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Investing in Nursing Home Transformation: A Toolkit for States

The State Investment in Culture Change Toolkit, created by the Institute for the Future of Aging Services, the research arm of the American Association of Homes and Services for the Aging, aims to help states play an active role in getting nursing homes to initiate or expand "culture change" efforts. (Culture change is a national movement working to help nursing homes transition from institutional to home-like places where people want to live and work.) This Commonwealth Fund–supported publication examines how government agencies and key organizations in seven states supported and promoted culture change activities; other states can build on these models to promote culture change in their own nursing homes.

The Issue

States have a major investment in the quality of care and life offered in nursing homes. Not only do states pay for nursing home care though Medicaid, they also license and regulate facilities, oversee funding for training programs for direct-care workers, and credential professional staff working in nursing homes. Yet despite their influence and stake in improving nursing homes, relatively few state governments have played a significant role in bringing about culture change in the industry.

Target Audiences

State officials and policymakers involved in reimbursing or regulating long-term care; long-term care organizations; consumer advocacy groups

The Tool

The "State Investment in Culture Change" project looked at seven states—Georgia, Kansas, Massachusetts, Michigan, North Carolina, Oregon, and Vermont—that made financial and human resource investments to support culture change initiatives in nursing homes. The states developed programs and activities that can guide other states interested in making similar investments.

The toolkit highlights features that contribute to the successful implementation of culture change activities across states, such as funding from Workforce Investment Boards; the buy-in of state survey agencies involved in regulation; and improved relations between state agencies, between state officials and providers, and between provider associations and consumer advocates.

The toolkit organizes its descriptions of the initiatives into three areas: Workforce Improvement Initiatives; Person-Centered Care Initiatives; and Continuous Quality Improvement Initiatives. For example, to address the lack of career advancement opportunities for certified nursing assistants, the North Carolina Department of Health and Human Services and North Carolina Board of Nursing convened a large group of stakeholders, including nursing home representatives, mental health providers, pharmacists, nurses and nurse educators, to develop a new class of workers. They divided into two taskforces, one focusing on the development of the curriculum and the other on the competency evaluation. When these pieces were in place, the state then passed legislation creating a new job category called "medication aide."

In addition to including related documents and contact information to learn more about such initiatives, the toolkit offers an appendix listing resources available outside of the seven states.

For More Information

 Visit the American Association of Homes and Services for the Aging Web site at to download the complete toolkit or browse the sections online.

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