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Published On September 22, 2013

CLINICAL CARE

The New Nursing Home

Can an aging nation transform the places no one wants to be? Innovations show the way, but the cost could mean slow progress.

JILL HEROLD'S WIDOWED 92-YEAR-OLD MOTHER Evelyn Mehlhop, had a broken hip and dementia, and clearly needed around-the-clock care. Yet Herold hated the idea of moving her into a nursing home, particularly after she toured facilities that lived up to her worst expectations—drab, highly regimented mini-hospitals with dim corridors and unhappy residents. Then she walked into the Leonard Florence Center for Living in Chelsea, Mass., where her first surprise was the aroma of baking cookies, not antiseptics. The lobby, known as Main Street, houses a bakery-café, a deli and a spa-salon, and there’s an outdoor garden for residents, among other amenities. “It was like an elegant hotel, about as far from anything medical as you could imagine,” Herold says.

At the vanguard of innovation in the nursing home industry, the three-year-old Leonard Florence Center for Living exemplifies a new model of long-term care known as the Green House, and nothing about it seems institutional. Each of the five upper floors constitutes two separate “households” with private rooms for 10 residents. The normally dominant nurse’s station has been eliminated and instead there are common areas in each household—a living room furnished with comfortable sofas and chairs around a fireplace, an open kitchen and a communal dining table where residents often eat together. Cooking, housekeeping and even laundry are handled by two certified nursing aides known as shahbazim—derived from Persian, it means “nurturing of elders”—who also care for residents. Traditional nursing homes, in contrast, have clear demarcations separating housekeepers, kitchen workers, nurses and aides, who follow rigid schedules for serving meals or dispensing medications.

At Leonard Florence, Mehlhop can sleep, bathe, eat and roam around whenever she wants. The environment is calm and cheery, with none of the physical restraints found in most nursing homes or the alarms that sound if residents get up from a wheelchair, for example. (Instead, patients wear ankle bracelets that help the staff keep tabs on them and will disable the elevator if a patient tries to leave.)

Leonard Florence is far from the only nursing facility striving to create a homelike atmosphere and improve residents’ quality of life. Building a new Green House or undertaking a major physical renovation can be part of the strategy, but other nursing homes are primarily working to transform how they’re run, embracing a movement known simply as “culture change” that entails shifting away from the emphasis on efficiency and economies of scale that characterizes most nursing homes. Culture change typically requires an operational reorganization to give staff members more autonomy and to let residents have a say in even the smallest details of their lives. “It’s about not looking at residents as a task, but rather as who they are as individuals,” says Angie McAllister, a director of cultural transformation at Signature HealthCare, a privately held for-profit nursing home chain.

More than half of the country’s 15,683 nursing homes say they are engaged in some aspect of culture change, according to a 2007 survey conducted by the Commonwealth Fund. To understand why reform is needed, consider a survey by the Johns Hopkins Bloomberg School of Public Health in which 98% of people over 65 said they would prefer to live anywhere but a nursing home, even if they needed a high level of care. In another study conducted by The NewsHour with Jim Lehrer, the Kaiser Family Foundation and Harvard School of Public Health, 45% of respondents worried that if they went to a nursing home they would be worse off than they were before. That’s a legitimate concern. Although the 1987 Nursing Home Reform Act established quality standards for nursing homes, numerous studies and reports, including some from the Institute of Medicine and the Government Accounting Office (GAO), have demonstrated facilities’ failure to meet federal regulations. Many residents do get worse, losing weight, being hurt in falls, or suffering bedsores, infections and other avoidable problems.

Research suggests that reforms can lead to marked improvement on several fronts, including quality of life and care for residents, staff retention, occupancy rates and operational costs. The government has weighed in by instituting several new requirements over the past three years that embrace the principle of individualized care, and starting next year under an Affordable Care Act initiative, all nursing homes must honor residents’ requests about their daily routines and use those routines to guide care delivery. But some facilities are unable or unwilling to embrace culture change, while other challenges—cost, safety and reimbursement pressures—could limit culture change’s reach. “The nursing home industry is at a potential tipping point,” says Barbara Frank, a consultant for Pioneer Network, a nonprofit that advocates for culture change. “This is a time of innovation on many fronts, and we need that evolution to deliver better care.”

A visit from Barn Babies, a traveling petting zoo featuring young pot-bellied pigs, goats and other animals, gets residents out of their rooms and out of themselves.

ALTHOUGH THE AGING OF THE BABY BOOM GENERATION is certain to put increasing pressure on nursing homes, questions of how to provide long-term skilled nursing care—and especially of how to pay for it—have troubled the U.S. health care system for years. For most people, the cost of an extended stay in a nursing home amounts to a financial crisis, and once they’ve exhausted their savings, state and federal governments end up footing the bill for the majority of care in the facilities. Those payments, however, fall far short of what it costs to provide high-quality care. Many homes depend on “private pay” residents to make up the difference, and the cost to those people can be very high—about $15,000 a month at the Leonard Florence Center, for example. Some facilities won’t take patients whose stays are funded by Medicare or Medicaid. And financial constraints mean that coming up with the cash for a major building project—or even to pay for reorganization and retraining for staff members—is problematic. The recent financial crisis and recession made matters worse, slowing new construction and leaving the country full of aging, inadequate facilities. “Lots of these buildings were poorly constructed and not meant to be around for as long as they have been, and they cost more and more to maintain,” says geriatrician Bill Thomas, a pioneer in culture change.

Thomas, who in 2003 came up with the Green House concept, believes it and similar models of reform will become necessary as a new generation of demanding patients moves into nursing homes. Baby boomers will require more respect, privacy and control over their schedules than prior generations did, says Thomas. “Living in a semi-private room, separated by a fabric curtain from a stranger and sharing a toilet is a no-go,” he says. “We need to rebuild the entire field.”

As medical director of a small-town nursing home in upstate New York in the early 1990s, Thomas created what he called the Eden Alternative, a response to the loneliness, helplessness and boredom he found among those forced to live in that era’s facilities. Through simple steps such as adding animals and plants that residents could care for as well as encouraging regular visits by schoolchildren, Thomas discovered he was able to improve his home’s environment and its residents’ well-being. He documented diminishing needs for restraints and drugs, and declining rates of illness and death in the home, and other facilities began to embrace similar reforms.

His subsequent Green House model called for redesigning facilities from the ground up to create communal living environments, transforming staffing patterns and providing a very different kind of care. In the decade since the first Green House home was built in Tupelo, Miss., 146 more have gone up in 26 states, and momentum seems to be growing, with another 150 in development, according to the Green House Project, a group promoting this model. The Robert Wood Johnson Foundation, partnering with NCB Capital Impact, is providing a 10-year, $10 million low-interest credit facility to help kick-start construction of Green Houses across the country.

Yet building a new, small nursing home that can handle only a relative handful of residents is an expensive proposition. “If it weren’t for the price tag, everyone would be doing it,” says Barry Berman, chief executive officer of the Chelsea Jewish Foundation, which owns the Leonard Florence Center. The home cost $36 million to build, with some two-thirds of the money coming from private donations and government programs. Most traditional nursing homes cost less than half that much, but the Leonard Florence Center is over twice the size of a traditional nursing home and was the first Green House to be built in an urban area. Its multistory construction is also a departure from the usual single-level, ranch-style homes that are typical of Green House centers. The payoff, however, has been the residents’ lower hospitalization and readmission rates. The center has also received high scores for resident and family satisfaction, which Berman describes as “off the charts.” The foundation is now undertaking a $13 million renovation of a 30-year-old, 120-bed skilled nursing facility across town from Leonard Florence. “We’re bringing in as many elements of the Green House as we can and doing our best to retrofit a traditional nursing home,” says Adam Berman, chief operating officer of the nonprofit.

The Green House model is receiving increased academic scrutiny, and early studies have shown positive trends in quality of life for residents, greater family satisfaction, and a lower incidence of rehospitalization, bedsores, depression and other health problems. According to the Green House Project, 83% of Green Houses received a rating of four out of five stars or better on the Centers for Medicare & Medicaid Services’ five-star quality rating system, compared to 42% of nursing homes nationally. But the data are early. “The jury’s still out on whether Green Houses or other small homes achieve equal or better clinical outcomes than traditional models, and whether they’re financially sustainable—factors that may ultimately matter a lot more than the humanistic components in terms of their future growth,” says Sheryl Zimmerman, a professor of social work and public health at the University of North Carolina, who authored a 2010 review of more than 150 articles on characteristics related to Green Houses.

Sophie Gatta can make herself comfortable in her room or venture into one of the common areas of the Leonard Florence Center.

EVEN IF GREEN HOUSES PROVE THEIR WORTH, not every nursing home operator will have the means or the motivation to build new facilities. “We’re investigating the Green House model, but some of our homes don’t have the space or land for new buildings,” says Signature HealthCare’s McAllister. “So the question for us is how to transform what we have for those who live and work there.”

Since 2011, Signature has implemented the Eden Alternative in one-third of its 73 facilities. At a Signature nursing home in north Florida, for example, residents run a country store, tend a large outdoor vegetable garden and greenhouse, and help at a local soup kitchen. At a Tennessee location, there are plants and aquariums throughout the facility, and many residents have caged birds in their rooms; in other homes, some people bring their own cats and dogs or interact with pets cared for by staff members.

More than 300 nursing facilities call themselves Eden homes, embracing the approach’s 10 principles aimed at reducing boredom and loneliness, and democratizing decision making among staff and residents. Studies of the model’s effectiveness have found a higher quality of care, reduced staff turnover and lower rates of infections for residents. “We felt Eden offered a lot of accountability, since it has processes to track the path of transformation, and it can be adapted to a particular environment,” says McAllister. At Signature, changes have ranged from renovations that eliminate nurses’ stations and replace administrative offices with larger common areas to coaching for staff and residents who create more flexible schedules. The organization is experimenting with different management models, such as a team approach that emphasizes more collaboration among nurses and aides, and with operational adjustments such as carving out “neighborhoods” to bring together residents who have been isolated in individual rooms along long corridors. According to McAllister, initial results from the 16 facilities in which Eden has been fully implemented show improvements in quality of life for residents and better scores on clinical measures, including a 50% reduction in the use of antipsychotic medications during six months at one facility.

In a similar effort at Glendale Center, a Genesis Healthcare facility in Naugatuck, Conn., staff received extra training as part of a yearlong pilot program. The Connecticut home had a traditional management hierarchy, and certified nursing aides (CNAs) who rotated throughout the facility had little chance to get to know particular residents. The pilot focused on changing that approach for 60 residents in two “neighborhoods” at the home that included dementia patients. Nursing assistants were consistently assigned to the same residents, encouraging stronger relationships and helping the aides detect subtle physical or behavioral symptoms that could be treated early. “I was against taking chair and bed alarms off my unit, because I was concerned about the safety of my dementia patients,” says Doreen Lloret, a licensed nurse at Glendale. “But consistent assignment really does work because it allows aides to be more attentive to the residents.”

Daily morning “huddles” that included nursing aides, nurses, social workers, housekeepers and dietary staff members encouraged collaboration, and nursing aides also joined in care-planning meetings and weekly quality-of-life rounds. Such steps led to better staff morale and happier residents. “Having CNAs involved in those processes has helped immeasurably with residents’ families,” says Taylor Boucher, the facility’s long-stay social worker. “It puts them at ease knowing a loved one is being taken care of by the same person every day.” There were also statistical improvements, including a reduction in falls and in the use of antipsychotic drugs. The nursing home has since incorporated this approach throughout the facility.

AS ENCOURAGING AS SUCH STORIES MAY BE, however, there are questions about how far relatively small-scale efforts can go to reform a giant industry. In a 2010 study by Susan Miller, a professor of health services, practice and policy at Brown University School of Public Health, leadership issues, higher costs and regulatory problems were cited by long-term-care leaders as the most common barriers to implementing culture change. Yet many experts believe those obstacles can be overcome. For example, a campaign called Advancing Excellence in America’s Nursing Homes provides an array of do-it-yourself resources and networks of advisors to help improve clinical outcomes. More than 9,000 nursing homes have participated since the campaign’s launch in 2006. Meanwhile, federal regulators have adjusted some rules to encourage and reward culture change—for example, rather than checking that a nursing home has regular meal schedules, making sure that residents are well fed. And proponents point to studies showing that nursing homes committed to culture change may benefit financially. A study by Pioneer Network, for example, found that from 2004 to 2008, facilities undergoing culture change achieved higher occupancy rates and increased revenue.

Still, many people worry that major forces in the nursing home industry will continue to stand in the way of meaningful, sustainable reforms. For example, high staff turnover, the result of low wages and little job satisfaction, is an industry plague, and improvement is unlikely at a time when federal and state funding for nursing homes is declining, says Charlene Harrington, a professor emeritus of sociology and nursing at University of California San Francisco School of Nursing.

Annual turnover rates for nurses and aides average nearly 40%, according to the latest American Health Care Association statistics. And the 10 largest for-profit chains, which control about 13% of all nursing home beds, typically maintain very low staffing levels—almost a third lower than those at nonprofit and government—owned nursing homes. “The top 10 chains have a strategy of keeping labor costs low to increase profits,” Harrington says. “They’re not making quality a priority.” A 2011 GAO survey also found that facilities owned by for-profits and private investment firms, which have purchased nearly 2,000 homes in the past decade, reported a larger number of total average quality deficiencies when compared with nonprofits. “Green House and culture change are nice concepts, but I don’t know if these are big solutions, because successful innovation will depend on adequate staffing,” Harrington says.

The need for solutions will only become more acute as the baby boomers’ demographic surge affects the industry. Some 10,000 people a day are reaching retirement age, and government statistics say that as many as seven in 10 of them will eventually need long-term care, likely in a nursing home. That “silver tsunami” will present unprecedented challenges, and the innovative approaches taken by the Leonard Florence Center may or may not be possible to scale up to handle such daunting numbers. Yet for Evelyn Mehlhop, at least, the facility has been everything Jill Herold could have hoped for. Herold says that since her mother moved in last year, she has become mentally and physically healthier, and she often smiles and interacts with other residents. “When she gets her words out, she tells me, ‘this is a very nice place,’” says Herold.

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