New management system is turning around demoralised facilities, writes Mary Maher.
Some 40 New York nursing homes, none in the private sector, have adopted a new management and training system aimed at improving both resident care and staff satisfaction, and US federal standard measurements show they have had significant results.
10.30pm, Brooklyn: A noisy night in the city, and high above us trains roar past on the elevated track that curves around the Wartburg Lutheran Home for the Aging. But there's a slightly strained silence in the room where the committee has gathered for its monthly meeting to accommodate night staff members.
The topic is the Model Unit, a pilot project to create a place where residents would have maximum choices over their meals, bath and bed schedules, and where staff would have control over their schedules and rosters.
Steve, on the management side, has raised the question of how the staff selected for the project would select the residents, and drawn a wary response from Leroy on the workers' side: "It's like school, isn't it? If teachers had a choice, they'd only pick the best students."
"If you did that you might not be able to budget," Steve replied. "You need to balance the case mix to get enough reimbursement to pay the staff."
After a minute or so, when management's burdens have been duly absorbed, there's a retort: troublesome patients put stress on staff and that leads to absenteeism. Another half dozen comments, objections, queries on details follow. Finally an earnest voice pleads: "We can't take away the meaning of this. We can't just have all the easy cases, that would destroy the meaning of the project."
That settles it and the meeting moves on.
Wartburg Lutheran is one of the 40 New York nursing homes participating in the Quality Care Committee (QCC) project, which means that decisions are made by a management-staff team. The process demands a lot of time for discussion, but Debora Lipsen, executive vice-president of Wartburg Lutheran Services (WLS), says it's worth it for the simple reason that decisions imposed by management frequently didn't work.
She described an episode from a previous era, when a problem was identified, corrected and monitored. "Then after a few months we checked again and everything had gone back to where it was. This happened time after time, until finally we had to call in the staff and say, listen, you are driving us to take disciplinary measures. That doesn't happen anymore."
Her opinion is supported not only by managers in the other homes I visited, but by the federal Medicare programme data on five standard measures of nursing home quality. Figures from a base period from 2002, before the QCC system was introduced, to the last quarter of 2004, showed that QCC homes had achieved improvements that significantly exceeded average gains registered by other homes across New York state and the nation on such crucial points as the reduction of residents suffering pain or delirium, or requiring physical restraint.
The success of the system was further endorsed last winter by an independent survey conducted by Dr Mhora Newsom-Stewart, a New York-based programme evaluator specialising in the measurement of organisational change in health and education.
The survey showed that staff in QCC nursing homes saw an increase in the number of residents who were eating well, maintaining a healthy weight, participating in activities; an increase in visitors, in family involvement; a decrease in sleeping or behaviour problems. They also reported a decrease in staff behaviour problems, staff turnover and absenteeism.
All of these homes are "NFPs" - not-for-profit facilities. They are primarily financed by public money through Medicare, the federal benefit available to everyone over 65, and Medicaid, a state provision for the disabled and destitute.
Balancing the budget means getting enough numbers on Medicaid, because Medicare for residential care runs out after 100 days. In practice, many long-term patients divest themselves of income to qualify for Medicaid.
Midday in the Bronx: Some 20 residents are gathered in a sunny corner room of the Jewish Home and Hospital's nursing home, laughing while Regina rises to the challenge of identifying individual breakfast preferences: "You like blueberry pancakes - and you, I know you, you won't start the day 'til you've had two prunes and your raisin toast."
The JHH committee made decentralisation of the food service a priority. Instead of a central kitchen and scheduled meals, residents in each unit now have a small catering service virtually on call, and the policy is to give the customers what they want.
At the meeting later, everyone laughed while Regina teased Winston, who was said to treat his dining room like a private restaurant. Winston was unapologetic. "I have a beautiful dining room for my residents and I want my residents to enjoy it. And I know my residents, I know what every one of them likes, and I want them to get it."
I asked him if his job was more satisfying now than it had been. "I think so," he says. "I haven't called in sick for three years now, and I'd have called in sick in any other three years!"
Regina and Winston are certified nursing assistants (CNAs), the largest single employee group and the backbone of the nursing home service. Because they provide most of the ordinary day-to-day care for residents, CNAs have been to the fore in identifying what patients - and their families - like, hate and want changed.
The lists were similar across the board: more choice about food and when to eat it, better bathing facilities, more flexibility about baths and bedtimes. The CNAs have a personal interest in making these things happen. As one of them said: "If my residents are unhappy and complaining, then my job is harder."
Bathing is a common problem because residents find it difficult and embarrassing, and creating pleasant bathrooms was on almost every list. Wartburg Lutheran organised a competition, giving staff and residents on each floor a small budget to plan, shop and decorate.
On Bathroom Party Night everyone - including the president of WLS, the Rev Dr Ronald Rademacher - dressed for the occasion in towels, dressing gowns and shower caps.
Flowers, music, colourful towels and soothing lighting are now the norm. In one home, I was told, the committee now interviews residents before admission to be sure that personal choices in soap, shampoo, bath salts and CD music are ready for them.
Workers have their own list of aims, with more control over work schedules at the top. Various systems are under experimentation, but at Daughters of Jacob, in another corner of the Bronx, the goalpost has been passed in at least one unit.
"There were constant complaints from the Adult Day Care Centre staff about the manager," Gil Preira, the chief executive officer, says. "I felt this was a personality clash problem they would just have to work out.
"Then one day the patients reared up in a body and rebelled against the manager. I finally realised the staff had been right all along, so I decided to let them run it themselves, with no management presence. If a group of people keep telling you you're wrong, and it turns out they're right, what can you do but let them do it themselves?"
Morning in Manhattan: The Village Care of New York nursing home is a Greenwich Village landmark, an elegant old building dating from 1906, when it was a women's residence. There are difficulties running a nursing home in a high-rise, but Aida Ramos, director, says the QCC system has proved a real success. "The process generates excitement and initiative. When the workers identify a problem and solve it themselves, it will work."
But it's about more than giving residents more choices, she adds. "In all these homes, staff havebenefited from the additional training." The training fund is a key component of the QCC project, covering the cost of courses, and the cost of paying for replacements for staff who are on courses.
There were two training courses in session when I arrived at the Isabella Geriatric Center, in the Latino district. One was on customer service, where teams were working on solutions to the apparently universal problem of getting the right clothes back from the laundry for each resident.
The other was on palliative care, and in the middle of the morning a small child's voice came on the intercom to announce the day's weather. No one commented, though several people smiled.
There is a creche on the premises, and no one has ever complained about noise, according to Hope Miller, vice-president for care services.
She thought Isabella had good practices before the system. "But when the QCCs were created, it energised us and gave us resources to do more."
Last stop in Harlem: The large alphabet squares are being stacked up in the corner as I arrive at the third floor dining room of the Greater Harlem Nursing Home.
It's a convivial scene, with lively music in the background and 15 residents tucking into lunch around a big dining table. There is no obvious evidence that this home has a markedly high age profile, with eight of the 200 residents over 100, or that 70 per cent suffer from some degree of Alzheimer's or dementia.
Their committee opted for training from the Alzheimer's Association. "It was unbelievably successful," administrator Reita Fuller says. "We asked for volunteers and got almost 100 per cent response. The training was for a pilot project, but everyone wanted to be on it - people got jealous!" Unit by unit, everyone was trained. It took a year to move to every floor.