End of the Line

Reforming the System

Medically Reviewed by Craig H. Kliger, MD
6 min read

Jan. 15, 2001 -- At the Fairport Baptist Home near Rochester, N.Y., residents spend their days in a community living room and dining room -- not hallway corridors.

At a group of 11 nursing homes in Wisconsin, bladder and bowel accidents occur less frequently. A few years ago, such accidents cost these facilities a total of $3.7 million in staff time per year. In 1999, they reduced that number by $1.3 million, more than a third.

And, in Marlton, N.J., the Wiley Mission is spending $6.9 million to renovate its nursing home and double the size of residents' bedrooms. But management first asked the nursing assistants for their input, wanting to make sure the renovations would mean a more home-like atmosphere, and make it easier for them to do their jobs.

Across the country, some nursing homes are finding ways to enhance their services despite cutbacks in government funding, staffing shortages, and a trend toward older and more fragile patients. They are working hard to make their residents more content and to reduce the hospital feel of their institutions, says Rose Marie Fagan, project director of Lifespan, a community-based agency in Rochester. "A hospital is not based on a relationship," she says. "We need a long-term care model."

Some, like Fairport, have reduced the medical environment by eliminating long corridors and strict schedules, and creating little "neighborhoods" within the facility. Each neighborhood has its own living room, dining room, and kitchen area. The bedrooms form the circumference around these rooms, similar to many college dormitories. Residents eat when they want; no one gets up before they're ready. Dogs, cats, birds, and children -- a daycare center is attached -- are welcome.

In Wisconsin, 11 nursing homes have formed an alliance called Wellspring Inc. Concentrating primarily on quality of care, the homes have dramatically increased training levels.

"The industry tends to say we're not paid enough," says Sarah Greene Burger, interim executive director of the National Citizens' Coalition for Nursing Home Reform. "They are no way making use of the assets they have; they've paid no attention to the good use of staff. They work things on a medical model, [instead of] going outside of the box, to suit the residents' needs instead of their own needs."

Such rethinking is occurring primarily in nonprofit nursing homes, according to those interviewed, but not exclusively. A case in point: The for-profit Apple Health Care group in Avon, Conn., has adopted a more social model, transforming its 21 homes in Massachusetts, Rhode Island, and Connecticut into places that respond more to residents' wishes, according to Tracy Wodatch, director of corporate nursing services.

"We are empowering [nursing assistants] to make more decisions," says Robert Greenwood, associate director of public affairs for the American Association of Homes and Services for the Aging. "It makes them more satisfied; they know the residents the best. ... It's not the traditional way medical facilities operate."

Fighting with someone to get him or her out of bed at 8 a.m., when that person clearly wants to sleep longer, doesn't make any sense, Burger says. "If it takes five minutes to deliver care in a person's own time, when it would take a half-hour according to some schedule that's appropriate only to the institution," the personalized approach is more logical, she says.

Some homes are concentrating on other areas. At the Johns Hopkins Geriatric Center in Baltimore, Michele Bellantoni's group is offering more rehabilitation services. "We are transferring [fewer patients] to acute care," says Bellantoni, MD, the center's director." As we upgrade our services here, we can take care of these complex patients."

The Wisconsin alliance began in the early 1990s, when nursing home administrators were discussing how to care for their patients while keeping their facilities afloat. Survival, they decided, meant partnership.

"We've got much more strength and much more capability as a group than we ever would have had alone," says Mary Ann Kehoe, executive director of Wellspring Inc., and executive director of Good Shepherd Home in Seymour, Wis. The alliance, she says, has saved money on workers' compensation and insurance, and reduced staff turnover by giving employees more of a say in patient care.

Using the federal government's nursing home quality indicators -- covering incontinence, skin care, nutrition, restorative care, and more -- as a basis, Wellspring created "care modules." Each facility has teams that are trained and dedicated to each module.

Turnover for nursing assistants at Good Shepherd dropped from 105% to only 23% last year. "There's no question about it, [Wellspring] is the major difference," Kehoe says.

Kehoe says the plan also has reduced the number and severity of falls, and that Wellspring residents are less restrained, take fewer psychotropic drugs, and report better pain management.

It wasn't easy getting Wellspring into gear, Kehoe says. Management and staff needed convincing -- and money. Between $50,000 and $75,000 had to be found. Not included in that price tag was $110,000 for 11 machines that assess the amount of urine in the bladder.

This device, somewhat like an EKG, saves time because an aide doesn't need to force a person to use the bathroom, Kehoe says. "It takes eight minutes to take a person to the toilet," she says. "It takes from 20 to 30 minutes of staff time to change that person." Last year, the Wellspring 11 prevented a net total of 256,623 such episodes, Kehoe says.

Kehoe says their results are being studied, and that numerous nursing homes from other states are looking at the Wellspring model.

While Wellspring was forming, the Rev. Garth Brokaw, Fairport's president, was facing similar issues. His facility needed revamping, but administrators were questioning whether it was wise to spend millions on a new, yet similar, setup. While considering more drastic changes, smaller ones were tried to make the facility more homelike: eliminating nurses' stations, setting up parlors, and creating more intimate dining areas, among others. Interestingly, the staff noticed that noise levels and behavioral incidents dropped.

Those improvements, plus Brokaw's knowledge of the Wisconsin and similar projects, convinced him that major change was needed, prompting $17 million in renovations. The 196-bed facility was divided into 20 households of nine to 12 residents. Permanent staff was assigned to each group. Staff members even were allowed to bring in their pets, which have become part of the households, as have children from the childcare facility, Brokaw says.

It wasn't long before staffers noticed that patients' families, including teens and young adults, were coming to visit for longer periods of time.

"People are re-engaging in life," Brokaw says. "They find purpose to live and hope. These smaller groupings turn into small households, and they take care of each other."

There still are improvements to be made. Staff turnover, though reduced, remains a problem. "We are lucky we can draw someone in with a hook," he says. "It's hard work."

One of the people who lived and died at Fairport was Fagan's mother. She recalls how the two of them sat together at the kitchen table and drank coffee. When her mother died, staff and residents came to her bedside, shrouded her body with an embroidered cloth, and in procession fashion, accompanied it to a waiting car. At most nursing homes, Fagan says, death is treated like a non-event -- no announcement, no respect, no acknowledgement.

"You don't live in your hallway, or [spend] all your time in your room, or eating with 60 other people," she says. "We don't live our life in ... therapy all day long, and yet we expect people to do this, to live like this in a nursing home."

Christine Bahls is a WebMD staff member. She is an award-winning investigative reporter and editor who previously worked for newspapers including the Philadelphia Inquirer and the Philadelphia Daily News.