Special Article
Beyond the Medical Model: The Culture Change Revolution in Long-Term Care

https://doi.org/10.1016/j.jamda.2009.04.004Get rights and content

Culture change in long-term care facilities involves a shift in philosophy and practice from an overemphasis on safety, uniformity, and medical issues toward resident-directed, consumer-driven health promotion and quality of life. Fundamental to this shift is a focus on the importance of the relationships between residents and direct care staff. This review presents and discusses the key elements of culture change, including workforce redesign, resident-centered care, leadership, and the implementation process and evaluation. A case report describes how medical staff can participate in this grassroots movement and help foster the social, cultural, programmatic, and physical changes that can alter the culture of long-term care one home at a time.

Section snippets

Workforce Redesign

In a traditional LTCF the leadership model is top-down. There is a “chain of command” in which nursing assistants are tightly regulated under licensed nurses' orders, and nurses are tied to onerous documentation that is required for reimbursement.12, 13 Because this model can often lead to tension among staff,12, 14 culture change promotes a redesign of the workforce where the goal is to “flatten” the hierarchy. This can be done by creating self-directed work teams.

Self-directed work teams are

Role of Administrative Leadership and Medical Professionals in Fostering Culture Change

Leadership is a central theme in culture change. Without leadership to translate the abstract philosophies into tangible practices and provide encouragement and direction, the process can lose momentum and implementation may fail. Furthermore, change is a continuous, ongoing process requiring lasting leadership for sustainability.

Successful LTCF leadership emphasizes both staff and resident empowerment.45 Empowerment has been shown to be instrumental in maintaining low turnover rates of direct

Case Example

St Camillus Health Center of Whitinsville, Massachusetts, serves as an example of a facility transformed by culture change. A nonprofit, 123-bed facility, it was owned and operated by the Roman Catholic “Order of St Camillus” until 2001. At that time it was near bankruptcy, and a local volunteer board of directors, led by the administrator and director of nursing, agreed to take control in an effort to prevent its closure. Shortly after the transition, St Camillus began its culture change

Conclusion

The culture change movement provides a tremendous opportunity for us to provide the best possible quality of care and quality of life for everyone who lives in an LTCF. At the 2008 Pioneer Network Conference, there were more than 1000 participants but only approximately 15 physicians. Thus, strategies to involve physicians more in culture change could both help the movement advance and enhance the image of medical providers as advocates for quality-of-life and patient-centered care.

Acknowledgments

The authors thank Ann Holme, Regional Ombudsman of Ortonville, MN, Sandra Newbauer, Regional Ombudsman of Mankato, MN, and Mark Wandersee, Executive Director of ElderCare Rights Alliance of Bloomington, MN for their thoughts on the demedicalization of language. Ms. Holme, Ms. Newbauer, and Mr. Wandersee did not receive any compensation for their contributions. We also thank Kimber Bouchard, NP of Evercare Nurse Practitioners for her perspective on culture change at St. Camillus Health Center.

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