One of the most pleasant parts of may daily routine is opening my email inbox and delighting in the profound insights that my correspondents offer on a regular basis. I hear from a wide range of people with widely disparate points of view.
Yummy.
Today I found this note from a very well known leader in the field who wishes (you’ll soon know why) to remain anonymous. I was stunned by the depth and subtlety of the insights offered here.
Read it, then offer your thoughts below…
During the last six months, I have been trying to determine why my state’s nursing homes have not been investing in the management and culture changes that The Eden Alternative (and others) has been presenting to them over the last number of years. There is overwhelming evidence that such changes positively influence the lives of both nursing home employees and residents. Why has such change not taken place?
I have talked with many administrators from both the private and non-profit sectors and have studied their organizational philosophies and structures. I have taken a close look at their current financial situations and have listened carefully to what they have said and not said. The conclusion that I have drawn is that the current approaches will not, by themselves, bring about significant culture changes in the operation of nursing homes in my state.
The for-profit chains see Medicaid nursing home beds as loss leaders. Although they use their volume to spread the costs, their profit centers are their “specialty services”, Medicare and off-site operations. Upper management is primarily focused on these areas. They have a fundamental disagreement with the culture change philosophy and a distrust of “the new way of doing things.” The for-profits have the financial resources to make the necessary changes but they currently have no interest in doing so.
In the non-profit sector there is an opening for cultural changes but they have little financial resources to take the necessary risks and no skilled people who know how to do it nor are there any concrete examples of how it can be done. Non-profit boards are typically reluctant to engage in anything out of the ordinary due to lack of understanding and financial limitations. Although the nursing home administrators might be interested in making certain changes, they are usually afraid to push the envelope. They have not seen how it can be done successfully in my state.
I believe that a solution exists which includes both continuing what Eden has been doing but augmenting this by establishing one or more nursing home pilot projects in my state. These pilot projects would incorporate the Eden principles and culture changes throughout their operations. These facilities would give existing non-profit nursing homes and their boards operating examples of what can be done and give them a tangible path that they can follow. Seeing the positive dynamics of a fully functional “new culture” facility in their own back yard will create a movement and desire for them to transform themselves.
With respect to the for-profit chains, these pilot projects and the movement of the non-profits will put pressure on them. This will increase especially when the State and federal regulators start enforcing the intent as well as the letter of the law for the regulators will now have something to hold as a standard. Somewhere out there is a tipping point, a point where it the for-profits realize it is no longer beneficial to continue in their old ways. Change will then take place on a significant scale.
Note from Dr. Thomas: The question here is: “Should Eden and Green House become more active and aggressive and place a new emphasis on showing providers what change looks and feels like?”
Al Power says
May 28, 2013 at 5:34 pmI think there’s a much bigger issue at stake here. While both The Eden Alternative and The Green House Project have led a revolution in elder care, “elder care” itself is a concept that needs to be more radically reinvented than what most current culture change practitioners have accomplished.
I say this, not because of the (very legitimate) financial arguments, or even the (also very legitimate) moral arguments, but rather due to a simple matter of demographics: if we do not do away with the notion that the solution to aging is simply “better long-term care”, then we are in for a lot of trouble. The reason is that our system of pulling elders out of communities and moving them to separate campuses–whether skilled, assisted or independent living–is unsustainable with our shifting demographic (in 2050 there will be only 4 working-age people in America for every elder).
This system creates a need for more infrastructure and more of a workforce to “provide services”. Thus, aging becomes a commodity that is heavily monetized, and elders are systematically disempowered and marginalized, albeit in a kind, paternalistic way.
I believe we need to create better ways for elders to succeed in our communities and create a social structure that enables those elders to continue to have important roles in those communities (including those living with dementia). What our culture change movement has not done effectively is to move beyond the paradigm of older adults “needing services”, so we are locked in this mindset of how to provide better care within a broken societal system. Providing opportunities to give and receive care in a nursing home is not enough; we need to go much farther.
Granted, there will always be people who need skilled care in a congregate living setting. For this group, the community-integrated Green House, in my mind, remains the best prototype, but I think the power of social capital and the gifts elders can return to society have yet to be fully explored and unleashed.
So…what’s the modern nursing home to do? I vote for continuing to work to create a new elderhood for our current communities through Eden and the Green House, but also realigning our strategic plans to move beyond simply being purveyors of skilled care and other services, toward being more truly integrated with our communities as vehicle for changing aging. Bring people into your organization with cafes, education offerings and community outreach projects, and move people out through expanded community connections. The sooner we start to blur the lines, the better positioned we are for the future in which simply being an SNF will not be a viable business.
I’m rambling a bit, but one thing is certain: we will never have more money or more staff; and we will likely have less of both. The time for a serious paradigm shift is upon us.
Meredith Ann Rutter says
May 29, 2013 at 6:42 pmAl Power makes a great point, and one that drove me back into Bill Thomas’s book “What Are Old People For?” – the chapter “Eldertopia,” pp. 299-314. He suggested some excellent ways to start bringing elders [sometimes back] into current communities. I hope people will add that chapter into their thinking on this topic.
Paul Riccio says
May 20, 2013 at 2:14 pmIf everything in the above written article is accurate (and I certainly believe it to be so – the gentleman did a fantastic job of saying what many know to be true), then there is only one way to convert both…
Perhaps culture change’s biggest roadblock is the misconception that it’s not profitable. That it does not fulfill the profit line as well as another method. However, Eden Alternative and culture change, done well, wisely, and thoroughly, will ultimately make an organization the provider of choice within their community.
When for-profits are losing that valuable Med A admission because an elder wants to go someplace that feels like home, where they feel valued and cared for, then they will start to invest in culture change. When non-profits start filling all their census and beating the for-profits because they treat the elders (and their staff) with dignity and respect in a home setting, the long-term care industry in the area as a whole will at the least take notice of culture change. Some will not chase it – but many more will.
The culture change movement should become more aggressive and active – yes – but it needs to do so in a way that shows this is a win-win-win situation. The Elders win, our industry and culture change wins, and the facilities ultimately win because they become the provider of choice.
Mark Anderson says
May 20, 2013 at 2:03 pmThen there are the state agencies that want facilities to be sterile places where substantial compliance means no mistakes, no variances and no cultural flexibility. I don’t see CMS becoming kinder and friendlier and that is the real bottom line we’re living with. Culture change is the right path but it seems like I have to disguise it when the state agency visits!
amanda griffin says
May 16, 2013 at 2:34 pmI give tours all the time to companies who “want to see it work”. Send them my way. I would be happy to show them the way.
Kayce Gentry says
May 16, 2013 at 2:11 pmAbsolutely. I have been trying to bring Eden to my facility’s nursing home for 5 years – and there is nothing to show them the benefit. Having a touchy-feely-look at the bottom line facility in our state would be SOOO helpful. Right now it’s like the blind men examining the elephant. Let’s figure out a way to show what the big picture is.
kirksey13 says
May 15, 2013 at 10:51 pmyes, but from what I have seen, the question is still all about the bottom line, can I still make money and not change the way we have been doing things? We will change, only when it is not profitable to stay the way we are. you are a visionary leader, you understand that it can be better, should be different. Most of us in the field are still struggling with leaders (organizations) that think they are doing it better and are making money providing “quality care”. Because quality care is measured on a traditional model base. saying this, i will also say..go get them bill!
MikeGamble says
May 15, 2013 at 10:38 pmYou can if you want, but it won’t do any good … unless and until you can show the owners and administrators a very favorable WIIFM (What’s in it for me?) … and that means only one thing, more profits and/or lower costs … and NOW, this quarter, not in the long term. Am I being cynical? No, just realistic.
Both The Eden Alternative and Green House Project, and other similar projects, ARE the morally correct thing to do. But very few businesses (and these facilities are businesses!) function under a compelling moral imperative. Their imperative is the bottom line … without profits, they cannot continue to provide their services for very long. Like it or not, this “business” reality also applies to the non-profits.
And, just what is their business? Even though they’ll tell you otherwise, they simply provide a place where people can be taken care of, with minimal effort and at the lowest possible expense, until they have the good manners to die. Needless to say, this is completely inhumane. Even the worst prisoners in our jails receive better treatment!
According to some political philosophies, the answer is to allow the free market process to work. In their view, The Eden Alternative and Green House Project offer the more moral approach and, if that’s what the market wants, they will naturally prevail.
So, let’s take a look at the results so far. There are 16,000 nursing homes [67% are for-profit] and 31,000 residential care facilities (mostly ALFs) in the U.S. Of these, only about 400 – less than 1% of the total – have implemented either The Eden Alternative or The Green House Project over the past 22 years.
It seems to me that the only way we can achieve culture change is to take the Howard Beale approach, that is, stand in unison and yell, “I’m mad as hell, and I’m not going to take it anymore!” (from the movie Network, Metro-Goldwyn-Mayer, 1976). That’s right, it’s probably going to take a grass-roots “uprising” to bring about our compelling moral imperative.
What is it?
“We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness.” Sound familiar? It should! It’s the foundation of our Declaration of Independence.
OK, so how does that apply to residents of nursing homes and ALFs?
Nearly 2 million of America’s elderly are warehoused in nursing homes, out of sight and, to some extent, out of mind. Other elderly Americans may live independently, but often are isolated and cut off from their families.
As a society, we need to re-frame our view and care of these people by creating transformed care environments that re-engage them with meaningful life. A philosophy that puts the needs, the interests and the lifestyle choices of the person at the center of their own care. Remember that our Declaration of Independence says, “… all men are created equal …”. It does NOT mean, “All [men] are equal, but some [men] are more equal than others.” (adapted from Animal Farm, by George Orwell)
In other words: “Instead of just waiting to die, help me find a reason to look forward to getting up every day; help me be all that I can and should be. Help me find me. Help me create a life worth living … a meaningful life … to enjoy a rich and fulfilling life (despite my declining abilities and increasing needs).”
They [residents] yearn for caregivers who recognize their worth, affirm their individuality, and relate to them in a healing bond of friendship.” And, let’s not forget that a tiny bit of affection added to the care of someone every day makes a huge difference in the life of that precious person.
Kayce Gentry says
May 16, 2013 at 2:19 pmMike, you have stunning perception and are absolutely right…..if I hear the Director of our SNF call the residents ‘cute little critters’ one more time, I’m going to clean her clock!!!!! Our CEO is politely interested and, if our next major project is the rumored ALF, I’m going to camp in his outer office and beg. We are not-for-profit and made made a semi-effort to redesign and include ‘like home’ features, but have a long way to go. It will take a ‘seeing is believing’ experience and I’d sure like to have the opportunity to give it to them!!
Christina Forbes says
May 16, 2013 at 10:24 pmI think it is important to educate those who place people in nursing homes that there are alternatives that are far superior to the standard model. The children of aging parents, and other professionals in the field, need to be awakened not to the moral imperative, but to the betterment of the lives of their aging parents and clients, if they choose, look for, and demand Eden and Greenhouse end of life fun and games! They are the ones choosing the type of care for their parents and clients. Let the market demand the kind of services that will make everyone better off. So, a big push to publicize Eden and Greenhouse to the market that matters!!! Big media push.
Dick Ambrosius says
May 15, 2013 at 7:18 pmMost definitely my friend!!
Christine Merzeder, Eden European Mentor says
May 15, 2013 at 2:22 pmYes, Eden and the Green House should be more aggressive until the tipping point is reached. The better solution is always the enemy of the present state.
Meredith Ann Rutter says
May 15, 2013 at 3:44 pmBill – Yes, of course! I read an excellent book called “Switch” a year or two ago that I think could help you/yours with the thinking you’re going after. Here I’ll quote from the website: “The Heaths [brothers, authors of the book] show how everyday people—employees and managers, parents and nurses—have united both [the rational and the emotional] minds and, as a result, achieved dramatic results.” It’s a well-written, entertaining book that may help guide your next steps.