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What Is Changing?

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Nursing homes that are involved in culture change are moving toward person-directed care. They are working to ensure self-determination, choice, dignity, and meaningful relationships for those who live and work there, as well as involving families and friends to create community. Culture change is causing all types of long-term care settings to focus on person-directed care. However, nursing homes serve as a good example of what is changing because they are often the most institutional long-term care settings.

The chart below illustrates some of the differences between traditional nursing home care and person-directed care.

Moving From Traditional to Person-directed Care

Traditional Care
 Person-directed Care
Residents are told when to wake up, go to bed, eat, and bathe, based on institutional schedules and set routines.Residents wake up, go to bed, eat, and bathe when they choose to. Staff alter their work routines to honor residents' preferences.
Residents frequently have different care staff. The staff do not know the residents well, so they are not familiar with their preferences. Studies find that residents
often feel unknown, insecure, or scared.
The same staff take care of the same resident; they know each other and good relationships develop. This motivates staff to provide better quality care. Studies show that residents feel more secure, content, and happy.
Management makes most of the decisions, often without consulting the residents,
families, or direct-care staff.
Management seeks input from residents, families, and staff before making decisions that affect their daily lives. Management also trains and supports staff to enable residents to make decisions.

In person-directed homes, staff members care for the same people day after day. This is called consistent assignment and helps the caregiver get to know each person (resident). Nursing homes with consistent assignment retain the same staff caregivers for many years (have a low turnover rate) and are not likely to use staff from temporary agencies to fill in. In general, agency staff is unfamiliar with the residents and their preferences. Therefore, they cannot meet their care needs as well as consistent staff. Nursing homes with a stable caregiver workforce often provide better care.
Person-directed care is appropriate for all residents, even those with some type of dementia, such as Alzheimer's disease. Residents with dementia are often unable to verbalize what they want, like, or don't like. The nursing assistant who consistently works with such a resident knows this information by the resident's body language, behavior, and/or information provided by the family. For example, a person with dementia may not be able to understand that she needs to be clean and, by her words and actions, refuses a bath or shower. A well-trained direct care worker, who knows the person, will have the knowledge, skills, flexibility, and equipment to find new and better ways to pleasantly assist her with washing.

Many people go to nursing homes for short stays to recover from surgery or an acute illness that required hospitalization. Even though they think of themselves as "patients" and not "residents," they too benefit from culture change. For these people, the emphasis of care is on supporting their healing, education, preparation, and choices for the next steps in their recovery.

The "look" of the nursing home is also changing. Many are creating smaller "units," often called neighborhoods. The goal is to create areas that in size and scale look and feel like normal homes, not like big institutional buildings. Forming a neighborhood does not have to include a large remodel or new building. Features of a neighborhood are smaller groups of residents, consistent assignments, and additional resident choice. For example, residents usually dine in their own neighborhood instead of a large dining room that serves the entire building.

Some nursing homes have chosen to build new, or renovate into, separate, self-contained areas where fewer than 25 people live. They are called households, small houses, or GREEN HOUSES®.  All three can be considered "small houses" and all have their own kitchen, private bedrooms, shared living and dining rooms, and consistent staffing in self-directed teams. They are furnished as a home would be.

In some neighborhoods and all households, GREEN HOUSES®, and other small houses, mealtimes look and feel more like family dining because small groups of familiar faces (including staff) eat around a table. Food is often served family-style from bowls, instead of on trays. Living rooms have comfortable chairs and good lighting. Bedrooms are decorated with personal items and furniture. Children feel welcomed by toy boxes or play areas as part of the setting. There is no traditional nurses' station or overhead paging. Such changes result in closer relationships and a sense of living in a real home with a community of people.

For those long-term care organizations that are not ready to renovate or construct new buildings, it is important that they begin their "culture change journey" by adopting person-directed values and implementing practices that promote choice and meaningful relationships.  Then when they are ready to renovate or build new, they will likely not go with the institutional physical environment and replace it with one of the new models.

These neighborhood and "small house" models are operating in a number of states around the country, but availability varies from state to state. Many are affordable and accessible to all people, including those with limited incomes or whose nursing home care is covered by Medicaid (See Definitions for explanation of Medicaid).  

It is important to understand that culture change is not just for "high-end" long-term care communities or for people of higher economic means. Culture change is happening in all types of long-term care communities, big and small, including homes caring for people with Medicaid. On average, at least half of the residents in culture changed homes are covered by Medicaid.

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