res mgt relation_chapt

Creating, Certifying, and Connecting Innovative Leaders in Aging Services

Integrating Gerontological Principles with Management

2.7

CASP Core Course 2 Section 2.7

2.7.1. TheManagement-ResidentRelationship

Creating, Certifying, and Connecting Innovative Leaders in Aging Services

CASP Core Course 2, Section 7

Table of ContentsThe History of Long-Term Care’s Administrative Approach to “Resident Care”:

The Basis for Culture Change ....................................................................................................... 4

The Culture Change Movement .......................................................................................................... 6

• The Eden Alternative .............................................................................................................. 8

• The Green House Project ........................................................................................................ 16

• The Wellspring Model ............................................................................................................. 19

• Other Culture Change Models or Paradigms ........................................................................... 21

Module 2.7.1The Management-Resident Relationship

CASP Core Course 2, Section 7 Module 2.7.1 – The Management-Resident Relationship

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Editor’s NoteSuccessful management is essential to achieving and maintaining

quality in any business; and, in the field of aging services, The

Management-Resident Relationship is at the heart of successful

management. In Module 2.7.1, Kendall Brune presents a comprehensive

and inspiring analysis of how that relationship promotes quality in

residential facilities for the elderly. After summarizing the historical

transition from a medical model to a social model of care in nursing

homes and other long-term care facilities, Dr. Brune focuses his

discussion on resident-/person-centered care and the exciting concept of

culture change: “the national movement for the transformation of older

adult services, based on person-directed values and practices, where

the voices of elders and those working with them are considered and

respected.” Culture change, however, is much more than just an idea

couched in impressive-sounding words. In this module, you will be

introduced to a variety of models in which the theory has been applied to

the daily operations of aging services organizations, including:

• The Eden Alternative (the earliest and perhaps the best-known

culture change paradigm),

• The Green House Project,

• The Wellspring Model,

• Eldershire,

• Elder cohousing,

• The Pioneer Network,

• Evercare, and

• The Coming Home Program.

Dr. Brune describes the approaches these programs use to deliver

quality care and services, presenting numerous modalities for your

consideration. His listing of the central elements of the culture change

movement (as summarized by Calkins in 2002) and his contrast of

the characteristics of institution- vs. person-directed care, embody

precepts that you can apply to all of your organization’s residents/clients,

personnel, and operations.

Dr. Brune’s list of references gives you dozens of documents available

online for further reading, with still more offered in his selection of

Learning Resources. The Learning Resources also include an extensive

glossary of terms commonly used in the field of long-term care and

Module 2.7.1 – The Management-Resident Relationship CASP Core Course 2, Section 7

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aging services, as well as Dr. Brune’s own diagram of a dynamic

management-resident relationship for building sustainable senior-engaged

communities.

About the AuthorDr. Kendall Brune, President of Future Focus Community, LLC,

provides senior leadership and oversight for development, owned,

and leased properties. He is a senior housing expert and an executive

instructor to leaders in the field, and he assists healthcare developers and

providers in identifying market growth opportunities.

Dr. Brune has more than 25 years of experience in the healthcare

field and has been on the leading edge of culture change in the healthcare

delivery system for the elderly in the United States. His academic

credentials include his designation as a Fellow with the American College

of Healthcare Administrators, his doctorate in healthcare administration,

and his authorship of two practical healthcare books for the senior care

field. He currently serves as an adjunct professor of senior healthcare

administration for two universities, A.T. Still University and the

University of North Texas. Dr. Brune also serves ATSU as a member of

the medical school faculty board and a curriculum committee member

for Geriatric Health Management.

During his graduate work with Project Life and the Center for the

Study of Aging at the University of Missouri-Columbia, he participated

in the national culture change phenomenon of the Eden Alternative as a

researcher, administrator, and disciple, from its infancy through putting

it into practice in one of Missouri’s first affiliated facilities. To further

develop the Eden vision, his practical experience as a licensed long-

term care administrator has allowed him to deliver improvements and

culture change through all continuum of care levels, from independent

senior housing, through assisted care and skilled nursing facilities, to a

major hospital sub-acute care facility. He continues to serve as a mentor

and educator for the Eden Alternative program. He has applied these

philosophies of care in the development and operation of 19 long-term

care facilities; representing $150 million of construction management. All

of these facilities are still operating successfully today.

Dr. Brune obtained his undergraduate degree in healthcare

administration from the University of Missouri-Columbia, an


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M.B.A from William Woods University, and a Ph.D. in healthcare

administration from Kennedy Western University. He is currently

completing a Ph.D. in applied gerontology from the University of North

Texas in Denton.

Learning Objectives• You will understand the driving forces changing the Resident/

Management Relationship.

• You will learn about “Culture Change.”

• You will learn about “Resident- or Person-Centered Care.”

• You will learn how to communicate “Quality Care” to your

customers:

o CMS directives for culture change;

o Medicare reporting mechanism.

• You will learn what wellness is all about.

• You will learn about creative programming to engage seniors.

• You will learn about community engagement.


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OverviewTo discuss the relationship between residents and the management

team, we must first review the transition from a medical model to a

social model of care. Long-term care (LTC) management models were

developed for a very autocratic and hierarchical style of management

based in the 1960s. Those facilities were built on the model of hospitals

(after the Hill-Burton Act of 1946), where the major focus was on

healing, or palliation of, physical ailments and, in the case of residents

with dementia, mental impairment. Residents were—and, for the

most part still are—isolated from family, friends, and community,

often without any view of the outside world. Baby Boomers today will

not tolerate such an environment for their parents, or themselves. A

cultural revolution called “Resident-Centered Care” started to occur and

change the Resident/Management Relationship. “Culture change” is the

common name given to the national movement for the transformation

of older adult services, based on person-directed values and practices

where the voices of elders and those working with them are considered

and respected. In the management process, decision-making is pushed

down to the lowest level of front line staff. Administrators have become

“facilitators of process improvement” and community advocates for

senior consumerism. We are now exploring new ways to enhance revenue

streams that entail home care, private-duty nursing, outpatient therapy

services, spa and wellness clinics, fitness and pool centers for seniors,

and any other creative outreach program that engages seniors to return

continuously to a facility. This module will explore the history of culture

change and the process of creating a new “well-being and connectivity”

model for senior retirement communities.

The Resident-Management Relationship

The History of Long-Term Care’s Administrative Approach to “Resident Care”: The Basis for Culture Change

The development of skilled and intermediate care nursing facilities

in the United States during the 1950s and 1960s served an honorable

purpose. Facilities of the pre-1990 era and, indeed, the vast majority

even today, serve the “medical” needs of those unfortunate individuals

who require skilled nursing care, i.e., medical care. The organizational


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structure of most facilities continues to be patterned after the hospital’s

hierarchical, departmentalized, top-down management scheme, similar

to most American corporations. In short, hospitals, nursing homes, and

retirement communities, have been designed to be efficient, standardized,

cost-driven, and regulation-compliant corporate institutions.

Although not all nursing homes prior to the mid-1990s were

sterile cinder-block structures, they did almost invariably provide the

same internal atmosphere, where front-line staff and residents alike

followed very structured routines with little opportunity for personal or

professional growth or self-expression. Residents were and, for the most

part still are, isolated from family, friends, and community, often without

any view of the outside world. Over half of nursing home residents

spent much of their day in restraints, a practice which was condoned by

regulators until the passage of the Nursing Home Reform Act as part of

OBRA in 1987 (Calkins, 2002). Traditionally, there has been little regard

for residents’ privacy, and a high level of neglect for their emotional,

social, and spiritual needs. Many residents just shut down, which, for

some, hastens their physical decline.

For most of us studying applied gerontology, this is not news. It is

safe to say that the “great dread” of becoming a dependent senior was to

be put in a nursing home, a sentiment shared by both residents and their

loved ones. In a PSB Online “NewsHour” report, Dentzer (2002) cited a

poll taken by NewsHour, the Kaiser Foundation, and the Harvard School

of Public Health, which revealed that 1) almost half of all Americans

thought people were worse off after going into nursing homes than before

they went in, 2) almost four in ten nursing home residents reported being

dissatisfied with their care and, 3) one in four Americans reported that a

nursing home resident they knew had been badly treated or abused by the

staff. Furthermore, a Congressional report released just prior to Dentzer’s

article stated that state inspectors had cited nearly one in ten nursing

homes for instances of serious abuse (“Nursing Home Abuse News,”

2001).

As background information, in a 1999 National Nursing Home

Survey, the National Center for Health Statistics reported that there were

1.6 million nursing home residents (usually referred to as “patients”),

living in 18,000 nursing homes nationwide, with an 87% occupancy rate,

and an average current resident length of stay of 892 days (nearly 2½

Abuse/Elder Abuse: Any knowing, intentional or negligent act by a caregiver or any other person that causes harm or a serious risk of harm to a vulnerable older adult. Types of elder abuse may include physical abuse–inflicting, or threatening to inflict, physical pain or injury on a vulnerable elder, or depriving him or her of a basic need; emotional abuse–inflicting mental pain, anguish, or distress on an elder person through verbal or nonverbal acts; sexual abuse–non-consensual sexual contact of any kind; exploitation–illegal taking, misuse, or concealment of funds, property or assets of a vulnerable elder; neglect–refusal or failure by those responsible to provide food, shelter, health care, or protection for a vulnerable elder; and abandonment–the desertion of a vulnerable elder by anyone who has assumed the responsibility for care or custody of that person. The specificity of laws varies from state to state (see National Center on Elder Abuse at www.ncea.aoa.gov; retrieved on October 2, 2009).

Resident: A person who lives in a long-term care setting, such as a nursing home or assisted living community.

Nursing Home or Skilled Nursing Facility (SNF): A residential care setting that provides 24-hour-care (all day and night) to individuals who are chronically ill or disabled. Individuals must be unable to care for themselves in other settings or need extensive medical and/or skilled nursing care.


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years!) (“Nursing Home Care,” 2008). A 1997 National Nursing Home

Survey reported that approximately 4.3 % of the US population age 65

or older were nursing home residents, about half of whom were age 85 or

older; and about 75% of these 65-and-over residents required assistance

in three of more activities of daily living (ADLs). Forty-two percent of all

nursing home residents were diagnosed with dementia (Gabrel, 2000).

According to Dr. Bill Thomas, founder of the Eden Alternative, “Any

adult in America who reaches the age of 65 has a 50% chance of spending

time, significant time, in a nursing home. That’s a vast proportion of our

society. . . . The only other segment of our society that is more likely to

be institutionalized are convicted criminals. . . . So here we have a society

that used an institutional pattern for convicted violent felons and our

frail mothers and fathers. And that is a losing proposition in the 21st

century” (“Thou Shalt Honor . . . The Eden Alternative,” 2002, [n.p.]).

And it is certainly not an option for many of the emerging Baby Boomer

population, who will demand more and much better options for their

LTC needs. Thomas predicts that the Boomer generation will completely

wipe out the traditional, institution-type nursing home, or at least that is

his goal!

With this historical and statistical background, it seems that a major

organizational reformation was brewing a perfect storm for change. Now

let’s begin to talk about how the resident and management relationship

process has changed in the continuum of senior care and housing.

The Culture Change MovementA paradigm shift in resident care occurred in the form of the culture-

change movement in the LTC field (Brune, 1992; Brune, 1995). We

can see that the Baby Boomers are coming, and we’re all aware that the

sheer number of retirees will strain our limited staff, plant, financial, and

emotional resources in the near future. Boomers will bring with them

new technologies and more diverse expectations. We must meet these

expectations and use technology to understand future demands by means

of dynamic assessment of service desires.

In actuality, the distinction of being the earliest recent culture change

movement could be given to the Gray Panthers, organized in 1970 by

Maggie Kuhn. This liberal activist organization is still alive and well

today, advocating for a range of social and political causes, many relating

Activities of Daily Living (ADLs): Daily functions such as getting dressed, eating, taking a shower or bath, going to the bathroom, getting into a bed or chair, or walking from place to place. The amount of help a person needs with ADLs is often used as a measure to determine whether he or she meets the requirements for long-term care services in a nursing home as well as government-subsidized home- and community-based services (also see Instrumental Activities of Daily Living).


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to healthcare, and including ageism and the rights and interests of seniors

(“Gray Panthers: Issue Resolutions Summary,” 2009; “Gray Panthers,”

[n.d.]).

In the context of our discussion here, “culture change’” is the

term commonly used to describe the national movement for the

transformation of older adult services, based on person-directed values

and practices where the voices of elders and those working with them

are considered and respected. Core person-directed values are “choice,

dignity, respect, self-determination, and purposeful living” (“What Is

Culture Change?,” 2008, [n.p.]). It is “an effort to radically transform

the nation’s nursing homes by delivering resident-directed care and

empowering staff ” (Rahman & Schnelle, 2008, p. 142). Although

the first real impetus for nursing home reform came in 1991 with Bill

Thomas’ Eden Alternative model, the culture change movement is

generally thought to have begun in 1997, following the first meeting

of the nursing home Pioneers (now known as the Pioneer Network),

during which the term “culture change” was coined. The University of

Missouri-Columbia’s “Project Life” was responsible for the publication

of Thomas’s first book, The Eden Alternative, and I was fortunate enough

to be working for Dr. Stan Ingman at UM-C’s Center for the Study of

Aging at the time of this project (1988-1992). The Eden Alternative

resident philosophy challenged administration to identify who residents

“had been” and how they could still add value to the greater community

in which they were engaged. Co-habitational communities like Heritage

of Green Hills, located in Reading, Pennsylvania, focus on the holistic

philosophy that each person has a personal path to wellness through

social, spiritual, physical, intellectual, emotional, and vocational activity

(“Building Premiere Retirement Communities for Today’s Active

Seniors,” 2007).

With various health care providers developing their own branded

versions of resident-centered care models, “culture change” has become

a generic term, encompassing a host of LTC concepts and models,

including the following:

1. Resident-centered care;

2. Resident-directed care;

3. Eden Alternative;

4. Green House Project;

Culture Change: The common name given to the national movement for the transformation of older adult services, based on person-directed values and practices, where the voices of elders and those working with them are considered and respected. Core person-directed values are choice, dignity, respect, self-determination, and purposeful living. Culture change transformation supports the creation of both long- and short-term living environments as well as community-based settings where both older adults and their caregivers are able to express choice and practice self-determination in meaningful ways at every level of daily life. Culture change transformation may require changes in organization practices, physical environments, relationships at all levels, and workforce models, leading to better outcomes for consumers and direct-care workers without being costly for providers.

Person-Directed Care/Person-Centered Care: An approach to care that honors and respects the voices of individuals and those working closest with them. It involves a continuing process of listening, trying new approaches, seeing how they work, and changing routines and organizational approaches in an effort to individualize and de-institutionalize the care environment (e.g., nursing home or assisted living facility).


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5. The Wellspring Model;

6. The Pioneer Movement;

7. Person-centered care;

8. Quality-Improvement Organizations;

9. Advancing Excellence campaign;

10. Culture of safety;

11. Best friends approach;

12. Validation therapy;

13. Activity-focused care;

14. Positive Interactions Program; and

15. Beyond the Green House Project Care Model (Nissenboim, 2004).

Calkins (2002) sums up the culture change movement as

1. Respecting the individual needs and desires of each person (even

people with dementia, including the right to control decisions

that are made about their lives;

2. Honoring the life patterns and accomplishments of every person

within the setting, residents and staff alike (staff means, especially,

nurse’s aides, traditionally the lowest in the organizational

hierarchy);

3. Supporting opportunities for continued growth;

4. Enabling continued productive contributions to their community

(including experiential sharing, i.e., legacy);

5. Encouraging meaningful connections with family and the

community (to combat feelings of loneliness and helplessness);

6. Fostering fun (to combat resident boredom and empowering

staff ); and

7. Restructuring of staffing roles and relationships (team approach,

consistent assignment of staff, empowerment of front-line staff ).

The ultimate goal is to achieve maximal quality of life, for both

residents and staff.

To begin understanding current philosophies of resident/

management relationships, we must review some present-day models of

resident care.

The Eden AlternativeThe Eden Alternative (EA), proposed by geriatrician and nursing

home physician William Thomas in 1991, was the earliest of the culture

Geriatrician: A medical doctor with special training in the diagnosis, treatment, and prevention of illness and disabilities in older adults (see American Medical Directors Association at www.amda.com; retrieved on October 2, 2009).

The GREEN HOUSE® Model: A small, intentional (“purpose-built”) community for a group of elders and staff. A Green House residence is designed to be a home for six to ten elders needing skilled nursing or assisted living care. The purpose of the Green House is to be a place where elders can receive assistance and support with activities of daily living and clinical care, without the assistance and care becoming the focus of their existence.

Provider: Typically a professional healthcare worker, agency, or organization that delivers health care or social services. Providers may be individuals (physicians, nurses, social workers, and others), organizations (hospitals, nursing homes, assisted living facilities, or continuing care retirement communities), agencies (e.g., home care and hospice), or businesses that sell healthcare services or assistive equipment (e.g., colostomy care supplies, wheelchairs, walkers, etc).


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change models. It also has been the most influential, successful, and

widely publicized; indeed it has become the model of models, and its

basic tenets are interwoven into almost all other proposed models of care.

It has led Dr. Thomas to conceive several offshoot or successor models,

including the Green House Project, the Eden at Home and the Eden at

Home Embracing Elderhood concepts, and Eldershire communities.

Dr. Thomas formulated the Eden Alternative concept while he was

the house physician for a nursing home in upstate New York, the name

Eden inspired by the Biblical garden that was created to help ease Adam’s

loneliness. Thomas noted that the majority of residents in his nursing

home suffered from what he called “the three plagues”—loneliness,

helplessness, and boredom—as described in the first of the ten Eden

Alternative Principles:

1. The three plagues of loneliness, helplessness, and boredom account

for the bulk of suffering among our Elders.

2. An Elder-centered community commits to creating a Human Habitat

where life revolves around close and continuing contact with plants,

animals, and children. It is these relationships that provide the young

and old alike with a pathway to a life worth living.

3. Loving companionship is the antidote to loneliness. Elders deserve

easy access to human and animal companionship.

4. An Elder-centered community creates opportunity to give as well as

receive care. This is the antidote to helplessness.

5. An Elder-centered community imbues daily life with variety and

spontaneity by creating an environment in which unexpected and

unpredictable interactions and happenings can take place. This is the

antidote to boredom.

6. Meaningless activity corrodes the human spirit. The opportunity to

do things that we find meaningful is essential to human health.

7. Medical treatment should be the servant of genuine human caring,

never its master.

8. An Elder-centered community honors its Elders by de-emphasizing

top-down bureaucratic authority, seeking instead to place the

maximum possible decision-making authority into the hands of the

Elders or into the hands of those closest to them.

9. Creating an Elder-centered community is a never-ending process.

Human growth must never be separated from human life.


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10. Wise leadership is the lifeblood of any struggle against the three

plagues. For it, there can be no substitute (Thomas, 2006; “Our 10

Principles,” 2009).

Any nursing facility can choose to adopt some or all of these

Principles; but, to be a bona fide (registered) EA facility, the nursing

home must agree to abide by all ten Principles, register with the EA

Registry, and participate in the ongoing Eden development process of

continual commitment and striving not only toward complete fulfillment

of the EA Principles but toward ever-improving resident quality of life

and transforming the institution into a warm Human Habitat. The

Eden Registry is maintained by the Eden Alternative, and both are

non-profit entities. The Registry is not an accreditation, monitoring,

regulatory, and punitive or organizationally controlling body. Rather,

it provides education and resources to help nursing facilities adopt the

Eden Principles and Practices (“Becoming Part of the Eden Registry,”

2009). EA-registered homes receive an Eden Tree plaque and Symbols

of Recognition (“The Eden Alternative: We Are Different,” 2009). Eden

also provides a multitude of training workshops and trainer certifications

(Brune, 1995). To date, Eden has trained over 15,000 Certified Eden

Associates, and the organization now claims over 300 registered homes,

in the United States, Canada, Europe, Japan, Australia, and New

Zealand (“Certified Eden Associates,” 2009). EA is a small and simple

organization, consisting of Dr. Bill Thomas; his wife Jude; the Eden

home office staff; 50 Eden Educators; 60 mentors and, of course, the

15,000 Eden associates (“The Eden Alternative: Improving the Lives of

the Elders and Their Care Partners,” 2009).

Combating the three plaguesThe major impetus of the EA movement was, and still is, the

elimination of loneliness, helplessness, and boredom. In an Eden facility,

the cure for loneliness is companionship: with other residents, with

front-line staff (empowered Certified Nurse Assistants, housekeepers,

maintenance personnel, etc.), and with an abundance of plants and

animals. CNAs are not only cross-trained to work in small teams, and

empowered with front-line decision-making; they are required to attend

to residents’ emotional needs, they treat all residents with dignity and

importance, and they come to know residents on a highly interpersonal,

intimate level.

Certified Nursing Assistant (CNA): A person trained and certified to assist individuals with non-clinical tasks such as eating, walking, and personal care (see ADLs and Personal Care). This person may be called a “direct-care worker” (DCW). In a hospital or nursing home the person may be called a nursing assistant, a personal care assistant, or an aide.

Direct-Care Staff/Direct-Care Worker (DCW): An individual working in a nursing home or assisted living community who provides “hands-on” help to residents with activities of daily living (see Certified Nursing Assistant).


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Eden facilities are universally teeming with birds, especially parakeets,

finches, and canaries; dogs and cats; rabbits; sometimes fish and guinea

pigs; and an abundance of plants, inside and out. This is why some have

called EA the “Fur and Feathers” program. Residents are encouraged

to tend to, and even adopt, plants and animals. Pets, especially dogs,

sometimes even adopt residents. In fact, some canines have actually

learned to operate the elevators to visit their “favorite people” (Bruck,

1997).

Thomas’ plan to uplift residents’ spirits and combat loneliness

through contact with animals was implemented from the very start,

when he introduced EA in his own Chase Memorial Nursing Home in

upstate New York in 1991 and said, “We’ll bring in 100 birds, two dogs,

four cats, three rabbits and a flock of laying hens . . . Then we’ll plow

the lawn and start a large organic vegetable garden outside our residents’

windows.” And he did. One day, the birds arrived—all 100 of them! (“An

Eden Alternative: A Life Worth Living, 2003).

The benefits of animal-assisted therapy (AAT)—although Thomas

prefers to regard animal-resident interaction as a natural bonding process

rather than a therapy (Bruck, 1997)—are well-documented. Companion

animals have been shown to be effective in reducing loneliness in both pet

owners and in nursing home residents, as measured objectively, especially

for those residents who had a life history of emotional attachment to pets,

usually in early childhood. A significant effect on loneliness was noted

with as little as 30 minutes of pet contact per week (Banks & Banks,

2002; Banks et al., 2008; Barker, 1999). A reduction in incidence and

severity of depression is also likely to be associated with pet and plant

contact, as well as promotion of “social capital” in the form of social

contact and interaction (Wood et al., 2005). Some have cautioned that

the use of companion pets could result in zoonosis (atypical infections),

but only one report of such an incident surfaced during my literature

review, a case of atypical scabies in a nursing home with an active EA

program (Morley & Flaherty, 2002). Based on my personal knowledge of

the facility in question, I believe that other infection sources and practices

are a more probable cause. Animals in EA homes are generally observed

and tested by veterinarians, and the spread of disease is apparently not

a significant problem. Furthermore, state regulations do not prohibit

animal residence in nursing homes. Thirty-two states do not address the


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issue; those that do usually have restrictions on numbers and/or kinds of

animals allowed (“Quality of Life: Pets and Animal Therapy,” 2008). Pets

and companion animals are generally not allowed in kitchen and dining

areas during meal service times.

Children, from pre-schoolers to high-schoolers, are often a key feature

in Eden facilities, allowing residents to interact and share life experiences

and knowledge, including playing games, sharing stories, helping with

homework, and working together in the garden. I first started Eden and

childcare in an LTC facility in 1989 at the Continuous Care Retirement

Community in Columbia, Missouri. Resident feelings of helplessness

tended to be alleviated by helping children, caring for pets and plants,

and making decisions about their environment and their daily activities.

“A home that opens its doors to pets, children, and the community

has little room for boredom . . . . Life in an Eden home is spontaneous”

(“An Eden Alternative: Life Worth Living,” 2003, [n.p.]). Meals are

varied, often chosen by the residents; activities are varied; the range

of visitors is varied. Each resident’s room is decorated to his or her

individual tastes, and personal living spaces are thus varied. Front-line

staff tend to interact frequently with residents, combating both loneliness

and boredom. At the Levindale Hebrew Geriatric Center in Baltimore,

Maryland, which became a registered EA facility in 2000, a family

atmosphere was created by the formation of small groups of residents

and staff called “kibbutzim” (plural of “kibbutz”). Kibbutzim groups

met regularly to become better acquainted and discuss issues, including

what kinds of pets to bring into the family (“Eden Alternative and

Neighborhood Model,” 2006).

Measurable benefits of the Eden AlternativeResults of studies assessing the benefits of “Edenizing” or “going

Eden” vary in amount of attributed benefit, but those measuring benefits

objectively and over a suitable time frame consistently show positive

results. In 2003, Bill Thomas’ study of his own Chase Memorial Nursing

Home showed a reduction in overall number of drug prescriptions,

infection rates, staff turnover, and the mortality rate. Studies of the Texas

EA Project involving several nursing homes charted significant decreases

in in-house pressure sores, anxiolytic and antidepressant medications, and

staff absenteeism. Perhaps the best indicator of success is that Eden homes

Turnover: The average percentage of staff who stop working at a care setting each year. Virtually all healthcare organizations (hospitals, nursing homes, assisted living facilities, etc.) track and measure the number of staff who stop working (turnover) and the length of stay of staff (retention) in the same or similar jobs. A high turnover rate in a nursing home or assisted living community means that the facility in question is constantly hiring and training new caregivers.


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across the nation report waiting lists for their beds (“An Eden Alternative:

Life Worth Living,” 2003).

In addition to quality-of-care and quality-of-life resident concerns,

a constant challenge for many nursing homes is staff dissatisfaction,

in particular among CNAs, and, more specifically, high rates of staff

turnover and absenteeism. In the test Eden facilities in Texas, a 25%

reduction in staff turnover was documented, along with a one-third

drop in absenteeism (Kleinman, 2009). In Bethel Lutheran Nursing

Home, overall drug costs were down 50%, the mortality rate was

reduced by 15%, and the infection rate was cut in half; benefits for staff,

family members and visitors were equally dramatic (“Eden Alternative

Philosophy: Life Worth Living,” [n.d.]). Data from Southwest Texas

State University showed a 50% reduction in the incidence of decubitus

ulcers, a 60% decrease in difficult behavioral incidents among residents,

a 48% decline in staff absenteeism, and an 11% drop in employee

accidents (Willging, 2000). A study of residents’ emotional needs showed

positive results on the Minimum Data Set items relating to helplessness,

loneliness, and boredom; the UCLA Loneliness Scale; the Geriatric

Depression Scale; and the Lubben Social Network Scale (Parsons &

Bergman-Evans, 2004). Another study showed significant improvement

in family satisfaction, as measured by the Family Questionnaire, after

implementation of EA. The improved satisfaction scores reflected greater

communication and interaction among families, staff, and residents

(Rosher & Robinson, 2009).

Research by Coleman et al. (2002) showed no significant benefit of

EA in terms of cognition, functional status, survival, infection rate, or

cost of care, one year after its implementation. This was an earlier study,

however, and the one-year study period may have been insufficient to

demonstrate benefits. Rahman and Schnelle (2008) believe that the

culture-change movement is spreading in advance of a solid research base

to support its quality-of-life improvement claims. They propose specific

and more focused research questions that will bring to light the costs and

benefits of EA and other innovative models of care.

Rather critical findings come from a study prepared for the Canadian

Union of Public Employees (CUPE) Health Care Council by CUPE

Research (2000) as summarized below.


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1. The Eden Alternative has been severely criticized by some elder

advocacy groups in the United States.

2. Measured benefits claimed by EA homes are based on a number of

small preliminary studies that lack rigor. There is no definitive study

that proves the benefits of EA (at least as of 2000, when the CUPE

study was released).

3. In the U.S., for-profit NHs may be promoting EA in an attempt to

counter widespread accounts of resident abuse and neglect. Critics

argue that no genuine improvements, such as increased staffing levels,

are being made to address the serious deficiencies in elder care.

4. While being promoted as inexpensive to implement and cost-effective

to maintain, elder advocacy groups counter that EA cannot be

implemented properly without additional money and staff. Limited

resources may be redirected towards the care of animals and plants.

5. In EA facilities, jobs in nursing, laundry, recreation, and food services

may be reduced or eliminated as aides’ jobs are expanded to include

some or all of these duties.

6. Most of workers’ complaints about EA center on the issue of

understaffing. Staffing numbers may not be increased in proportion

to the new workload, which includes caring for plants and animals

and coordinating residents’ activities with children.

7. The introduction of animals into the long term facility exacerbates

existing workload problems and has implications for health and

safety. Plants and animals could be neglected as a result of insufficient

staff.

8. Workers have expressed concerns about inadequate training.

9. Workers can suffer from burnout if they are permanently assigned to

a group of severely challenged residents.

In spite of these concerns, issued from a public employee union’s

perspective, EA and other culture-change models and proposals are

moving forward at an ever-increasing pace. One of the goals of the

Advancing Excellence campaign was to encourage nursing homes to

adopt consistent assignment—the practice of assigning nurse aides to

the same residents on a daily or nearly daily basis. With the endorsement

of the Centers for Medicare and Medicaid Services (CMS), one of the

founders of the campaign coalition, one-third of the nation’s nursing

homes (5,246 facilities) had registered as “official participating providers,”

Centers for Medicare and Medicaid Services (CMS): The entities responsible for regulating and paying nursing homes, home health agencies, and hospices for the care of Medicare and Medicaid (in conjunction with the states) beneficiaries. With a budget of approximately $650 billion and serving approximately 90 million beneficiaries, CMSs plays a key role in the overall direction of the healthcare system.

Consistent Assignment: Residents seeing and receiving care from the same caregivers (registered nurse, licensed practical nurse, direct-care worker/certified nursing assistant) during a typical work week. Consistent Assignment may also be called Primary Assignment.


15

as of June 1, 2007. Of these, 31% had committed to implementing

consistent assignment (Rahman & Schnelle, 2008).

National directives from CMS establish “person-centered” care as

one of the six aims of the Institute of Medicine. It can also be seen as a

defining aspect of the vision in the Quality Improvement Roadmap: the

right care for every person every time calls for care that reliably meets the

patient’s needs. To achieve this vision, care must be organized around the

person’s, not the provider’s, needs. Person-centered care can also result

in better self-care. This is particularly important in chronic conditions,

which constitute a substantial part of the burden of illness, and cost, in

the Medicare population. Thus, person-centered care is an important

element in the improvement of quality and efficiency for all senior care

providers (Leavitt, 2006).

A study published a year later by the Commonwealth Fund (Doty,

Koren, & Sturla, 2008) revealed similar nursing home adoption of

culture change principles and resident-centered care. The authors sent

questionnaires to a representative sample of 1,435 nursing homes

and, based on the responses, divided these facilities into three separate

categories: culture change adopters (31%), culture change strivers

(25%), and traditional nursing homes that had adopted culture change

principles very little or not at all (43%). Although the nursing homes in

general had been relatively successful at increasing resident involvement

in decision-making and, to a lesser extent, accommodating collaborative

and decentralized decision-making to empower direct-care workers, very

little organizational redesign or change in the physical environment had

occurred. Interestingly, the authors also found that “the more a nursing

home has adopted culture change principles, the greater the benefits that

accrue to it, in terms of staff retention, higher occupancy rates, better

competitive position, and improved operational costs” (Doty, Koren, &

Sturla, 2008, [n.p.]).

On the need for continual self-assessment and quality improvement

As part of her master’s degree study while at Kansas State University,

Kiyota ([n.d.]) lived in an EA nursing home for one month, posing as a

wheelchair-bound resident, to determine how the physical environment

was transformed to create a human habitat, and who were the agents


16

of these changes. Eventually, the focus of her study narrowed to the

question of where residents and staff found meaningful experiences

in the nursing home. Residents and staff members were asked to take

photographs of their favorite places in the facility. Interestingly, there

were categorical differences between residents and staff in what was

perceived as meaningful. Staff tended to value areas which had Eden

value and were especially appreciated by family and other visitors, such

as the home-like ambience of the facility’s front entrance, a bright and

airy and plant-bedecked reception desk with a small water-fountain, the

courtyard where children went outside to play, and the aviary in the living

room. Residents, on the other hand, chose the areas they used the most

and to which they were emotionally attached, such as their self-decorated

rooms or a specific area in the room (e.g., a family picture display, a dog’s

bed, a parakeet cage, plants, a television, and an angel that was a gift from

a middle school student), the physical therapy room where the staff were

particularly friendly, the quiet and serene chapel, or the candy shop where

visitors came to chat. Kiyota concluded—and I completely agree—that

the physical environment should be comfortable and restful, appealing

and inviting, homey and well-used, and should have emotional value for

staff, visitors, and residents alike. But, if the facility is to be truly resident-

centered, emphasis must be placed on those areas in the facility which

the residents identify as meaningful to them. LTC facilities must be

continually and fervently self-assessing and searching for ways to improve

residents’ quality of care and quality of life.

The Green House ProjectThe concept

In spite of the recent success of the culture change movement and EA

in particular, Thomas still regarded nursing homes as too institutional.

Despite the growing prevalence of resident-centered care practices,

nursing homes were still too impersonal and medically-focused, and their

physical layouts too large and spread-out, too cold and sterile, and too

resident-unfriendly, with their long corridors and semi-private rooms.

Thomas believed that significant, permanent LTC reform required a

radical redesign of nursing homes architecture and organization.

Thomas’ conception of the ultimate, yet doable, nursing home was a

typical outwardly-appearing house, in a typical residential neighborhood,


17

each house to be occupied by six to ten residents who would otherwise

be occupants of a typical traditional nursing home. Thomas coined the

name “Green Houses” (GHs) for these concept homes, signifying life and

continued growth. A traditional nursing home with perhaps a hundred or

more residents would now consist of a group of Green Houses, in varying

proximity to one another but always noncontiguous, linked together

by organizational management, technology, and communication. The

internal layout would be that of a warm, welcoming residential dwelling

that would foster both intimacy and privacy, care and autonomy, respect

and self-respect.

Physical and organizational design of GHsBecause GHs would be built (or perhaps sometimes remodeled)

from scratch, a similar architectural design would be employed for each.

Resident rooms are situated around the periphery of the house, with

each room opening directly into a central activity area or common space,

consisting of a large dining and activity area, kitchen, and central hearth.

Thus, the distance from a resident’s room to any other area in the house,

especially the central hearth area, the focal point of the home’s interior, is

short and readily negotiable by walking, walker, or wheelchair. This is in

marked contrast to the long corridors of the traditional NH.

There is one long dining room table, large enough for all residents,

two caregivers, and visitors all to sit together for dining or activities. Soft

music is piped in, and flowers are on the table. Each meal is intended to

be a pleasant, enjoyable, engaging social event called a convivium (“The

Green House Concept,” 2008). Each resident has his or her own private

room with private bath, and residents are encouraged to furnish their

rooms as they please, including their own furniture from home. There

is a sense of personal belonging. Outside entrance keys are given only to

residents and caregivers; visitors and other organizational staff, including

managers and nurses, must ring the doorbell to gain entrance.

ShahbazimSimilar to EA facilities (GHs are an offshoot or refinement of EA

homes), in GHs Certified Nursing Assistants (CNAs), or nurse aides,

assume responsibility for nearly all the residents’ needs. However, in a

GH, the CNA’s responsibilities are broadened to include housekeeping

Caregiver: A spouse, family member, partner, friend, or neighbor who helps care for an elder or person with a disability who needs assistance. Caregivers can also be people employed by the older adult, a family member, agencies, or care settings to provide assistance with activities of daily living (ADLs; see above) and instrumental activities of daily living (IADLs) (see below).


18

chores, meal preparation, and managing logistics. In fact, these do-it-

all caregivers are the only staff present in a GH except for emergencies,

and nurse, physician, or therapist visits (“Green House Project,” 2004).

Once lowest on the organizational ladder and now, in many respects,

the highest, these omnipresent workers are referred to by Thomas as

Shahbazim (plural of Shahbaz), a Persian term meaning “royal falcon.”

With an underlying belief that human life is sustained by affection,

Shahbazim are trained and required to befriend and sustain the elders

with whom they work, through the practice of convivium (pleasant

dining), homemaking, and befriending (Shapiro, 2005).

Shahbazim who are not CNAs upon hire must undergo training and

become state-certified. All GH Shahbazim receive 120 hours of training.

The first 40 hours are administered by GH staff and focus on GH

philosophy, policies and procedures, team-building and empowerment,

and dementia care. The remaining 80 hours consist of classes on CPR,

culinary skills, food safety, and home repair (“Green House Project,”

2004).

An elder country clubPlants, animals, and children are part of GH design. All GHs have a

screened-in porch and outdoor garden area. A nursing station is required

by some state statutes, but these are neatly tucked away out of sight,

usually in a utility or staff break room. Residents choose their activities,

mealtimes, and degree of participation in household tasks, with no strict

schedules (Rabig et al., 2006). A GH in Lincoln, Nebraska, even offers

happy hour two afternoons a week, where residents can purchase an

alcoholic beverage, country-club-style (“Green House” Communities

Reinvent Elder Care,” 2008).

Warm, smart, and greenThe idea of creating GHs that are warm, smart and green is, again,

that of Bill Thomas.

Warm: Thomas envisioned the houses as radiating warmth, created

by the floor plan, the décor, the furnishings, and the people within them.

The goal is to create and maintain human warmth.


19

Smart: The use of cost-effective and smart technology such as

computers, wireless pagers, electronic lifts, and adaptive devices cultivates

a sense of resident personal belonging, meaning, and purpose in life.

Green: Sunlight, plants, and access to outdoor spaces create

connections with the living world and its living gifts of life, laughter, and

companionship (Thomas, 2006; “The Green House Concept,” 2008).

Green House development and growthThe first GH, which opened in 2003, was actually a complex of four

GHs, on the campus of United Methodist Senior Services in Tupelo,

Mississippi (Woodrick, 2003), soon followed by six more homes in

Tupelo. With the much publicized success of the Tupelo project, and a

$10 million grant from the Robert Wood Johnson Foundation, many

more have been built and put into use around the country. On December

5, 2008, on target with its Green House Replication Project, the fiftieth

GH opened in the United States, one year earlier than anticipated (“The

Green House Replication Initiative,” 2008; “Green Houses Growing in

Numbers Across the States,” 2008). The homes are built by NCB Capital

Impact Development Corporation, under the direction of Bill Thomas

and the Green House Project Team (The Center for Growing and

Becoming). The 2006 published goal was to have, within five years, at

least one GH in every state (“Green Houses Growing in Numbers Across

the States,” 2008).

“The Green House” is a trademarked model. Any nursing care facility

bearing that label must meet certain standards for construction, living

arrangements, care, and other features” (DeBolt, 2008, [n.p.]). Because

GHs are licensed as nursing homes or skilled nursing facilities and meet

all federal regulations, they qualify for Medicaid reimbursement and can

largely operate within Medicaid payments, with the exception of a few

states where Medicaid reimbursement is much below average (Jenkens,

[n.d.]).

The Wellspring ModelIn keeping with the overall theme of the culture change movement,

and with many of the principles and practices of the Eden Alternative

and the Green House project, the Wellspring Model’s major emphasis

is on quality improvement through both improved clinical care and

Skilled Care/Nursing Care: A level of care that includes help with more complex nursing tasks, such as monitoring medications, giving injections, caring for wounds, and providing nourishment by tube feeding (enteral feeding). It also includes therapies, such as occupational, speech, respiratory and physical therapy. This care can be given in a patient’s home or in a care setting. Most insurance plans require at least some level of need for skilled care, requiring the services of a licensed professional (such as a physician, nurse, or therapist), before they will cover other home-care services.


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organizational culture change. The Wellspring model is a product of

Wellspring Innovative Solutions, Inc., arising out of an alliance of 11

freestanding, nonprofit nursing homes in eastern Wisconsin (Stone et al.,

2002). The organization was formed in 1994 and fully implemented in

1998. Within its 11 otherwise independent nursing homes, it espoused

six core elements: (Reinhard & Stone, 2001):

• An alliance of nursing homes with top management committed to

making quality of resident care a top priority;

• Shared services of a geriatric nurse practitioner, who develops training

materials and teaches staff at each nursing home how to apply

nationally recognized clinical guidelines;

• Interdisciplinary “care resource teams” that receive training in a

specific area of care and are responsible for teaching other staff at their

respective facilities;

• Involvement of all departments within the facility and networking

among staff across facilities to share what works and what does not

work on a practical level;

• Empowerment of all nursing home staff to make decisions

that positively affect the quality of resident care and the work

environment; and

• Continuous reviews by CEOs and all staff of performance data on

resident outcomes and environmental factors relative to other nursing

homes in the Wellspring alliance.

The best known study of outcomes, assessing the 11 Wisconsin

pilot facilities only, seems to be the report by Stone et al., with support

provided by the Commonwealth Fund (Stone et al., 2002; “Improving

the Quality of Nursing Home Care: The Wellspring Model,” 2004).

Results were generally positive:

• Retention rate for Wellspring staff increased slightly.

• Wellspring facilities performed better on annual state inspections.

The number of nursing homes with severe deficiencies fell from 22%

to 0.

• Evidence suggests that Wellspring staff are more vigilant in assessing

problems in quality and take a more proactive approach to resident

care.

• Wellspring residents appear to enjoy a better quality of life.

Nurse Practitioner (NP): A Registered Nurse with advanced education and training. NPs can diagnose and manage most common, and many chronic, illnesses. They do so alone or in collaboration with the healthcare team. NPs can prescribe medications and provide some services that were formerly permitted only to doctors. There are a number of types of nurse practitioners (geriatric, adult, psychiatric-mental health) who work with older adults.


21

• Implementation was essentially cost neutral. Costs were generally

neither more nor less.

In the words of Roman emperor/philosopher Marcus Aurelius, “Dig

within. Within is the wellspring of Good; and it is always ready to bubble

up, if you just dig” (“Wellspring Definition,” 2009, [n.p.]).

Other Culture Change Models or ParadigmsMultiple other culture change proposals and programs have also

surfaced. A few of them are briefly described below.

EldershireThe Eldershire Community is also a product of Dr. Bill and Jude

Thomas’ imagination and dedication to expanding and enhancing the

quality of life of elders and their families and caretakers. It is a planned

intergenerational community, designed to promote an active and ongoing

exchange among the generations. An Eldershire Community contributes

to bettering the quality of life by strengthening and improving the

means by which 1) the community protects, sustains, and nurtures its

elders, and 2) the elders contribute to the well-being and foresight of the

community (“Basic Tenets of the Eldershire Vision,” 2008). An Eldershire

is a community where residents work together to effect the realization of

well-being, the elements of which include identity, autonomy, security,

connectedness, meaning, joy, and space (“Basic Tenets of the Eldershire

Vision,” 2008). Eldershire residents are empowered to collaborate in the

design and ongoing development and management of their communities.

Private homes are “grouped together with common indoor and outdoor

spaces, including walking spaces, gardens, and a central house that

will offer shared meals, meeting spaces, recreational activities and basic

services.” Communities will have “shared values, including respect for the

contributions made by elders, accessible housing design, economic and

environmental sustainability, commitment to life-long learning, and self-

governance” (“Dr. Bill Thomas to Speak at Vital Aging Network Forum

on February 14,” 2006, [n.p.]).

Elder cohousingA multitude of cohousing units have sprung up across the country.

These are planned communities that are nearly identical to Eldershires,


22

in that they offer six common characteristics: participatory process,

design for community, shared common facilities, resident management,

collaborative decision-making, and no shared community economy

(i.e., not income-sharing) (Abraham & deLaGrange, 2006). Unlike

Eldershire Communities, they tend to enlist elders only, although they

may be situated adjacent to multi-generational communities; and they

tend to focus more heavily on shared values, such as spiritual growth

and sharing, a holistic view of aging, and meta-issues such as illness

and dying. Unlike Eldershires, they tend perhaps to offer a little more

planned uniformity and less diversity. But their practical assets are nearly

identical to Eldershires, emphasizing resident empowerment, mutual

respect, shared values, active lifestyle, social integration, some centralized

or shared services, economic and environmental sustainability, and

general social consciousness. Depending on the culture of the community

and the choice of shared values, these Elder cohousing communities

would seem immensely appealing to many of this country’s emerging

boomers (“Building Premiere Retirement Communities for Today’s Active

Seniors,” 2007).

The first cohousing communities in this country were organized in

the late 1980s, patterned after the Scandinavian model. They have also

been a presence in Denmark since the late 1980s. As of about 2006,

there were roughly 5,000 people living in 80 cohousing communities

across the United States. As elder cohousing communities are deliberately

small in size, rarely exceeding 40 households per neighborhood, their

residents have the opportunity to know one another well and develop

closer relationships. In contrast, some retirement communities may

contain as many as 500 to 10,000 households. Many other pre-planned

communities, such as continuing care retirement communities (CCRCs)

do not allow residents the opportunity to participate in the community-

envisioning process, where they develop deeper connections with other

residents and the community as a whole (“Elder Co-Housing: Building a

Collaborative Elderhood,” 2006).

The Pioneer NetworkThe Pioneer Network began in 1997, when a group of 33 LTC

professionals met in Rochester, New York, to discuss novel approaches to

LTC that, whether knowingly or not, would parallel the principles of the

Continuing Care Retirement Community (CCRC): A housing option that offers a range of services and levels of care. Residents may first move into an independent living unit, a private apartment, or a house on the CCRC campus. The CCRC provides social and housing-related services and may have an assisted living residence and a nursing home, often called the healthcare center, on the campus. If and when residents can no longer live independently in their apartment or house, they move into assisted living (unless it is provided in their apartment or house) or the nursing home.


23

culture change movement. Susan Misiorski (2003), the Network’s CEO,

envisions a culture of aging that is life-affirming, satisfying, humane,

and meaningful in whatever setting Elders live—home, assisted living,

or nursing home. The Pioneer Network is committed to working with

state culture change coalitions that currently exist in 33 states, to help

create home and community and advocate for change (Lieblich, 2008). It

seeks “a transformation of the entire culture of aging through education,

advocacy, leadership development, and resource support” (Nissenboim,

2004, [n.p.]). The Pioneer Network advocates for elders across the

spectrum of living options (which are often dictated by differing levels

of medical care required); and is working towards a culture of aging

that supports the care of elders in settings where individual voices are

heard and individual choices are respected, whether in nursing homes,

transitional care settings, or wherever home and community may be.

Cultivating and maintaining a community of relationships are important

at every phase of life, but are especially critical for elders and the aging,

many of whom may need a network of partners to live life to its fullest.

The Pioneer Network provides a global perspective for LTC facilities

to be the senior advocate beyond their four walls (“Pioneer Network:

Culture Change in medicaid,” 2009).

Continuing care retirement communitiesAlso sometimes called life care communities, CCRCs tend to be

large complexes that provide resident housing over a range of care-

dependency, from independent living units, to assisted living units,

to nursing home accommodations. Independent living units may be

small or large apartments, cottages, cluster homes, or single-family

dwellings. Assisted living quarters are usually small studio or one-

bedroom apartments. Nursing home accommodations historically have

been one-room units for two or more persons. As these facilities are all

on the same grounds, all residents are nearby and can be transferred up

or down the range of required services as needed, much like aging in

place. For this reason, CCRCs have been popular with some, although

they tend to be expensive, with entrance fees ranging up to as much as

$400,000 and monthly payments ranging from $200 to $2,500. Some

are affiliated with a specific ethnic, religious, or fraternal order, where

membership may be a requirement for admission (“Other Options:

Assisted Living/Personal Care Homes/Residential Care Facilities: A state-regulated and -monitored residential long-term care option that may have different names, depending on the state. Assisted living provides or coordinates oversight and services to meet residents’ individualized, scheduled needs, based on the residents’ assessment and service plans, and their unscheduled needs as they arise. There are more than 26 designations that states use to refer to what is commonly known as “assisted living.” There is no single uniform definition of assisted living, and there are no federal regulations for assisted living. In many states, most assisted living is private pay. Be sure to check with your state about any waiver programs that may be available through Medicaid to pay for the care provided in assisted living.

Independent Living: A residential location (including rental-assisted or market-rate apartments or cottages) that may or may not provide hospitality or supportive services. Residents can choose which services they want. Additional fees may be charged for some services.

Long-Term Care (LTC): A term used to describe the care needed by someone who must depend on others for help with daily needs. LTC is designed to help people with chronic health problems or dementia to live as independently as possible. Although many people think that long-term care is provided only in a nursing home, in fact most long-term care is given by family caregivers in the elder’s home.


24

CCRCs,” 2004). Furthermore, these communities do not lend themselves

easily to culture change transformation, with its emphasis on small size,

resident empowerment and privacy, and organizational reform. The

continued and rapid growth of the various culture change models will

force these more traditional and outmoded multifaceted communities to

either rebuild or remodel, or become extinct. As admission to a CCRC

is usually a one-time event, all three levels of care must eventually adopt

resident-centered care principles and practices, including perhaps elder

cohousing communities and Green House construction and practice

implementation.

The Evercare care modelEvercare is included here because it is a rather innovative approach

to helping elderly persons or those with chronic or debilitating illnesses,

and because it usually involves and is focused on the elderly. Organized

by two Minnesota nurse practitioners over 20 years ago, Evercare is an

agency that assigns a nurse practitioner to every Evercare member, to

assist that member in negotiating the healthcare system. Evercare nurses

help coordinate care by collaborating with physicians, nursing homes,

and families. They are trained to deliver personalized and compassionate

care, both to persons in nursing homes and to individuals living

independently at home. They serve hundreds of thousands of people in

38 states through Medicare and Medicaid health plans (“Evercare: About

Us,” 2008).

Coming Home Program“The Coming Home Program is designed to bring the benefits of

assisted living to low-income, frail seniors living in rural areas” (“Coming

Home Program,” 2008, [n.p.]). Assisted living facilities may be scarce or

absent in sparsely populated areas of the country, and many charge $100

or more per day, which is out of the price range of many rural seniors.

As a result, many of these seniors must either relocate some distance to a

place where assisted living services are available, or be prematurely placed

in nursing homes. The Coming Home Program seeks to rectify this

situation by providing technical assistance and grants to both providers

and states.

Medicaid: The federally- and state-supported, state-operated public assistance program that pays for healthcare services to low-income people, including older adults or disabled persons who qualify. Medicaid pays for long-term nursing home care and some limited home health services, and it may pay for some assisted living services, depending on the state. It is the largest public payer of long-term care services, especially nursing home care. Each state can determine the breadth and extent of what services it will cover above a certain federally required minimum.

Medicare: The federal program that provides medical insurance for people aged 65 and older, some disabled persons, and persons with end-stage renal disease. It provides physician, hospital, and medical benefits for individuals over age 65, or those meeting specific disability standards. Benefits for nursing home and home health services are limited to short-term rehabilitative care. Different parts of Medicare cover specific services if you meet certain conditions. For detailed information, visit the website (www.medicare.gov; retrieved on October 1, 2009) or call 1-800-Medicare for assistance.


25

SummaryThe culture change movement is growing, perhaps slowly, since

traditional LTC is a “mom and pop” family business. But the movement

will grow faster now that CMS has trained federal and state surveyors in

“Resident-Centered Care” evaluation, eliminating opposition and more

than a few barriers. The greatest remaining barrier appears to be fear

of change and of potential costs involved. But implementation can be

phased in, even as a preface to the seemingly drastic structural rebuilding

in the form of Green Houses, Pioneer Network Affiliated Partners, and

co-habitational communities.

It is fortunate for our generation of LTC professionals that culture

change movements are challenging, tearing apart, and rebuilding the

traditional nursing homes built in the 1950s and 1960s. With CMS

behind our movement, the time seems right for these facilities to

undergo a culture change reformation. From what has been discussed

here, it would seem imprudent to rebuild one outdated facility in the

place of another. It would seem much wiser to build several smaller,

more resident-accessible homes, with private rooms and a residential

appearance and atmosphere. However, facilities located at Anywhere,

USA may not have the funding to rebuild new, “culturally dynamic”

physical plants. The Pioneer Network has an excellent approach to

changing a facility’s resident and staff relationships through a process of

systematic change. The Network’s high-level review outlined below can be

used to create a baseline plan for change.

Institution-Directed Culture• Staff provide standardized “treatments” based upon medical diagnosis.

• Schedules and routines are designed by the institution and staff, and

elders must comply.

• Work is task-oriented and staff rotate assignments.

• As long as staff know how to perform a task, they can perform it on

“any patient” in the home.

• Decision making is centralized.

• There is a hospital environment.

• Structured activities are available when the activity director is on duty.

• There is a sense of isolation and loneliness.


26

Person-Directed Culture• Staff enter into a caregiving relationship based upon individualized

care needs and personal desires.

• Elders and staff design schedules that reflect their personal needs and

desires.

• Work is relationship-centered, and staff have consistent assignments.

• Staff bring their personal knowledge of elders into the caregiving

process.

• Decision-making is as close to the elder as possible.

• The environment reflects the comforts of home.

• Spontaneous activities are available around the clock.

• There is a sense of community and belonging (“Pioneer Network:

Culture Change in Long-Term Care,” 2009).

And of course, another driving force, in addition to consumer appeal,

is the emerging post-WWII Baby Boomer population, the front wave

already in their early 60s. As their numbers grow, and those in their

60s reach their 70s and 80s, their demands for more acceptable and

more optimal quality of care, and quality of life, will drive this change

in resident and facility relationships, not just by market demand but by

sheer political force from CMS.

References – Please refer to the online version of this module for the most current references.

Abraham, N. & deLaGrange, K. (2006). Elder cohousing: An idea whose time has

come? Retrieved on September 29, 2009 from: http://www.plan-b-retirement.

com/ElderCohoArticleC-Mag10.06.pdf

Banks, M., et al. (2008). Animal-assisted therapy and loneliness in nursing

homes: Use of robotic versus living dogs. Journal of American Medical

Directors Association. 9, 173-177. Retrieved on September 28, 2009 from:

http://download.journals.elsevierhealth.com/pdfs/journals/1525-8610/

PIIS152861007005166.pdf

Banks, M. R., & Banks, W. A. (2002). The effects of animal-assisted therapy

on loneliness in an elderly population in long-term care facilities. The

Journals of Gerontology Series: A Biological Sciences and Medical Sciences,

57(7), M428-M432. Retrieved on September 28, 2009 from: http://biomed.

gerontologyjournals.org/cgi/content/full/57/7/M428

Barker, S. B. (1999). Therapeutic aspects of the human-companion animal

interaction. Psychiatric Times. 16(2). Retrieved on September 28, 2009 from:

http://www.psychiatrictimes.com/display/article/10168/54671


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Basic tenets of the Eldershire community concept. (2008). Eldershire

Development Consortium. Retrieved on September 29, 2009 from: http://www.

eldershire.net/Vision/Eldershire_Tenets.php

Becoming part of the Eden Registry. (2009). Eden Alternative. Retrieved on

September 29, 2009 from: http://www.edenalt.org/becoming-part-of-the-

eden-registry

Bethel Lutheran Home. ([n.d.]). Eden Alternative philosophy: Life worth living.

Retrieved on September 29, 2009 from: http://www.bethellutheranhome.

com/eden%20alternative.htm

Bruck, L. (1997). Welcome to Eden—Nursing home care: Eden Alternative.

Medquest Communications. Retrieved on September 28, 2009 from: http://

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Building premiere retirement communities for today’s active seniors. (2007).

American Heritage Communities. Retrieved on September 28, 2009 from:

http://www.am-heritage.com/

Calkins, M. P. (2002, June). The nursing home of the future: Are you ready?

Nursing Homes/Long-Term Care Management. Retrieved on September 28,

2009 from: http://www.ideasconsultinginc.com/pages/TheFuture.asp

Canadian Union of Public Employees Research. (2000). The Eden Alternative:

A background paper prepared for the CUPE Health Care Council, CUPE Health

Care Workers. Retrieved on September 29, 2009 from: http://cupe.ca/updir/

The_Eden_Alternative_-_Final_(Web).pdf

Certified Eden Associates. (2009). Eden Alternative. Retrieved on September 28,

2009 from: http://www.edenalt.org/about/eden-associates.html

Coleman, M. T. (2002). The Eden Alternative: Findings after 1 year of

implementation. The Journals of Gerontology Series A: Biological Sciences and

Medical Sciences, 57(7), M422-M427. Retrieved on September 29, 2009 from:

http://biomed.gerontologyjournals.org/cgi/reprint/57/7/M422.pdf

Coming Home program. (2008). NCB Capital Impact, No. 64. Retrieved

on September 29, 2009 from: http://www.ncbcapitalimpact.org/default.

aspx?id=64

DeBolt, V. (2008). The Green House project: A revolution in elder care.

BlogHer. Retrieved on September 29, 2009 from: http://www.blogher.com/

green-house-project-revolution-elder-care

Dentzer, S. (2002, February 27). A nursing home alternative. PBS Online

NewsHour. Retrieved on September 28, 2009 from: http://www.pbs.org/

newshour/bb/health/jan-june02/eden_2-27.html

Dr. Bill Thomas to speak at Vital Aging Network forum on February 14. (2006,

January 30). St. Paul, MN: University of Minnesota. Retrieved on September

29, 2009 from: http://www.cce.umn.edu/pdfs/MKT/news/releases/VAN_

Forum_1-30-2006.pdf


28

Doty, M. M., Koren, M. J., & Sturla, E. L. (2008, May). Culture change in

nursing homes: How far have we come? Findings from the Commonwealth

Fund 2007 National Survey. The Commonwealth Fund, 91. Retrieved on

September 29, 2009 from: http://www.commonwealthfund.org/Content/

Publications/Fund-Reports/2008/May/Culture-Change-in-Nursing Homes—

How-Far-Have-We-Come—Findings-From-The-Commonwealth-Fund-

2007-Nati.aspx

An Eden Alternative: A life worth living. (2003). National Center on Physical

Activity and Disability Monograph. Retrieved on September 28, 2009 from:

http://www.indiana.edu/~nca/ncpad/eden.shtml

The Eden Alternative: Improving the lives of the elders and their care partners.

(2009). Eden Alternative. Retrieved on September 29, 2009 from: http://www.

edenalt.org

The Eden Alternative: We are different. (2009). SEM Haven Health and

Residential Care Center. Retrieved on September 28, 2009 from: http://www.

semhaven.org/eden.shtml

Elder Co-housing: Building a collaborative elderhood. (2006). Culture Change

Now! Retrieved on September 29, 2009 from: http://www.culturechangenow.

com/stories/cohousing.html

Evercare: About us. (2008). United HealthCare Services. Retrieved on

September 29, 2009 from: http://evercarehealthplans.com/about_evercare.

jsp;jsessionid=EDMGOGDHPKLA

Gabrel, C. S. (2000, April 15). Characteristics of elderly nursing home current

residents and discharges: Data from the 1997 National Nursing Home Survey.

Advance Data, No. 312. Retrieved on September 28, 2009 from: http://www.

cdc.gov/nchs/data/ad312.pdf

Gray Panthers. ([n.d.]). Temple University Libraries, Philadelphia, PA. Retrieved

on September 28, 2009 from: http://library.temple.edu/collections/urbana/

gray-01.jsp;jsessionid=D9FD11CF79D9F63816FAC2DDF5CE4431?bhcp=1

Gray Panthers: Issue resolutions summary. (2009, March). Gray Panthers: Age

and Youth in Action. Retrieved on September 28, 2009 from: http://www.

graypanthers.org/index.php?option=com_content&task=blogcategory&id=7

&Itemid=49

“Green House” communities reinvent elder care. (2008, January 23).

ChangingAging.org (Erickson School of Aging, Management, and Policy,

The University of Maryland, Baltimore County). Retrieved on September

29, 2009 from: http://www.umbc.edu/blogs/changingaging/2008/01/green_

house_communities_reinve.html

The Green House concept. (2008). NCB Capital Impact, No. 148, 2008.

Retrieved on September 29, 2009 from: http://www.ncbcapitalimpact.org/

default.aspx?id=148


29

Green House project. (2004). PHI National Clearinghouse on the Direct

Care Workforce..Retrieved on September 29, 2009 from: http://www.

directcareclearinghouse.org/practices/r_pp_det.jsp?res_id=187910

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Retrieved on September 29, 2009 from: http://www.ncbcapitalimpact.org/

default.aspx?id=146

Green Houses growing in numbers across the states. (2008, June 24). Robert

Wood Johnson Foundation Publications and Research. Retrieved on September

29, 2009 from: http://www.rwjf.org/pr/product.jsp?id=46068

Improving the quality of nursing home care: The Wellspring model. (2004). The

Commonwealth Fund. Retrieved on September 29, 2009 from: http://www.

commonwealthfund.org/innovations/innovations_show.htm?doc_id=234694

Jenkens, R. ([n.d.]). The Green House project: A model of culture change for

long-term care (PowerPoint presentation. NCB Capital Impact. Retrieved on

September 29, 2009 from: http://www.nhqualitycampaign.org/files/summit/

Jenkens.pdf

Kiyota, E. ([n.d.]). Resident-centered environment. Kansas State University,

Manhattan, KS. Retrieved on September 29, 2009 from: http://www.k-state.

edu/peak/PDFfiles/researchtopractice031203.pdf

Kleinman, C. (2009, January 7). The experience of aging, Part VII—The Eden

Alternative. Advance Healthcare POV. Retrieved on September 29, 2009 from:

http://community.advanceweb.com/blogs/ltc_3/archive/2009/01/07/the-

experience-of-aging-part-vii-the-eden-alternative.aspx

Leavitt, M. O. (2006). Report to Congress: Improving the Medicare Quality

Improvement Organization program—Response to the Institute of Medicine

study. Retrieved on September 29, 2009 from http://www.cms.hhs.gov/

QualityImprovementOrgs/downloads/QIO_Improvement_RTC_fnl.pdf )

Levindale Hebrew Geriatric Center and Hospital (2006). Eden Alternative and

neighborhood model. Retrieved on September 29, 2009 from: http://www.

lifebridgehealth.org/levindalebody.cfm?id=2073

Lieblich, C. (2008, September). The Pioneer Network and the culture change

movement: Changing the culture of aging in the 21st century. The Pioneer

Network, Center for Excellence in Assisted Living. Retrieved on September 29,

2009 from: http://www.theceal.org/column.php?ID=23

Misiorski, S. (2003). Pioneering culture change: The Pioneer Network shares

its approach to creating culture chance [sic] in long-term care. Nursing Homes.

Retrieved on September 29, 2009 from: http://findarticles.com/p/articles/

mi_m3830/is_10_52/ai_110267294

Morley, J. E., & Flaherty, J.H. (2002). Editorial: Putting the “home” back in

nursing home. The Journals of Gerontology Series A: Biological Sciences and

Medical Sciences, 57, M419-M421. Retrieved on September 29, 2009 from:

http://biomed.gerontologyjournals.org/cgi/content/full/57/7/M419


30

Nissenboim, S. (2004). Learn about the Pioneer movement, and step into the

future of eldercare. Caregiver’s Home Companion. Retrieved on September

28, 2009 from: http://www.caregivershome.com/professional/professional.

cfm?UID=23

Nursing home abuse news. (2001, August). Elder Abuse Foundation. Retrieved

on September 28, 2009 from: http://www.elder-abuse-foundation.com/html/

links.html

Nursing home care. (2008). National Center for Health Statistics. Retrieved on

September 28, 2009 from: http://www.cdc.gov/nchs/fastats/nursingh.htm

Other options: Continuing care retirement communities. AARP. Retrieved on

September 29, 2009 from: http://www.aarp.org/families/housing_choices/

other_options/a2004-02-26-retirementcommunity.html

Our 10 principles. (2009). Eden Alternative. Retrieved on September 28, 2009

from: http://www.edenalt.org/about/our-10-principles.html

Parsons M., & Bergman-Evans, B. (2004). The impact of the Eden Alternative on

quality of life in nursing home residents. University of Nebraska, Lincoln, NE.

Retrieved on September 29, 2009 from: http://cehs07.unl.edu/cehsabstracts/

docs/MaryParsons0504.pdf

Pioneer Network: Culture change in long-term care. (2009). Pioneer Network.

Retrieved on September 29, 2009 from: http://www.pioneernetwork.org

Quality of life: Pets and animal therapy. (2008). Nursing Home Regulations

Plus. The University of Minnesota, St, Paul, MN. Retrieved on September

29, 2009 from: http://www.hpm.umn.edu/nhregsPlus/category_face_pages/

category_quality_of_life_pets_and_animal_therapy.htm

Rabig, J., et al. (2006, December 29). Radical redesign of nursing

homes: Applying the Green House concept in Tupelo, Mississippi. The

Commonwealth Fund, 65 (originally printed in The Gerontologist, August,

2006, 46(4), 533-539. Retrieved on September 29, 2009 from: http://www.

commonwealthfund.org/publications/publications_show.htm?doc_id=437668

Rahman, A. N., &Schnelle, J. F. (2008). The nursing home culture change

movement: recent past, present, and future directions for research. The

Gerontologist, 48, 142-148. Retrieved on September 28, 2009 from: http://

gerontologist.gerontologyjournals.org/cgi/content/full/48/2/142

Reinhard, S., & Stone, R. (2001, January). Promoting quality in nursing

homes: The Wellspring model. Washington, DC: Institute for the Future of

Aging Services; American Association of Homes and Services for the Aging.

Retrieved on September 29, 2009 from: http://www.aahsa.org/uploadedFiles/

IFAS/Publications_amp;_Products/reinhard_wellspring_432.pdf

Rosher, R., &Robinson, S. (2009). Impact of the Eden Alternative in family

satisfaction. Journal of the American Medical Directors Association, 6(3), 189-

193. Retrieved on September 29, 2009 from: http://linkinghub.elsevier.com/

retrieve/pii/S1525861005001945


31

Shapiro, J.(2005, June 22). Reformers seek to reinvent nursing homes. NPR

Health Care. Retrieved on September 29, 2009 from: http://www.npr.org/

templates/story/story.php?storyId=4713566

Stone, R. et al. (2002, August 15). Evaluation of the Wellspring model for

improving nursing home quality. Washington, DC: Institute for the Future of

Aging Services; American Association of Homes and Services for the Aging.

Retrieved on September 29, 2009 from: http://www.commonwealthfund.org/

Content/Publications/Fund-Reports/2002/Aug/Evaluation-of-the-Wellspring-

Model-for-Improving-Nursing-Home-Quality.aspx

Thomas, W. H. (2006). In the arms of elders: A parable of wise leadership and

community building. Acton, MA: VanderWyk & Burnham.

Thou shalt honor . . . The Eden Alternative. (2002). pbs.org. Retrieved on

September 28, 2009 from: http://www.pbs.org/thoushalthonor/eden/index.

html

Wellspring definition. (2009). BrainyQuote. Retrieved on September 29, 2009

from: http://www.brainyquote.com/quotes/keywords/wellspring.html

What is culture change? (2008). Pioneer Network. Retrieved on September 28,

2009 from: http://www.pioneernetwork.net/CultureChange/

Willging, P. R. (2000). The Eden Alternative to nursing home care: More than

just birds. Aging Today. Retrieved on September 29, 2009 from: http://www.

asaging.org/at/at-214/eden.html

Wood, L., et al. (2005). The pet connection: Pets as a conduit for social capital?

Social Science and Medicine, 61, 1159-1173. Retrieved on September 28, 2009

from: http://www.ccac.net.au/files/The_pet_connection.pdf

Woodrick, W. (2003). Green House project aims to revolutionize elderly care.

United Methodist Church News Archives, Nashville, TN. Retrieved on

September 29 2009 from: http://www.wfn.org/2003/04/msg00283.html

Learning Resources – Please refer to the online version of this module for the most current resources.

Other ReferencesAbout the Eden Alternative. (2009). Spectrum Health/Reed City Hospital.

Retrieved on September 29, 2009 from: http://www.spectrum-health.org/

cs/Satellite?c=eHA_Content_C&cid=1165617906724&pagename=Reed_

City%2FReed_City_Central_Template

An alternative to nursing homes. ([n.d.]). ConsumerAffairs.com. Retrieved on

September 29, 2009 from: http://www.consumeraffairs.com/nursing_homes/

eden01.html

Assess your situation. ([n.d.). CareGuide at Home. Retrieved on

September 29, 2009 from: http://www.careguideathome.com/modules.

php?op=modload&name=CG_Resources&file=article&sid=888


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Brown, M. H. (2007). “Green Houses” provide a small group setting alternative

to nursing homes—and a positive effect of residents’ quality of life. Robert

Wood Johnson Foundation. Retrieved on September 29, 2009 from: http://

www.rwjf.org/pr/product.jsp?id=41208

Brune, K.B. (1992). Project Life research team. Columbia, MO: University of

Missouri.

Brune, K.B. (1995). Eden Alternative Certification, pilot group. New Berlin,

NY.

The Eden Alternative [Eden Associate training course]. ([n.d.]). Holyoke

Community College Center for Business and Professional Development. Retrieved

on September 29, 2009 from: http://www.thecenter-hcc.org/eden.htm

Eden Alternative: Autonomy for the elderly. (2008, April 11). NursingHomeLaw.

org. Retrieved on September 29, 2009 from: http://blog.nursinghomelaw.

org/2008/04/eden-alternative-autonomy-for-the-elderly/

Eden Alternative: Our other residents. ([n.d.]). Levindale Hebrew Geriatric

Center and Hospital and Jewish Convalescent and Nursing Home. Retrieved on

September 29, 2009 from: http://www.lifebridgehealth.org/levindalebody.

cfm?id=3208

Eden Alternative adds animals to retirement centers: Akbash dog is link to love

at Llanfair. ([n.d.]). Dog Owner’s Guide. Retrieved on September 29, 2009

from: http://www.canismajor.com/dog/llanfair.html

Eden Alternative and LifeBio.com come together to build relationships and

legacies of elders. (2007, July 2). PRWeb.com. Retrieved on September 29,

2009 from: http://www.emediawire.com/releases/2007/7/emw537129.htm

The Eden Alternative at work at West Ridge Care Center. ([n.d.]). West

Ridge Care Center. Retrieved on September 29, 2009 from: http://

westridgecarecenter.com/edenalternative.aspx

Examining the Green House project senior living concept. (2006, March

3). Nashville Business Journal. Retrieved on September 29, 2009 from:

http://nashville.bizjournals.com/nashville/stories/2006/03/06/focus3.

html?surround=etf

Institute for the Future of Aging Services. (2001). Evaluating the Wellspring

program as a model for promoting quality of care in nursing homes. Washington,

DC: American Association of Homes and Services for the Aging. Retrieved on

September 29, 2009 from: http://www.wellspringis.org/pdf/IFAS.pdf

Loughlin, L. (2007). The Third International Eden Alternative Conference session

synopses. Retrieved on September 29, 2009 from: http://www.tneden.org/

conference_synopsis.pdf

Marston, B. (2006, October 18). Respecting the elderly benefits everyone (big

surprise!). The Philadelphia, Inquirer. Retrieved on September 29, 2009 from:

http://www.relocalize.net/node/5018


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New concepts in elder housing: The Eden Alternative and Green Homes.

(2008). Parent Giving: Getter Care for Your Aging Parents. Retrieved on

September 29, 2009 from: http://www.parentgiving.com/articles/new_

concepts_in_elder_housing_the_eden_alternative_and_green_homes/

Pagans, C. (2008). How to find a village. Guide to Retirement Living Sourcebook.

Retrieved on September 29, 2009 from: http://www.retirement-living.com/

article/147/how-to-find-a-village

A place where love matters. (2008, January 23). Providence Women. Retrieved on

September 29, 2009 from: http://providencewomen.blogspot.com/2008/01/

place-where-love-matters.html

Pratt, J.R. (2004). Long-term care: Managing across the continuum (2nd ed.).

Sudbury, MA: Jones and Bartlett Publishers.

Study shows Green House project favored by staff, families, residents. (2004,

November 8). ElderWeb. Retrieved on September 29 2009 from: http://www.

elderweb.com/home/node/3052

The Village of Redford: A senior living community. (2009). Presbyterian Villages

of Michigan. Retrieved on September 29, 2009 from: http://www.pvm.org/

redford/assisted.asp

What is Eden at Home? (2009). Eden Alternative. Retrieved on September 29

2009 from: http://www.edenalt.org/eden-at-home/index.html

Definitions of Common Terms Used in Long-Term Care and Culture ChangeAbuse/Elder Abuse: Any knowing, intentional or negligent act by a caregiver

or any other person that causes harm or a serious risk of harm to a vulnerable

older adult. Types of elder abuse may include physical abuse—inflicting,

or threatening to inflict, physical pain or injury on a vulnerable elder, or

depriving him or her of a basic need; emotional abuse—inflicting mental

pain, anguish, or distress on an elder person through verbal or nonverbal acts;

sexual abuse—non-consensual sexual contact of any kind; exploitation—illegal

taking, misuse, or concealment of funds, property or assets of a vulnerable

elder; neglect—refusal or failure by those responsible to provide food, shelter,

health care, or protection for a vulnerable elder; and abandonment—the

desertion of a vulnerable elder by anyone who has assumed the responsibility

for care or custody of that person. The specificity of laws varies from state to

state (see National Center on Elder Abuse at www.ncea.aoa.gov; retrieved on

October 2, 2009).

Activities of Daily Living (ADLs): Daily functions such as getting dressed,

eating, taking a shower or bath, going to the bathroom, getting into a bed

or chair, or walking from place to place. The amount of help a person needs

with ADLs is often used as a measure to determine whether he or she meets

the requirements for long-term care services in a nursing home as well as


34

government-subsidized home- and community-based services (also see

Instrumental Activities of Daily Living).

Acute Care: Medical care for health problems that are new, quickly worsen, or

result from a recent accident. The care provided has recovery as its primary

goal; typically requires the services of a physician, physician assistant, nurse

practitioner, nurse, or other skilled professional; and is usually short term.

Acute care is usually provided in a doctor’s office, a clinic, or a hospital.

Adult Day Services: Community-based programs that provide meals and

structured activities for people with cognitive or functional impairments, as

well as adults needing social interaction and a place to go when their family

caregivers are at work (also see Respite Care).

Advance Directives: Legal documents that allow individuals to plan and make

their own end-of-life wishes about health care and treatment known in the

event that they are unable to communicate. Advance directives consist of

(1) a living will and (2) a medical (healthcare) power of attorney, sometimes

called “health care surrogate”, depending on the state (see Living Will and

Medical Power of Attorney). You can create a living will and medical power

of attorney form without a lawyer. It is very important that you use advance

directive forms specifically created for your state so that they are legal. Caring

Connections (www.caringinfo.org; retrieved on October 1, 2009) provides

free advance directives and instructions for each state.

Alzheimer’s Disease: A progressive, degenerative form of dementia that causes

severe intellectual deterioration. The first symptoms are impaired memory,

followed by impaired thought and speech, an inability to care for oneself; and,

eventually, death. Onset may be associated with or preceded by depression.

Area Agencies on Aging (AAAs): Agencies that coordinate and offer services

to help older adults remain in their home—if that is their preference—aided

by services such as Meals-on-Wheels, homemaker assistance, and whatever

else may be necessary to enable the individual to stay in his or her own home.

By making a range of options available, AAAs make it possible for older

individuals to choose home- and community-based services and a living

arrangement that suits them best.

Assisted Living/Personal Care Homes/Residential Care Facilities: A

state-regulated and -monitored residential long-term care option that may

have different names, depending on the state. Assisted living provides or

coordinates oversight and services to meet residents’ individualized, scheduled

needs, based on the residents’ assessment and service plans, and their

unscheduled needs as they arise. There are more than 26 designations that

states use to refer to what is commonly known as “assisted living.” There is no

single uniform definition of assisted living, and there are no federal regulations

for assisted living. In many states, most assisted living is private pay. Check


35

with your state about any waiver programs that may be available through

Medicaid to pay for the care provided in assisted living.

Caregiver: A spouse, family member, partner, friend, or neighbor who helps

care for an elder or person with a disability who needs assistance. Caregivers

can also be people employed by the older adult, a family member, agencies,

or care settings to provide assistance with activities of daily living (ADLs; see

above) and instrumental activities of daily living (IADLs; see below).

Care or Case Manager: A nurse, social worker, or other healthcare professional

who plans and coordinates services for an individual’s care. This person usually

works for an agency or care setting (also see Geriatric Care Manager).

Care Plan: A detailed written plan that describes what is needed for an

individual’s care provided by nurses, therapists, social workers, nursing

assistants, or personal assistants. For those living at home, a good care plan

should also list the caregiving activities that family members are able to do,

need help learning how to do, and will be doing. “I” Care Plans are written

in the first person, as if the person receiving care wrote it him- or herself,

and express the desires of the individual for his or her care. Care plans can

describe/detail the risks that an individual is prepared to take in exercising

his or her autonomous self-determination and choice. Creating the care plan

should involve an interdisciplinary team of caregivers, including the nursing

assistant and the resident, as well as the family (unless the resident objects).

Case Management: Assistance for families in assessing the needs of an older

adult and making arrangements for services to help him or her remain as

independent as possible.

Centers for Medicare and Medicaid Services (CMS): The entities responsible

for regulating and paying nursing homes, home health agencies, and hospices

for the care of Medicare and Medicaid (in conjunction with the states)

beneficiaries. With a budget of approximately $650 billion and serving

approximately 90 million beneficiaries, CMSs plays a key role in the overall

direction of the healthcare system.

Certified Nursing Assistant (CNA): A person trained and certified to assist

individuals with non-clinical tasks such as eating, walking, and personal

care (see ADLs and Personal Care). This person may be called a “direct-care

worker” (DCW). In a hospital or nursing home the person may be called a

nursing assistant, a personal care assistant, or an aide.

Cognition: The process of knowing, of being aware of thoughts; the ability to

reason and understand.

Cognitive Impairment: A diminished mental capacity, such as difficulty with

short-term memory; problems that affect how clearly a person thinks, learns

new tasks, and remembers events that just happened or happened a long time

ago; problems that affect cognition (see cognition).


36

Consistent Assignment: Residents seeing and receiving care from the same

caregivers (registered nurse, licensed practical nurse, direct-care worker/

certified nursing assistant) during a typical work week. Consistent Assignment

may also be called Primary Assignment.

Continuing Care Retirement Community (CCRC): A housing option that

offers a range of services and levels of care. Residents may first move into

an independent living unit, a private apartment, or a house on the CCRC

campus. The CCRC provides social and housing-related services and may

have an assisted living residence and a nursing home, often called the

healthcare center, on the campus. If and when residents can no longer live

independently in their apartment or house, they move into assisted living

(unless it is provided in their apartment or house) or the nursing home.

Culture Change: The common name given to the national movement for

the transformation of older adult services, based on person-directed values

and practices, where the voices of elders and those working with them

are considered and respected. Core person-directed values are choice,

dignity, respect, self-determination, and purposeful living. Culture change

transformation supports the creation of both long- and short-term living

environments as well as community-based settings where both older adults

and their caregivers are able to express choice and practice self-determination

in meaningful ways at every level of daily life. Culture change transformation

may require changes in organization practices, physical environments,

relationships at all levels, and workforce models, leading to better outcomes

for consumers and direct-care workers without being costly for providers.

Dementia: A general term for loss of memory and other mental abilities severe

enough to interfere with daily life. It is caused by structural and physiological

changes in the brain. Alzheimer’s disease is the most common type of

dementia, and it is estimated that 47% to 67% of nursing home or assisted

living residents have Alzheimer’s disease or a related form of dementia.

Direct-Care Staff/Direct-Care Worker (DCW): An individual working in a

nursing home or assisted living community who provides “hands-on” help to

residents with activities of daily living (see Certified Nursing Assistant).

Discharge Planner: A nurse, social worker, or other professional who

coordinates a patient’s transition (move) from one care setting to the next,

such as from hospital to nursing home or to one’s own home with home

health care and other services.

Elder Law Attorney: A lawyer who specializes in the legal rights and issues of

older adults and their health, finances, and well-being.

Family Caregiver: Any family member, partner, friend, or neighbor who

provides or manages the care of someone who is ill, disabled, or frail. More

than one family caregiver may be involved in a person’s care. Sometimes

family caregivers are referred to as informal caregivers. This is meant to show


37

that they are different from formal caregivers (paid healthcare workers). But

many caregivers do not like the term “informal” because it incorrectly implies

less skill and commitment.

Family Council: Family members of nursing home or assisted living

residents who join together to provide a consumer voice and perspective

to communicate issues to administrators and work for resolution and

improvement. Family Councils can play a crucial role in voicing concerns,

requesting improvements, discussing the mission and direction of a nursing

home or assisted living community, supporting new family members and

residents, and supporting the residence’s efforts to make care and life in the

home the best it can be. When Family Councils meet independently (without

representatives of the nursing home or assisted living community), they are

able to speak more freely and openly.

Five-Star Rating System: A new rating system for nursing homes launched

on December 18, 2008, by the federal Centers for Medicare and Medicaid

Services. You can use this system to compare nursing homes in your area on

several extremely important indicators of quality:

• Adequacy of nursing staff (including RNs, LPNs, and Nursing Assistants).

• Performance on quality measures—whether they prevent pressure sores, don’t

restrain their residents, prevent urinary tract infections, maintain residents’

ability to walk and perform daily activities, treat pain, and don’t catheterize

residents for staff ’s convenience.

• Performance on inspections.

Geriatric Care Manager: A person with a background in nursing, social work,

psychology, gerontology, or other human services fields, who has knowledge

about the needs of and services available for older adults. A geriatric care

manager coordinates (plans) and monitors (watches over) a person’s care. He

or she also keeps in contact with family members about the person’s needs and

how their loved one is doing. Most geriatric care managers are privately paid

and usually not covered by private insurance. Some long-term care insurance

companies use care managers to assess the individual’s need for services and

arrange for the services needed.

Geriatrician: A medical doctor with special training in the diagnosis, treatment,

and prevention of illness and disabilities in older adults (see American Medical

Directors Association at www.amda.com; retrieved on October 2, 2009).

Geriatrics: The branch of medicine that focuses on providing healthcare for

older adults and the treatment of diseases associated with the aging process.

Gerontologist: A professional trained to work with older adults and their

families. He or she may have a master’s degree or a doctorate.

The GREEN HOUSE® Model: A small, intentional (“purpose-built”)

community for a group of elders and staff. A Green House residence is

designed to be a home for six to ten elders needing skilled nursing or assisted


38

living care. The purpose of the Green House is to be a place where elders can

receive assistance and support with activities of daily living and clinical care,

without the assistance and care becoming the focus of their existence.

Healthcare Practitioner: A professional providing medical, nursing, and/or

other healthcare-related services.

HIPAA: The Health Insurance Portability and Accountability Act of 1966. The

Act’s Administrative Simplification provisions (HIPAA, Title II) required the

U.S. Department of Health and Human Services (HHS) to establish national

standards for electronic health care transactions and national identifiers for

providers, health plans, and employers. It also addressed the security and

privacy of health data. As these standards for efficiency and effectiveness are

adopted, the nation’s health care system will improve the use of electronic data

interchange.

Home- and Community-Based Services (HCBSs): Services provided in an

individual’s home or a setting in the community, such as adult day services,

senior centers, home-delivered meals, transportation services, respite care,

housekeeping, companion services, etc. These services are primarily designed

to help older people and people with disabilities remain in their homes for as

long as possible. Many states have requested and received “Medicaid waivers”

in order to enable low-income Medicaid recipients to receive long-term care

services in their own home, an adult day care facility, or an assisted living

community instead of moving into a nursing home.

Home-Delivered Meals (Meals on Wheels): Meals brought to people who

cannot prepare their own meals or are homebound (cannot leave their homes).

Home Health Aide (HHA): A person trained to provide basic health care tasks

for older adults and persons who are disabled in their homes. Tasks include

personal care, light housecleaning, cooking, grocery shopping, laundry, and

transportation. Tasks may also include taking vital signs (such as heart rate

and blood pressure) or applying a “dry dressing” for certain kinds of wounds.

HHAs are supervised by a registered nurse when they are employed by a home

health agency.

Home Health Care: Services given to patients at home by registered nurses,

licensed practical nurses, therapists, home health aides, or other trained

workers. Certified home health agencies often provide and coordinate such

services. These services, provided on a short-term basis and ordered by a

physician, are usually covered by Medicare and Medicaid. With Medicaid,

coverage differs from state to state.

Hospice: A program of medical and social services for people diagnosed with

terminal (end-stage) illnesses that focuses on comfort, not cure. Hospice

services can be given at home or in a hospital, a hospice residence, an assisted

living community, or a nursing home. They are designed to help both the

patient and his or her family. Hospice care stresses pain control and symptom


39

management. It also offers emotional and spiritual support. Medicare will pay

for hospice care if a physician states that a person probably has six months or

less to live. Hospice care can last longer than six months, in some cases.

Household Model: A small group of residents living within a physically-

defined environment that “feels like home” and that has a kitchen (with

a wide variety of food accessible to residents around the clock, including

breakfast-to-order and on demand), a dining room, and a living room. Staff

are consistently assigned so that they can develop meaningful relationships

with the residents, work in self-led teams, and perform a variety of tasks. The

sense of being at home is expressed in recognizing and honoring the rhythm

of each individual’s life. All residents in the household have opportunities to

participate in the daily life of the household in a manner and to the extent

they choose.

HUD Housing/Affordable Senior Housing: Subsidized housing offered by the

U.S. Department of Housing and Urban Development (HUD). The HUD

202 Program provides subsidized housing and rental assistance for low-income

individuals over 62 years of age who meet the eligibility requirements of the

federal program. These housing communities often help residents access a

variety of healthcare and supportive services as well as transportation.

Incontinence: Loss of bladder (urine) or bowel movement control. This

condition can be transient, intermittent, or permanent. Incontinence nurse

specialists and physicians can diagnose the kind of incontinence that is present

and suggest ways to effectively manage the situation through exercises and

timed toileting programs.

Independent Living: A residential location (including rental-assisted or market-

rate apartments or cottages) that may or may not provide hospitality or

supportive services. Residents can choose which services they want. Additional

fees may be charged for some services.

Informal Caregiver: A family member, friend, or any other person who

provides long-term care without pay.

In-Home Care: Care provided for older adults in their own homes. This type of

care is often performed by family members who become caregivers. Agencies

also provide in-home care that is not medical in nature, including help with

activities of daily living (ADLs) and instrumental activities of daily living

(IADLs), or older adults or their families may hire in-home caregivers on their

own. Unlike home health care provided on a short-term basis, these services

are not covered by Medicare but may be covered by Medicaid in some states.

Instrumental Activities of Daily Living (IADLs): A series of life tasks

necessary for maintaining a person’s immediate environment—e.g., shopping

for food and medications, cooking, laundering, house cleaning, and managing

one’s medication and finances. An elder may need help with IADLs and not

need help with ADLs (see ADLs).


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Licensed Practical Nurse (LPN)/Licensed Vocational Nurse (LVN): A

licensed nurse with one to two years of technical training. LPNs and LVNs

assist RNs (see Registered Nurse) with data collection, care planning, and

monitoring residents’ conditions. They are licensed to administer medications

and treatments, transcribe physician orders, etc. Most of the licensed nurses

working in nursing homes are LPNs or LVNs, especially on the evening and

night shifts.

Living Will: An advance directive that guides your family and healthcare

team through the medical treatment you wish to receive if you are unable

to communicate your wishes. According to your state’s living will law, this

document is considered legal as soon as you sign it and a witness signs it, if

that is required. A living will goes into effect only when you are no longer able

to make your own decisions.

Long-Term Care (LTC): A term used to describe the care needed by someone

who must depend on others for help with daily needs. LTC is designed to help

people with chronic health problems or dementia to live as independently as

possible. Although many people think that long-term care is provided only in

a nursing home, in fact most long-term care is given by family caregivers in

the elder’s home.

Long-Term Care Insurance: Private insurance designed to pay for long-term

care services provided at home or in an adult day care center, an assisted living

facility, or a nursing home. There are many long-term care insurance policies

with a wide range of benefits (services they pay for). Medicare and Medicare

supplemental insurance policies (Medigap) do not pay for long-term care.

Long-Term Care Services: A variety of services and supports to meet health

or personal care needs over an extended period of time. This includes both

medical and non-medical care to people with a chronic illness or disability.

Long-term care helps to meet health and/or personal needs. Most long-

term care assists people with ADLs such as dressing, bathing, and using the

bathroom. Long-term care can be provided at home or in an adult day care

center, an assisted living community, or a nursing home. In order for state

Medicaid programs to pay for home care or assisted living for an individual

who meets the income eligibility requirements, he or she must require a level

of care equivalent to that received in a nursing home.

Medicaid: The federally- and state-supported, state-operated public assistance

program that pays for healthcare services to low-income people, including

older adults or disabled persons who qualify. Medicaid pays for long-term

nursing home care and some limited home health services, and it may pay for

some assisted living services, depending on the state. It is the largest public

payer of long-term care services, especially nursing home care. Each state can

determine the breadth and extent of what services it will cover above a certain

federally required minimum.


41

Medical Director: A physician who oversees the medical care and other

designated care and services in a healthcare organization or care setting. The

medical director is responsible for coordinating medical care and helping to

develop, implement, and evaluate resident care policies and procedures that

reflect current standards of practice.

Medical (Healthcare) Power of Attorney: The advance directive that allows

you to select a person you trust to make decisions about your medical care

if you are temporarily or permanently unable to communicate and make

decisions for yourself. This includes not only decisions at the end of your life,

but also in other medical situations. This document is also known as a “health

care proxy,” “appointment of health care agent or health care surrogate, or

“durable power of attorney for healthcare.” This document goes into effect

when your physician declares that you are unable to make your own medical

decisions. The person you select can also be known as a health care agent,

surrogate, attorney-in-fact, or healthcare proxy. With a medical power of

attorney, you can appoint a person to make health care decisions for you in

case you are unable to speak for yourself.

Medicare: The federal program that provides medical insurance for people

aged 65 and older, some disabled persons, and persons with end-stage renal

disease. It provides physician, hospital, and medical benefits for individuals

over age 65, or those meeting specific disability standards. Benefits for nursing

home and home health services are limited to short-term rehabilitative

care. Different parts of Medicare cover specific services if you meet certain

conditions. For detailed information, visit the Medicare website (www.

medicare.gov; retrieved on October 1, 2009) or call 1-800-Medicare for

assistance.

Mild Cognitive Impairment: A transition stage between the cognitive decline

of normal aging and the more serious problems caused by Alzheimer’s disease.

The disorder can affect many areas of thought and action, such as language,

attention, reasoning, judgment, reading, and writing. The most common

variety of mild cognitive impairment, however, causes memory problems.

According to the American College of Physicians, mild cognitive impairment

affects about 20% of the population over 70. Many people with mild

cognitive impairment eventually develop Alzheimer’s disease, although some

remain stable and others even return to normal.

Nurse Practitioner (NP): A Registered Nurse with advanced education and

training. NPs can diagnose and manage most common, and many chronic,

illnesses. They do so alone or in collaboration with the healthcare team.

NPs can prescribe medications and provide some services that were formerly

permitted only to doctors. There are a number of types of nurse practitioners

(geriatric, adult, psychiatric-mental health) who work with older adults.


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Nursing Home or Skilled Nursing Facility (SNF): A residential care setting

that provides 24-hour-care (all day and night) to individuals who are

chronically ill or disabled. Individuals must be unable to care for themselves in

other settings or need extensive medical and/or skilled nursing care.

Ombudsman/Long-Term Care Ombudsman: An advocate for residents

of nursing homes, board and care homes, and assisted living facilities.

Ombudsmen provide information about how to find a nursing home or other

type of LTC facility and what to do to get quality care. They are trained to

resolve problems. An ombudsman can assist you with expressing complaints,

but this requires your permission because these matters are held confidential.

Under the federal Older Americans Act (OAA), every state is required to

have an ombudsman program that addresses complaints and advocates for

improvements in the long-term care system. To find the ombudsman nearest

you, visit the National Long Term Care Ombudsman Resource Center at

www.ltcombudsman.org (retrieved on October 1, 2009).

Palliative Care: Care that focuses on the relief of the pain, symptoms, and

stress of serious illness. The goal is to improve quality of life for patients and

families. Palliative care is appropriate at any point in an illness, not just for

end-of-life care, and it can include treatments that are intended to cure as well

as comfort. It is both a philosophy of care (as is hospice) and an approach to

caring activities. Palliative care is provided by trained staff in a hospital, home,

nursing home, assisted living community, or hospice. For more information,

visit Get Palliative Care.org (www.GetPalliativeCare.org; retrieved on October

1, 2009) or the National Hospice and Palliative Care Organization (www.

nhpco.org; retrieved on October 1, 2009).

Personal Care: Non-skilled nursing service or care, such as help with bathing,

dressing, eating, getting in and out of bed or chair, moving around, using the

bathroom, or any other activity of daily living (ADL) required or desired by

the individual needing care.

Person-Directed Care/Person-Centered Care: An approach to care that honors

and respects the voices of individuals and those working closest with them. It

involves a continuing process of listening, trying new approaches, seeing how

they work, and changing routines and organizational approaches in an effort

to individualize and de-institutionalize the care environment (e.g., nursing

home or assisted living facility).

Primary Care Provider (PCP): A term that almost always refers to physicians,

nurse practitioners, or physician assistants who provide routine care and

preventive care (before people are sick). PCPs diagnose and treat common

medical problems, determine how urgent these problems are, and may refer

patients to other specialists, if needed. PCPs practice in the community, not a

hospital or other healthcare facility. Some PCPs follow their patients into the


43

hospital; others do not, and a “hospitalist” is assigned to the patient who will

likely communicate with the PCP while the patient in the hospital.

Provider: Typically a professional healthcare worker, agency, or organization

that delivers health care or social services. Providers may be individuals (e.g.,

physicians, nurses, social workers, and others), organizations (e.g., hospitals,

nursing homes, assisted living facilities, or continuing care retirement

communities), agencies (e.g., home care and hospice), or businesses that

sell healthcare services or assistive equipment (e.g., colostomy care supplies,

wheelchairs, walkers, etc).

Registered Nurse (RN): A graduate from a formal nursing education program

(three to four years) who has passed a national examination and is licensed

to practice by a state board). RNs assess, plan, implement, teach, and

evaluate a person’s nursing care needs, along with the rest of the healthcare

team. In addition, they may do data analysis, quality assurance, research

implementation, and research. They work in all types of healthcare settings

and educational programs. In addition to providing care to individuals, RNs

also works with groups of people or populations to determine how to promote

health and prevent problems on a larger scale.

Rehabilitation (“Rehab”): Services to help restore mental and physical (bodily)

functions lost due to injury or illness. Rehabilitation services may be given at

the hospital or in a nursing home, some assisted living residences, a special

facility, or the patient’s home. The types of services offered generally include

physical therapy, occupational therapy, speech therapy, social services, and

nursing.

Resident: A person who lives in a long-term care setting, such as a nursing

home or assisted living community.

Resident Council: Required by nursing home regulations, an organized group

that gives persons living in care settings the opportunity to communicate

concerns to administrators and work for resolutions and improvements, and

to provide feedback about new programs (e.g., food services). Independent

and empowered Resident Councils can play a crucial role in voicing concerns,

requesting improvements, supporting new residents, and supporting efforts to

make care and life in the care setting the best it can be.

Respite Care: Temporary (from a few hours to a few days) care to offer relief

for the family caregiver. Respite care may be given in the elder’s home, a

community-based setting such as an adult day care center, an assisted living

facility, or a nursing home. It can be scheduled regularly (for example, two

hours a week) or provided only when needed. This service can be particularly

valuable for family members caring for persons with dementia.

Senior Centers: Centers that provide services to senior citizens, aged 60 and

over. They may offer social activities (such as music or crafts), meals, health


44

screenings (such as blood pressure checks and diabetes monitoring), learning

programs, creative arts, and exercise classes.

Skilled Care/Nursing Care: A level of care that includes help with more

complex nursing tasks, such as monitoring medications, giving injections,

caring for wounds, and providing nourishment by tube feeding (enteral

feeding). It also includes therapies, such as occupational, speech, respiratory,

and physical therapy. This care can be given in a patient’s home or in a care

setting. Most insurance plans require at least some level of need for skilled

care, requiring the services of a licensed professional (such as a physician,

nurse, or therapist), before they will cover other home-care services.

Subacute Care/Rehabilitation: Care or monitoring after hospitalization in

a less intensive and less costly setting, such as a rehabilitation service in a

nursing home or in a special unit in a hospital. Subacute care is usually short

term. Check with Medicare for specifics of how it is covered (see Medicare).

Survey (or State Survey): As used in long-term care, the process a state agency

uses to ensure that all nursing homes that receive federal and state funding

are in compliance with state and federal regulations, including standards of

care. All federally funded nursing homes are surveyed at least annually to

ensure compliance with CMS (Centers for Medicare and Medicaid Services)

regulations. The results of the latest survey must be posted and readily

accessible in all nursing homes and is also available online at Nursing Home

Compare (www.medicare.gov/NHcompare/; retrieved on October 1, 2009).

Telephone Reassurance Program: A service that provides reassurance calls to

check on the safety and well-being of older adults at home. These calls can

also offer reminders (such as when to take medication). This type of service

may be purchased, or volunteer service organizations may provide it.

Transition: A move from one care setting (hospital, home, assisted living,

nursing home) to another. Care during transitions involves coordination and

communication among patient, providers, and family caregivers. For example,

it is critical that there be a way to ensure that an accurate medication list for

the patient is communicated from setting to setting.

Turnover: The average percentage of staff who stop working at a care setting

each year. Virtually all healthcare organizations (hospitals, nursing homes,

assisted living facilities, etc.) track and measure the number of staff who stop

working (turnover) and the length of stay of staff (retention) in the same

or similar jobs. A high turnover rate in a nursing home or assisted living

community means that the facility in question is constantly hiring and

training new caregivers.

Visiting Nurse: A nurse who visits patients in their homes. The job of a visiting

nurse includes checking vital signs (such as heart rate and blood pressure) and

assessing physical and mental health and how well the person is functioning

at home. The visiting nurse consults with the physician regarding treatment


45

plans, implements the treatment plan, and may educate and train families and

other caregivers to perform care tasks. Some, but not all, are affiliated with

Visiting Nurse Association of America agencies.

Diagram of the Management-Resident Relationship

by Kendall Brune, Ph.D., M.B.A., L.N.H.A., ACHA FellowFuture Focus Community, LLChttp://www.futurefocuscommunity.com


46

NOTES

res mgt relation_chapt

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