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The History of Culture Change
By Barbara Speedling
Change, according to Webster’s, means to become different. There is a lot of talk in recent years about change in long term care. There are many people who want nursing homes to change, to become different than they are now. Myself included. How they should change, or what could be done differently, are the tough questions yet to be answered.
The evolution of the Culture Change movement is a curious one. It is a study in history repeating itself. In fact, if you examine the history, you’ll find the same basic premise repackaged in response to each new catalyst.
Until the 1960’s, nursing homes were the equivalent of poorhouses. No one of good sense or morals would find themselves or someone they loved living in one. They were largely unregulated and ignored.
With better health care comes longer life. As the numbers of aging Americans grew, so did the need to seek better solutions to their needs. The financial burden on aging people with low or fixed incomes who needed long-term healthcare led to the creation of Medicaid.
In the early 1970’s, widespread fraud and abuse of the Medicaid program was identified in nursing homes around the country. By the mid-70’s, advocacy groups, such as the National Gray Panthers, rallied Washington and the campaign to provide a better standard of care was initiated.
There was much talk across the country about quality. The seeds out of which OBRA ’87 would develop had been planted. The Omnibus Reconciliation Act of 1987 brought with it a host of new regulatory language on quality.
Nursing homes would be required to monitor the status of their care and services to maintain compliance with the expectations of quality care. The penalties for poor care increased and nursing homes responded by developing plans to make their environments more “homelike” (i.e., familiar, comfortable, welcoming, user-friendly).
In 1980, the Alzheimer’s Association was born out of a growing need to understand and manage nursing home residents who suffer memory loss. The association’s work toward public and professional awareness of the illness and it’s impact on individuals, families and professional caregivers is credited as the driving force behind new research and support.
With this new focus came calls for better assessment and accommodation of how the disease affects each person, and his or her personality. While there are behaviors common to many, there are subtler differences that must be recognized and addressed. As advocates and regulators became more aware, the industry was challenged to create environments that were “homelike” (i.e., familiar, comfortable, welcoming, user-friendly).
By the early 90’s, nursing homes were fast becoming big business. The numbers of those seeking care were growing. So was the need to think competitively. If a nursing home was to thrive, and attract the private-paying share of the market, it had to be more appealing than it’s competition.
Nursing homes began to advertise more aggressively, sending representatives out into the community to network and garner referrals. Brochures boasted about “homelike” environments (i.e., familiar, comfortable, welcoming, user-friendly).
Just about this time, there was another event that led to another refinement of rules and expectations. Things were not so good. People were running out of private money and there were fewer people looking to move in.
The answer: specialize.
Nursing homes began to develop specialty units for people with Alzheimer’s disease, young adults or those with specific, chronic conditions. Others initiated short-term orthopedic rehab programs, or began admitting residents with more complex medical needs. These environments were marketed as homelike or user-friendly, depending now on whether you were there for the duration, or just a short stay.
In 1995, President Clinton initiated the Operation Restore Trust anti-fraud and abuse demonstration project in five states in response to growing public pressure to improve the quality of care in nursing homes. Organizations like the Pioneer Network and National Citizen’s Coalition for Nursing Home Reform were gaining ranks and nursing homes were put on notice, once again, to become different.
The pressure of increasing regulatory oversight and consumer activism, coupled with the introduction of more appealing alternatives, such as homecare, adult daycare and assisted living, forced the industry to search for ways to become different. Special environments like the Eden Alternative were being explored. Nursing homes again vowed to become more “homelike” (i.e., familiar, comfortable, welcoming, user-friendly).
So now, in the last weeks of 2006, nursing homes are again waiting for the ax to fall. The Federal government has introduced its 2007 plan to improve the quality of care in nursing homes. One significant point made in this plan is that the Centers for Medicare and Medicaid have joined the national Culture Change movement. All eyes are on nursing homes to become different, again.
What, exactly, is culture change? Literally, it means to change the nature of a society. Our world, our human environment, has been trying to achieve culture change for as far back as our history extends. Becoming “homelike” is not as easy as it sounds.
For the nursing home industry it appears to be something forever just out of reach, yet it continues to be the ideal. There are those that are doing so successfully, in small ways, step by step.
It can be tedious this taking an interest in every single person--all of this listening and problem solving. Particularly, when you throw staff, families, visitors, and everyone else who crosses your threshold into the mix. Do you really have to pay attention to the needs of all these people? Yes.
Person-centered care: taking care of each person--all of them--everyone.
Barbara Speedling ©2006
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