Examining the Nursing Home Physical Environment Through Policy-Driven Culture Change

A critical need exists to challenge approaches to nursing home care due to rigid organizational factors and hospital-like culture. It has been argued that resident care needs to move toward a person-centered approach by addressing the organizational, social, and physical environments in nursing home facilities, a process often known as culture change. In response to this need, the Centers for Medicare & Medicaid Services (CMS) has created funding for pay for performance (P4P) nursing home incentive programs to allow nursing home providers to receive CMS reimbursements for culture change in the facilities. Through care staff interviews, site observations, and a document review, this qualitative study assesses the impact of a Midwestern state P4P incentive program in three participating nursing homes. Using an environment and behavior (E-B) policy orientation framework, this study examines culture change through a focus on policy, the physical environment, place attachment, and social and psychological processes in the study settings.     

“It’s a Dignity Thing”: Nursing Home Care Workers’ Use of Emotions1

This article examines how nursing home care workers use emotions to construct dignity at work. Previous scholarship has shown how the financial and organizational characteristics of nursing homes shape and constrain emotion work among staff. Using evidence gathered during 18 months of participant observation in two nursing homes and 65 interviews with staff, this article analyzes how, despite obstacles, nursing home care workers generated authentic emotional attachments to residents. Surprisingly, some staff members said they particularly appreciated working with residents difficult to control. They felt accomplished when such residents successfully transitioned from life at home to life in institutional care. Emotions created dignity for staff and induced compliance among residents. Emotions are not only generated by organizations and imposed on workers; staff themselves produced emotions—sometimes in ways consistent with organizational demands, and sometimes not—and they consistently found in their emotions a resource to manage the strains of their work lives.     

Towards Critical Intersections of Ageing,Housing and Well-Being

ABSTRACT

Across the life course, far-reaching socio-demographic and health related transformations are influencing the meaning of home in the UK. The collection presented in this Special Issue of Home Futures critically interjects into the ‘where and when’ of dwelling during the process of ageing with key concepts explored within this introductory article. It argues that, change is seen through the disruption of conventional ideas of ageing ‘at home’, traditional understandings of ‘the older person’ and its corollary social imaginaries, alongside the relationship between care practices and homes. Many of these shifts are being addressed through a range of emerging housing (and collaborative) alternatives. The article concludes by considering how discussions in this special issue disclose the home, from a range of social and material angles, as a diverse process and experience of meaning making over time, deeply entangled with health and well-being, disrupting traditional understandings of ‘place making’ in later life.     

Reimagining Nursing Homes: The Art of the Possible

Long-term care (LTC) needs to be reconceptualized. The current efforts to reinvent the nursing home perpetuate a flawed model of care. The heritage of the nursing home as the dominant model for LTC needs to be reexamined. The basic LTC building blocks—housing, services, and medical care—can be combined in various ways to meet consumers' needs and preferences. We need innovative solutions that can offer reasonable service while recognizing the value of acceptable risk taking. Modest personal care should not come at the price of surrendering one's autonomy.     

“That Model is Sooooo Last Millennium!” Residential Long-Term Care as a System,Not a Place

The current quandary with the design of existing long-term care settings results from focus on structures (“institutions”) instead of on a system of supports and services that transcends physical and traditional boundaries across settings, including nursing homes, assisted living residences, and the home. Supported by analyses of the commonalities, socio-historical and political contexts, core values, and fallacies of social and medical models in existing and emerging long-term care options, a holistic model is proposed based on new core values that facilitate community and family integration and that asserts dignity and personhood as universal attributes in an array of settings.     

Family Support in Nursing Homes Serving Residents with a Mental Health History

Using 2003 nursing home data from the Minimum Data Set (MDS) database, this study investigated the role of family support among nursing homes serving residents with a mental health history. Exploratory factor analysis was used to create and test a conceptual model of family support using indicators located within the MDS database. Families were found to be in regular contact with their relatives and supportive of their care. In nursing homes, daily contact, an ongoing relationship, involvement in assessment, and being responsible for the resident constitute the model family support. This study advances the understanding of family support in nursing homes and conveys information to guide practice through proposing ways to enhance family support and involvement in nursing homes.     

Factors Influencing Family-Member Perception of “Homelikeness” in Long-Term Care Homes

Background: A number of long-term care homes in Nova Scotia, Canada, have been built or redesigned with new models of care with expanded care aide scope of practice and neighborhood-style layouts. Our objective was to examine what physical characteristics (bed size, owner-operator), model of care, and relational (family–staff relationship, perceived staff–resident relationship) factors were associated with increased family-member perception of homelikeness in long-term care homes.

Methods: We analyzed surveys collected from 273 family members from 23 long-term care homes in Nova Scotia, Canada. We conducted a multivariate linear regression to assess variables associated with increased family-member perception of homelikeness.

Results: We found that relationships between family and staff, perceived resident-to-resident relationships, and family involvement in decision making were positively associated with increased family perception of homelikeness. We found no significant associations between model of care or physical characteristics and increased family perception of homelikeness.

Conclusion: Relationships among family members, residents, and staff are integral to family members feeling at home in their loved one's long-term care home. Feeling at home in long-term care is largely related to family-member perception of meaningful social interactions between family and staff, and between residents.     

The Effect of Care Setting on Elder Abuse: Results from a Michigan Survey

This study compares abuse rates for elders age 60 and older in three care settings: nursing home, paid home care, and assisted living. The results are based on a 2005 random-digit dial survey of relatives of, or those responsible for, a person in long-term care. Nursing homes have the highest rates of all types of abuse, although paid home care has a relatively high rate of verbal abuse and assisted living has an unexpected high rate of neglect. Even when adjusting for health conditions, care setting is a significant factor in both caretaking and neglect abuses. Moving from paid home care to nursing homes is shown to more than triple the odds of neglect. Furthermore, when computing abuse rates by care setting for persons with specified health conditions, nursing homes no longer have the highest abuse rates.     

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.     

“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.     

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.     

The Program of All-Inclusive Care for the Elderly (PACE)

Summary

This article examines the long-term care service system in the United States, its problems, and an improved long-term care model. Problematic quality of care in institutional settings and fragmentation of service coordination in community-based settings are two major issues in the traditional long-term care system. The Program of All-Inclusive Care for the Elderly (PACE) has been emerging since the 1970s to address these issues, particularly because most frail elders prefer community-based to institutional care. The Balanced Budget Act of 1997 made PACE a permanent provider type under Medicare and granted states the option of paying a capitation rate for PACE services under Medicaid. The PACE model is a managed long-term care system that provides frail elders alternatives to nursing home life. The PACE program's primary goals are to maximize each frail elderly participant's autonomy and continued community residence, and to provide quality care at a lower cost than Medicare, Medicaid, and private-pay participants, who pay in the traditional fee-for-service system. In exchange for Medicare and Medicaid fixed monthly payments for each participating frail elder, PACE service systems provide a continuum of long-term care services, including hospital and nursing home care, and bear full financial risk. Integration of acute and long-term care services in the PACE model allows care of frail elders with multiple problems by a single service organization that can provide a full range of services. PACE's range of services and organizational features are discussed.     

THE SOCIAL DYNAMICS OF ELDER CARE: RITUALS OF BUREAUCRACY AND PHYSICAL NEGLECT IN NURSING HOMES

This research concerns nursing home rituals involving bureaucracy and physical neglect. It uses 40 ethnographies, biographies, and autobiographies to explore various symbolic themes expressed through everyday interaction in nursing homes. The themes involve bureaucratic concepts such as staff separation, rules, documentation, and efficiency. They also involve ideas of physical neglect, such as medical dereliction, personal negligence, environmental negligence, and bodily harm. Relying on structural ritualization theory, this work argues ritualized symbolic practices of bureaucracy unintentionally manufacture attitudes and acts of mercilessness for workers in both for-profit and nonprofit nursing homes. This aids in the development of rituals facilitating the physical maltreatment of residents.     

Australian Approaches to Resident Classification and Quality Assurance in Residential Care

Summary

This paper begins with an account of the structure of Australia's residential long-term care program, which was divided into two distinct levels of hostel and nursing home care until 1997. In response to changed policy objectives, a number of measures were then taken to create an integrated residential care system. The main measures were the development of a single scale for classification of resident care need and associated funding to replace two previous separate scales, and the implementation of a new quality assurance system, which included new standards for buildings as well as revised standards for care. I give accounts of these measures and the extent to which they have achieved their intended outcomes before proposing some further developments that could see closer links among pre-admission assessment, resident classification, and quality assurance.     

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.     

Resource Effects on Access to Long-Term Care for Frail Older People

Abstract

Access to long-term care depends primarily on personal resources, including family members and income, and on external resources, including Medicaid and Medicare. This study investigates how resources affect frail older individuals' access to long-term care, with a focus on Black and White widows. Data from the 1989 National Long-Term Care Survey is used, in conjunction with state-level Medicaid and Medicare reimbursement rates for nursing home and home health care, to estimate the likelihood of five types of care arrangements. Results show that children are a primary resource for unmarried individuals in maintaining access to informal care. Income effects are nonlinear in relation to nursing home care: increasing incomes below the mean income are associated with decreasing probabilities of nursing home care, while increasing incomes above the mean are associated with increasing probabilities of nursing home care. Income and Medicaid effects are interrelated, with nonlinearities associated with income having the potential to adversely affect some older persons' ability to access nursing home care.     

Perceptions of physical restraint use and barriers to restraint reduction in a long-term care facility

The use of restraints in nursing homes has been curtailed in the United States since the passage of the 1987 federal legislation regulating restraint practices. This study used focus groups with administrators and nursing staff in a skilled nursing facility to examine their views of restraints and perceptions of conditions in the nursing home environment that affect restraint use. Although respondents lacked a shared definition of a "restraint," they did identify contextual factors that in combination with resident characteristics produced situations in which restraint use was justified. Implications of these findings for staff education on restraint reduction are discussed.     

Consistent Assignment of Nurse Aides: Association With Turnover and Absenteeism

Consistent assignment refers to the same caregivers consistently caring for the same residents almost every time caregivers are on duty. This article examines the association of consistent assignment of nurse aides with turnover and absenteeism. Data came from a survey of nursing home administrators, the Online Survey Certification and Reporting data, and the Area Resource File. The measures were from 2007 and came from 3,941 nursing homes. Multivariate logistic regression models were used to examine turnover and absenteeism. An average of 68% of nursing homes reported using consistent assignment, with 28% of nursing homes using nurse aides consistent assignment at the often recommended level of 85% (or more). Nursing homes using recommended levels of consistent assignment had significantly lower rates of turnover and of absenteeism. In the multivariate analyses, consistent assignment was significantly associated with both lower turnover and lower absenteeism (p < .01). Consistent assignment is a practice recommended by many policy makers, government agencies, and industry advocates. The findings presented here provide some evidence that the use of this staffing practice can be beneficial.