SHN BRAIN Conference: How Do We Create and Roll Out a Dementia Care Program?

This article is sponsored by Dementia By Day. This article is based on a Senior Housing News discussion with Rachael Wonderlin, owner of Dementia By Day, Trista Wilson, COO with English Meadows, and Mike Williams, CEO and co-founder of English Meadows. The discussion took place on July 20, 2023 during SHN BRAIN Memory Care Conference in Washington D.C.. The article below has been edited for length and clarity.

Senior Housing News: Rachael, what do you mean by the phrase, ‘dementia gives us gifts?’

Rachael Wonderlin: A lot of times, families will ask me questions like, oh, you work in dementia care. Isn’t that sad? I say sometimes, dementia gives us gifts. People living with dementia sometimes have forgotten painful pieces in their life. They’ve forgotten that they’ve lost people that they really care about. They don’t realize that they’re in dementia care sometimes.

I always encourage families and caregivers to communicate with people living with dementia by ​​Embracing Their Reality, doing what’s true for them, and not reminding them of painful things in their life. People who have passed, taking that person to a funeral to prove to them who has died, things like that.

SHN: One of the themes I want to mention is just understanding that there’s still quite a stigma around dementia care, in terms of a more broad society, but also, sometimes even when you get into dealing with staff, within memory care. You’re saying dementia gives us gifts. Is that trying to break down that stigma as well?

Wonderlin: Absolutely. I remember one time, giving a tour as a dementia care director, and I was so excited to show off this beautiful baby life station that we’d created, where the residents absolutely loved the baby dolls, believed they were real. I was giving a tour to this gentleman and he said, “What a sad disease.” It shocked me, because I had been so excited to show off this life station, and it didn’t maybe naively occur to me that he’s seeing it through a completely different lens.

He’s seeing it like, “Oh, these people are just playing with dolls, how sad for them.” Whereas really, when we give a baby doll to someone living with dementia who believes the doll is real, it gives them a sense of independence, importance. They’re being entrusted to care for a baby, and that’s a really wonderful thing.

SHN: It’s about meeting the residents where they’re at. Definitely very interesting. Thank you for that. Trista, how do you deal with resistance from staff at English Meadows when you’re implementing new training or new procedures?

Trista Wilson: That’s a great question. I think what we’ve seen, company-wide, is we just need all of our staff to be able to see the same common goal. We want everyone to know, the more engagement we have with our residents, the happier residents are, the easier their jobs are, the easier our job is, as a caregiver. When we have residents who are fulfilled and happy in our communities, the job is so much easier.

SHN: Rachael, is there anything else you want to add to that?

Wonderlin: Once we can really illustrate to staff, “Hey, if you are able to bring out what I call the creativity boxes, folding, sorting, organizing pre-made, easy-to-use, programming boxes in between the larger activities,” and this is something we do with English Meadows. As long as the staff’s bringing these out, they’ll have reactions. My residents are sitting there folding, sorting, feeling happy, useful, needed, and guess what they’re not doing?

Looking for the exit. Getting upset, agitated, English Meadows has done a lovely job implementing a lot of snacks and drinks into what they’re doing during the day. This really helps residents to make sure they’re getting enough food, and everybody’s happy when they’re full.

SHN: Mike, when you’re thinking about getting new families on board, who might not be familiar with memory care, what do you really do to try and educate them? What goes on behind the scenes to present that to families?

Mike Williams: Obviously, the families are a customer as well, and that’s very important. There’s a lot of training, there’s a lot of education that has to happen for the families. It goes back to training the people who are in the campus, the families need to buy in. A lot of the things that we do, when we created Lavender Hills, we needed to go to the core of not only dealing with the residents, but their families as well.

We all know there are families who sadly never show up, and then you have the helicopter-type family member, who is there four hours and five hours a day, that creates these challenges. We have families who are so invested, every single day, and then there’s families that sadly don’t know what’s going on, but having them on board, especially with the caregiver who’s three feet away, and that they’re on the same page as well, it’s priceless when that happens.

Wonderlin: That’s really why I wrote my books, because I found that there were so many gaps in the knowledge base for families. My first role as a dementia care director was with a Brookdale building, back in 2014. Families would come up and ask me questions that I thought, “This must be on Google somewhere.” I went home and I googled the questions that I was being asked, “When is it time to move my loved one with dementia? How do I know that my dad’s going to be a good fit here?

What do I do when mom starts up a relationship with a male resident, but dad’s still at home, but she thinks that he’s her husband?” We’ve all seen that. There was nothing online about that. That’s where I started writing my first book, that I eventually published with Johns Hopkins University Press, because I wanted to answer those questions for people, when I, myself, couldn’t even find the answer anywhere online. I thought, “What a huge gap for these families. It’s a tough topic.”

SHN: Rachael, getting back to something else that I think is really important to talk about, that is the relationship between sundowning and snack time. You want to talk about that and really unpack what you mean by that?

Wonderlin: Lavender Hills has a lovely snack program. One of the favorite things that we’re doing is, a lot of the communities, on Wednesdays, they’ll make a waffle bowl with the residents in the morning, and then in the afternoon, they’ll fill that with fruit, or with ice cream. You’re really getting an activity and a snack combined.

What could be better? At the end of a long day, maybe you want to go home, you want to relax, you want to have a glass of wine, you want to tell your kids or your spouse to not bother you for five minutes, so you can chill out. People living with dementia don’t necessarily have that filter, where they can say, “Hey, you know what? I’m overwhelmed,” or tired, or what have you.

Instead, we’re seeing people get agitated, upset, and really, those “behaviors” just come down to somebody feeling overwhelmed, bored, tired, hungry. If we don’t know how to meet that need, we’re going to keep seeing people feel that way, if they cannot express to us what’s going on.

SHN: Mike, I think one of the things here that’s also important to talk about is achieving consistency of care and programming across multiple buildings. Do you want to talk about how English Meadows really look to attack that with the Lavender Hills program, and how you achieve that consistency?

Williams: That’s a big question. Consistency is something I think we all try, keeping the same people doing the same things, doing the activities, having the structure in place. I think it comes down in the structure. None of us can replicate ourselves. We go from one maybe perfectly run community, and then you go to X number of communities. I think that the struggle in any industry is replicating. I grew up in senior living. In my twenties, I ran away, like anyone who was forced, from 10 to 20, to work somewhere.

I never want to be in it. I was in the restaurant business, I owned restaurants. For a couple of years, I had a mentor, his name was Truett Cathy. He was the founder of Chick-fil-A. We were sitting in a hotel in Richmond, for a couple of hours, talking, and he mentioned that it was infinitely harder for him to go from one Chick-fil-A to 10, than to go from 10 to 1,000. I think that’s what we all struggle with, is creating that structure so you have consistency at a level that you want.

It comes down to the systems and the training, and that’s something we really jumped in with Rachael before the pandemic hit. We were all just trying to survive, and now we’re really getting back into that, especially the training, the systems, and holding people in place, so that we know this is happening in every single community. It’s very tough.

SHN: Do you want to talk about just the importance of making sure that staff have that training to be able to rely on that and create that consistency that you’re ultimately trying to achieve?

Wilson: Yes, for sure. Something else that’s helped us have that consistency across all of our campuses is working with Rachael so closely. We do monthly check-ins, and everybody submits their calendars to Rachael, so that we can all review what everyone’s doing and bounce new ideas off of each other. That’s been really helpful, with us creating that consistency, but with Rachael’s Dementia By Day training as well. It’s a four-hour course our team goes through.

When we have new team members, there’s activity-based training for our activity directors. That’s been hugely beneficial in our communities.

SHN: Rachael, anything you want to just wrap up, in talking about that training piece and consistency piece? We’d love to know, just from your perspective, from the program development side, what that really looks like, and what you think about, to get to that ultimate consistency.

Wonderlin: I mentioned my first building was a Brookdale building. They put everybody in one room. We did three days of training, and one day was dementia training. I thought to myself, “This is haphazard and difficult.” Eventually, when I went out on my own, I put together Dementia By Day School, which is an online training platform. It’s fun, it’s engaging. The best compliment I’ve gotten from care staff was, “It didn’t make me want to go to sleep.”

That’s probably as good as I’m going to get from the care staff, I think. Really, that helps, because you don’t have to put everybody in one room, try to sort that out. That’s super difficult. Plus, if you do train the trainer, like Mike was saying, you want consistency. You’re relying on one person from the next person to be able to teach the same way, and the same thing. You’re not going to be able to accomplish that without training the trainer. That’s just not how it works.

What’s nice is, all the team members are able to go through my online program, and then when I go to the buildings, a lot of them already know who I am. That’s helpful.

SHN: That would obviously start to lead to that relationship building, right from day one.

Wonderlin: There’s a lot more trust, I think, especially with the care staff. They feel like, “This is somebody that I’ve essentially gotten to know a little bit over the course of those hours, watching her talk.”

SHN: I want to ask, what is the first step in creating a memory care program, and what is the most important part?

Wonderlin: The first thing I want to know when I’m talking with a company is, what have they done in the past? If they’ve done something with their dementia care, what has worked about it, and what hasn’t worked? Different things are going to work for different companies. The second piece, who are you hiring in each of your buildings, to create that consistency? Who’s going to be that dementia care key person?

It doesn’t necessarily need to be a dementia care director, but somebody needs to be a strong player in each building, who can take the program and really run with it. If you don’t have that in each of your buildings, it’s going to be all over the place. It’s very tough to nail it down.

SHN: Mike and Trista, anything you’d like to add to that point?

Williams: I’ll say buy-in, if your team does not buy in– I think that’s why we ultimately branded what we were doing with Rachael, with Lavender Hills. We brought Rachael down to speak at a conference. Was it about 2018?

Wonderlin: Yes.

Williams: Had about 100 people there, other providers around Virginia. I saw everyone buy into the three hours that she was talking. You see all the light bulbs popping off in the audience. After that, I engaged Rachael and said, “We need to do something. We need to buy in.” Assisted living, dementia care, on the street, people might think they’re the same thing. We all know there’s so many differences, and it’s at a different level.

We engaged with Rachael, it was buying in, and people understand this is a different world when you cross through that door. A lot of different things had to happen. A lot of things had to change. Going back to education, again, what Rachael does monthly, she visits our campuses. As we’re building our own training platform for all caregivers, it’s very important, but they have to buy in and be a part of it.

SHN: Rachael, another audience question I think would be really beneficial to our conversation. It’s asking, “What is the most unique aspect of a dementia care program?” It’s like asking what the million-dollar question is, I suppose. Is there something that you gravitate towards? Once you’ve identified who might be the strong staffing structure, is there something that you really look for, in terms of programming, that you want to start at the core, and then build off of?

Wonderlin: I like to find out, company by company, what is important to them. We started with their Blacksburg building. Something that was really core there was their dining program. That’s what we really honed in on when building Lavender Hills, is thinking about, “How can we incorporate dining in a really fun, unique, dementia-friendly way?” With me as a consultant, I always talk to the company and go, “What’s important to you, and how can we make that make sense?”

While I have plenty of intellectual property that I’ll bring in working with a client, I don’t just buy and apply. We will actually build something that’s unique to you, if that makes sense.

SHN: Mike and Trista, if you want to weigh in here. In those first initial discussions you had with Rachael, obviously, you touched on dining, of something being so important to English Meadows, but you want to talk about what that process was, getting those ideas cultivated, and being able to get on the same page, so that you could start to build the program? Would love to know just how that impetus really started, and really, how it grew, from day one.

Wilson: Lots and lots of planning. Lots and lots of discussions with Rachael, but it was Rachael coming to our campuses and walking those buildings, seeing our memory care communities and what they look like, what we needed to do differently. Engaging with the frontline staff, our department leaders, and with Mike and myself, to find out what we wanted our vision to look like. We really wanted to not just sell memory care as a care unit, but we wanted to sell an experience, which is what we wanted to do.

SHN: Mike, for you, I think talking about branding is really important because, obviously, once you can develop a program, you have to be able to tell the world about it and market it. In your mind, why is branding so important for memory care?

Williams: I think having Lavender Hills, whether it’s part of the building, or we do have two standalone that are just Lavender Hills, it goes back to that buy-in. Whether it’s the caregivers or the families. This is a program driven for these specific residents and their specific needs. We all brand ourselves. All of our companies are branded, so I think it created expectations of, “This is the way we’re going to do things here in this unit, or in this building.” I think that’s what made it important for it to have its own name and its own brand.

SHN: Rachael, is there anything else you want to add there?

Wonderlin: I think you summed it up really well. If you have a brand, you have something you can fall back on and say, like, “This is what this is. It’s not this ambiguous shape.” It’s like, “No, this is Lavender Hills. There is an identity to this.”

SHN: I know you touched on staffing, and that being one of the most important things when you go into working with a company. You want to just detail what you meant by talking about the program director role, and just talking about the importance of that role as the center of the program? Would love to know just how you really think about staffing, as you’re developing a program.

Wonderlin: Having a point person in each building is going to make a huge difference when you’re actually bringing the program in. Frankly, I need somebody I can talk to at the building. When I show up there, who am I talking to? When we have a virtual meeting, who’s that point person? Who’s that contact? Contrary to popular belief, this person does not need to be a nurse. Frankly, personally, I prefer that it’s not a nurse.

I prefer it’s somebody who has more of a social services background, because typically, nurses get pulled into nursing. You’re a little short on the floor, which happens frequently, what happens? The dementia care director, if that individual is a nurse, gets pulled into being on the floor. Then what happens? No programming. When there’s no programming, what happens? Chaos.

SHN: Trista, I think being able to understand English Meadows’ staff structure around the Lavender Hills program would be really beneficial here. Do you just want to talk about that structure and what that looks like, to be able to get back to what we’ve already talked about, getting that consistency and buy-in?

Wilson: We have activity directors in each of our campuses. Some of our campuses do have assistant activity directors, depending on the size of the campus, but we make sure a lot of our focus is geared toward memory care, Lavender Hills, and not just assisted living. I think a lot of times, what we see in memory care is, residents are forgotten. We make sure that we have enough staff and appropriate staffing levels, that we can have our nursing team also join in participation of those activities.

They have these easy grab-and-go creativity boxes that they can sit down with residents in that 5-minute, 10-minute increment, and have them engage the residents as well. It’s more of a team effort than just activity director roles, but everyone participates.

SHN: I think being able to get an inside look there gets to my next question, of just how does Lavender Hills help English Meadows stand apart from other companies, in your opinion?

Wilson: I think, again, it’s the experience. You’re not just bringing your loved one there because you need a secure placement, or you need safety. You’re bringing them there because when they come in, we want to sit down with you and say, what’s their history? What did they do for a living? What are their favorite things? What are their favorite foods? What are their dislikes? We want to know about your loved ones so that we can make that everyday experience great for them.

SHN: Thank you. Another audience question that I think is really going to be also beneficial to our conversation. It asks, “Are there common challenges or missteps that you see when providers are developing a program? I think, Rachael, this would be best guided for you, since you get a pretty holistic view of knowing what companies are doing. Just from your end, what are some of the biggest challenges that you see that are common?

Wonderlin: If everybody’s not on the same page, especially at the C-suite level, the rolling it out, doing it, planning area, in particular, if we’re not on the same page, even within the same company, about what the roles are in each building. Sometimes I’ve seen the clinical side disagree with the other operations side. What are we looking for when we’re hiring that dementia care director, or that key person? That’s a big piece.

Really just having everybody, to Mike’s point with the buy-in, having everybody on the same page from the jump is crucial, and they want to enhance their dementia care program. Sometimes I talk to companies, where they say, “Well, we’re doing it. We’re fine. We got it.” and that’s fine, but you have to really want to do this, because it is a time investment. It’s a serious investment to say we want a better dementia care program.

SHN: Trista, can you talk about staffing and staff-to-resident ratios. You want to talk a little bit about that?

Wilson: Just in memory care and Lavender Hills, staff to residents, of course, we have Virginia buildings, we have West Virginia and we have Carolina buildings. It also depends on the staffing ratio required, but 20 residents, it would be three staff members, 20 residents. Just about 30, would be four. As you add about 10 more, we would add another staff member for that staffing ratio.

SHN: Rachael, when you’re thinking about staff and what those ratios should look like, is that dependent on each company? When you’re developing a program, what should the staffing levels look like, in terms of those resident ratios?

Wonderlin: One of the pieces I look at is the ratio. I also look at who is working specifically in dementia care. Is the same staff working in memory care, day after day? They get to know those residents and then they really know what those residents need as individuals, as people. They can better attend to their needs, time of day, all of these things, and the people who are working in your dementia care part of your building can really get that extra dementia care education.

They can really lean into that, because we all know dementia care can be pretty draining at times. If you don’t like working with people living with dementia, you’re going to be tired.

SHN: Most definitely.

Williams: We talk about buy-in, in 2019, we didn’t all necessarily buy in to everything, as the guy who has to make sure the checking accounts keep money in them. When Rachael says, “Let’s add on a few more people,” I’m like, “Well, let’s talk about that before we–” and we have, since that point.

We would rather be overstaffed a little bit and deal with the margins getting smaller, but have a building where people want to come and live, or bring their loved ones. There’s that give and take. We did change ratios and staffing, bringing in Lavender Hill coordinators that work with the ED of the building, and it’s paid off.

SHN: Yes. It probably gets back to that whole point on consistency. If you have point people, you’re able to help have those support structures in place, that really help bring that consistency forward.

Wilson: It also depends on what that building needs. We have a building right now, where we have five or six team members, and a 30-bed memory care, but it’s what that memory care, Lavender Hills, needs, and how much focus needs to be there. Mike’s always been willing to bring that staffing level up to meet what we need.

Williams: To give them both credit, and especially the caregivers, who are three feet away, every day. Since we’ve done this, all of our Lavender Hills that are over a year old, I think they still all have a waiting list. Our new ones, one, within a year, have a waiting list. The one in Williamsburg has different cottages, but they filled up the first one. Now, we’re quickly renovating the second one, since we bought it, to open the second one. It’s really paid off, with occupancy, for sure.

SHN: As we all know, the demand for senior living has never been greater. It’s only going to continue to grow.

Williams: I think that you’re going to have 100% occupancy in maybe a year or two, almost everywhere. The more excellence you have, you’re going to guarantee it, and you’re going to get the right caregivers, because people want to go where there’s structure, and good things happening.

SHN: Rachael, this gets back to just talking about the challenges that you most commonly see within memory care programming, and as you’re working with companies, but what’s a common problem you see in memory care communities, that you think could be easily fixed and is seen across multiple companies?

Wonderlin: Staff education is a huge piece. Often, companies are relying on training the trainer. Everybody takes the Relias course, and it’s just not enough education. I have my online programs, and we’ll do webinars. English Meadows will continue to send staff members through. Just the other day, I got an email from a team member, they had me get everybody out of the program so they could all go back and take it again as a refresher, six months later, because it’s worth it.

This is information that sometimes people need to hear multiple times, to really understand how best to communicate with people living with dementia. In a lot of ways, it’s like learning another language. It’s not necessarily intuitive, for a lot of people.

SHN: I think there’s a point there, to be said, about continuing education and keeping that training going. Do you want to talk about training within, as you’re developing a program? How do you think about incorporating that training and making sure it’s something that isn’t stale, or like you said, isn’t something that’s visited once and then left in the dark? What do you think about training when you’re developing the programs?

Wonderlin: Staff need to not hate it, right? They need to be able to sit there, not just because they have to go through the training, but because they’re actually enjoying it a little bit. One of my clients, Claiborne Senior Living, I showed up at one of their buildings, their marketing director came out and she said, “Rachael, I have to tell you, I was told that I had to take your online course and I didn’t want to do it, because I said I don’t want to do another few hours of a dementia care program. I’m tired of it. It’s always so boring.”

She said, “I sat there and watched five and a half hours in one day, because I really enjoyed it.” When I’m teaching, I’m telling stories. I’m talking about how I’ve actually worked with residents, real, true life, the good, the bad, and the ugly stories, because that’s what people connect with, are stories. Not just like, “Here’s what dementia is.”

SHN: Do you want to just touch on why dedicated programming is also important, what that job description and role should look like, or what that person should bring?

Wonderlin: Somebody has to be handling programming. They have to be. Your residents need to be engaged most of the day. Otherwise, what are we doing? Life is for living. It’s to be enjoyed. It’s not just shuffling people from changing to showers to the dining room. What are we doing to help them enjoy their lives? If you don’t have somebody who’s actually making that happen during the day, there’s going to be a lot of sitting and staring, and watching movies.

Dementia By Day helps teach families and caregivers how to embrace the gifts that dementia gives us. It demonstrates how to communicate with a loved one who is living with dementia and how to kindly and effectively transition family members into a dementia care community. To learn more, visit: https://rachaelwonderlin.com/.

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