A Guide to Long-Term Care for State Policy Makers:
Guide to Nursing Home Culture Change
“The common thread is a desire to revolutionize how chronically frail and disabled individuals live and are treated. Culture change enthusiasts believe that the key to improvement is … implementing systems of care around individuals’ lifestyles, needs, and preferences.”
Brown University Report for the National Commission for Quality Long-Term Care (2006)
For many years, America’s nursing homes have been the cornerstone of the nation’s long-term care (LTC) system—despite widespread consumer dislike of the institutional environment and ongoing criticism about poor quality of care at some facilities. The country’s long-term care system has, however, been experiencing some gradual changes that have affected the nursing home environment. Given a greater choice of home and community alternatives, for example, many elderly Americans and those with disabilities have been obtain LTC services at home or in other community settings.
The number of nursing homes has declined by more than 1,000 facilities since 2000, and the aggregate occupancy rate was 88 percent in 2006. The number of residents has declined only slightly, to about 1.3 million people, but those numbers are low in the context of a growing elderly population. Even among the oldest-old (age 85+), use of nursing homes decreased from about 21 percent in 1985 to 13.9 percent in 2004.
Against this backdrop, advocates of nursing home quality improvement—and many nursing home providers themselves—have lead a drive to reinvent the nursing home. Their goal is to transform the nursing home into a setting that provides an improved quality of life and greater privacy, autonomy and comfort for residents. Changes also are under way to offer nursing home staff an opportunity to increase their training, expand their roles, and encourage relationships with residents. These strategies attempt to address problems of isolation, boredom, loss of individuality and loneliness that are prevalent among many residents.
“Culture change,” as the movement has become known, takes several different forms. The term can refer to the creation of smaller, more homelike housing that features living spaces for a few people built around a core central area, a kitchen and separate bedrooms. Where a typical nursing home might be a facility with several floors, numerous rooms along long corridors and multiple-occupancy rooms, the newer versions are smaller with more amenities. Another type of culture change can involve the introduction of pets, plants and children into the nursing home environment to provide residents with more pleasant surroundings.1
Still another initiative strengthens the role of the front-line worker in most nursing homes, the certified nursing assistant (CNA), in the care of the resident, to replace a management style that emphasizes top-level decision making. In some situations, the CNA will work in a team that is assigned a specific number of residents. The team works regularly with these residents and shares information and decision making with the residents and with each other about everyday care.2
Thus, both changes in physical space and architecture and change in organization and process are stressed. Examples of these efforts include the following.
- Green House homes began in Tupelo, Mississippi in 2003 and are now being replicated in other states. The homes are residences for six to 10 people, each with private bedrooms and bathrooms around a common area. Residents control their own schedules.
- The certified nurse aides, called “shahbaz” (“powerful falcon” in Farsi) manage the household, assisted by nurses and therapists. The aides receive additional training and manage their own work. (Additional Green House models are being built in at least 17 states. With support from the Robert Wood Johnson Foundation, the NCB Development Corporation and the Green House Project are introducing the model in at least 30 communities over five years.)
- The Pioneer Network coalition serves as a resource for facilities that want to improve quality of care and also provides a peer support network. The organization’s goal is to transform an institutional bureaucratic approach to care delivery into one that is person-directed, “…making elder care facilities places for living and growing rather than for declining and dying.” To create such a culture, the organization says, one must fundamentally transform values, structures and practices. More control must be shifted to residents, and CNAs must get to know residents and care for them as individuals.
- The Eden Alternative, started by Dr. William Thomas in 1992 in an upstate New York nursing home, has spread to about 200 facilities in America and other countries. Innovations include the introduction of companion animals, indoor plants and gardens, and frequent visits by children. Dr. Thomas also advocates more delegation of decision-making responsibility to the residents and their caregivers. (Dr. Thomas also developed the Green House Project.)
- Wellspring Innovative Solutions for Integrated Health Care, a coalition of 11 nursing homes in Wisconsin, began in 1994 to work together to share information about how to improve quality. The goal is to embed a resident-centered, continuous quality improvement process into nursing homes by improving skills, knowledge and collaboration among staff.
- An advanced practice nurse develops training materials and provides clinical teaching to multidisciplinary “care resource teams” who, in turn, are responsible for teaching other staff. A 15-month evaluation of the model found that the Wellspring facilities had fewer major deficiencies on inspections than other Wisconsin nursing homes and also experienced lower costs.
- Meadowlark Hills (Manhattan, Kansas), consists of a single building organized into six distinct households, each with from 13 to 25 residents. Each household has its own entrance and doorbell. Residents themselves arrange most of their daily schedules. Each household has a multidisciplinary staff and leadership team.
Several states have created incentives for nursing homes to redesign their facilities to create more livable spaces. In 2005, Michigan developed the Long-Term Care Facility Innovative Design Supplemental Program, intended to encourage renovation and replacements of nursing facility infrastructure. A nursing facility receives a $5 per day Medicaid supplemental for Medicaid beds designated by the Michigan Department of Community Health as part of an approved project.
To be eligible, a nursing facility had to provide at least 80 percent single occupancy resident rooms with private bathrooms in its new or renovated areas. The nursing facility also had to create a “culture change” environment such as the Eden Alternative model.
Of the 15 nursing home applicants that submitted approved projects in the first round, one facility developed the Green House concept of small residential buildings. Another eight projects renovated their existing buildings.
North Carolina adopted a grant program in 2004 for nursing homes that expanded staff training or introduced garden areas, pets and other culture-changing improvements in their facilities. Grants ranging from $6,000 to $25,000 have been awarded by the North Carolina Coalition for Long-Term Care Enhancement, which is composed of advocacy groups, industry providers and regulators.
Funding comes from the U.S. Centers for Medicare and Medicaid Services, which returns to the state fines levied against nursing homes in that state for use in improving nursing home care. The program is administered by the North Carolina Department of Health and Human Services.
Issues
- Regulatory and Legal Issues
Do a state’s licensing and regulatory rules allow for specific “culture change” innovations, such as pets in a nursing home? A review of the state’s regulations may be necessary to ascertain whether rules governing resident safety can be balanced against giving residents more autonomy and more satisfaction with daily activities. Could relaxed rules and more resident autonomy increase the potential for lawsuits alleging neglect?3
- Costs
Does it cost more? Shahbazim in the Mississippi Green House model are paid $2.50 per hour more than they received in their previous role as CNAs. However, supporters argue that the increased wages can be offset by reducing middle-management positions and stabilizing the work force. Staff turnover could be reduced, saving money on frequent recruiting and training of new staff.
Building new structures or significantly modifying old facilities to be more resident-centered is a different cost issue, however. Up-front costs of new construction may constrain many providers from moving in this direction.
- Staffing
With a constant shortage of direct care workers in the United States, can a nursing home afford to put models such as Wellspring and others into practice without encountering problems? Will there be conflict between top nursing home management and direct care workers? Will all direct-care staff support newer concepts of care management?
- Medicaid rules
The care of two-thirds of nursing home residents is covered by Medicaid? How might Medicaid rules affect a nursing home’s efforts to change its environment? Medicaid rules limit the use of private rooms by Medicaid residents, for example, and they also may limit the amount of social space available. Can expenses of a private room be covered by Medicaid?
Notes
1. Although the term “culture change” can embrace quality improvement strategies, this paper does not address the types of regulatory approaches or fiscal incentives (such as “pay-for-performance” initiatives) that are intended to improve quality in a nursing home. The focus here is on person-centered approaches to quality of life issues.
2. According to one source, 90 percent of traditional nursing homes rotate staff from one group of residents to another after a period of time, making it difficult to build relationships with any one resident.
3. The University of Minnesota received a 2005 foundation grant for a study, “Comparing State Regulations Affecting Nursing Homes: Implications for Culture Change and Resident Autonomy.” The study includes a website (http://www.hsr.umn.edu/NHRegsPlus) that allows users to examine and compare content of state nursing home regulations to review innovative nursing home designs accomplished within existing regulations, and to view state regulatory initiatives to foster culture change.
Resources
Pioneer Network: http://www.pioneernetwork.net/
The Eden Alternative official website: http://edenalt.com/
The Commonwealth Fund (http://www.commonwealthfund.org/) has several publications on nursing culture change under the topic “innovations”:
- “Case Study: Elder Homes Replace Nursing in Tupelo, Miss.” March 12, 2007
- “Improving the Quality of Nursing Home Care: The Wellspring Model.” August 6, 2004.
- “A Resource for Culture Change at Nursing Homes.” July 14, 2004.
Contact for more information
Donna Folkemer
Group Director, Forum for State Health Policy Leadership
National Conference of State Legislatures
(202) 624-8171
donna.folkemer@ncsl.org
Funding for this project was made possible through funding from the U.S. Administration on Aging. The views expressed in written materials or publications do not necessarily reflect the official policies of the Department of Health and Human Services nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.
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