Inside the Green House “Black Box”: Opportunities for High‐Quality Clinical Decision Making

Abstract

Objective. To develop a conceptual model that explained common and divergent care processes in Green House (GH) nursing homes with high and low hospital transfer rates. Data Sources/Settings. Eighty-four face-to-face, semistructured interviews were conducted with direct care, professional, and administrative staff with knowledge of care processes in six GH organizations in six states. Study Design/Data Collection. The qualitative grounded theory method was used for data collection and analysis. Data were analyzed using open, axial, and selective coding. Data collection and analysis occurred iteratively. Principal Findings. Elements of the GH model created significant opportunities to identify, communicate, and respond to early changes in resident condition. Staff in GH homes with lower hospital transfer rates employed care processes that maximized these opportunities. Staff in GH homes with higher transfer rates failed to maximize, or actively undermined, these opportunities. Conclusions. Variations in how the GH model was implemented across GH homes suggest possible explanations for inconsistencies found in past research on the care outcomes, including hospital transfer rates, in culture change models. The findings further suggest that the details of culture change implementation are important considerations in model replication and policies that create incentives for care improvements. Key Words. Medical decision making, nursing, qualitative research, long-term care, nursing homes, culture change Evidence suggests that between 25 percent and 70 percent of hospital transfers from nursing homes are "potentially avoidable" (Ouslander and Maslow 2012; U.S. Department of Health and Human Services [USDHHS] 2013;Ouslander et al. 2014). Older adults from long-term care settings are particularly vulnerable to the risks of hospitalization, which include hospital-acquired complications, morbidity, mortality, and excess health care expenditure

Staff Empowerment Practices and CNA Retention: Findings From a Nationally Representative Nursing Home Culture Change Survey

“…The value of these staffing practices in relation to retention speaks to the importance of opportunities for CNA involvement, inclusion, being wrapped in, informed, and at the table as part of a team. This positive relationship with retention is consistent with the literature on the relationship between being valued and job satisfaction (Probst et al, 2010), as well as with the benefits of aligning schedules and encouraging teamwork and CNA input (Bowers et al, 2016). …”

“…By contrast, for example, only 23% of traditional nursing homes include nursing assistants in social event planning and 13% involve them in staff assignment decisions. The problem of stressful work environments and dissatisfaction among staff has been a motivating component of the culture change movement (Banaszak-Holl, Castle, Lin, & Spreitzer, 2013; Yeatts & Cready, 2007), yet culture change initiatives targeting staff empowerment range widely and may be implemented with great variability (Bowers, Roberts, Nolet, Ryther, & THRIVE Research Collaborative, 2016; Doty et al, 2008). …”

Promoting an Alternative to Traditional Nursing Home Care: Evaluating the Green House Small Home Model. An Introduction from the Funders and the Green House Project

“…Bowers and team look at the sustainability of the GH model and into the “black box” of hospital transfers to explore differences in GH homes that have lower and higher hospital transfer rates (Bowers et al. ,b). In two papers, Afendulis et al.…”

“…); and Bowers et al. (,b) look at the factors that influence the ability of organizations to maintain the prescriptive GH model. Finally, Zimmerman presents a synthesis and critical examination of the evidence related to the GH model of nursing home care (Zimmerman et al.…”

The Green House Model of Nursing Home Care in Design and Implementation

“…Semistructured interviews were transcribed verbatim, entered into NVivo10 (QSR International), and coded thematically; additional details regarding these analyses are available elsewhere (Bowers et al. ; Bowers, Nolet, and Jacobson ). These coded interviews were then reanalyzed using a directed content analysis, with analytic categories prescribed by the structured interview findings (Hsieh and Shannon ).…”