Changing the Culture of Nursing Homes_ An Idea Whose Time Has

							Changing the Culture of Nursing
Homes: An Idea Whose Time Has
            Come
              Long Term Care Community Coalition
              (LTCCC)
              Richard J. Mollot, Executive Director
              March 2008
              All materials and resources are available for free
              at www.nursinghome411.org.
              This project was funded by the NY State Office
              for the Aging, Michael Burgess, Director.
Nursing Homes Now:
The Good and the Bad
What Good Things Do Nursing Homes
Do?


   Provide care and residence for people who
    can no longer live safely on their own.
   Place where people can have social activities
    and contacts – avoid isolation.
   What can you think of that is good about
    nursing homes…?
What’s Bad About Traditional Nursing
Homes?

   Unpleasant, institutional setting.
   Many residents receive poor care, including
    neglect and abuse.
   What can you think of that is bad about
    nursing homes…?
What is the Culture Change
Movement?

The culture change movement aims to de-
institutionalize the environment of nursing
homes.
It involves the transformation of nursing homes
from the traditional model to a more resident-
centered model.
What does the traditional nursing home
look like? – Organizational Structure

    Nursing Home Owner                      Hierarchical
                                            Authority and Control
        Administrator                        are “top down” starting
                                             with the owners &
     Director of Nursing
                                             administrators down to
  Professional Nursing Staff                 senior staff down to
        Nurse Aides                          workers down to
                                             residents (and, often,
         Residents                           their family members)
                        Family Members
What does the traditional nursing home
look like? – Physical Structure


                       Hospital ward like
                        setting
                       Central area with
                        nursing station, dining
                        and activity areas
                       Resident rooms branch
                        off in long corridors
                        away from central area
What does the traditional nursing home
look like? – Social Interaction

                       Long rows of residents
                        in wheel chairs lining
                        the halls
                       No consistent personal
                        care staff
                       Little interaction
                        between residents
                       Little interaction
                        between residents and
                        staff
We don’t have to – and should not –
accept the status quo.

   The Federal Nursing Home Reform Law (OBRA ‘87)
    celebrated its 20th anniversary last year.
   OBRA ’87 was a landmark law that came about as a
    response to the terrible scandals in nursing homes in
    the 1970s and 1980s and attempts by the Reagan
    administration to decrease nursing home oversight
    and enforcement of protections.
   It requires that nursing homes must ensure that
    residents receive quality of care sufficient to help
    them achieve or maintain their "highest practicable"
    physical, mental, and psychosocial well-being.
OBRA ’87: Resident Rights Provisions

   Each resident’s ability to walk, bathe, and perform
    other activities of daily living will be maintained or
    improved absent medical reasons;
   A resident assessment process is used, which leads
    to development of an individualized care plan;
   The resident has the right to remain in the nursing
    home absent non-payment, dangerous behaviors, or
    significant changes in a resident’s medical condition;
   New opportunities for potential and current residents
    with mental retardation or mental illnesses for
    services inside and outside a nursing home;
OBRA ’87: Resident Rights Provisions

   A right to safely maintain or bank personal funds with
    the nursing home;
   Rights to return to the nursing home after a hospital
    stay or an overnight visit with family and friends;
   The right to choose a personal physician and to
    access medical records;
   The right to organize and participate in a resident or
    family council;
   The right to be free of unnecessary and
    inappropriate physical and chemical restraints.
Where Does “Culture Change” Come
In?

   Culture change represents change and
    innovation, a different way of looking at
    nursing home care (from what we have come
    to expect when we go to a nursing home).
   BUT in many ways culture change is the
    realization of the mandate of OBRA 87.
   This means that we have a right to expect –
    and demand – the benefits of culture
    change now.
What does a culture change nursing
home look like? – Physical Structure

   Resident rooms are clustered in “pods” with lounge
    and dining areas and decentralized nursing.
 What does a culture change nursing home
 look like? – Organizational Structure

                                                        Resident is top priority,
                        Residents                        with direction and control
                                       Nurse Aides
                                                         emanating from him or
Family Members
                                                         her.
                  Professional Nursing Staff
                                                        Others come together
  Director of Nursing
                              Administrator              and interact to best
                                                         serve resident and those
               Nursing Home Owner                        most important to
                                                         caregiving and quality of
                                                         life: nurse aides and
                                                         family members.
What does a culture change nursing
home look like?

                    Rooms are laid out in
                     more community-like way.
                    Worker stations and social
                     areas are de-centralized.
                    Residents are full
                     participants in the
                     community.
                    Homes are truly home-like.
Almost Home
A Film About Culture Change in Real Life

   The story of St. John’s Nursing Home in
    Milwaukee: a traditional nursing home that is
    now instituting culture change.
   Residents, their family members, direct care
    workers and administrators come together to
    create a nursing home that is a true
    community.
   But, like any community, there are difficulties
    and challenges.
Almost Home:          Group Discussion


   What are the achievements here (verses
    what you expect a nursing home to be like)?
Almost Home:          Group Discussion


   What challenges did you notice to achieving
    culture change?
Beyond the Movie: Making Culture
Change a Reality in Our Lives

   There are several ways in which people and
    groups across the country are making culture
    change a reality in their communities.
   At its core, each method focuses on
    respecting the resident, providing
    individualized care and a living environment
    that is truly a home.
The Green House Project

   The vision of William H. Thomas, M.D., a Harvard-
    educated geriatrician from upstate New York.
   A Green House is a self-contained dwelling for
    seven to 10 people that is designed to look like a
    private home.
   Each resident has a private room and private
    bathroom.
   Each residence has a central hearth with open
    kitchen and dining areas, short hallways and a
    common living room area.
The Green House Project

   Residents can share meals together and with their
    families and caregiver staff.
   A separate caregiving “team” (including nurses,
    social workers, nutritionists, etc…) supports
    residents in multiple houses, with one nurse
    specifically assigned to two homes.
   There is no set routine in terms of medical care or
    institutional organization, except as determined by
    the community and needs of its residents, just as in
    a typical home.
Other Models of Culture Change

   Culture change can take varied shapes and
    forms in response to the community it serves.
   Some are very small, like the Green House
    Project.
   Some are larger, like the home in the film,
    that have been refitted.
   Other names: Eden Alternative, Pioneer
    Network & Wellspring Institute.
Exercise 1: Moving on From
Traditional Nursing Homes

      KEEP              CHANGE

1.                1.

2.                2.

3.                3.
Exercise 2: Moving toward a Culture
Change Nursing Home

     POSITIVES          NEGATIVES

1.                 1.

2.                 2.

3.                 3.
What can we do to make the positives of
culture change a reality in our communities?

   Form a state coalition to advocate specifically
    for culture change?
   Educate people in our communities through
    family councils; church, temple or mosque
    committees; senior centers?



Resources

Go to www.nursinghome411.org for:
 more information on culture change movements, like
the Greenhouse Project, that are making a real
difference in the lives of nursing home residents in
communities across the country;
 resources you can use to learn more and educate
people in your community about the benefits of culture
change, financial options, etc… to build support for
culture change;
 copies of today’s presentation and other materials.