Culture Change Now! is Action Pact's periodical for long term care professionals interested in Culture Change. It is filled with how-to information and articles of inspiration. All levels of staff and families will will enjoy the only publication solely dedicated to culture change!

During the 1980s and early 90s while most nursing homes became more institutionalized, impersonalized and hospital oriented, a handful of pioneers sat out to reclaim "home" for America's warehoused elders.

Their methods were similar to those successful in the 1980s in transforming the culture of U.S. industry. Back then, quality and customer satisfaction took a back seat in the drive for quantity, creating a crisis for American manufacturers with Japan emerging as a dominant leader in the global marketplace.

But out of crisis came opportunity. Following teachings by the likes of W. Edwards Deming and Malcolm Baldrige, U.S. companies like Ford and Motorola established themselves as leaders in the world market by improving quality through teamwork, leadership development, pride in workmanship and inclusion of all employees in problem solving.

Today, nursing homes face a similar crisis with a medical model of care that overshadows quality of life. But again opportunity lies just beyond the darkness. By learning from early culture change pioneers in long-term care, we can begin finding our way home.

Pioneer Stories: Building Community at Live Oak

While visiting his grandmother in a nursing home in the 1960's, Barry Barkan saw residents plagued by isolation, disconnection and lack of meaning.

"It became clear to me that community was the only sensible antidote," he says.

In 1977, he and a consulting partner introduced a model called the "Regenerative Community" at the Home for Jewish Parents in Oakland, CA. The model drew from community drug-rehab programs, a mental health plan Barkan had designed for depressed pipeline workers in Alaska, and consciousness raising techniques used by the Civil Rights and Women's Movements.

At the nursing home, they held daily group meetings with residents and together wrote poetry, sang, discussed current events, welcomed new residents and staff, planned events and held memorials for those who died. With some 50 residents regularly attending the meetings, the paradigm shifted as the environment began to center around the residents.

In 1986, Barkan, his wife, Debra, and 21 friends and investors created Live Oak Living Center in nearby El Sobrante where they have refined the Regenerative Community model for the benefit of thousands of elders.

Creating Life Worth Living With The Eden Alternative

The Eden Alternative grew out of a 1990 pilot project created by Dr. Bill Thomas in collaboration with caregivers at Chase Memorial Nursing Home in New Berlin, NY.

To combat the loneliness, helplessness and boredom afflicting the elders and the lack of confidence and respect among the caregivers, Dr. Thomas and his staff infused daily life at Chase with plants, pets and people of all ages.

They trained staff in all departments in communicating and problems solving, then reshuffled workers into care teams permanently assigned to a particular "neighborhood" of elders.

Results included lower infection rates, less need for medication and fewer deaths among residents than for those in the control model.

It's imperative that all staff be involved in creating a vision of how the Eden Alternative principles will be implemented in their nursing home, says Dr. Thomas.

Resident-Directed Care, Providence Mount St. Vincent

In 1990, culture change activists at Providence Mount St. Vincent in Seattle began pioneering "resident-directed" care.

"We had a vision, but not all the nuts and bolts about how," says Charlene Boyd, Administrator.

They visited different models across the country and began forging their own model with little nuggets gathered here and there.

They made deep systemic changes throughout their 80 year-old building. They created neighborhoods, flattened the organizational hierarchy, empowered and cross-trained staff, put decision-making closer to residents and stopped segregating them according to acuity and disease.

Today, the Mount is a showcase for culture change, has won numerous awards and is considered by many as one of the best nursing homes in the country.

New Realities Melt Resistance to Culture Change

But despite demonstrated successes like these and passage of The Nursing Home Reform Act of 1987 (OBRA), the industry remained firmly committed to the medical model of care.

The Medicare reimbursement system lent strong financial incentives. Nursing home chains invested heavily in equipment and property, gobbled up small, independent "mom and pop" facilities and turned them into something akin to mini hospitals.

Then in 1998, Medicare switched to the Prospective Pay System (PPS) and began reimbursing nursing homes at a predetermined rate. By the turn of the century, 11 of the top 12 nursing home chains were either bankrupt or reorganized.

Competition and bad press played a supporting role in their demise.

Gaining popularity in the 1980s, assisted living today accommodates more than one million elders in 20,000 facilities. Home health care serves more than 1.7 million elders.

All this has sparked growing interest in nursing home culture change as a means to improve quality of life for elders, retain staff, build census and become more competitive.

"People want more control over their lives, more independence, more choice," says Boyd. "[Many nursing homes] would say, 'I can't do culture change', but I don't think you have a choice."