9/19/2014 Expanding Culture Change to All Nursing Homes: Approaches and Challenges Peter Kemper, PhD Expanding Culture Change to All Nursing Homes: Challenges and Policy Approaches Peter Kemper Emeritus Professor of Health Policy and Administration Pennsylvania State University Presented at the Benjamin Rose Institute on Aging September 19, 2014 1 CULTURE CHANGE: MOVEMENT OR MODEL? 2 Benjamin Rose Institute on Aging 1 9/19/2014 Expanding Culture Change to All Nursing Homes: Approaches and Challenges Peter Kemper, PhD Multiple meanings of culture change • A philosophy or movement “[T]he national movement for the transformation of older adult services, based on person-directed values and practices…” --[Pioneer Network (2014)] • A model of nursing home care delivery – Artifacts of culture change [Bowman and Schoeneman (2006)] – Essential attributes [Colorado Foundation (2006)] – Intent to optimize quality of life [Shier et al. (2014)] • Movement and delivery model both important 3 General agreement on model attributes Essential Attributes Artifacts • Resident direction • Care practice • Homelike atmosphere • Environment • Close relationships • Family and community • Staff empowerment • Workplace practice • Collaborative decision making • Leadership • Quality improvement processes • Outcomes --Colorado Foundation (2006) --Koren (2010) --Bowen and Schoeneman (2006) 4 Benjamin Rose Institute on Aging 2 9/19/2014 Expanding Culture Change to All Nursing Homes: Approaches and Challenges Peter Kemper, PhD NURSING HOMES HAVE TO SURVIVE IN A MARKET “Follow the money” in assessing approaches to expanding adoption of culture change. 5 Most nursing homes have a bottom line Nursing Home Ownership [CATEGORY NAME] [PERCENTA GE] [CATEGORY NAME] [PERCENTA GE] [CATEGORY NAME] [PERCENTA GE] Source Harris-Kojetin et al. (2013) 6 Benjamin Rose Institute on Aging 3 9/19/2014 Expanding Culture Change to All Nursing Homes: Approaches and Challenges Peter Kemper, PhD Survival depends on mix of payers Nursing Facility Residents by Primary Payer [CATEGORY NAME] [PERCENTA GE] [CATEGORY NAME] [PERCENTA GE] [CATEGORY NAME] [PERCENTA GE] KFF (2013), Fig. 3. 7 Nursing homes compete with other settings Type of Facility Number of Facilities Number of Residents Nursing Homes 15,682 1,396,448 Residential Care 31,000 733,300 Source: Kemper (2013) 8 Benjamin Rose Institute on Aging 4 9/19/2014 Expanding Culture Change to All Nursing Homes: Approaches and Challenges Peter Kemper, PhD FRAMEWORK: HIGHPERFORMANCE WORKPLACE 9 High-performance workplace framework • Development of theory – Management and economics fields – In study of other industries • Culture change – Developed largely independently – Has some similarities • Framework is useful in analyzing expansion Source: Bishop (2014) Benjamin Rose Institute on Aging 10 5 9/19/2014 Expanding Culture Change to All Nursing Homes: Approaches and Challenges Peter Kemper, PhD Basics of high performance workplace framework • Distinguishes two types of management – Low-road: Jobs are standardized, routinized, heavily supervised, and require limited skill – High-road: Jobs with responsibility for quality, less supervision, and require greater skill • Benefits of high-road in other industries – Greater productivity – Product with higher quality, higher value • Greater quality better able to compete in market Source: Bishop (2014) 11 High performance work practices In Common with Culture Change Less Emphasized or Missing • Training in general and specific skills • Flattened supervisory hierarchy • Cross-training, expanded jobs • Training in enterprise goals • Flexibility in how job is done • Enterprise-wide information sharing • Self-managed teams • Incentive pay for performance and increased skills acquired on the job • Frontline worker participation in decision making • Job-specific information sharing • Employment security • Recruitment for skills, attitudes Source: Adapted from Bishop (2014), Table 1. 12 Benjamin Rose Institute on Aging 6 9/19/2014 Expanding Culture Change to All Nursing Homes: Approaches and Challenges Peter Kemper, PhD Implications of high-performance workplace theory • Expansion of culture change requires that nursing homes benefit from higher quality in the market • Work practices missing from culture change model – Selective recruiting – Job security and increased pay for skills and abilities “Ideally, the nursing home culture change work force could move from high turnover, low wage, low skilled work to selective, higher wage, high retention work, with respected skills and knowledge of residents developed on the job.” --Bishop (2014), p, S51. 13 CULTURE CHANGE ADOPTION Partial adoption of practices is prevalent; total adoption is not Practices adopted are driven by market 14 Benjamin Rose Institute on Aging 7 9/19/2014 Expanding Culture Change to All Nursing Homes: Approaches and Challenges Peter Kemper, PhD Partial adoption of culture change is prevalent, but total adoption is not Traditional 15% Adopters total NH 13% Adopters part NH 20% Partial adoption 52% Source: Adapted from Miller et al. (2014), Fig. 1 15 Culture change adopters are more often CCRCs and non-profits than traditional nursing homes 80 Percent Non-profit 70 60 50 40 30 Percent CCRC Culture change adopter Non-adopter 20 10 0 Source: Adapted from Grabowski (2014), Table 2. 16 Benjamin Rose Institute on Aging 8 9/19/2014 Expanding Culture Change to All Nursing Homes: Approaches and Challenges Peter Kemper, PhD Staff empowerment practices appear unrelated to percent Medicare residents Adoption of culture change practices (based on survey scores) 16 15 Staff 14 13 12 Bottom Quartile 2nd Quartile 3rd Quartile Top Quartile Source: Lepore (2011) 17 Percent of Medicare Residents ▬▬► Adoption of environment and resident practices increase with percent Medicare residents Adoption of culture change practices (based on survey scores) 16 15 Environment Resident 14 13 12 Bottom Quartile 2nd Quartile 3rd Quartile Percent of Medicare Residents ▬▬► Benjamin Rose Institute on Aging Top Quartile Source: Lepore (2011) 18 9 9/19/2014 Expanding Culture Change to All Nursing Homes: Approaches and Challenges Peter Kemper, PhD CHALLENGE OF CULTURE CHANGE IMPLEMENTATION 19 Survey of clinical managers about implementing Better Jobs Better Care To what extent have the following helped or hindered efforts to implement BJBC? Turnover of direct care workers Helped a Helped Hindered Neither great deal somewhat somewhat Hindered a great deal Turnover of other staff Helped a Helped Hindered Neither great deal somewhat somewhat Hindered a great deal The level of engagement Helped a Helped Hindered Neither of direct care workers great deal somewhat somewhat Hindered a great deal Source: Kemper et al. (2010) 20 Benjamin Rose Institute on Aging 10 9/19/2014 Expanding Culture Change to All Nursing Homes: Approaches and Challenges Peter Kemper, PhD Factors that disproportionately helped Percent Helped Hindered Factor Average for reference Head Engagement Supervisors Organizational Direct care workers Culture Policies 43 12 66 68 53 6 7 16 61 60 15 7 Above average 21 Factors that disproportionately hindered Percent Factor Resources Competition Turnover Helped Hindered Direct care worker time 38 28 Other staff time 39 31 Resources 35 27 Providers 21 15 Labor market 25 17 Management 19 3 Direct care worker 26 16 Above average Benjamin Rose Institute on Aging 22 11 9/19/2014 Expanding Culture Change to All Nursing Homes: Approaches and Challenges Peter Kemper, PhD Implementation conclusions • Management change faces major barriers • Limited staff time and resources • Labor market and provider competition • Turnover itself • To overcome the barriers managers need: • Engagement of staff at all levels • A positive culture • Resources---both staff time and money Source: Kemper et al. (2010) 23 APPROACHES TO EXPANDING CULTURE CHANGE Advocacy and collective action State and federal policy Adoption home by home 24 Benjamin Rose Institute on Aging 12 9/19/2014 Expanding Culture Change to All Nursing Homes: Approaches and Challenges Peter Kemper, PhD Advocacy and collective action for system-wide change • Advocacy: Pioneer Network, many earlier • Lessons from NC and AR coalitions – – – – – Recognize importance of strong leadership Include state agencies, other key stakeholders Respect for the role of structure and process Develop shared vision—but incrementally Develop relationships for sustainability NC source: Brannon (2009); AR source: Beck (2014) 25 State and federal policy • • • • • Policy tools are blunt instruments States have been most active in policy Large number, variety of (modest) efforts But indicative of strong policy interest Specific policies target different culture change practices 26 Benjamin Rose Institute on Aging 13 9/19/2014 Expanding Culture Change to All Nursing Homes: Approaches and Challenges Peter Kemper, PhD Culture change elements affected by policies Essential Elements of Culture Change Affected Policy Leadership & Empowerment ResidentCenteredness CQI Environment Payment & tax policy Pay for performance Investment incentives Regulatory policy Supportive survey process Public reporting, recognition Training & career advancement Staffing and certification Other policy Key: Essential elements most affected; sometimes affected Source: Stone (2014) 27 Implementing culture change home by home • Management practice change requires resources and sustained organizational commitment • Leaders should adopt high-performance workforce – Selective recruiting for skills and attitudes – Job security and increased pay for skills and abilities • Leaders should: – Plan to pay for staff time for training and team work – Anticipate staff turnover 28 Benjamin Rose Institute on Aging 14 9/19/2014 Expanding Culture Change to All Nursing Homes: Approaches and Challenges Peter Kemper, PhD SUMMARY AND CONCLUSIONS 29 Summary • Movement and delivery model lens, both relevant • Key work practices often missing – Selective recruiting – Job security and increased pay for skills and abilities • Culture change adoption: – Partial adoption is prevalent – Total adoption is not • Market drives culture change practices adopted 30 Benjamin Rose Institute on Aging 15 9/19/2014 Expanding Culture Change to All Nursing Homes: Approaches and Challenges Peter Kemper, PhD Summary (cont.) • Seek to expand culture change? Follow the money • Culture change implementation – Implementers face many barriers – Overcoming them requires staff time and engagement, resources, and a positive culture • Multiple approaches to expanding culture change – Advocacy and collective action – State and federal policy – Implementing home by home 31 Conclusions • Add high-road work practices to culture change – Recruiting for skills and attitudes – Job security and pay for performance and acquiring skills • Reward culture change on earth as well as in heaven • Beware of amenities in culture change clothing • Beware of 2 tiers in markets & within nursing homes – Culture change for the rich; traditional institutions for the poor – Culture change for the post-acute; traditional care for the long-term • Pursue multiple incremental approaches to expansion 32 Benjamin Rose Institute on Aging 16 9/19/2014 Expanding Culture Change to All Nursing Homes: Approaches and Challenges Peter Kemper, PhD REFERENCES 33 Beck, C, KJ Gately, S Lubin, P Moody, and C Beverly (2014). “Building a state coalition for nursing home excellence.” The Gerontologist, 54(Suppl. 1), S87-S97. Bishop, CE (2014). “High-performance workplace Practices in nursing homes: An economic perspective.” The Gerontologist, 54(Suppl. 1), S46-S52. Bowman, CS and K Schoeneman (2006). Development of the Artifacts of Culture Change Tool. http://www.artifactsofculturechange.org/Data/Documents/artifacts.pdf, accessed 7/29/14 Brannon, SD, P Kemper, and T Barry (2009). “North Carolina’s direct care workforce development journey: The case of the North Carolina New Organizational Vision Award partner team.” Health Care Management Review. 34(3): 284—293. Colorado Foundation for Medical Care (2006). Measuring Culture Change: Literature Review, August. http://www.artifactsofculturechange.org/Data/Documents/artifacts.pdf accessed 7/29/14. Grabowski, DC, AJ O’Malley, CC Afendulis, DJ Caudry, A Elliot, and S Zimmerman (2014). “Culture change and nursing home quality of care.” The Gerontologist, 54(Suppl. 1), S35-S45. Harris-Kojetin, Lauren, Manisha Sengupta, Eunice Park-Lee, and Roberto Valverde. (2013) Long-Term Care Services in the United States: 2013 Overview. Washington, DC: National Center for Health Statistics. 34 Benjamin Rose Institute on Aging 17 9/19/2014 Expanding Culture Change to All Nursing Homes: Approaches and Challenges Peter Kemper, PhD Kemper, P., D. Brannon, B. Heier, J. Vasey, M. Setia, J. Kim, and A. Stott. (2010) The Better Jobs Better Care Management Practice Change Initiatives: Implementation and Effects on Job Outcomes and Turnover. Princeton, NJ: The Robert Wood Johnson Foundation, September 2010. http://www.rwjf.org/content/dam/farm/reports/reports/2010/rwjf70019. Kemper, P. (2012). “Not Your Grandmother’s Nursing Home.” Presentation at the National Health Policy Forum, November 30, 2012. KFF (2013). Overview of Nursing Facility Capacity, Financing, and Ownership in the United States in 2011. Kaiser Family Foundation. http://kaiserfamilyfoundation.files.wordpress.com/2013/06/8456-overview-of-nursingfacility-capacity.pdf Accessed 9/4/14. Koren, MJ (2010). “Person-Centered Care For Nursing Home Residents: The CultureChange Movement” Health Affairs Vol. 29, No. 2, pp: 1-6. Pioneer Network (2014). https://www.pioneernetwork.net/CultureChange/Whatis/, accessed 7/29/14. Lepore, M, R Shield, D Tyler, J Looze, and SC Miller (2011). “The skilled care nursing home market and culture change approaches.” Presentation at the 64th annual scientific meeting of the Gerontological Society of America. 35 Miller, Susan C., Jessica Looze, Renee Shield, Melissa A. Clark, Michael Lepore, Denise Tyler, Samantha Sterns, and Vincent Mor (2014). “Culture Change Practice in U.S. Nursing Homes: Prevalence and Variation by State Medicaid Reimbursement Policies.” The Gerontologist 54 (3): 434-445 doi:10.1093/geront/gnt020 Shier V., Khodyakov D., Cohen L. W., Zimmerman S., Saliba D. (2014). What does the evidence really say about culture change in nursing homes? The Gerontologist, 54(Suppl. 1), S6–S16. doi:10.1093/geront/gnt147 Stone, RI and NS Bryant (2013). “Successful state leadership models for culture change.,” Ch. 8 in Culture Change in Elder Care. Edited by JL Ronch and AS Weiner. Baltimore: Health Professions Press. 36 Benjamin Rose Institute on Aging 18
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