Costs and Habits Get in the Way of Change

If reinventing nursing homes produces happier residents, reduces staff turnover, improves patient outcomes and doesn’t cost much more, why aren’t all nursing homes run like this?

“Making this kind of change is unbelievably tough,” says Ron Rothstein, president of Levindale Hebrew Geriatric Center in Baltimore, whose 1999 conversion to the Eden Alternative philosophy brought residents into regular contact with plants, pets and children. “It requires a tremendous commitment from everybody. And there’s a punitive regulatory system that makes [providers] afraid of change.”

Nursing home inspectors are typically more concerned about safety and medical issues than vaguer measures such as resident happiness.

Will a dog in a nursing home bite or cause allergic reactions? Will giving residents more freedom to roam lead to more falls? Will moving long rows of chairs out from the wall and rearranging them in cozy chat groups block fire-exit routes?

With a nursing home’s reputation and license riding on government inspections, managers are understandably skittish about trying innovations that regulators might question. There are also upfront costs to redesigning facilities. For example, Levindale spent $60,000 on a children’s playground, $70,000 on a greenhouse and $500,000 on a cafe-style dining room.

In addition, according to Rothstein, Eden homes spend roughly $30,000 a year on quality-of-life enhancements such as pet food and horticulture. For-profit facilities, which make up 70% of nursing homes, may face a greater challenge here than nonprofits, which can raise funds through charity drives.

“One big issue of resistance came from the front-line caregivers,” Rothstein says. “They said, ‘We have to give care to our residents and now we have to take care of dogs and cats, too?’ It has to be everybody’s responsibility.”

At Levindale, every staff member--from the accountant to the maintenance engineer--is expected to form a close relationship with a resident, as well as pitch in with plant and pet care. Instituting this type of cultural change can be difficult. Middle managers must shift their duties to direct care, for example, and registered nurses may need to give up some authority to nursing assistants.

Some balking has to be expected. Nursing assistants may be loath to take on the extra work that “empowerment” brings--making their own schedules, broadening their responsibilities. Families may question the notion of giving Mom so much freedom. Is it really good for her to override her doctor’s dietary advice and have that piece of chocolate cake? Is a bowl of ice cream at midnight really beneficial?

Still, says Tom Burke, spokesman for the American Health Care Assn., a trade group for for-profit homes: “Anything that opens a facility up to the community is a step forward, and any interaction that leaves residents feeling less isolated is very valuable.”