There are currently over 14,000 veterans receiving care in the VA's 137 Community Living Centers (CLCs-formerly Nursing Home Care Units), and veterans' CLC use is projected to increase dramatically. Transformation of the culture of care away from a medical model and toward a resident-centered approach has become a performance measure in CLCs. As part of this 'culture change' initiative, two CLCs, Tuscaloosa, AL and Danville, IL, will construct new facilities based on the Green House model and open them in late 2011. Implementing a Green House-type model (GHTM) facility requires construction of completely new, stand-alone, small, home-like facilities for 6-10 residents each. The GHTM emphasizes quality of life and quality of care while promoting empowerment, equality, and mutual respect for residents and staff. Yet almost no studies exist on outcomes for residents or staff related to adaptation of the GHTM or its principles. CLCs' adoption of this expensive, radical, new model has innumerable potential impacts on residents' and staff's interactions, organization, and care. However, only with the development of a comprehensive methodology to evaluate culture change and the GHTM and by understanding residents' and staff's current, pre-GHTM implementation experiences can the post-implementation impact of this new model be evaluated. The primary objectives of this project are (1) to adapt and pilot an evaluation methodology for the expected wide-ranging effects of culture change, including the GHTM implementation and (2) to conduct the baseline assessment necessary to evaluate the multiple impacts of having VA CLCs move from a nursing home model to the GHTM. Because our pilot study is an exploratory baseline study, there are no specific hypotheses to investigate. Instead, the study will explore the following research questions: (a) What are the optimal instruments and methods for collecting data about culture change? (b) What are current perceptions relative to culture change at the two CLCs? (c) What are CLC management, frontline staff, and resident outcomes on indicators related to culture change? (d) What are VA Central Office (CO) leadership and CLC staff expectations of and facilitators and barriers to adoption of the GHTM? This study will use a concurrent mixed-methods approach in a case study design. Members of the research team will conduct a preliminary site visit at Tuscaloosa and a full site visit to each Tuscaloosa and Danville. The preliminary site visit at Tuscaloosa will concentrate on adapting an observational data collection instrument. Subsequent to modifications to the observational tool, the researchers will conduct a full site visit to Tuscaloosa using all the instruments and methods. That is, during a full site visit, data will be collected through (1) Web- based surveys of staff using established instruments, (2) individual interviews with staff and focus groups with residents and family members, and (3) structured observation of life in the CLC. After any further revisions to the observation or interview instruments, the full site visit at Danville will be conducted using all the instruments again. Contiguous to the Danville site visit, members of the research team will conduct telephone interviews with leadership at CO. Qualitative data will be analyzed using grounded theory methods, and relevant overarching themes will be reported. Quantitative data will be reported in the form of frequencies, descriptive results, and survey scores. Exploratory regression analyses will also be conducted using summary ratings from the surveys and observational instruments as the dependent variables.
Achieving a culture change in Community Living Centers (CLCs) that moves care toward a resident-centered approach is one of the priorities of the VA. The comprehensive methodology adapted in this pilot project and the knowledge gained has the potential to enhance the VA's understanding of the impact of all of its culture change activities, including the implementation of a small house living facility model, greatly. Importantly, it has the potential to inform directly the care provided to veterans in CLCs by identifying areas in which culture change is having an effect. It also highlights aspects of culture change that that work well from the perspective of residents, family, and staff and those that could benefit from modification. Since culture transformation has as its ultimate goal the enhancement of the lived experience for veterans in CLCs, this pilot project lays the foundation for future assessments of resident and staff outcomes and thus comprises a vital, but heretofore missing, component of the culture change movement in the VA.
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| Hartmann, Christine W; Snow, A Lynn; Allen, Rebecca S et al. (2013) A conceptual model for culture change evaluation in nursing homes. Geriatr Nurs 34:388-94 |
