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These Nursing Homes Care About Their Elderly Charges

At new-culture facilities, the emphasis is on respect for residents and a homelike setting

Sarah Baldauf - US News & World Report
01/12/2010

U.S.News & World Report

Dick Harron's buddies think he's off his rocker when he tells them "how much fun it is" to visit his 99-year-old mother at her nursing home. "It sounds strange," says the Oshkosh, Wis., retired sales manager, but "when I walk in there, I feel good." Central to his peace of mind is the easy warmth of the nurses and aides, whom Harron likens to "kid sisters" or his own daughters. Most have been Dorothy Harron's caregivers for all seven years she has lived at the Evergreen Retirement Community in Oshkosh. Harron enthuses over their respectful yet playful interactions with his mom and the good-night kiss on her cheek when they help her into bed. "It's an informal, pleasant place," he says. "It's jovial." And it's a far cry from the usual nursing home image.

[See the latest America's Best Nursing Homes rankings.]

Like a growing number of progressive homes, Evergreen focuses on listening to residents, creating an environment less like a nursing home and more like a real one and giving employees uncommon flexibility and freedom. It's a movement that aims to revamp nursing homes from the inside out, stripping away a culture that has dominated American nursing-home care for decades. "There isn't a person around who would want to be in an institution," says Bonnie Kantor, executive director of the Pioneer Network, an advocacy group leading the charge. So residents' wishes and dignity are put first. Restrictive visiting hours are disappearing; arrangements are being made for opposite-sex roommates. "This is how care can and should be delivered," says Kantor.

[Read Be Sure a Nursing Home Is Doing Its Job.]

At Evergreen and other homes in the vanguard of the trend, nurses don't pass out medications to entire units or floors; drugs are delivered individually, timed to each resident's schedule. Belts and other physical restraints to keep residents from falling out of bed or a wheelchair, once commonplace, are absent. And many homes have silenced the constant overhead dinging of resident call bells. At the Madlyn and Leonard Abramson Center for Jewish Life in North Wales, Pa., such requests go directly to phones worn by nurses and their assistants.

At nursing homes that have made a commitment to the new model, most residents live in "households" or "neighborhoods" of 10 to 30 people, each usually with its own communal kitchen and living room, not in rooms lined up along hospital-like corridors anchored to nursing stations. Residents often wake up when they choose instead of being roused early to ensure they make it to breakfast at 7:30 and are back in time, say, for an 8:30 shower. "All that's gone now," says Steve Lindsey, chief executive officer of Garden Spot Village in New Holland, Pa., of the facility's old rigid scheduling. Instead of tending to residents in large groups as before, staff now care for them individually, making breakfast to order in the household kitchen whenever residents wake up, for example.

The majority of today's nursing homes grew out of a hospital model that emphasizes clinical efficiency over making a stay calm and pleasant. If checking blood pressure at 5 a.m. is logical only because that's when a new nursing shift begins, so be it. A hospital stay, though, is usually short. "A nursing home is where people live," says Matthew Wayne, assistant professor of medicine at Case Western Reserve University School of Medicine in Cleveland and medical director at two nursing homes. Blanket protocols like those in hospitals, such as putting everyone with a heart condition on a no-salt diet, may preserve life but diminish its quality.

In progressive nursing homes, by contrast, homey touches of normalcy abound, such as pets that drop by for a visit. "Not a day goes by that you don't see two or three animals, especially ones that once belonged to residents," says Cecilia Nitzberg, 95, who is part of a 27-person household at Abramson. "It's one of the wonderful things we have here," Nitzberg says of the encouraging attitude toward pets, a given for many residents when they lived independently.

Viewing residents as active participants in their care rather than passive recipients is a recurring theme. "In the old model, we tell [residents], 'Now it's time for us to take care of you,' " says Lindsey, as if they are helpless. In the new model, it's not uncommon for willing residents to help prepare meals, set the table for dinner, dust, or sweep, he says. It offers them the sense of purpose and control they had when they were living independently. One household at Garden Spot Village has been doing service work, gathering to sew bags, packed with a ruler and notebook, to send overseas for children lacking school supplies.

At some homes, residents even contribute to plans for large projects. Intending to build swimming facilities, Evergreen wanted to remove any barriers that might discourage residents from taking the plunge. Surveys indicated that the new facilities would go unused if the plans didn't address privacy concerns (so individual changing rooms were included), cold feet (heated floors), and dripping wet suits to carry back (speed-drying machines). The pools—one set at 88 degrees, the other warmed to 94 so that less vigorous residents don't get chilly—are a huge success, says Ken Arneson, Evergreen president and CEO.

The larger Oshkosh community is welcome to use the popular pools, along with several other amenities at Evergreen: a new restaurant featuring low prices and chairs that residents voted most comfortable, a lapidary with tools for shaping stones into jewelry and artwork, and monthly showings by local Oshkosh artists. Besides bringing in new folks to meet, the mingling might change how they define "nursing home," perhaps even aging in general. Arneson thinks so. Evergreen has a waiting list, which other homes might envy; the average occupancy rate for nursing homes is 86 percent, according to the Centers for Disease Control and Prevention.

Evergreen embeds constant reminders to caregivers, visitors, and residents themselves that each person living there is more than the sum of his or her ailments; before they arrived, they all had real and often fascinating lives. On the wall outside each room at Evergreen is an "identity box," an open wood case the resident is encouraged to fill with items that reflect his or her life story and interests. Arneson recalls one identity box that showcased a piece of the USS Lexington, the aircraft carrier that was the former resident's home base during World War II, and another that held a former teacher's first contract, earning her $30 a month.

Honoring residents' individuality also means avoiding the convenient labels common to old-style nursing homes. An institutional model typically shunts people with Alzheimer's disease and dementia, for instance, onto a single floor with the door locked to prevent them from roaming. At Evergreen, Abramson, and Garden Spot Village, however, many such residents are in households with folks who are still mentally sharp. The approach, says Lindsey of Garden Spot Village, seems to reduce the incidence of behavioral issues like anxiety and agitation in residents with dementia, a common concern. "She's always included, not just by the staff but by the other residents, too," Mary Anne Duffy of Lancaster, Pa., says of a 101-year-old friend with dementia who has lived in a household at Garden Spot Village for three years. Not only do residents consult Myrtle Tremblay, a former artist, on her eye for color during group craft-making sessions, but her caregivers give her nails a new shade of polish just about every week, says Duffy.

Good relationships between caregivers and residents improve medical care. And this is best established through "consistent assignment," as it's known in the industry. Instead of rotating nurses and other caregivers throughout the facility, which old-school nursing-home veterans defend because it allows all caregivers to know all residents, they always work with the same residents, explains Abramson's Valerie Palmieri, residence administrator and vice president. The reality of a floating staff, she says, is that "you get inconsistent outcomes." A nursing assistant who sees your dad only every few days, for example, may not notice a subtle change in skin tone that could be an early sign of a pressure ulcer due to inactivity. With Abramson's consistent-assignment approach, Palmieri has seen a significant drop over the past four years in pressure ulcers, falls, and weight loss—three particularly pressing challenges for nursing homes.

Finding a balance between honoring residents' choices and providing good clinical care, however, can be difficult for some staff. "Nurses have the most trouble embracing culture change in an organization," says Kantor. Unlike their coworkers, nurses have medical training and can be held legally liable for harm to residents, says Diane Carter, president and CEO of the American Association of Nurse Assessment Coordinators, a long-term-care nursing education nonprofit based in Denver. So relinquishing some control over what nurses see as medical care can be tough to swallow. When a person with diabetes wants sweets, for example, a nurse will inform her and her family members of the risks, "but sometimes it's 'I'm 92 and I'm eating ice cream,' " says Carter. Going along, she explains, can "feel like a double bind to the nurse," whose training taught her otherwise.

An "Aha!" moment revealed to Carter why she should embrace the change. The rigid schedule for giving residents antibiotics starting at 9 a.m., even waking them up if necessary, was "so ingrained in my nursing soul," she says, that when a doctor ordered the first daily pill to be given whenever the person woke up, she practically had heart palpitations. Then came the sudden insight: "I don't plan my day around taking a pill."

One way these homes make the transition easier for caregivers is to do for them what they are doing for residents: give them a voice, and be willing to bend traditional roles. Involving nurses as well as nursing assistants and "homemakers" (a blend of chef and housekeeper) in determining the cause of a medical problem and how to fix or prevent it—a resident who has fallen or has incontinence-related skin infections, say—empowers staff. And nursing homes with a culture-change bent will also nudge employees to step out of their traditional roles: "They'll put on a hairnet and help serve meals," says Lindsey of the nurses and nursing assistants at Garden Spot Village.

Encouraging input and removing some of the traditional hierarchy tend to lead to higher job satisfaction. And that translates into fewer employees calling at the last minute to say they won't be in, requiring overtime work by a colleague or hiring an agency temp to pick up the shift. It also reduces staff turnover, a notorious headache for nursing homes that leads to revolving caregivers for your loved one. Nationally, the average turnover rate for nurses working in long-term settings such as nursing homes is as high as 33 percent. Evergreen's 2009 rate: 9.5 percent. Of his mother's consistent staff for seven years, Dick Harron says, "That shows it's a good place to work. With changeover, you know it's either lack of pay or poor working conditions."

David Farrell, a leader in the culture-change movement and long-term-care administrator for SnF Management, a California-based healthcare group, suggests asking administrators if they measure staff satisfaction, how often, and what they do with the results, as you'll want to get a sense that they act on their findings. Another tipoff that employees are valued: "Progressive nursing homes feed their staff," says Farrell, by providing free or low-cost meals or other meaningful perks, like free flu shots or vitamins, to workers in a relatively low-paying industry.

Culture-change proponents agree that it is vital to keep care from taking a back seat to a resident-centered approach and less rigid schedules. The trick, says Wayne of Case Western Reserve, is diligent monitoring and flexibility. If your aunt has slept late for the past 10 years, she should be allowed to do so in a nursing home, says Wayne. But her caregivers need to keep a keen eye out for weight loss if she's skipping breakfast and for pressure ulcers, which can develop into painful skin wounds in sedentary elders. If either becomes a problem, says Wayne, then waking her is appropriate.

Families may let their diligence slip at a facility that treats their elderly relatives with respect, but standards of health and safety are still paramount. The federal Centers for Medicare and Medicaid Services rates nursing homes on health inspection results, nurse staffing, and quality of care. (The ratings are used to create the U.S. News America's Best Nursing Homes rankings.) Overall, nursing homes committed to culture change, like those that participate in the Pioneer Network, fare better than others do on average, particularly in overall ratings and nurse staffing (a reflection of the average time nursing staff spend with each resident), according to an analysis done by the group.

But better is far from perfect; a new culture doesn't eliminate human error. Evergreen, for instance, got a high overall rating (four out of five stars) in the latest CMS evaluation. But last October, an Evergreen nurse on her way to deliver medication first stopped in another resident's room to answer a call for assistance and set down the medication. The resident quickly swallowed the drug meant for a neighbor. A health inspection surveyor happened to witness the event. Though the resident was unharmed, Evergreen was still cited for a significant deficiency for failing to "make sure that residents are safe from serious medication errors." Evergreen's takeaway: "You learn from it," says Arneson soberly. Staff members were warned not to put drugs within reach of a resident for whom they are not intended when answering such calls.

Glitches aside, residents of homes like Evergreen, Abramson, and Garden Spot Village understand, and are grateful, that these are not typical places. "Compared with the nursing homes my mother and husband were in, this is heaven," Cecilia Nitzberg says of Abramson. "If I have to be in a nursing home, I couldn't do any better than this."

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