Learning from Sweden: A New Nursing Home for a New Century.

Transplanting the "ultimate model" to America--and the obstacles along the way

Our organization has recognized for some time that time is running out for the medical model nursing home. The pressures on this icon of the American long-term care system are too strong, damaging and irreversible for it to survive. Poor fiscal performance, labor shortages and over-regulation are certain to drive it out of existence-not to mention consumers' dissatisfaction (witness the popularity of assisted living and the residential options available to elderly persons across the country). No, the medical model nursing home cannot be saved. However, the planning dilemma we faced was: What will replace it?

Our answer came quite by chance. In 1993, a group of Swedes visited our Lyngblomsten Care Center, located in St. Paul, Minnesota. Although our organization was founded by Norwegians 94 years ago, we were receptive to the Swedes' overture to establish an employee exchange program with a "service house" in Rottne, Sweden. The pro gram was simple: Each year we would send two employees from Lyngblomsten to Sweden for four weeks in the spring, and they would send two to St. Paul in the fall.

What was really interesting was the Swedish reaction when they saw our medical model nursing home: "That's the way we used to do things in Sweden 20 years ago." What a shock! It was hard to believe that we were that far behind another country when it comes to providing housing and services to a dependent population.

We then set about, over the course of seven years, to learn as much as we could about the service house system in Sweden (see "Does Europe Have the Answers? Part 1," September 1999 Nursing Homes/Long Term Care Management, p. 52, in which editor Richard L. Peck describes the Swedish service house system), and then planned a conversion of our nursing home in St. Paul to a similar, yet Americanized, version.

In Sweden, as Peck notes, the municipalities are responsible for housing and services to the aged and handicapped. There are only two rules that are handed down from Sweden's federal government: (1) Do everything possible to keep people in their own homes; and (2) When a move to the congregate setting is necessary, make that setting as homelike as possible. When we examined our own services in light of those two rules, we discovered that Lyngblomsten was not doing a good job. Our focus was on institutional, not home, services, and our facility resembled a hospital more than a home.

The Swedes stress that what is "normal" for a person at home should continue to be normal in the congregate setting. Consequently, their service houses have individual apartments, not semiprivate rooms; each unit has a full bath, not a bath down the hall. There are no nurses' stations or soiled utility rooms. Breakfast and supper are taken in residents' own apartments, with their own food, allowing them to get up in the morning and go to bed at night when they want, not according to some predetermined schedule set by staff and dictated by mealtimes in the dining room.

In developing our own version of the Swedish service house, our plan was to convert a portion of our nursing home to serve as a "demonstration project." However, because we were determined to keep our facility a licensed and certified skilled nursing home, we approached the Minnesota Department of Health for a number of waivers. In the end, we asked for 76 waivers from state regulations and were granted 60, enough to proceed.

Next, we hired an architect from Stockholm to create the initial floor plan, as the Swedish designers are very experienced in conversion projects. The plan that we adopted converted 15 private rooms to nine service house apartments, with the physical remodeling done in the summer of 1997. We then selected nine current nursing home residents to move into the new space, three from each of the case-mix segments (low, medium and high ADLs), as we wanted a mix of clients that was representative of our larger nursing home population. Using funds from a grant by The Retirement Research Foundation of Chicago, we arranged for an independent study of our project with Dr. Leslie Grant of the University of Minnesota.

Finally, we hired 12 LPNs to work in our new Service House. Since the Swedish system uses a "generalist" type of staffing (often called "universal worker" in this country), the LPNs per formed all the nursing and support functions required on a daily basis: personal care, medication administration, treatments, cooking, cleaning, laundry, social activities and more. Initially, the Service House staff also provided home care to six off-site clients.

Since October 1, 1997, when we opened the Lyngblomsten Service House, much has been learned:

Residents love it. Grant's 1999 study showed a very significant increase in autonomy and satisfaction on the part of our clients (they actually liked living there); there was very little client turnover in two years--of the nine original clients, one moved off the unit when she developed dementia and could not participate in the study and one client died. This overall result is vastly different from the rest of the nursing home units.

It is not easy work. Even with the increased client-to-staff ratio, the workload is significant and physically demanding. The Service House currently has 2.5 FTE of LPNs (or, as we call them, TMAs, i.e., Trained Medication Aides) on the day shift, 2 FTE on evenings and 1 at night (and this is for the nine clients, because home care has since been discontinued). We provided training for the staff in the Swedish philosophy of care and some cross-training, mainly on nutrition, but most of the non nursing tasks are those that most of us are already familiar with: cleaning, cooking, laundry, etc. In addition to the TMAs, there is a part-time RN position. That person performs MDS assessments and coordinates care planning and delegation/training of care-related tasks. Perhaps because of the added challenges, we did experience greater turnover in staff than anticipated--about 50% during the first two years.

It is not less expensive than the nursing home to operate. For the first two years, expenses exceeded revenues by about 25%. Our theory was that the simplified organizational structure would allow us to fund the higher staffing ratio using all LPNs and still be at about 90% of the cost of operating the nursing home. However, we were not granted waivers to allow us to escape the time-consuming charting/documentation requirements of the skilled nursing facility. Also, we were using veteran LPN staff, whose rate of pay, on average, is much higher than that of other nursing assistant staff. Finally, our small size did not afford savings on the usual overhead of a complicated, regulated nursing home.

It was clear that if we devoted an entire building to the service house simplified model, we would be cost-effective. The model would similarly be financially feasible if we were able to set our own rates and operate as an assisted living facility.

Even with the challenges of implementing this new model of care, I am optimistic that we can shape a new type of nursing home for the new millennium-one that dispenses with the useless trappings of the medical model, retains the normal aspects of life (privacy, dignity, autonomy) but also provides supportive care in a manner that is consistent with the Swedish philosophy.

And, if we are 20 years behind the times, it's about time to get started!

Paul Mikelson is president and CEO of Lyngblomsten, a Lutheran-affiliated social ministry agency providing housing and services to the elderly in St. Paul, Minnesota.