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Making Nursing Homes Desirable Places to Live and Work

Mary Jane Koren

By Mary Jane Koren

Today, nursing homes are familiar places for many Americans—either they have family or friends who have been in a nursing home or they live in one themselves. And we are likely to get even better acquainted with nursing homes. By 2030, almost one of every five Americans—72 million people—will be 65 years or older, according to U.S. Census data. Moreover, nursing homes are increasingly being used for post-hospitalization rehabilitation.

Nursing Home Culture Change

Even though nursing homes are an established part of our long-term care system, most people dread the thought of living in one. The nursing home "culture change" movement is trying to change that. It is working to transform nursing homes from places that put institutional imperatives ahead of the needs, rights, and interests of the residents to places where residents come first. Picture a nursing home where you can stay up late to watch the end of a movie, get yourself a midnight snack, and then be helped to bed by an aide who knows all your quirks and enjoys listening to your stories. This evening is light years away from the usual way of doing business.

The Commonwealth Fund's Quality of Care for Frail Elders program recently surveyed a nationally representative sample of 1,435 nursing homes to learn how far the culture change movement has spread and to measure the extent to which nursing homes are adopting culture change principles and practicing resident-centered care. The survey was completed by directors of nursing. (In collaboration with the Pioneer Network, The Commonwealth Fund hosted a May 19 webinar on the survey findings; a recording of the event is available.)

The survey results are promising, although mixed. While few nursing homes were familiar with the term "culture change" several years ago, it is now known to almost all providers. Forty-three percent of nursing homes continue to follow the traditional model, but 31 percent say the definition of a culture change or resident-centered approach completely or for the most part defines their nursing home, and an additional 23 percent report they are committed to culture change even though it does not yet describe their facility.

Culture change includes initiatives that give residents more control over their lives, such as letting people get up when they want to and choose what to wear. Organizational changes need to be made as well. For example, for aides to really get to know residents, it's important that the same aide always take care of the same resident—a practice called "consistent assignment." Culture change homes involve certified nurse aides in care planning and decision making.

While the survey showed that such initiatives are becoming more common, relatively few homes have made alterations to their physical environments, such as eliminating the nurse's station or setting up small "households" rather than the typical long corridors with a large recreation/dining hall. The survey also showed that the more culture change initiatives that are under way, the greater the benefits in terms of staff retention, higher occupancy rates, better competitive position, and improved operational costs.

A Need for Knowledge

Long-term care providers and their staff, regulators, and especially consumers are hungry for information about how to make nursing homes better places to live and to work. The industry's response to the Advancing Excellence in America's Nursing Homes Campaign, of which I am this year's steering committee chair, reflects that interest. More than 6,800 nursing homes, or 43 percent of all homes in the country, have registered for this voluntary campaign. When a nursing home joins the campaign, it has to select at least three goals from the campaign's eight target areas, four of which address clinical problems such as reducing pressure ulcers, and four of which focus on operational issues such as reducing staff turnover. The participating nursing homes are asked to submit data to the campaign showing their rates of improvement. Anyone can go to the Advancing Excellence website at to find updates on the number of participating nursing homes and the percentage of nursing homes that selected particular goals. The campaign is open to consumer participants, as the supporting organizations are interested in hearing directly from consumers and involving them, as well as frontline staff, in efforts to improve nursing home quality.

The Advancing Excellence's Local Area Networks for Excellence (LANEs) are a key part of the campaign. LANEs are state-based coalitions that provide technical assistance for nursing homes as they work toward the campaign goals. They also work within the states to raise awareness and encourage and promote enrollment in the campaign. Their work is making a difference. For instance, a recent webinar on treatment of pressure ulcers marketed through the LANEs had 1,800 registered participants, more than 10 percent of the entire industry, with about 5,000 listening on shared lines. For organizations working at the state level in the LANEs, my thanks—nursing homes need the support and learning opportunities you are providing.

In the meantime, researchers must further explore how adoption of resident-centered care practices translates to improved quality, as well as how best to reward nursing homes that have adopted culture change through reimbursement and other incentives.

I encourage nursing homes to join the Advancing Excellence campaign and set performance goals, focusing on areas that are fundamental to becoming a resident-centered, high-performing organization, namely reducing staff turnover and making sure nurse's aides have the opportunity to know the people they are caring for through consistent assignment. In addition, I urge consumers, advocates, and frontline staff to join the campaign. It is only with your help that lasting change will be effected. Together, we can improve the lives of the millions of people who call nursing homes "home."

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May 2008

Written with the assistance of Christine Haran

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