End of Life

Transforming today’s nursing homes

Is it possible to celebrate life when you are elderly, frail, and living in a nursing home? Staff at hundreds of nursing homes around the country now answer this question with a resounding “Yes!” They are transforming their institutions into truly homelike environments where residents experience the joys of life.

Change is not easy, though, nor quickly accomplished. Most current homes were built like hospitals, with long, depressing halls and large nursing stations. Transformation may include physical renovation: creating comfortable common areas; remaking a huge, institutional dining room into several small rooms that look and feel more like home; even removing a nursing station and replacing it with an indoor waterfall and pond.

Traditional homes usually have what eldercare reform leader Dr. William Thomas calls “a paramilitary command structure” that oppresses both nursing assistants and the seniors they help. Reformers change that by giving staff more respect and responsibility. They provide continuity and quality of care by assigning staff to cover specific residents. It takes much retraining and what advocates call “deep culture change” to replace old ways of doing things. But the change pays rich dividends: more contented residents, less drugging to control residents’ behavior, happier staff, and much less staff turnover.

What transformation looks like

Residents, like staff, receive more respect. Ideally, they have a major say in culture change. Staff often call them “elders”—in deference to their experience and wisdom. As changes are made, the elders regain the power to make decisions about their schedules, food, and other aspects of daily life. They are not treated as children or inmates.

Many transformed homes are linked to the Eden Alternative (www.EdenAlt.org) which advocates having children, plants, and pets in the homes. Some of the children are volunteers; others are in child-care centers in the homes or in locations nearby, so that seniors can interact with them often. As Dr. Thomas (founder of the Eden Alternative) has written, children’s “play, laughter, and song are potent medicines for the elderly” (Life Worth Living: How Someone You Love Can Still Enjoy Life in a Nursing Home, VanderWyk & Burnham, 1996).

The pets—cats, dogs, parakeets, cockatiels, rabbits, and more—also live in the homes and provide welcome companionship for residents. There are outdoor gardens, including ones that provide fresh vegetables for the seniors. (They are encouraged to help with gardening if they can.) The gardens really fit in, since the Eden Alternative is named for the garden of Eden.

Many other homes, though not affiliated with Eden, now challenge everything from rigid staff roles to loud buzzers and public-address systems. And instead of placing all elders on the same sleeping schedule, transformed homes let them stay up late at night and sleep late in the morning (or the opposite). Rolling Fields, an Eden home in rural western Pennsylvania, tried various approaches to accommodate everyone’s sleeping habits.

Cindy Godfrey, who runs the family-owned home with her sister, said they now have 24-hour meal service. “Our elders love it,” she reported. Another staff member at Rolling Fields said food wastage there is “much less” than before the change to 24-hour service. It was expensive and time-consuming to make the change, but the results are delightful for residents.

Godfrey continued, “We have removed all nursing stations. The home looks much less institutional, and the elders use the new ‘common areas’ to socialize and have coffee.” She said that the Eden philosophy is now “our way of life,” and “we try to do everything by thinking differently. It’s not a program anymore—it’s who we are.”

While the early stages of changing a nursing home involve extra costs, a successful transformation reduces drug costs and the great expense of rapid staff turnover. It also leads to higher occupancy rates and thus more income for the home. But renovation costs are such a challenge for some homes that a 2011 conference on culture change included a long session titled “When Renovation Isn’t Possible: Culture Change in the Traditional Home.” On the other hand, many homes can raise renovation money through the efforts of auxiliary groups, holding special fundraising events or drives, and obtaining foundation grants.

Transformed homes usually retain some typical nursing-home activities. “We would be shot if we didn’t have bingo!” an administrator once said. But many also make special efforts to get their folks out into the surrounding community. They load up their vans or busses, and take the elders on field trips to baseball games, state parks, harbor cruises, antique malls, county fairs, town festivals, parades, and picnics.

Bringing about transformation

The Eden and other transformed homes share a philosophy, but do not form one large chain. Some are for-profit, many are nonprofit, and a fair number are church-affiliated. Beth Baker, in an excellent book called Old Age in a New Age: The Promise of Transformative Nursing Homes (Vanderbilt University Press, 2007), used a Catholic home in Seattle, Washington, as one of her top models. Providence Mount St. Vincent, faced with the common problem of an old and hospital-like building, made over one hallway into a “Main Street.” Strolling or wheeling down the “street,” elders and their guests can find an espresso bar, gift shop, thrift store, beauty parlor, child-care center, and more. Baker said there is even “a real park bench and street lamp.” The Mount kept its older chapel, though. When Baker “slipped in for a few moments of peace and serenity,” she noticed that a sister was wheeling many residents into the chapel for Mass.

Suppose a resident of a traditional nursing home or family members would like to see that home transformed. How should they go about it? Asked about this, Baker emphasized that “change will not happen unless the top administrator is on board.” She noted that “a group of family members and/or residents may exert more influence on an administrator than one individual” can. She added, “You might try organizing an event” and asking “the administrator to commit to participating.” The event could involve a guest speaker, video presentation, or book discussion on culture change.

When nursing-home administrators are ready to come on board, where should they go for more information? Baker’s suggestions included the Pioneer Network and Action Pact. She remarked that visits to transformational homes “are a great way to motivate and excite administrators.” Among the homes she recommended: Seattle’s Providence Mount St. VincentMeadowlark Hills in Manhattan, Kansas; and Fairport Baptist Homes in Fairport, New York. The websites she suggested offer reports on other successful transformations.

Much remains to be done, but exceptional nursing homes lead the way. Their staffs are positive, creative, and determined to keep changing for the better. The result? As one elder told Baker, these homes “are not where you come to die,” but “where you come to live.”

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About the author

Mary Meehan

Mary Meehan, a Maryland writer, has published widely on matters of life and death for many years. Her website is www.MeehanReports.com.