Culture-change movement concentrates on patient-centered care

The culture-change movement is a broad-based effort to transform nursing homes from impersonal health care institutions into true person-centered homes offering long-term care services. The movement encompasses almost three decades of consumer advocacy coupled with legal, legislative, and policy work aimed at improving both the quality of care and the quality of life in nursing homes.

In the 1980s, the National Citizens’ Coalition for Nursing Home Reform, a consumer advocacy group concerned about substandard care in nursing homes, emphasized residents’ rights and the importance of resident assessment. Later, with support from interested government and advocacy groups, the coalition conducted focus groups to learn how nursing home residents themselves defined quality.

In 1985, at a coalition symposium, residents told federal officials that "quality of care," — which encompasses such considerations as the medical treatments a resident receives and physical care routines including assistance with bathing, using the toilet, and eating— and "quality of life" — how one is treated: for instance, having one’s privacy respected or having one’s dignity maintained — are inseparably linked and, from the resident’s perspective, equally important. This principle figured prominently in subsequent legislation and regulations.

The Institute of Medicine reacted by recommending major regulatory changes that emphasized the home part of the description more than the nursing aspect of nursing home. Subsequently, Congress incorporated a sweeping set of nursing home reforms, known as the Nursing Home Reform Act, into the Omnibus Budget Reconciliation Act of 1987. The newly enacted law required that each nursing home resident "be provided with services sufficient to attain and maintain his or her highest practicable physical, mental, and psychosocial well-being." The law made nursing homes the only sector of the entire health care industry to have an explicit statutory requirement for providing what is now called "person-centered care."

As a result, some providers began to move away from the institutional model of nursing home care and toward a more homelike environment in which residents could have a say in their day-to-day lives. In 1997, leaders in the industry began to advocate for person-centered care and create a movement for "culture change" in the nation's nursing homes.

These leaders, along with consumer advocates, researchers, and regulators, founded an organization called the Pioneer Network, which partners with the Centers for Medicare and Medicaid Services (CMS) to explore ways to overcome regulatory barriers to culture change and to provide information to congressional staff on the importance of supporting innovation in long-term care.

Awareness of the culture-change movement grew slowly at first: as late as 2005, a Commonwealth Fund survey of health care opinion leaders showed that 73 percent of respondents were unfamiliar with culture change. But in 2008, when the survey was repeated, only about 34 percent reported unfamiliarity with the movement. Providers in particular became very aware of culture change, in part because of the CMS’s "Eighth Scope of Work" contract

with the nation’s quality improvement organizations. That contract specifically used the term "culture change" and required that quality improvement organizations work with nursing homes in each state to collect information on resident and staff experience and satisfaction with care.

Proponents of culture change support principles governing resident care practices, organizational and human resource practices, and the design of the physical facility. According to these principles, an ideal culture change facility would feature:

Resident direction. Residents should be offered choices and encouraged to make their own decisions about personal issues such as what to wear or when to go to bed.

Homelike atmosphere. Practices and structures should be more homelike and less institutional. For instance, larger nursing units with 40 or more residents would be replaced with smaller "households" of 10 to 15 residents, residents would have access to refrigerators for snacks, and overhead public address systems would be eliminated.

Close relationships. To foster strong bonds, the same nursing aides should always provide care to a resident.

Staff empowerment. Staff should have the authority, and the necessary training, to respond on their own to residents’ needs. The use of care teams should also be encouraged.

Collaborative decision-making. The traditional management hierarchy should be altered to give frontline staff the authority to make decisions regarding residents’ care.

Quality improvement processes. Culture change should be treated as an ongoing process of overall performance improvement, not simply as a superficial.

Culture change has shown promise in making care for nursing home residents truly person-centered, while alleviating such problems as high staff turnover. Policymakers can encourage culture change adoption through regulation, reimbursement, public reporting, and other mechanisms.


The Commonwealth Fund

Health Affairs