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The Nursing Home of the Future: Are You Ready?

June 1, 2002
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An expert outlines essential ingredients for resident-centered care By Margaret P. Calkins, PhD
The Nursing Home of the Future:
Are You Ready?
Tomorrow's resident care will take more than "quality-of-life" lip service By Margaret P. Calkins, PhD The largest movements usually start on a very small scale. A few people see a better way of doing something or begin to question the basic assumptions we all take for granted. They begin to experiment, to try new approaches, and then take their message to others. A few more will hear the call and join the movement, and it will begin to gain momentum. Eventually, if it is successful, it will cause a sea change in thinking, so that we will wonder how we ever accepted the old ways of thinking and doing. A classic example is restraint reduction. (see "The Restraint-Reduction Movement," p. 47). It's happening again-and there's nothing we can do to stop it. It will radically affect how nursing homes, and to some extent assisted living facilities, operate. It goes by many names-resident-centered care, culture change, Eden Alternative, re- engineering (to borrow a business term) or resident-directed care. While each of these labels might have a slightly different definition (and these definitions can vary from person to person), the movement reflects a fundamentally different way of structuring care settings.

Traditionally, nursing homes have been organized around the efficient provision of physical care to frail and impaired individuals. In the future, the focus won't be on the provision of care services (which is an "input" to the system) but on the quality of life of the residents (which is the ultimate "output" or outcome goal).
"Quality of life" is a thorny concept because it is so hard to define. But let's assume for the moment that quality of life relates to choice and control, positive and meaningful interactions, and quality medical care. Regulations and the survey process have already started moving in this direction (for once leading the pack instead of being behind the curve), so many facilities that receive good surveys think they are already doing this. In reality, however, they are barely scratching the surface. They are paying lip service to the concepts, changing their marketing language, describing former "units" now as "households" or "neighborhoods" without having made any structural or operational changes. Or they give the physical environment a face-lift-putting an extra set of fire doors between hallways to create "households," using updated colors and patterns, adding a few chintz throw pillows and carpeting-and assume this is a sufficient guarantee of quality of life.

It isn't.
What is? Different individuals might identify various goals, but the following list is generally accepted as being part of this movement: 1. Respecting the individualized needs and desires of each person (yes, even people with dementia!). While residents have had individualized care plans for many years, systems of care are often set up to maximize efficiency, not to address the unique needs and desires of each resident. Take, for example, residents' rising times and bathing schedules.

Traditionally, all meals in nursing homes have been offered at set times, and all residents have been expected to eat their meals at those times. Now, however, many facilities are beginning to recognize that they can allow residents more flexibility in when they wake up. If offered a late night snack, a continental breakfast for the early and late risers, and a hot meal at a specified time, residents can choose whether to get up for the hot meal or sleep in and eat a Danish or cereal. Initially, staff were worried that this would mean extra work for them. In reality, staff at most facilities find it easier not to have to get everyone up for breakfast at a specified time.

In terms of bathing, in most facilities every resident is bathed/showered a set number of times per week (once or twice). If the resident is lucky, it is his/her preference that determines whether it is a bath or a shower, and possibly even determines what time the bath/shower is given. But how many facilities bother to ask the residents' preferences related to frequency of bathing or showering-and follow through with those preferences? I can hear staff saying, "But if you gave all residents complete choice, some would say they never want to have another bath or shower!" That might be true. You might need to set some limits, such as getting cleaned (notice I didn't say having a bath or shower) at least once every other week. But by negotiating with the residents, showing that you are trying to individualize the care to their needs, you are likely to find them responding positively and accepting when compromises are necessary. Embedded in this goal is the concept that people, including frail and impaired residents of nursing homes, have the right to control decisions that are made about their lives. While this might seem self-evident, it is often glossed over and not respected in fundamental ways. The number of rules residents are expected to follow without being given much of a choice is substantial. Sometimes it will be difficult or costly to effect changes to give residents the level of autonomy they deserve. At other times, it might be less a matter of money than of working with staff to change the way they do things.

When all bedrooms are shared (I prefer not to use the term "semiprivate," as I find nothing even partially private about sharing a room with someone separated by only a piece of fabric), residents have little opportunity to control their space or ever have privacy. This is one reason so many new construction projects have virtually all private rooms. It gives people the choice as to whether to be alone in their rooms or with others in the shared areas.