32

Part I Introduction to Nutrition Care in Older Adults

conferences, and creates strategic partnerships with leading organizations—including the Commonwealth Fund, Centers for Medicare & Medicaid Services (CMS), and American Medical Directors Association (AMDA)— to advance their goals and embed principles into practice. This organization focuses on caregivers developing rela- tionships with each person, knowing the individual person, and promoting the growth and development of all to change the culture of aging (20). Pioneer Network created a task force to develop dining practice standards that were approved by 12 professional standard-setting organizations, including the Academy of Nutrition and Dietetics. A standard toolkit for nursing homes to imple- ment these practices was also developed (21).

Wellspring Nursing Home Alliance The Wellspring Nursing Home Alliance encourages facilities to form support groups, called alliances, to work together to improve care. “The Wellspring Model aims to enhance the quality of resident care and improve the working life of nursing home staff. It pro- vides a structure and set of processes for quality improvement, supported by a network of colleagues that work together to achieve shared goals” (22). One such alliance, Wellspring Innovative Solutions, formed in 1994, consists of a group of 11 nonprofit nursing homes in Wisconsin with the mission of improving care principally by empowering staff. Facilities belong- ing to the various alliances provide their frontline workers with training in “nationally recognized best practices while at the same time allowing all staff a voice in how their work should be performed. In addi- tion, each home in the alliance participates in joint training sessions on clinical care and organizational change, and each shares the results of its quality- improvement activities” (22).

Planetree

Planetree is a patient-centered model of care that began in 1978 in hospitals under the direction of Angelica Thieriot (23). Planetree affiliates focus on providing comfort foods by creating kitchens in patient care areas where families can prepare their relative’s favorite foods and never turning down a request for food at any time, day or night. The first facility to adopt the Planetree model was Wesley Village in Shelton, Conn- ecticut. Planetree has partnered with the Department of Veterans Affairs (VA) to collaborate with the new VA Office of Patient-Centered Care and Cultural Transformation in the development of the VA’s own patient- centered model for veterans who receive health care services within the VA system (24).

IMPLEMENTATION OF CULTURE CHANGE

Implementation of culture change varies greatly across the research spectrum. One difficulty within the culture change movement is evaluating the degree of imple- mentation from facility to facility. The lack of common definition or nomenclature to describe the culture change process has resulted in the proposal of two models: a Stage Model of Culture Change in Nursing Facilities by Grant and Norton and a Continuum of Person-Directed Culture by Misiorski and Rader (25,26). Facilities may follow one of these models, use both of the models, or utilize a combination of these models in their implementation process.

Stage Model of Culture Change in Nursing Facilities

Grant and Norton proposed categorizing culture change into four stages (see Table 3.2): Institutional (traditional, no change); Transformational (beginning stages of change); Neighborhood (smaller resident-cen- tered living areas within a larger whole); and Household (small self-contained living areas) (25). As organizations move from stage I to IV, innovation occurs in five organizational systems: decision-making, staff roles, physical environment, organization design, and leadership practices.

Continuum of Person-Directed Culture Similarly, Susan Misiorski and Joanne Rader developed a Continuum of Person-Directed Culture, illustrating the degree of change from provider-directed care throughout the continuum to person-directed care (26). This contin- uum focuses on the person(s) in charge of decision-mak- ing and delineates examples of specific practices (ie, care assignments, dining, bathing, moving in, death and dying, providing assistance at night, and medication administration) throughout culture change (26). The four phases are summarized in Figure 3.1.

CULTURE CHANGE IN FOOD SERVICE

Culture change runs the gamut of the physical facility, including staffing, administering medications, activities of daily living (ADL) schedules, and dining practices. For the purpose of this chapter, culture change will focus on the dining experience where the resident is allowed to make true choices of when, where, and how to eat and the facility and staff organize around the res- ident’s preferences.

Changes to dining practices can be as small as the addition of a selective style menu or as large as a full- scale dining service change, including staffing,