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OHCA The Oregon Caregiver Spring Summer 2022

Embracing DEI Efforts in Long Term Care A Publication of the Spring/Summer 2022 Oregon Health Care Association Diving into DEI in Long Term Care | LGBTQ+ Adult Survey Results | Q&A with Rep. Sanchez

SPRING/SUMMER 2022 © 2022. The contents of this publication may not be reproduced or distributed electronically or mechanically, either in whole or in part, without the express written consent of the Oregon Health Care Association. The advertisers assume complete responsibility to use any or all brand names, trademarks, guarantees, and statements which appear in their advertisements. CONTENTS FEATURE 30 32 34 pg6 Embracing DEI Efforts in Long Term Care In this article, several long term care leaders in Oregon share what they’ve learned through their diversity, equity, and inclusion (DEI) efforts and their plans to sustain the work for generations to come. 04 LETTER FROM THE CEO 06 EMBRACING DEI EFFORTS IN LONG TERM CARE 16 QUALITY DEI and Quality: How to Build Cultures of Belonging 18 LEGAL & REGULATORY Equality and Inclusion in Senior Living 20 DATA & RESEARCH Understanding Demographic Trends: Long Term Care Growing Increasingly More Diverse 22 PUBLIC POLICY Oregon Lawmakers Prioritize Long Term Care in 2022 Session 23 DEI Understanding the Results from the 2021 Oregon LGBTQ+ Adult Survey 26 SPONSORED CONTENT Tap into Staff to Refresh Resident Engagement Creating Workforce Diversity the Legal Way 30 PROFILES Representative Tawna Sanchez (D-North & Northeast Portland) Kenisha Wilson (Medication Technician, Our House of Portland) 34 2022 SPRING EXPO RECAP 36 UPCOMING EVENTS

The Oregon Caregiver SPRING/SUMMER 2022 www.ohca.com 4 Our time in lockdown has forced us to look introspectively and reflect on how we can better serve our residents, our clients, and our communities. Over the past two years, OHCA has committed to becoming better allies for our residents and staff of color and historically marginalized groups to create a more diverse, equitable, and inclusive sector as a whole. We know our caregivers, staff, and residents bring diverse experiences, backgrounds, and perspectives to the communities in which they work and live and we are committed to creating a safer and more inclusive sector. As we slowly come out of a global pandemic and racial reckoning, the long term care sector is tasked with building a stronger, more inclusive, and empathetic workforce. I have no doubt our provider members will rise to the occasion and take all the necessary steps to make every single person feel welcomed when they enter a long term care setting. In this issue of Oregon Caregiver, we focus on the importance of diversity, equity, and inclusion (DEI) work in long term care and share actionable steps to practice authentic allyship for staff, residents, and clients. In our feature article, we highlight what some long term care providers are doing to incorporate DEI into their communities and how they’re planning to sustain the work. In our quality article, Linda Kirschbaum shares some thoughts on DEI from our recent Quality Summit as well as a few preliminary tips for providers to consider as they incorporate DEI into their workplaces. OHCA legal counsel Eugenia Liu dives into the legal implications of discrimination and biases in the workplace. Libby Batlan, OHCA’s SVP of government relations, wraps up the 2022 short legislative session and highlights key bills that will impact our sector. Walt Dawson breaks down the demographics and data in our long term care communities. The Oregon Department of Human Services share highlights from the recent statewide Oregon LGBTQ+ Older Adult Survey. Two OHCA business partners share thoughts on how to create an inclusive and diverse senior community. Incite Strategic Partners focuses on ways to make residents and staff feel welcomed and celebrated, while Lane Powell illustrates how to expand recruitment efforts to become more diverse. In our policymaker profile, Representative Tawna Sanchez, shares her personal experiences as one of the first Native American women to take office in the Oregon Legislature and how she plans to humanize the laws put in place. Hear from Kenisha Wilson, a caregiver at Our House of Portland and the OHCA 2021 Caregiver of the Year Award recipient, who shares what she loves most about working in long term care in our leader profile. Review highlights from the 2022 Spring Expo in Salem and save the dates of important in-person and OnDemand events and trainings coming up this year. You can read this magazine and all past editions of the Oregon Caregiver on our website, www.ohca.com.  Embodying the Commitment to Diversity, Equity, and Inclusion 11740 SW 68th Pkwy, Ste 250, Portland, OR 97223 Phone: (503) 726-5260 www.ohca.com OHCA STAFF Libby Batlan • Senior VP of Government Relations Philip Bentley, JD • President & CEO James A. Carlson • Advisor Cheryl Durant • CRM Administrator/Accountant Melodie King, CMP • Director of Education Linda Kirschbaum, LNHA • Senior VP Quality Services Eugenia Liu • Senior VP & General Counsel Brenda Michael • Assistant Controller Lori Mueller • CFO Sara Schouten • Member & Administrative Services Coordinator Catherine Van • Communications Coordinator Rosie Ward • Senior VP of Strategy BOARD OF DIRECTORS CHAIR Kathy LeVee, Generations, LLC VICE CHAIR Rick Miller, Avamere Health Services TREASURER Mark Kinkade, Gateway/McKenzie Living IMMEDIATE PAST CHAIR Steve Fogg, Marquis Companies, Inc. NON-PROPRIETARY REPRESENTATIVE JoAnn Vance, Providence Child Center MULTI-FACILITY REPRESENTATIVE Ryan Delamarter, Prestige Care, Inc. BUSINESS PARTNER MEMBER REPRESENTATIVE Gabriela Sanchez, Lane Powell, LLC ALF REPRESENTATIVE Mauro Hernandez, PhD, Hearth & Truss; ITA Partners, LLC MULTI-FACILITY REPRESENTATIVE Jonathan Allred, EmpRes Healthcare Management, LLC INDEPENDENT NURSING FACILITY REPRESENTATIVE Kathleen Parry, Maryville Nursing Home BUSINESS PARTNER MEMBER REPRESENTATIVE Scott Reese, Alliance Insurance Group NON-PROPRIETARY REPRESENTATIVE Mark Remley, Aidan Health Services, Inc. IN-HOME/SENIOR HOUSING REPRESENTATIVE Kevin Call, Adeo In Home Care ALF REPRESENTATIVE Andy Becker, Sapphire Health Services ALF REPRESENTATIVE Lisa Maynard, The Springs Living ALF REPRESENTATIVE Tom Stanley, Cascade Living Group, Inc. OC EDITORS Catherine Van • cvan@ohca.com Rosie Ward • rward@ohca.com OC PUBLISHER LLM Publications • www.llmpubs.com Advertising Sales • Ronnie Jacko (503) 445-2234 • ronnie@llmpubs.com Design & Layout • Jon Cannon Phil Bentley President and CEO Oregon Health Care Association LETTER FROM THE CEO Stay connected with OHCA! Contact Catherine Van, cvan@ohca.com, to be added to our email lists.  Improving lives by advancing quality care in Oregon since 1950

The Oregon Caregiver SPRING/SUMMER 2022 www.ohca.com 6 FEATURE EMBRACING DEI EFFORTS IN LONG TERMCARE By Catherine Van, Oregon Health Care Association Staff of A Place at Home gather to bowl for a team building event.

www.ohca.com SPRING/SUMMER 2022 The Oregon Caregiver 7 FEATURE Growth can sometimes be messy, ugly, and uncomfortable, but it is sometimes necessary. When it comes to diversity, equity, and inclusion (DEI) work, the growth is often slow, but the payoff is insurmountable. DEI concepts, especially around race, can be uncomfortable for people to discuss. However, in order to make meaningful change in this space, this particular discomfort has to be embraced head on. Several OHCA provider members share their growing pains of operationalizing DEI and the value behind it. In addition to our sector having to deal with the traumatic outcomes, restrictions, and hardships of the COVID-19 pandemic, during the same time we also dealt with the challenges of growing racial tensions felt nationwide, and even globally. On top of dealing with COVID19, long term care providers also found themselves asking, “How do we address these tensions in our community?” Avamere Family of Companies began its diversity, equity, inclusion, and belonging (DEIB) efforts in late 2020. With the help of an external consultant and former Head of Talent Acquisition, Lisa Marie May, Avamere established core components for their efforts: • Identifying areas of focus • Establishing a council • Evaluating areas of growth In November 2020, the company surveyed a team of nearly 9,000 employees, inquiring about culture, experience, and identity. Jessica Burkard, the company’s division director of community and provider engagement says building team comradery, improving the morale, and addressing staffing issues that have impacted long term care were identified by survey respondents as essential. “Being a part of something bigger than yourself is something everyone has in common. Whether it’s your neighborhood, social hobbies, family, or work, belonging and interacting with people from different backgrounds is an everyday occurrence,” said Burkard. “It’s important to note that DEIB is more than addressing inequities and discrimination, which is critical; it’s about how we interact with one another and recognize and respect each other’s lived experiences. I think there is validity in all our perspectives and experiences, no matter how uncomfortable or disagreeable they may be.” After assessing the survey results, the company established a People and Culture Council, comprised of representatives from all aspects of the company including professionals in roles ranging from clinical, human resources, finance, home health and rehabilitation. To help guide the company through their DEIB journey, Burkard says the group focuses on key areas: procurement, people operations, development, education, talent acquisition, and marketing. Through this council, members were able to strengthen bonds by sharing and reflecting on their lived experiences and backgrounds, which provided some “ah-ha” moments. Avamere also worked to re-brand and create a space for DEIB. While the company’s efforts had wins, its ambition and size posed some challenges. Additionally, a company restructure and ongoing COVID-19 stressors slowed momentum, so the time came to pivot. The group decided to focus on their respective lines of business separately: skilled nursing, home health, and rehabilitation. The idea was to allow a more tailored approach to education and other efforts that fit the unique structures and variations in each line of business. Burkard was selected to lead DEIB efforts for 32 skilled nursing facilities in Avamere’s skilled nursing division. Burkard comes from a multiracial/ international family and has a professional background working with hospitals and federally qualified health centers with a focus on health equity. At Avamere, her focus is on culture. “Culture is the ‘I and B’ of DEIB. We all know long term care was decimated by CONTINUES » the pandemic. Many folks are experiencing exhaustion, tension, and the feeling of being overwhelmed, or they come from a background that was hit particularly hard in the last couple years (people on Visas, people with police in their families, working parents, people of color, caretakers, students). All of this has a huge impact on how we work together. I want to get back to basics and close the gaps that were unintended consequences of a pandemic,” said Burkard. “In order to address hard-hitting topics, like discrimination and prejudice, you have to get people feeling comfortable sharing and communicating with one another.” For Hearth and Truss, DEI initiatives have been foundational to the organization’s mission, but they’ve shifted over the years. Coming from leading a Florida assisted living community with a dominant Cubano culture, Mauro Hernandez, co-owner of Hearth and Truss, initially wanted to focus on how the assisted living model of care was relevant to a Hispanic community. One early and easy fix Hernandez noticed was that important routine materials at many communities, from food menus and handbooks, to policies, procedures, and contracts, weren’t even available in Spanish. “Oregon has really emphasized the traditional American values of privacy, individuality, dignity, choice, and a home life environment in assisted living. Yet, when I came to Oregon, I noticed a lot of things that didn’t quite fit with our resident population. Even back in Florida, we also had some challenges serving a multicultural population because we found that even though we were in the heart of Little Havana, the non-Hispanic residents never felt really welcome,” said Hernandez. “We really struggled with that because the myth of the melting pot of the U.S. assumes that everybody is willing to let go of their traditions and adopt the traditions of the dominant culture.” Having grown up in a primarily Hispanic family and identifying as LGBTQ+, Hernandez understands some of the challenges Oregon assisted living communities are facing. He took a

The Oregon Caregiver SPRING/SUMMER 2022 www.ohca.com 8 FEATURE diversity, equity, and inclusion in our workforce and our resident population, we also need to be looking at our leadership across our organizations and seeing what the barriers are. When I look around the room, I ask, ‘how do we increase the diversity in this group of people around the table and what do we need to do programmatically and structurally to create access to education, if needed?’ We know certain groups face greater barriers to education, housing, security, and food security, and we have to be mindful of that.” Hernandez and leaders in his organizations have actively reached out to different communities, particularly churches, to get to know the Hispanic community. They also addressed operational barriers by including a bilingual employee on every shift, including a visible LGBTQ+ decal at the front of buildings, revising menu options to include more inclusive dishes, and embedding DEI training into orientation. He says the biggest opportunity is getting to know how family, traditions, and beliefs may impact the behaviors of residents. “It’s a little bit easier to approach this from a person-centered care point of view. Getting to know the person and getting to know the resident and knowing what their traditions are, how they celebrate different holidays, and understanding their traditions around death and dying are crucial,” said Hernandez. “It was really important with my last company and this company to be really explicit about what matters to us and what shapes our strategy or how we do things.” When faced with pushback, mainly from residents, Hernandez says he always returns to the values of his communities. He makes sure the residents understand that everybody is welcome and that employees know leadership has their backs. He wants to make more of an effort to get to know staff and residents in his facilities better. “Every conversation feels effective and satisfying when we’re learning a little bit more about the barriers, but it does require a time commitment. People are uncomfortable with the term oppression, but it’s not about being the bad guy; it’s just understanding our history and being curious. Getting curious about other people who may look different from you is important. Being comfortable with uncomfortable conversations and being comfortable with not knowing what to do is important. Just do some research. There’s so much information out there and so many books that will help you get up to speed,” said Hernandez. In home health settings, employees are sometimes more vulnerable to discrimination because they are on their own when caring for clients. Jerome Phillips, owner of A Place at Home, an in-home care agency, says one of the biggest challenges he and his staff have faced is direct racism from clients. » FEATURE, CONT. sociological approach to looking at barriers in various social structures, including public and organizational policies, programming, and even the location of a facility. “If you’re going to find people of color living in assisted living, they tend to be in places where the administrator is of the shared ethnic background. So, when we think about where we locate our facilities, we have to recognize that we may not be as visible because of our location in the communities we may not be serving,” he said. “We have this great model that we’re proud of, in terms of assisted living in Oregon, but when you look at who’s really using it in different parts of the state, you find that, people of color and members of the LGBTQ+ community are less likely to access it.” Hernandez says there are missed opportunities when it comes to recruitment in long term care; other cultures have a tireless work ethic for caregiving and working with older adults—values that have not been fully appreciated or utilized. In his own buildings, they have worked hard to diversify their workforce, which requires building trust and outreach to actively bring people up from communities who normally don’t have access to the education, mentorship, and opportunities that many other staff have. “What I learned was it’s not the same way that we typically recruit employees, whether that’s through Facebook or Indeed or other places; it’s about showing up,” he said. “If we want to address “In order to address hard-hitting topics, like discrimination and prejudice, you have to get people feeling comfortable sharing and communicating with one another.” – Jessica Burkard, Division Director of Community & Provider Engagement, Avamere Jessica Burkard, Division Director of Community and Provider Engagement of Avamere Family Companies.

www.ohca.com SPRING/SUMMER 2022 The Oregon Caregiver 9 FEATURE “It’s a challenge on how we address that, especially for those who may have Alzheimer’s or any kind of dementia, and very racist behaviors are a prevailing thought process. We’re not going to send our minority caregivers to a client who might use intolerant language. The problem now is we’re preventing our high-quality caregivers from that quality work environment,” said Phillips. “When you go to the hospital in the ER and you want care, you get the doctor who’s in the ER, and it doesn’t matter what their race is. But somehow in the long term care community, some individuals feel that it is okay for clients or families to say, ‘I don’t want a caregiver who is this sexual orientation or is this specific race.’ As we grow and gain an understanding of the effect this has on our employees, caregivers, and nurses, we’re taking the stance of saying, ‘we’re going to send you a highly skilled, compassionate employee who is going to make a difference in your life. We have somebody who has all the qualifications in the world and would love to help you.’ If clients start to hear that from five different agencies, it starts to change and it affects change throughout the entire community.” CONTINUES » When some of Phillips’ staff face discriminatory requests from clients, Phillips stands firmly behind his employees. He quickly jumps into conversations with the client and provides education and humanizes his staff to help resolve the issues. While he wants to improve the experience of his clients, he also wants his employees to know they are an asset and are deeply valued. “That’s our stance and that’s something my team takes pride in. I can’t affect what every business is doing, but I take a lot of pride in my staff, especially the fact that they’re empowered to make tough decisions. We have lost clients, but we also have many clients who take pride in partnering with us and working with an agency that’ll take that stance for the community.” Phillips identifies with his employees as well as his clients. He cared for his father for several years after a heart surgery went sideways and has a background in social work, but says he still struggled to navigate through the gaps within the long term care sector. “One of the things that I ran into early on is that there’s a huge disparity in access to quality care in the community,” he said. “We have these communities that are deeply passionate for helping folks, but there’s this contrast in who they’re providing that care for. There’s a lack of understanding and how we approach groups that are different than our own, whether that’s sexual orientation, gender, or race, and we really struggle to identify ways that we can make those groups feel welcome in healthcare services that we provide and what we envision with our employees internally.” Even as a leader, Phillips says it can sometimes be difficult to advocate for his Jerome Phillips, Owner of A Place at Home. “Somehow in the long term care community, some individuals feel that it is okay for clients or families to say, ‘I don’t want a caregiver who is this sexual orientation or is this specific race.’ As we grow and gain an understanding of the effect this has on our employees, caregivers, and nurses, we’re taking the stance of saying, ‘We’re going to send you a highly skilled, compassionate employee who is going to make a difference in your life. We have somebody who has all the qualifications in the world and would love to help you.’ If clients start to hear that from five different agencies, it starts to change and it affects change throughout the entire community.” – Jerome Phillips, Owner, A Place at Home

The Oregon Caregiver SPRING/SUMMER 2022 www.ohca.com 10 FEATURE employees because he faces some of the same discomfort and discrimination that his employees of color face. While his clients are mostly white, he says his employee base is quite diverse. At his agency, most of the care is provided by women from historically marginalized backgrounds. It’s not lost on him that long term care organizations are mostly owned by men, including himself. With his role, he says he carries a responsibility as a leader who is also a person of color. “I know it is rare in this realm, especially in home care. There are only a handful of other home care agencies with a person of color in charge, so I want to provide that hand-up to those folks who struggle with moving up through their careers in healthcare and provide them with a path forward. I am lucky enough that I’ve gotten to this point and have an opportunity to lead this wonderful group of caregivers, but I’d like to see more folks of color in our sector. The long term care sector is very underrepresented, so I’ve opened those conversations in our community,” said Phillips. To mitigate some of the challenges, Phillips made several operational changes over the past three years. His team moved to an entirely phone-based interview process to remove any visual biases. He has also included caregivers in quarterly meetings with leaders to share different experiences and address any issues from the field, which has been invaluable. “If you take a group picture of your company today, what does that picture look like? Do you look at that picture and say, ‘this is a diverse group of people and they’re going to bring all these different values and cultures to the table, and that’s going to benefit my clients, or does everybody in this room look the same?’ If everybody in this room looks the same, we’re probably not bringing a lot of different views and, and cultures and stances to the table,” he said. Phillips comes from a Sri Lankan and Native American background—cultures that center around community and relationships. He wants to instill those core values into his agency and employees. » FEATURE, CONT. Prior to the pandemic, he would organize team building events, like bowling and hosting potlucks, to identify with and connect his team with one another. At a time when long term care communities are struggling to hire and retain workers, Phillips is working to change the perspective that healthcare staff are commodities. “They’ve risked everything throughout this pandemic to be out there with folks on an individual basis. We need to show respect in return,” he said. “While money is important, what keeps me up at night is making sure that all of my employees have food on the table, they have a roof over their head, and they’re able to buy their children school clothes. That is important to me,” he said. “It makes a difference when you let people know that they’re valued, their families are valued, and the experiences they bring are valuable.” Where to Begin While several OHCA members have taken initiatives to operationalize DEI, many members still struggle with knowing how to get started or where to go next. In 2020, the OHCA Board of Directors created a DEI workgroup to address and provide resources and ideas to provider members. At the beginning of 2021, OHCA enlisted the help of Engage to Change (ETC), LLC, a Portland-based anti-racism and anti-oppression DEI consulting firm to carry out OHCA’s DEI mission and CONTINUES » Employees of A Place at Home gather for one of many team building events. “It makes a difference when you let people know that they’re valued, their families are valued, and the experiences they bring are valuable.” – Jerome Phillips, Owner, A Place at Home

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The Oregon Caregiver SPRING/SUMMER 2022 www.ohca.com 12 FEATURE » FEATURE, CONT. values and better understand how to help serve members. ETC co-owners and facilitators, Rakeem Washington and Kasia Rutledge, help organizations look at structures and systems of power, particularly around race and oppressions, and build a new structure that is intersectional and human-first. “We call it anti-racism and anti-oppression work and what we’re trying to do is identify, address, and change the structures and the culture within an organization. It’s not just, ‘how do we hire more brown and Black folks?’ Rather it’s, ‘how have we created an organization where we don’t have brown and Black folks who want to work here?’” said Rutledge. ETC’s work involves dismantling, rebuilding, and recreating processes and structures, which can result in rejecting some of the principles that are connected to the status quo to create a space to include everyone. They help organizations level set—meeting people where they’re at—to build a foundation of understanding, which means diving into the topic of race right off the bat. “In this country, we don’t talk about race. In our experience, racism is the hardest conversation to have. If we don’t start there, people will use other pieces of their identities, especially pieces where they feel marginalization, to off-ramp from that really hard conversation about racism. Historically, racism is sort of the way in which business is done in United States, so it shows up everywhere. If we can start with racism and figure out how to account for that—how to change the structures that feature intentional or unintentional racism—all those other ‘-isms’ spaces will benefit from that process. We are laying the bare foundation for the way which we treat each other, the way in which business is done, the way in which organizations are structured,” said Washington. “If we talk about ableism without talking about racism, we’re talking about white bodies, not everybody who should be in that conversation. That’s because it’s so ingrained and built into all our structures, our forms of government, our interactions, our hierarchies, and even the way things are placed on grocery store shelves have some component of racism connected to it.” “Learning to have that conversation and learning to see and unpack pieces of race, racism, and white supremacy is a core component of being able to have the other conversations. white supremacy is at the root of other oppressions as well, whether it be patriarchy or transphobia or fatphobia or xenophobia or ableism or whatever. You can’t have an honest, nuanced conversation about those other pieces of oppression, unless you understand and unpack white supremacy first,” said Rutledge. ETC’s approach recognizes that often the people who are making decisions and policies aren’t always aware of the struggles the rest of their teams may be facing, whether it’s an employee of color having to deal with racist clients or residents and not having the tools or resources to interact, or it’s managers not knowing how to support people within long term care communities to get the care they need. In social services fields, Washington and Rutledge say the divide in experiences and understanding around race between the people doing the work is vast. There are folks who experience racism on a daily basis from CONTINUES » RakeemWashington and Kasia Rutledge, Co-owners of Engage to Change, LLC.

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The Oregon Caregiver SPRING/SUMMER 2022 www.ohca.com 14 FEATURE » FEATURE, CONT. coworkers to managers to residents, and there are folks who are working alongside of them who don’t want to acknowledge race or deal with it. “What we hear a lot is that anti-racism and anti-oppression work are seen as somehow separate or something that we don’t really have time for because we’ve got all these competing priorities, like staffing shortages and residents getting sick. In reality, they are intertwined, and they are inseparable. There are worker shortages in part because of racism and the experience of folks of color not feeling safe or supported at work. COVID-19 had a disproportionate impact on communities of color, so it’s not, ‘once we get through this, then we can do some anti-racism work;’ it has to be baked into all the pieces,” said Rutledge. After surveying OHCA members through ETC’s consultancy with OHCA, Rutledge and Washington said the biggest barrier they saw in Oregon’s long term care sector was the lack of effort to make DEI a priority. The survey results showed recurring themes, consistent with those found in the general Pacific Northwest. Some of the responses in the survey showed “overt discrimination, bias and racism.” The results revealed racism, sexism, xenophobia, ableism, homophobia, and other oppressions as barriers for some of those served by OHCA. The survey also revealed what level of support is needed to advance DEI in long term care and the appetite the sector has for more training and resources on the topic. When prompted, “I would be more active in advancing equity if…” the top three responses included: • “…I had more training,” translating to more education. • “…I was compensated for additional emotional labor,” translating to more resources. • “…I had more time.” Based on those results, ETC outlined recommendations for OHCA to further support our members. Those recommendations include level set trainings for OHCA internally, as well as trainings at the management and caregiver levels to complete. In their experience, some organizations want to be able to say they did the work but not engage in a way that makes meaningful changes. “A lot of times people in leadership positions within agencies don’t actually want to prioritize what the work is and how it needs to happen,” said Washington. “They don’t actually understand the harm caused by racism and oppressions that go unchecked and unaddressed within their staff, within their framework, within their relationship to community.” More people and companies are opening eyes and having those important conversations. For those who are ready to engage, Washington and Rutledge say examining unconscious biases on an individual basis and asking oneself uncomfortable questions is a great place to start. “You can’t perceive it if you’re in it, so how does someone start to examine it if they haven’t even perceived that it’s a thing they’re connected to? There is so much to learn and unlearn and unpack and engage—for white folks in particular—whether individually, interpersonally, or organizationally that we have to first and foremost be curious about ourselves and our relationship to how we have and haven’t learned things and what we need to do differently,” said Rutledge. “We have to approach the work from curiosity, from humility, and from a willingness to make mistakes and do it incorrectly, but to build the capacity to keep going.” DEI initiatives all have the goal of creating a working culture where employees know their value and feel not only welcomed, but fully included. Long term care leaders have the unique position to drive change within their organizations with simple and critical measures, whether that’s getting external help from experts in the field or resetting organizational missions and structures. Being open to making mistakes and to being challenged will be instrumental to making meaningful changes in our sector. There are no quick fixes or instant results in the DEI space; the work is gradual and part of a lifelong journey of listening, fumbling, and growing. OHCA will continue to walk this journey together with, and in support of, our members.  “What we hear a lot is that anti-racism and anti-oppression work is seen as somehow separate or something that we don’t really have time for because we’ve got all these competing priorities, like staffing shortages and residents getting sick. In reality, they are intertwined, and they are inseparable.” – Kasia Rutledge, Co-owner & Facilitator, Engage to Change, LLC

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The Oregon Caregiver SPRING/SUMMER 2022 www.ohca.com 16 QUALITY DEI and Quality: How to Build Cultures of Belonging By Linda Kirschbaum, Oregon Health Care Association Two years ago, OHCA made supporting diversity, equity, and inclusion (DEI) efforts within OHCA and the senior care sector one of the organization’s primary ongoing objectives. OHCA staff and members are dedicated to providing quality care to all individuals living in Oregon’s long term care settings regardless of their race, religious affiliations, and gender identities, and provide caregivers and staff equitable, inclusive, and opportunity-abundant workplaces. We pledge to take steps to educate ourselves as well as our provider members to determine the best way to promote person-centered services and amplify the voices of marginalized communities, including adults that may be aging, disabled, Black, Indigenous, people of color, and LGBTQIA+. We are committed to advancing and improving equity, respect, and unity in our sector and beyond. At OHCA’s February 2022 Quality Summit, keynote speaker, Lou Raja, described inclusion as follows: Inclusion is about making sure that the people [residents, staff, visitors] in your community [facility, agency] know that they are welcome, and they belong. Retention is about creating an inclusive culture so that people are engaged and feel like they are part of something important. Belonging, and connection, are all essential to humans. Everyone has experienced a time when they felt like they were the “odd person out,” including potentially being the only person of color in a meeting or living in a long term care community. Our workplaces and communities must be safe havens for all who enter. DEI in the Long Term Care Workplace One of the primary attributes people are looking for in their work experiences is a sense of community. Americans on average spend a third of their days engaged in work activity. While the pandemic fostered newfound unity among teams in long term care settings, national and local race-related events prompted employees and consumers to demand action for racial injustice and movement toward more equitable communities and workplaces, where all employees feel welcomed and accepted. An improved sense of community and a feeling of belonging to something bigger was a silver lining long term care derived from the pandemic. How do long term care organizations hang on to that gift? The need for belonging is universal and fundamental. If long term care leaders keep their focus on cultivating cultures of belonging, those actions will support forward progress with each organization’s DEI goals. DEI and Quality DEI work requires an “all-in” commitment, as does continuous quality improvement. These are work practices that are forever and evolving. Organizations that strive to better themselves are the ones that commit to being learning organizations. DEI education and information support an organization’s journey to grow and become more inclusive. A common theme or comment among organizations that have set afoot on the DEI path is, “This is hard work. It is uncomfortable work.” There is no denying those facts! However, the rewards are tangible and many of the efforts to foster belonging and inclusion are simple, small steps of change that can move an organization forward with their DEI goals. The work improves the work experience and satisfaction of each associate working in a community. It can increase staff retention, improve quality care and service outcomes, promote person-centered care, and enhance relationships and connection between residents and staff. The need to belong and be valued, respected, and appreciated are universal values. To quote Christopher Ridenour, the closing keynote speaker at the 2022 Quality Summit: “[These things] do not have ‘a color;’ [… These] human values, coupled with a mindset of positivity and conscious leadership will strengthen an organization by increasing quality and continuity of care, and developing a culture of belonging.” According to a recent article in the Harvard Business Review, “What Does it Take to Build a Culture of Belonging?,” to build a culture of belonging and reap the many benefits for employers and employees, leaders first require a clear understanding of what it means to belong at work. Informed by existing measures and extensive research by Coqual, the authors developed a quantifiable definition1 that states we belong at work when we are: 1. Seen for our unique contributions We are committed to advancing and improving equity, respect, and unity in our sector and beyond.

www.ohca.com SPRING/SUMMER 2022 The Oregon Caregiver 17 QUALITY 2. Connected to our coworkers 3. Supported in our daily work and career development 4. Proud of our organization’s values and purpose As organizations map ways to meet their commitments to racial equity and justice, closing these belonging gaps will help them join employees in a common mission—and retain and engage employees of all backgrounds. Everyday strategies and approaches to building a workplace where staff feel connected to the mission and their colleagues can be started with simple first steps. Recent OHCA member roundtable discussions on DEI brought forth several ideas to enhance employee onboarding and inclusivity: • For staff and residents with limited English proficiency, include the preferred language in an employee record or resident record. • Translate or offer translation services for job descriptions, employee handbooks, important policies, and procedures into preferred language other than English. (Contact OHCA for information about language translation business partner members.) • Review resident evaluation, service plan, and care plan tools from a DEI perspective. Are cultural, gender, religious, lifestyle, language, or other preferences and choices important to the resident included in the assessment tool? Does the community provide direct care staff with easy access to the information? • Provide DEI education at resident and family council meetings. • Offer and encourage staff to attend DEI education sessions regularly. The Oregon long term care community has an amazing opportunity to commit to and travel the path of continuous DEI quality improvement. Any small steps taken to create an environment that is inclusive, respectful, and supportive will reap tenfold benefits for residents and staff.  1. A Quantifiable Definition: https://www.talentinnovation.org/ _private/assets/PowerOfBelonging_KeyFindings-CTI.pdf

The Oregon Caregiver SPRING/SUMMER 2022 www.ohca.com 18 LEGAL & REGULATORY Equality and Inclusion in Senior Living By Eugenia Liu, Oregon Health Care Association In long term care settings, it’s not uncommon to hear statements that are borne out of concern for resident health and safety, such as: “Excuse me, you can’t bring the dog into the dining room for health reasons.” “Sorry, but we do not allow motorized wheelchairs on our community van because it’s not safe.” “Due to COVID-19 protocols, we cannot allow visitors or anyone other than the resident in the treatment area.” While well-meaning, contained within each of those statements is an element of bias. There is no doubt that promoting resident health and safety is a top priority for senior living providers, and it is also engrained in everything staff do for residents. However, it is critical to find a balance between that focus and other, equally important goals: eliminating bias and ensuring equality and inclusion in the care and services delivered. Oregon and federal law provide strong protections for residents’ individual rights, including the fundamental values of independence, choice, and dignity. In residential care and assisted living facilities, OAR 411-054-0027 outlines the resident’s bill of rights. For nursing facilities, resident rights are found under state rule OAR 411-085-300 and OAR 411-085-310 as well as federal rule 42 C.F.R. 483.10. Beyond the rules that are specific to assisted living and nursing facilities, there are broader rules such as Oregon’s public accommodation law, ORS 659A.403, as well as the Americans with Disabilities Act (ADA) and the Fair Housing Act, which are designed to prohibit discrimination and ensure equal access to care, services, and housing opportunities. Furthermore, facilities are prohibited from retaliating against a resident who exercises these rights and protections. Collectively, these rights and protections work together to enhance a resident’s quality of life, recognize each resident’s individuality, and ensure person-centered care. These rights and protections apply to all residents, regardless of race, color, sexual orientation, gender identity, or physical impairment. Under this framework, a resident’s service animal may be allowed to accompany the resident into the dining room. This framework could allow a resident to board a community van using the resident’s motorized wheelchair, or to have a visitor, such as a spouse or other person, accompany the resident into treatment areas to provide support with communications despite COVID-19 restrictions. These rights and protections also allow residents to choose roommates when sharing a bedroom, associate and communicate privately with any individual of their choice, and have equal access to services offered by a facility. At the same time, these rights and protections are not limitless nor absolute and they do not require a facility to undertake actions that would place resident or third-party health and safety at risk or create an undue hardship for the facility. Understanding the framework is key to cultivating an environment that values both concepts equally. As with every other aspect of care and services in a facility, the facility’s frontline staff play a critical role in executing on these core values. Staff already receive regular in-service training on protecting and respecting residents’ rights, as required by the statutes that govern these facilities. In-service training can include detailed examples of resident rights and reinforcement of existing communication channels, such as the grievance process or an ethics/compliance hotline. This training provides staff with the foundational awareness to not only treat residents with dignity and respect, but to identify and report violations of resident’s rights as well. Staff also need to be empowered to integrate resident rights and protections into resident care. This can be trickier as Staff need to be empowered to integrate resident rights and protections into resident care. This can be trickier as staff may avoid asking questions out of fear of doing or saying something wrong.

www.ohca.com SPRING/SUMMER 2022 The Oregon Caregiver 19 LEGAL & REGULATORY staff may avoid asking questions out of fear of doing or saying something wrong. However, incorporating practical examples and application guidance into existing training, such as providing staff with a FAQ that outlines common questions and answers, or conducting a mock interactive assessment, will help educate staff as well as equip them with the skills to engage in that delicate balancing act. For example, a FAQ with short bullet points on what staff can or cannot say when they see a dog in the dining room, what type of restrictions may be applied under different scenarios, as well as what alternative supportive services or aids may be available, will give staff the basic tools to be more thoughtful in their reaction. Similarly, providing staff with a pocket card with key concepts can also keep the importance of inclusion and access top of mind and facilitate appropriate follow up as staff can carry the pocket card with them. The pocket card can highlight a few standards of conduct (e.g., respect each individual, act with integrity, and have no tolerance for harassment or discrimination), remind staff that they are mandated reporters, and facilitate reporting requirements by providing the titles and telephone number for individuals to whom grievances and concerns should be made. It is also important to have consistency in the execution of these rules because inconsistency can give rise to, at a minimum, the perception of discriminatory conduct. Since different individuals can approach the same topic from different angles, one way to ensure consistency is to designate a qualified staff member or two to serve as the point person for handling such inquiries or concerns. This creates a uniform process, which can in turn, help demonstrate that the process as a whole is fair, and everyone is treated equally. Finally, safeguarding resident rights and protections should not come at the expense of facility staff, who have rights of their own to be free from harassment and discrimination in the workplace. Each resident must understand that they too must conduct themselves in a respectful manner. Resident-facing documentation, such as residency agreements or disclosure statements, are valuable tools in managing resident expectations. Facilities can use these documents to notify residents that the facility’s non-discrimination policies apply to staff and other residents and residents who engage in abusive, harassing, or discriminatory conduct towards others may be in breach of their agreement with the facility. Integrating equity and inclusion into health and safety requires a multi-faceted approach, but it will help build a stronger community for those who live and work there.  Integrating equity and inclusion into health and safety requires a multi-faceted approach, but it will help build a stronger community for those who live and work there.

The Oregon Caregiver SPRING/SUMMER 2022 www.ohca.com 20 DATA & RESEARCH Similar to national demographic trends, Oregon’s population is aging. According to the U.S. Census Bureau, more than 18 percent of all Oregonians are 65 years of age and older. By 2030, that percentage will grow to 22 percent or just over one million Oregonians. What may be less well known is that Oregon’s older adult population is also growing increasingly diverse. Approximately, 24 percent of all U.S. older adults are people of color, a number that is projected to grow to 34 percent by 2040. These demographic trends have important implications for the delivery and provision of long term care services in Oregon. Significant racial and ethnic disparities exist within the long term care sector that impact access to care, quality of care, and service delivery. The COVID-19 pandemic has even made some systemic inequalities in long term care worse. A better understanding of the populations and communities who utilize and provide long term care in Oregon is essential to mitigating pandemic-induced inequalities, reducing long-standing disparities within the sector’s service provision, and for ensuring greater equity in care outcomes. Like national trends, the vast majority of all Oregon long term care community residents are women. Some variation exists across care settings. For example, 70 percent of assisted living and residential care community residents are women, while 71 percent of Oregon’s memory care community residents and 57 percent of skilled nursing facility patients are women. Approximately 10 percent of Oregon’s assisted living and residential care community residents are people of color as are nearly 18 percent of skilled nursing facilities residents. There is less readily available data on the demographics of in-home care recipients in Oregon, which is a significant gap in the data given that the majority of those receiving long term care in Oregon receive in-home care rather than care provided in congregate settings. Table 1 provides additional details by care setting. Oregon’s long term care workforce is highly diverse. Racial and ethnic minority populations make up a slightly larger share of the sector’s workforce than the share of the overall population in Oregon. Approximately 31 percent of Oregon’s long term care workforce are people of color, compared with approximately 25 percent of the overall population. There is some variation in workforce demographics across long term care settings in Oregon. See Table 2 for further detail. The vast majority of Oregon’s direct care workforce is female (81 percent female versus 19 percent male). Very little variation exists in distribution across nursing facilities, community-based care, and the in-home care sector. The high proportion of women employed by Oregon long term care communities is Understanding Demographic Trends: Long Term Care Growing Increasingly More Diverse By Walt Dawson, D.Phil comparable to that of the long term care workforce in the United States. The age of the long term care workforce is another important dimension to consider. According to PHI, over 29 percent of Oregon’s home care workforce is 55 years of age or older, while 11 percent of the workforce over the age of 65. This contrasts with congregate care settings where the workforce is generally younger. Further, many nursing professionals in Oregon are at or nearing retirement, which may contribute to a shortage of nurses in the coming years. At the same time, the U.S. Bureau of Labor Statistics projects the need for nurses to grow by as much as 15 percent over the next six years. An awareness of how age intersects with other demographic factors will be essential to training and recruiting a workforce that can provide for the sector needs of Oregon’s increasingly diverse population. Geography is yet another important consideration. Oregon’s rural and frontier communities face unique challenges in terms of accessing long term care services and in service delivery. Indeed, Oregon’s rural and frontier Significant racial and ethnic disparities exist within the long term care sector that impact access to care, quality of care, and service delivery. The COVID-19 pandemic has even made some systemic inequalities in long term care worse.

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