Five Questions With: Susan Miller

Susan Miller is a professor of Health Services, Practice and Policy (Research) at the Center for Gerontology and Health Care Research, at the Brown University School of Public Health. She is trained in gerontology and epidemiology and focuses her research on nursing home end-of-life care and long-term care (LTC) quality and utilization. She is the author of a recently published study in the Journal of Applied Gerontology indicating that nursing homes investing in “culture change” must make extensive changes for the most important quality of care benefits to be produced.

PBN: Were you surprised by the results of your own study? Were you surprised, for instance, by how many changes were required for critical mass to be acquired by a senior care facility in its efforts to show substantial improvement?
MILLER:
We were somewhat surprised by the large difference in the findings for nursing homes with extensive culture change practice implementation versus those with some but less extensive implementation. However, these findings may help to explain some of the previous equivocal findings from quality studies when the extent of culture change practice implementation was not considered or measured. For example, one recent study showed culture change implementation resulted in fewer Medicare/Medicaid survey deficiencies but not in any improvements in resident outcomes; however, this study did not measure or consider the extent of practice implementation.

PBN: How hard is it to bring about a culture change of the kind you were looking for in your study?
MILLER:
Implementation of culture change practice takes hard work and time, and major physical plant changes require dollars that are hard to access for many nursing homes. As one nursing home administrator told us, “It’s hard to get there.” In interviews, administrators cited many challenges to implementation such as staff resistance and lean staffing. However, they also reported strategies they used to accomplish change. Invested leadership is essential but change cannot be achieved without active staff participation, and without buy-in from staff, residents and residents’ families. Thus, administrators described good two-way communication is a must. They also promoted small incremental changes initially so that these probably small successes would help to motivate further change. While the costs of culture change in nursing homes is cited by some as a barrier it does not seem to be a deterrent to most culture change practice implementation, according to those we interviewed.

PBN: Is it fair to say that the upper tier of rest homes has seen the greatest improvements to care because of culture changes? If so, how can similar changes be wrought with fewer resources, or is that asking the impossible on some level?
MILLER:
While we do know that nursing homes with fewer Medicaid residents (for whom reimbursement is lower compared to Medicare or private-pay residents) have been more likely to implement culture change practices, the design of our study controlled for a nursing home’s payer mix and other attributes to show that improvement occurs with much implementation regardless of a nursing home’s financial status. Furthermore, interviews conducted in 2013 with administrators of what we call “resource poor” nursing homes (i.e., high proportions of Medicaid and low proportions of Medicare residents) found many resource poor nursing homes have increased their implementation of culture change practices since our 2009-’10 study. This makes us think that culture change practices are truly beginning to catch on in nursing homes more generally.

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PBN: Did you and your co-authors independently verify any of the responses coming from rest home directors? How large an issue, if at all, is accurate self-reporting in the industry?
MILLER:
We independently verified responses in two ways. First, we compared the internal consistency of responses by comparing directors of nursing reports of facility involvement in culture change (a single question) with culture change environment, staff and resident domain scores (derived from director of nursing and administrator responses). We found that when directors of nursing reported greater facility involvement in culture change the scores for each of the three domains were consistently higher. Second, we conducted interviews with nursing home administrators. These interviews further validated survey responses as well as provided us with valuable information that helped us interpret the survey findings. We also encouraged them to talk about challenges or barriers they’ve encountered and we found that they were quite willing to give us less-than-rosy, idealized pictures of their situations. This helps us feel more confident that they were leveling with us for the most part.

PBN: Do residents of nursing homes invariably prefer the more residential style of living?
MILLER:
We did hear from administrators that residents for the most part liked the physical and other changes being made. However, the vast majority of nursing homes had not undergone the more costly major building or renovation efforts needed to create residential-style settings. Many did, nonetheless, make less costly changes to create homelike environments. For example, in interviews we heard about redecorating or less major physical plant changes aimed at making facilities more homey and less hospital-like, such as redecorating bathing rooms to give them a more spa-like feel or removing nursing stations to make a facility more homelike. Other efforts to achieve more homelike environments included having “happy hours,” outdoor barbecues, cozier sitting areas for congregating, gardens, and serving food from steam tables (as opposed to being served from distant central kitchens) that enable resident choice and enhance appetites with the smell of food.

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