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First of a four-part series Creating Home and Building Community II: The Urban Experience

September 1, 2008
by Jennifer A. Brush, MA, CCC/CLP, Margaret P. Calkins, PhD, Mark J. Kator, Ann Wyatt, and Hope Miller, RN
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A grant project sponsored by The Hulda B. and Maurice L. Rothschild Foundation

To demonstrate the feasibility of creating an urban high-rise culture change program, and to encourage the elder care community to consider this option, a national foundation provided a funding opportunity through a program titled: Creating Home & Building Community II: The Urban Experience. (Creating Home & Building Community I was awarded to the Garfield Community Hospital District in Pomeroy, Washington, which was pioneering a number of new management processes in long-term care.)

Approaches to the delivery of long-term care are changing dramatically. Virtually every aspect of the setting, from staffing models and staff training, to organizational structure, to the physical design is under scrutiny and being re-engineered.

Increasingly, elders live with a small number of other residents in settings that resemble a house more than a hospital. Staff consistently care for the same residents, supporting relationship-based care. The focus is shifting from the provision of good healthcare to an approach that attends to the psychosocial, emotional, and spiritual well-being of each individual, thereby ensuring they are achieving the highest practicable quality of life.

To illustrate and better understand ways in which this systemic change can be planned and managed, with particular focus on an urban setting, this is the first in a series of four articles following Isabella Geriatric Center, a large urban high-rise nursing home, as it continues its “journey of deep change” toward become more resident-centered. It is already engendering ideas that might apply to many nursing facilities seeking change, urban or otherwise.

“Deep change” targets more than care practices and belief systems. It changes management philosophy, organizational structure, job descriptions, and performance evaluations, as well as program philosophy, resident involvement in decision making, use of technology, board-CEO relationship, vision and values statements, and, of course, the built environment.

Isabella geriatric center, new york, ny

Isabella Geriatric Center, New York, NY


“Deep change differs from incremental change in that it requires new ways of thinking and behaving. It is change that is major in scope, discontinuous with the past, and generally irreversible.”

1 Deep change does not happen quickly and requires a commitment to the process for each and every function of the organization. The authors will observe and describe this process of transition at Isabella Geriatric Center over the next two years for the readers of

Long-Term Living.

Culture change defined

Culture change is the general term for a movement that is broadly described as an effort to move away from traditional, institutionally structured care settings toward an approach that respects the needs and desires of the people who inhabit them. A number of terms describe this new philosophy, including resident-centered, resident-directed, self-directed, homelike, individualized care, and others. This diversity reflects not only philosophical differences about how the care setting should be structured, but different approaches that homes are using to achieve their goals or realize their visions. While there is no one “right way” to accomplish this, a common unifying theme is the creation of “home.”

Most of the current models involve creating households, or even separate houses, for small groups of residents, with consistent staffing and greater resident involvement in the important decisions that affect their lives. Many of such models described in the literature or in conference presentations require substantial property for their construction, as they are either low-rise or ranch-style in design.

This “freestanding single-story household” model may not be financially viable, or even appropriate, for an urban setting. A typical residence in a major metropolitan area would be encompassed in a high-rise structure. Yet, the underlying principles of increasing resident autonomy and decision-making and providing relationship-based care in a setting that reflects a familiar home are certainly as important for residents in urban locations as they are in suburban or rural communities.

The Hulda B. and Maurice L. Rothschild Foundation sponsored a $50,000 grant opportunity to assist a not-for-profit, urban long-term care home that was engaged in the process of becoming more resident-centered. As part of the process, the home needed to be planning significant changes to its built environment. The Hulda B. and Maurice L. Rothschild Foundation is a private philanthropy based in Chicago, and was created in 1980 under the will of Hulda Bloom Rothschild, who lived to the age of 102 and was always concerned with the needs of elders in the community. The Foundation has a primary interest in improving the quality of life for elders, and a firm commitment to expanding knowledge about the therapeutic potential of the physical environment. It is the only national philanthropy in the United States exclusively focused on changing the culture of long-term care.


Garden courtyard encourages socialization

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