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Key Questions

Pioneer Network is working to create person-directed care in all long-term care settings including nursing homes, assisted living and a wide variety of residential, home and community based care settings. Person-directed care allows the elder to make their own choices, continue familiar routines and maintain their dignity after moving into the new setting -- or in other words, be at home wherever home may be.

There are many choices available, but many elders will still need nursing home care. Here is a set of questions that we have developed to help families determine whether or not a nursing home is engaged in person-directed care.

In this section you will find key questions to gauge whether a community is practicing person-directed care.  The primary questions for nursing homes are below. At the end of the page is a link to more key questions specifically about assisted living.

A Consumer's Guide to Finding a Nursing Home on the Culture Change Journey

What are Key Questions to Ask the Staff in Nursing Homes to Find Out If They Provide Person-Directed Care?

Listed below are some general and specific things to ask and to listen for in the response. These are not the only "correct" responses, but they will give you a general idea of what you might hear that indicates work toward creating home for residents.

  • How is your nursing home involved in culture change?

Listen for: "We have a committee that works on making our place a home for residents who live here. Residents and families serve on the committee. Staff members attend the state coalition meetings and go to conferences to learn more. Several of our staff (including direct care workers) have visited other places involved in culture change. We have consistent assignment so that our staff can get to know the residents they are caring for including their individual needs and wishes."

  • How will you get to know my family member?

Listen for: "It is very important for us to really get to know each person who lives here. We have a questionnaire for your family member to fill out that helps us get started. If they are not able to do this (because of dementia, for example), we want you to help us get to know them. Then we will talk with them and spend time together. We will learn about their preferences, their past, what they enjoy doing now, and their goals and wishes for the future. Everyone on the staff will get to know your family member." 

  • Do the CNAs/nursing assistants take care of the same group of residents each time they work, or do you rotate the assignments after a period of time?

Listen for: "Consistent Assignment." "With few exceptions, our caregivers care for the same group of residents each time they come to work."  

  • Will my loved one be awakened at a set time in the morning or will she have a choice? 

Listen for: "Residents may choose to sleep as long as they want without being awakened.

  • What is your policy regarding food choices and alternatives?

Listen for: "Let me show you a list of the alternatives we always have on hand if someone does not like the main entree being offered. Do you think your loved one would be satisfied with these? If not, we can usually accommodate her wishes."

  • Can my loved one be given a shower/bath when he or she chooses?

Listen for: "Yes. We can accommodate a person's lifelong pattern of bathing. Plus, we understand about the special needs of persons with dementia. We have many creative ways to keep people clean, so we can adapt to their preferences and comfort and still maintain cleanliness. 

  • What type of recreational activities are offered here?

Listen for: "We offer a wide variety of meaningful and purposeful activities. Residents have input into what is offered. Many of our activities are also spontaneous. Our CNAs do activities with residents based on what the resident likes to do, including at night for those who are awake. We also have someone here in the evenings and on weekends to engage residents."

  • How do you build a sense of community, and give those who live here a voice in the decisions about how things are done?

Listen for: "Residents are part of the home team. We have an active Resident Council. Discussion groups neighborhood or household meetings are held weekly with residents, staff and invited family members. Residents have a say in who cares for them."

  • How do you meet the special needs of people who have some type of dementia?

Listen for: "We educate our staff on how to best communicate with people with dementia. Because we have consistent assignments, staff know the residents well and can anticipate and meet their needs in flexible, creative ways. We also support and teach staff how to problem-solve difficult situations."

  • What is the role of family members? Do you have a Family Council?

Listen for: "Family members may visit here any time, volunteer, and participate in our Family Council. Let me provide you with a Family Council meeting schedule. Family members can always speak to any member of our staff to discuss their loved one's needs and preferences."

  • Do you have a rehabilitation team and access to therapists such as speech pathologists, physical therapists and occupational therapists?

Listen for: "We have licensed therapists on staff. We can provide one-to-one therapy, and our therapists also advise us on such things as how to adapt a room or bathroom to best meet individual needs, and how to transfer a resident from chair to bed in the most comfortable way."

  • Do you measure the turnover of your staff (defined as the average percentage of staff who stop working at the home each year)? If so, what is the turnover rate for your direct care workers (CNAs, nurse assistants)?

Listen for: Any number under 40 percent. (The national average is 70 percent.)

  • Do you measure the turnover rate of your licensed nursing staff? If so, what is your turnover rate of licensed nurses?

Listen for: Any number under 30 percent. (The national average is 50 percent.)

  • Do you measure staff satisfaction? If yes, what do you do with the satisfaction survey results?

Listen for: "Yes. We measure the morale and satisfaction of our staff with a survey and by meeting with them in small groups. We know that if our staff feels respected and supported, they give better care to residents. We use what we learn from the survey to make improvements." Ask for a recent example.

  • Do you also measure resident satisfaction each year?

Listen for: "Yes. We measure the satisfaction of our residents by using a survey and by meeting with them in small groups. We use what we learn to make improvements." Ask for a recent example. Ask residents about this.

  • Do you measure family satisfaction?

Listen for: "We do. Family opinions are important. However, we understand that our "customer" is the person living here."

  • What is your organization's policy regarding the use of "agency" nurses and "agency" CNAs (people who are brought in from the outside who are not your regular staff)?

Listen for: "Only our own nurses and aides work here. Only in a dire short-staffing emergency do we bring in people from an outside agency."

  • What is your mission statement? Is staff able to share the mission in their own words and indicate that it is meaningful to their work?

Listen for: "Our mission statement is….We try very hard to make our mission not just words but part of daily life for people who live and work here."

To get a feel of the tone of the nursing home during your "walk-about," look at the colors (furniture, walls, floors), lighting, real or artificial plants, bird cages and fish tanks, other animals, smells, lighting, signs, elements of privacy, options for sitting alone, conversation areas, and residents' facial expressions. Are staff and residents interacting in what looks like interest and kindness?

Look at the types of activities that are posted. Check to see if Resident Council and Family Council materials, and ombudsman contact information, are posted in obvious places and at a level where a person in a wheelchair could read them. The last report of the state survey should be available for you to review. Talk to residents and families when you are visiting. Ask them how they feel about the place and if they would recommend it. Remember that if you ask this in the presence of a staff person, individuals may fear sharing negative comments and so may give you an inaccurate impression.

Developed through the support of the Picker Institute, adapted with permission from the work of David Farrell and the California Culture Change Coalition.


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