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Tracking environmental enhancements

May 1, 2009
by Kaye Brown and Nadine Pfeiffer
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A North Carolina study investigates, ‘How much change in culture change?’

When the National Institute of Medicine issued its report to Congress on the condition of the nation's nursing homes as of 1986, few saw the profound effect it would have on the long-term care (LTC) industry in this country. The report's recommended reforms found their way into the Nursing Home Reform Act contained in the Omnibus Budget Reconciliation Act of 1987 (OBRA ′87). They mandated that residents in nursing environments were to receive quality care aimed at their “highest practicable physical, mental, and psychosocial well-being.”

OBRA ′87 created a radically new vision for the industry-one that depended on nursing homes crafting new opportunities for the fullness of life in residents of widely varying capacities. They were to do this by focusing on both quality-of-life and quality-of-care issues. This was, and remains, an enormous challenge.

State regulatory agencies are required to enforce the provisions of OBRA ′87 and to promote and support initiatives that improve the overall quality of nursing homes. One such initiative is the North Carolina Coalition for Long Term Care Enhancement Grant Program. In 1998, the state's Division of Health Services Regulation (DHSR) began to use civil money penalty funds collected from out-of-compliance nursing homes to fund demonstration grants in support of aspects of the Eden Alternative philosophy.1

When Bill Thomas promulgated the Eden Alternative doctrine, embedded in it were core elements used as tools to transform a traditional nursing home into what he called a “human habitat.” These elements were principally an empowered staff and teams, and the enhancement tools of intergenerational initiatives, pets, and living plants. Homes subscribing to the Eden Alternative philosophy usually have most or all of these enhancements in place. No claim is made that these elements in any sense define the core culture of an Eden Alternative home. However, they have been found to be reliable markers for identifying homes engaged in environmental transformation

From this simple beginning grew the state's current grant program, which supports a wide variety of enhancement initiatives aimed at implementing the intent and mandate of OBRA ′87.


This is what culture change can look like from a resident's perspective. The scene appears normal because all the design elements and furnishings are familiar and residential. The inside and outside are connected through sight lines and sunshine. Despite all the pets and plants that offer opportunities for spontaneous happenings, this scene is calm and restful

This is what culture change can look like from a resident's perspective. The scene appears normal because all the design elements and furnishings are familiar and residential. The inside and outside are connected through sight lines and sunshine. Despite all the pets and plants that offer opportunities for spontaneous happenings, this scene is calm and restful


Measuring enhancements

The objective of environmental enhancement is to restore choice and control to residents in LTC settings. Homes can do this better when their physical environments are aligned with their unique cultures of care. To assess the extent to which its nursing homes were changing their operations and environments in this fashion, North Carolina regulators began asking them about their experiences with culture change.

Each year, as part of the annual license renewal application, nursing home operators are asked what environmental enhancements they have implemented during the previous 12 months. Data collected from this source for the past eight years form the basis of this report.

The data clearly show that creating and sustaining culture change is a complicated social process.2

Early in the course of this study, the limitations that accompany self-assessment as a research tool were examined at length. The notion that operators might over-report their enhancement rates was debated. However, there was no apparent reason for operators to report nonfactual information to the state. If there was a bias during self-reporting, it was operating in the direction of under-reporting rather than over-reporting because of a persistent misunderstanding among operators that environmental enhancements are in conflict with nursing home regulations. Therefore, the data herein reported are likely to be valid. The one area of self-reporting found to be unreliable was with respect to what enhancement philosophy was being implemented, and that question has been dropped from the current surveys

Some homes begin enhancement slowly and tentatively, while others initiate and move forward with the transformation process more aggressively. Most nursing homes in the state have started this process at least once within the past eight years. However, a significant number of homes in North Carolina have never started to enhance at all.

Figure 1 shows the environmental enhancement elements that the state tracks, examplified by one's home's history, starting with the eight core elements of the Eden Alternative philosophy. Since 2000, when DHSR began to survey culture change, other enhancements have been added to the tracking record.3

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