Nursing care discards the old model

Carol Ranglin beams as she walks through her domain at the Tockwotton Home, a corridor of tidy double rooms.

“This one is my little light over here,” she says as she points into one room. “And this one is like my little husband.”

At the end of the corridor, she finds Marion Littleton, 93, watching the soaps. She sits down on the bed and begins petting Mrs. Littleton’s cat, Gem, and feeding her treats.

“This is my little family right here,” Ranglin says. “Marion and Gem.”

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Mrs. Littleton – who is so frail that she can barely speak, and who has no family nearby – lights up when she sees Ranglin. “I love her,” she says. “She’s so patient with me. There’s so much expected of Carol, and she is just so kind to me.”

This, advocates for the elderly will tell you, is how nursing home care should be: personal, gentle, affectionate, focused as much on the soul as on the body.

Sure, cats generally don’t belong in health care facilities, but Gem is a companion, so she’s OK. Sure, there’s a set breakfast time, but Mrs. Littleton likes to sleep late, so she does, and she gets her breakfast when she’s ready. And since she’s not comfortable being bathed by just anyone, Ranglin takes care of her before going home, even if that means leaving work late.

This isn’t the norm even at Tockwotton, and most certainly not in the nursing home industry as a whole. But across the nation and in Rhode Island, a “culture change” movement is trying to make it the norm – and turn nursing homes into true homes for elders.

Last spring, Quality Partners of Rhode Island, a health care consulting group that has been involved in nursing home quality improvement for several years at the national and local levels, launched a three-year project to work intensively with 33 local nursing homes.

The project, which is being financed by the federal Centers for Medicare & Medicaid Services, involves leadership and staff training, expert advice from Quality Partners about strategies used elsewhere, and targeted efforts to address each home’s specific issues.

At Tockwotton, for example, one of the first changes was to give certified nursing assistants such as Ranglin consistent assignments, so they’d care for the same few people every day. Ranglin, for example, has seven residents in her charge.

“We talk a lot now, which we didn’t use to do before,” she said. “We were close before, but now we’re closer, because now you have a set of residents who you go to see all the time.”

At Cedar Crest, in Cranston, consistent assignments have been in place for years, said Joan Hupf, director of quality improvement, but one recent change is “restaurant-style” dining, which gives residents more choices and feels less institutional.

Residents have 90-minute windows in which to go to the dining room for breakfast, lunch and dinner – or else they can have a tray brought up. And to ensure that each gets the right meal, the nursing staff works closely with the dining staff.

“It has eliminated so many food concerns – you wouldn’t believe it,” Hupf said. “It’s also brought a camaraderie and improved morale greatly between those two departments.”

At Elmhurst Extended Care, a 192-bed nonprofit in Providence, culture change is much farther along. Administrator Richard Gamache, who is slated to become president of the Rhode Island Health Care Association later this month, said the facility has adopted the “Eden Home” model, which aims to create a “holistic” environment by bringing in plants and animals and making nursing homes more home-like.

Eden creator Bill Thomas found the main reason why elders suffered in nursing homes was that they hated being institutionalized – the “mind-numbing routine,” the strict rules and the helplessness. An industry veteran, Gamache said he’s seen that reaction at many nursing homes, where it’s common to see residents slumped in their wheelchairs around the nurses’ station.

“Culture change, to me, has to happen,” Gamache said. “There’s no ‘Well, we’ll do it. We’ll try it’ – it has to happen.”

A key part of culture change is to empower the CNAs – the nursing assistants who statistics show are mostly women, often minorities, earning $9 to $14 per hour – to make decisions about the nursing home environment and the care their charges will receive, said Marguerite M. McLaughlin, manager of education services at Quality Partners.

CNAs deliver 80 percent of the hands-on care residents receive, McLaughlin said, and surveys have shown they go into this line of work because they want to care for people.

Yet in many homes, they’re so unhappy that in 2002, the turnover rate for CNAs in Rhode Island was 82.7 percent. And each time a CNA leaves, McLaughlin said, it costs the nursing home an estimated $2,500.

Even the registered nurses, who have higher status in nursing homes, have a high turnover rate – 58.9 percent, McLaughlin said. “It’s kind of like the secret epidemic. This is one of the key problems, so our culture change work in Rhode Island set a strategy that began with this.”

Culture change doesn’t just make the staff more stable, Gamache noted: At Elmhurst, the adoption of the Eden model dramatically reduced turnover among residents.

“Our discharge rate to hospitals dropped by 38 percent, and our death rate dropped by 40 percent,” he said. “So we had people suddenly living longer.”

In separate interviews, both Gamache and McLaughlin said one of the most important points that nursing home administrators need to understand is that culture change is good for business – as with Elmhurst’s higher occupancy rate, and the lower staff-turnover rates reported at a wide range of facilities that have implemented such measures.

It’s also better public policy, said Dr. David R. Gifford, the state health director and a gerontologist who used to be chief medical officer at Quality Partners. The institutional climate at most nursing homes is so bad, he said, that “elderly people beg their families not to put them in a nursing home. So we’re spending millions of dollars on care for the elderly that they beg not to get. That’s messed up.”

But it’s not just nursing homes and their staff that need to change, McLaughlin and others said. The regulatory and inspection system also creates hurdles.

McLaughlin said nursing home administrators are afraid to loosen their rules because they fear they may have worse medical outcomes and be penalized for it.

In reality, she said, culture change can improve outcomes. But the nursing home survey (inspection) system does follow strict federal and state laws and regulations that can be interpreted to discourage or forbid some of the newer practices, so Quality Partners recently did a presentation to clarify these issues for surveyors nationwide, sponsored by CMS.

“Here in Rhode Island, our survey folks have been genuinely fabulous, and came for training session so they could understand our work,” she said. In addition, Gifford said, the state has received for a grant to review the guidelines that surveyors follow, “to see if the way we’ve interpreted the regulations has created a barrier to adopting culture change.”

Because most nursing homes were built to be hospital-like, reformers have also pushed for whole new facility designs, with smaller, house-like settings. Tockwotton, which was built in 1856, is following that philosophy as it prepares to build a new facility in East Providence in 2008, dividing its nursing home into self-contained “neighborhoods.”
Public perception is also an issue.

“It’s well-entrenched in the culture of the community that the tighter, the more military-like way we could run things, equals quality,” said Gail Patry, director of long-term care at Quality Partners. “People were very impressed with the nursing home where you could walk down the hall at 7 a.m. and find all the residents up and dressed and all the beds made.

“Now, we’re saying a good nursing home is a place where you let old people get up later if they want, so it may be a bit messy even at 9:30 a.m.”