Updated March 28 at 10:02am

Five Questions With: Kevin McKay

Tockwotton executive director talks about a variety of issues affecting nursing homes.

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Five Questions With: Kevin McKay


With the opening of the new Tockwotton on the Waterfront scheduled for December 2012, the new facility represents a shift in the nursing home paradigm, where “self-determination is reinstated as a personal right for residents,” according to Tockwotton Executive Director Kevin McKay.

Changing demographics, as well as proposed changes in the way the state reimburses nursing homes for care, also present challenges for the nursing home industry in Rhode Island.

Providence Business News asked McKay to share how Tockwotton has responded to to these challenges.

PBN: Tockwotton Home was recently recognized by U.S. News & World Report as one of the “best nursing homes” in its 2012 honor roll. What distinguishes Tockwotton as a best care community?

MCKAY: About five years ago, we read about a household model of care that was changing how people live and work in a nursing home in Kansas. Intrigued, we sent staff to explore how our peers had successfully implemented this practice that empowers and provides self-direction for employees and residents alike.

We liked what we saw, so with the support of our board, we undertook the culture change initiative in 2008. The basic premise of the self-directed workplace that we’ve adopted is that the resident sets the terms of how they would like to live their life. With help from their direct care staff, residents are assured that their wishes are implemented. Administration simply serves as a resource to the direct care staff.

While the concept appears to be simple, it’s a significant switch from the hospital model that’s been in place for decades, where the nurses and doctors implemented what they thought was best for the residents. This institutional model meant that meals were served at a specific time, lights were out two hours later and bathing/changing happened when it was most convenient for the nursing staff.

Under the new, household model of care, the residents determine how they’d like to live each day. If they have ambulatory problems and want to go on walks, the risks are explained but they are not prevented from taking walks. If they want to sleep in and not take breakfast, they can skip the meal. If they’d like an extra dollop of whipped cream on their waffles, they can have it. It’s the little choices – and often even just the knowledge that you have the ability to make those choices – that help seniors retain their quality of life. Self-determination is reinstated as a personal right for residents.

What a self-directed workplace means from an employee perspective is that static job descriptions have become obsolete. You have a primary job but you do whatever is needed to help a resident and your team members. So, for example, if you’re a nurse and you are asked to change a bed or help with an activity, then that becomes part of your job. Conversely, the opinions and observations from a dietary aide are given equal weight with other team members in daily care meetings. What that translates into is greater job satisfaction. Happier employees make happier residents. You’ll never hear, “I can’t do that…it’s not my job” around here.

By working together as a family, we’re helping residents fulfill their vision of how they’d like to spend each day. The end result is a better quality of life for residents and employees alike

PBN: The new $52.3 million Tockwotton on the Waterfront, scheduled to open in December 2012, will have 156 private rooms and offer memory care and assisted living. Is this the new paradigm for nursing homes?

MCKAY: In recent years, our ability to adapt to the changing needs of seniors has been constrained by the historic physical structure in which we reside; however, with this new site, we’ve been able to start from scratch and let needs dictate design. When Tockwotton on the Waterfront opens in December, care will be coordinated and seamless, enabling residents to “age in place” without the trauma of having to move elsewhere to receive the services they need. In addition, the new community of care will enable couples to remain together while receiving different levels and types of support.

We’re also trying to bring the meaning of ‘home’ back to the seniors in our care by removing nursing stations, keeping corridors short, adding private bathrooms and private rooms and a fully functioning residential kitchen to bring intimacy back into our care setting. It is a trend in senior housing and we’re fortunate to have a board that supports that vision.

PBN: Steven M. Costantino, the secretary for the R.I. Executive Office of Health and Human Services, as part of a rate reform initiative, has shifted the way that nursing homes are reimbursed for care. LeadingAge RI has criticized the proposals, saying it will devastate high quality, non-profit nursing homes in the state. Do you agree?

MCKAY: Yes, if adopted, the price model will pay all homes essentially the same rate, based on the statewide average, regardless of the kind of care that they deliver. By not recognizing individual facility costs, organizations like ours with experienced staff and a high caregiver-to-patient ratio will be penalized – to the tune of $132,000 in the first year here at Tockwotton.

And, we’re not alone. In fact, 43 nursing homes will lose $12 million in the coming year if this new reimbursement model is adopted. The good homes with high caregiver ratios are the losers in this scenario. This is a zero-sum game for the state. Our losses will be the gain of others with fewer staff. The bottom line is that patient care will suffer. Better staffing ratios have been linked to better care in numerous studies. Yet, the money has to come from somewhere, and labor costs represent the largest portion of our operating costs. So people will be cut and care will suffer.

We’d like to see Secretary Costantino change course and adopt a hybrid model that factors care costs into reimbursement. Thankfully, there are legislators who agree. Legislation has been introduced by Rep. Raymond E. Gallison and Sen. Maryellen Goodwin, who are championing the hybrid model in the General Assembly. We’re hopeful that our lawmakers will adopt this alternative model that will be both easier to administer and more equitable. Without it, frail seniors will be the losers in this political accounting game.

PBN: Last week, the R.I. Department of Health issued an immediate compliance order regarding the Pawtuxet Village Care and Rehabilitation Center, ordering that the facility not accept new patients until problems at the facility were corrected. When this happens, how does it impact the other nursing homes in Rhode Island?

MCKAY: Unfortunately, it paints a poor reflection on our industry. Yet in actuality, Rhode Island nursing homes are nationally recognized for their quality of care and innovation.

PBN: Recently, two non-profit community agencies, Home & Hospice Care of Rhode Island and Visiting Nurse Home Care, created a new alliance, realigning the two agencies and their ability to provide palliative care. Do you expect that there will be other such alliances in the Rhode Island market? How important is the growth of palliative care?

MCKAY: Changes in reimbursement and the growth of supportive community-based services (adult day, for example) have kept seniors in their homes longer than in the past. Therefore, when families come to us for nursing home care, the people we’re admitting have a much higher level of acuity than we’re used to seeing. It would be safe to conclude that palliative care in the nursing home setting is on the [rise].

In regards to formal alliances, I’m not aware of any impending within our industry, however, we will continue to collaborate with other organizations on behalf of all of our patients to increase our collective brain power and our statistical accuracy as we search for better ways to help our residents live a healthy and full life.


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