Cultural Change in Long-Term Care Facilities A comparison of the medical model and the social model of care with resident-centered care as an example of the social model. Dr. Robin P. Bonifas, MSW, PhD Arizona State University School of Social Work

Acknowledgements  The development of this curriculum module was made possible through a Gero Innovations Grant from the CSWE Gero-Ed Center's Master's Advanced Curriculum (MAC) Project and the John A. Hartford Foundation.

Learning Objectives  Upon completing this module on Cultural Change and Resident-Centered Care are for students to be able to:  Discuss the strengths and limitations of the medical model of care.  Discuss the strengths and limitations of the social model of care.  Compare and contrast the medical and social models of care.  Describe the goals of cultural change models in long-term care facilities.  Articulate the benefits of cultural change models as identified by research in this area.  Discuss the characteristics of the Eden Alternative as an example of a cultural change model and specifically a resident-centered model of care.

Medical Model  Alleviation of human suffering  Professional responsibility  Expertise  Objectivity  Illness as a distinct category  Presumption of perfectibility  All people aspiring to the same ideal  View of patient as object  Search for efficient and rapid therapies  Focus on biology

Medical Model  Has definite strengths in some areas:  Situations where there is substantial consensus as to what constitutes a "problem.”  When such problems reflect situations involving fairly simple cause-effect relationships.  For example, intervention to treat a broken arm or laceration.

Medical Model  In other areas, has significant limitations: chronic illness, disability, mental health.  An over-reliance on "categories", "ideals", and "objectivity."  Does not appreciate the significance of internal experiences.  Lack of appreciation for diversity and for the role of individuals in their own healing and well-being.  Lack of consideration of the role of culture.

Social Model of Disability  Shifts the focus from impairment as residing within the individual or family to residing within the environment.  Challenges traditional beliefs that physical and cognitive differences are inherently bad and lead to life-long suffering.  Views disability as a socially-constructed concept.

Social Model of Disability  Limitations  Ignores real and distressing aspects of living life with limitations and illness.  May be difficult for some individuals to view their disability as a “neutral” characteristic or based solely in society:  Persons struggling with chronic pain  Persons with heavy caregiving responsibilities  Persons coping with rogressive loss of physical and/or cognitive abilities  Limited utility for people who are newly diagnosed and are just beginning to learn about the changes disability will bring to their lives.

Comparison Medical model  Painful hands, unable to open jars, doors  Difficulties in standing for long periods  Unable to climb steps into buildings  Employers won’t hire you because they think you couldn’t do the job. Social model  Better designed lids, automatic doors  More seats in public places  Ramps and lifts in all buildings  Educate people to look at the abilities of persons with disabilities rather than looking for problems.

How Would Medical Model View This Situation? How Would Social Model View It? Student Entrance to her school

An Example of the Social Model of Care  Cultural change and resident- centered care in skilled nursing facilities…

The Cultural Change Movement  Nursing homes were originally established to care exclusively for medical conditions.  Given that these settings are also individual’s homes, greater emphasis is now being placed on addressing a broader spectrum of care.  Cultural change models are transforming facility practices to:  Better address the needs of the whole person.  Enhance the work environment for direct care staff.

The Cultural Change Movement  Aims to create levels of privacy and choice that persons residing in skilled nursing facilities would experience if they were living in their own homes.  Facility operations are designed to reflect that residents’ needs and preferences come first.  Residents given more control over their daily lives.  Frontline workers given more autonomy to care for residents. Source: M. M. Doty, M. J. Koren, and E. L. Sturla, Culture Change in Nursing Homes: How Far Have We Come? Findings From The Commonwealth Fund 2007 National Survey of Nursing Homes, The Commonwealth Fund, May 2008

The Cultural Change Movement  Physical structure of facilities redesigned to maximize the feeling of a homelike environment.  For example, small “neighborhoods” rather than large “nursing units.”  Emphasis is on consistent care providers rather than rotating care providers. Source: M. M. Doty, M. J. Koren, and E. L. Sturla, Culture Change in Nursing Homes: How Far Have We Come? Findings From The Commonwealth Fund 2007 National Survey of Nursing Homes, The Commonwealth Fund, May 2008

The Cultural Change Movement  A study conducted in 2007 by the Commonwealth Fund examined the extent to which nursing homes (n = 1,435) are adopting culture change principles and practicing resident- centered care.  Results indicate that the more culture change initiatives that are under way, the greater the benefits in terms of staff retention, facility occupancy rates, market competitive position, and operational costs. Source: M. M. Doty, M. J. Koren, & E. L. Sturla. (May 2008). Culture Change in Nursing Homes: How Far Have We Come? Findings From The Commonwealth Fund 2007 National Survey of Nursing Homes. New York, NY: The Commonwealth Fund.

An Example Cultural Change Model: The Eden Alternative  Core belief: Aging is a continued stage of development and growth, rather than a period of decline.  Goal: De-institutionalize long-term care facilities to create “human habitats” instead of medical institutions.  Strive to eliminate the “three plagues” of aging in a nursing home: Loneliness, helplessness, and boredom. Source:

The Eden Alternative  Views the best methods to defeat the three plagues are:  Enhancing sources for companionship.  Offering opportunity to engage in the meaningful care of other living things.  Adding variety and spontaneity to life.  The above can be accomplished via the addition of pets, plants, and children into facilities. Source:

The Eden Alternative  Cultural change efforts also address nursing homes as places of work.  Move away from top-down administrative approaches to move decision making closer to facility residents.  Frontline workers more involved in setting their own priorities and organizing the flow of work. Source:

 In nursing homes that have adopted the Eden Alternative:  Employee satisfaction has improved.  Employee retention has improved.  Use of psychotropic medication has declined.  Use of physical restraints have declined.  Residents have greater participation in directing their daily lives. The Eden Alternative Source:

Video: The Eden Alternative 1 1 Available at

Discussion: Reactions to The Eden Alternative?

Other Sources of Information re: Cultural Change  Bibliography of journal articles on culture change   The Commonwealth Fund   National Coalition for Nursing Home Reform   The Pioneer Network   Paraprofessional Health Care Institute   Wellspring 