Breaking with tradition: long term care facilities have moved from sterile and foreboding to homes away from home.

Twenty-five years ago, sending someone to live in a nursing home was akin to throwing extra household items into a cold, dark cellar.

The cellar door was locked and the items forgotten. Once in a while, a garage sale or temporary use brought the items briefly back into circulation.

Despite the societal changes of the Me Decade during the 1970s brought on by the arrival of Gloria Steinham's Ms. magazine, the emergence of acupuncture and Transcendental Meditation as the new medicine, and the banning of cigarette ads from airwaves, nobody expected anything other than the status quo from long term care.

So, when Molly Forrest discovered the Oroville Community Convalescent Hospital, a 50-bed, mom-and-pop-owned, long term care facility in Oroville, Calif., she was understandably impressed.

"I said naively, 'oh this is not a nursing home. It doesn't smell bad,'" says Forrest, chief executive officer of the Jewish Home for the Aging in Los Angeles. "People were dressed in real clothes. I saw residents going on a picnic. One lady was pruning roses."

A revolutionary concept. Talk about forward-thinking.

But what may have been idealistic and unusual in the swinging 70s is the expected philosophy today. As health care providers during the past decade have begun servicing a more medically acute and amenities-demanding population, the concept of designing long term care facilities with a more homelike environment--and moving away from the circa 1970s medical model with its long corridors, centralized nurses station and stark hospital rooms--has gained momentum.

Some operators assert the changes occurred gradually during the past 20 years, often without people realizing it.

"Progressive approaches unknowingly happened, but everyone was working in a vacuum," says Rose Marie Fagan, executive director of The Pioneer Network, a Rochester, N.Y.-based organization founded in 2000 that offers advice and moral support to elders and those who work with them. "We began growing a culture."

Culturing change

While his colleagues were slower to come to a resident-centered orientation, Barry Barkan has had the elder-centered model in mind for quite some time--ever since he visited his grandmother in a nursing home in the 1960s.

Barkan says he watched her go from "being the matriarch of a bustling family to a lonely, bitter existence."

"No one knew her," notes Barkan on the Web site Culture Change Now.com. "No one sought to be connected to her. She lay in her bed, one meaningless day yielding to the next. With no future to look forward to, she dwelled with bitterness and longing on the past ... the whole place felt lifeless. Jails I have visited were far more alive."

Barkan was convinced that the opposite approach--one of infusing the nursing home with a feeling that residents could still have normal, happy lives--would be infinitely more rewarding for everyone involved. So, he set out to create a new model, a task he thought would take only three years.

In 1977, he and a consulting partner introduced their new Regenerative Community model at the Home for Jewish Parents in Oakland, Calif. The model drew from Barkan's experience with therapeutic community drug programs and included elements of a mental health plan he had designed to combat an epidemic of depression among pipeline workers and their families in Anchorage, Ala.

The central component of the Regenerative Community is the daily group meeting, designed to build a new sense of identity among residents. "It was to give them a sense of potency, to help them transition without falling apart," he says.

Barkan recalls the initial meeting's pandemonium, the ensuing "timid voices of [residents'] complaints," which soon escalated and then subsided, as participants felt they were being heard.

The first meeting lasted only 20 minutes. But within a year, the meeting grew to be an hour and a half daily event that consistently drew 50 or more elders out of a population of 115, along with workers, family members and visitors. Attendees wrote poetry, sang songs [including The Live Oak Resident Song, sung enthusiastically to the tune of "The Battle Hymn of the Republic"], talked about happenings at home, the community and the world, welcomed new residents and staff, panned events and held memorials for those who died.

The impact was transformational. "Staff began perceiving personalities, when before they saw a blank canvas," Barkan says.

One offshoot was conducting the first memorial service for one of the residents.

"It was prevailing practice that when someone died, they'd wheel them out the back door, clean the room and get ready for the next resident," Barkan says. "They lived at the edge of death and denied it."

In 1979, he founded the Live Oak Institute to educate others about the Regenerative Community Model; in 1986, Barkan, his wife Debra and 21 friends and investors created the Live Oak Living Center in El Sobrante, about 20 miles northeast of San Francisco. The center is now closed due to financial difficulties.

A few years later, the culture change light bulb illuminated William Thomas. In 1991, the emergency room doctor went to work as the medical director at Chase Memorial Nursing Home in upstate New York. Here, he encountered the pivotal patient--the "very old woman with the pale blue eyes."

The patient suffered from a persistent rash and was also very unhappy. Thomas went to work treating the apparent source of her discomfort when she jarred him into reality. "I made my diagnosis and in a half-whispered voice she said, 'I'm so lonely,'" Thomas says. "I felt like the biggest idiot in the world. Here I was treating a rash on her arm and she was suffering and dying of loneliness."

Shortly thereafter, Thomas created The Eden Alternative, which designs contemporary habitats for people who live and work in long term care facilities. Thomas built his reform effort around nature, deciding to "bring in 100 birds, two dogs, four cats, three rabbits and a flock of laying hens ... then plow the lawn and start a large organic vegetable garden outside our residents' windows."

If you think he's exaggerating, guess again. The day those 100 birds arrived at Chase Memorial, it was "pandemonium," according to Thomas. It was also the start of a major shift in what staff and residents expected from long term care.

Facilities that model themselves after the Eden Alternative's principles try unique, culture-changing methods, such as introducing large numbers of companion animals, indoor plants, gardens and children.

Fairview Manor, an Eden Alternative-certified facility since 2000, opened its first household by converting a few rooms.

"You used to have to walk 200 feet to the dining room. That's not home--that's an institution," says Judie Prentiss, director of nursing at the 40-bed facility in Fairmont, Neb. "When I saw the excitement in the residents [from the conversion], I knew we were going the right way."

Consistent with the Eden philosophy, Fairview also offers the residents pet therapy: Humphrey, a Golden Retriever, has been a fixture for two years. "He thinks he owns the place," Prentiss says.

Meanwhile, the lobby of the 187-bed Grace Living Center in Jenks, Okla., boasts an ice cream parlor, aviaries, a living room and access to a playground. Five days a week, preschoolers and kindergartners attend school here. The children adopt a resident and meet with their reading buddies in the residents' dining room. Their uplifting voices are heard throughout the day.

"We have an obligation to make their lives as enriching as they can be," says Grace Living Administrator Don Greiner. "Our challenge is to get the home back into it. With all the regulations, it's easy to think clinically all the time."

But it takes more than putting an aquarium in the lobby to achieve these quality of life aims, Thomas says.

"There's this notion that if you've put up a full activity calendar, you're set. That's not true. It's just one part of a holistic effort," Thomas says.

Another problem is that thousands of facilities are still opting for the status quo definition of perfection--"a perfect [regulatory] survey and meeting budgetary targets," Thomas says.

On one level, Steve Shields, executive director of Meadowlark Hills, a 60-bed skilled nursing facility in Manhattan, Kan., can understand why facilities might be reluctant to break with tradition. On paper, the status quo, institutional, albeit dehumanizing way of doing things, bodes well. "We had a decade of no deficiencies," Shields says of his long term care facility. "We were defined by the survey process."

But qualitatively speaking, that rating did not suffice.

Shields recalls his first few years at Meadowlark, when he often took note of the wheelchair-bound residents parked around the nurses' station. "Their heads tilted, the drooling, the vacant eyes ... I thought that it was age or disease," Shields says. "I thought, 'I [really] don't want to get old.'"

In 2000, Meadowlark underwent a momentous change he likened to a "spiritual cleansing." The facility's residents, be they ambulatory or comatose, were moved into their own homes called Healthcare Households. Call buttons became obsolete. Residents now determine their daily routine as they are cared for by a self-directed, interdisciplinary team.

"They can have their Earl Grey tea on the porch before they talk to anybody ... or they can go fishing every Friday [if they want to]," says Shields.

Instead of seeing cold, blank faces, Shields now associates particular clientele in the continuing care community with "cookies baking, dishes clacking."

"You see smiles. You don't see stress," he says.

Under new management

Management and staff have altered their approaches in response to a changing culture occurring within the walls of skilled nursing facilities.

In many cases, it has meant discontinuing the long-standing autocratic way of making decisions, with facilities opting instead for greater input from staff.

Mary Ann Kehoe, executive director at Seymour, Wis.-based Good Shepherd Services, notes that the leadership climate during the 1970s and 80s was characterized by a lack of respect. "It was very departmentalized and task oriented ... people did their own turf battles," she says.

In response to that dynamic, Kehoe in 1994 developed the Wellspring Model, which allowed staff to schedule their hours and to come up with creative solutions for particular issues.

Results of these collaborative sessions include a significant decrease in incontinence problems, saving the facility 6,000 hours in aide time and one ton less linen per month, and correspondingly increasing residents' dignity and family visitation.

In another case, collaboration between the music therapist and nurses resulted in the Walk to the Beat program, which increased residents' mobility. Creating a multi-sensory room with soft lighting, music and aromatherapy for $500, quelled residents' anxious behaviors.

Creating a culture of more staff input has been gradual, according to Karen Schwoerer, director of nursing at Souderton Mennonite Homes in Souderton, Pa.

"(Ten years ago,) the light dawned on the administration that maybe we shouldn't be making the decisions," she says. "The staff was right there at ground zero doing the work."

Still, there were those who had a paternalistic view toward the residents and preferred the old style of authority. Implementing change meant, in some cases, a mass exodus of middle management.

Celia Zuckerman, CEO at the New York Congregational Nursing Center in Brooklyn, N.Y. recalls the employee attitude when she took over in 1999. "Everyday I was getting a resignation letter," Zuckerman says.

But now, staff turnover at New York Congregational is down to 8 percent as team members, especially front-line personnel, "feel some control over what they're doing."

Along with increased staff participation and community outreach, Zuckerman also credited improved assessment tools for the residents as having a positively catalytic effect on shaping the organization's culture.

"In the late 1970s, early 80s, the resident was expected to become part of the culture that was there," Zuckerman says. "Now people are living longer, they're more independent and they're bringing their individualness to the facility. Staff now accommodates this and is reaching out to determine what makes them unique."

Done by design

What's in a name? When it comes to the recently opened Green Houses at Traceway in Tupelo, Miss., apparently plenty.

Although the name of the nation's first long term care "green" house implies an aesthetic element, the project actually signifies a sense of vitality, according to project chief architect Richard McCarty.

That "vital" element is catching on--residents who weren't eating much when living in a traditional nursing home are suddenly gaining weight; some people who were in wheelchairs are starting to walk again, according to McCarty.

"It's hard to pinpoint, but [our philosophy is] based on what's good for the elder, not what's best for the staff," adds Steve McAllily, president and chief executive officer of Mississippi Methodist Senior Services Inc., which opened the Green House in May. "[Residents are] taking the time to share life and break bread together."

The Green Houses at Traceway each house 10 residents. Their L-shaped configuration provides natural light. The award-winning design of the 6,000-square-foot, ranch-style dwellings has a hearth at its center, exemplifying one of the Eden Alternative ideals.

"Like moths to a flame, it's a natural gathering place," says McCarty, who was charged with translating the elder-centered philosophy into mortar and brick.

"We kept asking 'would you do this in your home?' We got rid of as many of the institutional elements as we could ... what was refreshing was we weren't entrenched in the traditional nursing home design."

The new homes are one of several architectural answers to a shifting approach to caring for the frail and elderly. The smaller-scale designs, which provided a greater feeling of privacy, were partially inspired by the projects addressing needs of long term care residents with dementia in the late 1980s and early 1990s.

For instance, Woodside Place in Oakmont, Pa., opened in 1991. Architect J. David Hoglund with Perkins Eastman Architects in Pittsburgh notes the ensuing decrease in mental deterioration, the increase in family visits and the decrease in the severity of injuries from falls due to the carpeting. The three houses joined by an enclosed common area offered "a better match between program and the environment," he says.

In 1981, his firm built one of the first household models in Miami, featuring private rooms and a shared bath. The concept appeared a bit before its time. "It took well into the 1990s for it to take hold," Hoglund says.

That's not surprising, according to architect Jack Bowersox, president of Mag-Net Architectural Alliance in Largo, Fla. He says prevailing hospital design in the 1970s and 1980s followed an illogical, circa-19th century rationale. "It dated back to a field manual that told you how to lay out cots during the Civil War. Up until 15 years ago, there had been no analysis of function or what worked," he says.

In contrast, during the past decade, architects have been in "design response mode" to the customers' demand for a homelike setting with family style dining, according to Rob Volzer, founder and principal of VOLZER Design Development in Lima, N.Y.

"You can't be designing roughshod over the providers. You need to be wary of imposing a design on an organization that's not ready," he says.

Still, the number of corridors are shrinking and common areas are becoming more decentralized. However, Volzer hopes the pendulum is not swinging back to the walled off nursing stations, characteristic of the 1970's approach, given recent privacy regulations.

"If you're talking industrywide, it's been gradual," says Maggie Caulkins, president of IDEAS (Innovative Design Environment for an Aging Society) Kirtland, Ohio. "For individual facilities, it can be like an epiphany, to understand how radically different the physical environment should be designed. There are a lot of (people) who still don't get it."

IN THEIR WORDS

"The biggest challenge was to change a culture to an elder-centered model, to break through the old paradigm. The traditional model revolves around the efficiency of administering medical treatment. Another difficulty has been to teach the front line staff how to function in a self-managed work team."

Steve McAllily, president and chief executive officer, Mississippi Methodist Senior Services Inc., Tupelo, Miss.

"There are numerous positive effects [to implementing culture change]. It dispels the notion the nursing home is a place to die. As a resident you can recreate things in your life you've loved, have them around you and share them with others. It allows you to create things that are out of the box using unusual activities to get them. One of the challenges of the culture change is to be sure you're addressing the residents' agendas and not yours."

Celia Zuckerman, chief executive officer, New York Congregational Nursing Center, Brooklyn, N.Y.

"The con side is life has gotten a lot more complicated, especially when we chose to listen to our residents' wants. It put a lot of expectations on the provider. The pro side is we're finally focusing on our ends and not just on the means, which translates into quality of life."

Victor Lane Rose, director of operations, Souderton Mennonite Homes, Souderton, Pa.

"It's not just about improving clinical care, it's changing the culture. Once you do that, it's difficult to tip it back to the other.... All leaders have been taught management by control. Initially, it's a huge time factor to educate staff. It's a lot easier to just say do something."

Mary Ann Kehoe, executive director, Good Shepherd Services and Wellspring Innovative Solutions, Seymour, Wis.

"The pro of the design changes is that they view the world through the eyes of the residents who live there and the staff who has the responsibility and honor of working in their home. The con side is that governmental funding does not support the cost of providing new or remodeled facilities to create a warm, residential home. You can't do them on welfare funding. It's very frustrating to care for poor people and have dreams of improving their environment with new equipment and not have the money to implement that dream."

CHRONOLOG

1979 The Live Oak Institute in Oakland, Calif., is established. Founders of the nonprofit introduce the Regenerative Community Model, which is based an a resident-centered approach, versus the traditional medical model, in operating a skilled nursing facility.

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1987 The Omnibus Budget Reconciliation Act (OBRA) mandating nursing reform becomes federal law; it takes five years to be formally enacted.

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1991 Woodside Place opens in Oakmont, Pa. Designed to enhance the experience of 36 residents with dementia, it features three, single-story houses that are physically connected to an enclosed common area. It is one of the initial plans that moved away from the traditional hospital configuration.

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1991 Dr. William Thomas develops the Eden Alternative. The humanistic philosophy includes a belief that residents in skilled nursing facilities need interaction with children, plants and animals to thrive, along with spontaneous activity.

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2000 Our Lady of Wisdom skilled nursing facility is completed in New Orleans. The project features a village-square atmosphere with a central courtyard and offshoots of six- to seven-bed clusters of rooms, each with their own kitchen and dining area.

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2003 The Eden Alternative-inspired Green Houses at Traceway open in Tupelo, Miss. Each 6,000-square-foot, ranch-style home houses 10 residents. The L-shaped configuration features a hearth at its center.

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Molly Forrest, chief executive officer, Los Angeles Jewish Home for the Aging, Los Angeles