Res mgt relation_chapt

CASP Core Course 2 Section 2.7

Integrating Gerontological
Principles with Management

2.7.1. The Management-Resident
Relationship

2.7

Creating, Certifying, and Connecting Innovative Leaders in Aging Services

Module 2.7.1
The Management-Resident Relationship

Table of Contents
The History of Long-Term Care’s Administrative Approach to “Resident Care”:
The Basis for Culture Change ....................................................................................................... 4
The Culture Change Movement.......................................................................................................... 6
• The Eden Alternative .............................................................................................................. 8
• The Green House Project ........................................................................................................ 16
• The Wellspring Model............................................................................................................. 19
• Other Culture Change Models or Paradigms ........................................................................... 21

CASP Core Course 2, Section 7
Creating, Certifying, and Connecting Innovative Leaders in Aging Services

CASP Core Course 2, Section 7 Module 2.7.1 – The Management-Resident Relationship

Editor’s Note
Successful management is essential to achieving and maintaining
quality in any business; and, in the field of aging services, The
Management-Resident Relationship is at the heart of successful
management. In Module 2.7.1, Kendall Brune presents a comprehensive
and inspiring analysis of how that relationship promotes quality in
residential facilities for the elderly. After summarizing the historical
transition from a medical model to a social model of care in nursing
homes and other long-term care facilities, Dr. Brune focuses his
discussion on resident-/person-centered care and the exciting concept of
culture change: “the national movement for the transformation of older
adult services, based on person-directed values and practices, where
the voices of elders and those working with them are considered and
respected.” Culture change, however, is much more than just an idea
couched in impressive-sounding words. In this module, you will be
introduced to a variety of models in which the theory has been applied to
the daily operations of aging services organizations, including:
• The Eden Alternative (the earliest and perhaps the best-known
culture change paradigm),
• The Green House Project,
• The Wellspring Model,
• Eldershire,
• Elder cohousing,
• The Pioneer Network,
• Evercare, and
• The Coming Home Program.
Dr. Brune describes the approaches these programs use to deliver
quality care and services, presenting numerous modalities for your
consideration. His listing of the central elements of the culture change
movement (as summarized by Calkins in 2002) and his contrast of
the characteristics of institution- vs. person-directed care, embody
precepts that you can apply to all of your organization’s residents/clients,
personnel, and operations.
Dr. Brune’s list of references gives you dozens of documents available
online for further reading, with still more offered in his selection of
Learning Resources. The Learning Resources also include an extensive
glossary of terms commonly used in the field of long-term care and

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Module 2.7.1 – The Management-Resident Relationship CASP Core Course 2, Section 7

aging services, as well as Dr. Brune’s own diagram of a dynamic
management-resident relationship for building sustainable senior-engaged
communities.

About the Author
Dr. Kendall Brune, President of Future Focus Community, LLC,
provides senior leadership and oversight for development, owned,
and leased properties. He is a senior housing expert and an executive
instructor to leaders in the field, and he assists healthcare developers and
providers in identifying market growth opportunities.
Dr. Brune has more than 25 years of experience in the healthcare
field and has been on the leading edge of culture change in the healthcare
delivery system for the elderly in the United States. His academic
credentials include his designation as a Fellow with the American College
of Healthcare Administrators, his doctorate in healthcare administration,
and his authorship of two practical healthcare books for the senior care
field. He currently serves as an adjunct professor of senior healthcare
administration for two universities, A.T. Still University and the
University of North Texas. Dr. Brune also serves ATSU as a member of
the medical school faculty board and a curriculum committee member
for Geriatric Health Management.
During his graduate work with Project Life and the Center for the
Study of Aging at the University of Missouri-Columbia, he participated
in the national culture change phenomenon of the Eden Alternative as a
researcher, administrator, and disciple, from its infancy through putting
it into practice in one of Missouri’s first affiliated facilities. To further
develop the Eden vision, his practical experience as a licensed long-
term care administrator has allowed him to deliver improvements and
culture change through all continuum of care levels, from independent
senior housing, through assisted care and skilled nursing facilities, to a
major hospital sub-acute care facility. He continues to serve as a mentor
and educator for the Eden Alternative program. He has applied these
philosophies of care in the development and operation of 19 long-term
care facilities; representing $150 million of construction management. All
of these facilities are still operating successfully today.
Dr. Brune obtained his undergraduate degree in healthcare
administration from the University of Missouri-Columbia, an

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M.B.A from William Woods University, and a Ph.D. in healthcare
administration from Kennedy Western University. He is currently
completing a Ph.D. in applied gerontology from the University of North
Texas in Denton.

Learning Objectives
• You will understand the driving forces changing the Resident/
Management Relationship.
• You will learn about “Culture Change.”
• You will learn about “Resident- or Person-Centered Care.”
• You will learn how to communicate “Quality Care” to your
customers:
o CMS directives for culture change;
o Medicare reporting mechanism.
• You will learn what wellness is all about.
• You will learn about creative programming to engage seniors.
• You will learn about community engagement.

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Overview
To discuss the relationship between residents and the management
team, we must first review the transition from a medical model to a
social model of care. Long-term care (LTC) management models were
developed for a very autocratic and hierarchical style of management
based in the 1960s. Those facilities were built on the model of hospitals
(after the Hill-Burton Act of 1946), where the major focus was on
healing, or palliation of, physical ailments and, in the case of residents
with dementia, mental impairment. Residents were—and, for the
most part still are—isolated from family, friends, and community,
often without any view of the outside world. Baby Boomers today will
not tolerate such an environment for their parents, or themselves. A
cultural revolution called “Resident-Centered Care” started to occur and
change the Resident/Management Relationship. “Culture change” is the
common name given to the national movement for the transformation
of older adult services, based on person-directed values and practices
where the voices of elders and those working with them are considered
and respected. In the management process, decision-making is pushed
down to the lowest level of front line staff. Administrators have become
“facilitators of process improvement” and community advocates for
senior consumerism. We are now exploring new ways to enhance revenue
streams that entail home care, private-duty nursing, outpatient therapy
services, spa and wellness clinics, fitness and pool centers for seniors,
and any other creative outreach program that engages seniors to return
continuously to a facility. This module will explore the history of culture
change and the process of creating a new “well-being and connectivity”
model for senior retirement communities.

The Resident-Management Relationship

The History of Long-Term Care’s Administrative Approach to “Resident Care”: The
Basis for Culture Change
The development of skilled and intermediate care nursing facilities
in the United States during the 1950s and 1960s served an honorable
purpose. Facilities of the pre-1990 era and, indeed, the vast majority
even today, serve the “medical” needs of those unfortunate individuals
who require skilled nursing care, i.e., medical care. The organizational

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structure of most facilities continues to be patterned after the hospital’s
hierarchical, departmentalized, top-down management scheme, similar
Abuse/Elder Abuse: Any knowing,
intentional or negligent act by a to most American corporations. In short, hospitals, nursing homes, and
caregiver or any other person retirement communities, have been designed to be efficient, standardized,
that causes harm or a serious risk
cost-driven, and regulation-compliant corporate institutions.
of harm to a vulnerable older
adult. Types of elder abuse may Although not all nursing homes prior to the mid-1990s were
include physical abuse–inflicting, or sterile cinder-block structures, they did almost invariably provide the
threatening to inflict, physical pain
or injury on a vulnerable elder, or
same internal atmosphere, where front-line staff and residents alike
depriving him or her of a basic followed very structured routines with little opportunity for personal or
need; emotional abuse–inflicting professional growth or self-expression. Residents were and, for the most
mental pain, anguish, or distress on
an elder person through verbal or part still are, isolated from family, friends, and community, often without
nonverbal acts; sexual abuse–non- any view of the outside world. Over half of nursing home residents
consensual sexual contact of any
spent much of their day in restraints, a practice which was condoned by
kind; exploitation–illegal taking,
misuse, or concealment of funds, regulators until the passage of the Nursing Home Reform Act as part of
property or assets of a vulnerable OBRA in 1987 (Calkins, 2002). Traditionally, there has been little regard
elder; neglect–refusal or failure
by those responsible to provide for residents’ privacy, and a high level of neglect for their emotional,
food, shelter, health care, or social, and spiritual needs. Many residents just shut down, which, for
protection for a vulnerable elder;
some, hastens their physical decline.
and abandonment–the desertion of
a vulnerable elder by anyone who For most of us studying applied gerontology, this is not news. It is
has assumed the responsibility for safe to say that the “great dread” of becoming a dependent senior was to
care or custody of that person. The
specificity of laws varies from state
be put in a nursing home, a sentiment shared by both residents and their
to state (see National Center on loved ones. In a PSB Online “NewsHour” report, Dentzer (2002) cited a
Elder Abuse at www.ncea.aoa.gov; poll taken by NewsHour, the Kaiser Foundation, and the Harvard School
retrieved on October 2, 2009).
of Public Health, which revealed that 1) almost half of all Americans
Resident: A person who lives in
a long-term care setting, such as thought people were worse off after going into nursing homes than before
a nursing home or assisted living they went in, 2) almost four in ten nursing home residents reported being
community.
dissatisfied with their care and, 3) one in four Americans reported that a
Nursing Home or Skilled Nursing
Facility (SNF): A residential care nursing home resident they knew had been badly treated or abused by the
setting that provides 24-hour-care staff. Furthermore, a Congressional report released just prior to Dentzer’s
(all day and night) to individuals
who are chronically ill or disabled.
article stated that state inspectors had cited nearly one in ten nursing
Individuals must be unable to care homes for instances of serious abuse (“Nursing Home Abuse News,”
for themselves in other settings or 2001).
need extensive medical and/or
skilled nursing care. As background information, in a 1999 National Nursing Home
Survey, the National Center for Health Statistics reported that there were
1.6 million nursing home residents (usually referred to as “patients”),
living in 18,000 nursing homes nationwide, with an 87% occupancy rate,
and an average current resident length of stay of 892 days (nearly 2½

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years!) (“Nursing Home Care,” 2008). A 1997 National Nursing Home
Survey reported that approximately 4.3 % of the US population age 65
or older were nursing home residents, about half of whom were age 85 or
older; and about 75% of these 65-and-over residents required assistance
in three of more activities of daily living (ADLs). Forty-two percent of all
nursing home residents were diagnosed with dementia (Gabrel, 2000).
According to Dr. Bill Thomas, founder of the Eden Alternative, “Any
adult in America who reaches the age of 65 has a 50% chance of spending
Activities of Daily Living (ADLs): time, significant time, in a nursing home. That’s a vast proportion of our
Daily functions such as getting
society. . . . The only other segment of our society that is more likely to
dressed, eating, taking a shower
or bath, going to the bathroom, be institutionalized are convicted criminals. . . . So here we have a society
getting into a bed or chair, or that used an institutional pattern for convicted violent felons and our
walking from place to place. The
amount of help a person needs with frail mothers and fathers. And that is a losing proposition in the 21st
ADLs is often used as a measure to century” (“Thou Shalt Honor . . . The Eden Alternative,” 2002, [n.p.]).
determine whether he or she meets
And it is certainly not an option for many of the emerging Baby Boomer
the requirements for long-term care
services in a nursing home as well as population, who will demand more and much better options for their
government-subsidized home- and LTC needs. Thomas predicts that the Boomer generation will completely
community-based services (also
see Instrumental Activities of Daily
wipe out the traditional, institution-type nursing home, or at least that is
Living). his goal!
With this historical and statistical background, it seems that a major
organizational reformation was brewing a perfect storm for change. Now
let’s begin to talk about how the resident and management relationship
process has changed in the continuum of senior care and housing.

The Culture Change Movement
A paradigm shift in resident care occurred in the form of the culture-
change movement in the LTC field (Brune, 1992; Brune, 1995). We
can see that the Baby Boomers are coming, and we’re all aware that the
sheer number of retirees will strain our limited staff, plant, financial, and
emotional resources in the near future. Boomers will bring with them
new technologies and more diverse expectations. We must meet these
expectations and use technology to understand future demands by means
of dynamic assessment of service desires.
In actuality, the distinction of being the earliest recent culture change
movement could be given to the Gray Panthers, organized in 1970 by
Maggie Kuhn. This liberal activist organization is still alive and well
today, advocating for a range of social and political causes, many relating

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to healthcare, and including ageism and the rights and interests of seniors
(“Gray Panthers: Issue Resolutions Summary,” 2009; “Gray Panthers,”
[n.d.]).
In the context of our discussion here, “culture change’” is the
term commonly used to describe the national movement for the
Culture Change: The common name
transformation of older adult services, based on person-directed values
given to the national movement for
the transformation of older adult and practices where the voices of elders and those working with them
services, based on person-directed are considered and respected. Core person-directed values are “choice,
values and practices, where the
voices of elders and those working
dignity, respect, self-determination, and purposeful living” (“What Is
with them are considered and Culture Change?,” 2008, [n.p.]). It is “an effort to radically transform
respected. Core person-directed the nation’s nursing homes by delivering resident-directed care and
values are choice, dignity, respect,
self-determination, and purposeful empowering staff ” (Rahman & Schnelle, 2008, p. 142). Although
living. Culture change transformation the first real impetus for nursing home reform came in 1991 with Bill
supports the creation of both long-
Thomas’ Eden Alternative model, the culture change movement is
and short-term living environments
as well as community-based generally thought to have begun in 1997, following the first meeting
settings where both older adults of the nursing home Pioneers (now known as the Pioneer Network),
and their caregivers are able to
express choice and practice self- during which the term “culture change” was coined. The University of
determination in meaningful ways Missouri-Columbia’s “Project Life” was responsible for the publication
at every level of daily life. Culture
of Thomas’s first book, The Eden Alternative, and I was fortunate enough
change transformation may require
changes in organization practices, to be working for Dr. Stan Ingman at UM-C’s Center for the Study of
physical environments, relationships Aging at the time of this project (1988-1992). The Eden Alternative
at all levels, and workforce models,
leading to better outcomes for
resident philosophy challenged administration to identify who residents
consumers and direct-care workers “had been” and how they could still add value to the greater community
without being costly for providers. in which they were engaged. Co-habitational communities like Heritage
Person-Directed Care/Person-
of Green Hills, located in Reading, Pennsylvania, focus on the holistic
Centered Care: An approach to
care that honors and respects the philosophy that each person has a personal path to wellness through
voices of individuals and those social, spiritual, physical, intellectual, emotional, and vocational activity
working closest with them. It involves
a continuing process of listening, (“Building Premiere Retirement Communities for Today’s Active
trying new approaches, seeing how Seniors,” 2007).
they work, and changing routines
With various health care providers developing their own branded
and organizational approaches in
an effort to individualize and de- versions of resident-centered care models, “culture change” has become
institutionalize the care environment a generic term, encompassing a host of LTC concepts and models,
(e.g., nursing home or assisted living
facility).
including the following:
1. Resident-centered care;
2. Resident-directed care;
3. Eden Alternative;
4. Green House Project;

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5. The Wellspring Model;
6. The Pioneer Movement;
7. Person-centered care;
8. Quality-Improvement Organizations;
9. Advancing Excellence campaign;
10. Culture of safety;
11. Best friends approach;
12. Validation therapy;
Geriatrician: A medical doctor with 13. Activity-focused care;
special training in the diagnosis, 14. Positive Interactions Program; and
treatment, and prevention of illness
and disabilities in older adults 15. Beyond the Green House Project Care Model (Nissenboim, 2004).
(see American Medical Directors Calkins (2002) sums up the culture change movement as
Association at www.amda.com;
1. Respecting the individual needs and desires of each person (even
retrieved on October 2, 2009).
The GREEN HOUSE® Model: A
people with dementia, including the right to control decisions
small, intentional (“purpose-built”) that are made about their lives;
community for a group of elders 2. Honoring the life patterns and accomplishments of every person
and staff. A Green House residence
is designed to be a home for six to within the setting, residents and staff alike (staff means, especially,
ten elders needing skilled nursing or nurse’s aides, traditionally the lowest in the organizational
assisted living care. The purpose of
hierarchy);
the Green House is to be a place
where elders can receive assistance 3. Supporting opportunities for continued growth;
and support with activities of daily 4. Enabling continued productive contributions to their community
living and clinical care, without the
assistance and care becoming the (including experiential sharing, i.e., legacy);
focus of their existence. 5. Encouraging meaningful connections with family and the
Provider: Typically a professional community (to combat feelings of loneliness and helplessness);
healthcare worker, agency, or
organization that delivers health
6. Fostering fun (to combat resident boredom and empowering
care or social services. Providers staff ); and
may be individuals (physicians, 7. Restructuring of staffing roles and relationships (team approach,
nurses, social workers, and others),
organizations (hospitals, nursing consistent assignment of staff, empowerment of front-line staff ).
homes, assisted living facilities, The ultimate goal is to achieve maximal quality of life, for both
or continuing care retirement
residents and staff.
communities), agencies (e.g., home
care and hospice), or businesses that To begin understanding current philosophies of resident/
sell healthcare services or assistive management relationships, we must review some present-day models of
equipment (e.g., colostomy care
supplies, wheelchairs, walkers, etc). resident care.

The Eden Alternative
The Eden Alternative (EA), proposed by geriatrician and nursing
home physician William Thomas in 1991, was the earliest of the culture

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change models. It also has been the most influential, successful, and
widely publicized; indeed it has become the model of models, and its
basic tenets are interwoven into almost all other proposed models of care.
It has led Dr. Thomas to conceive several offshoot or successor models,
including the Green House Project, the Eden at Home and the Eden at
Home Embracing Elderhood concepts, and Eldershire communities.
Dr. Thomas formulated the Eden Alternative concept while he was
the house physician for a nursing home in upstate New York, the name
Eden inspired by the Biblical garden that was created to help ease Adam’s
loneliness. Thomas noted that the majority of residents in his nursing
home suffered from what he called “the three plagues”—loneliness,
helplessness, and boredom—as described in the first of the ten Eden
Alternative Principles:
1. The three plagues of loneliness, helplessness, and boredom account
for the bulk of suffering among our Elders.
2. An Elder-centered community commits to creating a Human Habitat
where life revolves around close and continuing contact with plants,
animals, and children. It is these relationships that provide the young
and old alike with a pathway to a life worth living.
3. Loving companionship is the antidote to loneliness. Elders deserve
easy access to human and animal companionship.
4. An Elder-centered community creates opportunity to give as well as
receive care. This is the antidote to helplessness.
5. An Elder-centered community imbues daily life with variety and
spontaneity by creating an environment in which unexpected and
unpredictable interactions and happenings can take place. This is the
antidote to boredom.
6. Meaningless activity corrodes the human spirit. The opportunity to
do things that we find meaningful is essential to human health.
7. Medical treatment should be the servant of genuine human caring,
never its master.
8. An Elder-centered community honors its Elders by de-emphasizing
top-down bureaucratic authority, seeking instead to place the
maximum possible decision-making authority into the hands of the
Elders or into the hands of those closest to them.
9. Creating an Elder-centered community is a never-ending process.
Human growth must never be separated from human life.

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10. Wise leadership is the lifeblood of any struggle against the three
plagues. For it, there can be no substitute (Thomas, 2006; “Our 10
Principles,” 2009).
Any nursing facility can choose to adopt some or all of these
Principles; but, to be a bona fide (registered) EA facility, the nursing
home must agree to abide by all ten Principles, register with the EA
Registry, and participate in the ongoing Eden development process of
continual commitment and striving not only toward complete fulfillment
of the EA Principles but toward ever-improving resident quality of life
and transforming the institution into a warm Human Habitat. The
Eden Registry is maintained by the Eden Alternative, and both are
non-profit entities. The Registry is not an accreditation, monitoring,
regulatory, and punitive or organizationally controlling body. Rather,
it provides education and resources to help nursing facilities adopt the
Eden Principles and Practices (“Becoming Part of the Eden Registry,”
2009). EA-registered homes receive an Eden Tree plaque and Symbols
of Recognition (“The Eden Alternative: We Are Different,” 2009). Eden
also provides a multitude of training workshops and trainer certifications
(Brune, 1995). To date, Eden has trained over 15,000 Certified Eden
Certified Nursing Assistant (CNA): Associates, and the organization now claims over 300 registered homes,
A person trained and certified to in the United States, Canada, Europe, Japan, Australia, and New
assist individuals with non-clinical
tasks such as eating, walking, Zealand (“Certified Eden Associates,” 2009). EA is a small and simple
and personal care (see ADLs and organization, consisting of Dr. Bill Thomas; his wife Jude; the Eden
Personal Care). This person may
home office staff; 50 Eden Educators; 60 mentors and, of course, the
be called a “direct-care worker”
(DCW). In a hospital or nursing home 15,000 Eden associates (“The Eden Alternative: Improving the Lives of
the person may be called a nursing the Elders and Their Care Partners,” 2009).
assistant, a personal care assistant, or
an aide.
Direct-Care Staff/Direct-Care Combating the three plagues
Worker (DCW): An individual The major impetus of the EA movement was, and still is, the
working in a nursing home or
elimination of loneliness, helplessness, and boredom. In an Eden facility,
assisted living community who
provides “hands-on” help to the cure for loneliness is companionship: with other residents, with
residents with activities of daily front-line staff (empowered Certified Nurse Assistants, housekeepers,
living (see Certified Nursing
Assistant).
maintenance personnel, etc.), and with an abundance of plants and
animals. CNAs are not only cross-trained to work in small teams, and
empowered with front-line decision-making; they are required to attend
to residents’ emotional needs, they treat all residents with dignity and
importance, and they come to know residents on a highly interpersonal,
intimate level.
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Eden facilities are universally teeming with birds, especially parakeets,
finches, and canaries; dogs and cats; rabbits; sometimes fish and guinea
pigs; and an abundance of plants, inside and out. This is why some have
called EA the “Fur and Feathers” program. Residents are encouraged
to tend to, and even adopt, plants and animals. Pets, especially dogs,
sometimes even adopt residents. In fact, some canines have actually
learned to operate the elevators to visit their “favorite people” (Bruck,
1997).
Thomas’ plan to uplift residents’ spirits and combat loneliness
through contact with animals was implemented from the very start,
when he introduced EA in his own Chase Memorial Nursing Home in
upstate New York in 1991 and said, “We’ll bring in 100 birds, two dogs,
four cats, three rabbits and a flock of laying hens . . . Then we’ll plow
the lawn and start a large organic vegetable garden outside our residents’
windows.” And he did. One day, the birds arrived—all 100 of them! (“An
Eden Alternative: A Life Worth Living, 2003).
The benefits of animal-assisted therapy (AAT)—although Thomas
prefers to regard animal-resident interaction as a natural bonding process
rather than a therapy (Bruck, 1997)—are well-documented. Companion
animals have been shown to be effective in reducing loneliness in both pet
owners and in nursing home residents, as measured objectively, especially
for those residents who had a life history of emotional attachment to pets,
usually in early childhood. A significant effect on loneliness was noted
with as little as 30 minutes of pet contact per week (Banks & Banks,
2002; Banks et al., 2008; Barker, 1999). A reduction in incidence and
severity of depression is also likely to be associated with pet and plant
contact, as well as promotion of “social capital” in the form of social
contact and interaction (Wood et al., 2005). Some have cautioned that
the use of companion pets could result in zoonosis (atypical infections),
but only one report of such an incident surfaced during my literature
review, a case of atypical scabies in a nursing home with an active EA
program (Morley & Flaherty, 2002). Based on my personal knowledge of
the facility in question, I believe that other infection sources and practices
are a more probable cause. Animals in EA homes are generally observed
and tested by veterinarians, and the spread of disease is apparently not
a significant problem. Furthermore, state regulations do not prohibit
animal residence in nursing homes. Thirty-two states do not address the

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issue; those that do usually have restrictions on numbers and/or kinds of
animals allowed (“Quality of Life: Pets and Animal Therapy,” 2008). Pets
and companion animals are generally not allowed in kitchen and dining
areas during meal service times.
Children, from pre-schoolers to high-schoolers, are often a key feature
in Eden facilities, allowing residents to interact and share life experiences
and knowledge, including playing games, sharing stories, helping with
homework, and working together in the garden. I first started Eden and
childcare in an LTC facility in 1989 at the Continuous Care Retirement
Community in Columbia, Missouri. Resident feelings of helplessness
tended to be alleviated by helping children, caring for pets and plants,
and making decisions about their environment and their daily activities.
“A home that opens its doors to pets, children, and the community
has little room for boredom . . . . Life in an Eden home is spontaneous”
(“An Eden Alternative: Life Worth Living,” 2003, [n.p.]). Meals are
varied, often chosen by the residents; activities are varied; the range
of visitors is varied. Each resident’s room is decorated to his or her
individual tastes, and personal living spaces are thus varied. Front-line
staff tend to interact frequently with residents, combating both loneliness
and boredom. At the Levindale Hebrew Geriatric Center in Baltimore,
Maryland, which became a registered EA facility in 2000, a family
atmosphere was created by the formation of small groups of residents
and staff called “kibbutzim” (plural of “kibbutz”). Kibbutzim groups
Turnover: The average percentage met regularly to become better acquainted and discuss issues, including
of staff who stop working at a
what kinds of pets to bring into the family (“Eden Alternative and
care setting each year. Virtually all
healthcare organizations (hospitals, Neighborhood Model,” 2006).
nursing homes, assisted living
facilities, etc.) track and measure the
Measurable benefits of the Eden Alternative
number of staff who stop working
(turnover) and the length of stay Results of studies assessing the benefits of “Edenizing” or “going
of staff (retention) in the same or Eden” vary in amount of attributed benefit, but those measuring benefits
similar jobs. A high turnover rate
in a nursing home or assisted living objectively and over a suitable time frame consistently show positive
community means that the facility results. In 2003, Bill Thomas’ study of his own Chase Memorial Nursing
in question is constantly hiring and
Home showed a reduction in overall number of drug prescriptions,
training new caregivers.
infection rates, staff turnover, and the mortality rate. Studies of the Texas
EA Project involving several nursing homes charted significant decreases
in in-house pressure sores, anxiolytic and antidepressant medications, and
staff absenteeism. Perhaps the best indicator of success is that Eden homes

12


across the nation report waiting lists for their beds (“An Eden Alternative:
Life Worth Living,” 2003).
In addition to quality-of-care and quality-of-life resident concerns,
a constant challenge for many nursing homes is staff dissatisfaction,
in particular among CNAs, and, more specifically, high rates of staff
turnover and absenteeism. In the test Eden facilities in Texas, a 25%
reduction in staff turnover was documented, along with a one-third
drop in absenteeism (Kleinman, 2009). In Bethel Lutheran Nursing
Home, overall drug costs were down 50%, the mortality rate was
reduced by 15%, and the infection rate was cut in half; benefits for staff,
family members and visitors were equally dramatic (“Eden Alternative
Philosophy: Life Worth Living,” [n.d.]). Data from Southwest Texas
State University showed a 50% reduction in the incidence of decubitus
ulcers, a 60% decrease in difficult behavioral incidents among residents,
a 48% decline in staff absenteeism, and an 11% drop in employee
accidents (Willging, 2000). A study of residents’ emotional needs showed
positive results on the Minimum Data Set items relating to helplessness,
loneliness, and boredom; the UCLA Loneliness Scale; the Geriatric
Depression Scale; and the Lubben Social Network Scale (Parsons &
Bergman-Evans, 2004). Another study showed significant improvement
in family satisfaction, as measured by the Family Questionnaire, after
implementation of EA. The improved satisfaction scores reflected greater
communication and interaction among families, staff, and residents
(Rosher & Robinson, 2009).
Research by Coleman et al. (2002) showed no significant benefit of
EA in terms of cognition, functional status, survival, infection rate, or
cost of care, one year after its implementation. This was an earlier study,
however, and the one-year study period may have been insufficient to
demonstrate benefits. Rahman and Schnelle (2008) believe that the
culture-change movement is spreading in advance of a solid research base
to support its quality-of-life improvement claims. They propose specific
and more focused research questions that will bring to light the costs and
benefits of EA and other innovative models of care.
Rather critical findings come from a study prepared for the Canadian
Union of Public Employees (CUPE) Health Care Council by CUPE
Research (2000) as summarized below.

13


1. The Eden Alternative has been severely criticized by some elder
advocacy groups in the United States.
2. Measured benefits claimed by EA homes are based on a number of
small preliminary studies that lack rigor. There is no definitive study
that proves the benefits of EA (at least as of 2000, when the CUPE
study was released).
3. In the U.S., for-profit NHs may be promoting EA in an attempt to
counter widespread accounts of resident abuse and neglect. Critics
argue that no genuine improvements, such as increased staffing levels,
are being made to address the serious deficiencies in elder care.
4. While being promoted as inexpensive to implement and cost-effective
to maintain, elder advocacy groups counter that EA cannot be
implemented properly without additional money and staff. Limited
resources may be redirected towards the care of animals and plants.
5. In EA facilities, jobs in nursing, laundry, recreation, and food services
may be reduced or eliminated as aides’ jobs are expanded to include
some or all of these duties.
6. Most of workers’ complaints about EA center on the issue of
Centers for Medicare and Medicaid
Services (CMS): The entities
understaffing. Staffing numbers may not be increased in proportion
responsible for regulating and to the new workload, which includes caring for plants and animals
paying nursing homes, home health and coordinating residents’ activities with children.
agencies, and hospices for the
care of Medicare and Medicaid 7. The introduction of animals into the long term facility exacerbates
(in conjunction with the states) existing workload problems and has implications for health and
beneficiaries. With a budget of
safety. Plants and animals could be neglected as a result of insufficient
approximately $650 billion and
serving approximately 90 million staff.
beneficiaries, CMSs plays a key 8. Workers have expressed concerns about inadequate training.
role in the overall direction of the
healthcare system. 9. Workers can suffer from burnout if they are permanently assigned to
Consistent Assignment: Residents a group of severely challenged residents.
seeing and receiving care from the In spite of these concerns, issued from a public employee union’s
same caregivers (registered nurse,
licensed practical nurse, direct-care
perspective, EA and other culture-change models and proposals are
worker/certified nursing assistant) moving forward at an ever-increasing pace. One of the goals of the
during a typical work week. Advancing Excellence campaign was to encourage nursing homes to
Consistent Assignment may also be
called Primary Assignment. adopt consistent assignment—the practice of assigning nurse aides to
the same residents on a daily or nearly daily basis. With the endorsement
of the Centers for Medicare and Medicaid Services (CMS), one of the
founders of the campaign coalition, one-third of the nation’s nursing
homes (5,246 facilities) had registered as “official participating providers,”

14


as of June 1, 2007. Of these, 31% had committed to implementing
consistent assignment (Rahman & Schnelle, 2008).
National directives from CMS establish “person-centered” care as
one of the six aims of the Institute of Medicine. It can also be seen as a
defining aspect of the vision in the Quality Improvement Roadmap: the
right care for every person every time calls for care that reliably meets the
patient’s needs. To achieve this vision, care must be organized around the
person’s, not the provider’s, needs. Person-centered care can also result
in better self-care. This is particularly important in chronic conditions,
which constitute a substantial part of the burden of illness, and cost, in
the Medicare population. Thus, person-centered care is an important
element in the improvement of quality and efficiency for all senior care
providers (Leavitt, 2006).
A study published a year later by the Commonwealth Fund (Doty,
Koren, & Sturla, 2008) revealed similar nursing home adoption of
culture change principles and resident-centered care. The authors sent
questionnaires to a representative sample of 1,435 nursing homes
and, based on the responses, divided these facilities into three separate
categories: culture change adopters (31%), culture change strivers
(25%), and traditional nursing homes that had adopted culture change
principles very little or not at all (43%). Although the nursing homes in
general had been relatively successful at increasing resident involvement
in decision-making and, to a lesser extent, accommodating collaborative
and decentralized decision-making to empower direct-care workers, very
little organizational redesign or change in the physical environment had
occurred. Interestingly, the authors also found that “the more a nursing
home has adopted culture change principles, the greater the benefits that
accrue to it, in terms of staff retention, higher occupancy rates, better
competitive position, and improved operational costs” (Doty, Koren, &
Sturla, 2008, [n.p.]).

On the need for continual self-assessment and quality
improvement
As part of her master’s degree study while at Kansas State University,
Kiyota ([n.d.]) lived in an EA nursing home for one month, posing as a
wheelchair-bound resident, to determine how the physical environment
was transformed to create a human habitat, and who were the agents

15


of these changes. Eventually, the focus of her study narrowed to the
question of where residents and staff found meaningful experiences
in the nursing home. Residents and staff members were asked to take
photographs of their favorite places in the facility. Interestingly, there
were categorical differences between residents and staff in what was
perceived as meaningful. Staff tended to value areas which had Eden
value and were especially appreciated by family and other visitors, such
as the home-like ambience of the facility’s front entrance, a bright and
airy and plant-bedecked reception desk with a small water-fountain, the
courtyard where children went outside to play, and the aviary in the living
room. Residents, on the other hand, chose the areas they used the most
and to which they were emotionally attached, such as their self-decorated
rooms or a specific area in the room (e.g., a family picture display, a dog’s
bed, a parakeet cage, plants, a television, and an angel that was a gift from
a middle school student), the physical therapy room where the staff were
particularly friendly, the quiet and serene chapel, or the candy shop where
visitors came to chat. Kiyota concluded—and I completely agree—that
the physical environment should be comfortable and restful, appealing
and inviting, homey and well-used, and should have emotional value for
staff, visitors, and residents alike. But, if the facility is to be truly resident-
centered, emphasis must be placed on those areas in the facility which
the residents identify as meaningful to them. LTC facilities must be
continually and fervently self-assessing and searching for ways to improve
residents’ quality of care and quality of life.

The Green House Project
The concept
In spite of the recent success of the culture change movement and EA
in particular, Thomas still regarded nursing homes as too institutional.
Despite the growing prevalence of resident-centered care practices,
nursing homes were still too impersonal and medically-focused, and their
physical layouts too large and spread-out, too cold and sterile, and too
resident-unfriendly, with their long corridors and semi-private rooms.
Thomas believed that significant, permanent LTC reform required a
radical redesign of nursing homes architecture and organization.
Thomas’ conception of the ultimate, yet doable, nursing home was a
typical outwardly-appearing house, in a typical residential neighborhood,

16


each house to be occupied by six to ten residents who would otherwise
be occupants of a typical traditional nursing home. Thomas coined the
name “Green Houses” (GHs) for these concept homes, signifying life and
continued growth. A traditional nursing home with perhaps a hundred or
more residents would now consist of a group of Green Houses, in varying
proximity to one another but always noncontiguous, linked together
by organizational management, technology, and communication. The
internal layout would be that of a warm, welcoming residential dwelling
that would foster both intimacy and privacy, care and autonomy, respect
and self-respect.

Physical and organizational design of GHs
Because GHs would be built (or perhaps sometimes remodeled)
from scratch, a similar architectural design would be employed for each.
Resident rooms are situated around the periphery of the house, with
each room opening directly into a central activity area or common space,
consisting of a large dining and activity area, kitchen, and central hearth.
Thus, the distance from a resident’s room to any other area in the house,
especially the central hearth area, the focal point of the home’s interior, is
short and readily negotiable by walking, walker, or wheelchair. This is in
marked contrast to the long corridors of the traditional NH.
There is one long dining room table, large enough for all residents,
two caregivers, and visitors all to sit together for dining or activities. Soft
music is piped in, and flowers are on the table. Each meal is intended to
be a pleasant, enjoyable, engaging social event called a convivium (“The
Caregiver: A spouse, family
member, partner, friend, or neighbor Green House Concept,” 2008). Each resident has his or her own private
who helps care for an elder or room with private bath, and residents are encouraged to furnish their
person with a disability who needs
assistance. Caregivers can also rooms as they please, including their own furniture from home. There
be people employed by the older is a sense of personal belonging. Outside entrance keys are given only to
adult, a family member, agencies, or
residents and caregivers; visitors and other organizational staff, including
care settings to provide assistance
with activities of daily living (ADLs; managers and nurses, must ring the doorbell to gain entrance.
see above) and instrumental
activities of daily living (IADLs) (see
Shahbazim
below).
Similar to EA facilities (GHs are an offshoot or refinement of EA
homes), in GHs Certified Nursing Assistants (CNAs), or nurse aides,
assume responsibility for nearly all the residents’ needs. However, in a
GH, the CNA’s responsibilities are broadened to include housekeeping

17


chores, meal preparation, and managing logistics. In fact, these do-it-
all caregivers are the only staff present in a GH except for emergencies,
and nurse, physician, or therapist visits (“Green House Project,” 2004).
Once lowest on the organizational ladder and now, in many respects,
the highest, these omnipresent workers are referred to by Thomas as
Shahbazim (plural of Shahbaz), a Persian term meaning “royal falcon.”
With an underlying belief that human life is sustained by affection,
Shahbazim are trained and required to befriend and sustain the elders
with whom they work, through the practice of convivium (pleasant
dining), homemaking, and befriending (Shapiro, 2005).
Shahbazim who are not CNAs upon hire must undergo training and
become state-certified. All GH Shahbazim receive 120 hours of training.
The first 40 hours are administered by GH staff and focus on GH
philosophy, policies and procedures, team-building and empowerment,
and dementia care. The remaining 80 hours consist of classes on CPR,
culinary skills, food safety, and home repair (“Green House Project,”
2004).

An elder country club
Plants, animals, and children are part of GH design. All GHs have a
screened-in porch and outdoor garden area. A nursing station is required
by some state statutes, but these are neatly tucked away out of sight,
usually in a utility or staff break room. Residents choose their activities,
mealtimes, and degree of participation in household tasks, with no strict
schedules (Rabig et al., 2006). A GH in Lincoln, Nebraska, even offers
happy hour two afternoons a week, where residents can purchase an
alcoholic beverage, country-club-style (“Green House” Communities
Reinvent Elder Care,” 2008).

Warm, smart, and green
The idea of creating GHs that are warm, smart and green is, again,
that of Bill Thomas.
Warm: Thomas envisioned the houses as radiating warmth, created
by the floor plan, the décor, the furnishings, and the people within them.
The goal is to create and maintain human warmth.

18


Smart: The use of cost-effective and smart technology such as
computers, wireless pagers, electronic lifts, and adaptive devices cultivates
a sense of resident personal belonging, meaning, and purpose in life.
Green: Sunlight, plants, and access to outdoor spaces create
connections with the living world and its living gifts of life, laughter, and
companionship (Thomas, 2006; “The Green House Concept,” 2008).

Green House development and growth
The first GH, which opened in 2003, was actually a complex of four
GHs, on the campus of United Methodist Senior Services in Tupelo,
Mississippi (Woodrick, 2003), soon followed by six more homes in
Tupelo. With the much publicized success of the Tupelo project, and a
$10 million grant from the Robert Wood Johnson Foundation, many
more have been built and put into use around the country. On December
5, 2008, on target with its Green House Replication Project, the fiftieth
GH opened in the United States, one year earlier than anticipated (“The
Green House Replication Initiative,” 2008; “Green Houses Growing in
Numbers Across the States,” 2008). The homes are built by NCB Capital
Impact Development Corporation, under the direction of Bill Thomas
and the Green House Project Team (The Center for Growing and
Skilled Care/Nursing Care: A Becoming). The 2006 published goal was to have, within five years, at
level of care that includes help least one GH in every state (“Green Houses Growing in Numbers Across
with more complex nursing tasks,
such as monitoring medications, the States,” 2008).
giving injections, caring for wounds, “The Green House” is a trademarked model. Any nursing care facility
and providing nourishment by
bearing that label must meet certain standards for construction, living
tube feeding (enteral feeding).
It also includes therapies, such as arrangements, care, and other features” (DeBolt, 2008, [n.p.]). Because
occupational, speech, respiratory GHs are licensed as nursing homes or skilled nursing facilities and meet
and physical therapy. This care
can be given in a patient’s home
all federal regulations, they qualify for Medicaid reimbursement and can
or in a care setting. Most insurance largely operate within Medicaid payments, with the exception of a few
plans require at least some level of states where Medicaid reimbursement is much below average (Jenkens,
need for skilled care, requiring the
services of a licensed professional [n.d.]).
(such as a physician, nurse, or
therapist), before they will cover The Wellspring Model
other home-care services.
In keeping with the overall theme of the culture change movement,
and with many of the principles and practices of the Eden Alternative
and the Green House project, the Wellspring Model’s major emphasis
is on quality improvement through both improved clinical care and

19


organizational culture change. The Wellspring model is a product of
Wellspring Innovative Solutions, Inc., arising out of an alliance of 11
freestanding, nonprofit nursing homes in eastern Wisconsin (Stone et al.,
2002). The organization was formed in 1994 and fully implemented in
1998. Within its 11 otherwise independent nursing homes, it espoused
six core elements: (Reinhard & Stone, 2001):
• An alliance of nursing homes with top management committed to
making quality of resident care a top priority;
• Shared services of a geriatric nurse practitioner, who develops training
materials and teaches staff at each nursing home how to apply
nationally recognized clinical guidelines;
• Interdisciplinary “care resource teams” that receive training in a
specific area of care and are responsible for teaching other staff at their
respective facilities;
• Involvement of all departments within the facility and networking
among staff across facilities to share what works and what does not
work on a practical level;
• Empowerment of all nursing home staff to make decisions
that positively affect the quality of resident care and the work
environment; and
• Continuous reviews by CEOs and all staff of performance data on
resident outcomes and environmental factors relative to other nursing
homes in the Wellspring alliance.
Nurse Practitioner (NP): A The best known study of outcomes, assessing the 11 Wisconsin
Registered Nurse with advanced
education and training. NPs can pilot facilities only, seems to be the report by Stone et al., with support
diagnose and manage most provided by the Commonwealth Fund (Stone et al., 2002; “Improving
common, and many chronic, illnesses.
the Quality of Nursing Home Care: The Wellspring Model,” 2004).
They do so alone or in collaboration
with the healthcare team. NPs can Results were generally positive:
prescribe medications and provide • Retention rate for Wellspring staff increased slightly.
some services that were formerly
permitted only to doctors. There
• Wellspring facilities performed better on annual state inspections.
are a number of types of nurse The number of nursing homes with severe deficiencies fell from 22%
practitioners (geriatric, adult, to 0.
psychiatric-mental health) who work
with older adults. • Evidence suggests that Wellspring staff are more vigilant in assessing
problems in quality and take a more proactive approach to resident
care.
• Wellspring residents appear to enjoy a better quality of life.

20


• Implementation was essentially cost neutral. Costs were generally
neither more nor less.
In the words of Roman emperor/philosopher Marcus Aurelius, “Dig
within. Within is the wellspring of Good; and it is always ready to bubble
up, if you just dig” (“Wellspring Definition,” 2009, [n.p.]).

Other Culture Change Models or Paradigms
Multiple other culture change proposals and programs have also
surfaced. A few of them are briefly described below.

Eldershire
The Eldershire Community is also a product of Dr. Bill and Jude
Thomas’ imagination and dedication to expanding and enhancing the
quality of life of elders and their families and caretakers. It is a planned
intergenerational community, designed to promote an active and ongoing
exchange among the generations. An Eldershire Community contributes
to bettering the quality of life by strengthening and improving the
means by which 1) the community protects, sustains, and nurtures its
elders, and 2) the elders contribute to the well-being and foresight of the
community (“Basic Tenets of the Eldershire Vision,” 2008). An Eldershire
is a community where residents work together to effect the realization of
well-being, the elements of which include identity, autonomy, security,
connectedness, meaning, joy, and space (“Basic Tenets of the Eldershire
Vision,” 2008). Eldershire residents are empowered to collaborate in the
design and ongoing development and management of their communities.
Private homes are “grouped together with common indoor and outdoor
spaces, including walking spaces, gardens, and a central house that
will offer shared meals, meeting spaces, recreational activities and basic
services.” Communities will have “shared values, including respect for the
contributions made by elders, accessible housing design, economic and
environmental sustainability, commitment to life-long learning, and self-
governance” (“Dr. Bill Thomas to Speak at Vital Aging Network Forum
on February 14,” 2006, [n.p.]).

Elder cohousing
A multitude of cohousing units have sprung up across the country.
These are planned communities that are nearly identical to Eldershires,

21


in that they offer six common characteristics: participatory process,
design for community, shared common facilities, resident management,
collaborative decision-making, and no shared community economy
(i.e., not income-sharing) (Abraham & deLaGrange, 2006). Unlike
Eldershire Communities, they tend to enlist elders only, although they
may be situated adjacent to multi-generational communities; and they
tend to focus more heavily on shared values, such as spiritual growth
and sharing, a holistic view of aging, and meta-issues such as illness
and dying. Unlike Eldershires, they tend perhaps to offer a little more
planned uniformity and less diversity. But their practical assets are nearly
identical to Eldershires, emphasizing resident empowerment, mutual
respect, shared values, active lifestyle, social integration, some centralized
or shared services, economic and environmental sustainability, and
general social consciousness. Depending on the culture of the community
and the choice of shared values, these Elder cohousing communities
would seem immensely appealing to many of this country’s emerging
boomers (“Building Premiere Retirement Communities for Today’s Active
Seniors,” 2007).
The first cohousing communities in this country were organized in
the late 1980s, patterned after the Scandinavian model. They have also
Continuing Care Retirement been a presence in Denmark since the late 1980s. As of about 2006,
Community (CCRC): A housing
there were roughly 5,000 people living in 80 cohousing communities
option that offers a range of
services and levels of care. across the United States. As elder cohousing communities are deliberately
Residents may first move into an small in size, rarely exceeding 40 households per neighborhood, their
independent living unit, a private
apartment, or a house on the residents have the opportunity to know one another well and develop
CCRC campus. The CCRC provides closer relationships. In contrast, some retirement communities may
social and housing-related services
contain as many as 500 to 10,000 households. Many other pre-planned
and may have an assisted living
residence and a nursing home, often communities, such as continuing care retirement communities (CCRCs)
called the healthcare center, on the do not allow residents the opportunity to participate in the community-
campus. If and when residents can
no longer live independently in their
envisioning process, where they develop deeper connections with other
apartment or house, they move into residents and the community as a whole (“Elder Co-Housing: Building a
assisted living (unless it is provided Collaborative Elderhood,” 2006).
in their apartment or house) or the
nursing home.
The Pioneer Network
The Pioneer Network began in 1997, when a group of 33 LTC
professionals met in Rochester, New York, to discuss novel approaches to
LTC that, whether knowingly or not, would parallel the principles of the

22


culture change movement. Susan Misiorski (2003), the Network’s CEO,
Assisted Living/Personal Care
envisions a culture of aging that is life-affirming, satisfying, humane,
Homes/Residential Care Facilities: and meaningful in whatever setting Elders live—home, assisted living,
A state-regulated and -monitored
or nursing home. The Pioneer Network is committed to working with
residential long-term care option
that may have different names, state culture change coalitions that currently exist in 33 states, to help
depending on the state. Assisted create home and community and advocate for change (Lieblich, 2008). It
living provides or coordinates
oversight and services to meet seeks “a transformation of the entire culture of aging through education,
residents’ individualized, scheduled advocacy, leadership development, and resource support” (Nissenboim,
needs, based on the residents’
assessment and service plans, 2004, [n.p.]). The Pioneer Network advocates for elders across the
and their unscheduled needs as spectrum of living options (which are often dictated by differing levels
they arise. There are more than
of medical care required); and is working towards a culture of aging
26 designations that states use to
refer to what is commonly known as that supports the care of elders in settings where individual voices are
“assisted living.” There is no single heard and individual choices are respected, whether in nursing homes,
uniform definition of assisted living,
and there are no federal regulations transitional care settings, or wherever home and community may be.
for assisted living. In many states, Cultivating and maintaining a community of relationships are important
most assisted living is private pay.
Be sure to check with your state at every phase of life, but are especially critical for elders and the aging,
about any waiver programs that many of whom may need a network of partners to live life to its fullest.
may be available through Medicaid
to pay for the care provided in
The Pioneer Network provides a global perspective for LTC facilities
assisted living. to be the senior advocate beyond their four walls (“Pioneer Network:
Independent Living: A residential Culture Change in medicaid,” 2009).
location (including rental-assisted or
market-rate apartments or cottages)
that may or may not provide Continuing care retirement communities
hospitality or supportive services. Also sometimes called life care communities, CCRCs tend to be
Residents can choose which services
they want. Additional fees may be large complexes that provide resident housing over a range of care-
charged for some services. dependency, from independent living units, to assisted living units,
Long-Term Care (LTC): A term
to nursing home accommodations. Independent living units may be
used to describe the care needed
by someone who must depend on small or large apartments, cottages, cluster homes, or single-family
others for help with daily needs. dwellings. Assisted living quarters are usually small studio or one-
LTC is designed to help people with
chronic health problems or dementia bedroom apartments. Nursing home accommodations historically have
to live as independently as possible. been one-room units for two or more persons. As these facilities are all
Although many people think that
long-term care is provided only in a on the same grounds, all residents are nearby and can be transferred up
nursing home, in fact most long-term or down the range of required services as needed, much like aging in
care is given by family caregivers in
the elder’s home.
place. For this reason, CCRCs have been popular with some, although
they tend to be expensive, with entrance fees ranging up to as much as
$400,000 and monthly payments ranging from $200 to $2,500. Some
are affiliated with a specific ethnic, religious, or fraternal order, where
membership may be a requirement for admission (“Other Options:

23


CCRCs,” 2004). Furthermore, these communities do not lend themselves
easily to culture change transformation, with its emphasis on small size,
resident empowerment and privacy, and organizational reform. The
continued and rapid growth of the various culture change models will
force these more traditional and outmoded multifaceted communities to
either rebuild or remodel, or become extinct. As admission to a CCRC
is usually a one-time event, all three levels of care must eventually adopt
resident-centered care principles and practices, including perhaps elder
Medicaid: The federally- and state-
supported, state-operated public cohousing communities and Green House construction and practice
assistance program that pays for implementation.
healthcare services to low-income
people, including older adults or
disabled persons who qualify. The Evercare care model
Medicaid pays for long-term nursing Evercare is included here because it is a rather innovative approach
home care and some limited home
health services, and it may pay to helping elderly persons or those with chronic or debilitating illnesses,
for some assisted living services, and because it usually involves and is focused on the elderly. Organized
depending on the state. It is the
by two Minnesota nurse practitioners over 20 years ago, Evercare is an
largest public payer of long-term
care services, especially nursing agency that assigns a nurse practitioner to every Evercare member, to
home care. Each state can determine assist that member in negotiating the healthcare system. Evercare nurses
the breadth and extent of what
services it will cover above a certain
help coordinate care by collaborating with physicians, nursing homes,
federally required minimum. and families. They are trained to deliver personalized and compassionate
Medicare: The federal program care, both to persons in nursing homes and to individuals living
that provides medical insurance for
independently at home. They serve hundreds of thousands of people in
people aged 65 and older, some
disabled persons, and persons with 38 states through Medicare and Medicaid health plans (“Evercare: About
end-stage renal disease. It provides Us,” 2008).
physician, hospital, and medical
benefits for individuals over age 65,
or those meeting specific disability Coming Home Program
standards. Benefits for nursing home “The Coming Home Program is designed to bring the benefits of
and home health services are limited
to short-term rehabilitative care. assisted living to low-income, frail seniors living in rural areas” (“Coming
Different parts of Medicare cover Home Program,” 2008, [n.p.]). Assisted living facilities may be scarce or
specific services if you meet certain
absent in sparsely populated areas of the country, and many charge $100
conditions. For detailed information,
visit the website (www.medicare. or more per day, which is out of the price range of many rural seniors.
gov; retrieved on October 1, As a result, many of these seniors must either relocate some distance to a
2009) or call 1-800-Medicare for
assistance.
place where assisted living services are available, or be prematurely placed
in nursing homes. The Coming Home Program seeks to rectify this
situation by providing technical assistance and grants to both providers
and states.

24


Summary
The culture change movement is growing, perhaps slowly, since
traditional LTC is a “mom and pop” family business. But the movement
will grow faster now that CMS has trained federal and state surveyors in
“Resident-Centered Care” evaluation, eliminating opposition and more
than a few barriers. The greatest remaining barrier appears to be fear
of change and of potential costs involved. But implementation can be
phased in, even as a preface to the seemingly drastic structural rebuilding
in the form of Green Houses, Pioneer Network Affiliated Partners, and
co-habitational communities.
It is fortunate for our generation of LTC professionals that culture
change movements are challenging, tearing apart, and rebuilding the
traditional nursing homes built in the 1950s and 1960s. With CMS
behind our movement, the time seems right for these facilities to
undergo a culture change reformation. From what has been discussed
here, it would seem imprudent to rebuild one outdated facility in the
place of another. It would seem much wiser to build several smaller,
more resident-accessible homes, with private rooms and a residential
appearance and atmosphere. However, facilities located at Anywhere,
USA may not have the funding to rebuild new, “culturally dynamic”
physical plants. The Pioneer Network has an excellent approach to
changing a facility’s resident and staff relationships through a process of
systematic change. The Network’s high-level review outlined below can be
used to create a baseline plan for change.

Institution-Directed Culture
• Staff provide standardized “treatments” based upon medical diagnosis.
• Schedules and routines are designed by the institution and staff, and
elders must comply.
• Work is task-oriented and staff rotate assignments.
• As long as staff know how to perform a task, they can perform it on
“any patient” in the home.
• Decision making is centralized.
• There is a hospital environment.
• Structured activities are available when the activity director is on duty.
• There is a sense of isolation and loneliness.

25

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