From Clinical Care Facilities to Person-Centered Homes: Is Continued Change Possible?

Thanks to a broad coalition of resident advocates, human services organizations, and nursing professionals, the 1987 Nursing Home Reform Act marked what we may even be called a paradigm shift in nursing care. With an emphasis on the residents’ own emotional and social well-being, the law made nursing homes unique in the health care industry in that they were mandated to provide “person-centered care.” Nursing homes were to move from purely clinical institutions to real homes, where autonomy and dignity were emphasized.

In an informative and thought-provoking Health Affairs article earlier this year, Mary Jane Koren of the Commonwealth Fund argues that these changes have been ushered in by the “culture change” movement. This movement, a loose network of care providers, advocates, and others, encourages changes that are attuned to quality of life (the residents’ own sense of dignity and wellbeing) as much as quality of care (clinical, person-distant measurement outcomes).

In 1997, the Pioneer Network of consumer advocates, care-providers, researchers and regulators specifically articulated principles of culture change. Over the next 10 years this movement led to the growth of facilities where staff sought the input of residents and worked to make homes sites of fun and self-determination. Not only were new resident care practices emerging, but organizational, labor, and even architectural changes were coming into place.

At a 2006 meeting of the Agency for Healthcare Research and Quality, a culture change oriented, consensus definition of the “ideal facility” was developed. These facilities were to be, to the extent possible, resident-directed and homelike. Close relationships between residents, their families and facility staff should be fostered. Importantly, these weren’t just ideals—rather, several specific practices were encouraged to enable this culture change. For instance, the same nurse aids would consistently care for a given resident so they could get to know each other better.

In fact, hands-on staff would not only be closer to their patients, but would also be given more autonomy with decision making. Staff training would be centered on residents’ needs and desires more than solely on clinical outcomes. Also important was the consensus that culture-change improvements should be meaningful to residents and measurable by research.

Awareness of culture change grew quickly: While in 2005, a Commonwealth Fund survey showed that 73% of ”health care opinion leaders” were unfamiliar with the concept of change, a 2008 repeat of this survey showed this number down to 34%.  Koren also argues that culture change is being encouraged by a variety of government and industry practices. For example, certain state initiatives, such as Medicaid coverage for assisted living, are providing alternatives to nursing homes that force them to be more resident-centered in order to compete on the market. The emphasis on research-driven change has shown dramatic improvements in resident quality of life and work conditions for their staff caregivers.

While research such as the above has been positive, Koren argues that where research is lacking is on the business end: Is culture change cost effective? While several non-profits (such as Mather), and even one for-profit nursing home chain, have introduced a person-centered culture change initiative, the model is practiced by a minority of facilities. The Commonwealth Fund’s 2007 National Survey of Nursing Homes showed that only 5% of nursing homes meet the description of having undergone “culture-change,” and two-thirds had no plans to institute any culture-change practices. Most nursing facilities still retain a clinical orientation, and lack the staff hours and stability to pair quality of care and quality of life.

In her article, Koren blames “workforce, regulation, and reimbursement” for the relatively slow spread of culture change. For instance, the annual turnover rate for licensed administrators is over 50%, and the nursing profession hasn’t really prepared nurses for current work and care conditions. Safety-driven, liability-avoidant regulations interferes with both innovation and resident autonomy, reinforcing the clinical model. Although Koren proposes several regulatory, fiscal, civic, job-training, and research solutions, these challenges are daunting and expensive. On reading this thought-provoking conclusion, I wonder: will the demands of the market be enough create more person-centered culture change, or will budget-trimming and inertia win out when it comes to 21st century nursing care in the US?

More optimistically, Koren points out that the culture-change movement has proven that high-quality, person-centered care is not only possible but is preferred by consumers and workers. She concludes by saying that “a policy environment conducive to innovation, and supportive of both initial and sustained adoption of new models” might mean that “before the baby-boom generation needs long-term care… nursing homes will have become a better value proposition.” Koren suggests that research, among other changes, might foster such a policy environment.

Source: Mary Jane Koren (2010). “Person-Centered Care for Nursing Home Residents: The Culture-Change Movement,” Health Affairs 29(2).

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