Nursing Home "Neighborhoods" Emphasize Dignity and Independence, Leading to Improvements in Resident Health and Quality of Life and Lower Employee Turnover

Problem Addressed

• Little or no resident autonomy, with residents viewed as patients rather than people: Staff make most of the decisions about residents' activities, meals, sleep patterns, medications and the like, with little attention paid to an individual's life history, long-held interests, and personal preferences. Residents are categorized by medical conditions, disabilities, diseases, and the level of care they need.¹
• Sterile, uninviting environment: Many facilities are sterile and uninviting, marked by long halls and hard surfaces.¹
• Culture of dependence: This medical model can lead to a culture that fosters dependence, as residents become accustomed to not making decisions for themselves. Residents report being bored, lonely, and frustrated with the lack of control in their lives. For some residents, the inability to make choices affecting their lives can produce learned helplessness, leading them to withdraw from most or all activities.²
• Resident fear of reporting problems: Because many nursing homes house residents with cognitive impairments in a separate living area, residents may hide health problems such as incontinence and confusion because they fear being moved to the separate area.²
• High employee dissatisfaction and turnover: Employees at nursing homes that follow the medical model may find the work stressful and unrewarding, since the environment discourages them from making personal connections with residents. Annual turnover at conventional nursing homes typically ranges from 70 to 100 percent.¹

Description of the Innovative Activity

• Neighborhoods that emphasize autonomy: About 200 residents live in clusters of private and shared rooms known as neighborhoods, each with its own large kitchen/dining area that serves as the central gathering spot for meals and activities. There are 9 neighborhoods, each housing 20-23 residents. Neighborhood living encourages one-on-one care, empowering workers to use their judgment on how best to serve residents, with a focus on providing residents with autonomy and treating them with dignity. Key features of each neighborhood include the following: 
  
  • Dedicated, cross-trained staff who are encouraged to get to know residents: Each neighborhood has its own permanent staff that includes a neighborhood coordinator who has accountability over daily activities and responsibility for staffing (including hiring and firing), supervision, clinical nursing care, and budgets. Each neighborhood also has dedicated resident assistants (traditionally called nurse aides), recreational therapists, food and nutrition workers, a social worker, a nurse, and a housekeeper. Instead of being limited to specific tasks, all staff members assist residents with a variety of daily living needs and activities. Nurses, for example, not only perform their traditional duties of administering treatments and medications, but they may also serve food or clean up in the kitchens. Resident assistants help in all areas, including serving meals, leading activities, and folding laundry with residents. Recreation therapists help with rehabilitation and in other areas as well. As a result, staff and residents get to know each other as individuals, learning about their lives, hobbies, spirituality, and interests. A chaplain visits each neighborhood regularly. 
  • Home-like kitchen area and flexible meal times: Kitchens have round tables and common home supplies such as tablecloths and tea kettles, creating a home-like atmosphere. Residents awake when they are ready and ask a staff member to prepare breakfast. Lunch and dinner are prepared in the facility's central kitchen, brought to each neighborhood, and placed in steam tables that keep food warm. Between meals, residents can have snacks and drinks whenever they like.
  • Personalized living quarters: Residents have private rooms or share a bedroom with one roommate, and are free to furnish their living spaces as they choose, surrounding themselves with familiar objects. Plants and pets are welcomed.
  • Neighborhood care station: In place of a traditional nurse station, there is an open care team area for all staff and residents.
  • Option to do own laundry: A laundry room is available for the residents in each neighborhood.
• Similar approach to assisted living: About 110 residents who need some direct care due to physical impairments live in studio and one-bedroom apartments. Staffing includes a program manager, licensed nurses, resident assistants, a recreation coordinator, a social worker, and a chaplain. Staff provide help with daily routines such as medications, laundry, dressing, grooming, personal hygiene, housekeeping, personal safety checks, emergency care, and leisure activities.
• Integrated living community: A key feature of The Mount is its policy that there is no separate living area or silos for residents with cognitive impairments such as dementia and Alzheimer's disease. Instead, individuals with these conditions live among other residents in neighborhoods or in assisted living. This integration reduces residents' fears that they will be moved from where they live if they show signs of a disability or physical problem (such as incontinence) or ask for help.
• Childcare center: The Mount includes an onsite childcare center (known as the Intergenerational Learning Center, or ILC) that serves 125 children ages 6 weeks to 5 years. Children and their teachers have dedicated space and also move throughout the building, using shared spaces on various floors. The center meets the childcare needs of staff and the outside community while also providing integrated opportunities and linkages for residents to interact with the children.
• Offsite trips: Residents can go on outings such as shopping trips and visits to places of interest around the greater Puget Sound area.

References/Related Articles

Contact the Innovator

Results

• Markedly improved health and quality of life for residents: An internal study that compared resident health in 1995 and 2001 found that the number of residents who needed an indwelling catheter fell from 12 to 1; the number reporting a decline in activities of daily living fell from of 82 to 3; the number reporting weight loss fell from 20 to 3; the number requiring body restraints fell from 22 to 2; and the number of residents with pressure ulcers fell from 11 to 2. Although tracked as percentages instead of number of residents, 2007 Centers for Medicare & Medicaid Services quality indicator data for these measures remains consistently strong with only 5 percent of residents with indwelling catheters; only 4 percent of residents whose ability to move about and around their room worsened and 11 percent with an increase in activities of daily living. The percentage of residents who lost too much weight was well below the national average of 3 percent.  Seven percent of long-stay, high-risk residents had pressure sores while no long-stay, low-risk residents had them.  No residents were restrained.
• Lower employee turnover and higher employee satisfaction: Annual employee turnover fell from 50 percent prior to the implementation of the "neighborhood" model to 15-18 percent voluntary turnover in 2006-2007. In addition, use of sick leave by staff has fallen. Based on an Employee Engagement survey, 95 percent of employees surveyed responded that they would recommend Providence Mount St. Vincent "as a great place to work" in 2006 (73 percent response rate for overall survey).
• Reduced waste: Use of steam tables has significantly reduced the amount of wasted food, since residents now have more options and can choose foods they like.
• High occupancy: The changes at The Mount also improved its reputation in the community. It operates at full capacity and has a waiting list. In addition, Providence Mount St. Vincent ranked in the 97th percentile of the 2006 Press Ganey Nursing Home Survey national results for the response indicating that residents were likely to recommend services.

Evidence Rating (What is this?)

Context of the Innovation

• The Nursing Home Reform Law of 1987,³ which guaranteed residents fundamental rights to dignity, respect, freedom, privacy, full disclosure, and participation in their care, prompted administrators to examine residents' overall experience at the Mount.
• There was a growing awareness that the building, which opened in 1924, was outdated and needed an extensive makeover.
• Facility administrators believed a new model that gave residents more independence would be more cost-effective, since the changes would make the facility a more desirable site for both potential residents and employees.

Planning and Development Process

• Hiring of a new administrator: In 1990, a new administrator, who had previously made major changes to promote more independent living at a nursing home in Anchorage, AK, was hired to make similar improvements at The Mount.
• Planning team: In 1991, The Mount formed a nine-member strategic planning team comprised of the new facility administrator, an assistant administrator, a psychologist/researcher, two architects, two nursing managers, a physical therapist, and a social worker. The team met to discuss potential changes in programming and services, and also visited a nursing home in St. Cloud, MN, that had made changes giving residents more independence. In 1995, the team decided to implement the neighborhood living concept.
• Modified design: A series of design changes were gradually implemented:
  • Creation of neighborhoods: Bed capacity was reduced to provide more open space for living. The long corridors were divided into separate, 20- to 23-bed neighborhoods, each with its own decor. A large open area was built at the center of each neighborhood featuring a kitchen, dining room, lounge, and staffing station.
  • Redesign of kitchen services: Steam tables were installed in the kitchen, enabling staff to discontinue individual tray service and making it possible for residents to choose their food and portion size. The steam tables allow for a variety of hot, fresh dishes to accommodate special dietary and nutritional needs as well as personal preferences, reducing costly food waste and allowing residents to set their own sleep and wake schedules.
  • Other physical changes: Other physical changes included the addition of whirlpool baths, a solarium for use as a common space where group meetings or recreational activities take place, care team stations, and carpeting for halls and resident rooms to reduce noise and provide cushioning against falls and injuries.
• Staffing changes: The new service delivery model led to a major staffing reorganization:
  • Middle management reductions: Thirty-five middle management positions were eliminated to add more direct-care staffing. This occurred through attrition, terminations with severance packages, and retirements. Several department managers became direct-care providers. 
  • Creation of neighborhood coordinator position: The neighborhood coordinator was created to serve as the administrator in charge of a given neighborhood.
• Training: A variety of training programs have been used:
  • Initial and refresher training: All staff received training in the resident-directed philosophy during the transition to the new service delivery model; new staff receive similar training during orientation. Ongoing "refresher" training sessions are held.
    
  • Training for neighborhood staff: Neighborhood staff participate in trainings for household tasks such as dining services, laundry, housekeeping, and personal assistance.

Resources Used and Skills Needed

• Staffing: Overall payroll costs are roughly the same as before implementation of the new service delivery model. As noted, The Mount eliminated 35 middle management positions while simultaneously adding more direct staff to support consistent staffing. Overall environmental and organizational redesign resulted in changing the financial model to include more investment in direct care staffing. In addition, the neighborhood meal delivery system eliminated the need to have a large number of employees whose main responsibility was bringing residents to and from the dining hall for meals and to shift staffing consideration from "ratios" to relationships.
• Costs: The building redesign and addition of new features cost roughly $9 million.

Funding Sources

Pioneer Network; Providence Mount St. Vincent Foundation

Tools and Other Resources

Getting Started with This Innovation

• Expect turnover at the beginning: Some employees who are used to working according to the traditional nursing home service delivery model may be dissatisfied with their new roles, which require  assuming broader responsibilities and interactions with residents. 
• Introduce physical redesign changes gradually: One half of each neighborhood was completed at a time to minimize the number of residents who would be displaced. Working in phases allowed for normal attrition among staff and made it possible to limit disruption for residents.
• Change terminology: Changing the terminology to reflect the new model of service delivery sends a message that residents are valued as individuals, not patients. For example, The Mount refers to residential areas as "neighborhoods" and "apartments" (instead of using more traditional terms, such as "floors," "wards," or "units") and to direct care workers as part of a "resident-directed care team" (instead of the more traditional term, "nursing assistants").

Sustaining This Innovation

• Provide avenues for input from residents: All residents at The Mount can participate in quarterly conferences on their care plan. Conference participants may include the resident, a nurse, a resident assistant, the chaplain, the recreation coordinator and a social worker. Family members are invited to attend. In addition to information that helps the specific resident, the conferences can produce helpful feedback that can benefit the entire facility.
• Allow residents flexibility to make decisions affecting their lives: Just as individuals in the world at large are free to weigh the benefits and drawbacks of decisions affecting their health and quality of life, residents at The Mount can decide how they want to live. For example, a resident on a low-salt diet can still eat occasional salty foods such as bacon, because residents maintain an active role in their care plans.
• Value and recognize the workforce: The Mount makes a concerted effort to recognize employees' vital roles. For example, all workers are encouraged to contribute to the decisionmaking process within neighborhoods, employees provide input during other employees' performance evaluations, and employees' perspectives are considered during the hiring process.
• Include detailed job descriptions during the hiring process: Since The Mount's model of service delivery is nontraditional, new employees' roles are described in detail and culture change is explained during job interviews.  These efforts are designed to enhance new employee job satisfaction.

Use By Other Organizations