The death of culture change? One of the leaders synonymous with this movement tells how to prevent its demise.

Recently I had the opportunity to participate in an International Advisory Committee of CARF (Commission on Accreditation of Rehabilitation Facilities). A sign of our changing times, CARF has diversified significantly in its work of recent years to include accreditation in adult day services, assisted living, CCRCs, and other aging programs. The charge of our committee was to develop the first set of "International Person-Directed Long-Term Care Standards" for use in CARF accreditation activities. Professionals from several countries were present, representing a wide variety of skills and experience in long-term care and aging.

Following that meeting I attended a state nursing home convention where I was presenting a workshop on "person-centered care" and staffing a booth on a local "culture change" initiative. These terms and concepts brought many blank stares, apparent misperceptions, and confused responses. Others asked me if this "new stuff" was part of some regulatory changes they were facing. One provider told me they were now "doing culture change" by using the metaphor of a "holiday vacation" in their monthly activity calendar to promote staff wellness and fun.

These experiences highlight two great trends that we are facing with this phenomenon that has different names--cultural transformation, culture change, person-centered care, Pioneer movement, and perhaps others. (By the end of the CARF accreditation meeting, there was still no consensus as what to name the new standards.) The first trend has been an incredible burst of activity over the past ten years or more in bringing the values and practices of this work to the forefront of long-term care and aging. While there has been much focus on the plight of the American nursing home, there have been many other initiatives in home- and community-based services, end-of-life care, dementia, and other disabilities. A major Planetree movement has even sprouted around "patient-centered care" in hospitals. The core of all this work is the individual person (usually an elder)--who he is, what he wants and needs, how to preserve his quality of life wherever he chooses to live. More than a passing phase or just another quality initiative, this Pioneer movement has gotten the attention and involvement of virtually every major organization in aging, health, and long-term care.

But there is another, more disturbing trend. Despite the churn of activity in awareness, education, programming, research, and training, the actual practice of culture change is not unfolding or disseminating in an effective manner to achieve the desired "new culture." New culture is, in this sense, the deeper system changes reflecting different values about what it means to age and how to age successfully. The principles of this culture and the changes it demands are so subtle yet so dramatically in conflict with the current entrenched culture that attempts at meaningful, sustainable change often miss the mark or get put on that ever-present laundry list of "nice things to do." To many who saw the early principles of the Eden Alternative as just another "fur and feathers" fad, culture change has become the ongoing fad of fun things to do as work plans, resident census, risk management, and survey processes permit. Furthermore, as human services, especially Medicaid budgets, become the grand stepchild to war, terrorism, national disasters, and tax cuts, resources for person-centered care just don't seem to be in the cards.

These arguments can be spun in hundreds of ways, but the net result is that the work of the Pioneer movement is not reaching the grassroots providers and practitioners who could and should experience it. What this all means is that culture change dies on the shelf of quality improvement, and elders everywhere continue to drown in the "helplessness, loneliness, and boredom" that Dr. Bill Thomas described more than 15 years ago.

Can the funeral be prevented? I believe so, and I offer the following five points as both warning signs and opportunities for preventing the mitigation of culture change and to sustain its growth as a national movement:

1. Begin with "I." Fundamental change begins in the human heart. If we really don't believe that people are still people because they have a dementia, we will not care for them as persons, but as objects of medical maintenance. If we really don't believe that elderhood can be a great age of enlightenment and societal participation, then we will continue to relate to elders as retirees on the golf course. Each of us must work deeply on our own journey of aging, transforming our traditional fears and uncertainties into a hopeful, joyful embrace of who we are and our new capacities for growth and giving.

2. Learn from others. As I have traveled and studied this incredible world of culture change, especially through the prism of dementia care, I am struck by how much we can learn from other movements that have changed the American culture, including civil rights, the environment, people with disabilities, the peace movement, and other transformative efforts. We must study and reach out to these other movements and organizations as potential models for change.

3. Set the nomenclature. Words do symbolize our values and our values do drive our behaviors to effect change, so let's develop a national consensus around the words we use to lead this movement. If the concept of "culture change" is in fact an anomaly, then let's find the phrase that we can all get behind. Perhaps our naming should focus less on the attributes of culture and more on the quality of life we seek for our elders and ourselves. If this is truly a movement on a national scale, then we need to give up our turf words in favor of a certain message focus that will drive the movement.

4. We, the people. As I said earlier, the Pioneer activities have attracted a greater audience of providers, trade associations, regulators, and other interested parties. Many have brought new initiatives, work plans, and limited funding to the table. While these new players can be very attractive, their participation is often rooted in their organizational priorities, as well as changing mandates from the top and uncertain resource commitments. The result is that the movement is fragmented--it has lost its focus. Most successful movements in America (as mentioned above) have been rooted in creative, grassroots coalitions and collaborations. Long-term care's Pioneer leaders need to come together to arouse greater consumer awareness and involvement to inspire and drive organizational commitment.

5. Leadership from the top up. I have often said that the traditional top-down, micromanaging power structure of management doesn't work in building a community culture that is person-centered. Of course, no one sees themselves as favoring top-down management, but the reality is that we all have a tendency toward practicing it. The new culture of aging calls us to respect the power of community and interdependence. And the new role of leadership is to listen; to ensure participation by elders, staff, and other key stakeholders in decision making; to facilitate moving ownership of decision making as close to the elder relationship as possible; and to embrace the power of the team or community as the core fixture in the change process.

"New culture" leaders do exist and there are many great models of them in American business. The Pioneer leaders in long-term care must become a key resource for leadership development in the field, bringing all the tools of values clarification, education, skill development, mentoring, and personal acknowledgment together as a vital resource for a new generation of leader-managers in aging services.

As we all know from our own healthcare experiences, there is no quick fix when it comes to personal health and well-being. Longevity and good health are mostly the result of good genes, prevention activities, and healthy lifestyles. It has taken us 50 years of "unhealthy living" in long-term care to create the current system that we all acknowledge today is sick and broken. It is time to introduce major interventions and healthy management styles to bring the long-term care system "patient" back to life. This hard work in good faith will result in a better system, and that means greater longevity and well-being for millions of elders.

Bill Keane, MS, MBA, LNHA, formerly Director of Special Programs for Mather LifeWays, recently rejoined the world of long-term care management as Chief Operating Officer for Harbor Senior Concepts of Illinois, a 19-facilty assisted living company based in Madison, Wisconsin, and specializing in memory care. He can be reached at [phone]. To send your comments to the author and editors, please send e-mail to [e-mail]. To order reprints in quantities of 100 or more, call [phone].

BY BILL KEANE, MS, MBA, LNHA