Over the past ten years ‘Culture Change’ has become a mainstream concept in long-term care. Culture change was recently included in the Centers for Medicare and Medicaid Services proposed Reform of Requirements for Long-Term Care Facilities, regulations not amended since 1991, by referring to person directed care and involving the resident in their care goals. As the Executive Director of Green Hill Senior Residence in West Orange I have seen the culture shift in different ways in communities throughout New Jersey. However, the biggest shift was the Green House® Project which I discovered in 2003 when the 1st Green House home was built in Tupelo Mississippi.
The Green House concept is one “where elders and others enjoy excellent quality of life and quality of care; where they, their families, and the staff engage in meaningful relationships built on equality, empowerment, and mutual respect; where people want to live and work; and where all are protected, sustained, and nurtured without regard to pay.” (The Green House® Project) Learning that the deinstitutionalized physical environment where elders live, as in a Green House home, creates a foundation for culture change led us to build the first four Green House Homes in the State of New Jersey on our campus in West Orange. Through the resident directed care training learned with the Green House model we expanded culture change throughout our Legacy building as well.
“Culture change involves rethinking values and practices….. change that brings all who are involved in the nursing home culture – staff, management, residents, and families – to a new way of working that creates a humane environment supporting each resident’s life, dignity, rights and freedom. Culture change is about de- institutionalizing services and individualizing care.” (The National Consumer Voice For Quality Long-Term Care).
Culture change involves person directed care, not just for the body but for the mind and spirit as well. As staff work together with the residents to find out history and cultural backgrounds, relationships are formed, whenever relationships are formed there becomes a bond through trust and mutual admiration, as well as a protective instinct that is innate in all of us. Spending time with a resident, getting to know them, learning about their background can support positive behaviors. Communities with consistent staffing who have utilized person directed care find that the elders exhibit: more activity involvement for impaired residents; better outcomes in quality indicators; less resident agitation/anxiety, depression, withdrawal, behavioral and mood disturbance, delusions, hallucinations, psychosis, aggression and phobias.
Culture change in long term care has been proven to improve the medical outcomes for residents. Extensive literature has found the increased CNA time is widely associated with improved resident outcomes of infection, pressure ulcers, abuse, quality of life, resident satisfaction, and staff satisfaction and turnover, and better care in engagement, nutrition and documentation.
“Nursing homes that were identified as culture change adopters exhibited a 14.6% decrease in health-related survey deficiency citations relative to comparable non-adopting homes, while experiencing no significant change in nurse staffing or various MDS quality indicators.” (The Gerontological Society of America)
The psychosocial outcomes include better rapport, less abuse, more social involvement for impaired residents, fewer conflicts and emotional and behavioral symptoms; because the staff know the residents more intimately and there are fewer environmental demands on impaired residents.
Creating culture change in nursing communities has been evidenced to lead to a reduction of abuse or abusive behavior within the long term care community, and have aided in the ability of staff and administrators to recognize abuse of an elder. Creating a strong one-on-one, daily relationship enables the care giver to recognize changes in behavior, to develop trust whereby an elder may feel comfortable sharing abusive experiences, and an environment where administrators are more able to recognize financial abuse from those tasked with handling an elders financial affairs. The addition of culture change in the home care field, as with the Green Hill @ Home program enables caregivers to recognize signs of emotional, physical or financial abuse in elders when living in their own homes.
By simply changing the language associated with nursing care we can change the culture. Person directed care implies to a caregiver that the resident should be directing the course of their own care. Engagement in the community instead of an arbitrary schedule of activities means that instead of keeping someone “busy”, engagement with an elder is much more fulfilling for elder and care giver. We in the long term care culture change community are grateful that CMS recognizes the importance of the language in the updated regulations and is making amendments to reflect the movement. I am inspired by the work of my colleagues on culture change and honored to be a part of it at Green Hill, through my work with the State of New Jersey, serving on the Board of the NJ Alliance for Culture Change (NJACC) and on the national level to make culture change an integral part of elder care in America.