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Weekly UpdatesIn the mid-1990s, 2000, and 2004, a series of decline points in the overall market share of guests needing rehabilitation services and, specifically, those requiring services related to orthopedic conditions served as a call to action for Ballard Healthcare, in Des Plaines, Illinois. In response, we developed new and distinctive clinical service lines in post-acute care for complex conditions while augmenting existing clinical services and exiting others. We also deinstitutionalized the physical environment to make it more comfortable and homelike. All of these efforts were made to continually improve outcomes and attract clients.
Yet, with the market's continued shift toward lifestyle-driven decisions, we desired a broader, holistic approach to address the needs of active adults requiring care. Our goal was to dispel the popular notion that skilled nursing facilities were only for the chronically ill or dying. A leadership conference in April 2005 presented the cruise ship "experience" as a method of delivering high-value, high-touch customer-focused service.
Immediately, this was seen as being adaptable as a clinical therapeutic intervention--one that focuses on mobility, activity, fitness, and well-being to improve the restoration/recovery of function and community reintegration, and/or minimize the rate of decline/loss of function (see figure on page 28). In incorporating all of these elements, the experience would address all of a guest's physical, social, cognitive, and emotional needs to enhance function, independence, and quality of life.
Consequently, in summer 2005, Ballard launched its initiative, Passage to Discovery, to enhance its guests' (patients') rehabilitation outcomes and quality of life by offering virtual land and sea cruises to destinations around the country and around the world.
Passengers and "Crew"
We designed this "travel" initiative with a twofold purpose: (1) to improve rehabilitation and quality of life for our guests and (2) to educate our staff about the "soft" non-clinical mechanism of the service culture.
Passengers. Cruises consistently average nearly 50 guests, starting with 45 guests aboard the maiden "voyage" down the Mississippi from St. Louis to Memphis and on to New Orleans, and peaking with 65 on a trip to the Congo seven months into the initiative. Participants are active adults (active in that they are generally ambulatory, although most are still in need of wheelchairs or other assistance) who are cared for on either a short- or long-stay basis. Short-stay (SS) guests are those who reside in the building for less than two consecutive quarters. Overall, the average length of stay for SS guests is 22 days, with more than 20% having less than 14-day stays. Long-stay (LS) guests have called Ballard home for an extended period. Throughout their stay, SS guests typically have fewer than 10 opportunities to take a cruise. Obviously, LS guests have more opportunities to "travel."
Crew. Ballard staff at all levels and in all areas are involved with the Passage to Discovery program. We expect managers to participate regularly, along with a cross section of staff--51% of staff (representing approximately 125 staff members) have been involved with at least one cruise in the past year.
Each event is organized and coordinated by the "cruise director," activity director, and their supervisor, the assistant administrator. The "captain" of every cruise is Ballard's executive director, who sets the tone by exemplifying how staff members are to serve guests at all times. To demonstrate that no one is too important to participate as an actor, all senior leaders don costumes as the ship's officers or act as servers, transporters, dining room hosts, or photographer assistants. No role is viewed as higher or lower in importance; achieving the desired guest experience is the focus. Other cruise roles include tour guide, photographer, server, bartender, and safety officer. Because this is such an enjoyable and rewarding program for both guests and staff, many staff members invite their families and friends to join the cast. When we featured Nigeria, for example, staff members and their friends replicated a tribal wedding, complete with a native village, traditional clothing, authentic ceremonial dances, and drumming and instrumentation.
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Before Setting Sail
Our cruise experience is evocative of The Love Boat TV series, where guests have a fun, lighthearted, socially engaging vacation, shaped by the help of a friendly, attentive crew.
* Guests and their family/friends board the ship every other Thursday. We chose this day so weekend visitors would not distract the staff's focus of providing our SS and LS guests a full cruise experience.
* The days before the cruise are filled with a variety of activities reflecting the culture, cuisine, and customs of the featured destination. These include arts and crafts projects or, as when we went to Italy, a day sampling regional foods and listening to Italian operas.
* Before beginning the adventure, cruise staff review all aspects of the day's activities and assignments, and are briefed on any necessary guest precautions.
The Cruise Experience
All cruises start with a guest's picture with the captain. Visiting family members are included, too. When embarking on the virtual excursion, guests travel to an area(s) of the building where a "stage set" depicts one or more points of interest in the geographical area visited. As the guests arrive, they are greeted by a tour guide who explains the country's history, topography, culture, economy, and more.
The first Passage to Discovery sailed to Gdansk, Poland, and comprised management staff only as a training exercise to demonstrate what was intended and, if possible, the use of this concept as a clinical intervention. When participants arrived "onstage," they smelled the salty sea air and enjoyed local beverages and herring. They heard about the city's importance as a seaport and the historical impact of the worker's strike at the Gdansk shipyards. Elsewhere in the city, guests could shop for jewelry and art representing the style of Polish artisans.
The rollout cruise for guests--the trip down the Mississippi to the French Quarter in New Orleans--included stops at the St. Louis Arch and Graceland in Memphis for a tour, a virtual Elvis concert, and shopping for Elvis's "super souvenirs."
The grand finale of this and every cruise features the food (and aromas), beverages, and music of the destination. In this case, guests visited restaurant storefronts for food from three world-famous French Quarter eateries, including Cafe du Monde, where guests enjoyed chicory coffee and deep-fried beignets as they listened to Dixieland jazz. While enjoying native food and drink, guests can join in the singing and move to the music. Some guests even get up and dance. Ballard works with local talent and staff (when possible) to provide the entertainment.
When the guests return "home," they share memories and photographs of their fun-filled, educational, active trip. Since that first voyage, Passage to Discovery has transported its guests to nearly 50 locations across every continent except Antarctica.
Associated Expenditures
While the majority of the Passage to Discovery program cost represents additional incremental expense, much of it is non-variable recurring expense (specifically new labor). Cruise day costs include set construction, decorations, and entertainment. Other associated costs include staff expense for room setup, guest transportation (moving large numbers of guests at varying functional levels around the building in a short time frame), table service at dinner, and the extra staff needed to handle a large party event.
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Performance Measurement
Our goal in implementing Passage to Discovery is to improve rehabilitation and quality of life--specifically, measurable therapy and community reintegration outcomes, along with measures indicating that guests are able to enjoy an enhanced quality of life.
We weighed rehabilitation and quality of life for our population before and after the initiative launch against the nationally published and comparable Quality Indicators/Quality Measures (QIs/QMs) score derived from Minimum Data Set (MDS) survey data and activities of daily living (ADL) scores--a standard accepted measure to evaluate rehabilitation progress.
Originally, performance measurement focused on operational execution. Now, the process combines operational performance and clinical outcomes. Working with our partner eHealth Data Solutions (eHDS) for data compilation/reporting and statistical analysis, we extracted data from our MDS survey database (and comparable regional and national data) using the company's CareWatch tool to measure clinical outcomes. The MDS data are collected as part of the federally mandated process for clinical assessment of all residents in Medicare- or Medicaid-certified nursing homes. This process provides a comprehensive assessment of each resident's functional capabilities and helps nursing home staff identify health problems.
Theresa Schmidt from eHDS developed the indices below, among others, from the MDS tool to indicate outcomes improvement related to rehab function, community reintegration, and quality of life of residents experiencing the "tours." We measured:
Social engagement. We constructed a Social Engagement Index (SEI) from section F1a-f of the MDS 2.0. The SEI is an accepted indicator of time spent in social activities, as described by interRAI (www.interrai.org). It includes sense of initiative/involvement with others, planned activities, self-initiated activities, establishes personal goals, facility life, and accepts invitations. Social engagement is measured from 0-6, with 6 being the most socially engaged.
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