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Monday, August 14, 2006 - Page updated at 12:00 AM


Growing Older

Culture change is on the horizon for long-term health care

Special to The Seattle Times


A gust of fresh air is blowing across the long-term-care landscape.

Although it's made landfall in only a few spots, it's already raised the bar in eldercare.

Begun quietly by a few pioneers a decade or so ago, it's growing and attracting believers, foundations, families, elder advocates, caregiving staff, even the federal government. Nothing I've seen in my 30 years in the aging field has such potential for dramatically transforming the care of frail adults.

This new movement goes by many names, but calling it "culture change" or "person-directed care" quickly identifies it. The culture being changed is mainly nursing homes, though my bet is it'll soon sweep into all parts of the long-term-care continuum. And the person who directs the care is the person who needs care. Radical.

Early pioneers of this culture change charted their own course, driven by instinct. Today, the federal government is funding expansion of their ideas into as many nursing homes as possible.

In our state, 33 nursing homes — from Centralia to Seattle to Colville in Stevens County — have embarked on a three-year initiative facilitated by Qualis Health, a regional nonprofit that specializes in improving health-care quality.

One participant is an 81-bed nursing home at Warm Beach Senior Community in Stanwood. I visited recently and was blown away.


Wellspring Institute:, 920-434-0123.

Eden Alternative: or 907-747-4888.

Pioneer Network: or 585-271-7570.

Culture Change Now: or 414-258-3649.

"When you care for very impaired people, you forget to ask their opinion" says Jeff West, a nurse and clinical consultant with Qualis Health. So the first thing Warm Beach did a year ago was hold a meeting of residents and staff and ask, "What would you like changed?"

The answers were clear — and made amazing sense:

The bathing routine. The old schedule was rigid and the environment institutional and cold, set up to move as many people through the bath process as quickly as possible.

Soon walls came down, sinks and mirrors were lowered so people in wheelchairs could groom themselves, grab bars were lowered, aroma therapy and music were added and residents were allowed to decide which bath day and shift they preferred. Some residents now bathe themselves.

Turn off the call lights! Before culture change, when a resident needed help and pulled her call cord, a loud ring would echo repeatedly throughout the building. Overhead pagers to reach staff were loud and obnoxious. Today, signals for assistance go quietly to a nurses' station, and the staff uses walky-talkies.

Early risers get breakfast early . These may seem like small changes. But when you live in an institution with dozens of other people, having a say in what happens to you, and when, is a milestone.

There are bigger improvements as well. Most important:

Allow residents to have the same staff. It's called "permanent assignment" (something Warm Beach did before Qualis Health intervened). In most nursing homes, staff rotates among residents based on where shortages exist. Under culture change, nursing assistants, housekeepers, bath aides and nurses all care for the same residents consistently, so they get to know and care about each other. It's a hallmark of excellence — establishing relationships between care-receivers and caregivers — that's long overdue.

The benefits go even further. "Consistent assignments — creating relationships with residents — retains employees," says West.

Nursing-home-staff turnover is disastrous throughout the nation — about 70 percent a year. Says Laura Hofmann, director of nursing services at Warm Beach, "Ours was 45 percent before these changes, but it's now 34 percent."

Most nursing homes were built in the 1960s, with long sterile halls that mimicked hospitals. Unable to change this, Warm Beach has nonetheless formed "neighborhoods," bringing together the residents who live near each other to address problems and socialize.

"Last week, one neighborhood had a baby shower for a resident's daughter who had adopted a baby," Hoffman says. "No matter how demented you get, you never forget babies." One had Chinese food delivered, another pizza. One group decided to learn Spanish, another computers.

There are also initiatives to improve clinical care. With Qualis Health, Warm Beach is figuring out how to reduce common problems in nursing homes: resident pain, pressure ulcers (bed sores), depression symptoms and the use of physical restraints.

Mentoring programs pair new staff members with more seasoned ones, creating ongoing training and leadership skills that allow caregivers to rise in the ranks. No longer in dead-end jobs, they have career ladders.

The best news: None of this costs more than the old way. Because Medicaid, the lowest payer, covers 60 to 65 percent of residents at Warm Beach (the state average), increasing the cost of care was not an option. While costs rose in the short-term, they balanced out in the long-term. Other sites have had similar experiences.

One of my first questions to Qualis Health, since Warm Beach's care has always been better than most: Why didn't you pick one of the poorer nursing homes to work with? Answer: It's all voluntary.

Advice to readers: Start demanding better care. It's up to us to make this revolution spread.

Liz Taylor's column runs Mondays in the Northwest Life section. A specialist in aging and long-term care for 30 years, she consults with families and their elders. E-mail her at or write to P.O. Box 11601, Bainbridge Island, WA 98110. You can see all of her columns at

Copyright © 2006 The Seattle Times Company



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