34

Part I Introduction to Nutrition Care in Older Adults

BOX 3.2 Culture Change Implementation Examples

Food service methods: ●

specialty stations: omelet, soup, pasta, and salad bar; pizza; grills

● open dining—extended hours, 24-hour dining ●

room service, buffet-style dining, restaurant- style dining

Resident involvement: ●

●

preparation of a favorite recipe culinary school demonstrations ● menu development committees

Open dining: ●

● ●

kosher café open to residents, families, staff, and the public

cocktail/coffee shop that is open to residents and families

Mealtime activities: ●

●

aromas of baked goods in the dining rooms and into the halls

staff sitting and sharing meals with residents (14)

BENEFITS OF CULTURE CHANGE Numerous studies describe the benefits of culture change. Most facilities boast resident-reported improvements in quality of life, emotional well-being, and behavioral measures. Other benefits include a decrease in the number of residents on therapeutic diets and who have unintentional weight loss or pressure ulcers (32-34). While a financial commitment to culture change is assumed, studies have shown an offset to the cost in savings such as decreased plate waste, decreased employee turnover and training, decreased costs for unintentional weight loss and pres- sure ulcer intervention, and decreased supplement expenses (12,24). In a 2011 symposium called Culture Change: Enriching Lives in Nursing Homes, the Texas Department of Aging and Disability Services provided a summation of benefits of culture change affecting residents, staffing, and additional areas (14) as follows: ●

Residents: An evaluation of Eden Alternative homes found a decrease in the average number of prescriptions per resident, average cost of medica- tion, use of mind-altering drugs, infection rate, and mortality (20). A reduction in loneliness, helplessness, and boredom was found by a similar examination of Eden Alternative homes (35). Culture change also improved the physical health

of residents (reduced frequency of pressure ulcers, restraints, and bedfast residents) and their mental health (reduced depression and behavioral prob- lems, increased social function) (32,36-38). A din- ing-related benefit was increased caloric intake and reduction of unanticipated weight loss (39).

●

Staffing: Implementation of culture change with modifications in staffing assignments reduced employee turnover, minimized temporary agency staffing or mandatory overtime, and reduced workers’ compensation claims and associated costs (14). Added benefits range from employee job satisfaction to adequate shift coverage to vol- unteerism from outside sources (24).

Additional areas: Culture change significantly improved employee, resident, and family satisfac- tion (34). Referrals from residents or family members also increased due to improved satisfac- tion (12,40). Aspects of culture change models boost involvement with the outside community, including children, students, clubs, and religious organizations, consequently increasing resident satisfaction (41). Several facilities experienced improved admission rates and a decrease in nutri- tional supplementation costs (24). Facilities adopting culture change were also rewarded with a reduction in facility deficiencies and fines issued by CMS, less than one-third the average of com- parison facilities (42).

REGULATORY PROCESS AND CULTURE CHANGE

The regulatory interpretive guidelines for Federal Nursing Facility F240 Quality of Life state, “The inten- tion of the quality of life requirements specify the facil- ity’s responsibilities toward creating and sustaining an environment that humanizes and individualizes each resident” (14). F242 Self-Determination and Participation includes language that gives the resident the right to “choose activities, schedules, and health care consistent with his or her interests, assessments, and plans of care.” It also provides the resident the right to “make choices about aspects of his or her life in the facility that are significant to the resident” (14). CMS and the Texas Department of Aging and Disability Services are both concerned about culture change and regulatory compliance in skilled nursing facilities: “Nursing homes can actually reduce their deficiencies by seeking positive person-centered out- comes” (14). CMS offers clarification that “clearly pro- motes a resident’s right to choose and to exercise his or her autonomy. It also provides nursing home providers with some assurances that the regulations and