Culture Change in Nursing Homes: A New Start in Michigan for 2019

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For an enterprise that sometimes seems beleaguered, culture change in nursing homes is a bright spot of positive, forward-looking movement and quality improvement. Yet widespread implementation of culture change – anchored in comprehensive staff training in person-centered care — has not yet happened. Part of the reason is that the specific gains that culture change can achieve have not been sufficiently well characterized to be readily replicable, scalable and sustainable.

A three-year initiative [see press release] that Altarum’s Program to Improve Eldercare began in January will strive to change this. Funded by the Michigan Department of Health and Human Services, the project is designed to test, implement and evaluate two phases of comprehensive, person-centered training provided by The Eden Alternative in six Michigan nursing homes. The homes – Beacon Hill at Eastgate, Metron of Forest Hills, Metron of Big Rapids, Spectrum Health Rehabilitation and Nursing Centers-United and Kelsey, and the Martha T. Berry Medical Care Facility — will be working throughout the project to make concrete changes in a range of operational protocols and practices.

Altarum will evaluate what residents, families, and staff report about their quality of life and their living/working environments; assess changes in selected clinical quality metrics; and analyze the economic impact of culture change on participating homes.  We will track clinical quality metrics throughout the project using quarterly Minimum Data Set (MDS) information about pain, depression, and utilization of antipsychotics. The impact on hospitalizations will also be tracked.

To assess economic impact, Altarum will examine information on operational costs, capital investments, occupancy and staffing. To measure the possible impact of culture change on staffing, we will use data from the Payroll-Based Journal (PBJ), together with a consistent methodology for calculating staff turnover. An Altarum-designed “Systems Change Tracking Tool” (SCTT) will capture on-the-ground changes that nursing home leadership, working in conjunction with clinical and non-clinical staff, elect to make over time. For example, the SCTT asks staff to provide information about whether:

  • The home honors CNAs as key decision-makers in helping to prioritize and implement changes that aim to improve care and quality of life for residents;
  • The home’s overall physical environment fosters feelings of belonging and comfort;
  • Residents have easy, safe access to a garden/patio/outdoor space (i.e. doors are unlocked and residents are easily able to maneuver through doors, or team members are readily available to accompany and assist them);
  • Residents are engaged in determining menu selections;
  • Residents are offered alternative non-pharmacological therapies, treatments and modalities (e.g., music therapy, stress reduction techniques) and staff are trained in how to carry them out.

The six homes participating in this project are highly motivated and self-selected; they do not have “perfect” scores on Nursing Home Compare. They have enthusiastically agreed to participate in the hope that the Eden Alternative training and the careful, consistent monitoring and feedback that they will receive from Eden and Altarum over the three-year period will result in sustainable, improved quality of life for residents; more rewarding, relationship-focused work environments for staff; equivalent or higher scores in the three clinical quality metrics; equivalent or lower hospital readmissions; and solid economic indicators showing that culture change makes the homes a more desired residence in their market.

At Altarum, we look forward to seeing what unfolds and recording it all in an evaluation, while establishing what we hope will be a good roadmap that many other homes can choose to follow. We think that culture change offers excellent opportunities for individuals with disabilities to live well in an environment that removes any sense that one is living in a somewhat deficient hospital — and instead is living in a home that is comfortable, comforting, attuned to one’s needs and preferences, and that also delivers consistently good medical and supportive care.

A quick PowerPoint overview of the project, “Culture Change in Nursing Homes: Accelerating Quality Improvement for Long-Stay Residents in Michigan,” is available for download here.

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