Transforming nursing homes

Almost no one wants to enter a nursing home, yet sometimes it’s unavoidable. Since the 1980s a “culture change” movement has been underway. Its objective is to transform nursing homes from their hospital-like, institutional, clinical model, to a resident-centered home-like model. I learned a lot about the topic by reading Person-Centered Care For Nursing Home Residents: The Culture Change Movement, in February’s Health Affairs. I’m totally on board with the culture change principles, but disappointed at how few nursing homes have been transformed.A consensus meeting in 2006 outlined a set of characteristics of an “ideal” facility:

1. Resident direction, e.g., residents decide what to wear, when to go to bed
2. Home-like atmosphere. That means units of 10-15 people, meals prepared in the units, resident access to frigs, and elimination of institutional features like overhead PA systems
3. Close relationships. In particular, the same nurse aides should take care of a resident over time
4. Staff empowerment to respond to residents’ needs
5. Collaborative decision making so frontline employees have more autonomy. (This and #4 seem closely related)
6. Quality improvement processes to encourage continuous improvement with specific, measurable outcomes

A Commonwealth Fund survey found that just 5 percent of nursing directors at nursing homes reported their facilities had made it all the way to the “culture change” goal, while another 10 percent had made significant progress and a total of one-third had done something. I find those results pretty discouraging.The authors highlight barriers in workforce, regulation and reimbursement that hinder the transformation of nursing homes.  For example, they point to staff turnover in the 50 percent per year range, regulations preventing residents from rearranging their furniture, and rules forbidding open kitchens. Meanwhile nursing home quality report cards such as those on the Nursing Home Compare website emphasize clinical aspects rather than resident experience measures.The authors make a number of reasonable suggestions on how to address the situation including direct engagement to encourage nursing homes to embrace culture change, payment incentives, facility replacement, regulatory tweaks and public reporting.And as researchers, of course they didn’t forget to include a call for more research!They also mention that “[t]he number one challenge in long-term care today is securing a large enough and adequately trained workforce.” They make the usual suggestions for workforce improvement, e.g., improve training, revise licensing requirements to increase flexibility. This plan is fine as far as it goes, but I don’t it will ever be completely successful. It will be hard to dramatically increase the supply of nursing home staff, especially as the overall population ages, we continue to restrict immigration, and the jobs remain low-pay. In addition, it’s hard to instill culture change and consistency to the degree required.I return to my (controversial) enthusiasm for robot nurses. Sure, it sounds like a great idea to have a consistent nurse’s aide for a resident as called for in principle 4, but how is that really going to happen considering turnover and work schedules? Why not have a robotic assistant assigned full-time to each resident and under the resident’s control, rather than under the control of the nursing home? That would be empowering and resident-centered in my book. Instead of calling it a robot nurse, call it a resident’s personal assistant.Well-trained nurses will still be needed to handle higher complexity work, but they’ll be relieved of the need to do mundane tasks and to continuously bring new staff up to speed.