This dissertation explores the costs and values inherent in adopting the Household
Model; an environmental/organizational intervention intended to reform traditional long term
care settings into a person centered, meaningful place for living. The focus of the dissertation is
nursing home care settings, which are a place type that provide medical, skilled nursing services
for people who are elderly or infirmed. Because residents may live at the nursing home for
extended periods of time, these places are also forms of housing. Lawton (1986) arrays housing
settings for the elderly on a continuum in which skilled nursing provides the highest level of
support. Beyond their functional use, nursing homes are a meaningful reflection of society and
its views of elders. They reflect what is viewed as an appropriate home for elders, and these
views are beginning to change. Changing the nursing home is not an easy task. As providers
embrace this endeavor, they increasingly need evidence to guide their course, which is the role
of this dissertation.
The Nursing Home in Society
The Nursing Home is a socio-cultural phenomenon. The nursing home as we know it
today was shaped by society and continues to change as societal expectations alter and evolve.
Furthermore, nursing homes are a socio-physical phenomenon in which meaningful experience
results in an understood place type with expectations for what is normal and expected. An
essential focus of this dissertation is the socio-economic phenomenon of the nursing home in
2
Nursing Home as a Social Institution
Eisenstadt (1968) as cited by King (1980) argues that the conventional practice of
understanding societies occurs through the understanding of common institutions, such as the
“spheres of family and kinship, economy, policy, education, religion, and social stratification”
(p. 409). These spheres are evident in the historical rise of the nursing home as a social
institution for elders in the United States. Elders who lacked family support or had few
economic resources were provided for at poor houses and poor farms up until the early 1900’s
(Hubbard, 1992; Katz, 1996). Residents were viewed as recipients of needed charity in addition
to targets for moral reform. A strong protestant work ethic predicated that poor house
residents work for their keep; a practice that was also intended to reduce freeloaders (Vladeck,
1980). Vladeck (1980) argues widespread changes in the United States economy in the 1930s
made it increasingly obvious that being poor and elderly was not due to laziness or a lack of
foresight. Therefore, a new industry was born due to political and economic factors (Vladeck,
1980).
During the 1930’s Nursing homes emerged as a new structure to replace the welfare
based poor houses for the elderly, which is attributed to elders having funds through the Social
Security Act (Vladeck, 1980; Zinn, 1999). An assortment of private convalescent homes, rest
homes and nursing homes responded to this new market (Zinn, 1999). These care settings
primarily offered custodial care with few if any medical services (Vladeck, 1980). With the
passage of Medicare and Medicaid in the 1960’s, government policies transformed nursing
homes into healthcare institutions to justify paying for their services (Capitman, Leutz, Bishop,
3
becoming less and less acceptable to simply park the elderly wherever a bed could be found
and call it caring”(1999, p. 46). Regulations demanded professionally trained medical staff, and
an emphasis on medical care (Zinn, 1999). Thus, the nursing home began to be shaped as a
social institution by policies and regulations that emphasized medical care and imitated hospital
based settings, which were the epicenter of the medical care industry for the period (Vladeck,
1980).
Nursing Home as a Place
The concept of place provides further explanations for why early nursing homes
resembled and felt like hospitals. Per Cutchin (2005), Place is “a concept that broadly refers to
the ensemble of social, cultural, historic, political, economic and physical features that make up
the meaningful context of human life” (p. 121). Place expands social institutions to explicitly
include the experience of the physical environment. Imamoğlu (2007) argues that Place is a
schema or cognitive structure that organizes prior knowledge to provide understanding of
situations. Thus, the nursing home can be conceived of as a place type that gains meaning
though societal expectations for its purpose, inhabitants, activities and the physical setting
(Weisman, 2001). Silverstein and Jacobson (1978) refer to this implicit understood meaning as
the Hidden Program. The medical model has traditionally shaped the place type of a nursing
home with expectations for an efficient delivery of care for an ill and aging population, an
emphasis on nursing care and routines, and an environment that is perceived as efficient and
4
Nursing Home Quality Concerns
Nursing Homes in the United States are facing tremendous pressure to change from this
traditional medical model approach, towards a holistic, consumer-driven product. These
pressures come not only from current and future consumers of nursing homes, but also policy
officials and regulatory agencies who are concerned with improving nursing home quality
(Capitman, Leutz, Bishop, & Casler, 2005b; N. G. Castle, Engberg, & Liu, 2007; General
Accounting Office, 2005, 2002; Vladeck & Feuerberg, 1995). The hybrid nature of nursing
homes as both a place of living and a place of care renders quality an elusive concept (M. L.
Fennell & A. B. Flood, 1998; Vladeck, 1980). Numerous reports and studies have found nursing
homes to be wanting in quality, such as negative perceptions of the industry by potential
consumers and concerns for iatrogenesis (i.e. bedsores, falls, malnutrition, etc.) (Stone &
Steinbach, 1999; The Kaiser Family Foundation, 2007; J. M. Wiener, M. P. Freiman, & D. Brown,
2007b). There is a longstanding tradition of policies addressing nursing home quality concerns
with a watershed moment around the passage of The Omnibus Budget Reconciliation Act of
1987 (OBRA-87) (N. G. Castle & Ferguson, 2010). For the first time, nursing homes had to
consider the quality of life for nursing homes residents, rather than emphasizing quality of
medical care standards (J. M. Wiener et al., 2007b). This was the beginning of a holistic focus
for the nursing home resident, who no longer was being conceived as an ill patient.
Quality and Costs are Intertwined
While quality is paramount, the cost and efficiency of long term care are equally critical
5
organization must operate within a reasonable degree of economic efficiency to remain viable.
The United States government, as the primary payer source of long term care, is also concerned
with costs (Capitman et al., 2005b). The entitlement programs of Medicare and Medicaid that
pay for nursing home care are one of the largest proportions of government budgets at both
the state and federal level and are anticipated to grow in relation to the rising aging population
(Vladeck, 1980). Paradoxically, while significant calls have been made for addressing poor
quality in long term care, there have also been cuts in spending and payment policies that
hinder quality initiatives (Mor, Zinn, Angelelli, Teno, & Miller, 2004). Collectively, changes to
resident characteristics, the market, and revenue make it difficult to address quality concerns in
a nursing home, while ignoring efficiency and costs.
Changing Residents: Before the 1990’s nursing homes often provided custodial care for
a less frail population since few options for subsidized care by the government existed
(Administration on Aging, 2010). Once private funds were exhausted by the resident, Medicaid
paid for nursing home services for these long term residents (Singh, 2010). Currently, nursing
homes are also serving a population with more severe physiological and psychological
conditions, as well as a growing number of residents staying for short recuperative periods after
being discharged from a hospital (Singh, 2010). Short term residents are a source of higher
paying Medicare dollars and reimbursements for therapy services. Accordingly, nursing home
residents are a changing population with greater care needs compared to the past.
Changing Markets: Nursing homes are also facing a different market. Although most
nursing homes operate with high occupancy levels, some homes are facing competition as
6
care programs, as well as an anticipated shrinking customer base temporarily resulting from the
smaller age cohort found in the Silent Generation (Administration on Aging, 2010; N. G. Castle
et al., 2007). Consumers have more information when selecting a care setting through the use
of publically available statistics on the internet, as well as a government sanctioned five star
rating system which serves as a report card of nursing home quality (Mukamel & Spector,
2003).
Changing Revenue: Nursing Homes are often impacted by the external policies.
Government ratings may eventually lead to differences in reimbursements by the government,
which piloted a pay for performance program in the state of Colorado (A. E. Elliot, 2010).
Rachel M. Werner, Konetzka, and Liang (2010) identified nine states with existing pay for
performance programs and five states with planned pay for performance programs in a survey
issued in 2009. Nursing home revenues were significantly impacted by The Balanced Budget
Act of 1997, which changed the way nursing homes were reimbursed for services from
reasonable costs to a prospective payment system adjusted for the case mix of the residents
and the region (Bowblis, 2011). After the Act’s implementation, there was a notable increase in
nursing home closures or conversions from for-profit to non-profit (Bowblis, 2011).
Culture Change in Long Term Care
Dissatisfaction with the nursing home has led to changes. Strategic movements to
holistically alter nursing homes are increasingly referred to as culture change within the
industry. The movement was slow to gain legitimacy from its grassroots origins. Early stories
7
Uggen, and Erlanger (1999) described rational myths as “belief systems that embody stories
about cause and effect and successful solutions to problems” (p. 410).” Early culture cha nge
practices were often shared as provider stories with varying definitions, practices, outcomes,
goals or measurements (Chapin, 2010; Rahman & Schnelle, 2008; A. S. Weiner & J. L. Ronch,
2003). In 2005, a report generated by the National Commission for Quality Long-term Care
described the challenges of nursing homes adopting culture change as “swimming against the
tide of regulation, limited resources, and established practices” (Capitman et al., 2005b, p.33).
Economic sociology provides one lens for understanding how culture change gained
momentum and legitimacy in the nursing home industry field. In the introduction to the
Handbook of Economic Sociology, Dobbin (2004) summarized the findings of a study conducted
by Davis, Diekmann & Tinseley (1994) to suggest “business practices change through the
confluences of [1] a powerful set of actors introducing a new strategy, [2] a network promoting
the strategy, [3] regulatory institutions that permit the change, and [4] a cognitive framework
that legitimates the new strategy” (p. 14).
These four factors strengthened the Culture Change Movement in Long Term Care.
First, early culture change pioneers were vocal proponents of the movement who became a
powerful set of actors. For example, Dr. William Thomas, a medical doctor who founded the
Eden Alternative® to alleviate the three plagues of long term care, loneliness, helplessness and
boredom, became a strong messenger for the movement making frequent and empowered
presentations (W. H. Thomas & Johansson, 2003). Furthermore, the Eden Alternative also
empowered actors at the nursing home level through the use of Eden Associate training. Eden
8
networks formed to promote the culture change movement. Specifically, the Pioneer Network
was founded in 1997 by a small group of early adopters to offer education and support for the
movement (Pioneer Network, n.d.; Rahman & Schnelle, 2008). Eden Alternative® also created
regional networks for members to share resources and support one another during reform
efforts (A. S. Weiner & J. L. Ronch, 2003). Third, regulatory institutions permitted the culture
change movement and encouraged the movement. The Center for Medicare and Medicaid
Services (CMS) was involved indirectly or directly in promoting culture change, advocating for
culture change, and revised regulations to promote culture change practices and issued
interpretive guidelines for regulators (CMS, 2012). CMS also funded Quality Improvement
Organizations (QIO’s) to serve as resources for nursing homes with directives to improve
nursing home quality and promote the establishments of Culture Change Coalitions (N. G.
Castle & Ferguson, 2010; R. M. Werner & Konetzka, 2010). Karen Schoeneman, Deputy Division
Director of the Division of Nursing Homes at CMS (Retired 2012) , which regulates nursing
homes, was involved in rewriting regulations that address quality of life and promoting
outcomes based regulations (Berger, 2010; CMS, 2012; A. E. Elliot, 2010). CMS also funded the
creation of a measurement instrument to assess culture change progress called the Artifacts of
Culture Change (Bowman & Schoeneman, 2006). Starting on November 28th 2016 over the next
three years, a new section is being added to the federal regulations for nursing homes to
require person centered care planning (CANHR, 2016; Jaffe, 2015, Reform of requirements for
long term care facilities, 2016). Fourth, there was a cognitive framework that often guided
culture change efforts to replace the medical/hospital place type with the idea of a familiar
9
environments can serve as a therapeutic resource and contribute to the quality of life and care
for elders (M. P. Calkins & Weisman, 1999). Therapeutic goals for environments for elders and
people with dementia often included concepts that related to creating a familiar or homelike
setting (Briller & Calkins, 2000; Cohen & Weisman, 1991). Eventually a recognition that a
familiar home represents an ideal setting for all nursing homes residents began to resonate (M.
P. Calkins, 2008). The construct of “home” becoming a yardstick to gage culture changing
practices, routines and settings reflected a recognizable shared cognitive framework among
culture change participants (Action Pact, 2008; Shields & Norton, 2006).
Studies have found that culture change has gained more exposure in the industry.
Notably, the movement has traction with nearly 56% of nursing homes indicating some
engagement in Culture Change in 2007 (Doty, Koren, & Sturla, 2008). A survey conducted from
2009 to 2010 of 3695 Directors of Nursing and Nursing Home Administrators revealed that 85%
reported some culture change implementation, but only 28% indicated full implementation
(Miller, Looze, et al., 2014).
The Household Model
Culture change advocates implement multiple strategies to alter the nursing home.
Chapin (2006) identified over 300 different strategies employed by nursing homes for culture
change as part of her doctoral research that reviewed the efforts of pioneering organizations.
These strategies often fall into key categories of altering the organization’s mission, goals,
10
One comprehensive strategy for rethinking the nursing home is the Household Model,
which is an attempt to normalize the large institutional organizational structure into smaller
family-like structures which resemble and operate like a home (e.g. See Figure 3 & 4). As a
systemic change, the Household Model requires altering the built environment, the
organizational structure and the daily activities of both staff and residents. For example, an 80
resident nursing unit can be divided into four, 20 resident households, each with its own living
space, dining room and kitchen. Instead of all 80 residents reporting to one large dining room,
meals are prepared and served in the households. Staff members are reassigned to work in
specific households with expanded roles such as assisting with meals, housekeeping and
Certified Nursing Assistant duties.
The use of smaller care settings has its early roots in community based and cottage
based mental health institutions, which were an attempt to normalize versus institutionalize
mentally ill individuals in Scandinavian countries (Erickson, 1985; Nirje, 1970). Alzheimer’s and
Dementia Care Settings have also emphasized creating smaller care settings to provide latent
support for those suffering from cognitive decline to reduce decision making and promote
orientation by recreating more familiar living settings (M. P. Calkins, 1988; M.P. Calkins, Briller,
Proffitt, Marsden, & K., 2001; Cohen & Weisman, 1991). There was a recognition by
stakeholders in the industry, including senior living architects, that these smaller, residential
care settings were appropriate for all elders and reflected the more desirable qualities of a
11
Growth of the Household Model
Based upon national surveys and compiled directories, a small portion of the nation’s
nursing homes have adopted the household model. According to the 2007 Commonwealth
Survey of 1435 Directors of Nursing, less than one percent describe their nursing home as an
example of a Household Model, which was defined as “self-contained areas with a full kitchen,
living room and dining room, with relative small number of residents per household” (Doty,
Koren, & Sturla, 2007, p. 29). In 2008, ActionPact, a culture change consultancy practice,
provided a directory of 98 nursing homes in the United States that had built or were building
households. A study of 164 culture change adopters identified by Pioneer Network board
members identified 89 settings with altered physical environments: 57% (51) identified as
households and 43% (38) identified as small house (A. Elliot, Cohen, Reed, Nolet, &
Zimmerman, 2014). The authors defined households “as self-contained units for fewer
residents, with a living room, dining room, and full kitchen”; and small house was defined as “a
stand-alone house for fewer residents”(p. S18). Based upon these numbers, household models
represent less than one percent of the total number of nursing homes (i.e. 62%, 98/15,682 in
2010) in the United States (AHCA, 2011).
Defining the Household Model
A common agreed upon definition for the household model does not exist within the
industry. While the Commonwealth Fund Survey definition is fairly concise, it lacks what some
would consider the essential ingredient of the revamped organizational structure. A definitive,
12
ambiguity (M. A. Proffitt, Abushousheh, Kaup, & Basting, 2010). Advocates for the model have
made some inroads. Action Pact gave the following parameters for including an organization in
the previously mentioned directory of households:
. . . a household is a small group of residents living within a physically defined environment that feels like home; a kitchen(with a variety of food accessible to
residents 24/7 including breakfast to order and on demand), a dining room and a living room. It also has a permanently assigned, cross-functioning staff. (Action Pact, 2008, p. 28)
The ActionPact definition provides more emphasis on the activities of the Household and the
staffing expectations compared to the Commonwealth Survey that emphasized the
characteristics of the physical setting.
Lavrene Norton, the president of ActionPact, partnered with Leslie Grant, associate
professor of Health Policy and Management at the University of Minnesota, to further clarify
the household model. Grant and Norton (2003) devised one of the most comprehensive
conceptions of the Household Model as part of a four stage model for culture change in long
term care that utilizes five key benchmark domains to assess progress in altering a nursing
home: 1) decision making, 2) staff roles, 3) physical environment, 4) organizational design, and
5) leadership practices. Notably, households were identified as stage four of the culture change
process. The authors argue that a household should include the following:
Household Model consists of self-contained living areas with 25 or fewer residents who have their own full kitchen, living room and dining room. Staff work in cross-functional, self-led work teams. The hierarchical organizational structure is “flattened” through the elimination of traditional departments. (Grant & LaVrene, 2003, p. 3)
13
In contrast, a traditional institutional model is described by Grant and Norton as the following:
Institutional model is a traditional medical model organized around a nursing unit without permanent staff assignment. Neither residents nor staff are “empowered” in this model, because the organizational power structure is” top-down” or hierarchical going from administrator to department heads to supervisors to frontline staff. (Grant & LaVrene, 2003, p. 2)
Table 1 illustrates Grant and Norton’s expectations for the five key domains for the household
model stage compared to the institutional stage:
Table 1
Comparison of Institutional Model with Household Model
Orga nizational Sys tem
Sta ge Four – Hous ehold Model
Sta ge One – Ins titutional Model
Deci sion Ma ki ng
Res ident directed decision making occurs through group process such as learning ci rcle
Res idents have a ccess to a refrigerator that is