By 2050, one in five people in the United States will be age 65 and
older, and 12 million of them will need long-term care. But the old
paradigm for institutionalized care in the nursing home setting doesn’t
fit the preferences and expectations of the baby boomers and Gen-Xers
entering their golden years.

In general, consumers have a negative impression of nursing homes
as clinical, rigid and unappealing places to live out their final
years. Changing the nursing home culture to become better attuned to
consumer desires requires first an understanding of what consumers
want.

A recent study of the preferences of older Americans points to a
truth that social workers, case managers, and long-term care
professionals must face: the old-style nursing home culture, with its
focus on efficiency and the clinical aspects of care, doesn’t fit the
bill. The study, which looked at differences in long-term care for
younger disabled populations and older populations, found that older
people want the same things their younger counterparts desire:
“control, individuality and continuity of meaningful personal life.”

Older people want to live in a home-like setting where they have
autonomy over the daily routine—like meal times, bed times, and what
activities to pursue. They want to choose when to take a shower or
bath, and to decide whether to take a walk or read a book. They would
prefer to stay at home rather than live in an institutionalized setting
that focuses on care rather than daily life. They want to be surrounded
by their own personal items, and they would rather that the person
providing their care be a consistent presence who knows their
preferences.

To meet these preferences will require a cultural transformation, a
change in the perception of nursing homes from a place that is
clinician-centered to one that is patient-centered. Nursing homes are
now places that deliver long-term care, but they need to become places
where people live and can also get good care.

The patient-centered model has already been adopted by pioneers in
nursing home care, beginning with geriatrician William H. (Bill)
Thomas’s Green Houses. This model groups a number of small homes or
units, each housing six to 10 residents, on a campus. While each
resident has a private room and bath, they are free to come together
for meals and recreation in a family-style living room, dining room and
kitchen configuration. The Robert Wood Johnson Foundation is currently
supporting a five-year plan to develop Green House projects throughout
the United States, and has 24 sites in operation or development.

Other innovative nursing home management organizations are working
within traditional architectural configurations to transform resident
routines and programs to a more patient-centered approach. Not only are
patients reporting better satisfaction, but staff is more satisfied
with their work and retention rates are higher where cultural
transformation has been achieved.

Challenges to nursing home cultural change remain—financial
disincentives make change difficult, and some state regulatory mandates
must be changed. But CMS recently recognized the value of these new
models and has found no barriers to certification under current law.
Giving aging Americans what they want can not only be done, but it best
fulfills the intent of OBRA ’87 to provide care in a manner and
environment that enhances patient quality of life.