The Changing Face of Long-term Care

At the recent conference of the Association of Nutrition and Foodservice Professionals, FoodService Director gathered together five dietary directors of long-term care facilities to talk about how their segment of the industry is responding to business trends and challenges. What follows is an edited transcript of the 90-minute roundtable.

The participants were: Jeremy T. Manners, , CDM, CFPP, culinary and nutrition director, West Haven Manor, a 257-bed skilled and personal care facility in Monroeville, Pa.; Anne Dean, CDM, CFPP, general manager of dining services for Sodexo at Covenant Village of Turlock, Calif., a CCRC with 250 residents, 50 skilled beds and 55 assisted living beds; Terri Edens, CDM, CFPP, dietary manager field supervisor of 38 facilities that are part of Heritage Enterprise Inc., of Bloomington, Ill.; Evelyn Conner, CDM, CFPP, director of food and nutrition services for Buena Vida CCRC, a 240-bed facility with a 30-bed assisted living facility in Brooklyn, N.Y.; and C. Wayne Kuhn, CDM, CFPP, dietary manager, Long View Nursing Home, a 109-resident long-term care facility in Baltimore.

FSD: What is the biggest challenge you are facing?

Manners: There are a lot of challenges, but No. 1 would be the need to decrease operational costs. The first thing [administrators] want you to cut is staffing. So we have to find unique ways to reduce staffing, but we also look at other areas and go back and try to make a counteroffer. We weigh other things because although they want you to cut your costs and they want you to cut your labor, they still want you to come up with grand ideas and new programs.

Dean: I think our biggest challenge is keeping employees who are trained. Right
now the wage that we get to pay is not [the same as] the rest of the foodservice industry around the area that we’re in. I’ve been in my facility for two years and for those two years I’ve been working on trying to get an increase for these employees. We have lots of long-term employees and if we start new employees at a higher wage that would cause people to be upset with each other. So keeping staff is the hardest thing for us right now.

Edens: Our biggest challenge is training people in more hospitality-type roles as opposed to [jobs like] doing dishes in a kitchen. There is a lot of competition out there, and we have to stay ahead of the competition, but we have to train our staff with less.

Conner: What Jeremy said is very true, that administration always wants you to cut costs. They want you to do more with less, and they still want you to provide the same service with less staff. Last year I was given a 30-bed assisted living program within a senior apartment complex. I can’t [hire] any staff to serve them. I can’t [hire] a cook to come in and cook for them, so everyone on my staff has got a piece of it. Staff is upset, but it’s what we do. Now it’s only 30 beds, but that’s still 30 more people for my staff to have to prepare food for. They have to set things up and send it over there. We’re sending three meals in one shot. They do a continental breakfast, a cold lunch and a hot supper. So everything goes over at dinnertime.

Kuhn: I think I’ve been blessed because I work for a privately owned facility and fortunately the owner/administrator is willing to put money back into the facility and so the staff is very good. I don’t have a budget per se, but I do work within certain guidelines. I guess our basic problem is trying to maintain what the residents would like to see within those guidelines and regulations, which is sometimes a balancing act. Out of 109 residents we sometimes have 19 late breakfasts, which we put together after the regular breakfast trayline. That’s a challenge because you have to stop what you’re doing and jump in there and manage that portion of foodservice.

FSD: Given the Supreme Court ruling on healthcare insurance, how will your
facilities be affected?

Conner: In New York it’s already affected us because the Medicaid reimbursement has been cut and the state reimbursement has been cut. So they’re asking us to do more with less. What I don’t understand is how they can expect that in 2009 we had this amount of money to take care of residents and now in 2012 and 2013, we will have less money, but they still want us to provide the same level of service. And costs are increasing.

Dean: We also have issues with the Medicare and Medicaid money that’s coming in. I’m lucky because I work for a CCRC and so we can pull from the residential and assisted living [budgets] to help with the skilled area. For the most part our skilled area is running very smoothly and our residents are extremely happy. The labor is really our primary issue right now. As far as the healthcare laws we’re not really sure how that’s going to affect us.

Kuhn: Medicaid funding does affect what we can spend as far as, like, someone’s raises. Instead of getting an annual raise they have been giving them every other year, so that affects staff, unfortunately.

Manners: We’re seeing all the cuts with Medicare, but another thing that is forefront in long-term care is culture change. The biggest change is the clientele. We’re not getting 80-year-old people that are coming in to end their lives. We’re getting younger people who are in to rehab so they can go home. I’m seeing a lot of younger residents now coming in for total knee replacements and this and that. My home also seems to have found a niche with drug and alcohol rehab, so we’re also getting some younger folks, so culture change is big. I’m getting 30- and 40-year-old drug rehab residents who want pizza at 2 in the morning because that’s when they’re awake. We’re losing money, but I expect that we’re going to be doing more of that [specialized service].

FSD: How has long-term care changed during the last five to seven years?

Manners: Residents have more choices. Prior to the ’70s or ’80s, unfortunately, nursing home residents more or less were placed on a diet. You didn’t deviate from it. The nursing home per se or the people within it controlled a lot more of those residents’ lives. Things have changed for residents. They have a lot more access to decision-making than before. But the challenge for us is to meet [residents’] needs while still meeting our regulations and guidelines. Also, a lot of nursing homes were built in the ’70s, on the hospital model. We’re one of those older homes. But to compete with the newer homes that are being built now, that look like hotels, we’ve had to change over to that model, not only with the menus but the atmosphere as well—remodeling rooms and everything. With financial cuts they’re robbing Peter to pay Paul.

Dean: That has been our problem as a CCRC; we haven’t had room [in our skilled care unit]. We’ve been bedlocked, and haven’t had room for our own residents, so we’re losing Medicare and Medicaid dollars because we have to send them to another facility in the same town. Our goal has been to keep two open beds for our own residents who are coming back from the hospital. We’re also trying to move some of our residents who should be in assisted living because they really don’t need as much care as you get in a skilled facility. But they like it. They like being spoiled, so they don’t want to move, and it’s really hard to get the doctors and the family to let them go.

Conner: In New York state they put in a rule where they want the nursing homes or the long-term care homes to have more of a family style environment, and a lot of that has to do with the food. In some nursing homes they name the units for streets. They put the housing signs outside the rooms with the residents’ pictures on them, to kind of jazz it up, but there is only so much you can do. They might change the décor in the bedrooms but a lot of it has to do with food. [Administrators] don’t want you to put a tray in front of [residents] anymore where everything is the same. They want them to eat like they are in a restaurant. That takes staffing, trained staffing, and it has a lot to do with nursing and how nursing perceives what their duties are, how to assist in this. The state makes mandates, but they don’t realize how it affects the homes.

FSD: What are some of the things you can do with regard to the food?

Dean: We have a program called To The Table. We have carts that are heated and we put the food in attractive pans and we roll the salad and hot food carts down into the dining rooms and serve from the carts. The nursing staff or my staff take display plates of what’s available to the residents and they pick out what they would like. They get a nice choice and they can see what the food will look like, so they feel empowered in some part of their lives. And if they don’t like anything that’s offered we do have an “always available” menu that they can order from. We cook it fresh and take it back to them.

FSD: What does that mean in terms of staffing?

Dean: We’ve had this program for a while and everybody is involved in the serving process, including the cooks. So it really has to be a team effort to get it out to the dining rooms.

Kuhn: We started family style dining at lunch when I first came on board. It took a while for everyone to buy into it, nursing and dietary as well. But once they bought into it, once we established the procedure and let everybody have input, it really moved smoothly. Everybody wants it to work out now. We’ve had up to 20 residents go through the dining room; you have to be somewhat independent to participate. Family members like it because it offers the residents a chance for socialization and interaction and some of the residents do take other residents under their wing.

Conner: How to you handle the tray service? Does nursing handle the trays?

Kuhn: We don’t do trays in the dining room. We have the food in the steamtable pans and the food comes up from the kitchen on the dumbwaiter. Everything is served family style. [But] regardless of how the food is delivered, nursing is going to be involved, either passing the trays, setting them up, collecting them, whatever. They’ve learned to buy into [family style] because they’ve learned they no longer have to collect trays. It becomes more of a participatory thing. The residents just love it.

Edens: We’ve moved from traditional tray service to buffet style. We’ve even started, in some of our supported living units, room service. That is a challenge for dietary because nursing doesn’t have the time to serve it, so dietary gets to cook and serve it. One thing that we’re learning is that residents do like to come to the dining room. They do like conversing with other residents and they like going through the buffet line. We have some units where they have the buffet right in the dining room. We have others with the steamtables in the kitchen and we do restaurant style and have the “always available” menu as well. Our biggest challenge is keeping up with the changes. [Residents] are all food critics. They watch the Food Network.

FSD: In the 38 units you oversee is there standardization that applies or is there some freedom of choice among individual facilities?

Edens: At the corporate office my boss and I plan the basic menu, and then I have all the supporting dietary directors come and we do have a couple of chefs who help out with that. We meet monthly to plan the menus. We have one menu for the supported living facilities and the retirement homes and a different type of menu for the long-term care facilities. We have regional meetings with the dietary director of the long-term care homes to plan those menus because they know what the residents like and don’t like. We have different regions throughout the whole state of Illinois, so what we serve in southern Illinois, for instance, is not going to be the same thing we serve in Elgin.

FSD: How have menus themselves changed? What types of foods are you now offering?

Manners: We’re not doing the meatloaf and mashed potatoes as much anymore. I went with a 24-hour room service menu at the beginning of the year. I was slated to start that Jan. 1, but a new administrator came in in November, and I faced 68 hours per week cut from my department. I said, how am I supposed to roll out 24-hour room service? He said, ‘you erase your schedule and pretend it’s a blank slate.’ So I had 68 hours cut and still have to create a third shift and roll out this menu that we developed by asking the residents, what do you want? We left it up to them and they built it. Stuffed crust pizza, pierogies and fried onions, and we still have the tried-and-true grilled cheese and tomato soup for those residents who want it. We had a lot of vendor support. They came in and showed us different flatbreads and things like that to do sandwiches and it’s a big hit. My grandparents were not pizza people. These residents are. We still have the healthy part of the clientele who don’t want those things. If somebody wants city chicken, we’ll put together an activities program and set up nice long tables and do a fancy dinner and do the city chicken right there for them.

Conner: What is city chicken?

Manners: City chicken is actually pork on a skewer. I don’t know why it’s called city chicken. Residents are also asking for a lot of Asian food. We do a lot of stir-fries in the dining room and we’re getting a lot of people who I thought wouldn’t eat it coming up and enjoying it and asking for it again.

Kuhn: My residents love seafood. Crab cakes, fried oysters, and other seafood we do throughout the year. It’s part of the culture of Maryland. I’ve found most of the residents just enjoy good food. If you cook it the way they like it, they stay traditional for most things. They like comfort foods. Grilled cheese is still a popular comfort food. Every day we have soup on the steamtable because somebody will want soup. We try different things occasionally, but the tried-and-true foods, like spaghetti, are still popular. They’re just looking for good food, presented in a nice way. But no matter how good the food is, you’ve got to put a face to it. They want to see somebody with that meal. You can have the best steak, the best fried chicken, but if they can’t relate to the person who fixed it, then you lose something. With family style, our cooks come out and visit, and that gives them a one up on foodservice part of it.

Dean: We have a five-week cycle menu. I work for Sodexo and we do contracting for Covenant Retirement Communities, which is a system out of Skokie, Ill., and they have requested us to use a certain cycle menu that Sodexo has put together. [But] we’re in the process of changing the menu, which residents like because they are ready for some new variety. We have a bunch of world travelers, ministers and missionaries, and they are used to different types of food. Salmon is the most popular item that we do, and they really are not happy about Mexican food.

Manners: I have skilled care in one building and personal care in the other building, and they are right beside each other. In [the skilled care] building I have residents who usually are in bed for dinner, who will stay up when we do breakfast for dinner. But when we do that over at the personal care home, they don’t want it.

Kuhn: On Shrove Tuesday, it’s tradition to serve breakfast foods at dinner. But we’ve extended it throughout the winter months. I wasn’t sure whether it would go over, but they just love it.

Conner: I have a very high Spanish population, so we usually have arroz con pollo every week. In fact, I took it off the menu because I didn’t like the way my cooks made it. But the residents are asking for it. We have flan every week. The residents do like Chinese food. They also like spaghetti and meat sauce or spaghetti and meatballs. Turkey and hamburgers are also great choices, and so is soup. We have a resident menu council that meets once a month. We also have vendors who come in and the residents get to sample foods. They look forward to that, and if we don’t do it one month they will stop me in the halls and ask me about it.

Manners: My residents go to [local distributor] Reinhardt quarterly. They have a test kitchen and they suggested we start field trips. They decorate and do themes. The residents get gift bags. We didn’t have that five years, 10 years ago. We didn’t have the vendor support like we do now. But healthcare is changing and the vendors are seeing that as well. We are like a restaurant. We’re doing 600 meals a day.

Conner: We don’t have a way to transport [residents] to vendors, but they do enjoy it when the vendors come in. The especially like the bakery guy.

Manners: Our diet program is so liberalized now that my biggest problem with that is families calling, complaining about things like, “Mom’s getting chocolate cake.” And I say, “Well, that’s our diet plan. When you signed in you got a copy of our diet policy.” The residents, on the other hand, are loving it. 

Edens: Our residents like the fact that we are starting to cook in the dining rooms. We’ll do the omelet bars and the pancakes and French toast in the mornings and they like that. We even have a couple of the facilities where we are cooking at the tables—that’s a little scary, but for the most part it’s working. But that’s a lot of change. When you stop and think about all the changes we’ve been through, the culture change and offering choices is probably the biggest.

FSD: Staffing in the foodservice industry is a big challenge. If you can’t find the people you want who are trained to do the kinds of tasks you need, then you have to train them yourselves. What are some of the things you are able to do, in terms of training?

Kuhn: In dietary, there is nobody training people outside of the facility. There are no schools for us. You want to be a nurse you go to nursing school. You want to study business you go to business school. There is no dietary school. Even if a person has cooking skills, you then have to teach them volume cooking, preparing for steamtable service. You have to train them for a nursing home culture, a nursing home environment. Doing dishes in a nursing home is a lot different from doing them in a restaurant because of the regulations. You have all that training to do. It takes, I believe, a good year. You hire somebody and you give them three, four, five days of orientation. Even if you give them a buddy, they’re not going to learn everything they need in that time; they can’t. Take diets, for instance. These people don’t know what a controlled carb is. If you are serving thickened liquids, they don’t know what that is. So you’re training them for everything that you have to do, and it takes a good year for them to get a good hold on what they need. And then you have to teach them responsibility. If you work in a clothing store and a cashier doesn’t show, you just have longer lines at the other registers. We can’t just cancel something. Everything we do we have to do every day, regardless of staffing.

Manners: Unless you are lucky enough to get someone who is jumping ship to come to you, it’s really hard to get people in, get them trained and then keep them.

Kuhn: You’re working every day, holidays, whatever. I think that’s one thing that administration, even the person who owns the facility, doesn’t realize. We come in every day, 365 days a year. Every day has to be covered. The devotion and the dedication of these people is amazing. I applaud them. Not to put other professions down, but teachers get weekends off and summer off. If there is a snowstorm some businesses will simply shut down. We can’t do that. We’re responsible for taking care of these people every day.

Manners: It’s very hard to do, just in one home, to do the training on new things. When you train someone, you take them away from their job and you are taken away from your job. The time is just not there, and with staff reduction it’s even more impacted.

Dean: We usually train our cooks and dietary aides three to five days, depending on their skill level and how quickly they are catching on to the job. Every Sunday we have our in-services, which we’re required to do, which are food safety and physical safety and then we’re also going over personnel issues and sexual harassment training and service training and how to work as a team. The biggest challenge with that, as a Sodexo employee, we’re required to have 90% attendance. So, if we don’t get that 90% we’re running around to individuals asking them, ‘Can you read this? Can you go over this?’ so that we’re covered. But that’s one way we handle training.

Kuhn: Plus, you have the in-services that the state requires: fire safety, harassment issues, residents’ rights. There are like umpteen things that we’re inundated with and are expected to have a command of.

Dean: Like how to use the HAACP logs. And in long-term care you’re inundated with paperwork, filling out those temperature logs and such.

Kuhn: And then you have to look at all the canned goods that come in. Every little ding on a can could mean a citation. So you have a lot of hoops to jump through, every day.

Conner: I have instituted an ongoing in-service program. Nine months of the year I have my supervisors giving in-services; even I do one and the dietitians do one, so it’s not all on the supervisors. We also have the mandatory ones that we do ourselves so I don’t have to wait for someone from HR or nursing to come in to train my staff. When you start in my department, you have to go to the HR orientation, and when you finish that you get to come to me. We then have an hour and a half orientation with a book that you have to go through that shows everything from where the time clocks are to what the uniform is. It even tells you how to operate the dish machine. It has a listing of all the diets we do. You get all this before you start training. You get two days’ training with a staff member; on the third day you’re by yourself. We have nine positions, and every six weeks you move to another position. So my staff is trained to work everywhere. It works out very well. And we do the same in-services year after year. So with my staff I ask questions to see what they know. I tell them, ‘You’ve been here 10 years’ or whatever, you have to know this. I’m not going to sit and read this to you every year.’

Dean: Maybe you should ask one of your long-term employees to teach the class. It would break things up. I have several of my waitstaff who have asked to help with the in-services. They want to be involved with it, instead of sitting there going, [sighs]. When the supervisor teaches the class [some staff] make fun of her. They don’t always show respect. So if one of their peers is teaching the class, they may pay a little more attention.

Edens: We have what we call Silver Chair training, and we require all employees to go through it. It includes things like corporate compliance, sexual harassment, those types of things, but we also do classroom training in dietary, with either myself or dietitians teaching the class in all facilities. Managers email us and say, ‘Hey, I have [Silver Chair] scheduled for such-and-such day and time,’ and we make a point to be there. A lot of what we do is constant reminders. You know, you can post as many notices as you want on a wall, they’re never going to look at them. You come up with fancy posters and such, and it’s nice for the first day or so, and then it’s lost.

FSD: Are any of you able to do online or computer training modules?

Edens: We just started that. We just did our first company webinar. It was an in-service, but it was basically going over the menus and new abbreviations we have to use. They were very receptive to that because the whole staff can come into an office and view it. It took as 20 minutes.

Manners: With Silver Chair, you can kind of create your own personalized training. We’ve been able to do some foodservice training. I have people who have come in on their days off, at 4 or 5 in the morning, because that’s when they get up anyway, and they log into one of the computers. There are usually two a month, and if I want to throw in something on food safety, I can do that.

Edens: Some of the classes last 15 minutes. Some last 30 and some last 60 minutes.

Manners: And you get credit for an hour for all of them.

Edens: It prints out a certificate when you’ve completed the class.

Manners: And you can earn your CEUs, because they’re accredited.

FSD: What does it take to work in long-term care? What do you look for in employees?

Conner: I look for someone who may have had prior experience, working at McDonald’s or Burger King even, because at least they’ve had some foodservice experience. It’s very different, what they learned at Burger King or McDonald’s, from what we’re going to teach them, but it does help. I also look for college kids who can do part-time work. I’ll also take older workers.

Kuhn: People in dietary are working very close together. In other parts of the building, people can get away from each other, but in dietary people need to be able to find common ground and get along. So there has to be an ability to get along with different personalities, and there has to be a way to gauge what kind of personality you’re going to get, so I try to ask questions that let me know how this person is going to respond to situations, how they’re going to handle things. I will ask them questions such as, ‘at the last minute you find that you’ll have to work late. What do you do?’ I have to know what their response is. They also have to be able to handle this environment. You’re not going to see people at their best You’re not going to see swimsuit models in the nursing home. You’re going to see people who are aged. Can you handle that? Some young people don’t realize that not everyone looks like grandma at home.

Dean: I look for desire. They really have to want to work. I have one employee who came to check on her application every day for a month. She ended up getting hired and she’s a very good worker. I also look for some knowledge of the foodservice business. I look to see if they have goals in life, and what they want to do when they grow up. I ask them what they take pride in. I look at their appearance, because if they show up for the interview in just jeans, they probably aren’t going to care about the work. It’s just a job to them.

Kuhn: You continually have to [keep] the process [going] even after they are in your department. I had one girl, she emailed me for about seven months, wanting a job. But, since she was a good student, she had school things she was doing on the job on the job, along with family obligations. We did finally talk, and I said, ‘I applaud you for all your good efforts, but we need you here. This job has to count just as much as your church activities, your school activities, your time with your parents and family.’ And she did understand that.

Manners: I try to find people who want to learn. I try to gauge their honesty and their drive. Depending on what I’m looking for, I don’t really lean toward experience too much, because I’d much rather train them my way anyway. But personality is a huge one, because any foodservice department you walk into is probably the most volatile department in the building.

FSD: What is it about your job that keeps you working in this particular segment of the industry?

Dean: I have two things. The residents and my employees. I love every one of my employees and every one of my residents. The residents are what keep me coming back. They treat me like family. I’m another daughter to them. They want to know what’s going on in my life and they genuinely care about what’s going on. They ask about my dogs, my son, my daughter. They want to know and I want to know what’s going on in their lives.

Kuhn: It’s a mission. It’s a service thing. I went to college to be a teacher, and part of what I enjoy in this job is being able to teach people. You watch someone and you coach them, and they’re willing to let you coach them. Young kids that you teach to work in this environment. I get a lot of satisfaction from that. It’s like a class. There are challenges, but somewhere along the way you grow into it, or it kind of grows into you, and you realize what you’re accomplishing. It may not be perfect; living in a nursing home is not on anyone’s bucket list, and I’m not sure it’s on the list of anyone who works there. But you take the time that this is part of life, this is part of the community, and you begin to believe in what you’re doing. This is life’s journey for these people. It becomes important.

Manners: There is such a stigma, still, with nursing homes; they’re dirty, it’s where people go to die, etc. I grew up across the street from where I work now, and I kind of felt that way too. But I switched to healthcare foodservice. I started in restaurants, went to business and industry and then switched to healthcare and I’ll never regret it. You know, sometimes at night you might question why you want to go back the next day, but inevitably you come back every morning. I come back because I love the leadership opportunities I have with my employees, I love the interaction with them, that we can work together but at the end of the day we can go out and play together. I love the challenges; there’s always something different. At first you may think, ‘there’s no way in heck I can do this.’ I never thought I could run 24-hour room service in both buildings, and a Choices program in another building, cut all those hours and still be successful with it, and yet here we are. Most important is the relationship with the residents. You have to interact with them. I’ve grown so much in the past two years in that respect.

Conner: It’s all I’ve wanted to do. I’ve wanted to be able to run my own kitchen, to see if my ideas could be effective, and I’ve been in this role for eight years. My staff has a bet with me, wondering what I’m going to change next because they say I don’t like things to be the same. Every two or three years I’ll change something—every year, I might change something. I love what I do. It has its ups and downs; two years ago I was ready to quit because they kept bothering me, asking me to cut someone from the staff. I took the attitude, ‘who do you want? Who should I cut?’ And once I took that attitude, I felt much better and, you know, they never told me who to cut. And I love the residents. I have 40 years in foodservice, and I can’t imagine doing anything else.

Edens: I love what I do because I work for a very good company. I like being a mentor to other managers. I like being a mentor to the dietary employees, teaching them why we do what we do and how to do it, if need be.