A household in a nursing home.

An experiment in personalized lifestyle at the Evergreen Retirement Community

"If I can't be in my own home, this is the next best place to be." "I wish this area would have been available when my Mother was here. She would have loved it."

These comments from residents and family members are often heard in reference to a specially designed area of the nursing home at Evergreen Retirement Community in Oshkosh, Wisconsin. Evergreen, a continuing care retirement community, offers six different living options for 280 retirees, from independent condominium-style housing to a 108-capacity nursing home.

In June, 1992, the Board of Directors and staff launched a research project to test a new design and management approach to nursing home care. The project is called the Household Research Project, and although the data has not been completely analyzed, the new environment has resulted in improvement in resident mobility, socialization, and satisfaction. It has also demonstrated that staff is able to function optimally in this type of setting. Even though the research has officially ended, the Household continues to be a functional area in Evergreen's Health Center. What's more, because of its success, it will serve as the model for a new replacement nursing home to be developed by Evergreen, possibly next year.

"We knew that our nursing home, built in 1967, had many shortcomings," said David Green, Evergreen's President and CEO.

"We knew there was a better way to deliver high quality, resident-focused care. Buildings should be designed to meet the needs of the people who use them," Green continued. "Unfortunately, traditional medical-model nursing homes are designed to meet government regulations and the needs of professional staff rather than the needs of the residents and nursing assistants who provide most of the resident care."

Green said that in most states, regulations governing nursing home design are based on the concept that nursing homes are like mini-hospitals. "Hospital design presumes that most patient care will be provided in bed. When this concept is carried over to nursing homes, it results in a nursing home design centered around a fixed bed position perpendicular to the wall to allow access for caregivers from both sides. The lights are mounted over the head of the bed for reading in bed and caregiver examination, and a nurse call system is installed allowing primary access from bed. This is clearly not the way anyone would like to live for months, or maybe years."

Evergreen remodelled an exercise area at the end of the second-floor nursing area to combine a highly decentralized, small cluster nursing home design with a resident-centered management approach, based on the Continuous Quality Improvement (CQI) process implemented at the facility in 1991. Exercise equipment was removed and furniture and carpeting installed to create a large "living/dining room," with adjacent kitchen facilities. Eight residents elected to live in the Household area in four private and two double rooms arranged around the light, airy living space, with residents already living in those rooms given first option. A laundry room is also part of the Household area, where staff can wash the residents' personal laundry and return it to them the same day. Lost clothing, a perpetual nursing home problem, is not one in the Household.

Household residents dine together for every meal and participate in a variety of activities as they wish. The living space is visible from every room, encouraging residents to spend less time in their rooms, and more time interacting with the staff, other residents, and visitors.

"It's really like a family here," says Resident Assistant Pat Neubauer. "It's very relaxed, and for the staff, it's like doing your work at home. The residents are free to do what they like, and they spend far less time isolated in their rooms."

One lady, who never came out of her room without help, now comes out on her own to play cards at the dining room table with a staff or family member. Another woman, who had to be taken in a wheelchair down the hall to the dining room for every meal, walks with her walker to the dining table in the Household, a distance she can manage easily now.

"I love living here," says resident Hattie Luebke. Hattie, 102, moved into the Household from another room in the Health Center. She said she enjoys playing bingo and attending the Koffee Klatches, which are regular activities in the Health Center. Hattie also enjoys helping the Household staff by folding bibs, washcloths, and towels. "I don't see so well anymore," said Hattie, "but I can feel the edges of the things I'm folding, and I know I'm doing a good job."

What adds to the home-like environment created in the Household is the fact that the staff is a consistent set of 30 employees, all volunteers, who received 30 hours of Continuous Quality Improvement training. The CQI training was the most significant cost item involved in the project. "It was obvious that if we didn't have a new approach to management in place, the advantages of the physical design would be lost," said Karen Haines, RN and co-coordinator of the Household. "I've worked in health care settings for over 20 years, and this was the first time that staff was asked for their input on how to accomplish their jobs more efficiently, keeping the resident as the focus."

Hattie's daughter-in-law, Marge, believes the consistency in the staff has been helpful for Hattie. "It's great that Mother has the same set of people helping her on a day-to-day basis. She seems more alert since she moved into the Household," says Marge.

The staff in the Household call themselves the "Household Team," and that is exactly how they function: getting together to plan and solve problems on a regular basis. Members of the team include registered nurses, nursing assistants (now called "Resident Assistants"), and housekeeping, laundry, dietary, maintenance, and rehab services personnel. Although the nurses spend most of their hours in the Household, they are available for back-up throughout the rest of the Health Center. The other personnel work in both areas.

The teamwork shows. Ernie Wenski, whose mother, Frances, passed away in the spring, said, "Before my mother moved to the Household, she never communicated with the staff or other residents, and never wanted to leave her room. In the Household, she was rarely in her room, preferring to be out in the pleasant, quiet living area, playing cards or talking to the staff. The biggest change I noticed, however, was in the caregivers. It's fantastic! They really work as a team."

One of several innovative features of the Household which help improve staff efficiency and resident comfort, and also help meet state requirements for resident surveillance, are the two-way radios every staff members wears while on duty. These "staff communicators" are portable radios worn around the waist with a microphone pinned to the lapel. When a resident assistant needs help transferring a resident, for example, she/he pushes a button on the radio, and speaks into the microphone. The assistant's "buddy," elsewhere in the Health Center, can respond immediately. The resident is never left alone when help is needed.

Another innovation is the provision of specially designed storage units in each resident room. The storage units, called "staff servers," are cupboards installed in the wall between the bathroom and the bedroom which contain all supplies needed for the resident, and which are accessible from both rooms. There is no need for staff to have to run down a long hall to get supplies each time they assist a resident.

Family member Joyce Goers, whose mother-in-law lives in the Household, said she sees the smaller size of the Household compared to the other Health Center units as a distinct advantage. "The residents feel safe here, and they can roam around without feeling lost. It gives them a sense of belonging," said Joyce.

That sense of belonging is very apparent in this family-like setting. When Frances Wenski became ill and died, the staff, residents, and family members held her memorial service in the Household. This was the first time a service had been held in the nursing home area, because this was the first time a nursing home resident had developed such a sense of "connectedness" to her "family" of staff and co-residents.

Administrator David Green notes that the OBRA '87 legislation requires that nursing homes begin focusing on the needs of their residents. However, the legislation doesn't define how nursing homes should meet those needs cost-effectively. In order for nursing homes to put residents first, the nursing home industry must provide architectural designs and management approaches which make this possible.

"At Evergreen, we've taken steps to provide the data necessary to prove that proper nursing home design teamed with better management approaches will allow nursing homes to meet the needs of residents and OBRA regulations cost-effectively," says Green. "We recognize that the design of our Household and management style based on CQI principles will enable our nursing home staff and residents to be all they can be."

Deanie Minniear is Director of Public Relations at the Evergreen Retirement Community, Oshkosh, WI. Members of the Household Team will be making a presentation about the project at the National Convention of the American Association of Homes for the Aging (AAHA) in San Diego, CA, October 24-27.