Program Goals:
Today, nursing homes are familiar places for many Americans—either they have family or friends in a nursing home, or they live in one themselves. Still, many people dread the thought of living in one. And that shouldn't be the case.
The Picker/Commonwealth Fund Program on Quality of Care for Frail Elders aims to transform the nation's nursing homes and other long-term care facilities into resident-centered organizations that are good places to live and work, capable of providing the highest-quality care. The projects it supports aim to:
- identify, evaluate, and spread models of resident-centered care, or care delivered in accordance with the needs and desires of the people who live in nursing homes;
- equip nursing home operators to lead transformational change; and
- promote policy options that support resident-centered care.
The Frail Elders program, which builds on the Fund's previous experience with the Restraint-Free Nursing Home Program, is led by Assistant Vice President Mary Jane Koren, M.D., M.P.H.
The Issues:
In hospitals, good care is paramount. But in nursing homes, offering good care is only half the picture; it is equally important to provide a good place to live. Despite passage in 1987 of the Nursing Home Reform Act, which underscored the importance of quality of life and the preservation of residents' rights, there are still serious concerns about the quality of life at the nation's 16,000 nursing homes. Staff shortages and high turnover rates exacerbate problems.
A grassroots movement proposes a radical departure from the traditional nursing home model—in effect a total "culture change" that aims to improve the lives of the frail older adults who live in such facilities. Resident-centered care requires a fundamental shift from thinking of nursing homes as institutions where frail elders must live, to conceiving of them as homes that provide personal care and health services. A growing body of evidence is revealing that nursing homes that have undergone culture change—such as those following the Eden Alternative, or Green House models—not only are better for the people who live and work there, but they also are economically viable alternatives to more traditional facilities.
Recent Projects:
Advancing Excellence in America's Nursing Homes. Building on the success of the culture change movement and other quality initiatives, a coalition-based campaign called Advancing Excellence in America's Nursing Homes was begun in 2006. Its aim is to help nursing homes to improve the quality of life for both their residents and staff. The voluntary campaign is led by a national steering committee of 26 organizations, including long-term care providers, health care professionals, direct care workers, consumers, government agencies, and other organizations. Participating nursing homes must select at least three out of eight measurable goals that monitor key indicators of nursing home care quality, including clinical quality, such as better pain management, and organizational improvement, such as decreased turnover.
In September 2008, 44.4 percent of America's 16,000 nursing homes have signed up for the campaign. Consumers and nursing home staff can also sign up to participate. Through its Web site and the 49 state-based networks (called LANES or local area networks for excellence), the campaign is providing technical assistance to providers to help them with their improvement efforts. Data tracking shows that nursing homes participating in the campaign are improving at a faster rate than those not involved. The Fund has supported a field director for the state networks and helped with communications.
The Commonwealth Fund 2007 National Survey of Nursing Homes. With Fund support, Harris Interactive undertook a survey of a national random sample of nursing homes to evaluate the spread of the culture change. The results were published in May 2008 in a report, Culture Change in Nursing Homes: How Far Have We Come? Findings From The Commonwealth Fund 2007 National Survey of Nursing Homes, by Michelle M. Doty, Ph.D., Mary Jane Koren, M.D., M.P.H., and Elizabeth L. Sturla, M.P.H. Overall, the survey found that while many nursing homes are aware of the culture change movement and may be using some resident-centered practices associated with culture change, such as letting residents make decisions affecting their daily activities, progress has been slow in transforming long-term care facilities from institutions to homes.
Pioneer Network. The Pioneer Network, an organization that has spearheaded the culture change movement since 1997, is reaching out to providers across the country to offer training, practical tools, and resources, as well as a community for those trying to transform their facilities. With Fund support, the group, along with the Centers for Medicare and Medicaid Services, organized a symposium, Creating Home, in Washington D.C. in April 2008. The meeting addressed how nursing homes' physical environment can support resident-centered care. Six papers were presented to the 600 attendees on issues relating to transforming nursing homes' physical spaces, with barriers to doing so, and possible solutions. A second invitational workshop for national stakeholders was held to examine how regulations might inhibit or advance innovative design and to draw up detailed recommendations.
Building the Health Care Workforce. The Institute of Medicine's ad hoc Committee on the Future Health Care Workforce for Older Americans assessed the health care needs of Americans over 65 years of age and analyzed the forces shaping the workforce that will care for them, including education and training, reimbursement, and public and private programs. The April 2008 report, Retooling for an Aging America: Building the Health Care Workforce, is available at www.nap.edu. The study was supported by a number of foundations including The John A. Hartford Foundation, The Atlantic Philanthropies, and The Commonwealth Fund.
Nursing Home Hospitalizations. With a grant from The Commonwealth Fund, Nancy Barhydt, Dr.P.H., R.N., the former director of clinical affairs at New York State Department of Health and David Grabowski, Ph.D., of the Department of Health Care Policy at Harvard Medical School, studied the fiscal impact of hospitalizations of nursing home residents. They also fielded a survey to better understand the resources necessary to safely manage acutely ill residents in their nursing homes, rather than in hospitals. Several papers resulted from this work, including The Costs and Potential Savings Associated with Nursing Home Hospitalizations, which appeared in Health Affairs, and Predictors of Nursing Home Hospitalization: A Review of the Literature, which appeared in Medical Care Research & Review.
Future Directions:
In the coming year, the Fund's Program on Quality of Care for Frail Elders will work to raise the visibility of culture change, particularly among policymakers at the state and federal levels, which will help to make resident-centered care a reality in many more nursing homes. It also will continue to support Advancing Excellence by enhancing the capacity of the local area networks that are harvesting solutions for improving performance and disseminating them to others. In addition, building on New York State's work on hospitalizations of nursing home residents, a new project will look at the development of a package of tools for nursing homes to help them safely manage their residents for certain acute episodes in order to avoid the trauma of transfer to an emergency room or hospital.
To apply for a grant from the Program on Quality of Care for Frail Elders, visit the Applicant and Grantee Resources page.