# Presentation: 038298

## Culture TransformationNHCU Summit in San Antonio April 12-14, 2005

- Lisa Gibson, Gretchen Thorson, Becky Thompson

## Purpose

- Engage VA NHCU staff and leadership to significantly transform the culture of nursing home care to provide cost effective, competitive and compassionate world class care to our veterans; to solidify formation of VISN teams  to lead the VISN in the implementation and monitoring of culture transformation.

## Objectives

- Explain the difference between a traditional/medical model of nursing home care and a transformed culture that is resident centered and nurturing.
- Identify the benefits and expected outcomes for staff and residents of a transformed culture.
- Describe key components of a homelike nursing home environment.
- Identify barriers to transforming the nursing home culture and describe approaches to resolving the barrier.
- Develop a VISN team based action plan for nursing home culture transformation.

## Ask Yourself...

**Do you want to live where you work?**
**Are you planning to reside in a nursing home at the end of your life?**
**	****-According to a national study 70% of seriously ill older adults are unwilling to go into a long-term care facility and 30% state that they would rather die than go into one.**
**We have an obligation to give more connected care.**
**The nursing home should no longer be viewed as a clinical institution where residents are viewed as patients.**
**Our facility should operate as a home where everyone from the resident to the caregiver is viewed as making a rich contribution to the quality of life every day.**
**We need to be on the path to ensure that the beds we provide are beds that we would want to lie in.**

## Culture Change Transformation

- Physical
- 		-Bringing in plants, children, animals.
- 		-Assessing the physical aspects of the care center.
- Organizational
- 		-Creation of neighborhood teams.
- 		-Shift decision making to departments.
- 		-Holding staff accountable to each other.
- Personal
- 		-Foundation of a new home for patients and staff.
- 		-Patients and staff considering this their new home.

## Resident-Directed Culture

- A relationship-centered culture.
- Environment reflects the comforts of home.
- Sense of community and belonging.

## JCAHO Standard R1.2.140Ethics, Rights and Responsibility

- “Residents have a right to an environment that preserves dignity and contributes to a positive self image.”
- The environment’s essential components include the following:
- A home-like atmosphere.
- Sufficient space with access to personal living space.
- Appropriate communication about room and roommate assignments or changes.
- Environmental adaption to help those with dementia, cognitive impairment, or temporary confusion.
- Appropriate accommodations for married couples and clients with significant others regardless of sexual orientation, unless any limitations consistent with the organization’s mission and philosophy have been disclosed to the resident at the time of or before admission.

## From Traditional Care to Individualized Care

| Medical Model | Social Model |
| --- | --- |
| Staff provide “treatments” | Nurture the human spirit in addition to meeting medical needs |
| Residents follow facility routine | Facility follows residents’ routines |
| Staff float | Permanent assignments |
| Staff make decisions for residents | Residents make their own decisions |
| Facility belongs to staff | Facility is residents’ own home |
| Structured activities | Spontaneous activities 24 hours |
| Departmental focus | TEAM! |
| Staff know residents by diagnosis | Staff know residents as individuals |

## Key Components of a Resident-Directed Culture

- Gathering Space.
- Natural light.
- Line of sight.
- Varied artificial light.
- Experienced furniture.
- Pathways.
- Control of equipment.
- Natural smells.
- New technologies.
- Staff efficiencies.

- Natural sights.
- Natural sounds.
- Contact with nature.
- Contact between generations.
- Ritual celebrations.
- Group size/bonding.
- Residential materials/equipment.
- Abnormal noise.

## Environmental Transformation

- Personalization of the resident’s room.
- 	-Placing a recent picture of the resident on their door.
- 	-Hanging personal items of the resident on their door.
- 	-Placing a tack board in room to display pictures, photographs, cards, letters, and other mementos.
- 	-Painting the resident’s room with a variety of colors and textures.
- 	-Creating an “emphasis wall” decorated with wall hangings, art work, and residents’ personal items.
- 	-Valances above window treatments.
- 	-Light fixtures that direct light upward or downward.
- 	-Bedside lamps.

## Environmental Transformation

- Nurses Station
- 	-Invite interaction between staff and residents.
- 	-Open area.
- 	-Desks at wheelchair level to allow residents access to communicate with staff.

## Environmental Transformation

- Dining Experience
- 		-What do you remember from a good 	 	dining experience?
- 			-family
- 			-good conversation
- 			-great smells
- 			-nice atmosphere
- 		- Hunger follows pleasure.
- 			-Create a pleasurable dining environment.
- 			-Pleasurable dining involves the whole facility.
- 		- How often do you eat on a tray at home?

## Dining: From Medical to Community Model

**Normalize Eating**
- 	-Any therapeutic changes can be worked into the context of a “regular” diet through preferences.
- 	-For example: 6 different levels-modified mechanical, mechanical, regular, modified regular, pureed and finger foods..
- 	-Bibs are not dignified.  Avoid use of these, use of cloth napkins
- 	-Using more high calorie/high pro food items over supplements-whole milk, half and half , high calorie cookie, etc first; supplements as last resort.

## Community Model Dining

**Increase Accessibility to Food**
- 	-Real foods should be available 24 hours/day-snack carts or kitchenettes with snacks residents enjoy such as animal crackers, suckers, raisins, granola bars, crackers, popcorn, etc.
- 	-Include a bread machine and/or crock pot of soup in the veteran’s dining rooms/kitchenettes for the aroma/sensory stimulation and to serve at the beginning of meals.
- 	-Counter tops wheel chair accessible so residents could participate in cooking if they desire.
- 	-Having 2 breakfasts, an early am and a brunch time.
**Involve everyone at meal times, like home. **
- 	-All disciplines assist in serving the meal and feeding the residents, including, nursing, social work, rec therapy, etc.
- 	-Food eaten on place mate or  table cloth, with centerpiece.

## Community Model Dining

**Introduce choice**
- -Residents should be routinely  involved in determining what goes on the menu, planning special event menus and evaluating new menu items.
- -Offer buffet style meal services so a resident can have the choice of how much and what goes on their plate each meal.

## Buffet Meal Service Outcomes

- Thomas-Hood Veterans Center in Wilmore, KY
- State facility, 300 bed long term care facility, five resident units including one unit designed especially for resident who have dementia.
- Residents had very limited control over their dining experience, preset meal at a specified time with limited substitutions
- Changed to a Person-Centered Care Buffet Style meal service in October 2002
- Complaints became obsolete. If a resident isn’t pleased with a menu item or items, something else can be substituted immediately.
- Noticeable increase in weight gain/maintenance, less unintentional weight loss, 75% of population either gained or maintained
- Noticeable reduction in the food waste resulting in a reduction in food costs from FY 03 $749,081 to FY04 $409,143, 55% decrease

## Buffet Meal Service Outcomes

- A study in 1994 of VA Nursing Home residents found that 66% of the causes of poor consumption were modifiable; these causes related to the use of restrictive diets, poor dining environment, limited menu choices and prescription of maintenance diets instead of replenishment diets.  When the identified causes were modified, 50% of the residents gained an average 4.5kg over the 8 week intervention period.
- In 2000 a Canadian study  showed the effects of buffet meal style dining increasing consumption of underweight dementia residents by 370 calories/day.

## Buffet Meal Service Outcomes

- In Wichita, KS at Presbyterian Manor, housing 150 residents, implemented “The Way You Want to Live” program in 2001 featuring buffet dinning that changes daily. The buffet runs at each meal on a six-week cycle menu.
-  Less food waste and better consumption.
-  “Our commitment to our residents is to get them what they want within 24 hours”.

## The Neighborhood

- Neighborhoods contain 10-15 patients.
- Each neighborhood is self-sufficient with own staff members to assist residents.
- Exit doors on neighborhoods are hidden through decal pictures to deter wandering patients.
- Resident room doors may resemble the outside door of your home, with a mail holder, picture or personal item on door.
- Residents wake when they want to, eat when they want to and socialize with other neighbors.
- Pets live in the neighborhoods or staff bring pets in.
- Children are encouraged to visit neighborhoods and interact with the residents.

## The Neighborhood Continued

- Creates an environment that supports team interaction and relationship development.  Team leaders are front line caregivers.
- Creates an environment that enhances communication.  Neighborhoods meet weekly to discuss plans for the week.
- Creates a community that cares about and for one another.
- Creates relationships beyond tasks and department focus.
- Creates an environment that supports choices made by the team and elders.
- Creates an environment that respects each others unique qualities, contributions, and personalities.

## Study of the Neighborhood Model

**Falls decreased by 40%.**
**50% fewer residents were inactive.**
**150% increase in resident-to-resident social interaction.**
**Agitation levels/behavior problems in residents with dementia decreased by more than 40% and had a 20% increase in purposeful activity.**
**Turnover rate of Certified Nursing Assistants (CNAs) decreased by 12%.**
**Mortality rate dropped by 30% in 1997-1998, and continues to remain below the average mortality rate in New York.**
**Visits to the facility from relatives has skyrocketed.**
- Wachs, 2003. Fairport Baptist Home in New York, 1997-2002.

## The Eden Alternative

- Shows us how companion animals, the opportunity to give meaningful care to other living things, and the variety and spontaneity that mark an enlivened community care succeed where pills and therapy fail.
- Facility residents typically experience boredom, loneliness and helplessness.
- Researchers have been unable to find a medication to combat these three plagues experienced by our elderly who live in nursing homes.
- Eden Alternative is attempting to eradicate boredom, loneliness, and helplessness.
- Educate staff to look at their environment as habitats for human beings rather than for the frail and elderly.

## Eden Alternative Principles

**The three plagues of loneliness, helplessness and boredom account for the bulk of suffering among our elders.**
**An Elder-centered community commits to creating a Human Habitat where life revolves around close and continuing contact with plants, animals and children.  These are the relationships that provide the young and old alike with a pathway to a life worth living.**
**Loving companionship is the antidote to loneliness.  Elders deserve easy access to human and animal companionship.**
**An Elder-centered community creates opportunity to give as well as receive care.  Antidote to helplessness.**
**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.  Antidote to boredom.**

## Eden Alternative Principles

**Meaningless activity corrodes the human spirit.  The opportunity to do things that we find meaningful is essential to human health.**
**Medical treatment should be the servant of genuine human caring, never its master.**
**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 those closest to them.**
**Creating an Elder-centered community is a never-ending process.  Human growth must never be separated from human life.**
**Wise leadership is the lifeblood of any struggle against the three plagues.  There can be no substitute.**

## Creative Arts Program

- Goal is to humanize the care provided while offering creative channels for expression, stress reduction and enhancement of positive thought processes.
- Program includes: music appreciation, musical programs, creative movement, performances, art appreciation, hands-on art, creative discussion groups, storytelling, and poetry.
- Display art exhibitions in the nursing home, hospital, neighborhoods, and common areas.
- Receive many of their activity ideas from residents and staff.
- Assist neighborhoods to coordinate activities and complete.

## From Silos to Cooperative Interdisciplinary Teams

- Communicate a clear vision.
- Consistently model the behavior you desire for your team.
- Guide the development of the team.
- Support the team’s decisions.
- Plan and/or lead leadership activities and retreats.
- Educate, educate, educate.
- Stay the course; there is no turning back.
- Acknowledge that change IS challenging.

## Acknowledging the Barriers

- It will cost too much.
- We don’t have the staff.
- The residents won’t like it.
- The state/federal government will cite us for it.
- It sounds weird.
- I don’t have time to do anything “extra.”
- CNAs don’t have the skills to be team leaders.

## VA’s Top 10 Reasons We Can’t Change 

- Let the next shift do it.
- I’m working harder than everyone else.
- That’s not in my job description.
- I’m going to retire soon.
- Nobody told me what to do.
- I’m going on break.
- Has it been approved by the Union.
- The veteran won’t know the difference, he’s confused.
- We’ve tried it before; it didn’t work.

## VA’s Number One Reason Not to Change Is...

- It’s the VA way!!!

## Next Steps for FY05-2010

- Collaborative Model of change adopted.
- Establish a VISN 23 EC&R SL VA NHCU Team work group that will meet monthly by conference call.
- Presentation at VISN 23 EC&R SL Educational Summit, May 3-5, 2005.
- Each team member to share information with own facility EC&R staff regarding content of VHA VA NHCU Summit held April 12-14, 2005.
- VISN 23 team will assist local team members in establishing Facility VA NHCU Transformation Teams.
- 	a. Teams will include: Team Leader, Administrative Leader, Chaplin, Dietician, Food & Nutrition, Housekeeping/Facilities Management, LPN, Nurse Aid, PT/OT/KT therapist, Recreation Therapist, Provider, RN, Social Worker, and Union member.
- 			i. Plan to start with education of staff and leadership to
- 			   foster culture change.
- 			ii. Facility teams will develop veteran focus groups to
- 			    support and enhance the culture change.
- VISN 23 Team will request approval for a VISN 23 VA NHCU Culture Change Conference FY 2006.
- VISN 23 Team will present Success Stories at the VISN 23 EC&R SL FY 06 Educational Summit.
- The transformation of VA NHCU’s will be incorporated into the VISN 23 EC&R SL Strategic Plan and the VISN 23 Strategic Plan.
- To study the clinical outcomes of the NHCU culture change via the Evidence Based Practice Initiative.

## References

**Begin, S. 2004. Project puts new face on senior living, Crain’s Detroit Business. May 24, Vol. 20, Issue 21.**
**Brokaw, G. 2001. The Nuts and Bolts of Culture Change: The Journey of Fairport Baptist Homes. March.**
**Brown, W. 1994. Big Design Changes on Small Budgets. Nursing Homes Long Term Care Management, Vol. 43, Issue 7.**
**JCAHO. 2005-2006. Comprehensive Accreditation Manual for Long Term Care.**
**Nissenboim, S. 2001. Making a facility feel like home, Contemporary Longterm Care, Aug. Vol. 24, Issue 8.**
**Nursing Home Summit. 2005. Department of Veteran’s Affairs. San Antonio, TX April 12-15th.**
**Olson, J. 2001. Is this really a nursing home?, Contemporary Longterm Care, June, Vol. 24, Issue 6.**
**Thom, B. and Thom, J. 2005. The Eden Alternative [website] **_[www.edenalt.com](http://www.edenalt.com/)__._
**Wachs, B. 2003. Nursing homes around the state are looking to Fairport Baptist Homes as a model for what the future of elder care might be. Perinton-Fairport Post. June 26****th****.**

## References (continued)

**Shantenstein B, Ferland G. Absence of nutritional or clinical consequences of   decentralized bulk food portioning in elderly nursing home residents with dementia in     Montreal. J Am Diet Assoc 2000; 100: 1354-1360.**
**Abbasi AA, Rudman D. Undernutrition in the nursing home: Prevalence, consequences, causes and prevention. Nutr Rev 1994;52 113-122.**
**Remsburg RE, Luking A. Impact of a buffet-style dining program on weight and biochemical indicators of nutritional status in nursing home residents: a pilot study. J Am Diet Assoc 2001 Dec; Vol. 101 (12):1460-3.**
**Consumption Up, Plate-Waste Down; Wichita LTC Switches to Buffet. Food Service Director 11/15/2001, Vol 14, Issue 11, p 5.**
**Coker, M. Buffet Meal Service. Thomas-Hood Veterans Center.** _[www.research.uky.edu/aging/bestcarepractices/winners.html](http://www.research.uky.edu/aging/bestcarepractices/winners.html)_

## Audience Participation Required:Humming to Home on the Range

- Oh give me a home
- Where the residents can roam
- And the coffee and doughnuts are free
- The message is clear
- Everyday of the year
- Veterans are where they want to be
- Home, home sweet VA
- Where the veterans and staff all play
- It is seldom heard
- A discouraging word
- And the VA continues to pay...