The Prevalence of Culture Change Practice in US Nursing Homes

Abstract

Background and Objectives: Given the dynamic nursing home (NH) industry and evolving regulatory environment, depiction of contemporary NH culture-change (person/resident-centered) care practice is of interest. Thus, we aimed to portray the 2016/17 prevalence of NH culture change-related processes and structures and to identify factors associated with greater practice prevalence. Research Design and Methods: We administered a nationwide survey to 2,142 NH Administrators (NHA) at NHs previously responding to a 2009/10 survey. Seventy-four percent of administrators (1,583) responded (with no detectable non-response bias) enabling us to generalize (weighted) findings to US NHs. From responses, we created index scores for practice domains of resident-centered care, staff empowerment, physical environment, leadership, and family and community engagement. Facility-level covariate data came from the survey and the Certification and Survey Provider Enhanced Reporting system. Ordered logistic regression identified the factors associated with higher index scores. Results: Eighty-eight percent of administrators reported some facility-level involvement in NH culture change, with higher reported involvement consistently associated with higher domain index scores. NHs performed the best (82.6 /100 weighted points) on the standardized resident-centered care practices index, and had the lowest scores (54.8) on the family and community engagement index. Multivariable results indicate higher index scores in NHs with higher leadership scores and in states having Medicaid pay-for-performance with culture change-related quality measures. Conclusion: The relatively higher resident-centered care scores (compared to other domain scores) suggest an emphasis on person-centered care in many US NHs. Findings also support pay-for-performance as a potential mechanism to incentivize preferred NH practice.

Identifying the Implementation Conditions Associated With Positive Outcomes in a Successful Nursing Facility Demonstration Project

“…Our finding that investment by senior management is linked with successful outcomes is consistent with prior research identifying associations between leadership and the adoption of change ( Castle & Decker, 2011 ; Corazzini et al, 2015 ; Donoghue & Castle, 2009 ). Although the measurement in this study focused specifically on leadership’s willingness to invest resources in the adoption and implementation of a new clinical model, it is likely that this is associated with high-quality leadership characteristics that facilitate culture change, such as open communication, shared decision-making, staff education, and a focus on positive leadership–staff relationships ( Miller et al, 2018 ). In a prior qualitative study of barriers to implementation of OPTIMISTIC, we found that miscommunication was a major barrier to implementation which often resulted in a lack of knowledge about both the OPTIMISTIC program and how to interact with program staff ( Ersek, Hickman, Thomas, Bernard, & Unroe, 2018 ).…”

An Empirical Typology of Nursing Home Culture Change Implementation

“…The prevalence of culture change practices in Minnesota NHs was comparable to that of a national representative sample of NHs (Miller et al, 2018), wherein culture change practices associated with resident-centered care, physical environment transformation, and end-of-life care were more frequently implemented than practices associated with staff empowerment, staff leadership, and family and community engagement. This study, looking beyond individual culture change domains, integrated the multidimensional measures of culture change practices to identify an empirical typology of culture change implementation.…”

“…Items in the domain of physical environment were measured using a two-level Likert-type scale (0-1), and items in other domains were measured using a three-level Likert-type scale (0-2). As suggested by the previous use of the instrument (Miller et al, 2018), a composite score was obtained for each domain by summing the raw item scores, which were then rescaled to the range of 0 to 100. The missing value of an item was imputed using the mean of completed items in a given domain if one or two items were missing for that domain (imputations were performed for 1-11 NHs per domain).…”

“…NH structural and organizational characteristics. Cost reports submitted by facilities to the Minnesota Department of Human Services were used to obtain data of several structural and organizational NH characteristics known to be associated with the implementation of culture change practices (Miller, Looze, et al, 2014;Miller et al, 2018). These variables included profit status, chain affiliation, geographic location, size, occupancy rate, payer mix, and staffing (Table 1).…”

The Relationships of Nursing Home Culture Change Practices With Resident Quality of Life and Family Satisfaction: Toward a More Nuanced Understanding

“…As shown in a national survey of culture change practices in U.S. NHs, culture change practices associated with resident-centered care and physical environment association were more prevalent than practices associated with staff empowerment and family and community engagement (Miller et al, 2014(Miller et al, , 2018. With the development of comprehensive domain-specific culture change assessment tools, deconstructing the complex culture change into its domains and evaluated domain-sensitive outcomes has become possible (Miller et al, 2014(Miller et al, , 2018. Examining domain-specific relationships will better inform the development of outcomeoriented culture change initiatives and maximize the efficacy and cost-effectiveness of culture change interventions (Miller et al, 2014(Miller et al, , 2018.…”