Changing The Culture Of Nursing Homes

Sep 25, 2014

Maybe you didn’t know it, but by state law no new nursing homes can be built in Rhode Island unless the owners agree to build a new kind of nursing home. This week state officials approved the application of the first new home since the moratorium began. It’s based on a concept called “culture change.” And Rhode Island Public Radio health care reporter Kristin Gourlay takes us to a home that’s already adopted it.

Making a home, not an institution
Natalie Blais loves it when Maribel Almanzar has time to do her hair. And she has time right now on this sunny weekday morning at a nursing home called Elmhurst Extended Care in Providence. They’re in Blais’s cozy, peaches-and-cream colored room, chatting about their children.

Maribel Almanzar (left) has just fixed Natalie Blais's hair.
Credit Kristin Gourlay / RIPR

As Almanzar, a caregiver here, combs and sprays Blais’s fluffy white hair, Blais explains that she’s come full circle, moving into this place. The old brick building used to be the Providence Lying In Hospital, where she spent a little time as a younger woman.

“I had one of my children in here. I had Patrice. She was born in this hospital.”

Blais prefers this facility to the one she lived in just a few years ago.

“It lacked the warmth. After you’re here just a few days, you feel like you’re part of this place. They have a way of doing it, I don’t know how they do it.”

Blais's room at Elmhurst Extended Care
Credit Kristin Gourlay / RIPR

Elmhurst Extended Care vice president Richard Gamache swears he didn’t plant Blais or feed her lines for this reporter. But she’s expressed exactly what he hopes all of his residents are feeling. At home. Respected. Engaged. Gamache says nursing homes aren’t exactly known for feeling “homey.”

“There are 15,000 nursing homes roughly in the United States. And if we were to walk into 14,500 of them right now, you would see across from the nurses’ station a line up of elders, there in their wheelchair," says Gamache. "Those are models of care that are more institutional where the nursing assistant does the task of getting people up and they park them at the nurses’ station or in the day room where the television’s on 24/7.”

But not here. Gamache explains that his nursing home decided to change its culture a little over a decade ago. They retooled the way they cared for patients and how they organized the actual physical space, based on a philosophy called the “Eden Alternative.”

Eden Alternative homes let residents make the decisions about their care – from when they want to eat to whether they prefer a shower or a bath. In a traditional nursing home, staff schedules and workflows dictate those choices. And in many cases, so do tight budgets.

“There are limited financial resources and there are a lot of regulations," Gamache says. "And people who run, operate nursing homes tend to look for efficiencies. “

But that, says Gamache, is not how people live. People like to follow their own routines. So in Eden Alternative homes, the same staff care for the same small group of residents. That way, says Gamache, they can get to know each other, build relationships. They even adopt some new language - residents are called elders, and where they live isn’t a unit but a neighborhood. Gamache wants to point out some examples. He strolls down one of the home’s broad corridors, passing elders’ rooms.

Elmhurst Extended Care vice president Richard Gamache smiles next to the nursing home's resident parakeets.
Credit Kristin Gourlay / RIPR

“This is an area where there used to be a nursing station. The staff decided we don’t need all this space. Tthey put a couch here, breakfast nook over here…”

On the next floor down Gamache spots one of the home’s lazier residents.

“And down here on this floor there are several cats,” says Gamache.

OK, you might be thinking, sounds nice, but is Elmhurst affordable? Yes and no. At about $300 dollars a day – more than a hundred grand a year - for a private room, it’s right in the middle, and maybe a bit more expensive than many places. But most residents don’t pay for it out of pocket. For most, Medicaid pays the bill. That’s because Medicare doesn’t pay for long term care. So most residents have spent down any savings they had and turned to state aid.

One of Elmhurst's furrier residents spends the morning by a resident's room.
Credit Kristin Gourlay / RIPR

You might also be asking whether running a nursing home this way is really better for residents. Yes it is, says Raymond Rusin. Rusin heads up state nursing home regulation. Take, for example, he says, the Eden Alternative model of keeping staffing consistent.

“We’re seeing data across the country now that residents are less likely to have behavioral episodes when they’re consistently dealing with the same people," says Rusin. "So the consistent assignment in the resident-directed home is a requirement.”

One of many requirements for any new nursing homes in the state. A few others: private rooms, to be constructed around a central, communal living and kitchen area where residents and staff can congregate and share meals.

Rusin says many of the nursing homes already up and running in Rhode Island would love to transform into Eden Alternative-style homes. But the moratorium, while meant to reduce overbuilding, has kept nursing homes from making major changes. Because major renovations need state approval.

“That also prohibits any innovation in the industry, in terms of what nursing homes might be doing and wanting to change," Rusin says. "There’s a certain degree to which they can do it internally, and there’s a certain degree to which if you want to change the physical environment you have to build a new nursing home. So that’s a significant expense.”

Too great an expense for Elmhurst Extended Care, which wasn’t able to put up a new building to match the new philosophy. But resident Natalie Blais has made do with what she’s got: in her small, private room she’s artfully angled a white wicker dresser and pulled a bright, shell-print spread across the bed. Correction:  she’s not the decorator.

“I can’t take any of the credit. I have daughters. And when they heard I was coming in here they just took over. And it gives it a warm, homey feeling," Blais says.