Before: We used to bathe 50 residents a week in one whirlpool tub. We had bath aides whose entire job was to make sure that 14 bathes a day were done. They had to have such a rigid schedule that each resident had to be in and out in 20 minutes! No time for relaxation.

Before: Now, we have a whirlpool tub and/or shower for every 16 residents. Residents are able to tell us when they want to bathe and we work around their schedules. If a resident wants to soak in the tub for an hour, it's okay! The bath aide hours have been incorporated into the household hours so that everyone is able to give baths days, evenings or even nights if someone wants one. We admitted a resident recently who wanted to shower everyday. We knew it was coming, but with our current system we were able to accommodate his wishes.

Before: In the traditional nursing home, the hierarchical structure encouraged staff to report problems to the person higher on the "chain" then they were and not to worry because someone else would take care of it.

After: When we went to primary assignments to households with our new model, staff were not concerned about taking care of the same residents every day, but they were concerned about working with the same person every day. We set the expectation from the beginning that we expected them to initiate discussion with their co-worker if a problem arose between them and taught them conflict management and communication skills. If they don't feel comfortable handling it themselves, they can ask the Household Coordinator or RN to go with them, but it will be addressed before the end of the shift. We have many examples of how when problems are addressed right away they stay small and can be easily handled. Staff are much more willing to deal with their own problems and have found it to be helpful to their relationships with co-workers.

Before: As the DON, I would have developed a detailed plan, had the P&P ready with all the supplies they would need, and likely had a sample schedule of how I felt they should accomplish the task. With this in hand, I would have "told them how to do it." Of course, they would have complained about it behind my back but would have done it the way I had instructed them no matter how bad my plan was.

After: I went to the households, explained that they needed to be doing the residents' personal laundry by January 1st (in 3 months). They would need to use a soap with color safe bleach and should let me know if they needed any equipment or supplies to do it. I also told them I didn't know how they would do it but would leave it to the households to decide what they needed to do to get the task done. Within two weeks they were all doing their residents' personal laundry and have said that it was one of the easiest transitions that they made.

Shorehaven Health and Rehabilitation Center in Oconomowoc, WI moved into a new building of households in August of 2005. Lorna Gartzke, Administrator, tells us candidly about the way their transformation has breathed new life into breakfast making it once again the great way to start your day.

Before: We had tray service. The food was prepared in our huge downstairs kitchen two floors away. You got what was the menu item for that meal unless you told us you didn't like that item. Then we would give you the substitute but you did not get a choice in what that was. Food was placed on a silver heat plate that unnaturally raised your plate off from table height. Then your food was placed on the plate and covered with a mauve insulated cover. Other items were placed on your tray. All items like bowls, coffee cups, juice glasses were, of course, hard plastic, never glass or china. These items were covered with plastic covers like you get with take-out food. The trays were then placed on the massive silver food carts. Each tray was identified with your name and the name card listed the food items on the tray (just in case you could not identify them). When the food cart came lumbering up to the units it was placed in the dining room. Because it was so big, if you were on one side of it you could never see past the cart to see what was on the other side. Now, since you were awakened according to what worked best for the staff you might have been sitting at the table since 6:15am with your bib on. (Staff prided themselves in thinking they were very efficient to have the residents up and ready with their bibs on almost two hours prior to the meal.) Usually, the residents were sleeping because there was no stimulation or anything to do other than sit at the table and wait, and wait, and wait. The big silver cart came up about 8 a.m. Like good little soldiers, the staff marched to the big silver cart and began taking the food trays off and literally plopping them in front of the residents. The covers were taken off to reveal a soggy piece of toast (for example). The staff would then open the small single serve jelly packet and slap on the jelly. They might have not even asked you if you wanted jelly. They would then take off the plastic covers on the coffee cup and juice glass and open your small paper milk carton and stick in a straw. They would then announce, "Now, eat." If you didn't like the items on your tray you could ask for something else but it would take about 40 minutes for the nurses to call down to the kitchen and for a kitchen staff member to bring the item to the nursing station. It might sit there for a while getting cold and then finally, when you no longer had an appetite, it would be brought to your table. We did not even have a toaster in the area to make you a fresh piece of toast. We did not have any coffee brewing because residents might burn themselves. The dining room held about 35 residents so you could imagine the clatter. The dining room also connected to a nursing station so you could hear every alarm going off, the phone ringing, staff conversations (rarely including the residents) doctors barking orders, etc. The staff, again in their efficiency, would be wiping off the tables maybe even before you were done because they had tasks to complete.

After: First, you get up when you wake up and want to get up. You come to the table and are offered a selection of beverages served in a glass glass or china cup. You then are asked what you would like for breakfast and make your decision as soft music is playing - music that the first resident who came to the dining room requested. Your breakfast is made to order. You can smell the toast toasting and the bacon frying. Our households only have 15 residents so this would be the maximum number of folks eating, but because residents get up and come to breakfast when they want, there may only be three to five residents eating at any given time. Staff ask if you would like a clothing protector to use during the meal. They will also ask if you would like the fresh fruit cup served in a china dish and if you would care for fresh baked pastry. You can read the paper while you eat or if you prefer to eat in front of the TV in the family room, you can do this also. You can linger at the table as long as you like. Many residents do because they like to watch the staff load the dishwasher and continue to cook for others. The staff interacts with the residents and residents are informed of activities for the day and what is on the menu for the next meal. They can let us know what they would rather have if they do not like the menu item for lunch.

This is a homelike breakfast atmosphere. It is so different from what I am embarrassed to say we used to do in our traditional nursing home. We have had great success. We have residents gaining weight and enjoying the meals. Residents who never ate breakfast before are now eating it. Residents say they just love getting up in the morning - the meal is an event unto itself.

Of course there will be days when you wish a parking lot full of people in blue t-shirts would show up at your facility to do all the work, like on TV, to get you to the shiny new "after" version more quickly. But, the deep understanding and learning that comes from all those little steps from beginning to end will be what truly transforms the institution into home.

Marilyn Oelfke says, "With the old model, our nursing assistants said it was a job - one that they could never finish and always left work at the end of the day feeling frustrated because they hadn't been able to do enough. Now, they say that they still work very hard but they enjoy more time with the residents and the variety of work that they do each day. Many of our staff and residents say that they see each other as friends rather than caregiver and care receiver." There's just no Hollywood magic that could make that happen, only our own dedication to a better life for our elders.