Summary: Serious quality problems are endemic at many of the nation's 16,000 nursing homes. But an innovative approach, the Wellspring Model, holds promise for upgrading the quality of care for residents by combining clinical and cultural change. The Wellspring Model establishes an ongoing learning collaborative among a network of peer nursing homes that—through technical assistance, peer support, and a set of training modules for teams of nursing home workers—can help to achieve these goals. Thus far, 80 facilities around the country have formed "alliances" to work together to improve care. Alliances are coalitions of nursing homes that function like quality improvement collaboratives. They pool their forces to exchange performance data, conduct group training, and develop strategies to solve common challenges. A 2002 evaluation of the Wellspring Model showed that it could improve clinical care without raising costs. While each of the participating facilities made an investment in organizational resources, facility staff believed they experienced savings in areas such as reduced laundry costs and continence supplies due to scheduled toileting. Reduced staff turnover also led to savings.
The Issue: Despite the passage of major reforms in 1987, the U.S. General Accounting Office has found that one-fourth of the country's 16,000 nursing facilities have serious deficiencies that cause actual harm to residents or place their health and safety at risk. In 2001, annual turnover in nursing home nurses aides was at 40 to 75 percent nationally and exceeded 100 percent in certain facilities. New research finds that staff shortages, insufficient training, and disenfranchised workers are at the root of the quality problem. Many nursing home operators, state and federal regulators, and consumer advocates believe that—unless staffing problems are solved—quality will not improve significantly.
Objective: The Wellspring Model aims to 1) enhance the quality of resident care and 2) improve the working life of nursing home staff. It provides a structure and set of processes for quality improvement, supported by a network of colleagues that work together to achieve shared goals.
Organizations: Formed in 1994, Wellspring Innovative Solutions for Integrated Health Care is an independent, not-for-profit organization. It began with a group of 11 "charter" nursing homes that formed the first Wellspring Alliance in 1994. Since then, about 80 nursing homes have adopted the Wellspring Model, including 35 currently active Wellspring facilities and 40 that still use the alliance model to conduct group training and otherwise pool their efforts.
Target Populations: Nursing home residents, frontline workers, and administrators
The Intervention: The Wellspring Model combines resident-directed care concepts, staff empowerment, and clinical training modules. Facilities that belong to Wellspring alliances provide their frontline workers—particularly certified nursing assistants—with training in nationally recognized best practices on subjects such as nutrition, feeding, palliative care, leadership, and pain management. Training is based on problem-solving techniques and supplemented with a blueprint for action that helps administrators and managers translate ideas into everyday practices. At the same time, participating homes give their frontline workers a voice in how their work should be performed. The model assumes that care decisions need to take place close to the residents, and that an empowered workforce increases resident and employee satisfaction and reduces staff turnover. All Wellspring facilities collect and share clinical data from residents concerning the prevalence of incontinent episodes, number of falls, weight loss, and other problems. They follow a set of guidelines to help them use such data to monitor performance and improve care.
The Wellspring team recently introduced a management curriculum and self-assessment tool to encourage culture change among nursing home leaders. This "Leadership Module" was developed by Leslie Grant, Ph.D., of the Carlson School of Management, University of Minnesota. Nursing home administrators attend a one-day session to learn about the Wellspring Model and define what culture change looks like in practice. Then, attendees use a Culture Change Staging Tool to benchmark their performance in a number of areas, including leadership, education, staff development, and communication, and target resources where they are most needed. Six weeks after the initial session, nursing home leaders attend a two-day training session to articulate their plans and gain the skills needed to put them into action.
These leaders form "implementation teams," a concept developed by Barbara Bowers, R.N., Ph.D., of the University of Wisconsin School of Nursing. To facilitate changes on the ground and serve as a liaison with nursing home administrators, at least one member of each implementation team is embedded with frontline staff. According to Tom Lohuis, chief executive officer of Wellspring Innovative Solutions, "The Leadership Module has been integral in connecting administration to the line staff working teams and providing them with the resources to be more effective and successful."
Results: A 2002 Fund-sponsored evaluation comparing the charter Wellspring nursing homes with other Wisconsin facilities found promising results:
- The retention rate for Wellspring nursing staff increased over the four-year study period, from 70 to 76 percent. Among non-Wellspring homes in Wisconsin, the retention rate fell, from 74 to 68 percent.
- Wellspring facilities performed better on annual inspections conducted by the state department of health. Nursing homes had significantly fewer deficiencies after implementing the Wellspring model—1.9 average deficiencies before implementation vs. 0.8 deficiencies after implementation. The proportion of severe deficiencies in Wellspring homes fell from 22.2 percent prior to implementation to 0.0 percent after.
- Some evidence suggests that Wellspring staff are more vigilant in assessing problems in quality and take a more proactive approach to resident care.
- Based on observation and interviews, Wellspring residents enjoyed a better quality of life and benefited from improved interaction with the staff.
- No additional increases in net resources were required for the model's implementation, and Wellspring facilities generally had lower costs than other nursing homes.