ALMOST HOME

Nursing Home Reform

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Nursing Home Reform

An elderly Caucasian man, smiles at the camera, wearing in a white shirt, khakis, belt and a tie that blows in the wind, stands in a courtyard in front of a green hedge and pink and white flowers.
Ralph Nelson, independent living resident, on the grounds of Saint John’s

“Culture change” is the name of a grassroots movement to transform the culture of aging. Through culture change, nursing homes and other senior living facilities change from hospital-like institutions to communities that more closely resemble home. In ALMOST HOME, filmmakers Brad Lichtenstein and Lisa Gildehaus chronicle the daily lives of staff and residents at Saint John’s On The Lake, a retirement community in Milwaukee, Wisconsin whose leaders are striving to improve quality of life for residents and staff.

History

A black and white photo shows the back of people hunched over, sitting in wheelchairs, lined up in a long fluorescent-lit hallway; they are tied into their chairs with white fabric.
A nursing home in the 1960s

During the 1960s, the passage of Medicare and Medicaid laws led to the construction of large nursing homes based on a medical model. These facilities had long hallways and central nursing stations and operated with rigid routine to provide physical care until a patient’s death. In the 1970s, people began to complain about the care in these facilities, and a type of “reform” took place, but the changes were not significant.

In the mid-1980s, Congressional hearings brought to light testimony about widespread abuse and neglect in nursing homes. As a result, the Omnibus Budget Reconciliation Act (OBRA) of 1987, known as the Nursing Home Reform Act, declared, “residents in nursing homes need a home where they can live for the rest of their lives as individuals.” And social, spiritual, emotional, occupational, recreational and cultural needs were deemed as important as physical needs.

Old Model New Model

  • Individual choices limited by schedule and efficiency
  • High staff turnover, minimal training
  • Workers evaluated on cleanliness and timely completion of routines
  • Personal relationships with residents are discouraged
  • Mealtime is routine and without food choices
  • Sterile physical environment
  • Residents are forced to take part in planned activities

  • No agenda kept, residents enjoy choice, control and daily pleasures
  • Staff trained to handle stress; their own needs
  • Workers are evaluated on joy they bring to elders’ lives
  • Promote feeling of home and community among residents, staff
  • Dining is social experience with made-to-order
    food
  • Decor is warm, home-like and pleasing
  • Doing nothing is an activity too




  • Know each person, identify unique talents
  • Promote choice and creativity
  • Respect individuality and risk-taking
  • Trust staff
  • Keep decision-making close to the resident
  • Support relationships with people of all ages, animals and nature
  • Support function and mobility
  • Build on strengths and potential for healing, growth
  • Devote time and space to building community



  • Shape environment (social, physical, organizational) to express values
  • Ensure representation for all community members in policy decisions
  • Expect leaders to model values
  • Respect the need of all to give as well as receive
  • Look for meaning in all behaviors
  • Work with residents; do not fight and argue with them
  • Respect ethnic/cultural identities and religious beliefs

Culture Change is Born

Culture change in long-term care is an ongoing transformation based on person-directed values that restores control to elders and those who work closest with them.
—The Pioneer Network

A before and after shot of two bathrooms side by side: on the left, a cold industrial hospital-like tiled room; on the right, a painted yellow room, home-like toilet, sink and mirror with wood trim, a green plant visible in mirror.
Before and after: the bathroom on the right
illustrates how Saint John's renovations create
a home-like environment for its residents

In March 1997, progressive thinkers in the long-term care field—those who believed that aging could be a gratifying and dignified experience—convened in Rochester, New York to exchange ideas for culture change.

Culture change in long-term facility care is a transformation of the nursing home atmosphere and structure as a whole: the physical environment, staff routines, authority structure and resident care.

In Rochester, four models of culture change were introduced. Each demonstrated that changing the way that nursing facilities operated had a major impact on residents as well as staff. Although there were different approaches to culture change, each focused on the individual resident and reinstating choice into daily life.

Today, the New York-based Pioneer Network includes seniors, family members, physicians and caregivers of all kinds, educators, researchers and others, all working to educate seniors, their families, legislators and nursing home administrators on creating deep and lasting change in the way we age.

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