With Fund support, Charles Phillips, of the Texas A&M University System Health Science Center, and the National Citizen's Coalition for Nursing Home Reform surveyed consumer advocacy groups to gauge awareness of nursing home culture change. The survey revealed that consumer awareness of the movement has grown, though many people still have doubts about the industry's capacity to effect significant change, especially in the for-profit sector.

Culture change often requires seed money. Cynthia Rudder, Ph.D., executive director of the Long Term Care Community Coalition, and Charlene Harrington, Ph.D., of the University of California, San Francisco, investigated how states have been using the often sizable funds that accumulate from federal and state civil monetary penalties and fines imposed on nursing homes for providing poor care.⁽⁷⁾ The Fund-supported researchers found that several states are using the funds to sponsor culture change projects: for example, Maryland supported a Wellspring alliance, while Kansas helped fund development of the culture change toolkit described above. The majority of states, however are not using the penalty funds in such constructive ways, and some states have not collected any penalties at all.

Rudder and Harrington's study has led to several important changes. In New York, the findings helped convince policymakers to pass a bill authorizing the collection and release of civil penalties to support nursing home innovation. CMS, meanwhile, has begun to track penalty funds levied on behalf of the federal government.

From all of the evidence, it appears that the culture change movement is gaining momentum. Nursing home trade associations are realizing that their members can no longer do "business as usual." CMS and consumer advocacy groups are actively promoting resident-centered care. Researchers are becoming interested in measuring the impact of culture change.

But much work remains. Policymakers are, as yet, largely unaware of the movement, and the vast majority of nursing homes have yet to initiate systematic change. In the coming year, the Picker/Commonwealth Fund Program on Quality of Care for Frail Elders will work to raise the visibility of culture change among all those with a stake in long-term care. In the process, it will play an important role in making resident-centered care a reality in many more nursing homes.