September 2019 LeadingAge Catalyst

Garden Village

Yakima, WA

Garden Village photo 1

Excellence in Care and Services

“Is there no place on earth for me?” asks the main character in the title of journalist Susan Sheehan’s award-winning 1982 non-fiction book about the struggles of a woman with schizophrenia as she navigates the health care system … and life.

The LeadingAge Catalyst recognition this month goes to Garden Village in Yakima, WA, a nursing home whose dedicated staff can answer Sheehan’s question with a resounding yes.

Not only is Garden Village a “place on earth” for the most complex nursing home residents in the state, “most of them think of this as their home,” says Administrator Doug Bault.

Three-quarters of Garden Village’s 101 residents are older individuals living with advanced dementia accompanied by aggressive behaviors and sometimes violent outbursts. The rest have experienced serious mental illness most of their adult lives and now face additional comorbidities, such as COPD, cancer, or significant mobility challenges that arose with age.

Residents tend to be slightly younger than those in typical nursing homes, with half between 55 and 74. All Garden Village residents call the setting their home; all are supported by Medicaid. Garden Village provides minimal short-term, post-acute services.

For many, this community is the “last house on the block,” after other providers have determined an individual needs specialized services not always available in nursing homes. “Families come to us, often, as a last resort,” says Diana Buckalew, director of nursing.

Changing Focus to Serve the Underserved

The story begins in 1995, when staff and leaders at Heritage Grove, a skilled nursing community in Yakima, WA, saw a need for services for behaviorally challenged individuals (not necessarily those with serious mental illness or dementia-aligned behaviors).

For many, this community is the “last house on the block,” after other providers have determined an individual needs specialized services not always available in nursing homes.

“[There were] definitely people with behaviors that were not welcome almost anywhere. We began with one crisis bed,” says Buckalew, who at that time was charge nurse at Heritage Grove. With referrals from Central Washington Comprehensive Mental Health and local skilled nursing organizations, the design was that individuals would stay for 30 days, “but more than half wanted to stay permanently,” Buckalew adds.

By 1998, Heritage Grove leaders decided to change the focus of the whole building. “That’s when we started the ‘bed becomes a door’ diversion program,” Buckalew says. Individuals who were otherwise going to be long-term residents of public psychiatric hospitals could come to Heritage Grove and find a homelike setting. As time went on, in addition to providing diversions from the state hospital, the nursing home moved into serving people with dementia who needed services similar to those needed by people with serious mental illness.

By 1999, Heritage Grove was partnering with Central Washington Comprehensive Mental Health [now known as Comprehensive Healthcare] and Yakima Valley Memorial Hospital (YVMH). YVMH is now Virginia Mason Memorial.

Becoming a Different Kind of Nursing Home: Unanticipated Issues

Until 2009, Garden Village, only 2 miles away from Heritage Grove, was a more typical nursing home and was also affiliated with YVMH.

That year, lease problems meant Heritage Grove needed to move, and YVMH decided its residents should move to Garden Village. All but 11 of the latter’s residents were discharged—those 11 fit the characteristics of the new population.

“When our residents heard that we were stepping away from Medicare post-acute care and that we would be serving people with mental health challenges, most families couldn’t get their family members moved out quickly enough,” says Doug Bault.

When the move occurred, 75% of the original Garden Village staff were terminated and the Heritage Grove staff (who specialized in serving those with behavioral issues and mental illness) moved along with the residents. “We retained only 25 of the original staff for the 89 [residents] who moved over,” Bault says.

Unforeseen problems quickly arose.

“During what we called the ‘honeymoon period,’ residents were on their best behavior. We were required to complete 100% of the resident MDSs, and in a really short time, 2 weeks,” says Valerie Blanco, assistant director of nursing. “Everything was a moving storm,” and the true needs of residents weren’t reflected in those original MDS assessments.

“During this honeymoon period,” says Bault, “the behaviors plummeted and that caused the MDSs to plummet, and the scores and reimbursement plummeted too.”

In addition, the state selected a quality measure of low staff turnover. “Because it was one employer ID number,” says Bault, “we had 75% staff turnover and that hit our Medicaid rate as well. Everything worked against us, so those first few years [2009-11] were very lean.”

“Our 5-star rating is not good because we’re high in antipsychotics and antidepressants, and we don’t have short-stay residents,” says Blanco.

Understanding Prospective Residents

“The people we take have to have challenging behaviors due to a diagnosis of dementia or mental illness,” says Buckalew. “We take a deep dive into them before they come here to determine if we can take care of that person. We do a really good job of screening for those behaviors.”

Buckalew adds that a top priority is developing trust and bonds between staff and residents, who don’t trust staff when they first move in.

Garden Village staff spend a great deal of time making these admission determinations. “We don’t want to be surprised,” Buckalew adds. “There have been times when we don’t think we can manage certain behaviors and we don’t admit the person.”

“We only have 2 private rooms,” she adds, “and there are people who won’t be able to be in a room with another person or share a bathroom with 3 or 5 other people, without getting into a fight. What then? They will have to go to an adult home or a [community] better equipped to meet their needs. But Garden Village works hard to make it work, recognizing that most families want their family member to stay in the area.”

“Residents Have a Right to Refuse. We Have an Obligation to Keep Trying”

Staff expect that during the early days of residents’ time at Garden Village, residents won’t trust staff. They will be fearful of the environment, employees, and the other residents. Bault says that even once trust is developed, “we keep trying, keep working at it.”

He offers the example of flu shots. Garden Village’s rate of 98-99% of long-stay residents having flu shots is higher than state and national rates.

“People ask how we do it,” says Buckalew, noting that many residents refuse the vaccine at first. “We have learned not to get into power struggles. We offer them a choice. They can refuse, but we keep trying. That’s all part of our approach.”

Policies, programming, staff training, and management are all designed to meet the needs of this population. For example, employees are trained to recognize that when a person becomes unusually aggressive, there’s a reason.

“Everyone knows we start by ruling out a UTI, pain, or some other illness. Sometimes that’s all it is. We figure out what’s wrong medically, and the behavior simmers down,” Buckalew says.

Intentional Hiring Yields Lower Turnover and Longer Retention

Working at a place like Garden Village is not for everyone. Human Resources Director Serena Marquez does not varnish the truth. Leaders spell out, detail for detail, exactly what potential employees will face.

Garden Village photo 2
Working at Garden Village is challenging, and potential employees are
given detailed explanations of what the job might entail.

“We tell them our goals, [and] give them scenarios. We explain what ‘behaviorally challenged’ means,” says Marquez. And this work takes a total organizational commitment.

She adds, “New hires figure out if they’ll love it or hate it within a couple of weeks. Frankly, some say it’s more than they expected. If it’s not for them, they move on. But if they stay for a year, they’re here for life.”

Staff who stay discover a strong culture of continuing education. Activity staff study to become nursing assistants. Housekeepers have the opportunity to engage and get new qualifications. Garden Village serves as a clinical training site. “We’ve had students who didn’t want to come here but ended up staying after precepting,” says Blanco.

Training is Not One and Done

Over and above traditional nursing home training, every person in every position who comes to work at Garden Village is trained for 2 days on how to interact with behaviorally challenged individuals. Everyone is required to re-certify this training annually.

“The point is to not lay hands on them” if at all possible, says Blanco. “And our training isn’t one and done. We mentor new staff for a long time.”

Staff learn to search for behavior triggers, and to proactively look for pain and depression.

“New hires figure out if they’ll love it or hate it within a couple of weeks. Frankly, some say it’s more than they expected. If it’s not for them, they move on. But if they stay for a year, they’re here for life.”

Garden Village staff are trained to send residents to hospital emergency departments only as a last resort. They know that paranoia and mistrust will surface quickly at the hospital.

Bault says, “They’ll be given a pill or injection and sent back to us, but nothing’s fixed.”

Good training, augmented often, with low turnover, yields a fully skilled environment. Bault, who was at the nursing home in 2009 when the new residents moved in, tells his own story of “culture shock for an administrator used to short stays.” In the first couple of days, he saw a man who was very distraught, “hollering and physically acting like he was going to start a fight.” Bault then saw a housekeeper, a person from laundry, and a couple of nurse aides “appear out of nowhere. They removed everyone except the distraught individual, then seemed to go back into the woodwork,” leaving the upset man standing there with no stimulus to feed the outburst. And everything went back to business as usual. It was, says Bault, his own jaw that hit the floor in awe of what had transpired in front of him.

Working Lean, Within Our Means

As an organization serving residents who are overwhelmingly (92%) on Medicaid, Garden Village can face nearly insurmountable budget challenges. It has been well-established, as outlined in this July 2019 interview with Deb Murphy, CEO of LeadingAge Washington, that there’s a large discrepancy in the state between Medicaid rates and costs.

There’s one small redeeming factor: Every Washington nursing home has to make payments into a safety-net assessment fund—$23 for every non-Medicare occupied bed. Because Garden Village serves in excess of 32,000 Medicaid days, it only has to pay $1 (vs. $23) yet still receives the advantage of a higher federally matched reimbursement rate. According to Bault, this payment reduction equals about $45,000 annually.

Bault reflects on the good, the bad, and the ugly of operating such a special community. On one hand, he points out, “We are able to provide good access for people who don’t have anywhere else to go.” On the other, “We can’t go above our means. We try to hire qualified staff and sometimes they can’t afford to take the pay we offer. We’d like to build a better [place] for the people we serve, but we don’t have the resources to do that.”

Will There Be a Hybrid License One Day?

When Garden Village shifted its focus to provide for the Heritage Grove population in 2009, “multiple financial, compliance, and quality scores took a nosedive,” says Bault.

Garden Village photo 3
For many residents, Garden Village is “the last house on the
block,” for those who need specialized services not always
available in nursing homes.

Reimbursement is not set up to recognize behavioral health services. Compliance, yet another vital aspect of SNF care and services, also does not recognize and/or allow any determination variation, and behaviors do not easily fit into the surveyor’s check-off boxes.

Quality scores often reflect service focus vs. quality outcomes. For instance, a state quality measure to not introduce any new antipsychotic medications within the first 120 days of admission does not help Garden Village find a therapeutic intervention for an individual with a justifiable diagnosis whose quality of life would be regained or improved with this change in medication.

Garden Village can appear to be a square peg in a round hole, Bault explains. Alert surveyors understand that its MDS scores don’t achieve the kind of case mix scores they see elsewhere. The focus on staffing may tip more toward social workers and activity staff and less toward licensed nurses. Use of psychotropic medications is higher.

Will there ever be a solution on the horizon? “[I hope] someday we’ll see a hybrid license of some kind,” says Bault. “There’s one for people on ventilators, one for HIV, why not one for serving those with the most challenging behaviors?”

He relates the story of a similar provider in the state, that dropped its skilled nursing license and became an assisted living provider. That licensure allows for a high number of people with special behavioral needs.

Valerie’s Story: Our Door Is Always Open

It’s hard to talk about the Garden Village story without talking about Valerie Blanco’s story. In fact, when she tells it, she toggles between her history, her life at Garden Village, and her deep insights into the resident experience.

In her words:

“I didn’t realize what I was getting into when I applied here. Everyone was so warm and welcoming. I was really surprised. I grew up in a very abusive home, with Social Services in our house constantly from the time I was little. My dad shot my mom when I was 5. She survived. I believe my dad was mentally ill; he would turn on a dime. You could never predict when.

“We didn’t really know that other people didn’t live like us.

“I was taken out of our home when I was 15, along with my 3 younger siblings. We went into the same foster home, right in our community, [and] belonged to the same church.

“Growing up that way, you don’t know if you’ll even survive, but I made it through, and went to college. I knew I wanted to be a nurse, but I got married along the way and didn’t get my nursing license until I was 40. Two years later, I was working at Garden Village, after a stint in a hospital.

“People tell me ‘You’re so calm.’ Coming from my background, whatever is going on here can’t be that horrible. That’s why I’m calm. When someone presents me with a problem, I walk through it with them and help them come up with solutions.”

Blanco finishes with what appears to be the Garden Village view of the world: “These people have no place to go and I kind of understand that. Life was hard for me once. These are people just like everyone else. Our door is always open.”

Ruth Katz is senior vice president of public policy/advocacy for LeadingAge.