C. Haran, Transforming Long-Term Care: Giving Residents a Place to Call "Home," The Commonwealth Fund, April 2006
Watch a slide show about the "resident-centered care" movement in nursing homes.
Watch a video overview about culture change by program director Mary Jane Koren, M.D., as well as a clip from CBS' "The Early Show" about Fund grantee Stephen Shields, CEO and president of the Meadowlark Hills retirement community in Kansas.
Many Americans dread nursing homes. They smell the disinfectant, picture infirm elderly people in wheelchairs in the halls, and shudder. It's no wonder that so many people consider placement of a family member in a nursing home akin to outright abandonment. They don't see Grandpa moving to a new home that will meet his special needs; they simply see him being institutionalized.
However, the picture is changing. While many nursing homes still do function like impersonal and regimented institutions, over the last decade, a grassroots movement in long-term care known as "culture change," or "resident-centered care," has begun to spread throughout the country. Seniors in nursing homes that have undergone culture change enjoy much of the privacy and choice they would experience if they were still living in their own home.
"The idea is a small group of elders living together with their own staff dedicated to them," explains LaVrene Norton, the executive leader of Action Pact, Inc., a Milwaukee-based company that provides consulting and training to facilities interested in adopting resident-centered care practices. "The elders are living in their own house, defining their own day, and building the relationships they want."
A Paradigm Shift
The resident-centered approach, currently being practiced in somewhat different ways by the nonprofit nursing home collaborative Wellspring Innovative Solutions for Integrated Health Care, the Mississippi-based Green House Project, and the Meadowlark Hills retirement community in Manhattan, Kansas, among others, aims to enhance the satisfaction of residents, families, and staff members by raising the quality of care and of life experienced by the residents while ensuring that their rights are upheld. The key is to foster a culture in which the residents come first and the facilities operations' are shaped by this awareness. Culture change is also being adopted by a number of for-profit nursing homes that are a part of Golden Gate National Senior Care (formerly Beverly Enterprises). In addition, culture change is recognized by the federal Centers for Medicare and Medicaid Services through that agency's support of state quality improvement organizations, such as Quality Partners of Rhode Island.
"When I think about what's happening in the industry, I think there is a deep paradigm shift," says Leslie A. Grant, Ph.D., the director of the Center for Aging Services Management at the University of Minnesota. Grant, who led a Commonwealth Fund-supported evaluation of the culture change initiative at Beverly Enterprises (now Golden Gate National Senior Center), believes there is increasing awareness within the nursing home industry that the institutional model is not going to lead to a higher level of performance. "What's driving culture change is not short-term business goals—such as revenues or market share—but more of a long-term strategy to differentiate their company or facility from others by proactively addressing what's important to key stakeholders."
Indeed, the resident-centered approach not only makes life better for residents and staff, but it has forced nursing homes to change their culture to remain competitive at a time when new long-term care choices such as assisted living—which allows elders to remain in the community—are gaining in popularity. One factor driving the adoption of culture change may be the hope that a more livable and flexible environment will help nursing homes compete for baby boomers, who started turning 60 this year.
A Culture Change Community
Several organizations have been instrumental in igniting and sustaining the culture change movement, including Action Pact, a consulting organization that produces training videos and workbooks; Eden Alternative, an early model of culture change; and the Pioneer Network, which hosts national conferences and regional training sessions on culture change and provides an area on its Web site called "Pioneer Exchange" where people can share their stories and post their questions.
"We provide common ground where people can come together and tap into a shared energy," says Joe Angelleli, director of networking and development at the Pioneer Network. "[Culture change] takes leadership buy-in and the Pioneer Network has a role to play in holding leaders' feet to the fire and connecting them to resources."
Defining and Measuring Culture Change
While some worry that a resident-centered care approach will make life harder for nursing home staff while de-emphasizing the quality of clinical care provided, the evidence so far suggests the opposite. Fund grantee Stephen Shields, president and CEO of Meadowlark Hills, observes that staff turnover at his facility has dropped by more than 50 percent, and clinical outcomes have improved, too.
Yet, as the movement has gained momentum, it's become clear that resident-centered care needs to be measurable. Long-term care facilities must be able to identify the steps required and to assess their progress along the way.
In an effort to create a "roadmap" for facilities, both Grant and Norton have identified five areas within an organization that are transformed by culture change: decision-making, leadership, staff roles, the physical environment, and organizational design.
In the culture change model, greater control is given to "frontline" workers—the nurse aides who handle so much of the day-to-day care of residents—as well as family members and residents. Additionally, staff are permanently assigned to a particular group of residents as members of self-directed work teams. Rather than working in a single department, such as nursing, housekeeping, or food service, staff functions are blended so that all staff members can help residents with their personal care, lead activities, and do cooking and light housekeeping.
The physical and organizational structure of the facilities also becomes less institutional. Instead of having rooms off long double-loaded corridors, the facility is divided into "neighborhoods" and smaller "households" with their own names and often their own entrances. Each household has its own kitchen and comfortably furnished living room.
According to Action Pact's Norton, different facilities face different problems as they learn to accept and adapt to the principles of culture change. "The biggest challenge is often for the management team to scoot over and make room for informal leaders," she says. "When they do, very exciting things happen right away, but it's a struggle to change one's practices."
Pennybyrn at Maryfield, a long-term care facility in North Carolina that has worked closely with Action Pact, is currently transforming its staff and facility into a household model. For its leadership, the turning point was a visit to Meadowlark Hills.,
"We visited Meadowlark Hills and walked away convinced that now that we knew [culture change] was possible, we had to do it," says Rich Newman, executive leader and president of Pennybyrn, which is expected to begin construction on its first household in March. "We wanted to take on the renovation, the organizational change, the whole transformation... We got excited about the possibilities."
Pennybyrn's culture change effort got under way about two and a half years ago when—after gaining the support of residents, board members, and staff—the facility dismantled its formal leadership group of traditional department heads. The new team established in its place includes the former department heads as well as frontline workers, such as nursing assistants and housekeeping staff. The first opportunity to blend staff roles occurred though the transformation of the breakfast process.
Today at Pennybyrn, rather than waking at 7 a.m. to a tray of often-cold food served in bed, residents can wander into the dining hall at 7:30 or even 10:30 and order breakfast cooked-to-order from a menu. And because a number of housekeepers wanted to be involved, they have juggled their own schedules to become part of the breakfast experience.
"It's empowering for residents. Breakfast is what starts off the day, and they absolutely love it," Newman says. He points out that other developments, such as the creation of a new sitting area in the dining room suggested by staff and residents, have flowed from the new approach to breakfast. "We've had a 50-year history of a hierarchical structure. This really is countercultural."
The importance of direct care workers in the transformation of a nursing home's culture has been demonstrated by a study of certified nurse aids (CNAs) conducted by Dale E. Yeatts, Ph.D., a professor of sociology, and Cynthia M. Cready, an assistant professor of sociology, at the University of North Texas in Denton.
"Because CNAs are the ones who actually work with residents, if they don't change how they treat the residents, there is no culture change," says Yeatts, who writes that CNAs "know better than any other employees the likes and dislikes of residents, including what they want when they wake up in the morning (e.g., a glass of water or the newspaper), how they would like their hair combed, and what they want to wear when they go to bed at night."
Yeatts and Cready's study compared five nursing homes with no intervention with five homes in which nurse aids were organized into "empowered" teams that met weekly. These teams share supervisory responsibility, such as decisions about assigning tasks, scheduling, and monitoring of performance. Preliminary results show that after 16 months, CNAs and nursing staff reported CNA performance was higher, and family members and residents reported that resident care had improved—CNAs spent more time with residents and gave residents more control than they did before the teams were implemented.
Yeatts argues that many culture changes initiatives don't emphasize the role of direct care workers enough, noting that proper implementation of the team approach is critical to its success.
One of the critical questions facing the movement now is how to take culture change mainstream. "If you're going to make this normative and you're focusing on 16,000 nursing homes, that's a lot more difficult than focusing on early adopters," says Robyn Stone, Dr.Ph., executive director of the American Association of Homes and Services for the Aging's Institute for the Future of Aging Services, who observes that researchers now have to prioritize the various elements of culture change so that nursing homes with limited financial resources will know how best to invest their funds.
Stone conducted an evaluation for the Fund of the Wellspring module of nursing home care, which involved an alliance of 11 homes. "One of the powerful things about the evaluation was the importance of the alliance and peer mentoring at the organizational level to not only implement but sustain [culture change] activities."
Given the radical and challenging nature of culture change, the University of Minnesota's Grant warns long-term care administrators and staff that the process is not easy, "especially when you're starting to push the ball uphill. But once you're at the top, it'll just go."