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  1. 1. CASP Core Course 2 Section 2.7 Integrating Gerontological Principles with Management 2.7.1. The Management-Resident Relationship 2.7 Creating, Certifying, and Connecting Innovative Leaders in Aging Services
  2. 2. Module 2.7.1 The Management-Resident Relationship Table of Contents The History of Long-Term Care’s Administrative Approach to “Resident Care”: The Basis for Culture Change ....................................................................................................... 4 The Culture Change Movement.......................................................................................................... 6 • The Eden Alternative .............................................................................................................. 8 • The Green House Project ........................................................................................................ 16 • The Wellspring Model............................................................................................................. 19 • Other Culture Change Models or Paradigms ........................................................................... 21CASP Core Course 2, Section 7 Creating, Certifying, and Connecting Innovative Leaders in Aging Services
  3. 3. CASP Core Course 2, Section 7 Module 2.7.1 – The Management-Resident RelationshipEditor’s Note Successful management is essential to achieving and maintaining quality in any business; and, in the field of aging services, The Management-Resident Relationship is at the heart of successful management. In Module 2.7.1, Kendall Brune presents a comprehensive and inspiring analysis of how that relationship promotes quality in residential facilities for the elderly. After summarizing the historical transition from a medical model to a social model of care in nursing homes and other long-term care facilities, Dr. Brune focuses his discussion on resident-/person-centered care and the exciting concept of culture change: “the national movement for the transformation of older adult services, based on person-directed values and practices, where the voices of elders and those working with them are considered and respected.” Culture change, however, is much more than just an idea couched in impressive-sounding words. In this module, you will be introduced to a variety of models in which the theory has been applied to the daily operations of aging services organizations, including: • The Eden Alternative (the earliest and perhaps the best-known culture change paradigm), • The Green House Project, • The Wellspring Model, • Eldershire, • Elder cohousing, • The Pioneer Network, • Evercare, and • The Coming Home Program. Dr. Brune describes the approaches these programs use to deliver quality care and services, presenting numerous modalities for your consideration. His listing of the central elements of the culture change movement (as summarized by Calkins in 2002) and his contrast of the characteristics of institution- vs. person-directed care, embody precepts that you can apply to all of your organization’s residents/clients, personnel, and operations. Dr. Brune’s list of references gives you dozens of documents available online for further reading, with still more offered in his selection of Learning Resources. The Learning Resources also include an extensive glossary of terms commonly used in the field of long-term care and 1
  4. 4. Module 2.7.1 – The Management-Resident Relationship CASP Core Course 2, Section 7 aging services, as well as Dr. Brune’s own diagram of a dynamic management-resident relationship for building sustainable senior-engaged communities.About the Author Dr. Kendall Brune, President of Future Focus Community, LLC, provides senior leadership and oversight for development, owned, and leased properties. He is a senior housing expert and an executive instructor to leaders in the field, and he assists healthcare developers and providers in identifying market growth opportunities. Dr. Brune has more than 25 years of experience in the healthcare field and has been on the leading edge of culture change in the healthcare delivery system for the elderly in the United States. His academic credentials include his designation as a Fellow with the American College of Healthcare Administrators, his doctorate in healthcare administration, and his authorship of two practical healthcare books for the senior care field. He currently serves as an adjunct professor of senior healthcare administration for two universities, A.T. Still University and the University of North Texas. Dr. Brune also serves ATSU as a member of the medical school faculty board and a curriculum committee member for Geriatric Health Management. During his graduate work with Project Life and the Center for the Study of Aging at the University of Missouri-Columbia, he participated in the national culture change phenomenon of the Eden Alternative as a researcher, administrator, and disciple, from its infancy through putting it into practice in one of Missouri’s first affiliated facilities. To further develop the Eden vision, his practical experience as a licensed long- term care administrator has allowed him to deliver improvements and culture change through all continuum of care levels, from independent senior housing, through assisted care and skilled nursing facilities, to a major hospital sub-acute care facility. He continues to serve as a mentor and educator for the Eden Alternative program. He has applied these philosophies of care in the development and operation of 19 long-term care facilities; representing $150 million of construction management. All of these facilities are still operating successfully today. Dr. Brune obtained his undergraduate degree in healthcare administration from the University of Missouri-Columbia, an2
  5. 5. CASP Core Course 2, Section 7 Module 2.7.1 – The Management-Resident Relationship M.B.A from William Woods University, and a Ph.D. in healthcare administration from Kennedy Western University. He is currently completing a Ph.D. in applied gerontology from the University of North Texas in Denton.Learning Objectives • You will understand the driving forces changing the Resident/ Management Relationship. • You will learn about “Culture Change.” • You will learn about “Resident- or Person-Centered Care.” • You will learn how to communicate “Quality Care” to your customers: o CMS directives for culture change; o Medicare reporting mechanism. • You will learn what wellness is all about. • You will learn about creative programming to engage seniors. • You will learn about community engagement. 3
  6. 6. Module 2.7.1 – The Management-Resident Relationship CASP Core Course 2, Section 7Overview To discuss the relationship between residents and the management team, we must first review the transition from a medical model to a social model of care. Long-term care (LTC) management models were developed for a very autocratic and hierarchical style of management based in the 1960s. Those facilities were built on the model of hospitals (after the Hill-Burton Act of 1946), where the major focus was on healing, or palliation of, physical ailments and, in the case of residents with dementia, mental impairment. Residents were—and, for the most part still are—isolated from family, friends, and community, often without any view of the outside world. Baby Boomers today will not tolerate such an environment for their parents, or themselves. A cultural revolution called “Resident-Centered Care” started to occur and change the Resident/Management Relationship. “Culture change” is the common name given to the national movement for the transformation of older adult services, based on person-directed values and practices where the voices of elders and those working with them are considered and respected. In the management process, decision-making is pushed down to the lowest level of front line staff. Administrators have become “facilitators of process improvement” and community advocates for senior consumerism. We are now exploring new ways to enhance revenue streams that entail home care, private-duty nursing, outpatient therapy services, spa and wellness clinics, fitness and pool centers for seniors, and any other creative outreach program that engages seniors to return continuously to a facility. This module will explore the history of culture change and the process of creating a new “well-being and connectivity” model for senior retirement communities.The Resident-Management RelationshipThe History of Long-Term Care’s Administrative Approach to “Resident Care”: TheBasis for Culture Change The development of skilled and intermediate care nursing facilities in the United States during the 1950s and 1960s served an honorable purpose. Facilities of the pre-1990 era and, indeed, the vast majority even today, serve the “medical” needs of those unfortunate individuals who require skilled nursing care, i.e., medical care. The organizational4
  7. 7. CASP Core Course 2, Section 7 Module 2.7.1 – The Management-Resident Relationship structure of most facilities continues to be patterned after the hospital’s hierarchical, departmentalized, top-down management scheme, similarAbuse/Elder Abuse: Any knowing,intentional or negligent act by a to most American corporations. In short, hospitals, nursing homes, andcaregiver or any other person retirement communities, have been designed to be efficient, standardized,that causes harm or a serious risk cost-driven, and regulation-compliant corporate institutions.of harm to a vulnerable olderadult. Types of elder abuse may Although not all nursing homes prior to the mid-1990s wereinclude physical abuse–inflicting, or sterile cinder-block structures, they did almost invariably provide thethreatening to inflict, physical painor injury on a vulnerable elder, or same internal atmosphere, where front-line staff and residents alikedepriving him or her of a basic followed very structured routines with little opportunity for personal orneed; emotional abuse–inflicting professional growth or self-expression. Residents were and, for the mostmental pain, anguish, or distress onan elder person through verbal or part still are, isolated from family, friends, and community, often withoutnonverbal acts; sexual abuse–non- any view of the outside world. Over half of nursing home residentsconsensual sexual contact of any spent much of their day in restraints, a practice which was condoned bykind; exploitation–illegal taking,misuse, or concealment of funds, regulators until the passage of the Nursing Home Reform Act as part ofproperty or assets of a vulnerable OBRA in 1987 (Calkins, 2002). Traditionally, there has been little regardelder; neglect–refusal or failureby those responsible to provide for residents’ privacy, and a high level of neglect for their emotional,food, shelter, health care, or social, and spiritual needs. Many residents just shut down, which, forprotection for a vulnerable elder; some, hastens their physical decline.and abandonment–the desertion ofa vulnerable elder by anyone who For most of us studying applied gerontology, this is not news. It ishas assumed the responsibility for safe to say that the “great dread” of becoming a dependent senior was tocare or custody of that person. Thespecificity of laws varies from state be put in a nursing home, a sentiment shared by both residents and theirto state (see National Center on loved ones. In a PSB Online “NewsHour” report, Dentzer (2002) cited aElder Abuse at; poll taken by NewsHour, the Kaiser Foundation, and the Harvard Schoolretrieved on October 2, 2009). of Public Health, which revealed that 1) almost half of all AmericansResident: A person who lives ina long-term care setting, such as thought people were worse off after going into nursing homes than beforea nursing home or assisted living they went in, 2) almost four in ten nursing home residents reported beingcommunity. dissatisfied with their care and, 3) one in four Americans reported that aNursing Home or Skilled NursingFacility (SNF): A residential care nursing home resident they knew had been badly treated or abused by thesetting that provides 24-hour-care staff. Furthermore, a Congressional report released just prior to Dentzer’s(all day and night) to individualswho are chronically ill or disabled. article stated that state inspectors had cited nearly one in ten nursingIndividuals must be unable to care homes for instances of serious abuse (“Nursing Home Abuse News,”for themselves in other settings or 2001).need extensive medical and/orskilled nursing care. As background information, in a 1999 National Nursing Home Survey, the National Center for Health Statistics reported that there were 1.6 million nursing home residents (usually referred to as “patients”), living in 18,000 nursing homes nationwide, with an 87% occupancy rate, and an average current resident length of stay of 892 days (nearly 2½ 5
  8. 8. Module 2.7.1 – The Management-Resident Relationship CASP Core Course 2, Section 7 years!) (“Nursing Home Care,” 2008). A 1997 National Nursing Home Survey reported that approximately 4.3 % of the US population age 65 or older were nursing home residents, about half of whom were age 85 or older; and about 75% of these 65-and-over residents required assistance in three of more activities of daily living (ADLs). Forty-two percent of all nursing home residents were diagnosed with dementia (Gabrel, 2000). According to Dr. Bill Thomas, founder of the Eden Alternative, “Any adult in America who reaches the age of 65 has a 50% chance of spendingActivities of Daily Living (ADLs): time, significant time, in a nursing home. That’s a vast proportion of ourDaily functions such as getting society. . . . The only other segment of our society that is more likely todressed, eating, taking a showeror bath, going to the bathroom, be institutionalized are convicted criminals. . . . So here we have a societygetting into a bed or chair, or that used an institutional pattern for convicted violent felons and ourwalking from place to place. Theamount of help a person needs with frail mothers and fathers. And that is a losing proposition in the 21stADLs is often used as a measure to century” (“Thou Shalt Honor . . . The Eden Alternative,” 2002, [n.p.]).determine whether he or she meets And it is certainly not an option for many of the emerging Baby Boomerthe requirements for long-term careservices in a nursing home as well as population, who will demand more and much better options for theirgovernment-subsidized home- and LTC needs. Thomas predicts that the Boomer generation will completelycommunity-based services (alsosee Instrumental Activities of Daily wipe out the traditional, institution-type nursing home, or at least that isLiving). his goal! With this historical and statistical background, it seems that a major organizational reformation was brewing a perfect storm for change. Now let’s begin to talk about how the resident and management relationship process has changed in the continuum of senior care and housing.The Culture Change Movement A paradigm shift in resident care occurred in the form of the culture- change movement in the LTC field (Brune, 1992; Brune, 1995). We can see that the Baby Boomers are coming, and we’re all aware that the sheer number of retirees will strain our limited staff, plant, financial, and emotional resources in the near future. Boomers will bring with them new technologies and more diverse expectations. We must meet these expectations and use technology to understand future demands by means of dynamic assessment of service desires. In actuality, the distinction of being the earliest recent culture change movement could be given to the Gray Panthers, organized in 1970 by Maggie Kuhn. This liberal activist organization is still alive and well today, advocating for a range of social and political causes, many relating6
  9. 9. CASP Core Course 2, Section 7 Module 2.7.1 – The Management-Resident Relationship to healthcare, and including ageism and the rights and interests of seniors (“Gray Panthers: Issue Resolutions Summary,” 2009; “Gray Panthers,” [n.d.]). In the context of our discussion here, “culture change’” is the term commonly used to describe the national movement for theCulture Change: The common name transformation of older adult services, based on person-directed valuesgiven to the national movement forthe transformation of older adult and practices where the voices of elders and those working with themservices, based on person-directed are considered and respected. Core person-directed values are “choice,values and practices, where thevoices of elders and those working dignity, respect, self-determination, and purposeful living” (“What Iswith them are considered and Culture Change?,” 2008, [n.p.]). It is “an effort to radically transformrespected. Core person-directed the nation’s nursing homes by delivering resident-directed care andvalues are choice, dignity, respect,self-determination, and purposeful empowering staff ” (Rahman & Schnelle, 2008, p. 142). Althoughliving. Culture change transformation the first real impetus for nursing home reform came in 1991 with Billsupports the creation of both long- Thomas’ Eden Alternative model, the culture change movement isand short-term living environmentsas well as community-based generally thought to have begun in 1997, following the first meetingsettings where both older adults of the nursing home Pioneers (now known as the Pioneer Network),and their caregivers are able toexpress choice and practice self- during which the term “culture change” was coined. The University ofdetermination in meaningful ways Missouri-Columbia’s “Project Life” was responsible for the publicationat every level of daily life. Culture of Thomas’s first book, The Eden Alternative, and I was fortunate enoughchange transformation may requirechanges in organization practices, to be working for Dr. Stan Ingman at UM-C’s Center for the Study ofphysical environments, relationships Aging at the time of this project (1988-1992). The Eden Alternativeat all levels, and workforce models,leading to better outcomes for resident philosophy challenged administration to identify who residentsconsumers and direct-care workers “had been” and how they could still add value to the greater communitywithout being costly for providers. in which they were engaged. Co-habitational communities like HeritagePerson-Directed Care/Person- of Green Hills, located in Reading, Pennsylvania, focus on the holisticCentered Care: An approach tocare that honors and respects the philosophy that each person has a personal path to wellness throughvoices of individuals and those social, spiritual, physical, intellectual, emotional, and vocational activityworking closest with them. It involvesa continuing process of listening, (“Building Premiere Retirement Communities for Today’s Activetrying new approaches, seeing how Seniors,” 2007).they work, and changing routines With various health care providers developing their own brandedand organizational approaches inan effort to individualize and de- versions of resident-centered care models, “culture change” has becomeinstitutionalize the care environment a generic term, encompassing a host of LTC concepts and models,(e.g., nursing home or assisted livingfacility). including the following: 1. Resident-centered care; 2. Resident-directed care; 3. Eden Alternative; 4. Green House Project; 7
  10. 10. Module 2.7.1 – The Management-Resident Relationship CASP Core Course 2, Section 7 5. The Wellspring Model; 6. The Pioneer Movement; 7. Person-centered care; 8. Quality-Improvement Organizations; 9. Advancing Excellence campaign; 10. Culture of safety; 11. Best friends approach; 12. Validation therapy;Geriatrician: A medical doctor with 13. Activity-focused care;special training in the diagnosis, 14. Positive Interactions Program; andtreatment, and prevention of illnessand disabilities in older adults 15. Beyond the Green House Project Care Model (Nissenboim, 2004).(see American Medical Directors Calkins (2002) sums up the culture change movement asAssociation at; 1. Respecting the individual needs and desires of each person (evenretrieved on October 2, 2009).The GREEN HOUSE® Model: A people with dementia, including the right to control decisionssmall, intentional (“purpose-built”) that are made about their lives;community for a group of elders 2. Honoring the life patterns and accomplishments of every personand staff. A Green House residenceis designed to be a home for six to within the setting, residents and staff alike (staff means, especially,ten elders needing skilled nursing or nurse’s aides, traditionally the lowest in the organizationalassisted living care. The purpose of hierarchy);the Green House is to be a placewhere elders can receive assistance 3. Supporting opportunities for continued growth;and support with activities of daily 4. Enabling continued productive contributions to their communityliving and clinical care, without theassistance and care becoming the (including experiential sharing, i.e., legacy);focus of their existence. 5. Encouraging meaningful connections with family and theProvider: Typically a professional community (to combat feelings of loneliness and helplessness);healthcare worker, agency, ororganization that delivers health 6. Fostering fun (to combat resident boredom and empoweringcare or social services. Providers staff ); andmay be individuals (physicians, 7. Restructuring of staffing roles and relationships (team approach,nurses, social workers, and others),organizations (hospitals, nursing consistent assignment of staff, empowerment of front-line staff ).homes, assisted living facilities, The ultimate goal is to achieve maximal quality of life, for bothor continuing care retirement residents and staff.communities), agencies (e.g., homecare and hospice), or businesses that To begin understanding current philosophies of resident/sell healthcare services or assistive management relationships, we must review some present-day models ofequipment (e.g., colostomy caresupplies, wheelchairs, walkers, etc). resident care. The Eden Alternative The Eden Alternative (EA), proposed by geriatrician and nursing home physician William Thomas in 1991, was the earliest of the culture8
  11. 11. CASP Core Course 2, Section 7 Module 2.7.1 – The Management-Resident Relationship change models. It also has been the most influential, successful, and widely publicized; indeed it has become the model of models, and its basic tenets are interwoven into almost all other proposed models of care. It has led Dr. Thomas to conceive several offshoot or successor models, including the Green House Project, the Eden at Home and the Eden at Home Embracing Elderhood concepts, and Eldershire communities. Dr. Thomas formulated the Eden Alternative concept while he was the house physician for a nursing home in upstate New York, the name Eden inspired by the Biblical garden that was created to help ease Adam’s loneliness. Thomas noted that the majority of residents in his nursing home suffered from what he called “the three plagues”—loneliness, helplessness, and boredom—as described in the first of the ten Eden Alternative Principles: 1. The three plagues of loneliness, helplessness, and boredom account for the bulk of suffering among our Elders. 2. An Elder-centered community commits to creating a Human Habitat where life revolves around close and continuing contact with plants, animals, and children. It is these relationships that provide the young and old alike with a pathway to a life worth living. 3. Loving companionship is the antidote to loneliness. Elders deserve easy access to human and animal companionship. 4. An Elder-centered community creates opportunity to give as well as receive care. This is the antidote to helplessness. 5. 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. This is the antidote to boredom. 6. Meaningless activity corrodes the human spirit. The opportunity to do things that we find meaningful is essential to human health. 7. Medical treatment should be the servant of genuine human caring, never its master. 8. 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 into the hands of those closest to them. 9. Creating an Elder-centered community is a never-ending process. Human growth must never be separated from human life. 9
  12. 12. Module 2.7.1 – The Management-Resident Relationship CASP Core Course 2, Section 7 10. Wise leadership is the lifeblood of any struggle against the three plagues. For it, there can be no substitute (Thomas, 2006; “Our 10 Principles,” 2009). Any nursing facility can choose to adopt some or all of these Principles; but, to be a bona fide (registered) EA facility, the nursing home must agree to abide by all ten Principles, register with the EA Registry, and participate in the ongoing Eden development process of continual commitment and striving not only toward complete fulfillment of the EA Principles but toward ever-improving resident quality of life and transforming the institution into a warm Human Habitat. The Eden Registry is maintained by the Eden Alternative, and both are non-profit entities. The Registry is not an accreditation, monitoring, regulatory, and punitive or organizationally controlling body. Rather, it provides education and resources to help nursing facilities adopt the Eden Principles and Practices (“Becoming Part of the Eden Registry,” 2009). EA-registered homes receive an Eden Tree plaque and Symbols of Recognition (“The Eden Alternative: We Are Different,” 2009). Eden also provides a multitude of training workshops and trainer certifications (Brune, 1995). To date, Eden has trained over 15,000 Certified EdenCertified Nursing Assistant (CNA): Associates, and the organization now claims over 300 registered homes,A person trained and certified to in the United States, Canada, Europe, Japan, Australia, and Newassist individuals with non-clinicaltasks such as eating, walking, Zealand (“Certified Eden Associates,” 2009). EA is a small and simpleand personal care (see ADLs and organization, consisting of Dr. Bill Thomas; his wife Jude; the EdenPersonal Care). This person may home office staff; 50 Eden Educators; 60 mentors and, of course, thebe called a “direct-care worker”(DCW). In a hospital or nursing home 15,000 Eden associates (“The Eden Alternative: Improving the Lives ofthe person may be called a nursing the Elders and Their Care Partners,” 2009).assistant, a personal care assistant, oran aide.Direct-Care Staff/Direct-Care Combating the three plaguesWorker (DCW): An individual The major impetus of the EA movement was, and still is, theworking in a nursing home or elimination of loneliness, helplessness, and boredom. In an Eden facility,assisted living community whoprovides “hands-on” help to the cure for loneliness is companionship: with other residents, withresidents with activities of daily front-line staff (empowered Certified Nurse Assistants, housekeepers,living (see Certified NursingAssistant). maintenance personnel, etc.), and with an abundance of plants and animals. CNAs are not only cross-trained to work in small teams, and empowered with front-line decision-making; they are required to attend to residents’ emotional needs, they treat all residents with dignity and importance, and they come to know residents on a highly interpersonal, intimate level.10
  13. 13. CASP Core Course 2, Section 7 Module 2.7.1 – The Management-Resident Relationship Eden facilities are universally teeming with birds, especially parakeets, finches, and canaries; dogs and cats; rabbits; sometimes fish and guinea pigs; and an abundance of plants, inside and out. This is why some have called EA the “Fur and Feathers” program. Residents are encouraged to tend to, and even adopt, plants and animals. Pets, especially dogs, sometimes even adopt residents. In fact, some canines have actually learned to operate the elevators to visit their “favorite people” (Bruck, 1997). Thomas’ plan to uplift residents’ spirits and combat loneliness through contact with animals was implemented from the very start, when he introduced EA in his own Chase Memorial Nursing Home in upstate New York in 1991 and said, “We’ll bring in 100 birds, two dogs, four cats, three rabbits and a flock of laying hens . . . Then we’ll plow the lawn and start a large organic vegetable garden outside our residents’ windows.” And he did. One day, the birds arrived—all 100 of them! (“An Eden Alternative: A Life Worth Living, 2003). The benefits of animal-assisted therapy (AAT)—although Thomas prefers to regard animal-resident interaction as a natural bonding process rather than a therapy (Bruck, 1997)—are well-documented. Companion animals have been shown to be effective in reducing loneliness in both pet owners and in nursing home residents, as measured objectively, especially for those residents who had a life history of emotional attachment to pets, usually in early childhood. A significant effect on loneliness was noted with as little as 30 minutes of pet contact per week (Banks & Banks, 2002; Banks et al., 2008; Barker, 1999). A reduction in incidence and severity of depression is also likely to be associated with pet and plant contact, as well as promotion of “social capital” in the form of social contact and interaction (Wood et al., 2005). Some have cautioned that the use of companion pets could result in zoonosis (atypical infections), but only one report of such an incident surfaced during my literature review, a case of atypical scabies in a nursing home with an active EA program (Morley & Flaherty, 2002). Based on my personal knowledge of the facility in question, I believe that other infection sources and practices are a more probable cause. Animals in EA homes are generally observed and tested by veterinarians, and the spread of disease is apparently not a significant problem. Furthermore, state regulations do not prohibit animal residence in nursing homes. Thirty-two states do not address the 11
  14. 14. Module 2.7.1 – The Management-Resident Relationship CASP Core Course 2, Section 7 issue; those that do usually have restrictions on numbers and/or kinds of animals allowed (“Quality of Life: Pets and Animal Therapy,” 2008). Pets and companion animals are generally not allowed in kitchen and dining areas during meal service times. Children, from pre-schoolers to high-schoolers, are often a key feature in Eden facilities, allowing residents to interact and share life experiences and knowledge, including playing games, sharing stories, helping with homework, and working together in the garden. I first started Eden and childcare in an LTC facility in 1989 at the Continuous Care Retirement Community in Columbia, Missouri. Resident feelings of helplessness tended to be alleviated by helping children, caring for pets and plants, and making decisions about their environment and their daily activities. “A home that opens its doors to pets, children, and the community has little room for boredom . . . . Life in an Eden home is spontaneous” (“An Eden Alternative: Life Worth Living,” 2003, [n.p.]). Meals are varied, often chosen by the residents; activities are varied; the range of visitors is varied. Each resident’s room is decorated to his or her individual tastes, and personal living spaces are thus varied. Front-line staff tend to interact frequently with residents, combating both loneliness and boredom. At the Levindale Hebrew Geriatric Center in Baltimore, Maryland, which became a registered EA facility in 2000, a family atmosphere was created by the formation of small groups of residents and staff called “kibbutzim” (plural of “kibbutz”). Kibbutzim groupsTurnover: The average percentage met regularly to become better acquainted and discuss issues, includingof staff who stop working at a what kinds of pets to bring into the family (“Eden Alternative andcare setting each year. Virtually allhealthcare organizations (hospitals, Neighborhood Model,” 2006).nursing homes, assisted livingfacilities, etc.) track and measure the Measurable benefits of the Eden Alternativenumber of staff who stop working(turnover) and the length of stay Results of studies assessing the benefits of “Edenizing” or “goingof staff (retention) in the same or Eden” vary in amount of attributed benefit, but those measuring benefitssimilar jobs. A high turnover ratein a nursing home or assisted living objectively and over a suitable time frame consistently show positivecommunity means that the facility results. In 2003, Bill Thomas’ study of his own Chase Memorial Nursingin question is constantly hiring and Home showed a reduction in overall number of drug prescriptions,training new caregivers. infection rates, staff turnover, and the mortality rate. Studies of the Texas EA Project involving several nursing homes charted significant decreases in in-house pressure sores, anxiolytic and antidepressant medications, and staff absenteeism. Perhaps the best indicator of success is that Eden homes12
  15. 15. CASP Core Course 2, Section 7 Module 2.7.1 – The Management-Resident Relationship across the nation report waiting lists for their beds (“An Eden Alternative: Life Worth Living,” 2003). In addition to quality-of-care and quality-of-life resident concerns, a constant challenge for many nursing homes is staff dissatisfaction, in particular among CNAs, and, more specifically, high rates of staff turnover and absenteeism. In the test Eden facilities in Texas, a 25% reduction in staff turnover was documented, along with a one-third drop in absenteeism (Kleinman, 2009). In Bethel Lutheran Nursing Home, overall drug costs were down 50%, the mortality rate was reduced by 15%, and the infection rate was cut in half; benefits for staff, family members and visitors were equally dramatic (“Eden Alternative Philosophy: Life Worth Living,” [n.d.]). Data from Southwest Texas State University showed a 50% reduction in the incidence of decubitus ulcers, a 60% decrease in difficult behavioral incidents among residents, a 48% decline in staff absenteeism, and an 11% drop in employee accidents (Willging, 2000). A study of residents’ emotional needs showed positive results on the Minimum Data Set items relating to helplessness, loneliness, and boredom; the UCLA Loneliness Scale; the Geriatric Depression Scale; and the Lubben Social Network Scale (Parsons & Bergman-Evans, 2004). Another study showed significant improvement in family satisfaction, as measured by the Family Questionnaire, after implementation of EA. The improved satisfaction scores reflected greater communication and interaction among families, staff, and residents (Rosher & Robinson, 2009). Research by Coleman et al. (2002) showed no significant benefit of EA in terms of cognition, functional status, survival, infection rate, or cost of care, one year after its implementation. This was an earlier study, however, and the one-year study period may have been insufficient to demonstrate benefits. Rahman and Schnelle (2008) believe that the culture-change movement is spreading in advance of a solid research base to support its quality-of-life improvement claims. They propose specific and more focused research questions that will bring to light the costs and benefits of EA and other innovative models of care. Rather critical findings come from a study prepared for the Canadian Union of Public Employees (CUPE) Health Care Council by CUPE Research (2000) as summarized below. 13
  16. 16. Module 2.7.1 – The Management-Resident Relationship CASP Core Course 2, Section 7 1. The Eden Alternative has been severely criticized by some elder advocacy groups in the United States. 2. Measured benefits claimed by EA homes are based on a number of small preliminary studies that lack rigor. There is no definitive study that proves the benefits of EA (at least as of 2000, when the CUPE study was released). 3. In the U.S., for-profit NHs may be promoting EA in an attempt to counter widespread accounts of resident abuse and neglect. Critics argue that no genuine improvements, such as increased staffing levels, are being made to address the serious deficiencies in elder care. 4. While being promoted as inexpensive to implement and cost-effective to maintain, elder advocacy groups counter that EA cannot be implemented properly without additional money and staff. Limited resources may be redirected towards the care of animals and plants. 5. In EA facilities, jobs in nursing, laundry, recreation, and food services may be reduced or eliminated as aides’ jobs are expanded to include some or all of these duties. 6. Most of workers’ complaints about EA center on the issue ofCenters for Medicare and MedicaidServices (CMS): The entities understaffing. Staffing numbers may not be increased in proportionresponsible for regulating and to the new workload, which includes caring for plants and animalspaying nursing homes, home health and coordinating residents’ activities with children.agencies, and hospices for thecare of Medicare and Medicaid 7. The introduction of animals into the long term facility exacerbates(in conjunction with the states) existing workload problems and has implications for health andbeneficiaries. With a budget of safety. Plants and animals could be neglected as a result of insufficientapproximately $650 billion andserving approximately 90 million staff.beneficiaries, CMSs plays a key 8. Workers have expressed concerns about inadequate training.role in the overall direction of thehealthcare system. 9. Workers can suffer from burnout if they are permanently assigned toConsistent Assignment: Residents a group of severely challenged residents.seeing and receiving care from the In spite of these concerns, issued from a public employee union’ssame caregivers (registered nurse,licensed practical nurse, direct-care perspective, EA and other culture-change models and proposals areworker/certified nursing assistant) moving forward at an ever-increasing pace. One of the goals of theduring a typical work week. Advancing Excellence campaign was to encourage nursing homes toConsistent Assignment may also becalled Primary Assignment. adopt consistent assignment—the practice of assigning nurse aides to the same residents on a daily or nearly daily basis. With the endorsement of the Centers for Medicare and Medicaid Services (CMS), one of the founders of the campaign coalition, one-third of the nation’s nursing homes (5,246 facilities) had registered as “official participating providers,”14
  17. 17. CASP Core Course 2, Section 7 Module 2.7.1 – The Management-Resident Relationship as of June 1, 2007. Of these, 31% had committed to implementing consistent assignment (Rahman & Schnelle, 2008). National directives from CMS establish “person-centered” care as one of the six aims of the Institute of Medicine. It can also be seen as a defining aspect of the vision in the Quality Improvement Roadmap: the right care for every person every time calls for care that reliably meets the patient’s needs. To achieve this vision, care must be organized around the person’s, not the provider’s, needs. Person-centered care can also result in better self-care. This is particularly important in chronic conditions, which constitute a substantial part of the burden of illness, and cost, in the Medicare population. Thus, person-centered care is an important element in the improvement of quality and efficiency for all senior care providers (Leavitt, 2006). A study published a year later by the Commonwealth Fund (Doty, Koren, & Sturla, 2008) revealed similar nursing home adoption of culture change principles and resident-centered care. The authors sent questionnaires to a representative sample of 1,435 nursing homes and, based on the responses, divided these facilities into three separate categories: culture change adopters (31%), culture change strivers (25%), and traditional nursing homes that had adopted culture change principles very little or not at all (43%). Although the nursing homes in general had been relatively successful at increasing resident involvement in decision-making and, to a lesser extent, accommodating collaborative and decentralized decision-making to empower direct-care workers, very little organizational redesign or change in the physical environment had occurred. Interestingly, the authors also found that “the more a nursing home has adopted culture change principles, the greater the benefits that accrue to it, in terms of staff retention, higher occupancy rates, better competitive position, and improved operational costs” (Doty, Koren, & Sturla, 2008, [n.p.]). On the need for continual self-assessment and quality improvement As part of her master’s degree study while at Kansas State University, Kiyota ([n.d.]) lived in an EA nursing home for one month, posing as a wheelchair-bound resident, to determine how the physical environment was transformed to create a human habitat, and who were the agents 15
  18. 18. Module 2.7.1 – The Management-Resident Relationship CASP Core Course 2, Section 7 of these changes. Eventually, the focus of her study narrowed to the question of where residents and staff found meaningful experiences in the nursing home. Residents and staff members were asked to take photographs of their favorite places in the facility. Interestingly, there were categorical differences between residents and staff in what was perceived as meaningful. Staff tended to value areas which had Eden value and were especially appreciated by family and other visitors, such as the home-like ambience of the facility’s front entrance, a bright and airy and plant-bedecked reception desk with a small water-fountain, the courtyard where children went outside to play, and the aviary in the living room. Residents, on the other hand, chose the areas they used the most and to which they were emotionally attached, such as their self-decorated rooms or a specific area in the room (e.g., a family picture display, a dog’s bed, a parakeet cage, plants, a television, and an angel that was a gift from a middle school student), the physical therapy room where the staff were particularly friendly, the quiet and serene chapel, or the candy shop where visitors came to chat. Kiyota concluded—and I completely agree—that the physical environment should be comfortable and restful, appealing and inviting, homey and well-used, and should have emotional value for staff, visitors, and residents alike. But, if the facility is to be truly resident- centered, emphasis must be placed on those areas in the facility which the residents identify as meaningful to them. LTC facilities must be continually and fervently self-assessing and searching for ways to improve residents’ quality of care and quality of life. The Green House Project The concept In spite of the recent success of the culture change movement and EA in particular, Thomas still regarded nursing homes as too institutional. Despite the growing prevalence of resident-centered care practices, nursing homes were still too impersonal and medically-focused, and their physical layouts too large and spread-out, too cold and sterile, and too resident-unfriendly, with their long corridors and semi-private rooms. Thomas believed that significant, permanent LTC reform required a radical redesign of nursing homes architecture and organization. Thomas’ conception of the ultimate, yet doable, nursing home was a typical outwardly-appearing house, in a typical residential neighborhood,16
  19. 19. CASP Core Course 2, Section 7 Module 2.7.1 – The Management-Resident Relationship each house to be occupied by six to ten residents who would otherwise be occupants of a typical traditional nursing home. Thomas coined the name “Green Houses” (GHs) for these concept homes, signifying life and continued growth. A traditional nursing home with perhaps a hundred or more residents would now consist of a group of Green Houses, in varying proximity to one another but always noncontiguous, linked together by organizational management, technology, and communication. The internal layout would be that of a warm, welcoming residential dwelling that would foster both intimacy and privacy, care and autonomy, respect and self-respect. Physical and organizational design of GHs Because GHs would be built (or perhaps sometimes remodeled) from scratch, a similar architectural design would be employed for each. Resident rooms are situated around the periphery of the house, with each room opening directly into a central activity area or common space, consisting of a large dining and activity area, kitchen, and central hearth. Thus, the distance from a resident’s room to any other area in the house, especially the central hearth area, the focal point of the home’s interior, is short and readily negotiable by walking, walker, or wheelchair. This is in marked contrast to the long corridors of the traditional NH. There is one long dining room table, large enough for all residents, two caregivers, and visitors all to sit together for dining or activities. Soft music is piped in, and flowers are on the table. Each meal is intended to be a pleasant, enjoyable, engaging social event called a convivium (“TheCaregiver: A spouse, familymember, partner, friend, or neighbor Green House Concept,” 2008). Each resident has his or her own privatewho helps care for an elder or room with private bath, and residents are encouraged to furnish theirperson with a disability who needsassistance. Caregivers can also rooms as they please, including their own furniture from home. Therebe people employed by the older is a sense of personal belonging. Outside entrance keys are given only toadult, a family member, agencies, or residents and caregivers; visitors and other organizational staff, includingcare settings to provide assistancewith activities of daily living (ADLs; managers and nurses, must ring the doorbell to gain entrance.see above) and instrumentalactivities of daily living (IADLs) (see Shahbazimbelow). Similar to EA facilities (GHs are an offshoot or refinement of EA homes), in GHs Certified Nursing Assistants (CNAs), or nurse aides, assume responsibility for nearly all the residents’ needs. However, in a GH, the CNA’s responsibilities are broadened to include housekeeping 17
  20. 20. Module 2.7.1 – The Management-Resident Relationship CASP Core Course 2, Section 7 chores, meal preparation, and managing logistics. In fact, these do-it- all caregivers are the only staff present in a GH except for emergencies, and nurse, physician, or therapist visits (“Green House Project,” 2004). Once lowest on the organizational ladder and now, in many respects, the highest, these omnipresent workers are referred to by Thomas as Shahbazim (plural of Shahbaz), a Persian term meaning “royal falcon.” With an underlying belief that human life is sustained by affection, Shahbazim are trained and required to befriend and sustain the elders with whom they work, through the practice of convivium (pleasant dining), homemaking, and befriending (Shapiro, 2005). Shahbazim who are not CNAs upon hire must undergo training and become state-certified. All GH Shahbazim receive 120 hours of training. The first 40 hours are administered by GH staff and focus on GH philosophy, policies and procedures, team-building and empowerment, and dementia care. The remaining 80 hours consist of classes on CPR, culinary skills, food safety, and home repair (“Green House Project,” 2004). An elder country club Plants, animals, and children are part of GH design. All GHs have a screened-in porch and outdoor garden area. A nursing station is required by some state statutes, but these are neatly tucked away out of sight, usually in a utility or staff break room. Residents choose their activities, mealtimes, and degree of participation in household tasks, with no strict schedules (Rabig et al., 2006). A GH in Lincoln, Nebraska, even offers happy hour two afternoons a week, where residents can purchase an alcoholic beverage, country-club-style (“Green House” Communities Reinvent Elder Care,” 2008). Warm, smart, and green The idea of creating GHs that are warm, smart and green is, again, that of Bill Thomas. Warm: Thomas envisioned the houses as radiating warmth, created by the floor plan, the décor, the furnishings, and the people within them. The goal is to create and maintain human warmth.18
  21. 21. CASP Core Course 2, Section 7 Module 2.7.1 – The Management-Resident Relationship Smart: The use of cost-effective and smart technology such as computers, wireless pagers, electronic lifts, and adaptive devices cultivates a sense of resident personal belonging, meaning, and purpose in life. Green: Sunlight, plants, and access to outdoor spaces create connections with the living world and its living gifts of life, laughter, and companionship (Thomas, 2006; “The Green House Concept,” 2008). Green House development and growth The first GH, which opened in 2003, was actually a complex of four GHs, on the campus of United Methodist Senior Services in Tupelo, Mississippi (Woodrick, 2003), soon followed by six more homes in Tupelo. With the much publicized success of the Tupelo project, and a $10 million grant from the Robert Wood Johnson Foundation, many more have been built and put into use around the country. On December 5, 2008, on target with its Green House Replication Project, the fiftieth GH opened in the United States, one year earlier than anticipated (“The Green House Replication Initiative,” 2008; “Green Houses Growing in Numbers Across the States,” 2008). The homes are built by NCB Capital Impact Development Corporation, under the direction of Bill Thomas and the Green House Project Team (The Center for Growing andSkilled Care/Nursing Care: A Becoming). The 2006 published goal was to have, within five years, atlevel of care that includes help least one GH in every state (“Green Houses Growing in Numbers Acrosswith more complex nursing tasks,such as monitoring medications, the States,” 2008).giving injections, caring for wounds, “The Green House” is a trademarked model. Any nursing care facilityand providing nourishment by bearing that label must meet certain standards for construction, livingtube feeding (enteral feeding).It also includes therapies, such as arrangements, care, and other features” (DeBolt, 2008, [n.p.]). Becauseoccupational, speech, respiratory GHs are licensed as nursing homes or skilled nursing facilities and meetand physical therapy. This carecan be given in a patient’s home all federal regulations, they qualify for Medicaid reimbursement and canor in a care setting. Most insurance largely operate within Medicaid payments, with the exception of a fewplans require at least some level of states where Medicaid reimbursement is much below average (Jenkens,need for skilled care, requiring theservices of a licensed professional [n.d.]).(such as a physician, nurse, ortherapist), before they will cover The Wellspring Modelother home-care services. In keeping with the overall theme of the culture change movement, and with many of the principles and practices of the Eden Alternative and the Green House project, the Wellspring Model’s major emphasis is on quality improvement through both improved clinical care and 19
  22. 22. Module 2.7.1 – The Management-Resident Relationship CASP Core Course 2, Section 7 organizational culture change. The Wellspring model is a product of Wellspring Innovative Solutions, Inc., arising out of an alliance of 11 freestanding, nonprofit nursing homes in eastern Wisconsin (Stone et al., 2002). The organization was formed in 1994 and fully implemented in 1998. Within its 11 otherwise independent nursing homes, it espoused six core elements: (Reinhard & Stone, 2001): • An alliance of nursing homes with top management committed to making quality of resident care a top priority; • Shared services of a geriatric nurse practitioner, who develops training materials and teaches staff at each nursing home how to apply nationally recognized clinical guidelines; • Interdisciplinary “care resource teams” that receive training in a specific area of care and are responsible for teaching other staff at their respective facilities; • Involvement of all departments within the facility and networking among staff across facilities to share what works and what does not work on a practical level; • Empowerment of all nursing home staff to make decisions that positively affect the quality of resident care and the work environment; and • Continuous reviews by CEOs and all staff of performance data on resident outcomes and environmental factors relative to other nursing homes in the Wellspring alliance.Nurse Practitioner (NP): A The best known study of outcomes, assessing the 11 WisconsinRegistered Nurse with advancededucation and training. NPs can pilot facilities only, seems to be the report by Stone et al., with supportdiagnose and manage most provided by the Commonwealth Fund (Stone et al., 2002; “Improvingcommon, and many chronic, illnesses. the Quality of Nursing Home Care: The Wellspring Model,” 2004).They do so alone or in collaborationwith the healthcare team. NPs can Results were generally positive:prescribe medications and provide • Retention rate for Wellspring staff increased slightly.some services that were formerlypermitted only to doctors. There • Wellspring facilities performed better on annual state inspections.are a number of types of nurse The number of nursing homes with severe deficiencies fell from 22%practitioners (geriatric, adult, to 0.psychiatric-mental health) who workwith older adults. • Evidence suggests that Wellspring staff are more vigilant in assessing problems in quality and take a more proactive approach to resident care. • Wellspring residents appear to enjoy a better quality of life.20
  23. 23. CASP Core Course 2, Section 7 Module 2.7.1 – The Management-Resident Relationship • Implementation was essentially cost neutral. Costs were generally neither more nor less. In the words of Roman emperor/philosopher Marcus Aurelius, “Dig within. Within is the wellspring of Good; and it is always ready to bubble up, if you just dig” (“Wellspring Definition,” 2009, [n.p.]). Other Culture Change Models or Paradigms Multiple other culture change proposals and programs have also surfaced. A few of them are briefly described below. Eldershire The Eldershire Community is also a product of Dr. Bill and Jude Thomas’ imagination and dedication to expanding and enhancing the quality of life of elders and their families and caretakers. It is a planned intergenerational community, designed to promote an active and ongoing exchange among the generations. An Eldershire Community contributes to bettering the quality of life by strengthening and improving the means by which 1) the community protects, sustains, and nurtures its elders, and 2) the elders contribute to the well-being and foresight of the community (“Basic Tenets of the Eldershire Vision,” 2008). An Eldershire is a community where residents work together to effect the realization of well-being, the elements of which include identity, autonomy, security, connectedness, meaning, joy, and space (“Basic Tenets of the Eldershire Vision,” 2008). Eldershire residents are empowered to collaborate in the design and ongoing development and management of their communities. Private homes are “grouped together with common indoor and outdoor spaces, including walking spaces, gardens, and a central house that will offer shared meals, meeting spaces, recreational activities and basic services.” Communities will have “shared values, including respect for the contributions made by elders, accessible housing design, economic and environmental sustainability, commitment to life-long learning, and self- governance” (“Dr. Bill Thomas to Speak at Vital Aging Network Forum on February 14,” 2006, [n.p.]). Elder cohousing A multitude of cohousing units have sprung up across the country. These are planned communities that are nearly identical to Eldershires, 21
  24. 24. Module 2.7.1 – The Management-Resident Relationship CASP Core Course 2, Section 7 in that they offer six common characteristics: participatory process, design for community, shared common facilities, resident management, collaborative decision-making, and no shared community economy (i.e., not income-sharing) (Abraham & deLaGrange, 2006). Unlike Eldershire Communities, they tend to enlist elders only, although they may be situated adjacent to multi-generational communities; and they tend to focus more heavily on shared values, such as spiritual growth and sharing, a holistic view of aging, and meta-issues such as illness and dying. Unlike Eldershires, they tend perhaps to offer a little more planned uniformity and less diversity. But their practical assets are nearly identical to Eldershires, emphasizing resident empowerment, mutual respect, shared values, active lifestyle, social integration, some centralized or shared services, economic and environmental sustainability, and general social consciousness. Depending on the culture of the community and the choice of shared values, these Elder cohousing communities would seem immensely appealing to many of this country’s emerging boomers (“Building Premiere Retirement Communities for Today’s Active Seniors,” 2007). The first cohousing communities in this country were organized in the late 1980s, patterned after the Scandinavian model. They have alsoContinuing Care Retirement been a presence in Denmark since the late 1980s. As of about 2006,Community (CCRC): A housing there were roughly 5,000 people living in 80 cohousing communitiesoption that offers a range ofservices and levels of care. across the United States. As elder cohousing communities are deliberatelyResidents may first move into an small in size, rarely exceeding 40 households per neighborhood, theirindependent living unit, a privateapartment, or a house on the residents have the opportunity to know one another well and developCCRC campus. The CCRC provides closer relationships. In contrast, some retirement communities maysocial and housing-related services contain as many as 500 to 10,000 households. Many other pre-plannedand may have an assisted livingresidence and a nursing home, often communities, such as continuing care retirement communities (CCRCs)called the healthcare center, on the do not allow residents the opportunity to participate in the community-campus. If and when residents canno longer live independently in their envisioning process, where they develop deeper connections with otherapartment or house, they move into residents and the community as a whole (“Elder Co-Housing: Building aassisted living (unless it is provided Collaborative Elderhood,” 2006).in their apartment or house) or thenursing home. The Pioneer Network The Pioneer Network began in 1997, when a group of 33 LTC professionals met in Rochester, New York, to discuss novel approaches to LTC that, whether knowingly or not, would parallel the principles of the22
  25. 25. CASP Core Course 2, Section 7 Module 2.7.1 – The Management-Resident Relationship culture change movement. Susan Misiorski (2003), the Network’s CEO,Assisted Living/Personal Care envisions a culture of aging that is life-affirming, satisfying, humane,Homes/Residential Care Facilities: and meaningful in whatever setting Elders live—home, assisted living,A state-regulated and -monitored or nursing home. The Pioneer Network is committed to working withresidential long-term care optionthat may have different names, state culture change coalitions that currently exist in 33 states, to helpdepending on the state. Assisted create home and community and advocate for change (Lieblich, 2008). Itliving provides or coordinatesoversight and services to meet seeks “a transformation of the entire culture of aging through education,residents’ individualized, scheduled advocacy, leadership development, and resource support” (Nissenboim,needs, based on the residents’assessment and service plans, 2004, [n.p.]). The Pioneer Network advocates for elders across theand their unscheduled needs as spectrum of living options (which are often dictated by differing levelsthey arise. There are more than of medical care required); and is working towards a culture of aging26 designations that states use torefer to what is commonly known as that supports the care of elders in settings where individual voices are“assisted living.” There is no single heard and individual choices are respected, whether in nursing homes,uniform definition of assisted living,and there are no federal regulations transitional care settings, or wherever home and community may be.for assisted living. In many states, Cultivating and maintaining a community of relationships are importantmost assisted living is private pay.Be sure to check with your state at every phase of life, but are especially critical for elders and the aging,about any waiver programs that many of whom may need a network of partners to live life to its fullest.may be available through Medicaidto pay for the care provided in The Pioneer Network provides a global perspective for LTC facilitiesassisted living. to be the senior advocate beyond their four walls (“Pioneer Network:Independent Living: A residential Culture Change in medicaid,” 2009).location (including rental-assisted ormarket-rate apartments or cottages)that may or may not provide Continuing care retirement communitieshospitality or supportive services. Also sometimes called life care communities, CCRCs tend to beResidents can choose which servicesthey want. Additional fees may be large complexes that provide resident housing over a range of care-charged for some services. dependency, from independent living units, to assisted living units,Long-Term Care (LTC): A term to nursing home accommodations. Independent living units may beused to describe the care neededby someone who must depend on small or large apartments, cottages, cluster homes, or single-familyothers for help with daily needs. dwellings. Assisted living quarters are usually small studio or one-LTC is designed to help people withchronic health problems or dementia bedroom apartments. Nursing home accommodations historically haveto live as independently as possible. been one-room units for two or more persons. As these facilities are allAlthough many people think thatlong-term care is provided only in a on the same grounds, all residents are nearby and can be transferred upnursing home, in fact most long-term or down the range of required services as needed, much like aging incare is given by family caregivers inthe elder’s home. place. For this reason, CCRCs have been popular with some, although they tend to be expensive, with entrance fees ranging up to as much as $400,000 and monthly payments ranging from $200 to $2,500. Some are affiliated with a specific ethnic, religious, or fraternal order, where membership may be a requirement for admission (“Other Options: 23
  26. 26. Module 2.7.1 – The Management-Resident Relationship CASP Core Course 2, Section 7 CCRCs,” 2004). Furthermore, these communities do not lend themselves easily to culture change transformation, with its emphasis on small size, resident empowerment and privacy, and organizational reform. The continued and rapid growth of the various culture change models will force these more traditional and outmoded multifaceted communities to either rebuild or remodel, or become extinct. As admission to a CCRC is usually a one-time event, all three levels of care must eventually adopt resident-centered care principles and practices, including perhaps elderMedicaid: The federally- and state-supported, state-operated public cohousing communities and Green House construction and practiceassistance program that pays for services to low-incomepeople, including older adults ordisabled persons who qualify. The Evercare care modelMedicaid pays for long-term nursing Evercare is included here because it is a rather innovative approachhome care and some limited homehealth services, and it may pay to helping elderly persons or those with chronic or debilitating illnesses,for some assisted living services, and because it usually involves and is focused on the elderly. Organizeddepending on the state. It is the by two Minnesota nurse practitioners over 20 years ago, Evercare is anlargest public payer of long-termcare services, especially nursing agency that assigns a nurse practitioner to every Evercare member, tohome care. Each state can determine assist that member in negotiating the healthcare system. Evercare nursesthe breadth and extent of whatservices it will cover above a certain help coordinate care by collaborating with physicians, nursing homes,federally required minimum. and families. They are trained to deliver personalized and compassionateMedicare: The federal program care, both to persons in nursing homes and to individuals livingthat provides medical insurance for independently at home. They serve hundreds of thousands of people inpeople aged 65 and older, somedisabled persons, and persons with 38 states through Medicare and Medicaid health plans (“Evercare: Aboutend-stage renal disease. It provides Us,” 2008).physician, hospital, and medicalbenefits for individuals over age 65,or those meeting specific disability Coming Home Programstandards. Benefits for nursing home “The Coming Home Program is designed to bring the benefits ofand home health services are limitedto short-term rehabilitative care. assisted living to low-income, frail seniors living in rural areas” (“ComingDifferent parts of Medicare cover Home Program,” 2008, [n.p.]). Assisted living facilities may be scarce orspecific services if you meet certain absent in sparsely populated areas of the country, and many charge $100conditions. For detailed information,visit the website (www.medicare. or more per day, which is out of the price range of many rural; retrieved on October 1, As a result, many of these seniors must either relocate some distance to a2009) or call 1-800-Medicare forassistance. place where assisted living services are available, or be prematurely placed in nursing homes. The Coming Home Program seeks to rectify this situation by providing technical assistance and grants to both providers and states.24