Rethinking the Nursing Home: C A L I FOR N I A Culture Change Makes Headway in California H EALTH C ARE F OU NDATION Introduction operations. Additionally, concerns linger about Interest in nursing home culture change has regulatory barriers to culture change. been increasing at the federal, state, and provider levels, spurred by advocates’ efforts to promote What Is “Culture Change?” person-centered care, industry initiatives to The terms “culture change,” person-centered Issue Brief improve resident experiences, and new federal care,” and “person-directed care” are often used policy guidance and technical support. Recent interchangeably when referring to nursing home care that focuses on relationships and people additions to the literature show that nursing instead of regulations, policies, and procedures. homes embracing culture change have experienced Culture change often encompasses: positive quality and business impacts. • Care practices • Environment Although California has not been in the forefront • Workplace practice of culture change, there have been shifts in state • Leadership practice officials’ perspectives. The California Culture • Family and community inclusion Change Coalition (CCCC) is making strides • Regulation changes through: For more information see CHCF’s Fast Facts Resources for Nursing Home Professionals at www.chcf.org/topics/view. K The California Culture Change Person- cfm?itemID=120346. Directed Dining Pilot Project; K The launch of a regular schedule of Regional The State of Long-Term Supports Culture Change Forums; and Nursing homes are an important building K The enactment of a civil monetary penalty block of the nation’s long-term supports (LTS) (CMP) provision aimed at funding nursing system, which addresses the needs of people home quality improvements. with permanent disabilities and functional impairment. Long-term supports are defined Other positive developments include establishment as a set of coordinated medical, nursing, of the Country Crest household model in Oroville rehabilitation, personal care, and support services and an array of non-traditional sites, including ten that are delivered in a variety of settings including Eden Alternative sites, and a Green House® home the home, community-based residences, and effort in Southern California. See page 11 for institutions. profiles of culture change trailblazers. For nursing homes, the landscape is changing. California has unique challenges related to Over the past decade, national Medicaid-financed culture change, including higher-than-average nursing home spending has decreased by over construction costs and a volatile budgetary 12 percent.1 Utilization has decreased as well. environment that may affect providers seeking Since 1993, there has been a 13-percent drop D ecember long-term financing for construction and ongoing in use by the 85+ population.2 Younger seniors 2008 (75+) have been less inclined to use nursing homes as levels have trended upwards for many years. However, well. Approximately 7.4 percent of people 75+ resided in there is evidence that assisted living residents and nursing nursing homes in 2006, compared with 8.1 percent in home residents are becoming more similar.8 Second, even 2000 and 10.2 percent in 1990.3 states like Washington with robust long-term supports efforts aimed at reducing nursing home usage through Seniors are increasingly opting to remain at home longer home and community-based services have been unable or are choosing more home-like alternatives including to completely eliminate the need for nursing home care.9 assisted living, continuing care retirement communities Finally, in the coming decade LTS demand will reach (CCRC), and rapidly expanding Medicaid-financed home unprecedented levels, driven by population aging and and community-based services (HCBS).4 increasing disability prevalence among those under age 55.10 California has approximately 1,296 nursing facilities, the vast majority (1,244) in urban settings. Most are There will be an increasing number of older adults who free-standing — only 160 are hospital-based nursing will live longer and potentially need services for greater facilities.5 California nursing home supply and utilization periods of time than past groups of elders. The expected rates are below the national average. According to trade increase in demand and decrease in mortality suggest association information, the state has 123,920 certified that both home-based services and high-quality nursing nursing home beds — 32 for every 1,000 people age 65+. home care will be equally important policy and program This is lower than the national average of 46 beds for this considerations. Such strategy development will be age group. particularly important in California because of the state’s large population and the high growth rate of its 65+ For the 85+ population, the bed supply is equally low. population. California’s ratio of 241 beds per 1,000 people age 85+ is the ninth lowest in the nation, and 30 percent below the Barriers to Improvement national average of 345. The large majority of the nation’s nursing home facilities are 30 to 40 years old, but providers face many challenges California’s nursing home occupancy rate is equal to when attempting to make physical plant improvements, the national average (86 percent).6 Total nursing home add or improve information technology, or modernize admission rates for the state decreased by approximately service approaches. These difficulties frustrate efforts to 4 percent between 2000 and 2005. Researchers point focus on consumer preferences through culture change to community-based alternatives as the reason for the approaches, offer staff development and careering decrease. However, the decline was primarily in hospital- programs, or measure quality. The U.S. Government based nursing home admissions. Free-standing admissions Accountability Office (GAO) research on nursing home actually increased by 10 percent.7 care, as well as recent media coverage in such publications as the New York Times and the Wall Street Journal, Despite these trends, nursing home care will likely continue to raise serious questions about nursing home remain part of the state’s LTS continuum for a number providers’ capacity to deliver quality services.11 of reasons. First, it is unclear that HCBS programs have the capacity to support people as acuity and cognitive California, compared to the U.S. as a whole, has a higher impairments increase. It is questionable whether aging-in- rate of nursing home quality issues. Although there has place has been fully realized, since nursing home acuity been evidence of some recent improvements, research 2  |  California HealthCare Foundation has raised questions about the quality of nursing home provider taxes from 6 percent to 5.5 percent. California is performance data and related state action to address second in the nation in its use of nursing home provider concerns.12 Some California nursing home issues include: taxes to increase Medicaid payment levels.17 K Residents spend more time in bed, compared to other states.13 The majority of states have been in stable or good fiscal health over the last four years. However, beginning in K Residents experience more than twice the national fiscal year 2008, many states are projecting a return rate of physical restraint.14 to budgetary shortfalls; federal analysts also predict a K There are problems with the state’s survey and widening gap between state revenues and outlays.18 certification process, regional licensing and Currently, 24 states, including California, are projecting certification staffing, and related data systems.15 shortfalls in FY 2008. Unlike the federal government, all states (except Vermont) have balanced budget At the same time, California nursing home staffing and requirements and must make adjustments accordingly. turnover rates are on par with national trends. California faces a $14 billion deficit in 2008. In January 2008, the Governor proposed a 10-percent cut in Financing and Payment Rates Medi-Cal payment rates. Nursing home financing is extremely tight. Margins typically range from 3 to 5 percent, leaving little room for However, the state recently increased its nursing home environmental modifications that are key to many culture payment rates, and the Medi-Cal State Plan requires change models. Low margins also breed an aversion that long-term care (LTC) rates be adjusted each year to risk and change for many providers, limiting the by approximately 2.35 percent. With the passage of implementation of new service delivery and organizational AB 1629, this requirement now applies only to certain approaches, even when the budgetary impact is modest or facilities: level A nursing facilities; hospital distinct- negligible. To cover costs, nursing homes have increasingly part level B nursing facilities; rural swing beds; hospital moved toward service diversification or expanding higher- distinct-part sub-acute beds; pediatric sub-acute beds; paying lines of business to cross-subsidize services with and intermediate care facilities for the developmentally lower reimbursement levels, such as Medicaid-financed disabled (ICF-DD).19 Since the rate increase, the average long-term placement. Medicaid per diem shortfall decreased from $7.83 in 2005 to $3.34 in 2007.20 The 2007 shortfall placed For 2007, the national average projected daily Medicaid California among only eight states with less than a $4 reimbursement shortfall was $13.10, an improvement per day Medicaid shortfall. But, it is important to note over prior years when the Medicaid environment for the that the Governor’s budget calls for a 10-percent decrease nursing home industry was less stable.16 Between 2003 in local assistance for all long-term care facility rates. It and 2007, many states increased Medicaid payments is unclear how the local assistance cuts and state-level to nursing homes through rebasing, adjusting the rate Medi-Cal payment cuts for non-facility-based LTS will methodology, or implementing or expanding Medicaid impact providers with robust lines of business that are provider tax programs. Provider tax programs have subject to rate reductions (i.e., adult day health care, allowed states to use such funds, and related federal home health, multi-service senior programs (MSSP)). matching dollars, to increase Medicaid nursing home Additionally, the Governor has proposed administrative payments. However, last year Congress enacted legislation cuts that could impact state operations. that decreases the amount that states can assess in Rethinking the Nursing Home: Culture Change Makes Headway in California  |  3 Culture Change Overview K De-Medicalizing the physical environment. Culture change has expanded in the past two decades, Residential environments are redesigned to eliminate as state regulators, advocacy groups, and providers have or hide as many medical functions and tools as introduced related concepts such as self-directed care and possible. Some models create “neighborhoods,” person-centered services into most elements of the LTS “households,” or “small homes” that break up continuum. These approaches are frequently apparent in facilities and eliminate the traditional warehouse feel; assisted living, in-home services, independent community K Redesigning the organization. As staff take on living, and continuing care retirement communities more roles and are more involved in organizational (CCRC). decision-making, organizations become less hierarchical and have fewer silos enclosing such Culture change offers the promise of better quality care functions as food services or laundry services; and and quality of life for residents, as well as a more desirable workplace for direct care staff. K Creating new leadership practices. Organizational leadership becomes more decentralized, moves Generally, culture change models emphasize shifting to a coaching approach, emphasizes more staff from a program- or facility-based model of care to a involvement, and is multidisciplinary.22 consumer-driven model. This usually involves making changes to the physical plant to create a more home-like Researchers propose categorizing nursing home culture environment; restructuring staffing and management change progress across these five areas into four stages patterns to empower frontline workers; and creating a (see Table 1 on the following page). flexible and responsive service delivery system to meet the needs and preferences of individual residents. The staffing Six Models components are intended to improve worker satisfaction California is still “behind the curve,” according to and reduce the serious quality impacts of high turnover interviews with four culture change experts in the state. rates.21 A 2007 California Culture Change Coalition survey of both the for-profit and nonprofit trade association Five Key Areas memberships resulted in only 25 responses with very little There are a number of definitions and models for culture useful information. change, but recent research points to five areas as key to culture change: However, models for change do exist. The following six descriptions are based on Web research and phone K Establishing inclusive decision-making. The interviews. Because culture change is a unique process for traditional top-down approach is replaced with each facility or organization, the models reveal different more inclusive and consensus-driven organizational applications of the process stages shown in Table 1. decision-making; Additionally, it is important to note that emphasizing K Reinventing staff roles. Direct care staff do their consumer choice and home-like environments is not work more autonomously in self-directed work teams. limited to these six models or any particular model. They may take on multiple (“universal”) roles across traditional departments, providing some nursing care, The Eden Alternative. Developed by Dr. William housekeeping services, meal preparation, personal Thomas, this model is based on guiding principles that care, and social activities; incorporate four of the five of the key elements of culture 4  |  California HealthCare Foundation Table 1. Four Stages of Culture Change S ta g e F e at u r e s 1 – nstitutional Model I The traditional medical model is organized around a nursing unit without permanent staff assignment. Neither residents nor staff are empowered in this model. Staffing inconsistency limits relationship-building between staff and residents, and depresses job satisfaction. 2 – ransformational Model T Awareness of the key elements of culture change is pushed throughout the organization via workshops and educational sessions for various departments and types of staff. Permanent staff assignments to units may be made to start the development of communities within the facility. Low-cost physical changes may be introduced, including new furnishings, artwork, plants, carpeting, and higher-end finishes — such as crown molding. 3 – eighborhood Model N Traditional units are divided into smaller areas. Resident-centered dining may be adopted, eliminating full kitchens. Neighborhood coordinators are sometimes introduced and unique names and physical attributes are developed for each neighborhood. 4 – ousehold Model H Self-contained living areas have up to 25 residents. Typically, each household has its own kitchen, living area, and dining area. Staff are self-directed teams who perform a variety of functions. Household management is a collaborative process that places resident preferences first, followed by staff and household capacities. Source: Grant, L., Norton, L. (November 2003) A Stage Model of Culture Change In Nursing Home Facilities. Presented at the 56th Annual Scientific Meeting of the Gerontological Society of America. change. It does not require — but encourages — nursing Wellspring goals: (1) care decisions need to take place homes to make physical alterations to the facility. Staff closest to the resident; (2) a substantial knowledge training is based on restructuring the organizational base is required by all staff to enable participation in service philosophy and values. There are some 270 decision-making; and (3) an empowered workforce registered Eden alternative homes, of which ten are in increases resident and employee satisfaction and reduces California: Delta Nursing and Rehabilitation in Visalia; staff turnover. Wellspring consists of a series of clinical Elder Homes in Fresno; Hacienda Rehabilitation and and management training models; it is the only model Healthcare Services in Hanford; Hanford Nursing and that requires participating facilities to regularly submit Rehabilitation Center also in Hanford; Horizon Health performance data. The data are reported to the Wellspring and Subacute Center in Fresno; Kings Nursing and Institute using the Wellspring Outcomes Reporting Rehabilitation Center also in Hanford; Mercy Retirement System. Some culture change experts question whether and Care Center in Oakland; Oak Valley Care Center Wellspring is a culture change model or a quality in Oakdale; Piners Quest Home in Napa; and Salem improvement system. Based on the culture change Lutheran Home in Oakland.23 This model can span from progression model shown in Table 1, Wellspring efforts Stage 2 to Stage 4 (Table 1), depending upon whether fall mainly into Stage 2. There are currently no Wellspring significant physical changes are made to the facility. The sites in California.24 Eden Alternative often is considered a sister model of the Green House model discussed below. Planetree. This model has been primarily implemented in the hospital environment, although its Web site Wellspring. This organizational model focuses on points to expansion into the LTS marketplace. Planetree moving facilities from the traditional management describes itself as a holistic approach that encourages and institutional service delivery configuration to an healing in several dimensions including mental, environment that is more person-centered and empowers emotional, spiritual, social, and physical. It requires staff. It uses a set of essential elements to achieve the changes in architecture and interior design to create Rethinking the Nursing Home: Culture Change Makes Headway in California  |  5 a home-like and barrier-free environment. Planetree The Green House® Home Model. Licensed as skilled implementers must adopt values that align with patient- nursing, the Green House environment goes beyond centered service delivery and have ongoing staff training being “homelike” to what truly feels like “home” through to ensure a shift in day-to-day activities. There are fundamental changes to architecture, organizational approximately 130 Planetree-branded sites, including structure, and philosophy of care. Key aspects of the four in California: Enola Medical Center in Chico; Loma model: Linda University Medical Center in Loma Linda; Sharp K Each facility is a self-contained residence, designed Coronado Hospital and Healthcare Center in Coronado; like a private home while meeting institutional and South Coast Medical Center in Laguna Beach.25 construction standards. With a maximum of 10 to 12 Enola offers home-care and hospice, Sharp offers skilled elders per home, each resident has a private bedroom nursing, and South Coast offers home health and an and bathroom. The common space in the house, array of prevention and wellness programs for seniors.26 referred to as the “hearth,” includes a living area, Planetree efforts mostly fall into Stage 3. a single dining table that accommodates all of the residents for meals, and an open kitchen. Household Model. Fostered by Action Pact, Inc., the household model emphasizes culture change staffing K Specially trained workers (with core training as and organizational change elements. It typically involves certified nursing assistants) staff each residence as renovation or construction to replace traditional double a self-managed work team. They provide personal corridor designs with smaller units. The household care, activities, meal preparation and service, light model does not require a “universal” worker approach. housekeeping, and laundry. There is at least one example of the household model K Partnering with the direct care staff is a clinical in California: Country Crest, located in Oroville. The support team of licensed nurses, therapists, medical development of this household site, which began in directors, as well as social services, activities, and 2002, was laborious; the Office of Statewide Healthcare dietary specialists. Planning and Development approval took almost 18 months.27 The household model appears to be at Stage 4. The Green House model includes architectural, organizational, staffing, and philosophical changes. Neighborhood Model. This approach shares many Unlike most culture change approaches, this model is characteristics with the household model but typically implemented all at one time, in a carefully crafted method involves less environmental change. Facilities attempt to designed to support initial success as well as long-term create neighborhoods with unique, homelike atmospheres. sustainability. California had no Green House facilities Neighborhood model facilities must develop core service before December 2007, when Green House Replication philosophies aligned with patient-centered services, and Initiative began working with Mt. San Antonio Gardens must implement staff training modules to ensure day-to- in Pomona. Green House homes fall firmly into Stage day implementation. Typically, facilities permanently 4 of the culture change progress model, and might be assign staff, provide some cross-training, and may appropriate to a new stage defined by its practices and attempt to carve out neighborhood support services simultaneous implementation. within existing departments. For example, the facility kitchen might have certain staff dedicated to a specific Table 2 provides a high-level comparison of the various neighborhood. The neighborhood model appears to be at culture change initiatives. Stage 3. 6  |  California HealthCare Foundation Table 2. Comparison of Culture Change Models Eden Household Neighborhood Green House C h a r ac t e r i s t i cs A lt e r n at i v e Wellspring Planetree Model Model home model Core values and philosophy Yes Yes Yes Yes Yes Yes Requires staff changes N/A (in values) Yes – low Yes – high Yes – medium Yes – medium Yes – high Requires physical changes* Yes – No Yes – medium Yes – medium Yes – medium Yes – high low to medium May operate within N/A Yes Yes Maybe Yes No existing physical plant Model is branded or Yes N/A Yes No No Yes requires registration Notes: Level of effort within characteristic area is broken down by low, medium, and high where possible. * hysical changes at a moderate level might entitle repainting and other cosmetic changes. Medium might entail creating neighborhood elements such as neighborhood kitchens and living rooms. P The Green House model is “high” because it requires new construction. Source: MDK Consulting, modified by NCB Capital Impact Other than the Eden Alternative and Planetree, the major U.S. to look at both clinical outcomes of person-directed culture change models have not made significant inroads care and impacts on workforce retention. Researchers in California. Eden’s foothold in the state is modest; there found a decline in chronic pain rates for residents and are ten Eden-certified facilities in a state of 1,200 nursing a decline in the use of physical restraints. Outcomes in homes. However, many California nursing homes may workforce retention were quite pronounced. Compared be integrating elements of consumer choice and physical to estimated national nursing home turnover rates of changes without using a formal model. 70 percent, participating INHC facilities experienced a 10-percent decline in turnover.30 Other research on the Culture Change Outcomes Research impacts of empowering certified nursing assistants (CNA) Until recently, there has been very little peer-reviewed produced similar results — improvements in resident care research that directly linked culture change models to and better staff retention rates.31 outcomes.28 Research comparing the Green House homes with The majority of culture change research is funded by traditional nursing home care showed that the Green The Commonwealth Fund. In 2001, it underwrote an House homes had: (1) high levels of satisfaction reported evaluation of the Wellspring model; researchers found by residents, family, and staff; (2) reduced rates of decline improved staff retention and job satisfaction as well as in late-loss activities of daily living; (3) lower prevalence reduced survey deficiencies in a sample of 11 Wisconsin- of depression; (4) fewer residents classified as bedfast; and based Wellspring sites.29 Importantly, this model (5) fewer residents having little or no activity.32, 33 produced low or no new costs for participating facilities. However, some culture change experts question whether In 2007, the Pioneer Network released preliminary fewer deficiencies correlates with improved quality research findings on early culture change adopters. The outcomes for residents. findings include fewer deficiencies than before culture change or early in culture change; better quality of From August 2004 to October 2005, Quality Partners™ care (measured in terms of deficiencies); and operating of Rhode Island conducted a pilot study, “Improving margins comparable to nonparticipating homes.34 Nursing Home Culture” (INHC), in the northeastern Rethinking the Nursing Home: Culture Change Makes Headway in California  |  7 The majority of research projects were conducted with Federal and State Support for Culture nonprofit providers. However, in 2004, University of Change Pennsylvania researchers with the Hartford Center of Federal level efforts. The Omnibus Reconciliation Act Geriatric Nursing Excellence partnered with Beverly of 1987 (OBRA-87) helped set the stage for culture Enterprises, called National Golden Gate Senior Care, change by creating more resident-focused standards for to compare three NGGSC nursing homes using the services. In recent years, the federal Centers for Medicare company’s Resident Centered Care Model with three and Medicaid Services (CMS) has taken important traditional nursing homes. The study found improved steps to advance culture change principles. In 2005, the quality of life using evaluation design measures, and agency directed state quality improvement organizations better job satisfaction.35 (QIOs) to improve organizational culture. A year later, it released a facility self-assessment tool titled the “Artifacts The Commonwealth Fund is underwriting further of Culture Change Tool,” to help nursing homes measure research, titled “Evaluation of Culture Change in their progress. Also in 2006, CMS issued a detailed For-Profit Nursing Homes: Business Innovation at document to state survey agency directors explaining how Beverly Enterprises,” at the University of Minnesota. the Green House and similar culture change models fit Such research will be particularly important for California into the current federal survey requirements.38 The CMS due to the state’s high proportion of for-profit nursing “2007 Action Plan for (Further Improvement of ) Nursing home providers. Three points that have come out of the Home Quality,” stated that culture change principles University of Minnesota research include: “echo OBRA principles.” K Homes that already are high performers should be selected for culture change programs; A February 2007 CMS letter indicated that culture change models, such as the Green House, “more fully K Extensive prep work is needed to help board implement the Nursing Home Reform provisions of… members and shareholders understand the nature [OBRA-87],” including quality-of-life goals. CMS stated of culture change front-end investment, and that that no federal regulatory barriers exist for the model business units could lose money in the short term; and similar culture change approaches.39 Also, a series of and CMS-sponsored educational conference calls on culture K The regulatory and consumer focus is shifting from change was launched in September 2007. deficiencies to the quality of life a provider can offer, and this will directly impact a chain’s potential In 2008, CMS convened a symposium on the market share.36 implications of traditional nursing home physical environments and the Life Safety Code on culture Few studies have been conducted on the business change. One of the symposium aims was to identify implications of culture change. However, in May 2008, strategies to meet needed Life Safety Code requirements researchers found that the “more nursing homes are while embracing culture change principles related to the engaged in practices associated with culture change, the physical environment. more likely they are to report that culture change has made positive improvements in competition in their On July 23, 2008, the United States Senate Special market, nursing home operations, staffing, and occupancy Committee on Aging convened a hearing on person- rates.”37 centered care. Goals of the hearing were to understand strategies for restructuring nursing home care, in 8  |  California HealthCare Foundation particular the Green House approach, and to explore ways K North Carolina – Funding for Eden Alternative and to make it easier for other nursing homes to move toward Pioneer Network programs.42 these model programs.40 In 2008, the Institute for the Future of Aging Services State level efforts. The states have taken a variety of (IFAS) will release eight case studies assessing how the approaches to support culture change. Several, including states of Georgia, North Carolina, Massachusetts, Kansas, Arkansas and Oklahoma, have enacted legislation Oregon, Michigan, and Vermont are fostering culture changing state level regulations and statutes to fully change. IFAS also will release a culture change tool kit embrace the Green House model and other forms of tailored to state officials.43 culture change. Wyoming legislation establishes a Green House pilot project, and Massachusetts issued its first California efforts. California recently enacted civil certificate of need in ten years for a Chelsea, MA, Green monetary penalty legislation — similar to federal House project.41 legislation — targeting funds to nursing home improvements. State officials — particularly OSHPD and Other states are using funds secured through OBRA-87 L&C — have expressed a strong interest in advancing civil monetary penalties to improve nursing home quality culture change (see Table 3). For this issue brief, OSHPD and foster culture change. Examples include: and L&C provided important statements about their openness to nontraditional service delivery approaches K Arkansas – Planning grants for Green House homes focusing on consumer-driven care, direct care worker and Eden Alternative implementation; empowerment, and architectural features and design that K Louisiana – Culture change initiatives; reduce or eliminate medical model elements. Aside from K Maryland – Wellspring projects; the caveat that all innovations must comply with the statutory intent and regulatory requirements, both state K New Jersey – Eden Alternative grants; and agencies expressed keen interest in working with providers to explore culture change innovations. Table 3. OSHPD and L&C Statements on Culture Change California Department of Public Health “The California Department of Public Health Licensing and Certification (L&C) Program supports Licensure and Certification culture change, as well as Olmstead-compliant smaller, more community-based and community- integrated settings, and patient-centered care. At the same time, L&C, as the enforcement agency for minimum safe standards, indicates that it must balance innovation with patient safety by ensuring that the intent of the regulations, patient safety and quality care, is not compromised. L&C officials also stated that where regulatory challenges emerge with innovations that do preserve the intent of the regulations, L&C has tools including regulatory flexibility to allow for the use of alternative methods, procedures, and techniques that meet the regulatory intent.” California Office of Statewide Health “In general, the California Office of Statewide Health Planning and Development (OSHPD) is very Planning and Development supportive of innovative nursing home building design and philosophy of nursing home culture change. However, as the state agency responsible for enforcing the building code as it relates to health care facilities, OSHPD also must ensure that nursing homes comport with the California building code regulations. However, it is important to note that the building codes are written for conventional development and that, at times, OSHPD local and state officials may accommodate innovation and non- traditional concepts that still meet the building code through alternative compliance avenues.” Rethinking the Nursing Home: Culture Change Makes Headway in California  |  9 California Challenges and Opportunities as great champions at the director/deputy director level To understand the culture change movement in who created significant change in their states and also California, researchers interviewed about 20 people throughout the country. Interviewees noted that culture who are involved in culture change within the state change happens in states where there is a champion at the and nationally. The interviewees cited factors that make state level and champions in the public sector who come California a uniquely challenging environment and together to push change through both the legislative and also identified several opportunities for culture change regulatory processes. A first step could be an office or staff advancement. Some of their observations follow. person within the state charged with integrating culture change principles into agency priorities and policies. State agencies need to provide clear guidance for nursing home operators and local authorities. Despite California’s economy is in crisis and few legislators positive indications from California OSHPD and likely understand the value of culture change. L&C, providers remain concerned about implementing California’s severe financial crisis, marked by a $16 culture change innovations without official guidance. billion deficit, may detract from any type of innovation Interviewees recommended: (1) state transmittals to in the next year. However, policy alterations to advance providers on aspects of culture change that can be easily culture change often are cost-neutral or very inexpensive; implemented; and (2) integration of culture change such policy changes often focus on creating additional models and principles, using the CMS tools, into flexibility for nursing home providers. Interviewees OSHPD and L&C trainings for state and local staff. suggested briefings or educational events that highlight aspects of culture change that could help stabilize the Establishing strong centralized leadership is key to nursing home marketplace (e.g., reduced costs related coordination across departments, leadership, and to staff turnover) and highlight the positive impacts on bureaucracy. With no clear champions within the residents’ health. Enhanced flexibility or culture change system, moving culture change initiatives forward in the pilots could become part of a broader effort to save large California bureaucracy is daunting. Many states have money. acknowledged that if long-term care services are to be both functional and flexible, they must be housed in one A technical assistance strategy is needed to support department or there must be a process by which multiple California’s culture change. California’s complex departments work together.44 California has a number nursing home business environment is characterized of departments with some oversight of the long-term by unionized workers, exceptionally high costs for land care system, including the Department of Health Care and construction, and a high proportion of for-profit Services, Department of Public Health, Department providers. Interviewees recommended a targeted culture on Aging, Department of Social Services, and Office of change technical assistance strategy to help providers Statewide Health Planning and Development. understand and analyze culture change approaches in the context of their unique local markets. It could facilitate Interviewees defined strong leadership as the willingness connections with specialized technical assistance resources to tackle tough issues, a strong commitment to home- such as Action Pact and the Green House Replication and community-based services, and a willingness to work Initiative. with private-sector champions seeking to implement new models. They cited Richard Ladd in Oregon, Charles Reed in Washington, and Herb Sanderson in Arkansas 10  |  California HealthCare Foundation Interviews with California Trailblazers Below are interviews with three organizations that are in various stages of implementing culture change in California. Each has a slightly different starting point but all three have similar needs for technical assistance and clear guidance and support from the state. Bay Area For-Profit assignments, CNAs strive to provide care the way the resident wants it, although residents have no choice in Q. What did it take for you to get culture change meal times and many other activities. We could do far underway? more in providing resident-directed care. We were planning Our staff first heard about culture change through on starting on restaurant dining in January, with the help of consultants at Lumetra, who talked about things that could the California Coalition for Culture Change, but we were hit be changed to make facilities more person-centered. We with our state and federal survey and that has been put on took part in a Lumetra project about four years ago. Staff hold. We will still do it, but we don’t have a firm date. was encouraged to work with residents to change one aspect of the facility to be less institutional. One staff Q. What are your obstacles to change? person formed a group to work on our shower room, I know that many CNAs and licensed nurses would fully which was dismal. She offered the residents color choices, embrace change, and many go about small changes in their samples of fabric, and possible themes that they could own way. One staff person in particular stresses this with look at and decide on. She took on all the extra work on other staff members and works really hard at making the her own time. It was very successful. Residents chose changes she can for her hall and dining room. At this time a tropical theme, with new paint, wallpaper, and shower there has been a slowdown. However, changes will be curtains. All shower rooms were subsequently changed. happening in the future, such as restaurant dining. We now have fireplaces in our lobby and fireside room. All the residents’ rooms have been remodeled to be more Q. What do you need to move forward with more cheerful and homelike. We replaced all our old beds, culture change? and now have all high/low beds that look like they could We need organizations such as the California Association be in someone’s home. All our dining tables now have of Health Facilities (CAHF) to put culture change on the tablecloths and flowers. One of the things that culture forefront of their conferences. All administrators need to change encourages is consistent staffing, which we have really get immersed in the concept. The more that it is done for the last five years. Also with Lumetra assistance, put into the forefront of classes offered and meetings, we are restraint free, which is wonderful for our residents. the more widely it will be received. The California Culture Change Coalition puts on conferences that are excellent. Q. What will other California nursing home operators Once you see the value of this for the residents and the need to implement culture change? facility, the more facilities will change. At the time we made those changes, we had the encouragement of Lumetra and the support of other Southern California-Based Nonprofit facilities in our group. Now, with the California Culture Change Coalition, there are resources and help. Q. What did it take for you to get culture change underway? Q. What does your culture change process look like Our residents and families play an important role in our and what culture change approach are you taking? organization and demanded the improvements in the Our facility has been in operation for 35 years. So while structure of the current skilled nursing facility. While we have made some changes, no large physical plant we have good quality services, the current facility is changes have been instituted. We have a secured antiquated, with long hallways, semi-private rooms, 18-bed Alzheimer’s unit that is self-contained, with its and central showering facilities on each wing. We were own separate dining area, patio, and activities. There is looking for unique supports models that did not hinge on a higher staff ratio and the CNAs strive to provide care a traditional campus approach. We thought the Green when the resident wants it. However, this is not the case House home model would be best for us. In particular, on the other halls. Because we have consistent staffing we liked its capacity to prevent institutional creep. The Rethinking the Nursing Home: Culture Change Makes Headway in California  |  11 NCB Capital Impact Green House Replication Initiative Sacramento-Based Nonprofit technical assistance, funded by the Robert Wood Johnson Q. What did it take for you to get culture change Foundation, has really provided the structure and support underway? to move us forward. Additionally, two of our senior The residents deserve it! We have always been innovative, executives had parents in traditional settings — our personal successful, and have a culture of change. Our effort really experiences made it clear that a better way of delivering started with our management team. supports was needed. Q. What will other California nursing home operators Q. What will other California nursing home operators need to implement culture change? need to implement culture change? They will need education, tools, direct examples, and site Talk to committed family members of residents about what visits if necessary. they want for their loved ones. Our families told us they wanted an environment that encourages more socialization. Q. What does your culture change process look like and Also, we would really encourage providers to start a what culture change approach are you taking? dialogue with OSHPD, as needed, and L&C early, and make My direct observation is that most organizations adopt the them partners in whatever the culture change process is. concepts, philosophies, and ideals of culture change and Early engagement could head off confusion and delays later. they figure out how to implement them in their facilities. For example, we have worked on our dining program for Q. What does your culture change process look like and about five years now, blending a restaurant style with what culture change approach are you taking? family dining. We have updated the dining area to include We are using the Green House approach and are working new tables, chairs, floor, wallpaper, and decorations. We’ve closely with our architects, OSHPD, and L&C to develop also eliminated the “feeding” tables or half-rounds that a Green House home design. Those discussions have were so typical in nursing homes. We are in the process of been quite positive. We have identified direct care workers expanding our menu to offer options at all three meals. This who will be our Shabazim and are sending them to Green will be completed by the end of the year. Our ultimate goal House trainings. We also are working hard to help all of is “anytime” dining. our residents and families understand the model because it is so innovative. This education is important because we Additionally, we have implemented resident choices for are really a resident-driven organization with several on our awakening, going to bed, and shower schedules. For board of directors. the last three years, we have had consistent staffing assignments for CNAs, nurses, housekeeping, and dietary Q. What are your obstacles to change? staff. Nursing staff is self-scheduling. Schedules are posted We have had to help frontline staff, residents, and families three months in advance and vacation requests accepted to understand and support culture change. Because the one year in advance. We have a new “planned time off” new approach is so different and exciting, we’ve had to policy whereby employees can earn four extra days off work to keep our enthusiasm from pushing outside of our per year with good attendance and minimal call-ins. They budget. can also “cash out” their planned time off earnings within certain guidelines. We have a seniority bonus for all job Q. What do you need to move forward with more classes; it begins at five years with $500, then goes to ten culture change? years ($1,000), 15 years ($1,500) and 20 years ($2,000). We need continued creativity and flexibility in policy and regulation [from the state] with commitment on paper to Q. What are your obstacles to change? prevent a return to the old way of doing business. Basically, The physical plant is not conducive to change, and there are we’re talking about institutional creep at the regulatory level regulatory restrictions from OSHPD and CDPH. I would say rather than at the facility level. that for-profits sometimes have the perception that there is not a good business reason to implement culture change. “Because the new approach is so different and Q. What do you need to move forward with more exciting, we’ve had to work to keep our enthusiasm culture change? from pushing outside of our budget.” We do not need anything other than more time and regulatory relief. 12  |  California HealthCare Foundation Conclusion A c k n ow l e d g m e n t s The promise of culture change is that person-centered Authors: Michael Cheek, director of NCB Capital Impact’s services, a more home-like environment, and more stable Center for Long-Term Supports Innovation; David Nolan, staffing that wraps around individual health and LTS Va Piano, LLC; and Ragni Larsen-Orta. NCB Capital Impact is a mission-driven nonprofit organization providing needs will have real benefits for residents and providers. socially conscious lending and technical assistance targeted Early results point to the potential for a higher quality of to low-income and vulnerable populations, including persons life, improved outcomes, and reduced health care costs as using long-term supports. NCB Capital Impact is the project a result of fewer acute care episodes and slower functional site for the Robert Wood Johnson Foundation’s Green House ® decline. Replication Initiative. For more information, please visit www.ncbcapitalimpact.org. At the same time, the restructuring of jobs, organizational roles, and the physical environment improves job Bonnie Kantor, executive director of Pioneer Network, and satisfaction for direct care workers and increases staff Robert Jenkens, director of NCB Capital Impact’s Green retention rates. House effort provided valuable comments and contributions. The author also would like to thank the 20-plus individuals With momentum built by the California Culture Change who participated in interviews, particularly officials with Coalition and expanded interest among state agencies, the California Department of Public Health Licensing and particularly OSHPD, the state is likely to see more Certification Program, the California Office of Statewide culture change initiatives in its nursing facilities. In the Health Planning and Development, and the nursing home administrators who carved out valuable time for in-depth next two to three years, culture change approaches that interviews. require less up-front investment are the most likely to proliferate in the current fiscal environment. As the economy rebounds, other approaches that include higher- cost components such as changes to the physical plant also are likely to expand. About the F o u n d at i o n The California HealthCare Foundation is an independent philanthropy committed to improving the way health care is delivered and financed in California. By promoting innovations in care and broader access to information, our goal is to ensure that all Californians can get the care they need, when they need it, at a price they can afford. For more information, visit www.chcf.org. Rethinking the Nursing Home: Culture Change Makes Headway in California  |  13 Endnotes 1.Medicaid Expenditures for Long-Term Care Services: Fiscal 1 2.GAO (July 2003). “Nursing Home Quality: Prevalence of Years 1994 – 2006, by Burwell, B., et. al. Serious Problems, While Declining, Reinforces Importance of Enhanced Oversight” (GAO-03-561). 2.Alecxih, L (2006). Nursing Home Use by the “Oldest Old” Sharply Declines, The Lewin Group. 1 3.California HealthCare Foundation (2007). “The Changing Face of California’s Nursing Home Industry.” 3.USA Today, September 27, 2007. 1 4.Ibid. 4.Kane, R.L. and Kane, R.A. (2001). “What Older People Want from Long-Term Care, and How They Can Get It. 1 5.California State Auditor (2007). Problems Persist with the Health Affairs, Vol. 30, No. 6. Department of Health Services Licensing and Certification Division. 5.American Health Care Association, Health Services Research and Evaluation. OSCAR Data Reports: 1 6.BDO Seidman, LLP (September 2007). A Report on Operational Characteristics June 2006. Washington, D.C. Shortfalls in Medicaid Funding for Nursing Home Care, prepared for the American Health Care Association. 6.Burwell, B., and Tell, E. (June 2006). The Nursing Home Liability Insurance Market: A Case Study of California, 1 7.California Association of Health Facilities (2006). U.S. Department of Health and Human Services (HHS), President’s FY 2007 Budget Proposal Will Jeopardize Plans Office of Disability, Aging, and Long-Term Care Policy. to Improve Care in California’s Nursing Homes. Accessed at www.cahf.org. 7.California HealthCare Foundation (2007). The Changing Face of California’s Nursing Home Industry. 1 8.GAO (July 2007). State and Local Governments: Persistent Fiscal Challenges Will Likely Emerge in the 8.Zimmerman, S., Gruber-Baldini, et. al. (2003). “Assisted Next Decade (GAO-07-1080SP). Living and Nursing Homes: Apples and Oranges?” The Gerontologist, Vol. 43, Special Issue II, 107 – 117. 1 9.Hospital distinct-part sub-acute beds are parts of acute care hospitals. Hospitals must meet a variety of regula- 9.Presentation by Washington State officials in February tory requirements to define the distinct-part beds, which 2005. deliver sub-acute care from the acute care hospital. 1 0.NCB Capital Impact analysis of U.S. Census Bureau data; 2 0.BDO Seidman, LLP (September 2007). A Report on Lakwalla, D., et. al. “Are the Younger Becoming More Shortfalls in Medicaid Funding for Nursing Home Care, Disabled?” Health Affairs, January/February 2004; Foote, prepared for the American Health Care Association. S. et. al., “Disability Profile and Health Care Costs of Medicare Beneficiaries Under Age Sixty-Five,” Health 2 1.An Aging U.S. Population and the Health Care Affairs, Volume 20, Number 6. Workforce: Factors Affecting the Need for Geriatric Workers (February 2006). University of California, San 1 1.General Accounting Office (GAO) (July 2003). “Nursing Francisco. Home Quality: Prevalence of Serious Problems, While Declining, Reinforces Importance of Enhanced Oversight” 2 2.Grant, L., Norton, L. (November 2003). A Stage Model of (GAO-03-561); GAO (December 2005). Nursing Culture Change in Nursing Home Facilities, presented at Homes: Despite Increased Oversight, Challenges Remain the 56th Annual Scientific Meeting of the Gerontological in Ensuring High-Quality Care and Resident Safety Society of America. (GAO-06-117). 2 3.Information accessed at www.edenalt.org on January 12, 2008. 14  |  California HealthCare Foundation 2 4.NCB Capital Impact communiqué with Tom Lohuis, the 3 6.Grant, L. (November 2005). Culture Change in For-Profit Wellspring Institute’s president and CEO. Nursing Homes. University of Minnesota. 2 5.A discussion of Planetree is included because of some 3 7.Doty, M.M., Koren, M.J., and Sturla, E.L. (May 2008). unique attributes of the California marketplace that might Culture Change in Nursing Homes: How Far Have We make exploration of this model useful when considering Come?, Findings from The Commonwealth Fund 2007 Green House implementation in California. National Survey of Nursing Homes. 2 6.Information accessed at www.planetree.org on January 12, 3 8.Letter from the CMS director of the Survey and 2008. Certification Group to State Survey Agency directors dated December 21, 2006. Ref: S&C-07-07. 2 7.Interview with Pancake-Irwin. 3 9.Letter from Acting CMS Administrator Leslie Norwalk to 2 8.Rahman, A.N. and Schnelle, J.F. (2008). “The Nursing U.S. Senator Thad Cochran dated February 27, 2007. Home Culture Change Movement: Recent Past, Present, and Future Directions for Research.” The Gerontologist, 4 0.Accessed at www.aging.senate.gov on July 25, 2008. Vol. 48, No. 2, 142 – 248. 1.NCB Capital Impact Green House ® Replication Initiative 4 2 9.Stone, R. and Reinhard, S. (August 2002). Evaluating the Web site, www.ncbcapitalimpact.org/default.aspx?id=146. Wellspring Model for Improving Nursing Home Quality. 4 2.Mollot, R., Harrington, C., and Hedt, A., et al. (2006). Institute for the Future of Aging Services, American Funding for Innovation: A Review of State Practices with Association for Homes and Services for the Aging. Civil Monetary Penalties — Opportunities to Improve 3 0.Quality Partners of Rhode Island (October 2005). Nursing Home Care. The Commonwealth Club. Improving Nursing Home Culture Change Pilot Study, 4 3.Personal communication with IFAS project staff, Natasha prepared for the Centers for Medicare and Medicaid Bryant, managing director, Better Jobs Better Care Services. National Program Office July 2008. 3 1.Yeatts, D. and Cready, C. (June 2007). “Consequences 4 4.Fox-Grage, W., et. al. (February 2006). Pulling Together: of Empowering CNA Teams in Nursing Home Settings: Administrative and Budget Consolidation of State A Longitudinal Assessment.” The Gerontologist, Long-Term Care Services, AARP Public Policy Institute. 47(3):323 – 39. 3 2.The research showed that adults, age 85+ experienced reduced rates of decline in activities of daily living (ADL), such as bathing and dressing. 3 3.Kane, R., et. al. (2006). “Resident Outcomes in Small- House Nursing Homes: A Longitudinal Evaluation of the Initial Green House Program.” Journal of the American Geriatrics Society (OnlineEarly Articles) doi:10.1111/j. 1532 – 5415.2007.01169.x 3 4.Pioneer Network (June 2007). Preliminary Research Supports Nursing Home Culture Change Movement, accessed at www.pioneernetwork.net. 3 5.Evans, L., and Scalzi, C. (October 2004). Culture Change in Long-Term Care, University of Pennsylvania Hartford Center of Geriatric Nursing Excellence. 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