This month’s issue of The Gerontologist includes a supplement on culture change and transforming nursing homes. The issue features the work of long-time friends of the John A. Hartford Foundation and experts in the field like Deb Saliba, Phil Sloane, Claudia Beverly, Cornelia Beck, and Robyn Stone.
Because nursing homes are an important part of the continuum of care for older adults and not something likely to disappear, we at the Foundation think getting this part of long-term care right is very important (and why we support grantees like PHI—see Amy Berman’s post last week). The papers in the supplement grew out of a conference funded by the Office of the Assistant Secretary for Planning and Evaluation (ASPE) in the U.S. Department of Health and Human Services and convened by RAND to understand what is known and where the gaps are in our understanding of culture change.
Culture change requires modification in both the training and deployment of the health care workforce. It calls for more skillful workers in more effective teams focused on the unique needs and preferences of the individual resident/patient. This long-term care population is necessarily frail and uses a great deal of medical services, along with the supportive services provided by the facilities.
There is clear potential to improve the quality of people’s lives and lower overall costs while doing it, making it an excellent example of John Hartford’s advice to focus on “one small band that the heart and mind together tell you is the area in which you can make your best contribution.”
Unfortunately, the news is decidedly mixed. The excellent meta analysis that starts the issue, What Does the Evidence Really Say About Culture Change in Nursing Homes? gives a good bottom line: “…. nursing homes wanting to import culture change are currently unable to use the published literature to identify the best tested approaches to be implemented now.” And it is important that we understand what (if anything?) improves quality of life about culture change because “culture change is growing in the absence of consistent evidence as to its efficacy.”
The meta analysis and the entire supplement have some very useful conceptual frameworks and methodological suggestions for improving the quality of research and conclusions in this area, but I wonder why—after almost 20 years of culture change and general dissatisfaction with the nursing home sector—there has been so little research that can guide us.
And then I was reminded of one of the Foundation’s little-known efforts on the issue. Back in 1999, just as the culture change movement was getting started, with partners at the Retirement Research Foundation and the Helen Bader Foundation contributing almost $1 million, we funded an effort to improve the work lives of direct care workers in Wisconsin (home health aides and certified nursing assistants) so as to improve the quality of care they could deliver to older adults. The University of Wisconsin’s Alzheimer’s Institute led the project and contributed another million in state funds to WETA (Worker Education Training, and Assistance Program).
The intervention combined specific caregiving skills training (e.g., dementia care) with broader life-skills training, a worker assistance fund (to help these low-wage workers weather challenges such as sudden auto repairs), supervisor training and mobilization as coaches for organizational culture change, and finally pay increases for program completion (later converted into one-time bonus payments). The project evaluation used a fairly robust pre-post design with a non-random comparison group and included assessment of employee job satisfaction, turnover, and resident satisfaction with care.
Unfortunately, despite the excellent project design and very skilled implementation of the project at the Wisconsin Alzheimer’s Institute, the intervention and evaluation was busted. Alterra, a major long-term care provider participating in the project, went bankrupt and abruptly terminated its participation.
In a resolutely positive final evaluation report, Mary Jane Koren, MD, then a program officer for The Commonwealth Fund, concluded:
“If one considers the WETA intervention narrowly one might say it failed—it has not succeeded in establishing itself as an ongoing, state sponsored program, participating AL [assisted living] facilities did not experience a precipitous drop in turnover rates and the outcomes for individual participants as compared to non-participants were not significantly different in the short term. It success however lies in the lessons learned, chief among which are that:
- The AL industry is essentially indifferent to staffing turnover and accepts the quality trade-offs high turnover rates engender. Turnover costs are passed along to consumers, there are no penalties for poor quality and no rewards for good quality. From the industry’s perspective there is no incentive to change … ”
Of course our effort was followed by the much larger-scale effort funded by the Robert Wood Johnson Foundation and The Atlantic Philanthropies, Better Jobs, Better Care, which also resulted in very mixed and disappointing results.
I’m not willing to give up, but it is clear that nursing home quality improvement is a very challenging issue and one where we urgently need to make progress.