Partnering for progress.

In the sometimes frightening world of organizational evolution and change, you don't necessarily have to go it alone

Are the goals you've set for your facility too broad to accomplish on your own? Have you had to table innovative ideas and settle for less than what you've envisioned for your residents or staff? If so, you're in good company. Nearly every long-term care facility in the country is trying to do more with less. But for some of those facilities there may be a solution in a partnership or pooling of resources.

It's been almost six years since the article "Academic-Corporate Partnering to Improve Long-term Care" appeared in the July/August, 1991 issue of Nursing Homes. At that time, it had been only one year since ERA Care, Inc., developers and owner/operators of a North Seattle retirement community and nursing home, contracted with the University of Washington School of Nursing to design and manage the facility's health services.

Almost three years later, the partnership was still referred to as "an experiment in linking up long-term care services..." ("Progress Report on a 'Continuum of Care' Partnership," Nursing Homes, Nov/Dec, 1993). But today, what began as an idea hashed out over dinner has blossomed into a mutually satisfying and beneficial relationship. And while all relationships - business or otherwise - continue to evolve throughout their lifespan, it's probably safe to delete the word "experiment" from the description of ours.

We're now in a position to offer some advice to nursing facilities that might be considering a contractual pooling of resources. To that end, this article - while not intended to be a "how-to" blueprint - will explore some of the considerations that should be part of making such a major decision.

What we've gained

Why a partnership? A brief discussion of some of the benefits reaped by both the retirement community and the University may help to answer that question.

First, some background. Ida Culver House Broadview is a retirement community with independent and assisted living apartments and a 74-bed skilled nursing center. The facility houses more than 400 residents and employs 200-plus staff members. Our ten-year, renewable contract with ERA Care stipulates that the school will manage health services for the entire complex. The school's involvement spans the Nursing Care Center, assisted living, and the Wellness Clinic, which provides services for residents in the rental apartments.

From the outset, our shared objective has been to create a community orientation at Ida Culver House, with a focus on maintaining residents' independence and improving functional status. At the University, we viewed the partnership as an opportunity to improve the level of professional nursing practice in nursing homes and build up the gerontological nursing specialty. As it turns out, our efforts to achieve those goals have paid off for Ida Culver House.

Perhaps the biggest "pay off" has been in the professionalism of the nursing center staff. We're now able to attract highly competent staff and the number of baccalaureate-prepared nurses who now view long-term care as a meaningful career option is growing.

In addition to the executive director's leadership, we attribute this change to faculty involvement at Ida Culver House and to our emphasis on staff education. Specifically, as part of their faculty role at the university, School of Nursing faculty are on site at Ida Culver House daily, working on staff development, inservice education and, in some cases, working directly with residents. At any one time, there are 20 to 25 faculty members presenting on-site lectures, consulting with staff on clinical issues and conducting research.

We've also been involved in advising the nursing center staff about returning to school for additional formal education. Our special attention to nursing assistants at Ida Culver House has resulted in a decreased turnover rate and development of a staff that is more oriented to "customer" services and more in tune to the needs of the residents in their care.

Our rehabilitation program has been extremely successful, with 87% of patients admitted to the program from hospitals able to return home after only one month. Readmission rates remain low, because nursing center residents who are unable to return home are often moved to a "lower" level of care within Ida Culver House.

The School of Nursing also sets and monitors standards, staffs the facility's ethics and research committees, and coordinates placement of nursing students in the facility. While the school doesn't manage the day-to-day operations of the complex, the administrative staff members who do are jointly hired by the school and ERA Care, and are on the School of Nursing faculty.

Of course, there have been a few bumps along the road. A case in point is our effort to promote professionalism among the nursing home staff by getting through to our own students. At one point, I had a delegation of students in my office protesting their assignments to a clinical practicum in the nursing home. They were convinced they would have little to do and would learn even less and, in general, held the all too dominant lay view of nursing homes as little more than warehouses.

But at the end of the ten-week quarter, three of those six students returned to thank me for sending them. I attribute their complete turn-around to the quality of the faculty, the interactions with residents and the fact that these students were kept far busier and learned far more than they ever imagined.

Assessing the Need

Partnership affords opportunities that neither academic nor corporate sectors can pursue effectively on their own. Pooling your resources allows you to tackle a range of issues and explore future solutions. But is a formal partnership agreement right for your facility?

The ideal candidate for partnership is the facility in which the owners, administration and, preferably, the front-line staff want to go further in providing care for their residents. Of course, this applies - or should apply - to every LTC facility. But underlying that desire to go further, there needs to be a willingness to think beyond immediate needs, and to adopt a broader, longer-range view of your objectives.

If resource limitations are standing in the way of pursuing those objectives, some type of partnership, or even consortium activities, may be the solution.

A partnership can take many forms. It might involve, as in our case, university faculty on site in your facility to help you develop staff skills, improve resident services, measure outcomes or explore different ways to use your resources within the cost constraints faced by all LTC facilities. Some of these areas might involve research - something a university is equipped to take on. This pooling of resources is especially useful for the facility providing, or planning to provide, sub-acute or rehabilitation services.

If you still have doubts about the feasibility of such an arrangement, it may help to take a look at a facility with a partnership similar to the one you're considering. In our case, we had the model of the Robert Wood Johnson Teaching Nursing Home Project in 11 locations to show us a variety of ways schools of nursing are effectively collaborating with nursing homes.

Choosing a Partner

Once you've determined that some type of contractual relationship would be advantageous, the next step is to find a partner. Partnership is a marriage, of sorts, in the sense that it's a long-range relationship (or at least, is intended to be), the success of which depends upon compatibility and mutual trust. Partners need to feel comfortable with one another with respect to goals, expectations and willingness to work together.

A partnership can't exist without shared goals, sense of purpose and desired outcomes. Long before signing on the dotted line, we discovered that we shared with ERA Care a range of beliefs, values and objectives concerning the care of older adults both in and out of the nursing home: in particular, we shared the desire to improve the lives and health of older adults through a focus on functional ability and independence, rather than on a disease-centered approach. To this day, that shared philosophy is the glue that holds our partnership together through all our successes and bumps in the road.

A shared view of control, standards and practicalities of finance is also essential. In our case, the University does not have a capital investment in Ida Culver House. Of course, that potential exists and some partnerships might opt for that arrangement, but as a state agency, we felt it would complicate our situation.

Our collaboration has succeeded because neither partner insists on vertically structured control. We share the control and, over the years, have built up a solid foundation of trust.

That sense of trust will come much more easily if partners define their roles in the collaboration from the very beginning. Establishing what your role does not entail is just as important as defining, and agreeing upon, what it does.

As dean of the School of Nursing, I serve on a four-member executive committee along with ERA Care's Eli and Rebecca Almo and the chairperson of the School's faculty steering committee. During our monthly meetings, we review financial reports, admissions, discharges, and so on, in order to make both short and long-range operational decisions.

Patience Rewarded

The real work begins once you've found your partner, agreed on the terms of your partnership and ironed out all the preliminary details. But that's also when you start to reap the rewards, as you watch your vision begin to materialize.

It was three months after that fateful dinner in 1990 before the School of Nursing signed the partnership agreement. It was an additional seven months before the first residents were admitted to the assisted living units and the nursing care center.

That may not seem like a very long time in light of the magnitude of the step we were taking. But every day of those first three months was spent in intense deliberations of the pros and cons of the arrangement with my understandably cautious University colleagues.

Seven years later, everyone involved agrees it was time well-spent, and then some. The partnership continues to evolve as it matures, in concert with changes in the field of long-term care. The most important changes for our partnership, we feel, have been in the health and lives of our residents and their families.

Sue T. Hegyvary, PhD, FAAN, is Dean of the University of Washington School of Nursing.