SummaryLiberty Country Living, an alternative long-term care facility for people with dementia, offered a nurse-managed model of care in a small, home-like setting, with a focus on treating individuals with respect and building on their strengths and capabilities. Located outside of Iowa City, the facility offered up to 14 residents a family-oriented environment, with a high ratio of staff to residents. The residents could take part in many activities designed to promote their overall functional abilities, including social interaction, ambulation, and continence. The program helped residents remain ambulatory, maintain urinary and bowel continence, avoid weight loss, avoid falls and disruptive behaviors, and reduce psychotropic medication use. Staff and family members reported high levels of satisfaction with the facility. After 5 years of operation, Liberty closed abruptly owing to changes in State regulations and oversight.Suggestive: The evidence consists of staff observations of residents' health and functional status obtained through tabulation of records, along with responses to annual surveys of staff and family members of residents. The evidence is provided by clinically documented observations of the resident outcomes, surveys of staff regarding their satisfaction with their jobs, and surveys of family members regarding the care of residents.
Developing OrganizationsUniversity of Iowa College of Nursing
Liberty Country Living was developed and operated as an independent, privately funded facility by two members of the faculty at the University of Iowa College of Nursing in Iowa City.
Date First Implemented1998
Age > Aged adult (80 + years); Vulnerable Populations > Frail elderly; Age > Senior adult (65-79 years)
Problem AddressedTraditional assisted living facilities and nursing homes are not designed or staffed to meet the special needs of residents with dementia. As a result, residents often feel isolated and staff members feel dissatisfied.
- Limitations of traditional facilities: The size and complexity of traditional assisted living facilities and nursing homes are challenging for residents with dementia. Typical long-term care facilities have large open areas, long hallways, high noise levels, and unfamiliar features. In such settings, residents with dementia may become confused, anxious, or agitated. Moreover, the living conditions in traditional facilities afford residents with dementia few opportunities to interact with staff, other residents, and family members.1
- Frequent isolation and staff dissatisfaction: Lack of social engagement tends to produce loss of functional status and reduced quality of life among residents. Social isolation also causes boredom, anxiety, and depression, which can lead to aggression, wandering, elopement, or other inappropriate behaviors.2 In addition, the stress of working with residents in conditions that tend to promote functional decline and behavioral problems often leads to staff becoming dissatisfied and leaving their jobs.3 In a 2005 study of 354 nursing homes in four states, 1-year turnover rates were 98.6 percent for nurse assistants, 66.8 percent for licensed practical nurses, and 55.4 percent for registered nurses.4
- Unrealized potential of home-like facilities: Small facilities that offer home-like features and let residents interact with other people and engage in meaningful activities related to daily household tasks can improve outcomes. However, few such facilities exist.5,6
Description of the Innovative ActivityLiberty Country Living provided a nurse-managed, home-like setting for individuals in middle to advanced stages of dementia, with a focus on treating individuals with respect and building on their strengths and capabilities. With supervision by experienced nurse managers and ample staff, residents could take part in many activities designed to promote their overall functional abilities, including social interaction, ambulation, and continence. Key elements of the program included the following:
- Emphasis on respect, building on resident strengths: The therapeutic philosophy at Liberty viewed residents with dementia as people with functional capabilities. The idea was to provide a normal living environment and build on their strengths. As Dr. Maas (the co-developer) notes, "We focused on what individuals were able to do, rather than what they could not do." Staff aimed to treat each resident with respect, preserve their dignity, and encourage self-care and maintenance of bowel and bladder continence.
- Ample staff, supervised by experienced registered nurses: To maintain a high ratio of staff to residents, four nursing assistants worked during the day, three to four nursing assistants were on duty during the evening shift, and two nursing assistants covered the night shift. The facility provided an average of 5.7 staff hours of care per resident each day, well above the national average of 3 hours in nursing homes. Nurses with expertise in caring for persons with dementia supervised the facility on a daily basis. A nurse manager, present during the day and some evenings (and on call at other times), led the staff and served as a role model for interacting with the residents.7 Despite the high staffing ratio, the monthly cost per resident was comparable to or less than nursing home fees in the area.
- Home-like conditions: The facility design offered a small, family-style environment. It had private bedrooms for 14 residents, 5 and one-half bathrooms, a common living area, a kitchen, and other home-like amenities. The bedrooms did not have bathrooms or eating areas. This promoted a more normal home environment, with residents interacting with other residents and staff in the kitchen and common areas. Bathrooms were located close to common areas so that they could be easily identified and accessed. The fenced-in property included a large lawn with flowerbeds, mature trees, and farmland.
- Many daily activities: Residents had considerable freedom of movement and were encouraged to participate in cooking, cleaning, gardening, and other familiar activities. On a typical day, residents could take part in at least three planned recreational or craft activities. The facility also sponsored regular trips that let residents go shopping, get their hair done, and attend church or other community events.
- Frequent family interaction: Residents, staff, and visiting family members shared family-style meals, and family members were encouraged to visit and stay involved in the residents' lives. Facility-wide gatherings included family members on a monthly or quarterly basis.
References/Related ArticlesSpecht JP, Maas ML. Research-based model home for persons with dementia closes: policymaking and regulatory constraints on nursing innovation. Nursing and Health Policy Review. 2004;1(3):49-68.
Molyneux J. Reminders of home. Am J Nurs. 2007;107(2):94-5.
Mercer TA. Insisting on innovation: two nurses point the way to better care for persons with dementia, develop nurse-centered model of care. Advance for Nurses. April 7, 2010. Available at: http://nursing.advanceweb.com/features/article-2/insisting-on-innovation.aspx
Contact the InnovatorMeridean L. Maas, PhD, RN
John A. Hartford Center of Geriatric Nursing Excellence
University of Iowa College of Nursing
494 Nursing Building
50 Newton Road
Iowa City, IA 52242-1121
Phone: (319) 335-7084
Janet P. Specht, PhD, RN
Director, John A. Hartford Center of Geriatric Nursing Excellence
University of Iowa College of Nursing
432 Nursing Building
50 Newton Road
Iowa City, IA 52242-1121
Phone: (319) 335-6518
Innovator DisclosuresDr. Maas and Dr. Specht have not indicated whether they have financial interests or business/professional affiliations relevant to the work described in this profile; however, information on funders is available in the Funding Sources section.
ResultsDuring its 5 years of operation, the program cared for a total of 40 residents, helping them maintain function, sustain or increase body weight, avoid disruptive behaviors and falls, and reduce the use of psychotropic medications. Staff and family members reported high levels of satisfaction with the facility.
Suggestive: The evidence consists of staff observations of residents' health and functional status obtained through tabulation of records, along with responses to annual surveys of staff and family members of residents. The evidence is provided by clinically documented observations of the resident outcomes, surveys of staff regarding their satisfaction with their jobs, and surveys of family members regarding the care of residents.
- Maintenance of function: Residents remained ambulatory and maintained urinary and bowel continence for an average of 2 years. In the absence of this type of program, most of these individuals likely would have experienced declines in function. In addition, 90 percent maintained or increased their body weight, and most had reduced use of psychotropic medications. According to Dr. Maas, visitors to the facility often did not realize at first that residents suffered from dementia.
- Sustaining or increasing body weight: While living in the facility, 90 percent of residents maintained or increased their body weight.
- Few falls and disruptive behaviors: Falls, pacing, wandering, and attempted elopement were rare. During the facility's 5 years of operation, only four residents injured themselves as a result of a fall. In the typical month, less than one instance of disruptive behavior occurred at the facility.
- Less use of psychotropic medications: Most residents reduced their use of psychotropic medications. This decline likely contributed to their ability to maintain function and avoid disruptive behaviors and falls, because such drugs can impair physical and mental functioning.
- High family member and staff satisfaction: In annual surveys, family members reported high levels of satisfaction with the facility. Staff reported high levels of job satisfaction, which contributed to a low turnover rate. The facility had few vacant positions during its years in operation.
Context of the InnovationTwo members of the faculty at the University of Iowa College of Nursing, Meridean L. Maas, RN, PhD, and Janet P. Specht, RN, PhD, set out to develop an alternative model of care for elderly people with dementia. As advanced practice geriatric nurse specialists, they had expertise in the long-term care of people with dementia and had worked together in a special care unit for such individuals at the Iowa Veterans Home in Marshalltown. They concluded that standard approaches to care lead to behavioral problems and other undesirable outcomes. "We thought we could do it better if we had more control over it," Dr. Specht said. They decided to apply what they viewed as appropriate principles, including nurse management, use of a small facility with home-like qualities, and a plan to keep residents involved in daily activities like those in a regular household. The facility was established by converting a private, ranch-style home in North Liberty, Iowa. It was designed as a "community-supported living program" under the State regulations in effect at the time.
Planning and Development ProcessKey steps in the planning and development process included the following:
- Initial planning: During the initial planning phase, Dr. Maas and Dr. Specht spoke with state officials involved in regulation of long-term care facilities. After learning that their plan would be governed by rules for "community-supported living" facilities, they set out to comply with the relevant rules. They then developed a business plan and surveyed the potential market.
- Purchasing building: Dr. Maas and Dr. Specht formed a limited liability company to purchase a single-residence private home on 5 acres of land about 10 miles outside of Iowa City. They secured funding by tapping personal funds and taking out private loans and a Federal small business loan. Meetings with the city planner, zoning committee, a civil engineer, an architect, and a builder preceded the home's renovation.
- Planning facility and services: As the facility was being renovated, Dr. Maas and Dr. Specht defined admission and discharge policies, set fees, established policies and procedures for resident care and documentation, and commissioned a dietician to plan meals and recipes. Other steps included the purchase of furniture, equipment, and supplies; creation of marketing brochures; and development of collaborative relationships with physicians and other providers.
- Staff recruitment and training: Before hiring began, Dr. Maas and Dr. Specht selected a vendor to oversee staff benefits, plan training programs, and set policies regarding staff qualifications and employment. They hired registered nurses (RNs) and other staff with a variety of educational backgrounds. The staff received extensive training on best practices in the care of persons with dementia and the use of social engagement to support functional abilities.
- Recruitment and assessment of residents: Within 6 months of opening in March 1998, the facility reached its capacity of 14 residents. An RN assessed each new resident and then planned and evaluated the resident's care in collaboration with the resident's family and medical provider.
- Closing of facility: After 5 years of operation, the facility had to close in 2003 after changes to State regulations and oversight prohibited the continued operation of community-supported living facilities for persons with dementia. New rules called for enclosed stairways and other changes to meet fire codes designed for much larger facilities. The state legislature passed a bill that would have allowed the facility to operate as a pilot project, but the governor vetoed the bill.
Resources Used and Skills Needed
- Staffing: Overall, the facility employed roughly 25 people, including 3 to 4 RNs and a larger number of nursing assistants. As noted, an RN staffed both day and evening hours, four nursing assistants worked during the day, three to four nursing assistants were on duty during the evening shift, and two nursing assistants covered the night shift. Staff received a full range of benefits, including vacation days, holidays, health insurance, retirement contributions, and profit sharing (starting in year 3; see below).
- Costs: The monthly cost per resident initially averaged less than $3,000; over time, this cost rose to slightly more than $3,000. At the time, these costs were comparable to or less than nursing home fees in the area.
- As noted, funding for the initial purchase and conversion of the building came from personal funds and loans taken out by Dr. Maas and Dr. Specht, along with a Federal small business loan. Liberty Country Living did not qualify for Medicaid reimbursement (because it did not fit into existing long-term care models), so it charged private-pay fees similar to those charged by nursing homes. These payments covered the costs of operating the facility. By the third year of business, the facility was profitable enough to offer profit-sharing to employees.
Getting Started with This Innovation
- Invest in RN management: Although some observers cite the high cost of RN management as a possible barrier, the program developers believe that RN-managed facilities are best equipped to address residents' health concerns and social needs.
- Focus on residents' strengths: The traditional model emphasizes custodial care, but a more positive approach leads to better outcomes. The program should be organized and staffed to build on each individual's strengths and capabilities.
- Provide a home-like setting: Desirable features include shared rooms like those in a private home, freedom to move around the facility, and access to the outdoors with staff supervision.
- Ensure adequate staffing: The therapeutic approach used at Liberty Country Living requires a relatively high staff-to-resident ratio.
- Engage leaders in program operations: Dr. Maas and Dr. Specht were closely involved in the facility's operation. They typically visited the facility at least once a week and met weekly with the nurse manager. They often filled in to ensure adequate staffing, particularly at night or on weekends, and they attended family gatherings. Dr. Maas, Dr. Specht, and the RN manager participated in the facility's advisory committee, along with two family members, a geriatrician, a community representative, a pharmacist, a geriatric social worker, an RN who worked with community elders, and a nursing assistant. At quarterly meetings, the committed addressed facility policies, resident programs and outcomes, and staff and family satisfaction.
Sustaining This Innovation
- Seek to influence regulatory environment: Local and state laws and regulations must be flexible enough to allow the operation of such a facility. Program leaders should work with local and state officials and legislators to influence relevant laws, policies, and regulations.
- Seek partnerships with traditional facilities: Liberty Country Living "threatened" the business of traditional long-term care facilities in the area, according to Dr. Specht. Leaders of those facilities supported the regulatory changes that led to Liberty's closing. To minimize opposition from other facilities, leaders of innovative programs should reach out to explain the program's merits and build alliances and working relationships.
Additional Considerations and Lessons
- In 2006, the American Academy of Nursing awarded Dr. Maas and Dr. Specht the inaugural Edge Runners Award for this program. The award honors innovation in nursing care.
Use By Other Organizations
- After Liberty Country Living closed, the regulatory context in Iowa shifted to allow more innovation in long-term care facilities. Regulatory changes in Oregon and other states have led to the development of smaller, home-like facilities for long-term care, although most emphasize a social model and do not include a strong role for RN managers, according to Dr. Maas.
1 Cohen U, Weisman GD. Holding on to home: designing environments for people with dementia. Baltimore: Johns Hopkins University Press; 1991.
2 Algase D, Beck C, Kolanowski A, et al. Need-driven dementia-compromised behavior: an alternative view of disruptive behavior. American Journal of Alzheimer's Disease 1996;11:10-9. http://aja.sagepub.com/cgi/content/abstract/11/6/10
Alfredson BB, Annerstedt L. Staff attitudes and job satisfaction in the care of demented elderly people: group living compared with long-term care institutions. J Adv Nurs. 1994 Nov;20(5):964-74. [PubMed]
4 Engberg J, Castle N. Staff turnover and quality of care in nursing homes. Abstr AcademyHealth Meet. 2005;22:abstract no. 3547.
Kane RA, Lum TY, Cutler LJ, et al. Resident outcomes in small-house nursing homes: a longitudinal evaluation of the initial green house program. J Am Geriatr Soc. 2007 Jun;55(6):832-9. [PubMed]
Verbeek H, van Rossum E, Zwakhalen SM, et al. Small, home-like care environments for older people with dementia: a literature review. Int Psychogeriatr. 2009;21(2):252-64. [PubMed]
Harrington C, Carrillo H, Mullan J, et al. Nursing facility staffing in the States: the 1991 to 1995 period. Med Care Res Rev. 1998;55(3):334-63. [PubMed]
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Service Delivery Innovation Profile
Original publication: October 27, 2010.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: December 04, 2013.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.