Many of us dread the idea of spending our last months or years in a nursing home. But it doesn’t have to be this way, says Beth Baker, award-winning journalist and author.
Baker spent the past four years investigating pioneering nursing homes in the United States and talking to leading experts in the field of aging. Now, she has published her surprising discoveries in Old Age in a New Age: The Promise of Transformative Nursing Homes (Vanderbilt University Press). Hailed as a "must-read" by professionals in the field of gerontology, it provides a compelling snapshot of the revolution underway in nursing care. It also shows how visionary leaders are reinventing the nursing home.
We wanted to learn more, so AHB caught up with Baker at her home in Takoma Park, Maryland.
Ruth Dempsey: What sparked your interest in nursing homes?
Beth Baker: I had been covering aging and health issues for many years as a journalist when I stumbled on this story. I was intrigued for two reasons; for one, my own grandmother had died in a nursing home, and I had very sad memories of the place. As I describe in my book, when we took our little daughter to visit, there was a long row of women sitting in wheelchairs with nothing to do. When they saw our little Sarah, they reached out to touch her as she walked solemnly by. Their faces were filled with such longing and such hunger for life. That was my image of nursing homes.
When I heard that nursing homes could actually be rich and full environments, I wanted to see for myself. I am also the kind of writer who is drawn to hopeful stories; what could be more hopeful than a handful of people believing they could transform nursing homes from dreaded institutions to places that we wouldn’t mind moving to?
RD: The homes use a "resident-directed" approach to nursing care. What does this entail?
BB: Traditional nursing homes are run like hospitals with institutional efficiency as the goal. Nurse supervisors direct the aides to complete so many baths or meals each day. And the aides tell the residents what to do – when to wake up, what and when to eat, whether Thursday at 5 p.m. will be the time for their bath, and so on.
The nursing homes I write about turn this on its head. They try to make life as much like "home" as possible, rather than like a hospital. Residents wake up when they wish, and eat when they’re hungry. The overly restrictive diets that turn meals into medical regimens are replaced with normal food. The job of the aide becomes "how do I make your day as pleasant and meaningful as possible?" Interestingly, this often becomes MORE efficient, because less time is wasted cajoling people, trying to get them to do what they don’t feel like doing.
RD: Are the homes open to people from different economic backgrounds?
BB: The homes serve the same people as other nursing homes in our country – a mix of private pay and low-income people who are on Medicaid. Some of the best homes actually serve a majority of people who are on Medicaid. A small number of the ones I visited only served private pay. I tried to focus on those that could be replicated and serve everyone.
RD: Meadowlark Hills in Kansas was an early success story. Can you please elaborate?
BB: Meadowlark Hills had always been a high quality traditional nursing home. But when administrator Steve Shields witnessed his own mother dying there, it was as if he saw it for the first time: the flimsy curtain separating his mother from her roommate, the harried staff, loud alarms, and so on. After visiting a pioneering nursing home in Minnesota, and learning how they set out to create "home" in their nursing home, he led a transformation of Meadowlark. Today, people come from all over the world to visit the home.
For starters, Meadowlark renovated the old nursing home wings so that today they look like a household, with a front porch and doorbell, living room, country kitchen and more privacy in the bedrooms. Homemakers cook in the kitchen, so you smell good food. The staff went through a consciousness-raising of sorts to rethink their attitudes. They truly try to liberate residents from the shackles of institutionalization, and free them to spend their time as if they still lived in their own homes.
Steve shares wonderful stories, including one that readers love of a resident organizing a few of her friends there to hire a limo and go dancing at a country and western dive one evening.
RD: Green Houses offer another kind of success story? Is that right?
BB: The Green House – meaning a nurturing place – was created by Dr. Bill Thomas, a maverick, Harvard-trained geriatrician who is one of the heroes of my book. It looks and feels like a normal home, although with 10 bedrooms.
Each elder has her own private bedroom and bath, no matter what their ability to pay. There is a fireplace in the living room, a long dining room table and big kitchen, with home-baked cake and fresh fruit always available. The layout is compact, yet airy and
many of the elders who had been in wheelchairs in the old institutions with long hallways are now able to get around on their own using walkers.
As important is the transformation of the workforce. The aides have a new name – "shahbazim" – and they received considerably more training. They combine the roles of homemaker, aide and friend, and they run the households on behalf of the elders. The nurses, therapists and physician bring their services to each house. The close friendships I witnessed between the shahbazim and the elders at the Green Houses in Tupelo, Mississippi, were one of the most moving parts of my journey around the country.
RD: And what makes a home like Providence Mount Saint Vincent in Seattle a success story?
BB: "The Mount" is in a big old building, but they’ve really made a vibrant community within the walls. In addition to some renovation of the old nursing home wings to look more like home, they have wonderful common spaces that are unique.
For one, 100 children come to four-day care centers inside the building. Elders eat lunch with kids, if they wish, or do activities together. You see children all the time, and they’ve designed the centers with large windows facing the hallway, so as you’re walking you can stop and see the little kids playing.
They also have a lively espresso bar and gift shop where residents, staff, families and volunteers mingle over a cappuccino or a sandwich. And there is a thrift shop across the hall, a wellness center, art studio and lots of pets and plants.
The staff is extraordinary, especially the nurses who show incredible leadership in creating this new culture of resident-directed care. They also decided to completely integrate folks who have dementia with the rest of the population – a difficult and courageous step, but one they felt was in line with their values of creating home and community and not separating people by diagnosis.
RD: You say homes that cannot come up with money for major renovations can still make significant changes. Money is not the critical factor?
BB: No, and that surprises most people. There will always be some upfront costs in training people to think and work differently, but that is relatively minor. Of course major renovations or new construction are costly.
But the biggest change is one of attitude, of thinking and really of the heart. It’s also changing from a hierarchical, top-down management style to one that is team-based, multidisciplinary and collaborative. When you do that, costly problems like staff turnover are solved, and the savings are plowed back into increasing direct-care staff. One of the signature features of what I call transformative nursing homes is dramatically reduced turnover.
RD: You met an inspiring mix of residents from across the country. These people were eager for adventure. Can you give me an example?
BB: At Crestview Nursing Home in rural Missouri, the aides really were dedicated to getting people out of the place and having fun. A team leader named Charlie took residents to the county fair. He tells the story of being stuck on top of the Ferris wheel with Elsie, a resident. He said to her, "When were you last on a Ferris wheel?" She said, "Charlie, I ain’t never been on a Ferris wheel." She was 100 years old.
Residents at other homes went fishing, to the racetrack or to Little League baseball games. I learned that even those residents who are too frail to manage a Ferris wheel can still grow and explore new interests. At The Mount they have a professional artist on staff. I talked to people in their 80s, many with dementia, who loved painting and had never done it before.
RD: How can a home-like environment help people with dementia? Can you please elaborate?
BB: The hospital environment of a traditional nursing home – disembodied voices over a loud speaker, blinking call lights, strange alarms, cluttered hallways and constantly rotating staff – is difficult even for people who are cognitively healthy. Imagine what it is like for someone with dementia.
The places I visited that looked more like home had a serene and peaceful atmosphere. People were not shouting out or aimlessly wandering the halls looking agitated. As one administrator said to me, "If it looks like an institution, they try to escape. If it looks like home, they ask if they can set the table."
In addition to creating a homey environment, staff must be highly skilled in ascertaining the needs and wants of each individual, which of course can be difficult if a person cannot articulate these wants. The staff whom I interviewed said that in almost every case, they are able to determine what is upsetting a person. Perhaps it’s untreated pain, or maybe they are hungry or thirsty. They also believe that each person still has a life worth living; they offer people opportunities to help out around the household, or to sing or go outside. People, including those with dementia, seemed contented.
RD: Relationships between family and staff can be crucial. What tips do you have for family members?
BB: Unfortunately in the traditional model, family-staff relations are often strained and adversarial. Many studies show that aides feel picked on and unappreciated by both their supervisors and family members. Families need to appreciate the difficult, low-paying job that aides do, even as they try to be good advocates for their loved ones. Gratitude goes a long way. Just last week, I was told by a family member that she returned to the (traditional) nursing home after her mother died to express her thanks to the staff for the care they gave. She was told no one had ever done that before.
In these new homes, families are treated more like valued partners. And, as a result, they become less critical. Both sides seek to treat each other respectfully and with a collaborative, problem-solving attitude. But frankly, if the administration does not support its workers, there is little the family can do to change negative attitudes on the part of staff. The simple phrase "happy workers make happy residents" has a lot of truth to it.
Ideally, homes will be renovated so that families have space to do normal family things, like cook Mom’s favorite dish or organize a potluck. There are more private spaces, too, for families to gather, and there is a toy box or small playground outside for kids.
RD: Homes often tout a long list of activities to attract new residents. What are some high-quality activities?
BB: High-quality activities generally come from knowing each resident as an individual – finding out what interests they’ve had in the past, either by talking to them or their family members.
For example, at The Mount, one resident had very difficult behavior problems. It turned out she had traveled a lot with her job, and she really liked getting out of the building. Now, the staff invites her to accompany them if they need to go out on errands, and she has calmed down. She also enjoys dusting furniture and helping out around the place. Those are high-quality activities for her.
I also met people who liked helping prepare meals, feed pets, garden (many homes have raised beds so even people in wheelchairs can garden), sing in a chorus or work on their life story with help from a volunteer. Residents also long to help others and to have reciprocal relationships, rather than always being on the receiving end of care.
Simply having someone spend time in friendly companionship is what most people enjoy. And social engagement has been linked to all sorts of health benefits, as well.
RD: These are remarkable homes. How can we make them the norm?
BB: I wrote this book to raise awareness among the general public of what is possible. There is a role for each of us in pushing this movement forward. One of the biggest obstacles to change is our mass denial that we will ever grow old and need such services. We hope and pray we’ll be healthy until the very end. Then a crisis happens – we break a hip, or we get Alzheimer’s – and suddenly it’s too late to plan for the kind of home we long to have. So first and foremost, I urge people to plan now, both in a societal way and a personal way, for the kind of services we want in the future.
I would like to see ordinary people discussing this issue with their legislators and asking radio talk show hosts to devote programs to it. I would like to see universities assigning books, such as mine, to their students in nursing, medicine and social work, for example.
Or, why not discuss this topic in book clubs, adult Sunday School classes, adult education courses – the list goes on and on. Once you delve into it and let your imagination go, you realize there are all sorts of ways we could create home and community for people we once marginalized in nursing homes.
If you have a loved one in a nursing home, you can bring these ideas to the administration and hopefully begin a dialogue. The pioneers have led the way by creating these amazing models. They also have produced tool kits, DVDs, and training courses for nursing homes to use. Now we need to get the word out to nursing home administrators and get them on board.
Editor’s Note: For more information, please visit Beth Baker’s website.