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Nursing Homes Accent the 'Home'

New practices at a handful of facilities make happiness a top priority


You enter the nursing home to the sound of chirping birds. Sunlight streams through large windows and, across a courtyard, pansies and daffodils surround a small greenhouse. A black cat stalks down a corridor, looking as if it owned the place. Your grandmother's nursing home was nothing like this.

Like a handful of homes across the country, Levindale Hebrew Geriatric Center in Baltimore uses plants, pets and regular interaction with children to enliven and give meaning to the lives of frail elderly residents. Such innovations are the result of philosophies that share a common goal: to put the "home" into nursing home and scrap the hospital (some say prison) model.

The pioneering homes, which offer services at roughly the same cost as traditional facilities, judge their performance not only on medical outcomes, such as fewer bedsores or falls, but on whether nursing home life is a pleasant, even vibrant, experience. Hallmarks of these facilities include less institutional design, greater resident choice in how they spend their days, nursing assistants empowered to make more decisions and strengthened relationships between residents and staff.

Innovators profess no small ambitions. "Our mission is to advocate and facilitate deep system change and transformation in the culture of aging," says Rosemarie Fagan, executive director of the Pioneer Network, a coalition of providers, family members and others founded in 1997 to help reinvent nursing homes. "The nursing home is a microcosm of our society and our values. It really mirrors ... who we are."

With 1.5 million people living in the nation's 17,000 nursing homes and an estimated 40% of Americans expected to spend some time there in the future, according to University of North Carolina researcher Philip D. Sloane, the demand for improvement is strong. "Whenever you have a [place] that's viewed as so bad people say they would rather be dead than be in one, you have a problem," Sloane says.

Passage in 1987 of the Nursing Home Reform Act--which includes a 10-point Resident's Bill of Rights (such as the right to be treated with dignity and to exercise self-determination)--prompted industry changes, such as a reduction in the use of physical restraints. In 1998, the Health Care Financing Administration announced the Nursing Home Initiative, aimed at addressing persistent problems.

What's needed now, say many in the field, is not more regulations but tougher enforcement--and a change of mind-set. In the old medical model, the goal was to keep residents fed, dressed and bathed as efficiently as possible.

"They might be miserable, embarrassed or cold, they may have the food forced down them, but we would have accomplished our goal," Sloane says. "But if your goal is for them to have a good experience, we approach it differently. Maybe we won't bathe them as often or maybe they won't have exactly the right diet, but they'll be happier."

What may help the program catch on is this: Breaking the industry mold may make good business sense, at least in the long term. For example, at Levindale, the average daily occupancy rate jumped some 10 points to its current 98% after implementation of the Eden Alternative philosophy. The higher rate, says Levindale President Ron Rothstein, has offset renovation and other costs associated with the changeover.

It may sound reasonable, but it hasn't caught on in a big way yet: Fagan estimates that fewer than 1% of nursing homes have embarked on the kind of transformation espoused by the Pioneer Network.

One nursing home implementing such an approach is Providence Mount St. Vincent in Seattle. In 1991, when the home needed remodeling, its leaders decided to turn it into a facility based on "resident-directed care." The home was reconfigured into "neighborhoods" of two dozen residents each, with a new on-site day-care center for children of staff and others in the community.

"Residents are now at the top of the organization chart," says administrator Charlene Boyd, a Pioneer Network founder. "We got rid of most of the middle management and decentralized food service, laundry and housekeeping." Staff members pitch in and help residents with such tasks as getting a cup of coffee, doing a load of laundry or simply playing cards and talking.

"The entire building feels like a neighborhood in some ways, with pets and little kids coming and going," says Sandra Twist, whose mother, Meredith Groat, is a resident there. "People are in a variety of settings--in their room watching TV or reading or out in the open area near the kitchen, which is nicely lit with round tables. Some [residents] are pulled up to the nurses' station, chatting. On Mom's unit there's a solarium. It's got a computer for people to check their e-mail. Another floor has a nicely appointed library, like an old gentleman's club. Another has an aviary."

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