The Resident Engagement Institute, powered by the Linked Senior platform, is dedicated to defining a new era in resident engagement by establishing data-driven tools, benchmarks, and strategies that senior living operators can implement to engage residents in meaningful ways.

Recently, I spoke with clinical psychologist Dr. Jennifer Stelter, PsyD, CDP, CADDCT, CCTP, REI’s Chief Engagement Officer, about the Institute’s effort to enhance resident engagement by measuring and elevating psychosocial well-being.

Dan Cohen: Families seeking out residential care for themselves or a relative in need are made aware of all the activities offered. Given that, why would there be a need to focus on increasing resident engagement?

Jennifer Stelter: There are several goals that should be achieved when it comes to resident engagement: (1) determining the best amount of time for an individual to be engaged, (2) fulfilling the person’s preferences for which types of engagement, and (3) ensuring satisfaction. Therefore, increasing resident engagement isn’t the sole goal; providing meaningful engagement is a better goal.

In other words, increasing resident engagement is not only, of course, about volume, but quality as well. Studies have shown that, on average, residents are only engaged 11 minutes a day in skilled nursing facilities and 20 in assisted living. But when you take a holistic approach that includes cognitive stimulation, physical activity, psychosocial well-being, and environmental influences, studies and Linked Senior research show that, on average, about 35 minutes a day is key for engagement to maintain skills as we get older.

As for preferences, you can engage someone 11 minutes, 35 minutes, or 60 minutes, but if they’re not really interested then it’s not meaningful. Respecting the person’s preferences to create meaningful engagement is actually more important than the amount of engagement time.

Finally, how satisfied they are overall with those preferences and with the amount of time being engaged is also important to consider.

DC: Is that 35 minutes a day a minimum number or a sweet spot?

JS: It’s a sweet spot. For example, if you look at the research for cognitive engagement, more than 30 minutes a day would not provide any more rehabilitation; less than 30 minutes a day, you are not getting the full potential. So, we set that benchmark for 35 minutes based on an average taken from a literature review and our champion customers at Linked Senior. You also need to consider the person’s level of functioning.

DC: There’s a saying that you can’t improve what you don’t measure. CMS tracks medical care, resident status, and psychosocial status. Each nursing home provides quarterly reports on how residents are doing in terms of infections and bed sores and depression diagnoses, and more. I know you’re keen to capture more information that relates to how life is for residents. What do you envision down the road in terms of measurement?

JS: Ultimately what we’re trying to measure is how resident engagement impacts residents’ overall health outcomes. CMS is essentially tracking how a nursing home provides medical care. Most skilled nursing facilities are looking at what impacts their five star rating and their quality measures. and those are mostly medical in nature. There are a couple of psychosocial factors included, but it is heavily based on medical factors. We’re looking at psychosocial well-being, how that’s managed and cared for, and how that impacts clinical health outcomes, as well. We hope the Resident Engagement Institute, for the first time, will show through our research that resident engagement impacts clinical health outcomes; some of our preliminary studies already demonstrate this.

We know resident engagement lowers falls, depression, behavioral issues, the use of PRN psychotropics, hospitalizations and more; we want to be able to show this more consistently. This not only demonstrates the benefits of resident engagement, but also the return on investment, which a lot of organizations and operators want to know about. Additionally, if we can prove this through continued research, then just as facilities are paid a higher amount for therapy minutes, they should get paid for engagement minutes. However, the ideal measure would be a home’s performance in addressing the needs and psychosocial preferences of the population they care for.

DC: How can we measure satisfaction, particularly resident satisfaction, when not everyone may be able to fill out a survey?

JS: Within our platform we hope to have a behavioral satisfaction survey for the residents. As they are being provided an activity, the activity professional will ask them, “George, on a 1 to 5 star scale, with 5 being you’re mostly satisfied and 1 being not satisfied at all, how would you rate the activity you were just in?” Additionally, if the resident is non-verbal or has advanced dementia, then this approach would be altered either with visuals or observing the residents’ reactions. We would collect that data over time to determine how satisfied the residents are with the different kinds of programs.

A lot of organizations have invested in some kind of family survey, but not necessarily a resident survey, which is just astounding to me. They typically will take a portion of residents’ feedback from a formal resident council meeting, but it doesn’t capture the majority of residents’ satisfaction levels. Dr. Jiska Cohen Mansfield developed the agitation scale for behavior expression; there is similar work that can measure non-verbal level of engagement. You can also argue that absence of behavior expressions and repeated attendance to certain programs, or non-refusal of them, mean that they do provide something meaningful.

DC: In nursing homes, what percentage of people do you think would be able to answer? And is there accommodation for people who are more limited in their ability to answer? Or are their questions so basic that a lot of people would be able to answer, regardless?

JS: Based on CMS data, around 90 to 95 percent of nursing home residents should be interviewable and able to provide answers to the questions. But if someone cannot, we’d design a survey that could be based on facial expressions, body language, essentially staff observation of the resident, and then, of course, still including the family satisfaction component, too. The same rules that apply to a clinical assessment would apply here.

DC: To what degree are residents in nursing homes or assisted living receiving their preferences? And how do we ensure consistency across all nursing homes or assisted living communities, that everybody is getting their preferences effectively? What’s it going to take beyond just knowing their preferences are good?

JS: Preference-based living involves first assessing what the residents’ preferences are and then creating programs around those preferences. We must take into account what they may be able to do independently, with another person, or in a group of people. It’s a lot of information to process. And it’s about how one can efficiently take the data that’s provided, group that data together to determine which residents like these preferences versus those preferences. Then create groups around those individuals, so they are meeting those needs in a group format. For those who require or prefer one-on-ones, those engagement sessions can be based on what they prefer. And for those who are independent, the facility can ensure the residents have their supplies in order to have their independent time doing the things they like to do.

How in this industry can we move more towards standardization? We need to use data—and this can only be done by moving these processes from paper to digital. We used a tool in 2021 called the Elder Engagement Performance Improvement Tool or the EEPI tool to look at the QAPI process to see if organizations were being efficient with the engagement process. We promote APIE: Assess, Plan, Implement and Evaluate, which is a standard practice model in healthcare. Most organizations have at least invested in some kind of electronic health record, but not necessarily for activities. That’s the next step in order for there to be a more standardized engagement process for using APIE in senior living.

DC: That’s really a wonderful approach. An organization’s activity schedule is transformed because you’re starting off with a whole different set of preferences and directions and putting it together. It’ll be based on the culture, the age, the geographical part of the country you’re in.

A number of organizations are devoted passionately to improving care and quality of life for people, such as Eden Alternative, Green House Project, Pioneer Network, Planetree. The Resident Engagement Institute’s approach is different, because you’re focused on preference-based living to maximize quality of life. How does all of this come together?

JS: All those organizations advocate for the residents and senior living in various ways, but the Resident Engagement Institute is focused on enabling social prescription by ensuring that psychosocial well-being is included and it’s just as important as medical care—demonstrating this through research, tying resident engagement to clinical outcomes to prove that psychosocial well-being should be one of the primary focuses. That will be, of course, not only groundbreaking for our industry to invest more in these programs and in the staff that run them, but also for organizations to see an ROI for their organization with better clinical outcomes, and if CMS is willing to reimburse for engagement minutes. Even more so, some insurance companies have moved toward allocating health benefits toward non-pharmacological approaches to care, like using essential oils; therefore, there’s an opportunity for insurance to cover engagement as well under a prescriptive model.

DC: Will physicians agree to that? This is their domain. To move this forward, it needs to be a direct question to the medical community. This is what we believe. We need you to support this. I think unless that happens, then 10 years from now, we’ll pretty much be talking about this in much the same way.

JS: Right, absolutely. I think the pandemic has shed light on the psychosocial dimension more strongly than ever. Depression rates skyrocketed in the last two years in senior living. We’ve seen use of psychotropic medication increase significantly, with insurance companies having to pay, and more services needed. The pandemic has demonstrated how impactful isolation has been for our seniors and what they need to thrive. At least the door has opened up a little bit more. But we hope to put some data to this to really show people this is what we’re talking about.

Additionally, hopefully one day a physician will “prescribe” how much exercise a person should do, how much meditation is recommended, how much essential oil use is needed, and so on. That would be incorporated in the person’s treatment plan and covered by their insurance. Being proactive about health is better than being reactive. Some physicians have started doing this before the pandemic: Dr. Arif Nazir’s initiative around de-prescribing and CMS’s partnership for dementia is rooted in this concept. But it needs to be taken to the industry level and made into policy. Furthermore, this culture change needs to be included in staff training.

DC: So REI is really data driven, programmatically driven, guidance for others to help people set up. Great Britain is moving towards what they’re calling social prescription—everybody in the community lives a full meaningful life, but with assistance from someone. The goal is to inform and encourage people with cognitive and physical challenges at home to be more active in the community. They’re in the process of hiring some 3,000 people to visit people in their homes and see what the situation is and recommend improvements to quality of life. Have you come across this?

JS: What they’re doing is going to be similar to our efforts in senior living. We are looking to build a process to create prescriptive engagement plans. Essentially what we hope to do through our assessment process in the Linked Senior platform is to pull significant data points that would help us determine each resident’s level of functioning. That computation of the resident’s level of functioning would define a “prescription” for how many minutes per day that resident would be engaged, and with what kinds of programs based on their preferences. The activity team would then carry out those prescriptions when implementing their programs. For example, engage the resident this many minutes a day in two groups and one one-on-one, with these preferences, based on the assessment. Then, if they are following that prescription, outcomes can be measured to see if the resident’s health is improving, stabilizing, or deteriorating.

Again, it’s taking that kind of medical model and making it more of a psychosocial model with the same kind of processes, and taking into account that individual person for true person-centered care.

DC: So if someone has their prescriptive engagement plan developed in assisted living and then they go to the nursing home, would that plan go with them? You’ve done all this work. You know what they need. This is similar to someone’s medications. The list of all their meds is shared when they transfer somewhere else. The receiving institution continues “treatment” without skipping a beat.

JS: This could definitely move with the residents. However, you would need to consider why were they moved from assisted living to skilled. For example, maybe they were at a high level of functioning at an assisted living and now they are assessed as moderate at the skilled nursing facility due to decompensation, so then the number of minutes would change as well as the types of programs offered. That would need to be considered through a reassessment process.

If the new organization works with Linked Senior and/or if they request the medical records from the previous placement, they would have that information as part of the care plan. But if the new organization does not have Linked Senior, hopefully, they’ll see the advantages of Linked Senior because of all the available data, and, of course, all of the bells and whistles that are part of this phenomenal engagement platform.

DC: Is there any other information you’d like to share?

JS: We conducted a few surveys in 2021 and had close to 1,000 respondents. We found that 38 percent said that social distancing had caused a huge issue with being able to provide individualized, meaningful engagement, and 68 percent said that these staffing shortages really have prevented them from engaging all their residents. It’s astounding to look at how many departments are still suffering because of the staffing shortage, that they are admitting that they cannot get to all of their residents.

So when you look at the average residents being engaged 11 minutes a day, there are some residents who are being engaged at zero minutes, still. We have a lot of work to do, but it is certainly a challenge. We’d like to offer our assistance as part of the solution.

I would close by saying that this effort cannot be done by one organization alone; it needs to be a collaboration. We are excited to have amazing faculty members at the Resident Engagement Institute, like Cameron Camp, David Troxel, Vicki de Klerk and more, and would love to consider working with any other organizations that believe in this work. This is the future; we just need to make it happen sooner—this is what we want, this is what the industry needs, and what residents deserve.