What It Takes to Become a Dementia Friendly Hospital

The William S. Middleton Memorial Veterans Hospital in Madison, Wisconsin, was recently recognized as the first Dementia Friendly VA hospital in the country. We hear from Dr. Mary Wyman and Margaret Flood on the importance of Dementia Friendly and what it takes to reach this designation. Guests: Dr. Mary Wyman, Clinical Psychologist, and Margaret Flood, Clinically Licensed Social Worker, VA Caregiver Support Coordinator

Transcript

Intro: Welcome to Dementia Matters, a podcast created by the Wisconsin Alzheimer's Disease Research Center. It's our goal to humanize Alzheimer's research so that our community, our patients, our participants, and anyone else interested can get a better understanding of the work that's happening to fight back against this disease. My name is Nathaniel Chin and I'm a geriatric memory clinic position at the University of Wisconsin. I'm also the family member and son of someone with dementia. I'll be serving as your host for this podcast and asking the questions I believe are in the minds of many in our community. Thanks for joining us. 

Dr. Nathaniel Chin: Welcome to Dementia Matters. Our guests today are from the William S. Middleton Memorial Veterans Hospital in Madison, Wisconsin. The Madison VA provides tertiary medical, surgical, neurological, and psychiatric care along with a full range of outpatient services to approximately 45,000 area veterans. Recently the Madison VA Hospital was recognized by the state of Wisconsin and Dane County as a dementia friendly hospital, making it the first VA in the country with that designation. Today we're going to talk about what it takes to become a dementia friendly hospital with our guests, Dr. Mary Wyman, a clinical psychologist, and Margaret Flood, a clinically licensed social worker and the VA caregiver support coordinator. Thank you both for joining us.

Margaret Flood: Glad to be here. Thank you.

Chin: Here we have a VA married to a hospital that specializes in Alzheimer's research and care, and so that relationship has really blossomed into this first ever dementia friendly hospital.

Dr. Mary Wyman: I think the origins of dementia friendly hospital really have been a collaboration between staff at the VA who are very committed to really improving services for our veterans with dementia, their family members, and then, of course, our community collaborators. That includes the folks at Dane County who developed the model of the dementia friendly hospital and the experts at the university in dementia care who understand that right now we don't have a cure for dementia. There's a lot of focus on helping people who have dementia live the best lives they can and that's really what the dementia friendly initiative is about. This particular model really comes from a history of grassroots dementia friendly community – the idea of keeping people who have dementia living in their community, being safe, being involved, being included, being engaged for as long as possible. Sort of a disability rights kind of theory underlying this, which is the idea that because someone can't do something anymore doesn't mean that they shouldn't be able to participate, that they'll have to kind of stay in their corner that's set up for them. No, we're going to change the environment. We're going to change how the fellow citizens support that person so they can continue to remain involved. I think about some of the legal efforts in the ‘70s in this country where there were laws that were brought in to regulate having elevators, having the built environment, ramps getting rid of the curbs at the crosswalks so people who are using wheelchairs for example are able to get around, continue to participate, continue to stay engaged. It's kind of the same idea.

Chin: Now you both were integral in the Madison VA attaining this dementia friendly status. Can you explain to our listeners what your role is at the VA and how your expertise was utilized in this Dementia Friendly Hospital Planning Committee? 

Flood: As the caregiver support coordinator, I was asked to join the dementia committee. What we looked at with the help of Dr. Carey Gleason, who really inspired us to move forward with this, was a two-pillared kind of – look we knew we needed to educate our staff and we also had to make our physical plant a much friendlier and warmer place for folks with cognitive changes because navigating the space, feeling good in the healthcare facility, and getting a good outcome on what they're seeking treatment for we knew was critical. My role as the caregiver support coordinator evolved into steering this effort because that caregiver experience, which I hear from my clients on a regular basis, what it's like to bring in a veteran with dementia and to face some of the systemic issues in a healthcare facility around just finding the bathroom or finding a bathroom that both of us can go into because he needs assistance with toileting. Or that sign is not useful to me on trying to find my way to the clinic and my veteran has trouble understanding from a stimulus perspective what that sign says and how if I leave him alone for five minutes is he going to be here safely when I get back from the bathroom. Approaching an appointment where the provider isn't recognizing my veterans cognitive changes and they're telling them things without involving me that I know my veterans not going to retain. Working over the past three years with the caregivers in our facility and having encountered hundreds of them, their experiences informed my input into this process. With a lot of awesome support from our administration, we were able to start some movement and put some very logistical concrete changes in place that included staff training and some changes to our environment.

Chin: I really appreciate the pillars that you talk about because it's not just education. That can only go so far. It is our environment. It is the logistics. So for you to be able to tap all of these things and put that into the hospital is incredible.

Flood: We're finding that it's actually a very holistic approach that's extremely unique. As the first facility in the VA to reach this designation, we've been in conversation across the country about this. Many facilities are doing wonderful things to increase the quality of their care for folks with dementia but we're finding that it's really targeted mainly at that clinical interaction or the care piece. Really what's awesome about the Dane county model is that it looks at the physical environment, the connection to the external community, and it really is a much more holistic approach than just a traditionally medicine-based one that happens just in the office with the doctor. 

Wyman: One of the really unique pieces of the Dane county model is this focus on educating staff that are non-clinical staff, so those are the folks who are sitting at the front desk and they're calling our patients to schedule appointments. They're taking inquiries over the phone. They're checking people in for their appointments. They're helping them navigate their way around the facility. We've also educated our police force. We've hit the environmental services, so the folks who are maintaining the building.

Flood: And the many, many volunteers.

Wyman: We've also trained our whole engineering staff. That's a very diverse group of folks. Those are some workers who provide transportation for our veterans to and from their appointments. They maintain the grounds, so they might encounter someone outside of the actual physical building and have a little better idea now paying attention to some of those warning signs – this person may have some cognitive problems. That's why they're acting confused or that's why they're getting frustrated or irritable. Now I have some strategies to interact with that person and help them out more effectively than I could before.

Flood: One thing they said to me after I trained all the environmental services staff was, ‘This is good training for anyone.’ Dementia friendly changes translate into folks with other disabilities, with traumatic brain injury or with sensory losses, whether it's vision or loss of hearing. It's just respectful, so they were thrilled to get the training. They're thrilled to be a part of this 

Wyman: Most of our non-clinical staff now know what dementia is. They have a basic understanding of what dementia is. They have a sense of the warning signs, what to pay attention to. They also have a sense of how common it is – about one in 11 veterans has dementia. It's very often not obvious when they come into our facility or when they're admitted to our hospital wards that they have a cognitive impairment. Sometimes that takes a long time to figure that out. Hopefully we have made a dent in reducing the stigma associated with dementia among our staff, and therefore that visibility also impacts our veterans and their families who are coming to the facility. But I think we've also just improved staff ability, again, to identify it or at least to have their eyes and ears open. While this could be someone – even though this veteran doesn't really seem like this idea of what I have in my mind of what someone with dementia looks like or acts like, maybe that's part of what's going on with this person. The staff training is different for clinical staff and for non-clinical staff. For non-clinical staff, time is really of the essence. They're busy. They do a lot of training already, so we developed a 30-minute training. It uses a really nice video, which was filmed in a VA hospital showing non-clinical staff interacting with a veteran who has mild cognitive impairment. He's there with his wife. The video sort of shows a kind of a typical way of interacting with them, how they might do that with a person who doesn't have cognitive impairment and then a different way of interacting with them so providing more focused attention, reducing distraction during a conversation, using visual cues – for example a written map and giving that to the veteran to help find his way around the clinic or the hospital. Those are just a few examples. Then the training also just provides some information on Dementia Friendly Hospital and Dementia Friendly Community and why we're doing this.

Flood: Also if I can just interject –

Wyman: Yeah of course!

Flood: One thing that's been really fantastic to convey in these trainings is the really critical role of the caregiver. With early detection and trying to schedule appointments with clients who have memory difficulties, feeling supported to engage their caregiver in that conversation up front so that we have a much better health outcome because they're much more likely to show up for their appointment if someone besides the person with memory problems knows about the appointment. Kind of breaking down that systemic process and saying, ‘As the clerk please, here's some language you can use.’ Veterans are very proud and independent people. They say to me, ‘Well I'm afraid I would offend the veteran.’ I'm like, well let me tell you language on how to frame that for them so that they're comfortable putting their caregiver on the phone with you. Because if you set up the appointment and nobody else knows about it, the chances are it's going to be a no-show, right? Reducing the missed appointments, bringing that caregiver in the conversation, feeling empowered to do that, having language to have those kind of compassionate conversations in a respectful way that engages the client in a way that they feel supported – giving some of those hands-on skills to folks who are you know scheduling hundreds and hundreds of appointments a week. I mean and then raising their awareness that statistically out of the 500 you just talked to this week, 55 of them – when you didn't realize it maybe – are battling this illness or dealing with this. Adding that into that training has been really a wonderful thing because it's not like it's easily recognizable in a chart necessarily. There isn't like a big red flag that pops out until they're at the point where we have to activate their healthcare power of attorney or something at that stage, but that's so far into the illness that we've spent five years, perhaps, scheduling appointments with somebody who has memory challenges. That has really been a breakthrough, I think, and unique about our training is talking day-to-day, getting that importance of the caregiver voice and how to bring that in in a balanced way so the vet still feels engaged and like he's participating and not diminished by that, but empowered by that.

Wyman: To bounce off what Margaret said, to empower the non-clinical staff who have so much contact with our veterans and their caregivers. They are so integral to what we do as clinical providers every single day and yet before we started this training they were getting absolutely no training in dementia. We had one clerk who, after she did the half-hour training, said, ‘Oh my gosh, this is all making sense now. I had this veteran who kept calling me. He was very confused. He was more and more irritated every time he called me, but he hadn't remembered that he had called me before and I didn't know what to do.’ So she was essentially doing sort of her very best job at sort of crisis management but it didn't occur to her that this person might be forgetting the previous conversations. As a result of the training she felt empowered to go to her clinical staff, talk to the doctor, talk to the nurse, say, ‘This isn't in the chart and you don't know this, but Mr. Jones has now called me ten times this week and these are the conversations we've had. I think this might be important clinical information.’ This is a gentleman that hadn't been identified as having cognitive problems and he wasn't getting the care he needed because of that. That was a really important part of not only empowering our non-clinical staff to work more effectively with the caregivers, but also with the whole clinical team as well.

Chin: I was hoping you guys could share with me just a few of either the most important or the interesting changes that the Madison VA made to become more friendly to people with dementia.

Flood: The fact that we had eight clinics named A, B, C, D, E, F, G, and then we have wings that are A, B, C, D, E, F. We started with that because navigation, especially for those with cognitive challenges, it's extra difficult for them. I mean, to be honest, it was a little difficult for me to find certain clinics – clinic D in wing A on floor three. How can we make familiar, redundant, sensory-based images part of our environment as we replace the names of those clinics. That's one of, I think, the most exciting things we've achieved, is that we have renamed essentially the clinics where the bulk of our outpatient care is provided. Our interior designer did a lovely job of picking not just beautiful art but recognizable art. One of our clinics is the Bluffs Clinic and it has a picture from Devil's Lake, which is a state park north of here. She chose images that not only are soothing and visually appealing to replace those names of the clinics, but also recognizable to veterans who might say, ‘Hey I used to hike here. I'll remember that clinic name, make those associations.’ We also renamed our elevator banks because they were actually central in clinic and started with the same letter. It was confusing. Now we're going to use the military insignia. They are now going to be the star and the eagle elevators. Again we're tapping into that connection for our veterans with what's familiar and recognizable and using both better-quality signage accompanied by visual images. I think that's one of the most visible and exciting changes we've been able to implement. From my understanding, there's been debate about changing those clinic names for at least seven to ten years, so the fact that this committee was the impetus to achieve that goal was extra exciting and nice to do it for the right reason because it helps our patients. To put that much thoughtful expertise into the name choices and a lot of time, attention, and thought was given to even what color star should it be? Gold stars in the military, silver stars; they all have a special meaning.

Chin: Thank you both for coming into Dementia Matters. As the the next phase or goals of the Dementia Friendly Hospital are achieved, I'd like to have you both back.

Flood: That would be wonderful. Thank you, Dr. Chin.

Wyman: That would be great. Thank you so much.

Outro: Dementia Matters is brought to you by the Wisconsin Alzheimer's Disease Research Center. The Wisconsin Alzheimer's Disease Research Center combines academic, clinical, and research expertise from the University of Wisconsin School of Medicine and Public Health, and the Geriatric Research, Education and Clinical Center of the William S. Middleton Memorial Veterans Hospital in Madison, Wisconsin. It receives funding from private, university, state, and national sources, including a grant from the National Institutes of Health for Alzheimer's Disease Centers. This episode was produced by Rebecca Wasieleski and edited by Zoey Rugel. Our musical jingle is "Cases to Rest," by Blue Dot Sessions. Check out our website at adrc.wisc.edu. You can also follow us on Twitter and Facebook. If you have any questions or comments, email us at dementiamatters@medicine.wisc.edu. Thanks for listening.