Culture Change Practice in U.S. Nursing Homes: Prevalence and Variation by State Medicaid Reimbursement Policies.

*Address correspondence to Susan C. Miller, Center for Gerontology & Health Care Research, Department of Health Services, Policy and Practice, Warren Alpert Medical School, Brown University, 121 South Main Street, G-S121-6, Providence, RI 02912. E-mail: .
The Gerontologist (Impact Factor: 2.48). 03/2013; DOI: 10.1093/geront/gnt020
Source: PubMed

ABSTRACT Purpose of the Study: To estimate the prevalence of culture change practice in U.S. nursing homes (NHs) and examine how state Medicaid policies may be associated with this prevalence. DESIGN AND METHODS: In 2009/2010, we conducted a survey of a stratified proportionate random sample of NH directors of nursing (DONs) and administrators (NHAs) at 4,149U.S. NHs; contact was achieved with 3,695. Cooperation rates were 62.6% for NHAs and 61.5% for DONs. Questions focused on NH (physical) environment, resident-centered care, and staff empowerment domains. Domain scores were created and validated, in part, using qualitative interviews from 64 NHAs. Other NH covariate data were from Medicare/Medicaid surveys (Online Survey, Certification and Reporting), aggregated resident assessments (Minimum Data Set), and Medicare claims. Medicaid policies studied were a state's average NH reimbursement rate and pay-for-performance (P4P) reimbursement (including and not including culture change performance measures). Multivariate generalized ordered logit regressions were used. RESULTS: Eighty-five percent of DONs reported some culture change implementation. Controlling for NH attributes, a $10 higher Medicaid rate was associated with higher NH environment scores. Compared with NHs in non-P4P states, NHs in states with P4P including culture change performance measures had twice the likelihood of superior culture change scores across all domains, and NHs in other P4P states had superior physical environment and staff empowerment scores. Qualitative interviews supported the validity of survey results. IMPLICATIONS: Changes in Medicaid reimbursement policies may be a promising strategy for increasing culture change practice implementation. Future research examining NH culture change practice implementation pre-post P4P policy changes is recommended.

  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: To understand the process of instituting culture change (CC) practices in nursing homes (NHs). NH Directors of Nursing (DONs) and Administrators (NHAs) at 4,149 United States NHs were surveyed about CC practices. Follow-up interviews with 64 NHAs were conducted and analyzed by a multidisciplinary team which reconciled interpretations recorded in an audit trail. Results: The themes include: (a) Reasons for implementing CC practices vary; (b) NH approaches to implementing CC practices are diverse; (c) NHs consider resident mix in deciding to implement practices; (d) NHAs note benefits and few costs to implementing CC practices; (e) Implementation of changes is challenging and strategies for change are tailored to the challenges encountered; (f) Education and communication efforts are vital ways to institute change; and (g) NHA and other staff leadership is key to implementing changes. Diverse strategies and leadership skills appear to help NHs implement reform practices, including CC innovations.
    07/2013; 33(6). DOI:10.1177/0733464813491141
  • [Show abstract] [Hide abstract]
    ABSTRACT: Purpose of the Study: Descriptions of culture change adoption are often complex and varied, creating a challenge for those seeking guidance about which of the many components of culture change to adopt and in what order and combination. To begin to address this question, members of The Research Initiative Valuing Eldercare (THRIVE) developed and distributed an online survey to 327 known culture change adopters. Of these, 164 (50%) completed the survey. Data were analyzed to identify adopted components, co-occurrence of adopted components, and differences in these across various types of nursing home models (i.e., traditional unit, household, and small house). Our findings support unique co-occurrence of components across nursing home models. Results also show that homes with more traditional environments have been able to implement certain culture change components without large capital investments required by renovations. The adoption patterns suggest that the co-occurrence of components should be considered when pursuing organizational transformations to support culture change.
    The Gerontologist 02/2014; 54(Suppl_1):S17-S24. DOI:10.1093/geront/gnt133 · 2.48 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Purpose of the Study: To examine how Medicaid capital reimbursement policy is associated with nursing homes (NHs) having high proportions of private rooms and small households. Through a 2009/2010 NH national survey, we identified NHs having small households and high proportions of private rooms (≥76%). A survey of state Medicaid officials and policy document review provided 2009 policy data. Facility- and county-level covariates were from Online Survey, Certification and Reporting, the Area Resource File, and aggregated resident assessment data (minimum data set). The policy of interest was the presence of traditional versus fair rental capital reimbursement policy. Average Medicaid per diem rates and the presence of NH pay-for-performance (p4p) reimbursement were also examined. A total of 1,665 NHs in 40 states were included. Multivariate logistic regression analyses (with clustering on states) were used. In multivariate models, Medicaid capital reimbursement policy was not significantly associated with either outcome. However, there was a significantly greater likelihood of NHs having many private rooms when states had higher Medicaid rates (per $10 increment; adjusted odds ratio [AOR] 1.13; 95% CI 1.049, 1.228), and in states with versus without p4p (AOR 1.78; 95% CI 1.045, 3.036). Also, in states with p4p NHs had a greater likelihood of having small households (AOR 1.78; 95% CI 1.045, 3.0636). Higher NH Medicaid rates and reimbursement incentives may contribute to a higher presence of 2 important environmental artifacts of culture change-an abundance of private rooms and small households. However, longitudinal research examining policy change is needed to establish the cause and effect of the associations observed.
    The Gerontologist 02/2014; 54(Suppl_1):S76-S86. DOI:10.1093/geront/gnt141 · 2.48 Impact Factor