Creation of Households Program in Nursing Home Improves Residents' Health Status, Reduces Staff Turnover, and Boosts Demand for Services

Problem Addressed

• Unpleasant environment for residents leads to a decline in health status: Facilities frequently resemble hospitals, with long, sterile hallways and centralized nursing stations. Residents have little control over their lives, with staff determining when they wake up and go to sleep, when and what they eat, and what they do during the day. Many residents become bored and depressed, which leads to cognitive and physical decline.¹
• Unpleasant environment for staff leads to high turnover: This model also creates a negative work environment for staff, who may have little opportunity to get to know the patients.  Many nursing home staff become disenchanted with their jobs and quit. Annual turnover at conventional nursing homes typically ranges from 70 to 100 percent.²

Description of the Innovative Activity

• Redesigned living areas: Meadowlark Hills was divided into six living areas, known as "households," with each being home to 12 to 25 residents. Each household has a living room, dining room, kitchen, porch, and patio. In six of the eight households, residents have their own bedroom and bathroom. In two households, residents share the bedroom and bathroom with a roommate. A number of features make the households similar to typical houses or apartments:
  
  • Privacy and independence: Each household has a doorbell, so (like anywhere else) visitors cannot walk in unannounced.
  • Pleasant design: Large windows and strategically placed lights provide an inviting view of the area's mountains. In addition, Meadowlark Hills has an aviary and an aquarium.
  • Opportunity to decorate: Residents can decorate households with plants, paintings, and other items. Residents may have pets, including cats and dogs.
  • Own identity: Each household was named after individuals (e.g., "Starkey"and "Honstead") whose donations helped fund the renovations and expansions.
• Control over daily schedules and activities: Residents control their own activities. They decide when they want to wake up, bathe, and go to sleep; when and what they want to eat; and what activities they will participate in. Residents have a number of options for activities, including the ability to go to the onsite hair salon or see a physiotherapist. In addition, Meadowlark Hills maintains several vans and small buses, enabling residents to arrange to leave Meadowlark Hills to engage in activities such as shopping, seeing a movie, or going out for dinner.
• Self-directed work teams for each household: Each household has its own permanent staff consisting of a nurse, a nurse's aid, a cook, and a housekeeper. These positions are staffed in 3.6-3.7 hours per resident day. Instead of being limited to prescribed set of tasks, all staff handle a broad range of responsibilities. For example, in addition to dispensing medication, a nurse may help with cooking and doing light housekeeping. Having a permanent staff allows employees to get know residents as individuals, including learning about their personal preferences (e.g., preferred wake-up time, favorite foods, and health issues).
• Continuous improvement: Meadowlark Hills holds ongoing meetings, known as "learning circles," during which staff, residents, and family members discuss ways of addressing a particular problem. Whoever has the most expertise in the subject matter leads the session. Learning circles are critical to enhancing residents' quality of life.

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Results

• Improved outcomes for residents: Staff observed residents who had previously been inactive and vacant-eyed re-engage socially as a result of the households program. Survey results as well as informal feedback from residents and families showed that their satisfaction levels increased. Residents' families became more engaged in life at Meadowlark Hills as a result of the redesign.
• Increased job satisfaction and reduced turnover: Staff turnover was reduced by 50 percent compared to turnover rates prior to the redesign and staff indicated that they were more satisfied. Prior to implementing the household model, staff turnover at Meadowlark was approximately 80 percent. Within the first year of the redesign, the staff turnover rate decreased dramatically and has continued to do so—currently, staff turnover at the facility is 30 percent. Additionally, Meadowlark Hills has increased its opportunities for employee career advancement, growth, and promotion.
• Constant costs: Despite the improvements, ongoing operating costs at Meadowlark Hills have held steady. The ratio of number of staff per resident has remained constant because while the number of residents has increased so as the number of employees (78 in 2000 vs. 370 in 2007). 
• Enhanced reputation, leading to wait lists and ability to raise prices: Since the redesign at Meadowlark Hills, more people in the community have wanted to live there. In 1997, about 12 percent of beds were vacant; by 2008, the facility was completely full with a 300-person waiting list. The increased demand enabled the facility to raise its prices. The additional revenue more than covered the nonoperating costs required to implement the new model (e.g., architectural redesign and additional training).

Evidence Rating (What is this?)

Context of the Innovation

Planning and Development Process

• Formation of planning committee: The director formed a steering committee comprised of 12 formal and informal leaders of the Meadowlark community, including department directors, board members, and staff members, to investigate potential changes that would eliminate as many medical/institutional features of the facility as possible. The committee, which met monthly for several years, solicited ideas from residents, family members, staff, vendors, and community members via focus groups; conducted demographic and financial feasibility studies; and developed a strategic plan. The original steering committee eventually formed focused action groups, which are ongoing and comprised of Meadowlark residents, staff members, family members, and community members. These action groups address specific topics important to the community, such as dining options and learning circle topics.
• Architectural redesign: In 2001, the facility was redesigned to eliminate institutional features and make the living environments into group households. In addition to the redesign of the living areas (described previously), key design changes included replacing the hospital-style nurses' stations with roll-top desks and eliminating the stainless steel transport racks, medicine carts, and beeping wander-guard alarms.
• Training: All employees received training to broaden their skills to areas outside their typical expertise. The training was conducted by professionals outside of the Meadowlark Community and addressed core competencies such as listening, critical thinking, and empathy. Staff were trained in small groups and it took approximately 1 year to have all staff trained in each core competency.

Resources Used and Skills Needed

• Staffing: The new households program was implemented with existing Meadowlark staff.
• Costs: The facility redesign cost roughly $1.5 million, while initial training costs for employees at this facility were approximately $80,000. After about 3 years, these costs were offset by increased profits due to the facility's higher occupancy rates and prices. 

Funding Sources

Tools and Other Resources

Getting Started with This Innovation

• Do not be hemmed in by preconceptions: Nursing home leaders are often reluctant to make major changes, fearing that "it can't be done" or that government regulators will object. In Meadowlark Hills' experience, regulators greeted the planned changes with enthusiasm and encouraged further innovation.
• Connect with like-minded leaders: Although most nursing homes still follow the traditional medical model, a small but growing number have adopted new approaches. Meetings and discussions with the leaders of these facilities (such as those active in the nonprofit Pioneer Network) can generate ideas for reforming a facility.
• Articulate the vision in nonbureaucratic language: In building support for change, describe the new vision in direct language that everyone can understand. For example, comments from Meadowlark Hills' CEO included easily understood statements such as: "It's not like a home, it is home," and "A retirement community should be a place to continue to grow, not a place to come to die."

Sustaining This Innovation

• Seek continuous improvement: Meadowlark Hills' use of "learning circles" provides an open atmosphere which encourages staff and residents to suggest changes that can improve quality of life for residents at the facility. A key to the success of these meetings is the ability of anyone with expertise in the subject to lead the discussion, regardless of his or her educational background or job title.
• Involve the community: Encouraging visits from community groups, volunteers, and the media helps make the facility more vibrant, raises awareness of what life is like in later decades, and often leads to good suggestions on how to improve residents' quality of life.

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