South Carolina Nursing Home Blog : South Carolina Nursing Home Lawyer & Attorney : Poliakoff & Associates Law Firm : Elderly Care, Senior Care

Chicago Tribune had an article about the transformation of the culture at nursing homes.  The article discusses Bethesda Home and Retirement Center. Traditionally, the world of nursing homes have been run like highly regimented mini-hospitals. Bethesda made a change two years ago taking its first step to join a movement that hopes to transform the nation's nursing homes.

The "culture change" movement seeks to get these facilities to alter their physical layout and their caregiving practices to create homelike environments where residents are seen not as passive recipients of care but as individuals with control over their lives. Nursing homes that embrace the new philosophy are letting residents decide when to bathe, eat and sleep; allowing them to organize their own activities; and redesigning nursing units into small "households."

Advocates say residents in such homes are happier and healthier; the employees have more job satisfaction; and giving care this way even costs less. The idea is not new. The Pioneer Network, a national umbrella group of nursing home providers and consumer advocates, has been promoting it since it was formed in 1997.

Yet only 25 percent of the nation's nursing homes say they have "for the most part" embraced culture change, according to a 2007 survey by the Commonwealth Fund, and only 5 percent say they have done so "completely."

Nursing home operators, who are under tremendous pressure to cut costs, are often afraid that culture change would cut into their profits.  However, flexibility is more cost-efficient.

The experience of the Bethesda Home illustrates the challenges. Janet Meyer, the home's director of nursing, had proposed a single change: letting residents sleep late. But "that's a bigger deal at a nursing home than you might think," she said.

Mealtime practices had to be changed to accommodate late risers. Housekeeping had to be done more flexibly to avoid waking residents for vacuuming.

Most challenging, the morning medication system had to be changed. Nursing homes traditionally give out medications during a two-hour period. But if residents were allowed to sleep late, Bethesda could no longer give morning medications only between 8 and 10.

So the home made another change: Residents could get their morning medications any time between 6 and noon, by individual request.

Other practices were loosened too. At staff meetings, administrators told employees that they needed to be flexible and perform caregiving tasks like bathing when residents wanted them.

The Health Reform Act passed in March calls for conducting demonstration projects at nursing homes to establish the best ways to effect culture change. So many organizations and government agencies are now working toward culture change that "everything is in place for widespread dissemination," said Bonnie Kantor, executive director of the Pioneer Network.

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A group of nursing organizations released a list of 10 nurse competencies for nursing home culture change. The new list is the result of a joint effort by the Hartford Institute for Geriatric Nursing, the Coalition of Geriatric Nursing Organizations and the Pioneer Network. See Pioneer Network website here with the list of 10 competencies.

The organization convened a panel of 31 experts in nursing and other areas to explore the role of nurses in the culture change movement. The competencies include effective communication skills, creating a system to maintain consistency of caregivers for residents, and including residents and families in shared problem solving, decision-making and planning. Here is a summary of the list:

1. Models, teaches and utilizes effective communication skills such as active listening, giving
meaningful feedback, communicating ideas clearly, addressing emotional behaviors,
resolving conflict and understanding the role of diversity in communication.
2. Creates systems and adapts daily routines and “person-directed” care practices to
accommodate resident preferences.
3. Views self as part of team, not always as the leader.
4. Evaluates the degree to which person-directed care practices exist in the care team and
identify and addresses barriers to person directed care.
5. Views the care setting as the residents’ home and works to create attributes of home
6. Creates a system to maintain consistency of caregivers for residents.
7. Exhibits leadership characteristics/ abilities to promote person-directed care.
8. Role models person-directed care.
9. Problem solves complex medical/psychosocial situations related to resident choice and risk.
10. Facilitates team members including residents and families, in shared problem-solving,
decision-making, and planning.

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McKnight's site had an article and Science Daily also ran an article about how nurses and relatives routinely fail to detect the severity of chronic pain among nursing home residents, especially those with cognitive impairments, according to a new study in the September issue of the Journal of Clinical Nursing.

The five-year study from The Netherlands followed 174 nursing home residents at six different facilities. A total of 171 nurses and 122 relatives also took part in the study. Researchers conducted interviews with the non-cognitively impaired residents to determine how much, if any, pain they had reported in the week prior to the interview. Relatives and healthcare staff find it hard to diagnose pain levels in nursing home residents accurately, especially if they are cognitively impaired with illnesses such as dementia or unable to speak, according to a study .

The findings have led experts from The Netherlands to call for nurses to be given more education about how to assess and treat chronic pain and encouraging greater mobility and providing soothing massages, to alleviate pain.

Previous studies have shown that some people with mild or moderate cognitive impairment are still able to use simple zero to ten scales, where zero is no pain at all and ten is the worse pain imaginable.   "When the team interviewed the residents without cognitive impairments they found that all of them reported pain in the last week, but that only 89 per cent of the caregivers and 67 per cent of the relatives were aware of that pain" says Dr Rhodee van Herk. "However, if they were aware that the patient had experienced pain, the nurses and relatives gave it a median score of six out of ten, with the same score reported by the patients."

Nurses and relatives were less unaware of pain levels when the patient was at rest. They gave their pain levels a median score of zero, compared with the patients, who gave it a median score of four out of ten. However relatives were more aware of pain issues than nurses, with their median scores ranging from zero to five, compared with nurses, who reported a median score of zero to two. 

In general, there was more agreement between residents and relatives on pain levels than between relatives and nurses.

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The Tracy Press out of California had an article about the death of a nursing home resident caused by the neglect and negligence of the nursing home.   New Hope Care Center which is owned by the for profit corporate owner Evergreen Healthcare Companies, LLC failed to properly monitor her medication and failed to check her into an emergency room fast enough when her brain started bleeding.  Caregivers failed to keep a close eye on the condition of the patient after a doctor ordered an increase in medication to prevent blood clots. A possible side effect of the medication is excessive bleeding. Because the nursing home staff didn’t monitor a change in the woman’s condition after the doctor upped her anticoagulant prescription, the state said they missed warning signs that could have saved the woman’s life.  Days after the doctor-ordered increase in her blood-thinning medication, the woman started slurring her words and complaining of a headache.  Even though the woman woke up just a couple hours earlier, she started nodding off, waking up only to vomit.

The facility was fined $100,000 after the nursing home ignored the worsening condition of a patient.  State investigators concluded that New Hope caregivers “failed to ensure that the resident’s medications were monitored and failed to fully assess the resident or promptly notify the physician when there was a change in the resident’s condition, which resulted in the resident’s death,” according to Al Lundeen, a spokesman for the state agency. The fine levied on the nursing home is the maximum penalty the agency can impose for a “AA” citation, the harshest assessment for hospitals and nursing homes in California.

The article mentions several other complaints and investigations into New Hope.

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The Charlotte News & Observer had a great article on how the culture of nursing homes are changing.  Hopefully, for the better. This culture change is long over due and is desperately needed in most nursing homes.  Instead of a hospital-style nurses' station, staff members talk with residents in an area that looks like a comfortable office, den and kitchen in someone's home.  The physical and organizational structure of facilities is made less institutional. Large, hospital-like units with long, wide corridors are transformed into smaller facilities where small groups of residents are cared for by a consistent team.   All this means that the center has adopted the long-term care approach known as culture change.

What does culture change mean?  In the culture change model, seniors enjoy much of the privacy and choice they would experience if they were still living in their own homes.  Residents' needs and preferences come first; facilities operations' are shaped by this awareness.  To this end, nursing home residents are given greater control over their daily lives -- for instance, in terms of meal times or bed times, and frontline workers -- the nursing aides responsible for day-to-day care -- are given greater autonomy to care for residents.

A symposium in Raleigh on Tuesday will examine facets of the movement's main tenet: that residents' preferences should guide the way nursing homes are run, not what's most expedient for owners and staff.   The label "culture change," or "resident-centered care," may give the approach a touchy-feely sound, but it's serious business to the several facilities in central North Carolina already adopting the changes. Some are even spending millions in building renovations to make it all work.

Changes at Hillcrest include:

Allowing residents more choice in schedules and dining choices, a move away from the structured regimes of many facilities.

Creating "neighborhood" halls with an approachable nurse's work station, small kitchen and den to service 16 or so residents. Carpeting, wall sconces and light wells that bring in sunshine create a homier appearance.

Having frontline workers such as certified nursing assistants take on some housekeeping and food-preparation duties so that residents get consistent care from fewer staff members.

Taking soiled laundry outside -- out of living areas -- as soon as it's gathered, avoiding waste smells not usually evident in homes.

Getting medicine and housecleaning carts off the halls when not in use, making for easier walking and less of a hospital-corridor feel.

Advocates for older people have pressed for better conditions in nursing homes for decades, but the specific improvements grouped as culture change have gained momentum during the past 10 years. A survey in 2007 by the Commonwealth Group, a national nonprofit, showed that about 30 percent of homes have adopted the approach, with an additional 25 percent striving toward it.  Hopefully, this kind of change will become madatory throughout the country.

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The Denver Post had an interesting article about new developments in elder care.  Facilities are trying to move away from institutional settings and make resident's stay feel more like home.

The article states that "a generation of retirees resists the fate of nursing homes they've grown to dread, supporters of a cultural revolution say they are reforming an industry long tainted by images of neglected patients languishing on soiled sheets".

Reforms will likely quicken in the next year as Colorado begins sending higher Medicaid payments to homes that make changes ranging from reducing bed sores to giving residents a peanut-butter sandwich on demand.   Critics of traditional nursing- home care are not ready to declare lasting success. Reforms at a given home too often depend on the energy and dedication of a few key staff members, and those changes are difficult to replicate in more than 16,000 nursing homes nationwide.

"In general, the quality of nursing-home care is really bad," said Charlene Harrington, a professor of sociology and nursing at the University of California at San Francisco who has studied national reforms. Truly improving care almost always requires increasing staff, she said.

"There's some basic merits to the idea of the culture-change movement," Harrington said. But "the nursing-home industry is trying to promote the idea you don't need the staff; you just change the culture. That's why I'm skeptical of the whole effort."

"The heart of it is just treating people the way you want to be treated," said Barbara Moore, administrator of Bruce McCandless Colorado State Veterans Nursing Home in Florence. Once entrenched in a notorious state nursing system, McCandless has won kudos for trying everything from consistently matching staff with the same patients to parking a Patton tank outside for grandkids to climb on.

Promotion of culture change or comparable reforms is vital for baby boomers who want to avoid mass warehousing in the coming decades. The U.S. population 65 and older will jump from 40 million in 2010 to 55 million in 2020, according to the federal Administration on Aging.

The vulnerable population 85 and older, meanwhile, will need many new care beds, with the population in that oldest group rising from 6.1 million to 7.3 million that same decade.
By all accounts, they want to avoid the nursing homes of their parents' day.

Another Medicare and Medicaid report in September said that more than 90 percent of U.S. nursing homes were cited for violating federal standards in the past three years, but those transgressions can range from improper food storage to acute medical problems.
Caring for the elderly, meanwhile, consumes a good share of the state budget.

In Colorado and across the country, nursing-home occupancy rates are flat or dropping even as the population ages. More families are keeping aging relatives at home, hiring home-health aides, or choosing newer and smaller assisted-living sites for patients who don't need extensive medical care.

Culture change can be as varied as adopting a cow for a pet or building a $1 million adapted home from the ground up to house only six residents — but the basic tenets across the country are consistent:

• Breaking from institutional schedules and rules in which residents must eat at common times or take showers at a rigid hour set by the staff.

• Training staff in resident-centered care and reassigning employees to more-consistent jobs.

• Some attempt to alter the physical monotony of nursing-home settings dominated by institutional 1960s and '70s architecture. Larger homes may parcel themselves into "neighborhoods;" others renovate with resident input on colors and materials; still more add gardens, meditation rooms or restaurant-style dining areas.

A national survey of the transformation of nursing-home culture found that 31 percent of homes had adopted significant portions of the movement. The results "indicate a hopeful picture about the potential for deep, systemic change within the industry," according to the Commonwealth Fund.

Proponents believe the new state reimbursement system for Medicaid will eliminate any reason not to participate in the changes being made.  Culture change is not more expensive in the long run — it can save on staff turnover, food costs and expensive acute care. But for managers concerned about immediate costs, the state program to come on line next summer offers immediate financial rewards.

Nursing homes will earn points for quality of medical care, satisfaction of patients and their families, and culture-change tenets like consistent staffing and resident-controlled decisions. A home that scores 100 points will receive $4 more per Medicaid patient per day (on top of the current Medicaid rate of about $178 a day).

Medicaid pays for about 63 percent of nursing-home residents; the new payment system will mean, for example, that a high-scoring home with 70 Medicaid patients could earn an extra $8,400 a month. The first year of the program will cost $4 million, half coming from the federal government and half from a new fee charged to all nursing homes.

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