THE EDEN ALTERNATIVE TO NURSING HOME CARE: MORE THAN JUST BIRDS

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By PAUL R. WILLGING

Editor's note: During a special program titled "Joining the Pioneer Approach to Culture Change in Long-Term Care," held at the American Society on Aging 46th Annual Meeting in San Diego in March, we chatted with a conference registrant who has a unique perspective on the nursing home "pioneers," who are leading the way in altering long-term care in the United States. Paul R.Willging, now a professor of health services at George Washington University, Washington, D.C., spent 15 years as the chief executive of the American Health Care Association, the largest lobbying group for the nursing home industry. Aging Today has included articles about the nursing home pioneers and their proponents in recent issues ("The Pioneer Challenge--Changing the Culture of Long-Term Care," by Wendy Lustbader, March/April 2000, and "Eden Alternative Founder Thomas: Nursing Home Industry 'Crumbling,'" May/June 2000, are both posted on ASA's website at www.asaging.org). We asked Willging to add his voice, seasoned by the hard economic and political realities of long-term care, to the debate over how to change a realm of healthcare that most Americans regard with fear and confusion. Here is his commentary.

The Pioneer Movement, Wellspring, the Eden Alternative--we've heard the names, we've drawn conclusions and made judgments about these novel approaches to facility-based long-term care (LTC). Pro or con, perhaps our positions have been premature. We're beginning to see impressive results when programs such as the Eden Alternative are effectively introduced into a facility. For example, initial data from research conducted in "Edenized" facilities by Southwest Texas State University has shown a 50% reduction in the incidence of decubitus ulcers; a 60% decrease in difficult behavioral incidents among residents; a 48% decline in staff absenteeism; and an 11% drop in employee accidents. Clearly, Eden and similar programs seem to have a favorable impact on residents and staff alike.

What is premature are assessments as to what such movements are really all about. Many veterans in the LTC field initially expressed the opinion that Eden was a fringe philosophy consisting of little more than the integration of plants, pets and children into the nursing home environment--perhaps the most inaccurate of the early impressions. This sort of impression led to early skepticism among nursing home administrators, who frowned on the movement as impractical and expensive. What they failed to comprehend is that bringing into the home "livestock," as some derided the use of animals, was a result of program implementation, not one of its critical elements.

The pioneer movements all share common values. Resident-centered, the initiatives look to what concerns the patient: loneliness, a sense of helplessness, boredom. These programs empower frontline staff to deal with such patient concerns and to make decisions regarding patient care and the environment in which that care is delivered. In short, what the pioneer programs all have in common is a customer focus, a determination to look at care from the perspective of the patient and to look to staff to determine what will most satisfy the patient. If birds serve that purpose, so be it.

However, critics of the pioneer movement were not alone in making premature assessments. The movement's advocates sometines seem to be unsure of what they have gotten into. One, for example, argued recently that "we cannot rely solely on CQI," or continuous-quality improvement, to improve the quality of the care." I would argue, though, that CQI is precisely what the advocates of the Eden Alternative have got right. I am reminded of what one of my mentors in long-term care once said of her longtime commitment to resident-centered care. "I was practicing total quality management," she suggested, "before I knew it had a name." Business buzzwords like CQI and total quality management are nothing more or less than customer-oriented management, which is what makes Nordstrom unique, what makes Ritz-Carleton an example to be emulated, and what leads people to flock to Disney for management training. It is also what might just save nursing homes.

The fact is, it ain't the birds. It's the change in culture. In LTC, no matter what the setting, there are three prerequisites for quality: resources, skills and motivation. You can't provide nursing care without nurses--nurses who know what they're doing, nurses who want to do it right--not to mention aides, housekeepers, administrators and other key personnel.

MOTIVATION

The LTC trade associations have continued to focus on the issues of resources, and rightly so. Absent staff can't deliver care. Also, the professional associations laudably have pushed for enhanced skills. Nurses, aides, housekeepers and administrators have to know how to deliver care. However, people like William H. "Bill" Thomas, founder of the Eden Alternative, have focused on what is arguably the most critical of the three prerequisites for quality--motivation. Motivation encompasses the culture of care, resident-centered management, the focus on customers. Without motivation, skills and resources are wasted, like a yacht without a rudder. Attitude, culture and mindset are the key elements of compassionate and effective LTC. But let us not elevate motivation to the point where we lose sight of the need for skills and resources.

Thomas recently suggested it was a fallacy to view LTC exclusively from the perspective of dollars. He admitted, however, that "the system is extremely hemmed in by reimbursement, hemmed in by public perception, hemmed in by a vast army of regulators." He's right. When I attended the daylong session on the Pioneer Movement at ASA's meeting this spring, I was impressed with the enthusiasm of the true pioneers, those who recognize that culture change is critical as we look to improve LTC quality. And I shared their dismay as they expressed frustration with a regulatory environment that looked to culture as the sole determinant of quality of care.

Government has failed largely to extend its quality assurance focus beyond the issue of providers' attitudes. It has implemented a system of assessment and enforcement that aims to change providers' behavior while denying its own responsibility to focus on skills and resources as well. One could perhaps forgive government for ignoring the former. After all, the LTC industry and its individual providers must take responsibility for assuring that practitioners possess the requisite tools to do their jobs. But, given the role of the government as the primary payer of LTC services, its failure to adequately fulfill that responsibility is frustrating. Indeed, it is discouraging to observe regulators' current preoccupation with the adequacy of staffing ratios to numbers of patients--and nursing homes are understaffed--while ignoring its own culpability in that regard.

The nursing home industry has much to answer for when it comes to incidents of neglect and abuse. It can't, as it is often wont to do, attribute the entire blame to federal and state parsimony. But government, for its part, must share the blame. To focus exclusively on punishing lapses in care with little or no interest in resolving their underlying causes makes the regulatory agencies no less responsible than the industry for inadequacies in care delivery.

Government must eventually ask whether the responsibility for high-quality care in America's nursing facilities isn't a responsibility it must share with the nursing home industry. Both parties can continue debating these issues in an adversarial, confrontational mode. Or, joined by consumer advocates, the two sectors can look to resolution as a shared responsibility, examine all the prerequisites of quality care, and can endeavor jointly to address these prerequisites. The latter approach would better serve our customers, who should, after all, be our primary focus.

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