Community Living Centers (CLCs) in VA are undertaking a cultural transformation to shape facilities' designs, routines, and care around residents' needs and preferences. At the far end of the cultural transformation spectrum lies the Green House-type model (GHTM), a radically new, innovative approach requiring construction of stand-alone, small, home-like facilities for 6-10 residents. In these homes, quality of life and quality of care are emphasized concurrent with promotion of empowerment, equality, and mutual respect for residents and staff. The GHTM is instinctively appealing in many respects, but it has undergone only minimal evaluation in relation to resident or staff outcomes. A number of CLCs are building GHTMs. To understand fully whether such expansive, expensive, and radical changes in VA CLC facilities are warranted and under which circumstances they can best be achieved, this pilot project used a comprehensive methodology for assessing the current state of care, work, and culture at two CLCs.
This study had two primary objectives. (1) To adapt and pilot an evaluation methodology for the expected wide-ranging effects of cultural transformation, including the GHTM implementation. (2) To conduct a baseline assessment of cultural transformation at two CLCs to evaluate the multiple impacts of having VA CLCs move from a traditional nursing home model to the GHTM, and to interview VA Central Office (VACO) leadership about this transition. The goal was to explore the following research questions: (1) What are the optimal instruments and methods for collecting data about cultural transformation? (2) What are current perceptions of cultural transformation? (3) What are CLC management, frontline staff, and resident outcomes on indicators related to cultural transformation? (4) What are VACO leadership and CLC frontline staff and management expectations of and facilitators and barriers to adoption of the GHTM?
Comprehensive qualitative and quantitative assessments of cultural transformation efforts at the two CLCs were performed. Existing instruments and adapted, open-ended interview and focus group guides from prior work were used. Additionally, a structured, systematic, observation-based tool for measuring resident-staff interaction and resident engagement, the Resident-centered Assessment of Interaction and Staff Engagement (RAISE), was developed in response to identified measurement needs. RAISE development was performed by conducting over 60 hours of ethnographic observations at one CLC of life on units over all shifts and weekdays and weekends. A qualitative analysis of the data highlighted two important aspects of resident-centered care not captured by current assessment methods: (a) the type, quality, and number of staff-resident interactions and (b) the type, quality, and level of resident engagement. Because these two aspects of care can only realistically be assessed using observations, the RAISE was developed. Subsequently, at the two CLCs the following were conducted: (a) over 80 hours of observation using the RAISE; (b) over 40 interviews with staff members and residents about cultural transformation activities, staff-resident interactions, and staff engagement of residents; (c) surveys of all CLC staff at each facility; and (d) 3 interviews with VACO leadership.
Data from the RAISE observations, interviews, and surveys are currently being analyzed.
This project will result in a valuable, in-depth understanding of the cultural transformation of two CLCs before their transition to GHTMs. Cultural transformation supports the improvement of quality of care and quality of life for Veterans living in CLCs. The results of the study are anticipated to help improve the cultural transformation efforts of the two participating CLCs particularly but also CLCs nationally. The latter will be operationalized as the study team works with the Office of Geriatrics and Extended Care to disseminate findings from the study highlighting specific areas and methods for improving resident-centered care and the Office supports the submission and execution of subsequent projects aimed to improve CLCs' abilities to make meaningful movement forward on cultural transformation.
External Links for this Project
Grant Number: I01HX000258-01
- Hartmann CW, Snow AL, Allen RS, Parmelee PA, Palmer JA, Berlowitz D. A conceptual model for culture change evaluation in nursing homes. Geriatric nursing (New York, N.Y.). 2013 Sep 1; 34(5):388-94. [view]
- Palmer JA, Parker VA, Burgess JF, Berlowitz D, Lynn Snow A, Mitchell SL, Hartmann CW. Developing the Supporting Choice Observational Tool (SCOT): A Formative Assessment Tool to Assist Nursing Home Staff in Realizing Resident Choice. Research in gerontological nursing. 2017 May 1; 10(3):129-138. [view]
- Hartmann CW, Snow AL, Allen R, Parmelee P, Palmer J, Berlowitz DR. Conceptual Model for Examining Outcomes of Culture Change in Nursing Homes. Paper presented at: Gerontological Society of America Annual Scientific Meeting; 2011 Nov 14; San Diego, CA. [view]
- Snow AL, Jacobs L, Machac-Burleson M, Vinson L, Palmer J, Parmelee P, Allen RS, Berlowitz DR, Hartmann CW. Development of the Resident-centered Assessment of Interactions with Staff and Engagement (RAISE): A Nursing Home Quality of Care Observational Tool. Poster session presented at: Gerontological Society of America Annual Scientific Meeting; 2011 Nov 14; San Diego, CA. [view]
- Snow AL, Jacobs L, Machac-Burleson M, Vinson L, Palmer J, Parmelee P, Allen RS, Berlowitz DR, Hartmann CW. Development of the Resident-centered Assessment of Interactions with Staff and Engagement (RAISE): A Nursing Home Quality of Care Observational Tool. Poster session presented at: VA HSR&D / QUERI National Meeting; 2012 Apr 1; National Harbor, MD. [view]
- Snow AL, Hartmann CW. Increasing Engagement between Staff and Residents: Using the RAISE Rating System as a Quality Improvement Tool. Paper presented at: Pioneer Network Annual Meeting; 2013 Aug 15; Bellevue, WA. [view]
- Snow AL, Palmer J, Jacobs L, Allen RS, Parmelee P, Berlowitz D, Hartmann CW. Measuring Resident and Staff Engagement and Interaction Quality. Paper presented at: Pioneer Network Annual Meeting; 2012 Aug 5; Jacksonville, FL. [view]
- Palmer JA, Parker V, Berlowitz DR, Burgess J, Hartmann CW. Promoting Choice in Nursing Home Daily Care: A Standardized Observational Protocol of Staff Behavior. Paper presented at: Gerontological Society of America Annual Scientific Meeting; 2011 Nov 14; San Diego, CA. [view]
- Snow AL, Palmer J, Jacobs L, Allen RS, Parmelee P, Berlowitz DR, Hartmann CW. The Resident-centered Assessment of Interactions with Staff and Engagement (RAISE): Refinement, Video-based Rater Training, and Scoring Considerations. Paper presented at: Gerontological Society of America Annual Scientific Meeting; 2012 Nov 4; Charlotte, NC. [view]
Aging, Older Veterans' Health and Care, Health Systems