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How Nursing Homes Can Make a Culture Change

When they do, residents, family and staff all benefit

By Beth Baker and SCAN Foundation

This is how Sarah Tooley knew her workplace had changed for the better: Vina, who lived at the nursing home where Tooley works, asked Tooley, a certified nursing assistant, to sing with her. And even with her other responsibilities, Tooley found that she could fulfill the request. It was a matter of prioritizing tasks differently, part of a changing model of care at Signature HealthCARE of Putnam County in Cookeville, Tenn.

“We sang Heaven’s Bright Shore,” Tooley recalls. “Vina couldn’t see and she needed me to help her learn the words” so she could sing at a memorial service. A 21-year nursing home veteran, Tooley gets choked up telling this story. To her, it is a shining example of how the nursing home is reshaping its care to be less institutional and more guided by residents’ own priorities.

“It’s a blessing to go into a job” like this, Tooley says. “We feel secure enough to go beyond [basics] and to meet people’s needs.” Before Vina died, she asked Tooley to sing at her funeral.

Signature HealthCARE of Putnam County is one of the nursing homes around the country undergoing what is called “culture change.” The goal is to provide a high quality of life in an environment that feels more like home and less like a hospital. Key to this change is the idea of person-centered care, which the American Geriatrics Society defines as care based on eliciting and supporting individuals’ values, preferences and goals.

Nursing Home Residents’ Wishes Count for More Now

“The big change is, instead of asking ‘What do we have to get done?’, now everything we do first centers around that elder — what they want, what their choice is,” explains Ruthie Birdwell, director of nursing at Signature HealthCARE of Putnam County. If a resident has a hankering for a meal from Red Lobster, a milkshake or a Superman t-shirt, Birdwell has seen staff members get it. “It’s those simple things,” she says. “When it’s taken away [by moving to a nursing home], you see how important it is to you.”

Virginia Pryor participating in a Shrove Tuesday Pancake flipping competition in the home. She won the competition and was crowned Mardi Gras Queen for the day.  |  Credit: Signature HealthCARE of Putnam County

Birdwell has worked at this home for 26 years. Kentucky-based Signature HealthCARE purchased it in 2014 and urged the staff to adopt the Eden Alternative, one approach that nursing homes can use to transform the lives of those who live and work in long-term care. Of Signature HealthCARE’s 128 nursing homes, 40 are on the Eden Alternative registry. Nationally, the number of nursing homes that are in the process of making culture change is not tracked. A 2014 study by Brown University researchers found that culture-change practices, as self-reported by nursing homes, are spreading rapidly. Those homes that adhered the most to culture change principles (less institutional, resident-centered, empowering direct-care staff) delivered a higher quality of care compared to other nursing homes.

“Taking the Eden classes affected me profoundly,” Tooley says. They cover practical ideas for changing work routines and bigger questions such as how to create a feeling of home physically, emotionally and spiritually. “I feel like it was an ‘aha’ moment,” she adds. “It should have always been this way.”

Regulations Aren’t the Biggest Challenge

Birdwell and Tooley both admit that initially they doubted that meaningful change was possible.

“I was so regulation-driven,” Birdwell says. “I thought, ‘Well, we can’t do this because the state would say something.’ Now we try to educate [state] surveyors about our culture change. If someone wants a different diet, and we’ve gotten the speech therapist and dietician involved, and we’ve educated [the resident] on the safety of it, ultimately it’s their choice. I’ve come a long way.”

Gertie Thorpe with Jeff the cat, who is one of the two cats residing on Orchard Neighborhood.  |  Credit: Signature HealthCARE of Putnam County

Tennessee’s surveyors did not object to the changes at the Signature HealthCARE home. “Two years ago, we went through a difficult survey, just as we were going to start this process,” says the home’s administrator, Lee Rooney, who was recruited to lead the transformation. During a more recent survey, he says, “Both surveyors came up to me individually to say how unbelievable the changes were. They felt the warmth and love” between staff and residents.

Regulations and finances are often seen as the biggest obstacles to nursing home transformation, but the main challenge is having motivated leaders in place, says Lynda Crandall, executive director of the nonprofit Pioneer Network, another organization that helps nursing homes overhaul their culture and care.

“The hard work of change comes from inspired, caring leaders in nursing homes,” Crandall says. “It is their passion for improvement that leads them to take on all the challenges inherent in change.”

Change Brings Costs, Then Gains

Most nursing homes that attempt deep transformation are not-for-profit facilities. Signature HealthCARE is unusual as a for-profit operator making culture change. The Putnam County home has beds for 175 residents, 60 percent of whom are on Medicaid. According to Rooney, the company has invested $500,000 in renovations, and did not offset that expense with cuts elsewhere. "Since the renovations, we have steadily seen our net revenue grow," he says. "We are approximately $40 per patient day higher than where we were before the changes." At a time when nursing homes nationally are seeing a decline in occupancy, their numbers are stable.

To make the old hospital-like building more homey, this nursing home is ripping out nurse’s stations and creating “neighborhoods,” turning “B Wing” into “Laurel Street,” with residents choosing the names. Main Street has a bistro and a general store, the latter operated by residents.

Language at the nursing home is changing, too. Staff are “care partners;” residents are “elders.” Two cats, a dog, birds and fish call this place home as well, a hallmark of the Eden Alternative model.

Tooley says whatever else is altered, change has to happen within each staff member. “You can have all the animals and plants you want, you can have all the activities in place, but there has to be a change in everybody’s attitude,” she notes.

More Choice Can Improve Health

One of the first initiatives was to improve food service. When her late mother first moved to the nursing home, the food “was just cheap and kind of bland and not a lot of variety,” says Judy Copeland. “It’s really good food now, and they offer them choices. It’s more like eating in a restaurant.”


Throughout the day, elders select from food carts stocked with fresh fruit, pastries and drinks. Simply having the freedom to choose an orange and sit in a rocker to enjoy it can make a difference in the residents' health. Birdwell tells about one woman “who I was so worried about because she would not eat. But since we’ve got the cart, she has gained weight. I was so pleased because I see her not only eating better, but she’s interacting with the staff better. She has a smile on her face. She feels more independent.”

Just a few years ago, if a Putnam County nursing home resident wanted to drink Coke or Pepsi as he or she had at home, supplying it was a big production. Family members had to bring in sodas from the outside, label each can or bottle with the resident’s name and ask the staff to stow the sodas in a refrigerator. Then each time residents wanted a drink, they had to ring a call bell and ask staff to retrieve a soda from the kitchen. Now, there’s a free soda fountain.

Meals are served family style with salt and pepper shakers on the table and residents can season their food as they wish. Unintended weight loss, which contributes to skin breakdown and is endemic in nursing homes, has declined, Birdwell says.

Contributing Is Transformative

Antidepressant use at the Putnam County home is also down by 25 to 30 percent. The Eden approach aims to ameliorate the “three plagues” of loneliness, helplessness and boredom.

“There’s so much going on — meetings, movies, so many good things,” says Roberta Kaiser, head of the elders council. “I like to go to things where people like each other, and that’s pretty much how it is here.” She enjoyed a vacation to Virginia Beach, one of many excursions that residents help raise funds for.

At elders council meetings, residents can voice “what you think is good or if you want a change,” she says. After residents complained that the shower room felt cold and institutional, the home began redoing it, adding towel warmers, a separate changing area and aroma therapy. Residents also plan monthly community service projects, such as collecting books for a local literacy program.

“I just had one lady come to me and say, ‘I see that plant looks dead outside. Can I bring it in and try to bring it back?’” Rooney says. “That gives her an opportunity to be helpful. A lot of the time, you don’t have the chance to give back. You’re taking care from a nurse, taking from a CNA [certified nursing assistant], taking food that dietary makes — and you feel helpless.”

Copeland says her mother, who died recently, seemed more contented because of the culture change. But the transformation of the Signature HealthCARE home was also a comfort to Copeland.

“I felt guilty when she first moved there. It wasn’t where she wanted to be, but it was where she had to be,” Copeland reflects about her mother's time at the nursing home. “She liked it better after they made those changes, and I felt so much better about her being there.”

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Beth Baker is a longtime journalist whose articles have appeared in the Washington Post, AARP Bulletin, and Ms. Magazine. She is the author of With a Little Help from Our Friends — Creating Community as We Grow Older and of Old Age in a New Age — The Promise of Transformative Nursing Homes. Read More
By SCAN Foundation
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