This document summarizes Sally Damm's professional report on the journey of one nursing home's transition from a medical model to a resident-centered culture change model over 10 years. The nursing home implemented the Alleviating Loneliness in a Vibrant Environment (A.L.I.V.E.) philosophy to shift from an institutional, sterile environment to one focused on residents' individual needs and preferences. National studies show most people view nursing homes negatively as places to die rather than live. Common complaints involve inadequate care, neglect, and abuse. The nursing home faced resistance but was able to successfully integrate children and make other changes to create a more home-like environment while maintaining quality care.
DIFFERENCE BETWEEN COMMUNITY HEALTH NURSING & INSTITUTIONAL NURSING HEALTHMAHESWARI JAIKUMAR
This document compares and contrasts community health nursing and institutional nursing. Community health nursing involves providing care in the community where people live and work, such as homes, farms, schools and clinics. It focuses on primary care and serving the overall community. Institutional nursing provides care in hospitals and involves secondary and tertiary care for sick individuals. It focuses on diagnostic and therapeutic care for episodic illnesses. The key differences between the two are their place of work, clientele, level of care provided, and roles and responsibilities of the nurses.
Cultural Influence on Child and Maternal Health in Singkil District, ACEH, In...iConferences
Prepared by Daniel Richard Kambey, The University of Tokyo, Japan for International Conference on Public Health and Well-being 2019, 4-5 April, Negombo, Sri Lanka
Co-Authors
Amandha BTR, Fitriana, Ayuningtyas SL
This document discusses models of integrating behavioral and primary health care. It begins by outlining some of the problems with the current lack of integration, such as high rates of untreated mental illness among children. Several collaborative care models are presented, including co-location, integrated care, and the patient-centered medical home model. Successful examples of integrated care programs in both adult and pediatric settings are described. The document argues that the medical home model provides an opportunity to engage patients in services without stigma and to shift costs from acute to preventive care. It concludes by noting the inconsistent use of terminology in describing collaborative versus integrated care models.
This paper analyzes the determinants of health facing residents of Vancouver's Downtown Eastside neighborhood. It identifies two key determinants: income and social status, and education and literacy. Poverty and lack of education are barriers to accessing health services, nutrition, and stable housing. The "Hello Neighbour Project" aims to educate the public about residents' challenges and lives in order to gain support. The paper recommends health promotion interventions like developing affordable housing, increasing access to services, and co-locating health centers to address chronic illnesses linked to social determinants of health in the neighborhood.
Volunteer Services Program by Kamran Ishfaq, PhD Scholar in Sociology, University of Peshawar, Social Welfare Officer, The Children's Hospital & the Institute of Child Health Multan. Ph: 0300-7303808. email. hikami36@hotmail.com.
Deepti Reddy is a physician who received her MD from Wayne State University in 2010 and her MPH from the University of Michigan in 2015. She completed residencies in family medicine and preventive medicine. She operates an integrative medicine practice in Ann Arbor focused on bio-psycho-socio-spiritual health. She has experience in clinical practice, public health, research, and leadership roles promoting integrative and holistic approaches to health.
Living University of Postural Care - Living Local Postural Care Project Evalu...Sarah Clayton
The document provides an evaluation of a postural care training project involving 186 learners. The project aimed to raise awareness that body shape distortion is avoidable for those with mobility issues and to teach postural care techniques. Postural Care CIC delivered 5 accredited training courses covering topics like pain assessment, thermal comfort, and 24-hour positioning. Feedback was overwhelmingly positive, with over 85% of participants passing. Attendees found learning how bodies change shape and hands-on practice most useful, and felt the information should be more widely available. The evaluation concludes the project successfully challenged assumptions and built expertise in postural care.
DIFFERENCE BETWEEN COMMUNITY HEALTH NURSING & INSTITUTIONAL NURSINGMAHESWARI JAIKUMAR
This document compares and contrasts community health nursing and institutional nursing. Community health nursing involves providing care in the community where people live and work, such as homes, farms, schools and clinics. It focuses on primary care and serving the overall community. Institutional nursing provides care in hospitals and involves secondary and tertiary care for sick individuals. The nature of care differs between the two settings, with community health nursing emphasizing comprehensive and continuous promotive, preventive, curative and rehabilitative care, while institutional nursing focuses mainly on diagnostic and therapeutic episodic care when people are sick.
DIFFERENCE BETWEEN COMMUNITY HEALTH NURSING & INSTITUTIONAL NURSING HEALTHMAHESWARI JAIKUMAR
This document compares and contrasts community health nursing and institutional nursing. Community health nursing involves providing care in the community where people live and work, such as homes, farms, schools and clinics. It focuses on primary care and serving the overall community. Institutional nursing provides care in hospitals and involves secondary and tertiary care for sick individuals. It focuses on diagnostic and therapeutic care for episodic illnesses. The key differences between the two are their place of work, clientele, level of care provided, and roles and responsibilities of the nurses.
Cultural Influence on Child and Maternal Health in Singkil District, ACEH, In...iConferences
Prepared by Daniel Richard Kambey, The University of Tokyo, Japan for International Conference on Public Health and Well-being 2019, 4-5 April, Negombo, Sri Lanka
Co-Authors
Amandha BTR, Fitriana, Ayuningtyas SL
This document discusses models of integrating behavioral and primary health care. It begins by outlining some of the problems with the current lack of integration, such as high rates of untreated mental illness among children. Several collaborative care models are presented, including co-location, integrated care, and the patient-centered medical home model. Successful examples of integrated care programs in both adult and pediatric settings are described. The document argues that the medical home model provides an opportunity to engage patients in services without stigma and to shift costs from acute to preventive care. It concludes by noting the inconsistent use of terminology in describing collaborative versus integrated care models.
This paper analyzes the determinants of health facing residents of Vancouver's Downtown Eastside neighborhood. It identifies two key determinants: income and social status, and education and literacy. Poverty and lack of education are barriers to accessing health services, nutrition, and stable housing. The "Hello Neighbour Project" aims to educate the public about residents' challenges and lives in order to gain support. The paper recommends health promotion interventions like developing affordable housing, increasing access to services, and co-locating health centers to address chronic illnesses linked to social determinants of health in the neighborhood.
Volunteer Services Program by Kamran Ishfaq, PhD Scholar in Sociology, University of Peshawar, Social Welfare Officer, The Children's Hospital & the Institute of Child Health Multan. Ph: 0300-7303808. email. hikami36@hotmail.com.
Deepti Reddy is a physician who received her MD from Wayne State University in 2010 and her MPH from the University of Michigan in 2015. She completed residencies in family medicine and preventive medicine. She operates an integrative medicine practice in Ann Arbor focused on bio-psycho-socio-spiritual health. She has experience in clinical practice, public health, research, and leadership roles promoting integrative and holistic approaches to health.
Living University of Postural Care - Living Local Postural Care Project Evalu...Sarah Clayton
The document provides an evaluation of a postural care training project involving 186 learners. The project aimed to raise awareness that body shape distortion is avoidable for those with mobility issues and to teach postural care techniques. Postural Care CIC delivered 5 accredited training courses covering topics like pain assessment, thermal comfort, and 24-hour positioning. Feedback was overwhelmingly positive, with over 85% of participants passing. Attendees found learning how bodies change shape and hands-on practice most useful, and felt the information should be more widely available. The evaluation concludes the project successfully challenged assumptions and built expertise in postural care.
DIFFERENCE BETWEEN COMMUNITY HEALTH NURSING & INSTITUTIONAL NURSINGMAHESWARI JAIKUMAR
This document compares and contrasts community health nursing and institutional nursing. Community health nursing involves providing care in the community where people live and work, such as homes, farms, schools and clinics. It focuses on primary care and serving the overall community. Institutional nursing provides care in hospitals and involves secondary and tertiary care for sick individuals. The nature of care differs between the two settings, with community health nursing emphasizing comprehensive and continuous promotive, preventive, curative and rehabilitative care, while institutional nursing focuses mainly on diagnostic and therapeutic episodic care when people are sick.
Determinants of delivery of health services by community health workers a cas...Alexander Decker
1) The document examines the determinants of health service delivery by community health workers (CHWs) in Embu District, Kenya.
2) It finds that CHWs provide vital health services at the community level, including referrals, community meetings, and health education. However, household visits are low.
3) The main factors influencing health service delivery are the availability of income, supplies, refresher training, number of days working, feedback, and disease knowledge. Older and younger CHWs and male CHWs were more active than others.
This document contains quotes from various nurses and healthcare professionals discussing why they chose their profession and what matters most to them. Many expressed their passion for caring for patients and helping improve peoples' lives, independence, and quality of life. Others mentioned ensuring high standards of care, safety, and optimizing treatment through education and new technologies like telehealth.
The document discusses the roles and responsibilities of local health departments in providing public health services. It describes how the nearly 3,000 local health departments in the US vary in size and services depending on the community needs. The core services identified by the National Public Health Performance Standards Program include monitoring health status, diagnosing and investigating diseases, informing and educating the public, developing health policies and plans, and enforcing regulations. Employees of local health departments are responsible for assessing community health needs, investigating disease outbreaks, providing health education, and ensuring access to healthcare. The Washington County Health Department in Tennessee was used as an example, outlining its mission and services such as WIC, immunizations, and health promotion programs.
This document provides information about three programs that received the 2015 AHA NOVA Award for improving community health. The first summary describes a partnership between United Global Outreach and Florida Hospital in Orlando to transform the poor community of Bithlo, Florida through initiatives like a medical village, affordable housing, and improved infrastructure. The second summary discusses the Mayor's Healthy City Initiative in Baton Rouge, Louisiana, a collaboration of over 70 organizations focused on issues like obesity, HIV, and emergency department overuse. The third summary outlines Presbyterian Healthcare Services' program in Albuquerque, New Mexico to address food insecurity and related health issues in the rural South Valley region through initiatives improving access to healthy, affordable food.
This document introduces standards for social work practice in health care settings developed by the National Association of Social Workers (NASW). It provides background on the role of social workers in health care, outlines guiding principles for social work, and defines key terms. The standards are intended to enhance social workers' skills and knowledge when working with individuals, families, providers, and communities in health care.
The document discusses how social and environmental factors impact health and access to healthcare. It outlines that where someone lives determines their health based on things like water quality, smoking bans, food access, and healthcare resources. Access to healthcare varies across communities based on race, income, education, insurance status, and disability. A behavioral model shows how predisposing characteristics, enabling factors, and health needs influence healthcare utilization. Neighborhood characteristics like socioeconomic disadvantage, physical environments, and social networks can decrease access to primary care and increase unmet needs. Investing in community prevention and changing neighborhood environments can increase access and produce healthcare savings.
This document provides an overview of India's health care system and services. It discusses the purpose of health care and characteristics of a good health service. The major agencies that make up India's health care system are described, including the public health sector, private sector, indigenous medicine systems, voluntary agencies, and national health programs. It then focuses on primary health care in India, describing the three-tier rural health care delivery system and the roles of village health guides, local dais, anganwadi workers, and ASHAs at the village level. Finally, it discusses the sub-centre and primary health centre levels of the health care system.
Performance of Community Health Workers: Optimizing the benefits of their uni...REACHOUTCONSORTIUMSLIDES
This document discusses factors that influence the performance of community health workers (CHWs), including both "hardware" factors like training, supervision, and supplies, as well as "software" factors like relationships, trust, and power. It presents a framework showing how the broader community and health sector contexts can influence mechanisms like trusting relationships between CHWs and communities or health workers, leading to outcomes like high or weak performance. The intermediate position of CHWs between communities and the health sector is also discussed.
This document discusses using the Community Empowerment theory to address uncontrolled type 2 diabetes in urban African Americans. It notes that African Americans have higher rates of diabetes and poorer outcomes. The theory focuses on community involvement, lay health workers, and reciprocal health to empower communities and improve self-management. The document proposes that community health workers could help address barriers African Americans face in managing diabetes.
Mary Elizabeth Nuttall received a Master's in Public Health from the University of Georgia in 2016 with a concentration in Health Promotion and Behavior. She also received a Bachelor's in Health Promotion and Behavior from UGA in 2016. Her research has focused on metabolic syndrome risk factors in St. Lucia and post-traumatic stress disorder following civil wars. She has held research positions with UGA, the American Cancer Society, and the CDC Museum. Nuttall has also volunteered extensively on campus and in the community. She received the CURO Scholarship and Zell Miller Scholarship for her academic achievements.
The document discusses the importance of resilient health systems and the role of nurses in building resilience. It makes three key points:
1. Resilient health systems are able to respond effectively to challenges and are key to achieving health-related sustainable development goals. Factors like governance and human resources contribute to resilience.
2. Nurses are well-positioned to strengthen health system resilience due to their presence across all care settings and large overall numbers. Their skills and roles in coordination, community work, and data collection support resilient systems.
3. Building resilience requires collaboration, leadership, and developing personal resilience among nurses. Nursing must be recognized at all policy levels to strengthen systems. Their contributions are vital to universal health
The document discusses access to healthcare as defined by Healthy People 2020, including key determinants of health and implications of access such as quality of care and equitable delivery of services. It also outlines dimensions of access related to availability, accessibility, affordability, accommodation, and acceptability. Barriers to access and populations most affected are identified along with solutions provided by the Affordable Care Act.
This document discusses several key issues and challenges facing nursing as a profession. It outlines 4 main issues: 1) Lack of health workers and nurses in poor rural areas due to personal orientations, working conditions, and lack of plantilla positions. 2) Low wages and poor working conditions due to lack of full implementation of relevant laws and benefits being given only partially. 3) Heavy workload due to understaffing resulting in overtime or 16-hour shifts with lack of equipment and supplies. 4) Unfair labor practices such as demands for experience and oversupply of nurses leading to volunteerism. Options proposed include fully implementing relevant laws, increasing health budget allocation, and positioning nurses as leaders in primary healthcare.
Community health nursing aims to promote health and prevent illness at the community level. It identifies community health problems, supports community participation in health initiatives, and works to improve overall community health. Community health nurses perform managerial, nursing, educational, and other roles. Their work settings include homes, schools, workplaces, institutions, and the broader community. The goals of community health nursing are to increase life expectancy, reduce mortality rates, prevent disabilities, provide health services, evaluate health programs, and strengthen community resources.
Care farming in the UK: Evidence and OpportunitiesElisaMendelsohn
Care farming in the UK provides physical and mental health benefits to a wide range of people through agricultural activities. There are over 76 care farms in the UK, employing over 650 paid staff and volunteers. Care farms offer services like developing basic skills, work skills, and social skills. A survey found improvements in participants' physical health, self-esteem, well-being, mood, confidence, and social skills. Care farming has potential to benefit farmers, health services, and communities in the UK.
The principles of primary health care according to the document include equitable distribution of health services to all people irrespective of ability to pay, community participation in health programs, use of appropriate and affordable technologies, and a multisectoral approach involving coordination between health and other sectors. Primary health care aims to provide universally accessible essential health services through community involvement at a cost communities can afford.
District Care provides home care services that aids independent living, respect for individual choice, cultures and personal values. Professional home care.
This document provides an introduction to community and community health concepts. It defines a community as a social group within geographical boundaries that interacts and shares common values. A community has defined roles and functions for its members. Community health refers to the health status, problems, and care provided to the whole community. The objectives of community health are to promote health, diagnose and treat diseases early, and control disability through organized community efforts. Community health nursing aims to empower communities to improve health through education and programs tailored to their needs and resources.
This document discusses family health nursing. It defines family health nursing as providing health care to families within the scope of nursing practice. It discusses key concepts like the family as a unit and how individuals, families, and society intersect. The objectives of family health nursing are to identify family health needs, ensure understanding of problems, plan and provide services, help families develop abilities, and educate family members. Principles include establishing relationships with families and providing services without discrimination. Approaches include seeing the family as context, client, or a system. The nursing process involves assessment, planning, implementation, and evaluation.
Rich Goidel is an expert in many roles including technologist, business consultant, producer, and more. He has over 30 years of experience in fields such as creative direction, technical direction, marketing, development, and instruction. He currently holds several roles including President of McGill and instructor.
Nadley Alexis has provided a resume summarizing their relevant skills, qualifications, education and work experience. They have experience in stocking/packaging and machine operation roles with companies like Schick-Wilkinson Sword as well as security officer training. Their objective is to obtain long term employment with growth potential where they can contribute their hard work and positive attitude.
Determinants of delivery of health services by community health workers a cas...Alexander Decker
1) The document examines the determinants of health service delivery by community health workers (CHWs) in Embu District, Kenya.
2) It finds that CHWs provide vital health services at the community level, including referrals, community meetings, and health education. However, household visits are low.
3) The main factors influencing health service delivery are the availability of income, supplies, refresher training, number of days working, feedback, and disease knowledge. Older and younger CHWs and male CHWs were more active than others.
This document contains quotes from various nurses and healthcare professionals discussing why they chose their profession and what matters most to them. Many expressed their passion for caring for patients and helping improve peoples' lives, independence, and quality of life. Others mentioned ensuring high standards of care, safety, and optimizing treatment through education and new technologies like telehealth.
The document discusses the roles and responsibilities of local health departments in providing public health services. It describes how the nearly 3,000 local health departments in the US vary in size and services depending on the community needs. The core services identified by the National Public Health Performance Standards Program include monitoring health status, diagnosing and investigating diseases, informing and educating the public, developing health policies and plans, and enforcing regulations. Employees of local health departments are responsible for assessing community health needs, investigating disease outbreaks, providing health education, and ensuring access to healthcare. The Washington County Health Department in Tennessee was used as an example, outlining its mission and services such as WIC, immunizations, and health promotion programs.
This document provides information about three programs that received the 2015 AHA NOVA Award for improving community health. The first summary describes a partnership between United Global Outreach and Florida Hospital in Orlando to transform the poor community of Bithlo, Florida through initiatives like a medical village, affordable housing, and improved infrastructure. The second summary discusses the Mayor's Healthy City Initiative in Baton Rouge, Louisiana, a collaboration of over 70 organizations focused on issues like obesity, HIV, and emergency department overuse. The third summary outlines Presbyterian Healthcare Services' program in Albuquerque, New Mexico to address food insecurity and related health issues in the rural South Valley region through initiatives improving access to healthy, affordable food.
This document introduces standards for social work practice in health care settings developed by the National Association of Social Workers (NASW). It provides background on the role of social workers in health care, outlines guiding principles for social work, and defines key terms. The standards are intended to enhance social workers' skills and knowledge when working with individuals, families, providers, and communities in health care.
The document discusses how social and environmental factors impact health and access to healthcare. It outlines that where someone lives determines their health based on things like water quality, smoking bans, food access, and healthcare resources. Access to healthcare varies across communities based on race, income, education, insurance status, and disability. A behavioral model shows how predisposing characteristics, enabling factors, and health needs influence healthcare utilization. Neighborhood characteristics like socioeconomic disadvantage, physical environments, and social networks can decrease access to primary care and increase unmet needs. Investing in community prevention and changing neighborhood environments can increase access and produce healthcare savings.
This document provides an overview of India's health care system and services. It discusses the purpose of health care and characteristics of a good health service. The major agencies that make up India's health care system are described, including the public health sector, private sector, indigenous medicine systems, voluntary agencies, and national health programs. It then focuses on primary health care in India, describing the three-tier rural health care delivery system and the roles of village health guides, local dais, anganwadi workers, and ASHAs at the village level. Finally, it discusses the sub-centre and primary health centre levels of the health care system.
Performance of Community Health Workers: Optimizing the benefits of their uni...REACHOUTCONSORTIUMSLIDES
This document discusses factors that influence the performance of community health workers (CHWs), including both "hardware" factors like training, supervision, and supplies, as well as "software" factors like relationships, trust, and power. It presents a framework showing how the broader community and health sector contexts can influence mechanisms like trusting relationships between CHWs and communities or health workers, leading to outcomes like high or weak performance. The intermediate position of CHWs between communities and the health sector is also discussed.
This document discusses using the Community Empowerment theory to address uncontrolled type 2 diabetes in urban African Americans. It notes that African Americans have higher rates of diabetes and poorer outcomes. The theory focuses on community involvement, lay health workers, and reciprocal health to empower communities and improve self-management. The document proposes that community health workers could help address barriers African Americans face in managing diabetes.
Mary Elizabeth Nuttall received a Master's in Public Health from the University of Georgia in 2016 with a concentration in Health Promotion and Behavior. She also received a Bachelor's in Health Promotion and Behavior from UGA in 2016. Her research has focused on metabolic syndrome risk factors in St. Lucia and post-traumatic stress disorder following civil wars. She has held research positions with UGA, the American Cancer Society, and the CDC Museum. Nuttall has also volunteered extensively on campus and in the community. She received the CURO Scholarship and Zell Miller Scholarship for her academic achievements.
The document discusses the importance of resilient health systems and the role of nurses in building resilience. It makes three key points:
1. Resilient health systems are able to respond effectively to challenges and are key to achieving health-related sustainable development goals. Factors like governance and human resources contribute to resilience.
2. Nurses are well-positioned to strengthen health system resilience due to their presence across all care settings and large overall numbers. Their skills and roles in coordination, community work, and data collection support resilient systems.
3. Building resilience requires collaboration, leadership, and developing personal resilience among nurses. Nursing must be recognized at all policy levels to strengthen systems. Their contributions are vital to universal health
The document discusses access to healthcare as defined by Healthy People 2020, including key determinants of health and implications of access such as quality of care and equitable delivery of services. It also outlines dimensions of access related to availability, accessibility, affordability, accommodation, and acceptability. Barriers to access and populations most affected are identified along with solutions provided by the Affordable Care Act.
This document discusses several key issues and challenges facing nursing as a profession. It outlines 4 main issues: 1) Lack of health workers and nurses in poor rural areas due to personal orientations, working conditions, and lack of plantilla positions. 2) Low wages and poor working conditions due to lack of full implementation of relevant laws and benefits being given only partially. 3) Heavy workload due to understaffing resulting in overtime or 16-hour shifts with lack of equipment and supplies. 4) Unfair labor practices such as demands for experience and oversupply of nurses leading to volunteerism. Options proposed include fully implementing relevant laws, increasing health budget allocation, and positioning nurses as leaders in primary healthcare.
Community health nursing aims to promote health and prevent illness at the community level. It identifies community health problems, supports community participation in health initiatives, and works to improve overall community health. Community health nurses perform managerial, nursing, educational, and other roles. Their work settings include homes, schools, workplaces, institutions, and the broader community. The goals of community health nursing are to increase life expectancy, reduce mortality rates, prevent disabilities, provide health services, evaluate health programs, and strengthen community resources.
Care farming in the UK: Evidence and OpportunitiesElisaMendelsohn
Care farming in the UK provides physical and mental health benefits to a wide range of people through agricultural activities. There are over 76 care farms in the UK, employing over 650 paid staff and volunteers. Care farms offer services like developing basic skills, work skills, and social skills. A survey found improvements in participants' physical health, self-esteem, well-being, mood, confidence, and social skills. Care farming has potential to benefit farmers, health services, and communities in the UK.
The principles of primary health care according to the document include equitable distribution of health services to all people irrespective of ability to pay, community participation in health programs, use of appropriate and affordable technologies, and a multisectoral approach involving coordination between health and other sectors. Primary health care aims to provide universally accessible essential health services through community involvement at a cost communities can afford.
District Care provides home care services that aids independent living, respect for individual choice, cultures and personal values. Professional home care.
This document provides an introduction to community and community health concepts. It defines a community as a social group within geographical boundaries that interacts and shares common values. A community has defined roles and functions for its members. Community health refers to the health status, problems, and care provided to the whole community. The objectives of community health are to promote health, diagnose and treat diseases early, and control disability through organized community efforts. Community health nursing aims to empower communities to improve health through education and programs tailored to their needs and resources.
This document discusses family health nursing. It defines family health nursing as providing health care to families within the scope of nursing practice. It discusses key concepts like the family as a unit and how individuals, families, and society intersect. The objectives of family health nursing are to identify family health needs, ensure understanding of problems, plan and provide services, help families develop abilities, and educate family members. Principles include establishing relationships with families and providing services without discrimination. Approaches include seeing the family as context, client, or a system. The nursing process involves assessment, planning, implementation, and evaluation.
Rich Goidel is an expert in many roles including technologist, business consultant, producer, and more. He has over 30 years of experience in fields such as creative direction, technical direction, marketing, development, and instruction. He currently holds several roles including President of McGill and instructor.
Nadley Alexis has provided a resume summarizing their relevant skills, qualifications, education and work experience. They have experience in stocking/packaging and machine operation roles with companies like Schick-Wilkinson Sword as well as security officer training. Their objective is to obtain long term employment with growth potential where they can contribute their hard work and positive attitude.
This document discusses VAT (value added tax) for buy-to-let investors in the UK, outlining some key considerations. It notes that rental income from residential properties is usually VAT exempt, meaning VAT paid on related costs may not be reclaimed. Certain property renovations or conversions can qualify for reduced 5% or 0% VAT rates. The document provides two case studies as examples of common VAT issues for buy-to-let projects and how to potentially resolve them through engaging with suppliers and HMRC. The key takeaways are to understand your project's VAT implications, explore available reliefs, communicate effectively with suppliers and tax authorities, and follow the proper steps if a preferential VAT treatment depends on certain actions.
Dash Interior Indonesia was established in June 2014 as a leading interior and furniture design consultant in Indonesia. In January 2015, it collaborated with Great Décor Group, a group of furniture and interior factories in China, to become a supplier and consultant while relying on Great Décor Group for mass production. This collaboration allows Dash Interior Indonesia to provide higher quality furniture and interior decorations to Indonesian customers with promised delivery and attractive prices. The document introduces Dash Interior Indonesia and its collaboration with Great Décor Group to be the sole supplier in Indonesia.
Distance Education Course In B.Sc In Physics In Delhi, Noida @9278888356path2career
We are proving a Distance Education Course In B.Sc In Physics In Delhi, Noida . Interested student can contact 9278888356 or visit : www.path2career.org.
Looking to sell statistical products on Amazon? Do it in five steps, using th...Stats Cosmos
This document provides a five-step guide, three tips, and two blogs for selling statistical products on Amazon. The five steps are: 1) registering and setting up selling, 2) checking private labeling, 3) obtaining product approval, 4) optimizing business processes, and 5) increasing product offerings. The tips suggest signing up for Kindle trials, using social media for marketing, and selling on additional platforms. The blogs recommended for staying up to date are R-bloggers and SAS blogs. Favorite topics and posts from each blog are highlighted.
The document introduces the Silvertech Marketing Team and outlines their lead to loyal customer process. It shows where the team is currently in attracting traffic and capturing leads, with statistics on leads generated since July. It then lists accomplishments and next steps to continue attracting more traffic and capturing additional leads to grow their customer base.
This document provides a summary personal development report for Jean Manson. The report analyzes Jean's basic/natural self, priority environments that require adjustment, and predictor/outward self. It identifies her strengths as adaptability, flexibility, and the ability to assume different roles. It also describes her natural communication, leadership, and back-up styles along with traits, logic, energy levels, and motivators. The report is intended to help Jean better understand herself and develop stronger interpersonal skills.
The document discusses the benefits of exercise for mental health. Regular physical activity can help reduce anxiety and depression and improve mood and cognitive functioning. Exercise causes chemical changes in the brain that may help protect against mental illness and improve symptoms.
This marketing initiative aims to increase employee participation in Everything Electronics' financial wellness program. It proposes producing an instructional movie modeled after "A Christmas Carol" that shows the consequences of poor financial planning. It also suggests holding an internal video competition where employees create before-and-after stories and a rewards card system where employees earn points for engaging with financial lessons. The goal is to make the program more engaging and encourage employees to prioritize their retirement planning.
El documento describe la estructura organizativa de la Dirección Ecológica de Baja California. Se divide en varias subdirecciones y departamentos relacionados con la normatividad ambiental, análisis, autoridad, regulación, consultoría jurídica, auditoría, gestión ambiental y planeación ecológica. También incluye delegaciones en Mexicali, Ensenada y San Quintín.
EDUC 510Interview Assignment Template – Questions for Special EdEvonCanales257
EDUC 510
Interview Assignment Template – Questions for Special Education Teacher or Paraprofessional
Interviewer, you may type the interview responses directly onto this template.
First name or initials of interviewee:
Subjects taught or supported:
Age of students:
Description of the special needs of these students, including:
· Name or types of conditions, syndromes, or disorders in the class
· Physical challenges
· Intellectual challenges
· Emotional challenges
· Social challenges
Equipment, therapies, additional support needed to address classroom challenges:
Activities the class enjoys. Include a description of any adaptations required Qfor students to be able to participate in these activities.
What kinds of skills are required to work with students who have special needs? How do you work with others who support your students?
How has your life been impacted by teaching students with special needs?
Student choice question: Create your own question for the person you are interviewing. Erase this line and type your question in its place.
After you have completed the interview, you will write a 200-word summary of what you learned from the interview and a 300-word conclusion. The conclusion must include citations from at least one scholarly resource and the course textbook. A reference page should be included. The interview template, summary, and conclusion should be submitted in one document.
C A S E
C. W. Williams
Health Center:
A Community
Asset
The Metrolina Health Center was started by Dr. Charles Warren
“C. W.” Williams and several medical colleagues with a $25,000 grant
from the Department of Health and Human Services. Concerned
about the health needs of the poor and wanting to make the world
a better place for those less fortunate, Dr. Williams, Charlotte’s first
African American to serve on the surgical staff of Charlotte Memorial
Hospital (Charlotte’s largest hospital), enlisted the aid of Dr. John
Murphy, a local dentist; Peggy Beckwith, director of the Sickle Cell
Association; and health planner Bob Ellis to create a health facility for
the unserved and underserved population of Mecklenburg County,
North Carolina. The health facility received its corporate status in
1980. Dr. Williams died in 1982 when the health facility was still in
its infancy. Thereafter, the Metrolina Comprehensive Health Center
was renamed the C. W. Williams Health Center.
“We’re celebrating our fifteenth year of operation at C. W.
Williams, and I’m celebrating my first full year as CEO,”
commented Michelle Marrs. “I’m feeling really good about a lot
This case was written by Linda E. Swayne, The University of North Carolina at
Charlotte, and Peter M. Ginter, University of Alabama at Birmingham. It is intended as
a basis for classroom discussion rather than to illustrate either effective or ineffective
handling of an administrative situation. Used with permission from Linda Swayne.
16
both16.indd 742both ...
This is due within 30 hoursIntegrating Literacy ArticleGrazynaBroyles24
***This is due within 30 hours****
Integrating Literacy Article
Literacy is an area that crosses all content curriculum. Without mastery of reading and writing skills, many students will struggle to learn and demonstrate understanding in other content areas. It is important for teachers in all content areas to consistently integrate literacy skills into their curriculum, as well as assess them regularly to support the learning of every student.
As the department lead, your principal has asked you to write an article for the monthly district newsletter explaining the importance of integrating literacy into all classes and content areas.
The 500-750 word article must include the following:
· An engaging title and author byline
· Definition of interdisciplinary literacy and fluency in contemporary education
· Overview of three key theories related to reading and writing processes and development across content areas
· Explanation of how cross-disciplinary instruction supports the historically shared knowledge base of literacy in all content areas
Support your findings with a minimum of 3-5 scholarly resources.
Prepare this assignment according to the guidelines found in the APA Style Guide, located in the Student Success Center. An abstract is not required.
This assignment uses a rubric. Review the rubric prior to beginning the assignment to become familiar with the expectations for successful completion.
You are required to submit this assignment to LopesWrite. A link to the LopesWrite technical support articles is located in Course Materials if you need assistance.
Submit Manuscript | http://medcraveonline.com
Abbreviations: UN, united nations; WHO, world health
organization; PAHO, pan american health organization; UNICEF,
united nations international children’s emergency fund
Introduction
The family has been, is and will be the main social institution
par excellence, the social niche within which bonds of affection are
woven between the members that comprise it. It is therefore an issue
that is of interest to all: society, governments, major international
organizations and individuals in particular. The great events and world
changes are directly and indirectly influencing family processes, to the
point of presenting the so-called “family mutation”, which consists
of the changes that occur within each family and alter the structural
harmony, functional and evolutionary development of the family life
cycle. It is for this reason that addressing the family and family health
from an integral perspective is an arduous task that would require
a much more thorough, exhaustive and detailed review, in order to
show a more complete and complex picture of the situation. However,
it would be interesting to reflect on better ways of caring for the
family, simply by changing the care approach with which families are
intervened and studied.
The purpose of the present paper is to highlight the importance
and recognition that the f ...
The purpose of this Health Policy Study is to better understand adolescents’ views on what are considered core components of the medical home and identify barriers to promoting adolescent health in relation to the medical home.
In addition, this study sought to better understand the needs and challenges in providing adolescents with access to medical homes—from the perspective of both adolescents and experts in adolescent health and medical home policy. To accomplish these goals, researchers conducted focus groups with adolescents, presented these findings to experts, and gathered experts’ reactions to the adolescents’ perspectives. This report includes a detailed description of the methods used for this study, followed by a summary of key focus group findings and the expert reactions to these findings.
The document discusses a research proposal to explore the knowledge that family members of patients admitted to hospice palliative care have, and whether providing an educational meeting can improve that knowledge. The research question asks if implementing an educational meeting improves relatives' knowledge of the importance and scope of palliative care management and treatment. A literature review found that family caregivers often lack knowledge about palliative care and symptoms, and educational interventions have been shown to increase knowledge and improve perceptions of palliative care. The proposal aims to identify current family member knowledge and establish if education meetings can improve their understanding of palliative care.
capstonewritingservice.com provides Nursing capstone project writing service at cheap rate. To get the service please visit here http://www.capstonewritingservice.com/our-affordable-capstone-project-writing-service/nursing-capstone-project-writing-service/
Check this BSN Capstone paper samples to see how to write it right. For more information you can visit site . https://www.capstonepaper.net/our-capstone-papers/capstone-nursing-paper-writing-services/
Diagnosing Human Relations in OrganizationsValerieBez1
This review summarizes the book "Diagnosing Human Relations in Organizations" by Chris Argyris. The book describes a study conducted with nurses and management at a hospital to understand problems in their relationships. Researchers asked both groups about problems and suggestions. For nurses, important findings were their need to feel indispensable but also maintain independence, as well as satisfaction from patient care but not desire for management roles. The book provides suggestions for management to improve work satisfaction and understanding between groups. It also has implications for nursing education. The review praises the book for revealing relationship pressures and tensions in hospitals and offering corrective measures.
Minnesota State University, MankatoCornerstone A Collection.docxARIV4
Minnesota State University, Mankato
Cornerstone: A Collection of
Scholarly and Creative Works for
Minnesota State University,
Mankato
Theses, Dissertations, and Other Capstone Projects
2013
Leadership and the Implementation of Culture
Change in Long-Term Care
Alexandra Natasha Garklavs
Minnesota State University - Mankato
Follow this and additional works at: http://cornerstone.lib.mnsu.edu/etds
Part of the Gerontology Commons
This APP is brought to you for free and open access by Cornerstone: A Collection of Scholarly and Creative Works for Minnesota State University,
Mankato. It has been accepted for inclusion in Theses, Dissertations, and Other Capstone Projects by an authorized administrator of Cornerstone: A
Collection of Scholarly and Creative Works for Minnesota State University, Mankato.
Recommended Citation
Garklavs, Alexandra Natasha, "Leadership and the Implementation of Culture Change in Long-Term Care" (2013). Theses,
Dissertations, and Other Capstone Projects. Paper 1.
http://cornerstone.lib.mnsu.edu?utm_source=cornerstone.lib.mnsu.edu%2Fetds%2F1&utm_medium=PDF&utm_campaign=PDFCoverPages
http://cornerstone.lib.mnsu.edu?utm_source=cornerstone.lib.mnsu.edu%2Fetds%2F1&utm_medium=PDF&utm_campaign=PDFCoverPages
http://cornerstone.lib.mnsu.edu?utm_source=cornerstone.lib.mnsu.edu%2Fetds%2F1&utm_medium=PDF&utm_campaign=PDFCoverPages
http://cornerstone.lib.mnsu.edu?utm_source=cornerstone.lib.mnsu.edu%2Fetds%2F1&utm_medium=PDF&utm_campaign=PDFCoverPages
http://cornerstone.lib.mnsu.edu?utm_source=cornerstone.lib.mnsu.edu%2Fetds%2F1&utm_medium=PDF&utm_campaign=PDFCoverPages
http://cornerstone.lib.mnsu.edu?utm_source=cornerstone.lib.mnsu.edu%2Fetds%2F1&utm_medium=PDF&utm_campaign=PDFCoverPages
http://cornerstone.lib.mnsu.edu/etds?utm_source=cornerstone.lib.mnsu.edu%2Fetds%2F1&utm_medium=PDF&utm_campaign=PDFCoverPages
http://cornerstone.lib.mnsu.edu/etds?utm_source=cornerstone.lib.mnsu.edu%2Fetds%2F1&utm_medium=PDF&utm_campaign=PDFCoverPages
http://network.bepress.com/hgg/discipline/1276?utm_source=cornerstone.lib.mnsu.edu%2Fetds%2F1&utm_medium=PDF&utm_campaign=PDFCoverPages
http://cornerstone.lib.mnsu.edu/etds/1?utm_source=cornerstone.lib.mnsu.edu%2Fetds%2F1&utm_medium=PDF&utm_campaign=PDFCoverPages
LEADERSHIP AND THE IMPLEMENTATION OF CULTURE CHANGE
IN LONG-TERM CARE
By
Alexandra Garklavs
An Alternate Plan Paper Submitted in Partial Fulfillment of the Requirements for
Master of Science
In
Gerontology
Minnesota State University, Mankato
Mankato, Minnesota
May 2013
2
ACKNOWLEDGEMENTS
This project is dedicated to a number of individuals, without whom I could not have
completed this. I would first like to thank my family for their unending support; Mom, you have
always believed in me, giving me support and encouragement. I couldn’t have gotten here
without you! Kate, I can’t thank you enough for all of your support, advice, and good hum ...
Care Coordination in a Medical Home in Post-KatrinaNew OrleaTawnaDelatorrejs
Care Coordination in a Medical Home in Post-Katrina
New Orleans: Lessons Learned
Susan Berry • Eleanor Soltau • Nicole E. Richmond •
R. Lyn Kieltyka • Tri Tran • Arleen Williams
Published online: 14 July 2010
� Springer Science+Business Media, LLC 2010
Abstract This is a prospective study to evaluate ability of a
nurse care coordinator to: (1) improve ability of a pediatric
clinic to meet medical home (MH) objectives and (2)
improve receipt of services for families of children with
special health care needs (CSHCN). A nurse was hired to
provide care coordination for CSHCN in an urban, largely
Medicaid pediatric academic practice. CSHCN were iden-
tified using a CSHCN Screener. Ability to meet MH criteria
was determined using the MH Index (MHI). Receipt of MH
services was measured using the MH Family Index (MHFI).
After baseline surveys were completed, Hurricane Katrina
destroyed the clinic. Care coordination was implemented for
the post-disaster population. Surveys were repeated in the
rebuilt clinic after at least 3 months of care coordination. The
distribution of demographics, diagnoses and percent
CSHCN did not significantly change pre and post Katrina.
Psychosocial needs such as food, housing, mental health and
education were markedly increased. Essential strategies
included developing a new tool for determining complexity
of needs and involvement of the entire practice in care
coordination activities. MHFI showed improvement in
receipt of services post care coordination and post-Katrina
with P \ 0.05 for 13 of 16 questions. MHI demonstrated
improvement in care coordination and community outreach
domains. Average cost was $36.88 per CSHCN per year.
There was significant improvement in the ability of the clinic
to meet care coordination and community outreach MH cri-
teria and in family receipt of services after care coordination,
despite great increase in psychosocial needs. This study pro-
vides practical strategies for implementing care coordination
for families of high risk CSHCN in underserved populations.
Keywords Care coordination � Medical home �
Children with special healthcare needs (CSHCN) �
Title V CSHCN � Hurricane Katrina
Eleanor Soltau has relocated to Atlanta, Georgia, after her
involvement with this research.
S. Berry (&) � N. E. Richmond � A. Williams
Department of Pediatrics, Louisiana State University
Health Sciences Center, 1010 Common Street Suite #610,
New Orleans, LA 70112, USA
e-mail: [email protected]
N. E. Richmond
e-mail: [email protected]
A. Williams
e-mail: [email protected]
E. Soltau
Children’s Hospital Medical Practice Corporation,
New Orleans, LA, USA
e-mail: [email protected]
S. Berry � N. E. Richmond � A. Williams
Louisiana Office of Public Health, Children’s Special Health
Services, New Orleans, LA, USA
R. L. Kieltyka � T. Tran
Department of Pediatrics, Louisiana State University Health
Sciences Center, 1010 Common Street Suite #2710,
New Orleans, LA 7011 ...
Madeleine Leininger developed the Culture Care Theory, which emphasizes that nursing care should be provided in a way that respects a patient's cultural values, beliefs, and practices. Her theory was groundbreaking as the first to incorporate culture and consider it essential to quality nursing care. The theory is depicted in her Sunrise Model and has guided 50 years of research on diverse cultural healthcare practices and their influence on health outcomes.
The document discusses the scope of practice for social workers in medical settings. It begins by providing background on medical social work and its focus on applying social work methods and philosophy to health and medical care. It describes the typical educational requirements to become a medical social worker and provides a brief history of the profession. The bulk of the document then outlines the various roles and responsibilities of medical social workers, which include conducting assessments, providing counseling, advocating for patients, coordinating care, assisting with resources, engaging in research, and administrative duties. It also discusses the various hospital departments social workers support and challenges they may face. In closing, it emphasizes the unique value social workers provide in meeting patient psychosocial needs and enhancing family support.
Going Where the Kids Are: Starting, Growing, and Expanding School Based Healt...CHC Connecticut
Webinar broadcast on: June 28 | 3 P.M. EST
This webinar will address the benefits, challenges, and strategic advantages of a school based health center program from a clinical, data, quality, operational viewpoint, communications, and community engagement perspective. Experts will share the strategy for integrating oral health and behavioral health to ensure the best outcomes for patients.
Meleis's Theory of Transitions and Nursing Home Entryfchiang
Increasing numbers of older adults are entering nursing homes and skilled nursing facilities. Meleis's Theory of Transitions informs nurses how to better understand and develop interventions for the transition process.
1. Preparing HIV+ youth for self-advocacy and self-care is a gradual process that should begin in early adolescence to lay the groundwork for transition to adult care.
2. Key topics to discuss include disclosure, medication adherence, understanding one's diagnosis and health history, identifying adult providers, and transferring care.
3. Encouraging youth to take on more responsibility for their care over time- such as making appointments, understanding medications, and asking providers questions- helps build self-advocacy skills for managing care as an adult.
The document discusses Healthy People 2020 objectives around maternal, infant, and child health. The goals are to improve health and well-being of expectant mothers and infants to determine future generations' health. Objectives include reducing fetal/infant mortality, increasing prenatal care and multivitamin use pre-conception, and reducing substance use during pregnancy. Recommendations include implementing electronic screenings/brief interventions for substance use, quitline programs for smoking cessation, and expanding health insurance coverage for low-income women.
The document discusses the role of nurses and different models of care. It covers topics like the nursing process, assessment, biomedical and holistic models. The biomedical model focuses on the physical body, while the holistic model sees individuals as complex with psychological, social, cultural and spiritual factors influencing health. Over time, perspectives have shifted from biomedicine to recognize broader determinants. Public health aims to improve health through prevention, health promotion, and empowering individuals and communities. The document examines how nursing's role and understanding of health has evolved in relation to changes in models of care and public policy.
The document discusses the importance of documenting social history for older patients in general practice. It found deficits in documenting key details like living arrangements, mobility aids, carers, and language barriers that negatively impact care. A social history checklist was found to help practice nurses and increase collaboration between general practice and aged care providers. The conclusion advocates for improved social history documentation to enhance care coordination and quality of life issues for older patients.
community oeiented nursing and family oriented nursingRahulPawar515923
1) Community-oriented nursing focuses on preserving the health of entire communities and populations, as well as individuals and families. It aims to provide care in community-based settings to reduce healthcare costs.
2) Public health nursing is a form of community-oriented nursing that emphasizes disease prevention for populations through services like health monitoring, policy development, and ensuring access to care.
3) Family-oriented nursing provides care to families as a unit, with the goals of identifying health needs, educating families, and helping them manage health independently.
Similar to DammProfessional paper04-17-22 (4) (20)
community oeiented nursing and family oriented nursing
DammProfessional paper04-17-22 (4)
1. Alleviating Loneliness in a Vibrant Environment:
A. L. I. V. E.
A Journey to Culture Change in Long-Term Care
By
Sally A. Damm
B.S., Huron College, 1977
A Professional Report Submitted in Partial Fulfillment of
The Requirements for the Degree of
Master of Science
Administrative Studies Program
In the Graduate School
The University of South Dakota
3. Table of Contents
Abstractpage3
Verification Statementpage4
Chapter 1page5
Purpose of this Studypage6
Author’s Role in Organizationpage7
Organizational Historypage7
The Problems with Nursing Homespage10
National Ombudsman Reporting Systempage11
The NewsHour with Jim Lehrerpage12
Chapter 2page19
The Culture Change Toolpage20
Chapter3page28
Preparing for the Transitionpagepage29
Implementationpagepage31
Figures
Figure 1.
Figure 2.
Figure 3.
Figure 4.
Figure 5.
Figure 6.
Figure 7.
5. Abstract
This study examines the revolutionary journey that one facility has taken over the
past 10 years to transition from a medical model to a resident centered home for the
elderly. The movement sweeping the nursing home industry in this country is referred
to as culture change. This project documents a paradigm shift away from a staff
directed medical treatment to a resident centered environment that focuses on “living in
a nursing home” rather than “dying at the nursing home”. The result of this study gives
substance to the words “Alleviating Loneliness in a Vibrant Environment”. It documents
living in a nursing home can only be advanced when the leadership adopts a major
change in principles and works toward making actual concrete changes to policies and
practices within the physical environment. This includes management of staff,
empowerment of residents, the education of federal and state licensing agencies and
the community at large.
The facility in this study had a positive image in the community. It had a
successful history of caring for the resident using a model that mirrored the hospital’s
delivery system. This nursing home confronted the uncertainties of long-term-care and
responded to the new consumers’ demands by pledging to change the culture of the
nursing home. This shift of the day-to-day duties away from institutional efficiencies and
medical emphasis to focusing on the consumers’ strengths, desires, likes, dislikes,
routines, needs, and social interests has brought a positive result in several areas.
Culture change can be defined as a nursing home shifting from a cold, sterile, hospital
6. model to an environment that is more centered on the individual needs and unique
preferences of the people who live and work in the facility.
Verification Statement for the MSAS Professional Report
In preparing my MSAS Professional Report, I held myself to a standard of
academic honesty. Academic honesty includes drawing on the work of others in
preparing my Professional Report. I recognized that when I utilized other’s facts or
ideas I made the appropriate citation in the body of the Professional Report, followed by
the appropriate citation in the reference page.
Further, in preparing my Professional Report I did not use the assistance of an
editor other than my advisor. If I did use the assistance of an editor following is the
name and identification of the editor:
Janet Brubakken
1807 Half Moon Road
Brookings, SD 57006
My signature attests that this MSAS Professional Report represents my own
work and that any editorial assistance I had in its preparation was minor.
________________________
Signature
Sally Damm______________
Printed/Typed Name
3
9. The purpose of this study is to document a journey of transition from a medical
model to a resident centered home for the elderly. The movement sweeping the
nursing home industry in this country is referred to as culture change. The documented
paradigm shift away from a staff directed medical routine toward a resident centered
environment that focuses on “living in a nursing home” rather than “dying at the nursing
home” is the basic premise of this philosophy. This sense of living in a nursing home
can only be advanced when the leadership adopts a major change in principles and
works toward making actual concrete changes to policies and practices within the
physical environment. This includes management of staff, empowerment of residents,
and the education of federal and state licensing agencies and the community at large.
Historically, this nursing home cared for the residents using a model that mirrored
the hospital’s delivery system. Culture change is a shift of the day-to-day duties of this
nursing home away from institutional efficiencies and medical emphasis to focusing on
the consumers’ strengths, desires, likes, dislikes, routines, needs, and social interests.
Culture change can be defined as a nursing home shifting from a cold, sterile, hospital
model to an environment that is more centered on the individual needs and unique
preferences of the people who live and work there.
Alleviating Loneliness in a Vibrant Environment (A.L.I.V.E) has been a maturing
philosophy of this author for many years. As a high school student and nursing
assistant at the local nursing home in the early 1970’s, this author began a career
dedicated to healthcare. A.L.I.V.E. was not an acceptable philosophy of elder care for
6
10. the next 30 plus years. The author and the facility staff against all odds pushed through
barriers and implemented the philosophy of A.L.I.V.E.
The author of this report currently is employed as the Administrator and is
responsible for the key services provided by this innovative and progressive 79 bed
Skilled Nursing Home with a 36 bed Assisted Living facility, a 24 apartment complex,
Adult Day Care Program, Respite Care Services and a nationally certified Child
Development Center program for 50 children. All these programs are found on one
intergenerational campus. This organization is certified for participation in the programs
as directed by the Center for Medicare and Medicaid Services (CMS) for the elders and
children that are served.
This free standing facility originated in 1959 by the citizens of the Brookings area.
This organization remains free standing at the present time; however, it became
affiliated with Avera McKennan Health System under a management agreement in
2006. This facility is in a rural community of approximately 18,000 people approximately
an hour away from the Sioux Falls metropolitan area in southeastern South Dakota. The
community is also home to a land grant university.
This corporation is home to residents from age 34 to 104 years, shares space
with children from 4 weeks to 6 years of age, and averages 150 plus employees. This
establishment allows residents to bring their personal pets that meet the safety and
health requirements to live in their home. This institution also has live-in dogs, cats,
birds, plants and a rabbit. This facility was part of the first wave of facilities on the
cutting edge of culture change as the Alleviating Loneliness in a Vibrant Environment
(A.L.I.V.E.) philosophy continues to expand, develop and divide into cells producing
7
11. living, breathing neighborhoods within the facility. During the last ten years under the
leadership of the administrator, this facility has reached out to the community as a
resource service that has endeavored to enhance the quality of care and life its
customers desire and deserve.
This long-term-care home is one of only a few intergenerational care facilities in
South Dakota, and is the only one that integrates the curriculum for children with elders
to the extent that this facility does. Originally, the intergenerational culture change was
met with significant resistance. Because the philosophy implementation involved
significant levels of change for all of the facility departments (house-keeping, dietary,
nursing, social work, etc.), some of the staff were resistant to change. Some battled the
change while others embraced it, and still others chose to leave the facility to work
elsewhere. Many community members were also critical of the mixing of the
generations, and the novelty of a facility that looked and felt much like a family home
rather than a housing unit exclusively for medically needy elders seemed risky. The
leadership and employees committed to preserving the quality of daily medical care but
adopting the culture changes needed to bring “home” back into the nursing home
equation. The leadership continued to be persistent even in the light of strong
confrontation. One of the largest community concerns was the marriage of one of health
care’s lowest cost margin services with another very low cost margin service: childcare.
The apprehension of the community was alarming to this author in that the elderly could
physically or emotionally injure the children, and that the children could expose the
elders to childhood diseases.
8
12. This organization had a successful history of management and care delivery
system; therefore, there were those that were happy with the status quo. Because of the
guidance of the administrator and the leadership team, department managers, and
community supporters not one of the original fears related to developing culture change
have been realized.
The following two sources give the staggering problems that nursing homes face
today. A national study that was aired on National Public Television in 2001 gathered
data that supports the fact that 50% of Americans would be reluctant to move from
home into a nursing home if the need arose. The majority of the public judge that people
who enter a nursing home never leave until death occurs, and nearly 50% of the public
believes that living in a nursing home affects people negatively in all areas of their life
(Jim Lehrer/Kaiser Family Foundation/Harvard, 2001).
Rosalie and Robert Kane in a publication co-authored with Dick Ladd, “The Heart
of Long-term Care”, 1998 states that the bulk of the regulations are based not on
realistic evidence of what activities are associated with better outcomes, but on
professional judgments which quickly approach rules and mandates. Strict statements
about what should be done for whom become rapidly restrictive at a time when long-
term-care is starved for modernization and creativity. There is limited confirmation about
how to deliver the best care and with the knowledge that there is every likelihood that
more than one way is available to achieve a positive outcome, it is premature to
become inflexible or settle on only one method of transforming the culture of the nursing
home.
9
13. This author will address the issue of society’s attitude that a nursing home is a
place for the dying rather than a home for the living. By using the A.L.I.V.E concept,
implementing the programs over a period of 10 years and allowing it to grow, mature
and finally drill deep into the very fabric of the nursing home is just one way to change
the negative image of nursing homes from a “place to die” to a “home in which to live”.
The Problem with Nursing Homes:
Nationally, from 1996 to 2000, the number of grievances submitted to nursing
home staff increased. (Department of Health and Human Services, JULY 2003 p6) If the
grievances were unresolved to the customer’s satisfaction the complaints were
reviewed by state officials. On occasion the federal agency would review the
investigative results and issue a statement of their findings. The categories
of complaints did not change significantly according to the National Ombudsman
Reporting System (NORS) even after the implementation of the national nursing home
reform mandates referred to as the Omnibus Budget Reconciliation Act 87. (OBRA 87)
(Department of Health and Human Services, JULY 2003 p8) Nationally, the NORS
documents that the total number of nursing home complaints increased from about
145,000 in 1996 to roughly 186,000 in 2000. During the same time frame, the number of
objections per 1,000 beds climbed from 78.4 to 102.1. This denotes a 28 percent
increase in the number of complaints and a 30 percent increase in the number of
criticisms per thousand beds. (Department of Health and Human Services, JULY 2003
p10)
The nature of these complaints reported to NORS since 1996 have not been
modified significantly. Nationally, each of the top 12 complaint groupings remained in
10
14. the top 12 between 1996 and 2000. In 2000, these top 12 categories accounted for
more than one-third of the total number of complaints. The allocation of complaints per
1,000 beds shows a comparable uniformity according to the NORS.
According to the NORS the highest occurrences of nursing home complaints
involve resident care. By 1999, complaints regarding resident care (e.g., accidents, not
responding to call lights, patient symptoms unattended) had exceeded those concerning
resident rights (e.g., abuse, access to information, issues about transfer and discharge).
From 1996 through 2000, resident care accusations escalated 37 percent compared to
a 21 percent growth for complaints involving resident rights. As of 2000, 6 of the top 10
identifiable complaint categories were related to resident care.
The NORS has recorded the following complaints as the top six concerns in
nursing homes across the nation:
1. failure to answer to call lights or requests for assistance
2. accidents and inappropriate handling of residents
3. lack of satisfactory care plans and resident assessments
4. incompetent administration of medications
5. unattended resident triggers
6. inadequate personal hygiene
(Department of Health and Human Services, JULY 2003, p 9)
According to the NORS, one of the major changes (for categories with at least
1,000 complaints in the year 2000) is that of complaints regarding staff turnover
increased by approximately 208 percent between 1996 and 2000. (Department of
Health and Human Services, JULY 2003, p15)
11
15. Abuse cases reported to NORS spiked in 1998 and have dropped about 3
percent since then. The total for all reported abuse cases increased from 13,469 in
1996 to 15,501 in 1998, and declined to 15,010 in 2000. Physical abuse was the most
common type of abuse reported. (Department of Health and Human Services, JULY
2003 p10)
A second non governmental national survey completed for The NewsHour with
Jim Lehrer, the Kaiser Family Foundation, and the Harvard School of Public Health
finds that Americans see an important role for nursing homes in providing care for
individuals that are not able to care for themselves, yet they express significant
concerns about the care provided in nursing homes. The majority of the public have the
perception that nursing homes are staff challenged, that staff training programs are
lacking, that residents are abused and neglected, that privacy is limited or does not
exist, that personal belongings are lost or stolen, and that many residents are lonely.
(The NewsHour with Jim Lehrer, 2001)
About half of Americans would rather die than move into a nursing home if the
situation arose that they could not take care for themselves at home. (Department of
Health and Human Services, JULY 2003 p10)
12
16. According to the NewsHour with Jim Lehrer the vast majority of the public
believes that most people entering a nursing home never go home, and nearly half the
public believes that once people enter the nursing home their condition worsens and
that they will die.
Approximately one third of people utilizing a nursing home have made a
complaint to the administration of a nursing home. Often these complaints were not
resolved to their satisfaction and one in ten continued their request upward to a state or
federal government agency, according to The NewsHour with Jim Lehrer report.
Figure 1 Public Perceptions of Nursing Home Residents
13
17. Nursing homes receive mixed ratings from Americans with about a third of the
respondents saying that nursing homes are doing a good job serving health care
consumers (34%). However, 66% of the people rated the facility below acceptable
outcomes. Americans agree (52%) that nursing home residents participate in more
recreational and social activities than when they were living at home, however, 44% do
not agree with this belief (The NewsHour with Jim Lehrer, 2001 p28)
Figure 2 Public Perceptions of Nursing Home Staff
14
18. Figure 3. Positive Public Perceptions about Nursing Homes
The general public (50%) believes nursing home residents do not live in clean
facilities. A large majority (80%) consider nursing homes understaffed, and (65%) of
Americans think the staff at nursing homes are inadequately trained as reported by the
televised NewsHour with Jim Lehrer on public television in 2001. (The NewsHour with
Jim Lehrer, 2001 p28)
15
19. Another frightening statistic reported on the The NewsHour with Jim Lehrer
referred to the public image, perceptions and factual experiences that were reported.
Nationally, 77% of these surveyed believe the staff neglects and overmedicate at least
some nursing home residents respectively. Approximately two thirds or (67%) respond
that staff abuse and use physical restraints on nursing home residents.
Figure 4 Negative Public Perceptions about Nursing Homes
16
20. Figure 5. Public Experiences with Nursing Homes
It is unfortunate that six in ten of the survey populace thinks that residents are not
treated with dignity, nor do they have privacy, and that their personal belongings are lost
or stolen within the institutional setting. Finally, the majority of (63%) the public
perceives that many or almost all nursing home residents feel lonely, isolated, and have
less than adequate recreational and social activities.
In 2002, Mr. Larry Minnix, President and CEO of the American Association of
Homes & Services for the Aging, (AAHSA) identified technology and financing as the
two greatest uncertainties facing the elder care industry (The Long and Winding Road,
2006 p16). Today, technology is transforming the way elder care is delivered and the
long-term-care financing system as we know it today is unsustainable. A mere four
years later two very different uncertainties were identified in the publication by this
national association. The Long and Winding Road of 2007 as published by AAHSA
17
21. identifies consumer expectations and the availability of a talented labor force as the
challenges of the future coupled with sustaining financial solvency and technology
modernization. (Minnix, 2007 p38-39)
Even without this knowledge and before the trends had been identified, studied
and published, the administrator this facility in 1997 made a decision to move from the
medical model to a more social home-like atmosphere. The staff of this facility took
proactive steps to address the challenges that have become nationally identified as the
leading uncertainties of long-term-care and took the long journey to resident centered
care outcomes.
18
23. Alleviating Loneliness in a Vibrant Environment (A. L. I. V. E.) has a clear goal:
to reduce the percentage of negative images of the public by demonstrating through
action, word, and deed that a resident can live in a positive environment and receive
positive care within a nursing home.
The Culture Change Tool:
The culture change tool was first conceived in 2001 by Karen Schoeneman and
Mary Pratt of CMS, who were co-project officers of the CMS Quality of Life study in
(Bowman, 2006) nursing homes as led by Dr. Rosalie Kane of the University of
Minnesota. (Kane, Kane, & Ladd, 1998) The tool fills the purpose of collecting the
major concrete changes homes have made or are making in resident care and
workplace practices, policies, schedules and the resident centered care environment.
(Bowman, 2006) (Appendix A)
The culture change tool was issued in 2007 for use by the long-term-care
industry upon written request from Schonememan or the CMS agency. This tool has no
facility bench marks or comparison data to date. However, it is the goal for this tool to
be used by the industry and CMS to work together to bring forth a positive change to the
long term care industry in the 21st
Century. (Bowman, 2006)
Eight facility’s leaders completed the tool for the first time in February of 2007
using their historical knowledge of the former medical model and the present birthing of
the resident centered model. The results are not research-validated measures, nor are
they a sign of deficiencies. This tool is intended to represent a change in heart, mind
and attitude within the facility itself and includes vision and leadership.
20
24. This tool confirms that culture change is a journey and is not a singular item that
can be duplicated in every nursing home across the nation. To change culture means
to know the culture, traditions, values and expectations of the community within and
outside the four walls which the residents call home. The scoring system begins at zero
for each facility and the benchmark becomes the total possible score for a home that
has achieved a perfect score. This facility’s score is 286.75 out of a possible 500.
The score documents the journey of this facility over the past ten years and the
growth potential needed to reach a score of 500. Those involved in the journey are
making progress with movement toward more change to come as residents and
employees work together to effect the culture within the walls of this facility.
CarePractices Enviroment Family&Community Leadership WorkplacePractice Outcomes Total
PotentialPoints 70 320 30 25 70 65 580
Survey1 30 134 20 5 24 57 270
Survey2 51 89 25 0 30 57 252
Survey3 56 269 25 21 68 47 486
Survey4 36 72 25 10 21 57 221
Survey5 41 79 25 18 36 64 263
Survey6 42 90 20 3 44 48 247
Survey7 35 96 20 10 33 61 255
Survey8 50 124 20 8 41 57 300
Average 42.625 119.125 22.5 9.375 37.125 56 286.75
PotentialPoints 70 320 30 25 70 65 580
PercentageofPotential 60.89 37.22 75 37.5 53 86 49
ArtifactsTotal
Table 2. Culture Change Date for the Organization
21
25. 0
100
200
300
400
500
600
700
Care Practices Enviroment Family and
Community
Leadership Workplace
Practice
Outcomes Total
Potential Points
Average
Figure 7. Culture Change Potential and Actual Points
This facility’s 10 year journey of culture change occurred when the historical
medical model was allowed to erode and a new path was slowly carved into the day-to-
day operations. The medical model in which employees direct, schedule and perform
the day to day living cares to the residents is crumbled by the shear power of a new
flowing mind set. Leadership must empower the residents to work with the staff closest
to the resident to seek out, develop and plan individual schedules for personal needs,
wants, desires, interests, events, and levels of involvement.
The shift away from a staff driven environment of tasks, decisions, timelines,
pills, treatments and cares performed to and for the resident has been a long standing
acceptable viewpoint. Styling the day-to-day events, tasks, activities and shaping
personal cares to enhance the resident centered care plan within an environment much
22
26. like one’s own home takes a radical attitude adjustment. Culture change is based on an
environmental makeover.
Turnover of staff is the most researched outcome of culture change. Key items
indicate that the success of the culture change at this facility is staggering and worthy of
interest. Staff turnover at this facility prior to 1997 was averaging over 100%. Nationally
the average turnover rate is 81% in long-term-care facilities. Over the past seven years
at this facility the turnover rate has leveled to an average rate of 13 to16%.
The occupancy rate for this long-term-care facility has averaged 95% to 97%
over the past seven years. The South Dakota Department of Health reports a 71%
occupancy rate, and in some areas of the less populated parts of the state the
percentage is even lower.
Customer Satisfaction Rating
Roles in the Environment 3.5 - 3.7
Dining Room 2.7
Recreation 3.5 - 3.7
Table 3. Customer Satisfaction
Qualitatively at this facility program benefits are seen for both children and elders
as they interact. Elders have greater opportunities to be active with young children,
increasing their number of positive interactions with others, and allowing the building of
relationships with the children. One particular elder comes to the infant room every day
to hold the infants and interact with them. She sees it as her job to help the new infants
in the center adjust to the environment by holding, cuddling, and responsively
interacting with them. Her volunteer time in the infant room serves a strong purpose for
her life. Parents have reported during the first funding cycle that one of their initial
23
27. concerns has not been realized: their children are not afraid of elders or the
“grandparents” living in the center. Instead, the children have developed positive
relationships with them. Parents have also noticed that their children’s awareness of
and acceptance of wheelchairs has transferred to when they are in public places.
Rather than staring at the person in a wheelchair, they now greet the individual or they
may ask a person who uses a wheelchair if he or she needs help. The child then may
hold the door for him or her when given an affirmative reply.
Quantitatively, the most noted benefit was the decrease in various infections in
the elders who lived at the center – especially involving skin infections. These were
measured in the frequency of infections before the child center opened and compared
to the frequency of infections after its opening. The most noticeable results are the
following:
• Skin infections (before mean = 11.3, after mean = 7.0, t = 1.43, p < .17;
approaching significance);
• Urinary Tract infections (before mean = 16.33, after mean = 10.2, t = 1.86,
p < .08; approaching significance);
• Respiratory infections (before mean = 18.3, after mean = 10.3, t = 2.16, p
< .05);
• *GI Tract infections and Conjunctivitis (the other two types of infections
tracked) have had a continued low incidence throughout the entire data
collection period.
24
28. Before Child
Center After Child Center
Skin Infections 11.3 7
Urinary Tract Infections 16.33 10.2
Respiratory Infections 18.3 10.3
GI Tract Infections and
Conjunctivitis * *
* Insufficient Data
Table 4 Quantitatively Results
Customer satisfaction surveys at this facility indicate that all elements measured
received a rating that ranged from very good to excellent (many rating between 3.5 to
3.7) with the exception of the dining room experience (mean = 2.7). The rating scale
ranged from 4 = excellent to 1 = poor. The elements on the satisfaction survey
included: roles in the environment (i.e. the administrator, the director of nursing, the
social worker, nursing staff and certified nursing assistants, registered dietitian and
dietary staff, child care staff, recreational therapy, housekeeping, business office
personnel, volunteers, maintenance and chaplain). It included experiences such as
cleanliness, temperature, atmosphere, elements of the meals, and recreational
experiences. The recreational experiences received the highest rating of all (mean
range of 3.5 to 3.7) – this included planned intergenerational activities. The presence
of the children is benefiting the elders in that there is a trend for them to be healthier
with fewer infections, and that the elders are benefiting the children by giving them
positive experiences and a better perspective of older people.
25
29. Turnover of Staff
Nationally 81%
Prior to 1997 >100%
After 1997 13% - 16%
Table 5. Turnover of Staff
The A.L.I.V.E. philosophy has resulted in an impressive reduction in facility
deficiencies during the annual surveys over the past seven years. According to the
official web site, Medicare Nursing Home Compare this facility in 2003 received a
deficiency free annual survey. As the implementation of A.L.I.V.E philosophy became
increasingly acceptable by the state survey team there has been no level of harm
deficiency identified higher than a potential for minimum harm (1) or minimum of
potential of harm (2) on a scale of one to four.
Increasing numbers of nursing homes are moving from the traditional medical
model to a more life-affirming resident-directed care continuum. Fewer than one
percent of America’s 17,000 nursing homes have made a deep system change to their
physical, psycho-social, spiritual and organizational environments, according to the
NORS. (Department of Health and Human Services, JULY 2003 p 6-3) Taking a
modernistic look at how services have been provided in the past presents opportunities
to revise the status quo and improve residents’ and employees’ quality of life. Nursing
homes are undertaking the grueling process of fundamentally changing the culture of
the organization with marked enhancement in resident satisfaction, staff retention and
recruitment. Facilities willing to change may risk survey deficiencies or reimbursement
difficulties. There will be personal transformations which involve assessing values and
attitudes, and in finally shaking the long held belief that medical models reflect a nursing
home with emphasis on “nursing”. “Emphasizing (home) with nursing as one service
26
30. that is provided is a paradigm shift. Medical therapy should be the maid of original
human caring, never its master.” (William H. Thomas, M.D., 1999 p 212)
Culture-change fosters relationships by putting the person before the task. It
promotes growth and development with a shift of decision making to the residents
and/or the employees closest to the residents. This empowerment embarks on culture
change aimed at restoring self-determination in facilities that resemble a personal
atmosphere of living rather than dying.
27
31. Chapter 3
Conclusion
and
Recommendations
The quality of a nation is reflected in the way it recognizes that its strength
lies in its ability to integrate the wisdom of its elders with the spirit and vitality of
its children and youth. Margaret Mead
28
32. This facility’s history is known for its high degree of innovative methods and
proactive approach to elder care. The A.L.I.V.E project was born out of that culture that
has brought intergenerational activities, events and therapies in which children
consistently and constantly interact with elders. This philosophy continues to enhance
and stimulate within the facility programming to meet the needs of the community.
This nursing facility sought a balance that would allow progressive achievement
and compliance with state and federal requirements, while simultaneously ensuring
optimal well-being for residents with a wide range of extremes in age, acuity level,
physical independence, cognitive ability and customer expectations. A further challenge
was to sustain a positive labor force within financial restraints.
To design, develop and implement culture change, this facility’s administrator
had to cultivate a significant level of cooperation with key staff in each department, the
Board of Directors and the community. To advance culture change a shift to a resident
centered care philosophy and its principles was implemented. Through educational
opportunities held on and off campus for staff, a slow, consistent and progressive
change began to emerge. These steps are referred to as “warming the soil” as
described by Dr. William Thomas M.D., founder of the Eden Alternative philosophy.
(Thomas, 1999 p 213)
Preparing for the Transition:
To prepare for the transition from a medical model to a resident centered
philosophy the administrator of this facility began an educational tour of the local
community. The educational sessions were presented to board members, families,
residents, staff and the community. The sessions had two purposes. The first was to
29
33. inform the public that this facility was actively pursuing solutions to balance the negative
societal attitude that one goes to hospitals to get well and nursing homes to die.
Second, was to share with those in attendance how this facility under its administrator’s
leadership was intending to address the negative image.
Monthly newspaper articles were written by the facility staff to keep the public
informed of the day to day activities and events that occurred. A 30 minute live, call-in
radio program referred to as “Long-Term-Living” was introduced. The administrator of
this facility read articles and shared these articles with the public.
A partnership was developed with the land grant university colleges of Early
Childhood Development, Engineering, Nursing, Family Consumer and Sciences,
Pharmacy and the various agricultural departments. The students are part of the
workforce at the facility. The university has approved the facility has a work study site
for the students. Students work with the facility to complete internship programs,
preceptor programs, classroom assignments and service learning opportunities. The
facility gains the enthusiasm of university students and the most update research in
their respective areas.
Gathering information, forming partnerships and educating of the community is
an ongoing and necessary staple to ensure the continued success of culture change.
The leadership of each facility must find methods for implementing culture change and
brand it uniquely the “homes” The implementation of the A.L.I.V.E philosophy and the
steps taken to date is neither a recipe for success nor step by step instructions for the
execution of future programs. The steps taken can be used a guideline for achieving
change in elder care.
30
34. Implementation 1998
The first animals this facility introduced were 21 birds housed in a large aviary.
This was a very acceptable step with regulatory agencies and the public. The birds
were contained and there was no human contact between the people and the birds.
The birds were colorful, sang beautiful melodies, they were fun to watch and the
residents enjoyed listening to the chatter of the song birds. Today this facility is home to
more than 40 birds. The bird cages are found in resident rooms, in the rehabilitation
area and hallways for all to enjoy.
Another segment that contributed to the success of this culture change process
was the administrator attending and participating in national convocations concerning
the developing public concerns of the services provided by long term care facilities. By
attending national educational sessions the administrator was exposed to useable
research and become more informed of the negative images of nursing homes. The
administrator was pleasantly surprised to find that others serving in the long-term-care
industry were working toward changing the negative images of nursing homes across
the nation.
These experiences gave the administrator the courage to continue the quest to
replace the medical regulated model with a more home style atmosphere. This was a
delightful return to earlier experiences as a nursing home caregiver.
The sharing of this information with the board of directors, staff, residents,
families and the public at large was extremely important. Through this knowledge the
facility’s leader gained support to move forward with the A.L.I.V.E. project. This
approval contributed to the success and survival of culture change movement.
31
35. The second animal introduced to the facility was a cat named Shadow. Then two
more cats, then the fourth cat joined the family. At this time a request was received
and approval was granted for a new resident to bring her privately owned cat to live with
her in her new home. Both the resident and her friend Kitty had care plans. A staff
member and a local veterinarian addressed the medical needs of Kitty. The care team
included Kitty on the resident’s care plan. This method used by this facility to ensure the
health of the animal and the individualized resident care plan was accept by the
licensing agency.
Shadow was the catalyst that advanced the need for a written policy and
procedure to address the A.L.I.V.E project. The policy reads as follows: “All animals
entering this facility to live will be certified “clean”, receive appropriate treatments, and
receive all necessary annual shots by a licensed veterinarian before entering the facility.
The medical records of each animal will be kept for public review. The animals are to
been seen by a licensed veterinarian at least annually, during any suspected illness or
injury and if there is a single question as to the wellness of the animal.” This is the only
policy and procedure made for the introduction of the A.L.I.V.E. program at this facility.
(Facility manual 1999)
As with all new “introductions” to the culture change environment there were a
number of apprehensions, questions and concerns expressed to the administrator. The
negative predications, questions or concerns expressed by staff, residents, or families
never materialized. Today this facility has three resident owned cats and six cats that
are owned by the facility.
32
36. In 1999, a puppy named Sassy was admitted. This was the most difficult step
and by far the most controversial. Sassy was a black lab puppy with all the puppy
behaviors both positive and the negative. The human failure in this situation was
evident. A puppy needs uniform and routine training. This type of training is not
possible in a workplace setting with over 100 employees, numerous visitors, volunteers
and 80 plus residents. Introducing Sassy into this nursing home tested the total
A.L.I.V.E philosophy and its future.
Sassy bonded with Jacob a resident who was single, male, and who had
resigned himself to dying in the nursing home. In his words he “had nothing left to live
for” until Sassy came into his life. This two year relationship was remarkable to
observe. The administrator and community witnessed for the first time culture change in
action and began to understand the significance of the A.L.I.V.E philosophy.
There were daily walks, conversations, giving and receiving affection and shared
naps. The walks consisted of Sassy pulling Jacob in his wheelchair around the park,
down Main Street and they were known to stop at the local pub for liquid refreshments.
To experience life being poured back into Jacob’s world was refreshing. The dedication
between Jacob and Sassy was the breath needed to solidify the A.LI.V.E. philosophy as
an acceptable model for this long-term-care facility.
In retrospect this author would caution leaders not to have a live-in puppy. The
difficulty of consistent and routine training is an unacceptable risk to the overall success
of culture change. The second caution is to be aware of exclusive bonding between
facility live-in pets with an individual resident. Jacob lived for almost three years at this
facility. After Jacob’s death Sassy was devastated, she mourned and displayed
33
37. aggression toward others. Sassy became an unacceptable risk to the facility. The
survival of the A.L.I.V.E. program was in jeopardy. The administrator of this facility
made the decision Sassy would need to be euthanized. This was by far the most
difficult and important decision this leader made concerning the continuation of the
A.L.I.V.E. project.
When a leader chooses to “think outside the box”, there are tough decisions that
need to be made and those decisions usually are never black or white. There is more
to culture change than what can be contained within the four walls of the facility.
Leaders of a facility under culture change must be able to accept the critics and humbly
accept praise equally.
The step that set this facility apart from others is the intergenerational
programming. The implementation of the intergenerational program is the most recent
step towards culture change within this nursing home. In 2001, the introduction of 50
children sharing space with elders was met with trepidation and momentous concerns.
Parents of the children were concerned about the “old people harming their children”.
The families of the residents were concerned about the young “spreading all those kid
diseases” to the elders. Together they asked one single question: How was the facility
going to protect and keep their loved one safe?
Through an educational process and the positive actions of the staff the
administrator brought forth an understanding of the how each generation would benefit
from the other. Again, as demonstrated with the introduction of the animals there have
been no negative outcomes of the relationship between elders and children.
34
38. Over the past ten years the following transformations were implemented with the
understanding that there is no official completion date. Within each area of
implementation there is a constant evolution of culture change ideas. This facility’s
leaders understand that improvement and the expansion of culture change is
dependent on the residents they serve. The A.L.I.V.E. philosophy at this facility includes
but is not limited to the following beginnings:
• Live-in, facility-owned dogs, cats, birds, a rabbit, fish and plants were
introduced during the first 3 years of the program.
• Residents were also allowed to bring their own pets to live with them in
their new home in the third year of the program
• Cross training of staff was introduced for the first time on the facility’s
campus in 1999.
• The traditional chain of command of top down supervision was replaced
with a resident centered philosophy in 1999.
• In the year 2000, non-nursing staff were instructed to respond to a
resident’s call for assistance when the call light was illuminated. If a
resident was verbally calling out for help or if the resident appeared to be
in need of assistance, the staff person was to respond appropriately.
• The wings of the facility were transformed into neighborhoods in 2002,
with regular staff assigned from all departments including nursing,
housekeeping, rehabilitation, and activities.
35
39. • An intergenerational program comprised of 50 children sharing space with
the elders by eating together and sharing in curriculum based activities
was implemented in the year 2001
• Open meal times have been established. Specific set times for meals
were eliminated in 2006
• Departmentalization is being phased out within the nursing facility. This is
a long and tedious process which will be an ongoing process for many
years. Under this philosophy cross training of employees is an essential
paradigm shift.
Finally, the staff continues to be encouraged and supported as they continue to expand
their knowledge of positive approaches and creative methods in responding to the
residents’ requests and concerns.
Culture change takes place over an extended period of time; thus, the research
is limited and evidence based studies must be completed in order to change public
policies. This paradigm shift from the traditional medical model created copious and
innumerable questions from the initial team members, state surveyors, consumers and
the community.
However, even without hard data interest grows. As the culture change is
established, each discipline in a facility feels the effects. Department lines gray, as
black and white policies flex with the individual resident. Job descriptions and
responsibilities cross and decisions are made with the resident as the hub, and
employees adapt to new roles as the “spokes” of support. Cross training coupled with a
team centered attitude is the reality of culture change as seen with the diagram below.
36
40. Figure 6. Resident Centered Chain of Command
Each employee is equally responsible for the residents and to their physical,
social, spiritual and mental needs. They are allowed to focus on the consumer’s
strengths and interests with the full support of the leadership. It is clear that the resident
directs, and the employees respond. Culture change can be modified according to each
resident, staff member, and the personality of the community in which the facility is
located.
In summary, there are three major issues which confront long-term-care
nationally and state wide. Demographic studies demonstrate the graying of America.
As the Baby Boomer generation begins to age, an adequate workforce is essential for
Administrative
Assistant
Chaplain
Medicare
Maintenance
Housekeeping
Laundry
Beautician
URC-CDC
Business Office
Manager
Social
Services
Rehab
Recreation
Activities
Human
Resource
PPAL
Manager
Director
of Dietary
Director of
Nursing
Administrator
Administration
Resident
Administrative
Assistant
Chaplain
Medicare
Maintenance
Housekeeping
Laundry
Beautician
-
Child Development
Center
Business Office
Manager
Social
Services
Rehab
Recreation
Activities
Human
Resource
Assisted Living
Manager
Director
of Dietary
Director of
Nursing
Administrator
Administration
Resident
37
41. the level of care demanded, and for a life that screams quality. Staff must be able to
identify their needs and respond to their wants. The financing of this enormous task will
take center stage in policy debate and political platforms. Long-term-care managers
and leaders owe it to themselves, the residents, families, employees and the community
to minimize the negative and maximize the positive benefits of living and working
towards the changing culture in health care.
The essence of this important segment of the health care continuum is being
reshaped from its very core to the outer skins of society. Caught in the vise of
regulations, punitive survey processes, reimbursement reductions, related budget
restraints and staffing compromises, the long-term-care industry is rising above the
turbulent times and new ideas are emerging. In order for the culture change movement
to be sustained at the facility level, government policy and regulations will need to be
altered; medical providers must accept alternative methods of treatment; societal
attitudes toward nursing homes must be educated away, with elders themselves
learning about the aging process. Care giving must be looked upon as a profession
rather than an entry level job.
Lamenting about the quality of life and care in nursing homes occurs daily, along
with negative media stories, congressional hearings and government findings. Many
facilities are striving to change the image of nursing homes by changing the culture for
residents, employees, families and the communities they serve. In the mid 90’s a small
but determined group of early pioneers in the long-term care field worked to
fundamentally change the values, practices and culture of their respective
organizations. They began to create places for living and growing rather than for
38
42. declining and dying. In pockets across the country, four early pioneering approaches
were developed: the Regenerative Community, Resident-Directed Care, Individualized
Care, and The Eden Alternative.
As a director of a long-term-care facility it will be your responsibility to lead the
community in selecting an appropriate philosophy of culture change. As the leader you
may choose to immolate a nationally acceptable movement from those listed above.
The community may be receptive to creating a program designed by and specific to the
personality of the facility.
The administrator chose to design a philosophy that is reflective of the
community’s needs, traditions and values. The A.L.I.V.E philosophy is an important first
step of changing the culture of the nursing home. It is a conscious, visible, participatory
and living philosophy that is designed to assist the public in learning that life not death
can be found in long-term-care facilities locally and across the nation.
Figure 1. Rehab bird & Bonnie Figure 2. Marie with her quilt and
sewing machine
39
43. Figure 3. Playing hockey in the dining room Figure 4. Planting a tree of life
together
In the traditional long-term-care paradigm, predictability and control are the norm
for the nation’s facilities. The emerging paradigm shift is that 1% of the facilities are
focusing on eliminating the loneliness, helplessness, and boredom of the residents
living within a community which can be called “home” for those that live there.1
This
new view recognizes that nursing homes are adaptive to a new thought of service.
Everything or everyone cannot be tightly controlled. Instead, ideas for improving quality
of care and life for residents and employees alike come about when employees are
empowered to create new approaches under the direction of the resident and with the
support of the leadership and management.
Figure 5. Intergenerational event Figure 6. 6Sharing a mid-afternoon snack
1
Written permission received for photographs
40
44. This facility took a bold step in addressing the widespread belief that nursing
homes are a place to die. Through changing the culture within the nursing home, by
using the state university resources and by finding substantial financial support from the
community, the A.L.I.V.E philosophy will continue to lead the nation in culture change.
In closing, this author looked back at a 10 year career of this facility’s
administrator and found one nugget of information that a leader needs to know. A
leader that chooses to think outside the box and swim upstream against all odds needs
to accept that change of this magnitude takes time, dedication, commitment and a
fortitude that can overcome criticism and humbly take praise This facility has a bright
future.
Figure 7. Bring life & care to a resident Figure 8. The profession of caring for
and about the resident
41
45. References
Bowman, C (2006). Development of the artifacts of culture change tool. Retrieved March 4,
2007, from Development of the Artifacts of Culture Change Tool Web site:
http://siq.air.org/PDF/artifacts.pdf
Bowers, B (2001,November 30). Organizational change and workforce development in
long-term-care. Retrieved March 4, 2007, from Organizational Change and
Workforce Development in Long-term-care. Web site:
http://www.directcareclearinghouse.org/download/CULTURE5.doc
Department of Health and Human Services , OFFICE OF INSPECTOR GENERAL
INSPECTOR GENERAL (JULY 2003 ). OEI-09-02-00160 STATE OMBUDSMAN
DATA: NURSING HOME COMPLAINTS . Retrieved March 4, 2007, from NURSING
HOME COMPLAINTS Web site: http://www.oig.hhs.gov/oei/reports/oei-09-02-
00160.pdf
Evans, L & Scalzi, C, (Fall 2004). Culture Change in Long-term-care. Hartford Center of
Geriatric nursing Excellence. Retrieved November 6, 2006, from Culture Change in
Long-term-care. Hartford Center of Geriatric nursing Excellence. Web site:
http://www.nursing.upenn.edu/centers/hcgne/science_ltc.htm
Giguere, N (2006). Culture change in long-term-care. Retrieved November 5 from Culture
Change In Long-Term-Care 2006 Web site:
http://www.startribune.com/1758/story/454515.html
Hamilton, T (2006) Nursing home culture change regulatory compliance questions and
answers, Retrieved February 12, 2007, from Nursing home culture change
regulatory compliance questions and answers Web site:
http://www.lsni.org/whatsnew/CMSSCCultureChange.pdf
Haran, C (2006, April). Transforming long-term-care: Giving residents a place to call home.
The Common Wealth Fund, Retrieved November 6, 2006, from
http://www.cmwf.org/publications/publications_show.htm?doc_id=365728
Howorth, J (2005, March 12). Transforming long-term-care: Creating Human Habitats.
Retrieved November 8, 2006, from Transforming long-term-care: Creating Human
Habitats Web site: http://www.edenalt.com/pdf/Transforming%20Traditional
%20LTC.ppt
Kane, R, Kane, R, & Ladd, R (1998). The heart of long-term-care quoted in Paul R.
Willging, PhD, “It’s time to take the politics out of nursing home quality,” Nursing
Homes Magazine, January 2005, 22.. New York, NY: Oxford University Press.
42
46. Keane, B (2006). Building the new culture of aging: One leader at a time. Retrieved
November 8, 2006, from Building the new culture of aging: One leader at a time Web
site: http://www.nursinghomesmagazine.com/Past_Issues.htm?ID=3341
Minnix, L. (Ed.). (2006). The Long and Winding Road (1st ed., Vol. 1). West
Conshohocken: Decision Strategies International.
Minnix, L (2007, March). How your future might look. McKnight, 38-39
The NewsHour with Jim Lehrer, Kaiser Family Foundation/Harvard School of Public Health
(October 2001). Retrieved accessed December 5, 2006, from The NewsHour Web
site: http://www.pbs.org/newshour/health/nursinghomes/highlightsandchartpack.pdf
Thomas, W (1999). Learning from Hannah: Secrets for a life worth living. Acton,MA:
VanderWyk & Burnham.
Thomas, W (1999). The Eden alternative handbook: The art of building human habitats.
NewYork,NY: The Summer Hill Company, Inc.
Thomas, W (2004). What are old people for? How elders will save the world. Acton,MA:
VanderWyk & Burnham.
Witrogen-McLeod, B (2001). And thou shalt honor: The cargiver. Rodale, CA: Rodale Inc.
43
47. APPENDIX
ARTIFACTS OF CULTURE CHANGE TOOL
Artifacts of Culture Change
Home Name ________________________________________ Date _______________
City ___________________ State ___________ Current number of residents _________
Ownership: _____ For Profit _____ Non-Profit _____ Government
Care Practice Artifacts
1. Percentage of residents who are offered any of the following
styles of dining:
� restaurant style where staff take resident orders;
� buffet style where residents help themselves or tell staff
what they want;
� family style where food is served in bowls on dining
tables where residents help themselves or staff assist
them:
� open dining where meal is available for at least 2 hour
time period and residents can come when they choose;
and
� 24 hour dining where residents can order food from the
kitchen 24 hours a day.
_____ 100 – 81 % (5 points)
_____ 80 – 61% (4 points)
_____ 60 – 41% (3 points)
_____ 40 – 21% (2 points)
_____ 20 – 1% (1 point)
_____ 0 (0 points)
2. Snacks/drinks available at all times to all residents at no
additional cost, i.e., in a stocked pantry, refrigerator or
snack bar.
_____ All residents (5 points)
44
48. _____ Some (3 points)
_____ None (0 points)
3. Baked goods are baked on resident living areas.
_____ All days of the week
(5 points)
_____ 2-5 days/week (3 points)
_____ < 2 days/week (0 points)
4. Home celebrates residents’ individual birthdays rather
than, or in addition to, celebrating resident birthdays in a
group each month.
_____Yes (5 points)
_____ No (0 points)
5. Home offers aromatherapy to residents by staff or
volunteers.
_____Yes (5 points)
_____ No (0 points)
6. Home offers massage to residents by staff or volunteers. _____Yes (5 points)
_____ No (0 points)
7. Home has dog(s) and/or cat(s).
_____ At least one dog or one cat
lives on premises (5 points)
_____ The only animals in the
building are when staff bring
them during work hours
(3 points)
_____ The only animals in the
building are those brought in
for special activities or by
families (1 point)
_____ None (0 points)
8. Home permits residents to bring own dog and/or cat to live
45
49. with them in the home.
_____Yes (5 points)
_____ No (0 points)
9. Waking times/bedtimes chosen by residents. _____ All residents (5 points)
_____ Some (3 points)
_____ None (0 points)
10. Bathing without a Battle techniques are used with residents. _____ All (5 points)
_____ Some (3 points)
_____ None (0 points)
11. Residents can get a bath/shower as often as they would
like.
_____Yes (5 points)
_____ No (0 points)
12. Home arranges for someone to be with a dying resident at
all times (unless they prefer to be alone) - family, friends,
volunteers or staff.
_____Yes (5 points)
_____ No (0 points)
13. Memorials/remembrances are held for individual residents
upon death.
_____Yes (5 points)
_____ No (0 points)
14. “I” format care plans, in the voice of the resident and in
the first person, are used.
_____ All care plans (5 points)
_____ Some (3 points)
_____ None (0 points)
Care Practice Artifacts Subtotal: Out of a total 70 points, you scored
__________.
Environment Artifacts
15. Percent of residents who live in households that are selfcontained
46
50. with full kitchen, living room and dining room.
_____ 100 – 81 % (100 points)
_____ 80 – 61% (80 points)
_____ 60 – 41% (60 points)
_____ 40 – 21% (40 points)
_____ 20 – 1% (20 points)
_____ 0 (0 points)
16. Percent of residents in private rooms. _____ 100 – 81 % (50 points)
_____ 80 – 61% (40 points)
_____ 60 – 41% (30 points)
_____ 40 – 21% (20 points)
_____ 20 – 1% (10 points)
_____ 0 (0 points)
17. Percent of residents in privacy enhanced shared rooms
where residents can access their own space without
trespassing through the other resident’s space. This does
not include the traditional privacy curtain.
_____ 100 – 81 % (25 points)
_____ 80 – 61% (20 points)
_____ 60 – 41% (15 points)
_____ 40 – 21% (10 points)
_____ 20 – 1% (5 points)
_____ 0 (0 points)
18. No traditional nurses’ stations or traditional nurses’
stations have been removed.
_____ No traditional nurses stations
(25 points)
_____ Some traditional nurses’
stations have been removed
(15 points)
_____ Traditional nurses’ stations
47
51. remain in place (0 points)
19. Percent of residents who have a direct window view not
past another resident’s bed.
_____ 100 – 51% (5 points)
_____ 50 – 0 % (0 points)
20. Resident bathroom mirrors are wheelchair accessible
and/or adjustable in order to be visible to a seated or
standing resident.
_____ All resident bathroom
mirrors (5 points)
_____ Some (3 points)
_____ None (0 points)
21. Sinks in resident bathrooms are wheelchair accessible with
clearance below sink for wheelchair.
_____ All resident bathroom sinks
(5 points)
_____ Some (3 points)
_____ None (0 points)
22. Sinks used by residents have adaptive/easy-to-use lever or
paddle handles.
_____ All sinks (5 points)
_____ Some (3 points)
_____ None (0 points)
23. Adaptive handles, enhanced for easy use, for doors used by
residents (rooms, bathrooms and public areas).
_____ All resident-used doors
(5 points)
_____ Some (3 points)
_____ None (0 points)
25
24. Closets have moveable rods that can be set to different
48
52. heights.
_____ All closets (5 points)
_____ Some (3 points)
_____ None (0 points)
25. Home has no rule prohibiting, and residents are welcome,
to decorate their rooms any way they wish including using
nails, tape, screws, etc.
_____Yes (5 points)
_____ No (0 points)
26. Home makes available extra lighting source in resident
room if requested by resident such as floor lamps, reading
lamps.
_____Yes (5 points)
_____ No (0 points)
27. Heat/air conditioning controls can be adjusted in resident
rooms.
_____ All resident rooms (5 points)
_____ Some (3 points)
_____ None (0 points)
28. Home provides or invites residents to have their own
refrigerators.
_____Yes (5 points)
_____ No (0 points)
29. Chairs and sofas in public areas have seat heights that vary
to comfortably accommodate people of different heights.
_____ Chair seat heights vary by 3”
or more (5 points)
_____ Chair seat heights vary by 1
3” (3 points)
_____ Chair seat heights do not
vary in height (0 points)
49
53. 30. Gliders which lock into place when person rises are
available inside the home and/or outside.
_____Yes (5 points)
_____ No (0 points)
31. Home has store/gift shop/cart available where residents
and visitors can purchase gifts, toiletries, snacks, etc.
_____Yes (5 points)
_____ No (0 points)
32. Residents have regular access to computer/Internet and
adaptations are available for independent computer use
such as large keyboard or touch screen.
_____ Both Internet access and
adaptations (10 points)
_____ Access without adaptations
(5 points)
_____ Neither (0 points)
33. Workout room available to residents. _____Yes (5 points)
_____ No (0 points)
34. Bathing rooms have functional and properly installed heat
lamps, radiant heat panels or equivalent.
_____ All bathing rooms (5 points)
_____ Some (3 points)
_____ None (0 points)
35. Home warms towels for resident bathing. _____Yes (5 points)
_____ No (0 points)
26
36. Protected outdoor garden/patio accessible for independent
use by residents. Residents can go in and out independently,
including those who use wheelchairs, e.g. residents do not need
assistance from staff to open doors or overcome obstacles in
traveling to patio.
50
54. _____Yes (5 points)
_____ No (0 points)
37. Home has outdoor, raised gardens available for resident
use.
_____Yes (5 points)
_____ No (0 points)
38. Home has an outdoor walking/wheeling path which is not a
city sidewalk or path.
_____Yes (5 points)
_____ No (0 points)
39. Pager/radio/telephone call system is used where resident
calls register on staff’s pagers/radios/telephones and staff
can use it to communicate with fellow staff.
_____Yes (5 points)
_____ No (0 points)
40. Overhead paging system has been turned off or is only
used in case of emergency.
_____Yes (5 points)
_____ No (0 points)
41. Personal clothing is laundered on resident
household/neighborhood/unit instead of in a general allhome
laundry, and residents/families have access to washer
and dryer for own use.
_____ Available to all residents
(5 points)
_____ Some (3 points)
_____ None (0 points)
Environment Artifacts: Out of a total 320 points, you scored ___________.
Family and Community Artifacts
42. Regularly scheduled intergenerational program in which
children customarily interact with residents at least once a
51
55. week.
_____Yes (5 points)
_____ No (0 points)
43. Home makes space available for community groups to
meet in home with residents welcome to attend.
_____Yes (5 points)
_____ No (0 points)
44. Private guestroom available for visitors at no, or minimal,
cost for overnight stays.
_____Yes (5 points)
_____ No (0 points)
45. Home has café/restaurant/tavern/canteen available to
residents, families, and visitors at which residents and
family can purchase food and drinks daily.
_____Yes (5 points)
_____ No (0 points)
46. Home has special dining room available for family
use/gatherings which excludes regular dining areas.
_____Yes (5 points)
_____ No (0 points)
47. Kitchenette or kitchen area with at least a refrigerator and
stove is available to families, residents, and staff where
cooking and baking are welcomed.
_____Yes (5 points)
_____ No (0 points)
Family and Community Artifacts Subtotal:
Out of a 30 possible points, you scored __________ points.
Leadership Artifacts
48. CNAs attend resident care conferences.
_____ All care conferences
(5 points)
52
56. _____ Some (3 points)
_____ None (0 points)
49. Residents or family members serve on home quality
assessment and assurance (QAA) (QI, CQI, QA)
committee.
_____Yes (5 points)
_____ No (0 points)
50. Residents have an assigned staff member who serves as a
“buddy,” case coordinator, Guardian Angel, etc. to check
with the resident regularly and follow up on any concerns.
This is in addition to any assigned social service staff.
_____ All new residents (5 points)
_____ Some (3 points)
_____ None (0 points)
51. Learning Circles or equivalent are used regularly in staff
and resident meetings in order to give each person the
opportunity to share their opinion/ideas.
_____Yes (5 points)
_____ No (0 points)
52. Community Meetings are held on a regular basis bringing
staff, residents and families together as a community.
_____Yes (5 points)
_____ No (0 points)
Leadership Artifacts Subtotal: Out of a total 25 points, you scored
__________.
Workplace Practice Artifacts
53. RNs consistently work with the residents of the same
neighborhood/household/unit (with no rotation).
_____ All RNs (5 points)
_____ Some (3 points)
_____ None = 0 points.
53
57. 54. LPNs consistently work with the residents of the same
neighborhood/household/unit (with no rotation).
_____ All LPNs (5 points)
_____ Some (3 points)
_____ None (0 points)
55. CNAs consistently work with the residents of the same
neighborhood/household/unit (with no rotation).
_____ All CNAs (5 points)
_____ Some (3 points)
_____ None (0 points)
56. Self-scheduling of work shifts.
CNAs develop their own schedule and fill in for absent CNAs.
CNAs independently handle the task of scheduling, trading
shifts/days, and covering for each other instead of a staffing
coordinator
_____ All CNAs (5 points)
_____ Some (3 points)
_____ None (0 points)
57. Home pays expenses for non-managerial staff to attend
outside conferences/workshops, e.g. CNAs, direct care
nurses. Check yes if at least one non-managerial staff member
attended an outside conference/workshop paid by home in past
year.
_____ Yes (5 points)
_____ No (0 points)
58. Staff is not required to wear uniforms or “scrubs.” _____ Yes (5 points)
_____ No (0 points)
59. Percent of other staff cross-trained and certified as CNAs
in addition to CNAs in the nursing department.
_____100 – 81 % (5 points)
_____ 80 – 61% (4 points)
54
58. _____ 60 – 41% (3 points)
_____ 40 – 21% (2 points)
_____ 20 – 1% (1 point)
_____ 0 (0 points)
60. Activities, informal or formal, are led by staff in other
departments such as nursing, housekeeping or any
departments.
_____ Yes (5 points)
_____ No (0 points)
61. Awards given to staff to recognize commitment to persondirected
care, e.g. Culture Change award, Champion of
Change award. This does not include Employee of the
Month.
_____ Yes (5 points)
_____ No (0 points)
62. Career ladder positions for CNAs, e.g. CNA II, CNA III,
team leader, etc. There is a career ladder for CNAs to hold a
position higher than base level.
_____ Yes (5 points)
_____ No (0 points)
63. Job development program, e.g. CNA to LPN to RN to NP. _____ Yes (5 points)
_____ No (0 points)
64. Day care onsite available to staff.
_____ Yes (5 points)
_____ No (0 points)
65. Home has on staff a paid volunteer coordinator in addition
to activity director.
_____ Full time (30 hours/week or
more) (5 points)
_____ Part time (15-30 hours/week)
(3 points)
55
59. _____ No paid volunteer
coordinator (0 points)
66. Employee evaluations include observable measures of
employee support of individual resident choices, control
and preferred routines in all aspects of daily living.
_____ All employee evaluations
(5 points)
_____ Some (3 points)
_____ None (0 points)
Workplace Practice Artifacts Subtotal: Out of a total 70 points, you
scored __________.
Outcomes
67. Average longevity of CNAs.
Add length of employment in years of permanent CNAs and
divide by number of staff.
_____Your CNA average longevity
Above 5 years (5 points)
3-5 years (3 points)
Below 3 years (0 points)
68. Average longevity of LPNs (in any position).
Add length of employment in years of permanent staff LPNs
and divide by number of staff.
_____Your LPN average longevity
Above 5 years (5 points)
3-5 years (3 points)
Below 3 years (0 points)
69. Average longevity of RN/GNs (in any position).
Add length of employment in years of all permanent RNs/GNs
and divide by number of staff.
_____Your RN/GN average longevity
Above 5 years (5 points)
56
60. 3-5 years (3 points)
Below average (0 points)
70. Longevity of the Director of Nursing (in any position). _____ Longevity as DON
_____ Longevity at home
Above 5 years (5 points)
3-5 years (3 points)
Below average (0 points)
71. Longevity of the Administrator (in any position). _____ Longevity as NHA
_____ Longevity at home
Above 5 years (5 points)
3-5 years (3 points)
Below average (0 points)
72. Turnover rate for CNAs. Number of CNAs who left, voluntary
or involuntary, in previous 12 months
divided by number of total CNAs
employed = turnover rate
Your home’s figure _______________
0 percent (5 points)
20-39 % (4 points)
40-59 % (3 points)
60-79 % (2 points)
80-99 % (1 point)
100% and above (0 points)
73. Turnover rate for LPNs.
Number of LPNs who left, voluntary or
involuntary, in previous 12 months
divided by number of total LPNs
employed = turnover rate
Your home’s figure _______________
0 – 12 % (5 points)
13-25 % (4 points)
57
61. 26-38 % (3 points)
39-51 % (2 points)
52-65 % (1 point)
66 % and above (0 points)
74. Turnover rate for RNs. Number of RNs who left, voluntary or
involuntary, in previous 12 months
divided by number of total RNs
employed = turnover rate
Your home’s figure _______________
0 – 12 % (5 points)
13-25 % (4 points)
26-38 % (3 points)
39-51 % (2 points)
52-65 % (1 point)
66 % and above (0 points)
75. Turnover rate for DONs. ______ Number of DONs in
the last 12 months
1 (5 points)
2 (3 points)
3 (0 points)
76. Turnover rate for Administrators. ______ Number of NHAs in
the last 12 months
1 (5 points)
2 (3 points)
3 (0 points)
77. Percent of CNA shifts covered by agency staff over the last
month.
Total number of CNA shifts in a 24
hour period (all shifts no regardless of
hours in a shift) _____________
Multiplied by number of days in last
58
62. the last full month _____________
Of this number, number of shifts
covered by an agency CNA _______
________ Your percentage (agency
shifts/total number X days X 100)
0 % (5 points)
1-5% (3 points)
Over 5% (0 points)
78. Percent of nurse shifts covered by agency staff over the last
month.
Total number of nurse shifts in a 24
hour period (all shifts no regardless of
hours in a shift) _____________
Multiplied by number of days in last
the last full month _____________
Of this number, number of shifts
covered by an agency nurse _______
_______ Your percentage (agency
shifts/total number X days X 100)
0 % (5 points)
1-5% (3 points)
Over 5% (0 points)
79. Current occupancy rate.
_____Your home figure
Above 86 % (5 points)
At average 83-85 % (3 points)
Below 83 % (0 points)
(Using the national 2004 average of
84.2% from CMS)
Outcomes Subtotal: Out of a total 65 points, you scored _______________.
59
63. Artifacts Sections
Potential Points Your Subtotal Scores
Care Practices 70
Environment 320
Family and Community 30
Leadership 25
Workplace Practice 70
Outcomes 65
Artifacts of Culture Change 580 Grand Total
Developed by the Centers for Medicare and Medicare Services and Edu-Catering, LLP.
Formore information contact Karen Schoeneman at karen.schoeneman@cms.hhs.gov or
Carmen S. Bowman at carmen@edu-catering.com.
60