CULTURE CHANGE IN NURSING HOMES: HOW FAR HAVE WE COME? FINDINGS FROM THE COMMONWEALTH FUND 2007 NATIONAL SURVEY OF NURSING HOMES Michelle M. Doty, Mary Jane Koren, and Elizabeth L. Sturla May 2008 ABSTRACT: Although The Nursing Home Reform Act, passed in 1987, established residents’ rights and quality standards for nursing homes nationwide, serious concerns remain about quality of care and quality of life for nursing home residents. The “culture change” movement is working to radically transform nursing home care, and help facilities transition from institutions to home. This report presents results from the Commonwealth Fund 2007 National Survey of Nursing Homes, fielded to examine the penetration of the culture change movement at the national level and measure the extent to which nursing homes are adopting culture change principles and practicing resident-centered care. Results are mixed, with much room for improvement. The survey highlights important lessons, including the finding that the more a nursing home has adopted culture change principles, the greater the benefits that accrue to it, in terms of staff retention, higher occupancy rates, better competitive position, and improved operational costs. Support for this research was provided by The Commonwealth Fund. The views presented here are those of the authors and not necessarily those of The Commonwealth Fund or its directors, officers, or staff. This and other Fund publications are available online at www.commonwealthfund.org. To learn more about new publications when they become available, visit the Fund’s Web site and register to receive e-mail alerts. Commonwealth Fund pub. no. 1131. CONTENTS List of Figures and Tables.................................................................................................. iv About the Authors................................................................................................................v Acknowledgments................................................................................................................v Executive Summary ........................................................................................................... vi Introduction..........................................................................................................................1 Culture Change in Nursing Homes: Survey Findings..........................................................2 Conclusions........................................................................................................................19 Appendix. Survey Methodology........................................................................................23 Notes ..................................................................................................................................25 Tables.................................................................................................................................27 iii LIST OF FIGURES AND TABLES Figure ES-1 Adoption of Culture Change by Nursing Homes, 2007......................................... vii Figure ES-2 Residents’ Ability to Determine Daily Schedules and Make Decisions Varies Widely Between Culture Change Adopters and Traditional Nursing Homes .........ix Figure ES-3 Improvements in Business and Operations Greatest in Homes with More Culture Change Initiatives Under Way ..................................................xi Figure 1 Adoption of Culture Change by Nursing Homes, 2007............................................4 Figure 2 Resident-Directed Culture Change Principles Currently Under Way.......................5 Figure 3 Residents’ Ability to Determine Daily Schedules and Make Decisions Varies Widely Between Culture Change Adopters and Traditional Nursing Homes ..........6 Figure 4 Culture Change Adopters Report Residents Are More Involved in Decisions About Their Home ...............................................................................8 Figure 5 Culture Change Adopters More Likely to Include Residents in Personnel and Staffing Decisions, But Overall Few Do .......................................8 Figure 6 Staff-Related Culture Change Principles Currently Under Way ............................10 Figure 7 Traditional Nursing Homes Lag Behind Culture Change Adopters in Staff Leadership, Empowerment, and Autonomy...............................................11 Figure 8 Direct Care Workers More Empowered to Make Operational Decisions in Homes That Are Culture Change Adopters ........................................................13 Figure 9 Few Nursing Homes Have Changed Their Physical Environments .......................15 Figure 10 Improvements in Business and Operations Greatest in Homes with More Culture Change Initiatives Under Way .................................................16 Figure 11 Staffing Improvements Are Greatest in Homes with More Culture Change Initiatives Currently Under Way .................................16 Figure 12 Nursing Homes Cite Staff Resistance, Cost, Regulations, and Facility Size as the Greatest Barriers to Culture Change Adoption........................18 Figure 13 Cost Greatest Barrier for Traditional Nursing Homes in Implementing Culture Change............................................................................19 Table 1 Resident-Directed Initiatives, Daily Living Choices and Involvement in Decision Making, by Culture Change Groupings...............................................27 Table 2 Staff Initiatives, Roles, Leadership, and Decision Making, by Culture Change Groupings ................................................................................28 Table 3 Nursing Home Physical Environment, by Culture Change Groupings...................29 Table 4 Impact of Culture Change, by Number of Culture Change Initiatives Currently Being Implemented.................................................................................30 Table 5 Barriers to Culture Change, by Culture Change Groupings ...................................31 Table 6 Characteristics of Nursing Homes, by Culture Change Groupings ........................32 iv ABOUT THE AUTHORS Michelle McEvoy Doty, Ph.D., associate director of research directs survey development and analysis at The Commonwealth Fund and conducts research examining health care access and quality among vulnerable populations and the extent to which lack of health insurance contributes to barriers to health care and inequities in quality of care. She received her M.P.H. and Ph.D. in public health from the University of California, Los Angeles. Mary Jane Koren, M.D., M.P.H., assistant vice president, joined the Fund in 2002 and leads the Picker/Commonwealth Program on Quality of Care for Frail Elders. Dr. Koren is also chair of the Advancing Excellence in Americas Nursing Homes campaign Steering Committee for 2008. Dr. Koren, an internist and geriatrician, has practiced in both nursing home and home care settings and was the associate medical director of the Montefiore Home Health Care Agency. Later, she was appointed director of the New York State Department of Health’s Bureau of Long Term Care Services, where she ran the nursing home survey and certification programs, led the state’s implementation of OBRA’87. Elizabeth Sturla, M.P.H., is executive assistant to the executive vice president for programs. She is a graduate of the Mailman School of Public Health at Columbia University with an M.P.H. in health policy. ACKNOWLEDGMENTS The authors would like to extend sincere thanks to the expert team at Harris Interactive for survey development, administration, and analytic support: Jordon Peugh and Eleanor Chand-Matzke. We would also like to thank our advisory committee who provided advice on content and structure of the tool, as well as invaluable insight into the culture change movement: Joe Angelelli, Denise Cherenfant, Yael Harris, Alice Hedt, Margie McLaughlin, Vince Mor, Laura Palmer, Karen Schoeneman, Steve Shields, Bill Spector, Robyn Stone and Nancy Zweibel. We would also like to thank our reviewers, David Stevenson at Harvard University and Yael Harris at the U.S. Department of Health and Human Services, for their helpful comments. Finally, we thank Deborah Lorber at The Commonwealth Fund for her invaluable editorial support. Editorial support was provided by Deborah Lorber. v EXECUTIVE SUMMARY BACKGROUND The Nursing Home Reform Act, passed in 1987, established quality standards for nursing homes nationwide, emphasized the importance of quality of life, and preserved residents’ rights. However, despite enactment of this law, serious concerns remain about the quality of care provided to residents in the nation’s 16,000 nursing homes. To improve the quality of care and the quality of life for nursing home residents, a growing movement, known as “culture change,” is working to deinstitutionalize long-term care and radically transform the nursing home environment. In the culture change model, which has gained momentum over the past decade, 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. In addition, 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. The Commonwealth Fund 2007 National Survey of Nursing Homes In the past decade, there has been growing awareness of culture change among professionals and providers in the field, but the extent to which nursing homes across the country have adopted a resident-centered culture is still unknown. In 2007, The Commonwealth Fund conducted a nationally representative survey of nursing homes to learn more about the penetration of the culture change movement at the national level and measure the extent to which nursing homes are adopting culture change principles and practicing resident-centered care. A representative sample of 1,435 nursing homes was surveyed between February and June 2007. The questionnaire was administered to directors of nursing who were asked about three domains of culture change: resident care, staff culture and working environment, and physical environment. Specifically, the survey examines whether nursing homes have adopted practices that make care more resident-directed, that engender a work environment that fosters staff autonomy and decentralized decision-making, and that alter the physical environment to make their facilities look and function like a home, rather than a hospital. vi Although survey results are mixed regarding the degree to which nursing homes report they have adopted resident-centered practices, findings indicate a hopeful picture about the potential for deep, systemic change within the industry. Four or five years ago, few nursing homes were familiar with the term “culture change.” Today it is recognized by and familiar to almost all providers. If the first step to change is awareness of a problem and the availability of an alternative, then the field of nursing home care is indeed poised for transformation. Furthermore, the survey shows that in facilities that incorporate some aspects of culture change, the more culture change initiatives that are under way, the greater the benefits in terms of staff retention, higher occupancy rates, better competitive position, and improved operational costs. As the awareness of these and other competitive and operational advantages becomes more widely known, it is likely that many more nursing homes will begin to shift toward making the changes in human resource management, the physical environment, and care delivery that are the hallmarks of resident-centered care. HIGHLIGHTS FROM THE SURVEY Using self-reported data from directors of nursing, we categorized nursing homes that participated in the survey as culture change adopters, culture change strivers, or traditional nursing homes (Figure ES-1). Figure ES-1. Adoption of Culture Change by Nursing Homes, 2007 Categories of Nursing Homes, by Extent of Culture Change Adoption Culture change definition* completely or for the most part describes nursing home Culture Change Adopters 31% Culture change definition* describes nursing home only in a few respects or Traditional not at all, and leadership 43% Culture change definition* Culture Change is not very committed to describes nursing home only Strivers in a few respects or not at all, adopting culture change 25% but leadership is extremely or very committed to adopting culture change * Culture change or a resident-centered approach means an organization that has home and work environments in which: care and all resident- related activities are decided by the resident; living environment is designed to be a home rather than institution; close relationships exist between residents, family members, staff, and community; work is organized to support and allow all staff to respond to residents' needs and desires; management allows collaborative and group decision making; and processes/measures are used for continuous quality improvement. Source: The Commonwealth Fund 2007 National Survey of Nursing Homes. vii • Culture change adopters. Only 5 percent of nursing homes report that the definition of culture change or resident-directed care “completely” describes their home. An additional 25 percent indicate that their nursing home “for the most part” fits the description of a culture change. A total of 31 percent of surveyed nursing homes are considered culture change adopters. † • Culture change strivers. The 25 percent of nursing homes in this category indicate that the definition of culture change describes their nursing home “in a few respects” or “not at all” but leadership is “extremely” or “very” committed to adopting culture change. • Traditional nursing homes. The remaining 43 percent of facilities that fall into this group say that the definition of culture change describes their nursing home “not at all” or only “in a few respects” and the leadership is only “somewhat,” “not very,” or “not at all” committed to the adoption of culture change (Figure ES-1). In general, nursing homes have been most successful at increasing residents’ involvement in decision-making, and there is some evidence that management is accommodating collaborative and decentralized decision-making to empower direct-care workers. However, very little organizational redesign has penetrated the field and very few homes have changed their physical environment to support culture change. Culture change adopters are more likely than traditional facilities to implement resident-centered care approaches. The survey finds that there is wide variation among nursing homes in terms of the choices and autonomy given to residents and in providing environments that are resident-centered (Figure ES-2). About 30 to 40 percent of all nursing homes report they are currently implementing some principle of culture change that fosters resident-directed care, including allowing residents to determine their own daily schedules, practicing resident-centered bathing techniques, or by actively involving residents in nursing home decisions. † Numbers do not add because of rounding. viii Figure ES-2. Residents’ Ability to Determine Daily Schedules and Make Decisions Varies Widely Between Culture Change Adopters and Traditional Nursing Homes Percent of nursing homes indicating they are currently implementing: 100 Culture Change Adopters Culture Change Strivers Traditional 75 70 64 58 50 45 37 39 28 27 25 22 0 Residents able to determine Resident-centered bathing Residents are actively involved their own daily schedules techniques, like “Bathing in decisions regarding their Without a Battle” residence Culture Change Adopters = culture change definition completely or for most part describes nursing home. Culture Change Strivers = culture change definition describes nursing home only in a few respects or not at all but leadership is very/extremely committed to the adoption of culture change. Traditional = culture change definition describes nursing home only in a few respects or not at all AND leadership is less than very/extremely committed to the adoption of culture change. Source: The Commonwealth Fund 2007 National Survey of Nursing Homes. • Fifty-eight percent of culture change adopters allow residents to determine their own schedules, compared with only 22 percent of traditional nursing homes (Figure ES-2). • Nearly two-thirds (64%) of culture change adopters implement bathing practices that are more resident-centered, while only 37 percent of traditional nursing homes do so. • Seven of 10 culture change adopters report that residents are involved in decisions about their facility, but only one-quarter of traditional nursing homes (27%) involve residents in such decisions. Culture change adopters have initiated a range of staff empowerment initiatives. Overall, a minority of nursing homes have undergone organizational changes, such as supporting a team approach for workers or cross-training staff, which makes the organization less hierarchical and empowers direct care nursing home staff. But, direct care workers are more likely to have leadership opportunities and be authorized to make decisions about delivering resident care in nursing facilities that self-identify as culture change adopters. ix • Overall, just over half of nursing homes (53%) provide staff with leadership training opportunities but only 15 percent indicate that they currently enable direct care workers to create self-managed work teams and only 14 percent currently cross-train staff to play several functional roles (for example, housekeeping, nursing, food service, and activities) to serve a variety of resident needs. • Among culture change adopters, one third (32%) support self-managed work teams yet far fewer traditional homes do so. • Fifty-nine percent of culture change adopters include direct care workers and residents on the senior management team, compared with only 24 percent of traditional nursing homes. • Culture change adopters are more likely than traditional homes to consistently assign the same aides to residents (86% vs. 74%). Very few homes are altering their physical environments. Very few nursing homes have renovated their traditional nursing units into “neighborhoods”—smaller functional areas that can include common community and dining areas—or “households,” which are small home settings with a full kitchen, dining room and living areas for 25 or fewer residents and their dedicated staff. Even culture change adopters have difficulty altering their physical environments to make facilities more home-like. • On average, nursing homes report that only 8 percent of residents currently reside in neighborhoods and only 1 percent live in households. • Only 16 percent of culture change adopters report they are currently breaking down large units into smaller operational units and only 7 percent have eliminated large nursing stations, which are often given prominent placement in the center of the unit in institutional-style nursing homes. • While more nursing homes are making the dining experience resident-centered, progress in this area is still slow. About three of 10 nursing homes (29%) in the U.S. indicate they have implemented initiatives to make dining less institutional, such as offering restaurant, family, and buffet styles and providing more dining times. • Nearly half (46%) of culture change adopters report they have changed how meals are served. In contrast, only 22 percent of traditional homes report they are making such changes. x The more culture change principles are embraced, the greater the increase in staff retention and occupancy rates and the greater the decrease in operational costs. As nursing homes become more engaged in culture change and adopt more of its associated practices, staff retention, market competitiveness, occupancy rates, and operational costs also improve (Figure ES-3). Figure ES-3. Improvements in Business and Operations Greatest in Homes with More Culture Change Initiatives Under Way Percent of nursing homes indicating that culture change has had the following impact: (Base: Definition of culture change describes this nursing home completely, for the most part, or in a few respects) High Number of Initiatives* 100 Medium Number of Initiatives* 78 Low Number of Initiatives* 73 75 60 57 60 54 50 44 35 31 25 0 Culture change improved Culture change improved Culture change improved competitive position in occupancy rate operational costs market area * Respondents were asked whether their home was currently implementing any of 11 different resident-centered, staff, or physical environment initiatives associated with culture change. High = 7 or more initiatives; Medium = 4 to 6 initiatives; Low = 3 or less initiatives. Source: The Commonwealth Fund 2007 National Survey of Nursing Homes. • Among facilities that are engaged in some aspect of culture change, 78 percent currently implementing seven or more culture change initiatives report that culture change has improved their competitive advantage in their market area. In contrast, only 54 percent of nursing homes that are implementing three or fewer culture change initiatives report such an improvement. • Another 60 percent of nursing homes that are currently implementing at least seven or more culture change initiatives report improved occupancy rates, while only 44 percent with three or fewer culture change initiatives under way report this improvement. • Half of nursing homes that are most engaged in culture change report that staff absenteeism decreased; in contrast, only one-third of nursing homes with three or fewer culture change initiatives under way report this improvement in staff absenteeism. xi Committed leadership can be a driver of culture change. Nursing homes that are considered strivers—that is, they are not yet culture change adopters, but have leaders who are committed to culture change and resident-directed care—are similar to the culture change adopters in their ability to provide resident-directed care. They also demonstrate that they are moving toward being the type of facility that empowers workers, provides direct-care workers with leadership opportunities, encourages decentralized decision-making, and allows staff to make decisions about resident care. Indeed, culture change strivers reported significantly more positive responses on all measures related to improving staff working environments, compared with traditional nursing homes. These findings reiterate the importance of a committed leadership for encouraging culture change. The Commonwealth Fund 2007 National Survey of Nursing Homes finds that while many nursing homes are aware of the “culture change” movement, progress has been slow in transforming long-term care facilities from institutions to homes. But with the examples and best practices gleaned from the culture change movement, nursing homes can begin to make the necessary changes to improve the quality of life for their residents and staff. xii CULTURE CHANGE IN NURSING HOMES: 3HOW FAR HAVE WE COME? FINDINGS FROM THE COMMONWEALTH FUND 2007 NATIONAL SURVEY OF NURSING HOMES INTRODUCTION WHAT IS CULTURE CHANGE? The Nursing Home Reform Act, which was passed in 1987, granted nursing home residents freedom from neglect and abuse, emphasized the importance of quality of life, and preserved residents’ rights. 1 However, despite the enactment of this law, serious concerns remain about the quality of care provided to residents in the nation’s 16,000 nursing homes. 2 To address the concerns over the quality of nursing home care, a growing movement, known as “culture change,” is working to deinstitutionalize long- term care and radically transform the nursing home environment. In the culture change model, which has gained momentum over the past decade, seniors enjoy much of the privacy and choice they would experience if they were still living in their own home. 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, deciding for themselves when to get up, eat meals, and bathe—and frontline workers—the nursing aides responsible for day- to-day care—are given greater autonomy to care for residents. 3 In addition, the physical and organizational structure of facilities is being made less institutional. Large, hospital- like units with long, wide corridors are being transformed into smaller facilities where small groups of residents are served by a consistent care team. 4 When the Pioneer Network, an organization dedicated to the promotion of culture change, was formed in 1997, only a handful of nursing homes were experimenting with ways to make their facilities truly resident-centered. 5 Since then, interest in culture change has spread within the industry through its efforts, along with those of the Center for Medicare and Medicaid Services (CMS), the Quality Improvement Organizations (organizations that work under the direction of CMS to monitor the appropriateness, effectiveness, and quality of care provided to Medicare beneficiaries), the media, and other concerned individuals, providers, and organizations. 1 THE COMMONWEALTH FUND 2007 NATIONAL SURVEY OF NURSING HOMES Awareness of culture change has grown among professionals and providers in the field, but the extent to which nursing homes across the country have adopted a resident- centered culture is still unknown. In 2007, The Commonwealth Fund conducted a national survey of nursing homes to learn more about the penetration of the culture change movement at the national level and to measure the extent to which the nation’s nursing homes are adopting culture change principles and practicing resident-centered care. The survey focused on three key areas related to culture change: resident-directed care, staff culture and working environment, and physical environment. The survey excluded facilities located within hospitals and those that are Medicare-only, as these facilities handle mostly short-stay patients, rather than long-term care residents who are the focus of this survey. A total of 1,435 directors of nursing completed the pencil-and-paper questionnaire mailed between February and June 2007, yielding a response rate of 37 percent. While differences between survey homes and non- responding homes are fairly small, non-responding homes were somewhat more likely to be large (200 or more beds), located in the Southern region, be part of a multi-facility chain, and have for-profit status. The survey results are weighted to be representative of all nursing homes in the United States. One quarter (24%) of surveyed homes are nonprofit, slightly more than one- quarter (27%) are located in urban locations, 41 percent are in suburban locations, and 32 percent are in rural areas. Forty-five percent of surveyed homes have 99 or fewer beds and 48 percent have between 100 to 199 beds. For more details on the survey, see Survey Methodology (Appendix). CULTURE CHANGE IN NURSING HOMES: SURVEY FINDINGS Many nursing homes have adopted at least some practices associated with resident- centered care. Overall, however, culture change has been limited. Nursing homes have been most successful at increasing residents’ involvement in decision-making, and there is some evidence that management is accommodating more collaborative and decentralized decision-making to empower direct-care workers. However, operational changes, such as revising the management structure to encourage collaborative and decentralized decision-making are rare, and very few homes have altered their physical environments to support resident-centered care. 2 DEFINING AND MEASURING CULTURE CHANGE A “culture change nursing home” is defined as an organization that has home and work environments that include the following: • care and resident-related activities directed by residents; • environment designed as a home, rather than an institution; • close relationships among residents, family members, staff, and community; • work that is organized to support and empower all staff to respond to residents’ needs and desires; • management that allows for collaborative and decentralized decision-making; and • systematic processes that are comprehensive, measurement-based, and used for continuous quality improvement. 6 Respondents indicated whether or not the above definition described their nursing home “in a few respects,” “for the most part,” “completely,” or “not at all.” Directors of nursing also reported whether the leadership of the nursing home (including owners, board and administrators) was committed to adoption of culture change or a resident- centered approach, on a scale from “extremely committed” to “not at all” committed. Using these two measures, this study categorized nursing homes as either culture change adopters (i.e., respondents indicate that the definition of culture change “completely” or “for the most part” describes their nursing home) or culture change strivers (i.e., respondents indicate that the definition of culture change describes the nursing home “in a few respects” or “not at all” but leadership is “extremely” or “very” committed to the adoption of culture change). The remaining nursing homes fall into the category of traditional nursing homes. Respondents in this category indicate that the definition of culture change describes their nursing home only “in a few respects” or “not at all” and the leadership is only “somewhat,” “not very,” or “not at all” committed to the adoption of culture change. The survey finds that 31 percent of homes are culture change adopters, 25 percent are culture change strivers, and the remaining 43 percent are traditional nursing homes (Figure 1). Among the culture change adopters, only 5 percent of homes indicate that the definition of culture change “completely” describes their nursing home; the rest report that the definition describes their nursing home for the most part. 3 Figure 1. Adoption of Culture Change by Nursing Homes, 2007 Categories of Nursing Homes, by Extent of Culture Change Adoption Culture change definition* completely or for the most part describes nursing home Culture Change Adopters 31% Culture change definition* describes nursing home only in a few respects or Traditional not at all, and leadership 43% Culture change definition* Culture Change is not very committed to describes nursing home only Strivers in a few respects or not at all, adopting culture change 25% but leadership is extremely or very committed to adopting culture change * Culture change or a resident-centered approach means an organization that has home and work environments in which: care and all resident- related activities are decided by the resident; living environment is designed to be a home rather than institution; close relationships exist between residents, family members, staff, and community; work is organized to support and allow all staff to respond to residents' needs and desires; management allows collaborative and group decision making; and processes/measures are used for continuous quality improvement. Source: The Commonwealth Fund 2007 National Survey of Nursing Homes. RESIDENT-DIRECTED CULTURE CHANGE Resident-directed care in nursing homes is an approach that values independence and empowerment for residents and staff alike. In traditional nursing homes, the timing of residents’ meals, bathing, sleeping, and social activities is scheduled. Alternatively, in resident-directed nursing homes, residents are free to choose when they go to bed and wake up, when and what they eat, and when and how they are bathed. Nursing homes that organize daily routines around residents’ preferences reflect a greater degree of culture change adoption because they prioritize residents’ wants and needs over what is convenient for the facility. Only one of three nursing homes currently let residents determine their own daily schedules. The survey finds that about 30 percent to 40 percent of all nursing homes report they are currently implementing some principle of culture change that fosters resident-directed care by allowing residents to determine their own daily schedules, practicing resident-centered bathing techniques, or by actively involving residents in decisions about their nursing home (Figure 2). Allowing residents to determine their own daily schedules is the hardest policy to implement, probably because it affects staffing schedules, as well as the timing, preparation, and delivery of meals. Indeed, only one of three (29%) nursing homes in the U.S. indicates it currently lets residents determine their own daily schedules. The majority of residents can make 4 decisions regarding sleeping and bathing habits, but far fewer are given the opportunity to make decisions about their dining experience (Table 1). Thirty-eight percent of homes report they are implementing practices that actively involve residents in decisions about their facility. Figure 2. Resident-Directed Culture Change Principles Currently Under Way Percent indicating that they are currently implementing the following initiatives: 75 50 38 35 29 25 12 0 Enable residents Actively involve Fully implement Currently to determine residents in decisions “Bathing Without a implementing their own daily regarding their Battle” techniques ALL THREE schedules household/ resident-directed neighborhood/unit^ initiatives ^ Neighborhoods: Areas in which traditional nursing unit is broken down into smaller functional units, in which ancillary services are shared with other neighborhoods; Households: Self-contained areas with a full kitchen, living room and dining room, with a relatively small number of residents per household. Source: The Commonwealth Fund 2007 National Survey of Nursing Homes. While nearly two-thirds (62%) of nursing homes report that residents can eat when they want, two survey indicators—allowing residents to access food from a refrigerator whenever they want and to access appliances to prepare their own meals— point to the large gap that exists between an institutional orientation and a resident- centered approach (Table 1). Less than half of nursing homes (47%) report that residents can access food from a refrigerator whenever they want, and only 20 percent give residents access to appliances to prepare their own meals or snacks. One-third of all nursing homes (35%) have implemented resident-centered bathing techniques such as “bathing without a battle,” 7 which promotes methods like keeping residents covered during showers to preserve their sense of dignity or using warmed towels to sooth and relax them. The degree of resident autonomy varies greatly between culture change adopters and traditional nursing homes. Allowing residents to determine their daily schedules, implementing resident-directed bathing techniques, and actively involving 5 residents in decisions regarding their nursing homes are all approaches that demonstrate a resident-centered approach that take into account the comfort and preferences of residents. The survey finds wide variation among nursing homes regarding giving residents autonomy (Figure 3). For example, 58 percent of culture change adopters allow residents to determine their own schedules compared with only 22 percent of traditional nursing homes. Furthermore, 78 percent of culture change adopters report residents can eat when they want compared with 54 percent of traditional nursing homes (Table 1). Similarly, 58 percent of culture change adopters indicate that residents can access food from a refrigerator whenever they want whereas only 41 percent of traditional nursing homes report this. Likewise, nearly two-thirds (64%) of culture change adopters implement resident-centered bathing practices whereas only 37 percent of traditional nursing homes do so (Figure 3). Finally, as many as seven of 10 culture change adopters report that residents are involved in decisions about their facility but only one-quarter (27%) of traditional nursing homes involve residents in such decisions. (Figure 3). Figure 3. Residents’ Ability to Determine Daily Schedules and Make Decisions Varies Widely Between Culture Change Adopters and Traditional Nursing Homes Percent of nursing homes indicating they are currently implementing: 100 Culture Change Adopters Culture Change Strivers Traditional 75 70 64 58 50 45 37 39 28 27 25 22 0 Residents able to determine Resident-centered bathing Residents are actively involved their own daily schedules techniques, like “Bathing in decisions regarding their Without a Battle” residence Culture Change Adopters = culture change definition completely or for most part describes nursing home. Culture Change Strivers = culture change definition describes nursing home only in a few respects or not at all but leadership is very/extremely committed to the adoption of culture change. Traditional = culture change definition describes nursing home only in a few respects or not at all AND leadership is less than very/extremely committed to the adoption of culture change. Source: The Commonwealth Fund 2007 National Survey of Nursing Homes. Overall, residents are involved in very few decisions regarding their nursing home. A closer look at decision-making in nursing homes reveals that staff are far less likely to involve residents in decisions about day-to-day operations than in decisions regarding their own care plan. The survey asked directors of nursing whether decisions related to their nursing home, such as planning menus, decorating communal areas, and 6 making decisions about personnel, were usually made by residents independently, jointly by residents and staff alike, primarily by staff with some input from residents, or entirely by staff, independent of resident input. Residents are more likely to be given the opportunity to make decisions independently or jointly with staff about developing their own care plan (42%), planning social events (31%), and creating the calendar for social events (28%) than they are about the operational needs of the nursing home (Table 1). Slightly more than one of 10 nursing homes indicate that residents make decisions with staff about: creating the schedule for meals (12%), planning menus (14%), decorating communal areas (13%), and determining who will provide their hands-on care (14%). Hardly any nursing homes (3%) say residents are involved in making decisions about which staff members will work in the unit, neighborhood, or household. Culture change adopters provide their residents with more opportunities to participate in decisions regarding their care, as well as those about daily operations, giving residents some control over the events or activities that most directly affect their lives (Figure 4). Nearly six of 10 (58%) culture change adopters say residents participate with staff in developing their care plan, whereas half as many (33%) traditional homes include residents in these decisions. Nearly half (46%) of culture change adopters also report residents, together with staff, can make decisions about creating the social calendar or planning social events; in contrast, only 20 percent or fewer of traditional nursing homes indicate that residents, together with staff, make these types of decisions (Figure 4). Although culture change adopters are more likely than traditional nursing homes to provide residents with opportunities to make decisions about planning social events and menus, decorating communal areas, or selecting caregivers for hands-on care, resident empowerment in these areas is still very low—ranging from 22 percent to 26 percent. In all nursing homes—culture change adopters and traditional nursing homes, alike—few residents have a say about who will provide hands-on care or other personnel issues (Figure 5). 7 Figure 4. Culture Change Adopters Report Residents Are More Involved in Decisions About Their Home Percent indicating that decisions are usually made by residents and staff jointly for the following: 75 Culture Change Adopters Culture Change Strivers Traditional 58 49 50 46 40 33 33 26 27 23 22 25 20 16 17 13 9 7 8 5 0 Creating Planning Decorating Creating Planning Developing schedule menus communal calendar for social events resident’s for meals areas social events care plan Culture Change Adopters = culture change definition completely or for most part describes nursing home. Culture Change Strivers = culture change definition describes nursing home only in a few respects or not at all but leadership is very/extremely committed to the adoption of culture change. Traditional = culture change definition describes nursing home only in a few respects or not at all AND leadership is less than very/extremely committed to the adoption of culture change. Source: The Commonwealth Fund 2007 National Survey of Nursing Homes. Figure 5. Culture Change Adopters More Likely to Include Residents in Personnel and Staffing Decisions, But Overall Few Do Percent indicating that decisions are usually made by residents and staff for the following: 75 Culture Change Adopters Culture Change Strivers Traditional 50 25 22 14 8 5 3 2 0 Decisions about who provides Decisions about personnel^ their own hands-on care Culture Change Adopters = culture change definition completely or for most part describes nursing home. Culture Change Strivers = culture change definition describes nursing home only in a few respects or not at all but leadership is very/extremely committed to the adoption of culture change. Traditional = culture change definition describes nursing home only in a few respects or not at all AND leadership is less than very/extremely committed to the adoption of culture change. ^ Includes decisions about personnel who will be or are working in the household, neighborhood, or unit. Source: The Commonwealth Fund 2007 National Survey of Nursing Homes. Leadership commitment to culture change is important. In between the two ends of the culture change continuum (i.e., adopters versus traditional) are the culture change strivers. This category includes nursing homes that may not identify as culture change 8 adopters but do have leadership that is extremely or very committed to adopting culture change or a resident-centered approach. These nursing homes are similar to the culture change adopters in their ability to provide resident-directed care, give residents more control over how they spend their day, and provide residents, together with staff, opportunities to make decisions about their own care and their facility (Figures 3, 4, and 5). In most areas related to resident empowerment and autonomy, nursing homes with strong leadership commitment to resident-directed care or culture change are significantly more likely to implement resident-directed activities than traditional nursing homes that lack committed leadership. STAFF-RELATED CULTURE CHANGE One of the most pressing problems in long-term care is the recruitment and retention of certified nursing assistants, the caregivers who provide 90 percent of direct patient care. 8 Some of the reasons for high staff turnover rates and job dissatisfaction are low wages, heavy caseloads, lack of respect, inadequate initial training and continuing education, rotating assignments and limited involvement in decision making, and little or no opportunity for professional growth and career advancement. 9 As such, improving staff retention has become a top priority for the long-term care community. The culture change model proposes different staff and organizational initiatives to improve the working environment for frontline workers, including consistent assignment of staff to the same group of residents to foster better relationships between staff and residents, providing frontline workers with decision-making autonomy and leadership opportunities, increasing the flexibility of the staff caregiver roles, and creating a sense of community through teamwork. 10 Past research has shown that empowering workers to make decisions regarding patient care leads to better performance from certified nursing assistants, improved resident care and choices, and improved cooperation between certified nursing assistants and nurses. 11 Staff–Resident Relationships and Staff Empowerment One method for fostering better relationships among staff, residents, and families is to permanently assign staff to a particular group of residents. Survey findings indicate that the vast majority of directors of nursing (74%) say their nursing home consistently assigns certified nursing assistants to the same group of residents (Figure 6). Creating a stable workforce of empowered staff is another important hallmark of culture change. Some strategies to empower staff and increase job satisfaction include providing direct care workers with opportunities to assume leadership roles and professional growth within the organization, offering continuing education, and encouraging the development 9 of self-managed work teams. 12,13 Encouraging direct care workers to create self-managed work teams that have decision-making authority is the most difficult to accomplish because it requires dismantling the traditional hierarchical organizational structure. The survey finds that while slightly over half of nursing homes (53%) provide staff with leadership training opportunities and one-third (32%) include direct care workers and residents on the senior management team, only 15 percent allow direct care workers to create self-managed work teams in their nursing home. Figure 6. Staff-Related Culture Change Principles Currently Under Way Percent indicating that they are currently implementing the following initiatives: 100 74 75 53 50 42 32 25 15 5 0 Consistent Staff Include direct Include Create Currently assignment of leadership care workers certified nursing self-managed implementing certified nursing training and residents assistants in work teams ALL FIVE assistants to opportunities on senior resident-centered staff initiatives residents management care planning team sessions^ ^ For instance, utilizing the “I Care” or “First Person” approach. Source: The Commonwealth Fund 2007 National Survey of Nursing Homes. Opportunities for staff leadership and autonomy vary widely; traditional nursing homes lag behind adopters. Opportunities for staff autonomy and leadership vary widely between culture change adopters and traditional nursing homes. Three- fourths of culture change adopters say they currently provide staff with leadership training opportunities, compared with just half of traditional nursing homes (Figure 7). Furthermore, 59 percent of culture change adopters include direct care workers and residents on their senior management team, compared with only 24 percent of traditional nursing homes. A large portion of culture change adopters (69%) also indicate they currently include nursing assistants in resident-directed care planning sessions; half as many traditional homes (37%) do so. The use of self-managed work teams is not pervasive overall, but culture change adopters are still far more likely than traditional nursing homes to support this type of management style than traditional homes. Only 10 11 percent of traditional nursing homes indicate they currently support the creation of self-managed work teams compared with one-third of culture change adopters. Figure 7. Traditional Nursing Homes Lag Behind Culture Change Adopters in Staff Leadership, Empowerment, and Autonomy Percent indicating that they are currently implementing the following: 100 Culture Change Adopters Culture Change Strivers Traditional 86 80 74 74 75 69 59 54 49 49 50 40 37 32 24 25 16 11 0 Consistent Staff Include direct care Include certified Create assignment of leadership workers and nursing assistants self-managed certified nursing training residents on senior in resident- work teams assistants to opportunities management team centered care residents planning sessions^ Culture Change Adopters = culture change definition completely or for most part describes nursing home. Culture Change Strivers = culture change definition describes nursing home only in a few respects or not at all but leadership is very/extremely committed to the adoption of culture change. Traditional = culture change definition describes nursing home only in a few respects or not at all AND leadership is less than very/extremely committed to the adoption of culture change. ^ For instance, utilizing the “I Care” or “First Person” approach. Source: The Commonwealth Fund 2007 National Survey of Nursing Homes. Little organizational redesign has penetrated the field. Increasing the flexibility of staff caregiver roles—sometimes called cross-training—is another strategy used in the culture change model to improve job satisfaction. Cross-training allows staff members to assume different duties and be more responsive to resident needs. Rather than work in a single department, such as nursing or housekeeping, staff work in blended roles that cross cut the departmental functions. For example, social workers, housekeeping staff, and administrators can all be trained to feed residents, lead activities, or attend to personal care, which ensures there are more people available to assist residents and also serves to promote camaraderie among staff and break down social barriers. This type of reorganization is difficult to execute because it requires a dismantling of traditional department heads and hierarchical management styles. Not surprisingly, the survey finds that, nationally, only 14 percent of homes currently cross-train staff to serve a variety of resident needs (Table 2). Staff Roles and Decentralized-Decision Making Decentralized decision-making increases job satisfaction by empowering staff to make decisions about how they provide care to residents. 14 However, survey findings indicate 11 there is a limited amount of collaborative and decentralized leadership and decision- making involving direct care workers. For example, only 5 percent of homes report that certified nursing assistants develop their own schedules for day or evening shifts (Table 2). Nursing homes are most likely to allow direct care workers to make decisions—either independently or jointly with a department head—about planning social events (35%) and least likely to allow collaborative decision-making about hiring and staff selection (5%) and budget and resource requests (3%). Scheduling direct care worker shifts and assigning staff to residents with direct-care worker input is also less common; just 17 percent of homes say direct care workers are significantly involved in decisions regarding their shifts. These findings are yet another indicator that, nationally, few nursing homes have undergone organizational changes to focus on a team approach. Culture change adopters have initiated a wide range of staff empowerment initiatives. There are stark differences between culture change adopters and traditional nursing homes in terms of providing autonomy to direct care workers to make decisions affecting resident care and general nursing home operations (Figure 8). For example, one- third of culture change adopters indicate their staff—independently or jointly with the department head—make decisions regarding assigning staff to residents, while only 13 percent of traditional nursing homes do so. Half (51%) of culture change adopters indicate that direct care workers are involved in making decisions regarding planning social events. In contrast, only 23 percent of traditional homes include direct care workers in these decisions. Still, very few culture change adopters include direct care workers in decisions regarding hiring and staff selection (9%) or budget and resource allocations (5%). 12 Figure 8. Direct Care Workers More Empowered to Make Operational Decisions in Homes That Are Culture Change Adopters Percent indicating that decisions are usually made by direct care workers independently or jointly with department head for: 75 Culture Change Adopters Culture Change Strivers Traditional 51 50 38 35 25 27 23 22 25 19 17 11 13 9 9 5 5 4 2 1 0 Planning social Scheduling Staff Performance Hiring and staff Budget and events staff shifts assignment to evaluations selection resource residents requests Culture Change Adopters = culture change definition completely or for most part describes nursing home. Culture Change Strivers = culture change definition describes nursing home only in a few respects or not at all but leadership is very/extremely committed to the adoption of culture change. Traditional = culture change definition describes nursing home only in a few respects or not at all AND leadership is less than very/extremely committed to the adoption of culture change. Source: The Commonwealth Fund 2007 National Survey of Nursing Homes. Committed leadership can be a driver of culture change. Culture change strivers—those facilities that are not yet culture change adopters but have leaders committed to culture change and resident-centered care—demonstrate they are moving toward the goals of culture change: empowering workers, providing direct care workers with leadership opportunities, encouraging decentralized decision-making, and allowing staff to make decisions about resident care (Figure 7). Indeed, all measures related to improving staff working environments are significantly more positive among culture change strivers compared with traditional nursing homes. These findings reiterate the importance of a committed leadership for encouraging culture change. CHANGES TO THE PHYSICAL ENVIRONMENT Altering the physical environment of nursing homes to make them more homelike is arguably the most difficult transformation to undertake. The range of physical changes can depend on many different factors, including the age of the building, layout, availability of capital, and state regulations. 15 Some physical changes are large scale, such as creating decentralized dining, eliminating traditional nurses’ stations, or breaking up traditional nursing units into smaller functional areas to create neighborhoods or households with their own entrances, instead of an institutional, hospital-like environment. Others are smaller in scale, such as 13 removing overhead paging systems or renovating existing spaces to make bedrooms and bathrooms more homelike and inviting. 16 Survey findings indicate that, nationally, very few homes are making major structural changes. On average, nursing homes report that only 8 percent of residents reside in neighborhoods and only 1 percent of residents live in households (Table 3). Only 8 percent of nursing homes indicate they are engaged in initiatives to break down large units into smaller operational ones. And only 3 percent of surveyed nursing homes indicate they have eliminated the nurses’ stations and integrated them into the living space. The majority of nursing homes (72%) have not eliminated the use of a paging system and only one of five uses them for emergency situations only. More nursing homes are making the dining experience resident-centered, but progress in this area is slow. About three of 10 nursing homes (29%) in the U.S. indicate they have implemented initiatives to alter the dining experience (Table 3). In traditional nursing homes, meals are usually prepared in a central kitchen and served to residents from multiple units in one or more common dining rooms. One way to create a more resident-centered dining experience is to prepare and serve meals at the unit, household, or neighborhood. The survey finds that the vast majority (74%) of nursing homes prepare meals in a central kitchen and serve them in one or more common dining rooms; 2 percent of homes prepare and serve meals at the unit, household, or neighborhood and another 22 percent prepare meals in a central kitchen but serve them at the unit, household, or neighborhood (Table 3). Very few nursing homes use the household or neighborhood model; even culture change adopters have difficulty altering their physical environment. Very few culture change adopters report implementing physical transformations to make their facilities more homelike (Figure 9). Only 16 percent of culture change adopters report they are breaking down large units into smaller ones and only 7 percent have eliminated nurses’ stations. The easiest transformation is changing the dining experience from a tray service to a system that provides residents more options and freedom to choose when to eat. Nearly half (46%) of culture change adopters report they have changed how meals are served. In contrast, only 22 percent of traditional nursing homes report they are implementing new measures to change how meals are served. 14 Figure 9. Few Nursing Homes Have Changed Their Physical Environments Percent indicating that they are currently implementing: 75 Culture Change Adopters Culture Change Strivers Traditional 50 46 34 25 22 16 9 7 4 4 1 0 Change dining experience Break down Eliminate nurses stations large units into smaller operational units Culture Change Adopters = culture change definition completely or for most part describes nursing home. Culture Change Strivers = culture change definition describes nursing home only in a few respects or not at all but leadership is very/extremely committed to the adoption of culture change. Traditional = culture change definition describes nursing home only in a few respects or not at all AND leadership is less than very/extremely committed to the adoption of culture change. Source: The Commonwealth Fund 2007 National Survey of Nursing Homes. While progress is slow in transforming the physical environment, major structural changes are not necessary to provide resident-directed care. Indeed, even in the most institutional facilities, relatively simple reconfigurations can provide a more homelike feel even if it is not possible to create self-contained households. Survey findings demonstrate that nursing homes are providing resident-directed care, giving staff more autonomy, and converting to a resident-directed model despite lack of progress in renovating the physical plant. IMPACT OF CULTURE CHANGE Culture change has a positive impact on business, operations, and staffing. Although previous studies have shown that the implementation of culture change is an effective way to enhance the quality of life for frail elders and improve work environments, 17 there is little evidence in the peer-reviewed literature on the effect of culture change on market share, occupancy rates, and operational costs. In this survey, directors of nursing were asked to indicate whether they believed culture change had any impact on various business measures. Only directors of nursing who indicated that their nursing home was engaged in culture change in at least “a few respects” were asked whether culture had improved, worsened, or had no impact on various business or organizational measures. Results indicate that the more nursing homes are engaged in practices associated with culture change, the more likely they are to report that culture 15 change has made positive improvements in competition in their market, nursing home operations, staffing, and occupancy rates (Figures 10 and 11). Figure 10. Improvements in Business and Operations Greatest in Homes with More Culture Change Initiatives Under Way Percent of nursing homes indicating that culture change has had the following impact: (Base: Definition of culture change describes this nursing home completely, for the most part, or in a few respects) High Number of Initiatives* 100 Medium Number of Initiatives* 78 Low Number of Initiatives* 73 75 60 57 60 54 50 44 35 31 25 0 Culture change improved Culture change improved Culture change improved competitive position in occupancy rate operational costs market area * Respondents were asked whether their home was currently implementing any of 11 different resident-centered, staff, or physical environment initiatives associated with culture change. High = 7 or more initiatives; Medium = 4 to 6 initiatives; Low = 3 or less initiatives. Source: The Commonwealth Fund 2007 National Survey of Nursing Homes. Figure 11. Staffing Improvements Are Greatest in Homes with More Culture Change Initiatives Currently Under Way Percent of nursing homes indicating that culture change has had the following impact: (Base: Definition of culture change describes this nursing home completely, for the most part, or in a few respects) 100 High Number of Initiatives* Medium Number of Initiatives* 75 Low Number of Initiatives* 59 58 52 50 50 40 33 23 25 19 16 0 Culture change improved Culture change improved Culture change improved staff retention staff absenteeism use of agency staff * Respondents were asked whether their home was currently implementing any of 11 different resident-centered, staff, or physical environment initiatives associated with culture change. High = 7 or more initiatives; Medium = 4 to 6 initiatives; Low = 3 or less initiatives. Source: The Commonwealth Fund 2007 National Survey of Nursing Homes. 16 Among facilities engaged in some aspect of culture change, 78 percent that are currently implementing at least seven or more culture change initiatives report that culture change has improved their competitive advantage in their market. In contrast, only 54 percent of nursing homes implementing three or fewer culture change initiatives report this improvement. Another 60 percent of nursing homes that are currently implementing at least seven or more culture change initiatives report improved occupancy rates as a result of culture change, while only 44 percent of facilities with three or fewer culture change initiatives under way report this improvement. Similarly, 60 percent of the homes with seven or more culture change initiatives under way report improvements in operational costs. About half as many facilities (31%) implementing three or fewer initiatives report these improvements as a result of culture change. As many directors of nursing will attest, staff turnover and absenteeism are among the leading challenges to running a successful facility. Survey results indicate that culture change is associated with improvements in staff retention and absenteeism. Indeed, the more engaged in culture change, the more likely is a nursing home to report improvements in these areas as a result of culture change (Figure 11). Three of five (59%) nursing homes that are engaged in seven or more culture change initiatives report improvements in staff retention, compared with just 52 percent of less-engaged homes. In addition, 50 percent of nursing homes that are most engaged in culture change report that staff absenteeism decreased; only one-third of nursing homes with three of fewer culture change initiatives under way report this improvement. When all three staffing indicators are combined, as many as 64 percent of homes that have adopted seven or more resident- centered culture change initiatives report improvements in staffing, compared with only 52 percent of homes that are engaged in three or fewer culture change principles (Table 4). BARRIERS TO CULTURE CHANGE IMPLEMENTATION Nursing homes cite staff resistance, cost, regulations, and facility size as the greatest barriers to culture change adoption. As nursing homes embark on the journey to transform their facilities into resident-directed environments, it is important to understand the barriers to culture change implementation. Results indicate that nursing homes find staff resistance and cost as the two leading obstacles, with 61 percent and 59 percent of nursing homes, respectively, citing these items as major or minor barriers (Figure 12). Nearly half or more of nursing homes also cited regulations (56%) and the size of facility (49%) as barriers to adoption. While roughly one-third of nursing homes consider human resource policies and family or resident resistance as minor barriers to adoption, fewer than 10 percent see these as major barriers. 17 Figure 12. Nursing Homes Cite Staff Resistance, Cost, Regulations, and Facility Size as the Greatest Barriers to Culture Change Adoption Percent indicating the following items as major or minor barriers to implementing culture change: 100 Minor barrier Major barrier 75 61 59 56 49 50 42 28 38 47 33 27 27 25 34 16 35 31 23 22 14 11 8 3 0 Staff Cost Regulations Size of Corporate/ Human Family/ resistance facility board resource resident support policies resistance Source: The Commonwealth Fund 2007 National Survey of Nursing Homes. For traditional nursing homes, cost is by far the leading barrier to culture change—56 percent report it is a major barrier (Figure 13). Although investments in structural changes can be high, there is increasing evidence that empowering staff and providing residents with more choice and decision-making opportunities, can accrue considerable savings as a result of reduced staff turnover, decreased reliance on agency staff, and increased revenues from higher occupancy as facilities realize competitive advantages. 18 18 Figure 13. Cost Greatest Barrier for Traditional Nursing Homes in Implementing Culture Change Percent indicating the following areas as major barriers to implementing culture change: 75 56 50 34 36 32 26 22 23 23 25 14 0 Cost Regulations Size Cost Regulations Size Cost Regulations Size ADOPTERS STRIVERS TRADITIONAL Culture Change Adopters = culture change definition completely or for most part describes nursing home. Culture Change Strivers = culture change definition describes nursing home only in a few respects or not at all but leadership is very/extremely committed to the adoption of culture change. Traditional = culture change definition describes nursing home only in a few respects or not at all AND leadership is less than very/extremely committed to the adoption of culture change. Source: The Commonwealth Fund 2007 National Survey of Nursing Homes. CONCLUSIONS The Nursing Home Reform Act provided a statutory basis for resident-centered care by obligating nursing home operators to provide an environment that structurally and organizationally ensures residents’ rights, provides high-quality care, and maintains a satisfying and fulfilling quality of life. Nevertheless, transformation within the industry has been slow. Even two decades after the enactment of the Nursing Home Reform Act, only a small number of nursing homes appear to have made the transition from institutionally driven to resident-centered, although slightly more have started or are contemplating change. The Commonwealth Fund 2007 National Survey of Nursing Homes asked directors of nursing to answer questions about three areas critical to culture change: the use of resident-centered care practices, empowerment of workers, and a homelike environment that supports organizational redesign. Because the respondents are directors of nursing (and not frontline staff, residents, or family) and may not be fully aware of the impact on frontline workers, day-to-day operations, or residents, it is possible that this study overestimates the degree of culture change penetration. Despite this limitation, this is the first national survey to measure practices specifically associated with culture change and provides a valuable baseline to measure the effectiveness of ongoing efforts within the nursing home industry. There is room for improvement in making nursing home care more resident-centered, as indicated by the following findings from the survey: 19 • While in many facilities residents can shape their daily routines, free access to refrigerators and simple kitchen appliances to fix a snack is less common. Allowing residents input about who provides their care on their unit or in their neighborhood is almost non-existent. • By and large, workers still are not routinely able to participate in matters that are important to them. For example, only 17 percent of facilities involve direct care workers in decisions about staffing shifts and only 5 percent let certified nursing assistants develop their own schedules. • Living conditions remain more institutional than homelike. Only 9 percent of residents are living in either neighborhoods or small household clusters. Overhead paging systems are used everyday in 72 percent of nursing homes. Despite the relatively slow pace of culture change penetration, the results of the survey are encouraging for the movement overall. The survey provides evidence that culture change makes a difference: The more nursing homes adopt practices that are associated with culture change, the more likely they are to report culture change has made positive improvements in market competitiveness, occupancy rates, staff retention, and improvements in the rate of staff absenteeism. • Among facilities engaged in some aspect of culture change, 78 percent that are implementing seven or more culture change initiatives report that culture change has improved their competitive advantage in their market. In contrast, 54 percent of nursing homes implementing three or fewer culture change initiatives report this improvement. • Sixty percent of nursing homes currently implementing seven or more culture change initiatives report improved occupancy rates as a result of culture change; only 43 percent of facilities with three or fewer culture change initiatives under way report this improvement. • Half of nursing homes that are most engaged in culture change report decreased staff absenteeism as a result of culture change. In contrast, one-third of nursing homes with three or fewer culture change initiatives under way report this improvement. To encourage more nursing homes to adopt principles associated with culture change and resident-directed care, a number of barriers must be addressed or dispelled. 20 • Cost. As in any new venture, there is an upfront investment but increasing evidence shows that considerable savings accrue as a result of culture change in terms of reduced staff turnover, decreased reliance on agency staff, and increased revenues from higher occupancy rates as facilities realize competitive advantages and word spreads that the facility is like a real home not an institution. • Regulations. CMS, the agency responsible for overseeing compliance with federal regulations, has been in the forefront of the movement to promote culture change. Likewise, the Quality Improvement Organizations, which work under CMS to monitor the quality of care provided to Medicare beneficiaries, provide technical assistance to nursing homes. Part of their work includes measuring several performance areas that reflect a culture change philosophy. Getting all surveyors comfortable with culture change is an ongoing challenge, yet most nursing homes that work with their state survey agencies on new culture change initiatives have found they are given considerable latitude to use creative, resident-centered techniques. • Staff resistance. Nursing home staff have been slower to embrace culture change. The participative nature of culture change, however, can help to reduce frustration and build morale. By inviting workers to replace old habits with new skills that fully utilize their training, culture change can help them to see positive effects on residents and take pride in their work—a new and welcome experience for many nursing home employees. Among nursing homes that have embraced culture change, staff members say that once they have experienced working in a culture change nursing home, they could never go back to the old way. Several encouraging trends are emerging to help promote adoption of resident- centered care, as follows: 1. A growing body of research provides evidence for the benefits of culture change. 19 New tools are being developed to help nursing homes initiate and maintain culture change principles. 20 2. The media is starting to recognize the story of culture change in nursing homes. This will serve to educate consumers and make the status quo a less viable business strategy in the competitive world of residential long term care. 3. Thanks to resident-centered models like the National Greenhouse Project and Eden Alternative, there is now a critical mass of adopters available to guide and encourage facilities that are just starting out. 21 21 4. Many culture change coalitions have developed, including the Pioneer Network, the Paraprofessional Healthcare Institute, and the National Nursing Home Quality Campaign, to provide resources and training and connect nursing homes to learning collaboratives. 5. CMS is starting to consider ways it can use its influence—through surveys and enforcement processes—to encourage better compliance with the residents’ rights and quality-of-life sections of the federal regulations. At the same time, states are trying to build resident-centered requirements into pay-for-performance reimbursement mechanisms. Progress has been slow in transforming long-term care facilities from institutions to homes, but the survey findings indicate a hopeful picture about the potential for deep, systemic change within the industry. Four or five years ago, few nursing homes were familiar with the term “culture change.” Today it is recognized by and familiar to almost all providers. If the first step to change is awareness of a problem and the availability of an alternative, then the field of nursing home care is indeed poised for transformation. Facilities must go beyond the recommendations of the Nursing Home Reform Act and make the fundamental changes necessary to preserve and maintain residents’ privacy, choices, and dignity, and to provide an environment that looks and feels like home. With the examples and best practices gleaned from the culture change movement, nursing homes can begin to make the necessary changes to improve the quality of life for their residents and staff. 22 APPENDIX. SURVEY METHODOLOGY The Commonwealth Fund 2007 National Survey of Nursing Homes surveyed directors of nursing (DONs) from a nationally representative sample of certified long- term care nursing facilities across the U.S. The pencil and paper mail survey was conducted by Harris Interactive Inc. from February 16, 2007 through June 8, 2007. Directors of nursing were paid an honorarium of $30 for their participation. A total of 1,435 surveys were completed, yielding a response rate of 37 percent . The sampling frame was drawn from the CMS Provider of Services data file, representing a comprehensive database of certified nursing facilities. From the list of nursing homes, a stratified sample of 4,000 homes was pulled, based on bed size. The sample excluded facilities located within a hospital and those that are Medicare only, as these facilities handle mostly short-stay patients, rather than long-term care residents who are the focus of this survey. Oversampling was also used to target a minimum number of 100 interviews in 11 states. In order to make final estimates representative of all nursing facilities in the U.S., the final data were weighted by facility size using weighting targets for facility size generated from the Online Survey and Certification Reporting System (OSCAR) database. The data were also weighted by profit type, region, and multiple facility ownership in order to incorporate each of the state oversamples in their correct proportions into the final data. This report groups nursing homes according to DONs’ perception of whether or not their nursing home facility has adopted culture change and whether their nursing home leadership (including owners, board and administrators) is committed to culture change or a resident-centered approach. Based on these two measures of culture change, nursing homes are classified into the following three groups: culture change adopters (N=425), culture change strivers (N=371), and traditional nursing homes (N=586). Sixty- three nursing homes did not provide sufficient information to be classified. The report shows where differences between “traditional” homes and culture change “adopters” and “strivers” are statistically significant at the 5 percent level or better. An examination of nursing home characteristics across culture change groupings reveals little variation (Table 6). Culture change adopters are no different than culture change strivers or traditional homes when it comes to facility size, region, suburban or rural status, director of nursing tenure, and number of different administrators of record 23 in the past two years. Culture change adopters (66%) and strivers (69%) are less likely than traditional homes (76%) to be for-profit. Traditional homes are also more likely than adopters to have had three or more different directors of nursing in the past two years (20% versus 13%). While culture change strivers are more likely than adopters to be multiple facility organizations (62% versus 50%), differences between traditional homes and adopters in this regard are not significant. There is some variation by region of the country—culture change adopters are less likely than strivers and adopters to be located in the Northeast. Culture change adopters and strivers also have slightly fewer mean number of residents who are Medicaid recipients than traditional homes, but these differences are not large. The survey has an overall margin of sampling error of +/– 3 percentage points at the 95 percent confidence level. 24 NOTES 1 The Omnibus Reconciliation Act of 1987 (OBRA), was the federal legislation that included the Nursing Home Reform Act of 1987. OBRA was a fundamental shift for the nursing home industry since it changed the focus for evaluating nursing homes from inputs to outcomes. 2 National Commission for Quality Long-Term Care, From Isolation to Integration: Recommendations to Improve Quality in Long-Term Care (Washington, D.C.: National Commission for Quality Long-Term Care, Dec. 2007). 3 L. A. Grant, Culture Change in a For-Profit Nursing Home Chain: An Evaluation (New York: The Commonwealth Fund, Feb. 2008). 4 C. Haran, Transforming Long-Term Care: Giving Residents a Place to Call “Home” (New York: The Commonwealth Fund, Apr. 2006). 5 R. M. Fagan, “Pioneer Network: Changing the Culture of Aging in America,” in Culture Change in Long-Term Care, ed. A. S. Weiner and J. L. Ronch (New York: Haworth Press, 2003), 125–49. 6 The survey used a definition of “culture change” that was developed by a group of experts in the field of long-term care. W. D. Specter, M. R. Limcangeo, and D. B. Mukamel, “Identifying Culture Change Nursing Homes: Final Report to The Commonwealth Fund,” submitted to the Fund on Oct. 30, 2006, in fulfillment of the requirements for Grant #20050687, Aug. 1, 2005– Aug. 31, 2006, $36,592; A. S. Weiner and J. L. Ronch, eds., Culture Change in Long-Term Care (New York: Haworth Press, 2003). 7 These methods were developed by Drs. Joanne Rader, Ann Louise Barrick, and Philip Sloane based upon their research in bathing people with dementia and are described in their book and training video, Bathing Without a Battle. A copy of the training package was sent to every nursing home and survey agency in the United States in 2004. 8 P. J. Capehart, Recruitment and Retention of Nursing Assistants: Community Perspectives on a National Issue, Duke Long Term Care Resources Program Paper, July 1999, No. 9. 9 E. A. Miller and V. Mor, Out of the Shadows: Envisioning a Brighter Future for Long-Term Care in America, Brown University Report for the National Commission for Quality Long Term Care, 2006. 10 R. I. Stone, S. C. Reinhard, B. Bowers et al., Evaluation of the Wellspring Model for Improving Nursing Home Quality (New York: The Commonwealth Fund, Aug. 2002); D. E. Yeatts and R. R. Seward, “Reducing Turnover and Improving Care in Nursing Homes: The Potential Effects of Self-Managed Work Teams,” Gerontologist, June 2000 40(3):358–63. 11 D. E. Yeatts and C. M. Cready, “Consequences of Empowered CNA Teams in Nursing Hone Settings: A Longitudinal Assessment,” Gerontologist, June 2007 47(3):323–39. 12 C. Rudder, Improving Working Conditions for Nursing Home Direct Care Staff: A Ten Step Guide to Improving Working Conditions (New York: Long Term Care Community Coalition, July 2004). 13 Yeatts and Cready, “Consequences of Empowered CNA Teams,” 2007. 14 Ibid. 25 15 R. A. Kane, “Long Term Care and a Good Quality of Life: Bringing Them Closer Together,” Gerontologist, June 2001 (41)3:293–304; R. A. Kane, T. Y. Lum, L. J. Cutler et al., “Resident Outcomes in Small-House Nursing Homes: A Longitudinal Evaluation of the Initial Green House Program,” Journal of the American Geriatrics Society, June 2007 55(6):832–39. 16 J. Rabig, W. Thomas, R. A. Kane et al., “Radical Redesign of Nursing Homes: Applying the Green House Concept in Tupelo, Mississippi,” Gerontologist, Aug. 2006 46( 4):533–39. 17 Yeatts and Cready, “Consequences of Empowered CNA Teams,” 2007; Kane, Lum, Cutler et al., “Resident Outcomes in Small-House Nursing Homes,” 2007. 18 Kane, Lum, Cutler et al., “Resident Outcomes in Small-House Nursing Homes,” 2007. 19 Grant, Culture Change in a For-Profit Nursing Home Chain, 2008; Yeatts and Cready, “Consequences of Empowered CNA Teams,” 2007; Kane, Lum, Cutler et al., “Resident Outcomes in Small-House Nursing Homes,” 2007. 20 See, for instance, any of the following tools developed in conjunction with Household Matters: A Good Life ‘Round the Clock, an integrated toolkit of manuals, guides, and other materials written for long-term care providers who want to become resident-centered. Further information available at: http://www.commonwealthfund.org/General/General_show.htm?doc_id=508020. Also see A Tale of Transformation: Four Stages Tell the Story, a DVD and accompanying workbook offering learning points and inspiration for teams working to change the culture of nursing homes. Further information available at: http://www.commonwealthfund.org/innovations/ innovations_show.htm?doc_id=365182. Also see Champions for Care: A Workbook for Long- Term Care Providers, a workbook that offers guidelines and handouts for training sessions designed to help long-term care facility staff members develop skills to build teams and take on leadership roles. Further information available at: http://www.commonwealthfund.org/ innovations/innovations_show.htm?doc_id=342998. Also see Getting Started: A Pioneering Approach to Culture Change in Long-Term Care Organizations a 300-page handbook designed to provide nursing homes with a compendium of lessons learned from those already several years into the transition from a medical model to resident-centered care. Further information available at: http://www.commonwealthfund.org/innovations/innovations_show.htm?doc_id=232592. 21 A. March, Case Study: Elder Homes Replace Nursing Homes in Tupelo, Miss. (New York: The Commonwealth Fund, Mar. 2007). 26 Table 1. Resident-Directed Initiatives, Daily Living Choices and Involvement in Decision Making, by Culture Change Groupings Base: All respondents Culture Change Groupings Culture Change Culture Change Total Adopters a Strivers b Traditional c Unweighted N 1435 425 371 586 Weighted percentages 100% 31% 25% 43% Resident-Directed Initiatives: Percent of homes that are currently implementing the following resident-directed initiatives Enable residents to determine their own daily schedules 29 58* 28* 22 Actively involve residents in decisions regarding their household/neighborhood/unit 38 70* 39* 27 Fully implement “Bathing Without a Battle Techniques” 35 64* 45 37 Yes to all 12 25* 7 5 Percent of homes indicating this it is practice for residents to be able to choose the following Sleeping Choices: Go to bed when they want 96 98* 97 95 Get up when they want 89 96* 90* 85 Yes to all 88 95* 90* 83 Bathing Choices: Choose how they are bathed 87 94* 89 83 Choose when bathed or showered 72 86* 69 65 Yes to all 68 81* 64 61 Eating Choices: Request and receive favorite foods that are not on the menu 84 93* 87* 79 Eat when they want 62 78* 64* 54 Access food from a refrigerator whenever they want 47 58* 51* 41 Access appliances necessary to prepare own meals 20 26* 20 17 Yes to all 13 22* 13* 8 Resident Autonomy and Decision Making Decisions for the following activities are usually made by residents independently or jointly with staff Daily Living Choices and Social Events: Creating schedule for meals 12 23* 9* 7 Planning menus 14 26* 13* 8 Decorating communal areas 13 22* 16* 5 Creating calendar for social events 28 46* 27* 17 Planning social events 31 49* 33* 20 Personnel Issues and Care Planning: Developing the resident’s care plan 42 58* 40* 33 Decisions about who provides their own hands- on care 14 22* 14* 8 Decisions about personnel who will be or are working in the household, neighborhood, or unit 3 5* 3 2 a Culture change adopters = culture change definition completely or for most part describes nursing home. b Culture change strivers = culture change definition describes nursing home only in a few respects or not at all, but leadership is very or extremely committed to the adoption of culture change. c Traditional = culture change definition describes nursing home only in a few respects or not at all AND leadership is less than extremely or very committed to the adoption of culture change. * Compared with traditional, differences are statistically significant (p<.05). Source: The Commonwealth Fund 2007 National Survey of Nursing Homes. 27 Table 2. Staff Initiatives, Roles, Leadership, and Decision Making, by Culture Change Groupings Base: All respondents Culture Change Groupings Culture Change Culture Change Total Adopters a Strivers b Traditional c Unweighted N 1435 425 371 586 Weighted percentages 100% 31% 25% 43% Staff Initiatives: Percent of homes that are currently implementing the following staff initiatives Consistent assignment of Certified Nursing Assistants to residents 74 86* 80* 74 Staff leadership training opportunities 53 74* 54* 49 Include direct care workers and residents on senior management team 32 59* 40* 24 Include Certified Nursing Assistants in resident-centered care planning sessions, for instance using the “I Care” or “First Person” approach 42 69* 49* 37 Create self-managed work teams 15 32* 16* 11 Yes to all 5 12* 3 3 Staff Roles: Percent of homes indicating that Certified Nursing Assistants are assigned to care for residents in the following ways Rotate to provide care for different residents on a scheduled basis 26 22* 24 31 Consistently provide care for the same group of residents each shift they work 72 78 76 69 Percent of homes indicating that Certified Nursing Assistant schedules are determined in the following ways A staffing coordinator determines schedules 93 91* 94* 97 Certified Nursing Assistants develop their own schedules for day and evening shifts 5 8 5 3 Staff Leadership: Percent of homes indicating that any of the following are part of the senior management team that makes important decisions affecting the entire nursing home Direct care worker(s) 58 73* 66* 45 Resident(s) 48 64* 55* 35 Families of residents 42 57* 48* 30 ALL serve on senior management team 37 51* 42* 24 Staff Training: Mean percent of Certified Nursing Assistants on staff that attended continuing education courses or other educational courses paid for by facility in past year 38 47* 38 33 Mean percent of staff trained to do tasks outside of their primary duty 14 20* 16* 10 Staff Autonomy and Decision Making: Decisions for the following items are usually made by direct care workers independently or jointly with department head Planning social events 35 51* 38* 23 Scheduling of staff shifts 17 25* 19* 11 Staff assignment to residents 23 35* 27* 13 Performance evaluations 15 22* 17* 9 Hiring and staff selection 5 9* 5* 2 Budget and resource requests 3 5* 4* 1 a Culture change adopters = culture change definition completely or for most part describes nursing home. b Culture change strivers = culture change definition describes nursing home only in a few respects or not at all, but leadership is very or extremely committed to the adoption of culture change. c Traditional = culture change definition describes nursing home only in a few respects or not at all AND leadership is less than extremely or very committed to the adoption of culture change. * Compared with traditional, differences are statistically significant (p<.05). Source: The Commonwealth Fund 2007 National Survey of Nursing Homes. 28 Table 3. Nursing Home Physical Environment, by Culture Change Groupings Base: All respondents Culture Change Groupings Culture Change Culture Change Total Adopters a Strivers b Traditional c Unweighted N 1435 425 371 586 Weighted percentages 100% 31% 25% 43% Physical Environment Initiatives: Percent of homes that are currently implementing the following physical environment initiatives Break down larger units into smaller operational units 8 16* 9* 4 Eliminate nurses stations 3 7* 4* 1 Change dining experience 29 46* 34* 22 Yes to all 1 3* - - Overall Structure and Living Design: Mean percent of residents living in the following settings Traditional nursing units – areas with a larger number of residents under care, often occupying a hallway or floor of a building 89 79* 92 92 Neighborhoods – areas in which the traditional nursing unit is broken into smaller functional units, in which ancillary services, such as laundry, dining, and bathing are shared with other neighborhoods 8 15* 6 5 Households – self-contained areas with a full kitchen, living room and dining room, with a relatively small number of residents per household 1 2* 1 1 Nursing Station Design: How are nurses’ stations typically structured in this nursing home? Traditional – stations occupy a centralized location near resident rooms 86 81* 85* 91 Informal design – some/all stations have been redesigned to be more informal with desks and counters designed to be more open 11 16* 13* 8 Complete redesign – nursing work space has been integrated into resident living space 2 4 2 1 Overhead Paging System: Used on a regular basis 72 64* 68* 79 Used only in case of emergency 20 22* 25* 16 Not used at all 8 14* 7 5 Meal Preparation and Service: Which of the following best describe how meals are prepared and served for the majority of residents? Prepared in central kitchen; served in one or more common dining rooms 74 66* 75 81 Prepared in central kitchen; served in individual unit 22 31* 23 18 Prepared & served at the unit level 2 3 2 1 a Culture change adopters = culture change definition completely or for most part describes nursing home. b Culture change strivers = culture change definition describes nursing home only in a few respects or not at all, but leadership is very or extremely committed to the adoption of culture change. c Traditional = culture change definition describes nursing home only in a few respects or not at all AND leadership is less than extremely or very committed to the adoption of culture change. * Compared with traditional, differences are statistically significant. (p<.05). Source: The Commonwealth Fund 2007 National Survey of Nursing Homes. 29 Table 4. Impact of Culture Change, by Number of Culture Change Initiatives Currently Being Implemented Base: Definition of culture change describes this nursing home completely, for the most part, or in a few respects Number of Culture Change Initiatives Currently Being Implemented^ Total High a Medium b Low c Unweighted N 805 145 362 298 Weighted percentages 100% 38% 44% 18% Organizational Impact: Percent of homes responding that culture change has had an improvement on the following Staff retention 56 59* 58* 52 Staff absenteeism 38 50* 40 33 Use of agency staff 18 23 16 19 Staff retention/staff absenteeism/ or use of agency staff 58 64* 60* 52 Competitive position in market area 67 78* 73* 54 Occupancy rate 52 60* 57* 44 Operational costs 38 60* 35 31 ^ Respondents were asked whether their home was currently implementing any of eleven different resident-centered, staff, or physical environment initiatives associated with culture change. a High = 7 or more initiatives currently being implemented. b Medium = 4 to 6 initiatives currently being implemented. c Low = 3 or less initiatives currently being implemented. * Compared with low number of initiatives, differences are statistically significant (p<.05). Source: The Commonwealth Fund 2007 National Survey of Nursing Homes. 30 Table 5. Barriers to Culture Change, by Culture Change Groupings Base: All respondents Culture Change Groupings Culture Change Culture Change Total Adopters a Strivers b Traditional c Unweighted N 1435 425 371 586 Weighted percentages 100% 31% 25% 43% Barriers to Implementation: How much of a barrier are the following to implementing culture change? Major Barrier Cost 31 26* 32* 56 Regulations 23 22 23 34 Size of facility 22 14* 23* 36 Staff resistance 14 5* 14* 25 Corporate/board support 11 5* 2* 28 Human resource policies and procedures 8 4* 6* 17 Family or resident resistance 3 3* 1* 8 Minor Barrier Cost 28 34* 45* 30 Regulations 33 38* 40* 37 Size of facility 27 26 37* 32 Staff resistance 47 50* 58* 51 Corporate/board support 16 15* 15 26 Human resource policies and procedures 34 31* 42 46 Family or resident resistance 35 32 42 48 Not a Barrier Cost 18 38* 22* 10 Regulations 28 39* 36* 25 Size of facility 35 57* 38* 27 Staff resistance 26 43* 27* 21 Corporate/board support 49 71* 77* 33 Human resource policies and procedures 40 63* 49* 33 Family or resident resistance 45 64* 55* 41 a Culture change adopters = culture change definition completely or for most part describes nursing home. b Culture change strivers = culture change definition describes nursing home only in a few respects or not at all, but leadership is very or extremely committed to the adoption of culture change. c Traditional = culture change definition describes nursing home only in a few respects or not at all AND leadership is less than extremely or very committed to the adoption of culture change. * Compared with traditional, differences are statistically significant (p<.05). Source: The Commonwealth Fund 2007 National Survey of Nursing Homes. 31 Table 6. Characteristics of Nursing Homes, by Culture Change Groupings Base: All respondents Culture Change Groupings Culture Change Culture Change Total Adopters a Strivers b Traditional c Unweighted N 1435 425 371 586 Weighted percentages 100% 100% 100% 100% Facility Size: Small (99 beds or less) 45 47 46 45 Medium (100-199 beds) 48 47 47 48 Large (200+ beds) 7 6 7 8 Profit Type: For profit 72 66* 69* 76 Non profit 24 29* 27* 20 Government 4 4 3 4 Multiple Facility Organization: Yes 55 50 62* 53 No 45 50 38 47 Region: North East 18 14* 21 19 North Central 33 36 30 34 South 34 34 32 35 West 15 16 17 12 Urban-Rural Status: Urban 27 30* 29* 23 Suburban 41 39 43 42 Rural 32 31 28 35 Payer Mix: Mean percent of residents who are Medicaid recipients 65 64* 64* 67 Mean percent of residents who are Medicare recipients 12 12 12 12 Mean percent of residents covered by other types of payment 23 24 24 22 Private Rooms and Bathrooms: Mean percent of residents with private room 14 18* 16* 13 Mean percent of residents with private bathroom 10 13* 12* 9 Tenure of Management: Number of different Directors of Nursing in past 2 years One 57 60 54 59 Two 25 26 29* 21 Three or more 17 13* 17 20 Number of different Administrators of Record in past 2 years One 65 67 60 68 Two 22 22 26 21 Three or more 13 11 14 11 Director of Nursing Tenure at Current Facility Less than 1 year 29 26 33 29 More than 1 to less than 5 years 39 43 37 39 5+ Years 31 32 30 32 a Culture change adopters = culture change definition completely or for most part describes nursing home. b Culture change strivers = culture change definition describes nursing home only in a few respects or not at all, but leadership is very or extremely committed to the adoption of culture change. c Traditional = culture change definition describes nursing home only in a few respects or not at all AND leadership is less than extremely or very committed to the adoption of culture change. * Compared with traditional, differences are statistically significant (p<.05). Source: The Commonwealth Fund 2007 National Survey of Nursing Homes. 32 RELATED PUBLICATIONS Publications listed below can be found on The Commonwealth Fund’s Web site at www.commonwealthfund.org. Culture Change in a For-Profit Nursing Home Chain: An Evaluation (February 2008). Leslie A. Grant. Resident Outcomes in Small-House Nursing Homes: A Longitudinal Evaluation of the Initial Green House Program (June 2007). Rosalie A. Kane, Terry Y. Lum, Lois J. Cutler et al. Journal of the American Geriatrics Society, vol. 55, no. 6. Consequences of Empowered CNA Teams in Nursing Hone Settings: A Longitudinal Assessment (June 2007). Dale E. Yeatts and Cynthia M. Cready. Gerontologist, vol. 47, no. 3. Radical Redesign of Nursing Homes: Applying the Green House Concept in Tupelo, Mississippi (August 2006). Judith Rabig, William Thomas, Rosalie A. Kane et al. Gerontologist, vol. 46, no. 4. Transforming Long-Term Care: Giving Residents a Place to Call “Home” (April 2006). Christine Haran. Evaluation of the Wellspring Model for Improving Nursing Home Quality (August 2002). Robin I. Stone, Susan C. Reinhard, Barbara Bowers et al. 33