its nursing homes, and then its adult day services. Van Haitsma, who is also director of the Program for Person Centered Living Systems of Care at Penn State University, says there is an academic/provider partnership in the use of PELI. “The meaningful use of data is determined by the trajectory of how the information is actually used by the provider to improve person-centered plans of care.”
Why is it important to understand the preferences of the people we serve? The consequences of not beginning to understand the preferences of the people we serve goes beyond compliance with the Medicaid waiver HCBS Settings regulations, the SNF Requirements of Participation or the Home Health and Hospice Conditions of Participation. Caring about another person’s feelings is the right thing to do. Ohio adopted the use of PELI for its value-based purchasing program in nursing homes, and Tennessee is also planning to recommend this tool in its value-based purchasing program.
The Abramson Center has a very low turnover of staff, even though the work is not easy. Palmieri believes one reason for this low turnover is that employees know their jobs go beyond routine tasks in caring for older adults. Knowing the person changes the dynamic: staff place the individual first, and the task second. This change further elevates the importance of the roles of the direct care and recreation staff.
Varsity, a marketing and media firm, completed a study, “The Next Generation: Understanding What the Boomer Consumer wants from Retirement Living,” and concluded that older adults now expect a wide variety of choices, active lifestyle and they expect to have a voice in all decisions.
The use of PELI and applying preferences to activities has also been a boost for development at the Abramson Center. The narrative of philanthropy is dominated by the concept that people who give do so because they identify with the story being told by the nonprofit organization. “Our participants and residents are telling their life stories to us every day,” says Palmieri. “Donors identify with the people we serve.”
How Do We Match Care With Clients’ Preferences?
Abramson researchers and clinicians have developed a preference matched tracking tool, which is electronic and easy to use to show how well care and preferences match. The tool is color-coded, which gives a visual representation of where the provider is in achieving the goals of the person-centered plan of care, and the preferences stemming from the responses on the PELI. This process leads the staff to the development of clinical pathways to address specific challenges in achieving goals and meeting client preferences. These innovative practices are also a catalyst in attracting students—interns from local universities—to provide activities such as art or horticulture therapy.
Loneliness is a major problem, especially for older adults living alone in the community. When the adult day center staff know the preferences of a participant, it gives the staff the opportunity to introduce older adults with similar preferences, backgrounds and interests to each other. Many clients have formed great relationships that go beyond the walls of the adult day center. Caitlyn Manning, director of recreation, medical adult day services, gives an example of a participant that was a dressmaker. Unfortunately, she was no longer able to use a sewing machine to make dresses, but the Abramson staff were able to give her the material and opportunity to make beautiful pillows. It gives her a feeling of accomplishment.
Eshraghi says Abramson tracks engagement in activities and matches attendance in activities to the preferences noted from PELI in the electronic medical record. Staff reviews this information in their monthly quality improvement meetings. Program Director Lana Pozdnyakov says that knowing clients’ preferences, and what makes them happy, sad, fearful or anxious, helps them use their active participation in activities to address these emotions and behaviors, instead of needing medications to address harmful behavior.
In our daily lives, we all make decisions based on our preferences, from the time we get up to the time we go to sleep. We develop them at a young age, and our preferences for everyday living stay with us throughout our lifetimes. As providers of services for older adults, we need to put our best foot forward and begin customizing our services to meet the needs and wants of the individuals we are proud to serve. Remember, it starts with a conversation!
Resources to Start the Conversation About Person-Centered Care
- A set of PELI tools, training videos and webinars is available from Preference Based Living, a library of resources on person-centered care delivery to older adults, compiled by a group of university researchers, including Kimberly Van Haitsma.
- Two papers from the Journal of the American Medical Directors Association: “Person-Centered Care Planning: Preferences Are a Priority,” and “Delivering Person-Centered Care: Important Preferences for Recipients of Long-term Services and Supports.”
Peter Notarstefano is director of home and community-based services at LeadingAge.
This LeadingAge member uses purposeful conversations and a measurement tool to understand the preferences of residents and clients in all levels of care.