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New Roles for States in Changing the Culture of Long-Term Care

In this Ask the Expert column, we talk with Bonnie Kantor, executive director of the Pioneer Network and a leader in the national "culture change" movement for the transformation of long-term services for older adults.

What is the goal of culture change and how would you describe progress to date?

Culture change refers to the progression from institutional or traditional models of care to more individualized, consumer-directed practices that embrace choice and autonomy for care providers and recipients. For example, residents living in nursing homes that provide resident-centered care go to bed and wake when they want, eat what they want when they want, and create their own living spaces in the rooms. This kind of care not only enhances quality for consumers and staff but also creates opportunities for the organization to improve operational benchmarks in areas such as quality of care, efficiency of operation, revenue generation, and stabilized staffing.

While many specific approaches have been developed in care settings, the core values that unite them are choice, dignity, respect, and self determination. Person-centered long-term care environments, ranging from nursing homes to home- and community-based settings, become places where elders can continue to make their own choices, have control over their daily lives, and practice self-determination in meaningful ways. The transformation accompanying culture change requires changes in organizational practices, physical environments, workplace practices, and relationships.

Because we now are able to articulate operational linkages between person-centered care, quality of care, and financing, culture change has progressed from a grassroots movement to one that is embraced and supported by policymakers, providers, national and state associations, and CMS. Most specifically, we have moved from a discussion of "culture change at what cost" to "culture change at what gain." And, of course, health care reform now provides the support of policymakers and the strength of policy to further change the culture of aging in America.

Could you provide a recent example of CMS support or participation in the culture change movement?

CMS has been supportive of culture change since the beginning of the movement in 1997. A good recent example of this commitment is the national symposium CMS cosponsored with the Pioneer Network in 2008. Creating Home in the Nursing Home: A National Symposium on Culture Change and the Environment was convened to promote discussion, dispel barriers, and coordinate action that supports culture change in nursing home environments. This was a groundbreaking effort to broaden and deepen the discussion of the linkages between resident-centered implementation and the regulatory environment. Chief among the outcomes are the 2009 revision to the Interpretive Guidelines. As a result, surveys are now being conducted with a sharpened focus on elements of quality of life. The new guidelines enhance instructions to surveyors on how to evaluate compliance with areas such as resident choices about daily schedule—including when to get up, got to bed, eat, and bathe.

Does health reform support culture change priorities?

Health care reform is not only consistent with culture change, but it actively promotes culture change principles and practices. As components of heath care reform focus on improving the quality and efficiency of our health care system, they also strengthen long-term care options that give seniors more choice about and over their care. The inclusion of person-centered care in health care reform has multiple implications for addressing the complexities of Medicare and Medicaid, since cost and efficiency improvements resulting from culture change have the potential to reduce outlays from government resources.

In addition, some of the market and fiscal challenges addressed in health care reform can be ameliorated by culture change, since organizations work with and for their communities and operate with greater efficiencies while providing superior care to consumers. For example, the looming crisis of direct-care provision addressed in health care reform is one that affects both elders and our vulnerable population of direct-care workers. Culture change in action empowers these frontline workers, resulting in improved turnover rates and care enhancement.

What specific improvements relating to culture change are likely to result from national health reform?

The Affordable Care Act includes the "National Demonstration Project on Culture Change" for the development of best practices in skilled nursing facilities and nursing facilities that are involved in the culture change movement, including the development of resources for facilities to find and access funding in order to undertake culture change. (Section 6114). We believe the goal of this section is to showcase the best of culture change to make it applicable to every nursing home in the country.

While many other sections of the Affordable Care Act promote person-centered care, I'd like to mention two others that are of special interest to the Pioneer Network. Section 6111 (page 649) sets aside Federal Civil Money Penalty (CMP) funds, which currently are deposited to the U.S. Treasury, to provide a stable funding stream for resident-centered care. In addition, Section 6107 (page 649) describes a General Accountability Office study on the Five-Star Quality Rating System for nursing homes. The purpose of this study is to determine how the system is being implemented, identify problems, and suggest improvements. This rating system, launched by CMS in December 2008, is intended to help consumers assess care settings, but currently there is no "star" (i.e., measure) for quality-of-life indicators. What a tremendous opportunity this provides us all to include the kinds of quality-of-life measures that are so important to consumers of care.

With this increased level of support for culture change in policy, the shift from an institutional to a person-centered model of care is clearly on the horizon. Culture Change has "come of age" in the Affordable Care Act.

What role does state government play in culture change?

In addition to the federal focus and dialogue, state governments and state-level organizations are becoming more active in the field and are significant contributors to the discussion and dissemination of culture change transformation. More than 35 state culture change coalitions, many of which include representatives of state government, focus on advancing person-centered care in their states. In addition, state survey agencies, ombudsman programs, and the Department of Aging are often supports or the catalysts for change in their states and communities.

Payment reform is another key arena for states. For example, pay-for-performance programs in states such as Colorado create incentives for culture change through increased Medicaid reimbursement. Many states also provide funding through the use of Civil Monetary Penalties for the activities of state culture change coalitions and person-centered initiatives. In nursing home environments, the Association of Health Faculty Survey Agencies—recognizing its own need to review its practices—has formed an Individualized Care Committee and each state survey agency is designating a "culture change lead" to pursue resident-centered initiatives and efforts.

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