“Would You Do That in Your Home?” Making Nursing Homes Home-like in Culture Change Implementation

Qualitative interviews with nursing home administrators reveal innovative and cost-conscious ways to physically modify facilities that help institute culture change practices. Telephone interviews were conducted following a national survey of nursing home nursing directors and administrators. In this cross-sectional snapshot of administrator experiences, motivations for making facilities more home-like and less institutional and creative responses to challenges are described. State and corporate support and regulator encouragement are noted that help their reform efforts. Administrators note that small steps to create a more home-like environment can result in a positive impact that minimizes disruption to existing care processes. They describe how they respond to challenges, such as the physical plant and high costs, and note how comparative shopping, cost-conscious physical improvements, and continuous involvement of staff and residents contribute to successful efforts. Their examples illustrate novel ways to humanize long-term care facilities that other nursing homes can emulate.     

Non‐job work/unpaid caring: Gendered industrial relations in long‐term care

This article explores the operation of gender and industrial relations in long‐term care work or nursing home work, ‘from within’ the experience of the predominantly female workforce in seven unionized facilities in Canada. Drawing on qualitative case study data in non‐profit facilities, the article argues that the main industrial relations challenges facing long‐term care workers are that their workplace priorities do not fit within existing, gendered, industrial relations processes and institutions. This article starts from the experience of women and threads this experience through other layers of social organization such as: global and local policy directions including austerity, New Public Management, and social and healthcare funding; industrial relations mechanisms and policy; and workers’ formal [union] and informal efforts to represent their interests in the workplace. The strongest themes in the reported experience of the women include: manufacturing conditions for unpaid work; increasing management and state dependence on unpaid care work; fostering loose boundaries; and limiting respect and autonomy as aspects of care work. The article extends the feminist political economy by analysing the links between the policies noted above and frontline care work. Building on gendered organizational theory the article also introduces the concept of non‐job work and suggests a fourth industrial relations institution, namely the needs and gendered expectations of residents, families and workers themselves, operating within the liminal spaces in care work.     

Bringing Assisted Living Services into Congregate Housing

Beginning in April 2000 and continuing for 21 months, Florida's legislature allocated $31.6 million (annualized) to nursing homes through a Medicaid direct care staffing adjustment. Florida's legislature paid the highest incentives to nursing homes with the lowest staffing levels and the greatest percentage of Medicaid residents—the bottom tier of quality. Using Donabedian's structure-process-outcomes framework, this study tracks changes in staffing, wages, process of care, and outcomes. The incentive payments increased staffing and wages in nursing home processes (decreased restraint use and feeding tubes) for the facilities receiving the largest amount of money but had no change on pressure sores or decline in activities of daily living. The group receiving the lowest incentives payment (those highest staffed at baseline) saw significant improvement in two quality measures: pressure sores and decline in activities of daily living. All providers receiving more resources improved on deficiency scores, suggesting more Medicaid spending improves quality of care regardless of total incentive payments.     

Culture Change in Skilled Nursing: An Exploratory Comparison of a Traditional Home to a New Model

Abstract

The culture change movement has pushed for reform for more than two decades to align policy, the long-term care industry, and resident preferences with regard to care. Evidence from research indicates that culture change has the potential to improve quality in nursing homes. There is no one-size-fits-all way to implement culture change; however, there are key elements and associated concepts and models. A common thread is that they run counter to the medical model, typically found in nursing homes, where care is provided in a hospital-like setting according to the schedules and routines of physicians and staff with little resident input. This qualitative study looks for evidence of culture change in a traditional model of care compared to a newer culture change model, by describing the differences in practices associated with the medical model, person-centered care, and person-directed care between the two settings. Our results indicate that there is evidence of person-directed care in one model of culture change—the Green House home—but not in the traditional nursing home. Future studies should examine other culture change models to compare the differences in the utilization of person-directed care. This information will help to clarify the definitions and concepts of culture change, along with developing best practices for future culture change models.     

Comparing States' Medicaid Nursing Facilities and Home and Community-Based Services Long-Term Care Programs: Quality and Fit with Inclination,Capacity, and Need

States employ home and community-based services (HCBS) increasingly in Medicaid support of long-term care and rely less on nursing facilities. We examine how states' nursing facilities and HCBS programs compare and whether states' long-term care responses match their ideological inclination toward, material capacity for supporting, and their citizens' need for these public social programs. We use cross-sectional panel data on structural, process, and outcome quality for nursing facilities and HCBS congregate residential programs. We rank states, correlate these measures, and use regression to link inclination, capacity, and need to quality. We find that states' nursing facility and HCBS program quality are not closely related and that state HCBS congregate residential program quality is independent of inclination, capacity, and need. This latter result underscores a need for uniform HCBS standards and better data on quality.     

An Assessment,Using the Multiphasic Environmental Assessment Procedure (MEAP), of a Rural Life-Care Residential Center for the Elderly

This study reports the findings of an assessment of a life-care center for elderly persons in a rural area using the Multiphasic Environmental Assessment Procedure (Moos and Lemke, 1979a). The study assesses the physical and architectural features, the social climate, and the policies and programs of the home. The results are compared to previous assessments of sheltered-care facilities, and the findings of the study support similar research conducted by Moos and Lemke. The facility's selection process leads to a population with similar characteristics, tending to promote a harmonious environment. The residents have a positive perception of their personal environment which encompasses the physical and social environment and organizational structure. This type of environment offers a smooth transition from living in a private residence to a residential life-care center.     

Nursing Home Ownership Trends and Their Impacts on Quality of Care: A Study Using Detailed Ownership Data From Texas

The role of ownership in the provision of nursing home care has long been a challenging issue for policy makers and researchers. Although much of the focus historically has been on differences between for-profit and not-for-profit facilities, this simple distinction has become less useful in recent years as companies have employed more complicated ownership and management structures. Using detailed ownership data from the state of Texas, we describe the evolution of nursing home corporate structures from 2000 to 2007, analyze the effect of these structures on quality of care and staffing in nursing homes, and discuss the policy implications of these changes.     

Assessing the efficacy of ombudsman services for the aged in long term care institutions

Long term care ombudsman programs are a recently established component within the gerontological services continuum. Public policy in this area is not yet well defined and there is a conspicuous absence of systematic studies assessing the effectiveness of such program efforts. This research reports on the accomplishments of an urban based, volunteer nursing home ombudsman program. Survey findings show moderate levels of goal attainment in the policy and social relations domains and more promising results in the organizational/managerial sphere. The relationship between perceptions of program success and varying ombudsman role behaviors is underscored.     

Defining the challenges of providing long-term care: the case of the nursing home industry's response to the AIDS epidemic

Acquired Immune Deficiency Syndrome (AIDS) is now viewed as a chronic disease requiring long-term management. As a result, more persons with AIDS (PWAs) are seeking long-term care in facilities that have primarily served the elderly. In some regions, however, the nursing home market into which PWAs may introduce new demand is a market already characterized by excess demand. In light of this, competition for limited long-term care resources may develop between the frail elderly and PWAs. The nursing home industry has raised many issues regarding the feasibility of admitting AIDS patients as residents, but little is known about how important these issues are in deciding admissions policy. How the industry perceives and resolves the concerns it has regarding delivery of care to PWAs can affect the overall long-term care system and thus affect the traditional users-the frail elderly. Knowing the concerns and preferences of the industry may help guide and anticipate future changes in the system. In this pilot study, a random sample of 250 nursing home administrators in the five highest AIDS-incidence areas in the United States was surveyed to determine (1) the industry's concerns and issues regarding AIDS care, (2) data regarding requests for admission by PWAs to nursing homes, and (3) data concerning the industry's preferred way of delivering AIDS care. Important admissions policy issues cited by the respondents included the ability to meet special care needs, costs of care, and inadequate reimbursement. The majority also believed the most appropriate methods of providing care were special care units for AIDS within nursing homes or dedicated HIV/AIDS nursing facilities.     

Autonomy and Control in Everyday Life in Care of Older People in Nursing Homes

Self-control and autonomy are not guaranteed when people age and are in need of help from others, especially in institution-based housing. This occurs despite the fact that it is a generally accepted belief that care should be delivered with the greatest possible degree of independence and autonomy. This article discusses older people's experiences with and the opportunities for autonomy in institution-based housing. Through focus group interviews and observations, the daily lives of residents at two nursing homes in Sweden were studied through a comparative approach using the theoretical framework of organizational culture. Three themes emerged showing how autonomy was not a reality for the residents. The first theme revealed an ambivalent mission, indicating ambiguity as to whether the nursing home was a place to live in or a place in which to be cared for. The second theme was symbolic power, which encompassed the staff's power embedded in the organization. The third theme was the ageist approach to care, which was noted in the way staff considered the residents to be old people who were unable and unwilling to strive for autonomy. The three themes were embedded in the organizational culture and were created and recreated in the interaction between residents and staff. A key question for further research is how to change the culture to strengthen the residents’ autonomy.     

Beyond Clinical Complexity: Nonmedical Barriers to Nursing Home Care for Rural Residents

We conducted a qualitative content analysis of barriers to nursing home admission for rural residents. Data came from semi-structured interviews with 23 rural hospital discharge planners across five states (Georgia, Idaho, Minnesota, Pennsylvania, and Wisconsin). From those, we identified four themes around nonmedical barriers to rural nursing home placement with particular salience in rural areas: financial issues, transportation, nursing home availability and infrastructure, and timeliness. We also identified policy and programmatic interventions across four themes: loosen bureaucratic requirements, improve communication between facilities, increase rural long-term care capacity, and address underlying social determinants of health.     

Do high rates of OSCAR deficiencies prompt improved nursing facility processes and outcomes?

Recently, some researchers have argued that high state rates of Centers for Medicare and Medicaid Services (CMS) Online Survey, Certification and Reporting (OSCAR) nursing facility deficiencies indicate stringent enforcement, leaving the impression of better-quality care soon to follow; others maintain that the rank ordering of states' quality of nursing facility care remains fairly constant, resting on deep-seated state characteristics that change slowly, so that short-term improvement in poor-quality care is unlikely. The authors examine change in the process and outcome quality of states' Medicare nursing facility long-term care programs across 1999 to 2005, using linear and two-stage least squares regression. They find that (1) nationally, process quality generally falls across this period while outcome quality generally increases; (2) neither a prominent enforcement stringency index nor state culture, a relatively stable state characteristic, exerts much influence on state process and outcome quality scores over time, but (3) the relative costs and benefits for CMS compliance appear to contribute to explaining change in states' quality of resident outcomes over time; and (4) states' process quality is much less stable than outcome quality, and outcome indices distinct from OSCAR deficiency data provide more reliable and possibly more valid measures of care quality.     

Conditional Cash Incentive and Use of Health Care Services: New Evidence from a Household Experiment

Studies have recently provided insights into the effects of incentive modalities in the health care sector. However, there is insufficient evidence on the underlying causes of the partial effectiveness of these strategies in the health systems of developing countries. This study presents results from a large-scale randomized experiment across 6848 households in Afghanistan that evaluates the impact of a conditional incentive pay scheme on health facilities. Supported by the target-income hypothesis framework and relaxing the compliance assumption in the empirical modeling, the estimated coefficients yield causal effects of the supply-side conditional incentive on the utilization for health care services. After 2 years, the conditional incentive increased the use of pre-targeted maternal and children health care services among the households at lower levels and at contracted-out health facilities. Additionally, the incentive scheme is associated with sizable efficiency gains at the facility level. These gains are realized at the expense of deterring service users’ satisfaction with physicians’ communication qualities. This study establishes that margins of improvement do exist in the supply-side performance conditioning on an organizational structure and the service contractual arrangements of health facilities. This work provides a framework for the plausible implementation of incentive policies in the health care sector.

     

The Quality Indicator Survey: Background,Implementation, and Widespread Change

The Quality Indicator Survey (QIS) is the most comprehensive regulatory change to the nursing home survey process since the Omnibus Budget Reconciliation Act of 1987 (OBRA-87). In this article we describe the policy evolution that led to the QIS, summarize the QIS method and implementation, and profile the QIS survey results. Following over a decade of development, in 2007 the Centers for Medicare and Medicaid Services (CMS) began the national rollout of QIS. The intent was to improve consistency in the nursing home survey and to render the survey process more resident-centered and aligned with the intent of OBRA-87. We reviewed policy reports and firsthand accounts from the lead developer of the QIS methodology and leader of the national training contract for QIS. Changes in survey findings are profiled based on analysis of the publicly available Nursing Home Compare database from 2004 to 2010. Nineteen states implemented the QIS between 2007 and 2010, with nearly 20% of U.S. nursing homes receiving QIS surveys in 2010. Nursing homes surveyed with the QIS received more survey deficiencies on average than in the traditional survey; however, average numbers of deficiencies across states became more similar over the early implementation of QIS, with lower-than-average geographic areas experiencing increases and higher-than-average geographic areas experiencing decreases in survey deficiencies. The explicit and structured questioning of residents in the QIS is associated with increases in deficiencies related to choice, dignity, dental care, and nurse staffing. We describe ways in which the QIS affected the regulatory agencies, providers, and resident communities, although these effects are difficult to quantify. CMS's implementation of QIS is a significant step toward a more resident-centered, comprehensive, and consistent survey process. Substantial changes, however, are required not only among regulators but also among nursing homes. We argue that these new expectations and norms surrounding quality assessment and quality assurance are an important component of achieving culture change in U.S. nursing homes.     

Home and community-based care: recent accomplishments and new challenges

This article traces the development of home and community-based care to its current place in the worlds of health and social policy. An argument is developed to the effect that such services have by now gained both heightened policy legitimacy and organizational capacity. Building on these contentions, the article goes on to suggest that such services should continue to gain a more prominent place within long-term care policy, and that long-term care issue deserve a more central place within social insurance policy more generally. The article concludes by suggesting that demonstrations of policy efficacy such as those that are taking place in home and community services might help to at least modestly offset the frontal assault which is currently taking place across the range of American social policy.     

Job Prospects for Mature Workers

This article traces the development of home and community- based care to its current place in the worlds of health and social policy. An argument is developed to the effect that such services have by now gained both heightened policy legitimacy and organizational capacity. Building on these contentions, the article goes on to suggest that such services should continue to gain a more prominent place within long-term care policy, and that long-term care issues deserve a more central place within social insurance policy more generally. The article concludes by suggesting that demonstrations of policy efficacy such as those that are taking place in home and community services might help to at least modestly offset the frontal assault which is currently taking place across the range of American social policy.     

Choosing Privacy over Interaction: Restructuring Expectations and Interpretations of Community Integration in Canadian Small-House Long-Term Care Settings

In Nova Scotia, Canada, the small-house model of care has been introduced as an alternative to institutional care settings, and the province has funded and built 11 new long-term care (LTC) communities in the small-house model. Each of the new facilities was built with multiple cottages housing 12 to 15 residents; each cottage features private bedrooms and a residentially scaled kitchen and dining area. Through smaller numbers of residents living in home areas, the goal of the Provincial Department of Health was to encourage relationship building, as well as to provide opportunities for autonomy and choice in resident daily living. A qualitative case study was conducted in one of these small-house communities, focusing on the model's impact on resident interaction and community integration. Thematic analysis revealed that while resident social patterns were directly impacted by the physical environment and culture of care in the new model, interpretations of these patterns by staff and family members were influenced by preexisting expectations of community integration rooted in institutional care models of the past.     

European Union Policy on Older Adult Learning: A Critical Commentary

Recently, some researchers have argued that high state rates of Centers for Medicare and Medicaid Services (CMS) Online Survey, Certification and Reporting (OSCAR) nursing facility deficiencies indicate stringent enforcement, leaving the impression of better-quality care soon to follow; others maintain that the rank ordering of states' quality of nursing facility care remains fairly constant, resting on deep-seated state characteristics that change slowly, so that short-term improvement in poor-quality care is unlikely. The authors examine change in the process and outcome quality of states' Medicare nursing facility long-term care programs across 1999 to 2005, using linear and two-stage least squares regression. They find that (1) nationally, process quality generally falls across this period while outcome quality generally increases; (2) neither a prominent enforcement stringency index nor state culture, a relatively stable state characteristic, exerts much influence on state process and outcome quality scores over time, but (3) the relative costs and benefits for CMS compliance appear to contribute to explaining change in states' quality of resident outcomes over time; and (4) states' process quality is much less stable than outcome quality, and outcome indices distinct from OSCAR deficiency data provide more reliable and possibly more valid measures of care quality.