Administrators' view: nursing homes' image problems.
Jack Billingsley, long-term care and hospital administration consultant, past-president of American College of Health Care Administrators; recipient ACHCA 1994 Distinguished Service Award.
Stephen Shelton, Assistant Administrator, Branford Hills Health Care Center (190 beds), Branford Hills, CT; ACHCA Distinguished Young Administrator, 1992.
Bonnie Wood, Administrator, Camelot Care Center (242 beds), Sun City, AZ; ACHCA Distinguished Administrator, 1993. Moderator: Richard L. Peck, Editor, Nursing Homes
What are some examples you have seen of nursing homes' "image problems," and how do you account for them?
Wood: First of all, one has to remember that nursing homes began as "poor houses" for people who had no place else to go. We didn't even have administrator licensing until 1970. Nursing homes have made tremendous progress in 25 years, but it seems as though just as we're beginning to make this known among the general public, a story comes out in the media that set us back and has us defending ourselves all over again.
Shelton: That seems to occur especially during labor union actions. Strikers warn about the potential "dangers" involved for nursing home residents, and that feeds directly into the public's worst fears about nursing homes. Even if the media coverage is even-handed, the graphic allegations of poor care "hit the headlines," and most people tend to be headline readers.
Billingsley: Some of the older women in our communities -- the mothers and grandmothers -- tend to have a very negative image of nursing homes. They've heard about how some friend of theirs, perhaps, died of aspiration pneumonia in a nursing home, and that one incident gets talked up throughout the community.
They also tend to see a nursing home as a place you go to die. You know, "Once Mom goes in there, she'll never get out." There is this image that we're warehousing old people, and it's their last stop.
The fact, as Bonnie says, is that nursing homes have undergone great change since the introduction of Medicaid and Medicare, but most people don't realize it.
Wood: You see that realization sink in when prospective families visit a nursing facility. When they first arrive, families look very hesitant and worried about this; then they take the tour and get some information, and when they return to the lobby, it's as though a great weight has been lifted from their shoulders.
Shelton: I see that reaction all the time. I think a lot of it depends on the atmosphere you create in the institution. If you develop the philosophy, from the leadership on down, that basically what you are doing is great, humanitarian work, and this belief is reflected throughout your institution, families pick up on that. And once they do, they'll stick with you, even through some difficult times.
What about the image nursing homes have in the political community, where many of the financing decisions are made?
Wood: As administrators, we're sometimes reluctant to get involved in politics, and because of that miss out on chances to be proactive, to take advantage of opportunities -- for example, inviting politicians to tour the facility during an election year, which many will be very happy to do.
Shelton: I am very active politically. Most of our discussions with politicians have to do with Medicaid rates, which here in Connecticut are being cut on an annual basis. To counteract this, we try to prepare very simple documents for legislators showing the potential effects of the Medicaid cuts. We also emphasize that keeping people employed generates payroll and sales taxes essential to the state's economy. This "return on investment" theory for Medicaid spending is an effective strategy for many legislators.
Billingsley: Traditionally, nursing homes have been sort of out in left field politically. At the national level, not much serious thought has been given to us -- for example, the Clinton health care plan made little mention of nursing homes. We in the nursing home industry are beginning to wake up to the need for political activity, though, if only for one reason: return on investment is dwindling. Where the return used to be as high as 10%, say, 10 years ago, today some owners would contend they're getting, maybe, 1.5%, at best. This is a pretty widespread phenomenon.
Shelton: Yes, it's very low here, as well, and diminishing constantly.
Billingsley: Against this, though, are government budget pressures, which are immense, and unfortunately there's not enough voting power out there to counteract them.
Getting back to the local facility, what are some current practices they might consider changing in order to improve their images?
Billingsley: Facility standards vary so much. I know that Bonnnie and Steve administer top-notch facilities. But I still see facilities that are dirty, where the staff doesn't seem to be very well-trained, and so forth. These would seem to be fix-able, but some facilities either don't have the dollars, or management is so distracted by meeting regulatory requirements that they lose sight of hands-on quality of care issues.
Wood: There is no getting around it, though, you have to be survey-ready every day. You have to work on it constantly. Administrators sometimes fall to keep themselves on their staffs educated and up-to-date on changes in the industry. Some concern themselves only with getting the continuing education requirements they need and no more, and they don't keep up. They must do this to stay survey-ready.
Administrators also need to be media-ready. That is, when an adverse event occurs, they should be prepared to try to work with the media, and not rely on denial and "no comment."
Shelton: That's true, if something unfortunate occurs, you have to acknowledge that what happened, happened. This can be difficult at any time, and its ten times more difficult with the media, because complete explanations require detail, and it's tough to come up with a good "sound bite" for this sort of thing. Yet the negative imagery and allegations become exploded on TV and in the newspapers.
In trying to deal with this, it is so easy to misspeak, or give information that is somehow turned around on you. That is why some organizations -- for example, the Connecticut Association of Health Care Facilities, in conjunction with a professional public relations firm -- have developed a set of "Media Commandments" to guide you along these lines. This is worth paying attention to, because, although we all hope that nothing like this will happen to us, it is always possible. It comes with the territory of taking care of the sick and the elderly.
Wood: I learned an important lesson several years ago when I was the Chief Operating Office of a hospital. ACT scanner blew up, creating a lot of smoke and necessitating evacuation of patients. I stepped outside and found a microphone pushed toward my face. As the senior person available, I had to handle the media's questions as best I could. This experience taught me to be ready for something like this literally every day. I have a binder in my office ready at hand to refer to and help guide me in dealing with the media during any crisis event.
Billingsley: There are other ideas nursing facilities can implement to upgrade their image, much of which is based on the resources they have available. For example, they should consider changing the patient mix to avoid relying too heavily on Medicaid. Nursing facilities that have a census of more than 50% Medicaid tend to be facilities in trouble, and they don't have the funds to attract and maintain qualified staff and good staff/patient ratios. And their image suffers.
Another is to get local family members involved on citizen advisory committees. Have them serve as your spokespeople; they tend to get considerable respect, particularly since they are not salaried employees who may seem self-interested.
Another is to emphasize a home-like atmosphere. Even if a facility is old, it doesn't have to be dirty. It should be kept up -- remember, it's a home.
Shelton: That's the approach we take with one of our two facilities, which is quite old. We try to keep the appearance home-like, and we find that, in competing with newer facilities, many families and residents do prefer a closer, intimate environment, more similar to their residences in the community.
Wood: One of our two facilities is about 19 years old, and we've made a point of maintaining it well, and also maintaining good attitudes among the staff toward residents. This is a very important factor. I have a competitor that charges less than we do, but we get the patients, simply because of my nursing staff's reputation for caring.
What are some future considerations nursing homes might want to think about to improve and maintain their images?
Billingsley: I think staffing is going to be a major issue. Who do you think will be the nursing home staff of 10 to 15 years from now, the young people? I don't think so. What we're seeing more and more are people 65 years old and older going back to work, not because they have to, but because they want to. Will they join staff? They could make some real contributions. But how will unions react to this? This is something to think about.
Shelton: One thing's for sure: Image doesn't mean anything if you can't get good, well-qualified staff to provide service. And this is getting more difficult every day.
One facet of "image" that community members talk about -- for any business, actually -- is the number of immigrants and non-English-speaking staff members that are hired.
Wood: Being in the southwest, we frequently hire Hispanic immigrants as employees. It can present a real problem if they don't speak English.
Where there can also be a problem, sometimes, is with residents who have certain prejudices. There are some residents who refuse to be taken care of by employees of certain ethnic backgrounds. In consideration of residents' rights, we try to respect their wishes, but obviously that can present problems at times.
Billingsley: Another thought on upgrading image would be to get family members who are willing and able to be more involved in direct care activities. Maybe they can help with the occasional feeding, or even with bathing two or three times a week. Some might appreciate the opportunity to do more than just sit and visit.
Then there's the "nursing home without walls" idea -- for example, providing transportation or grocery shopping or housekeeping service to elderly in the community, under the nursing home's name. In the old days, we waited for the patients to come to us, but that situation no longer exists. This active, helping image can go a long way toward building image and census.
Shelton: All of these suggestions are very much on-target. But, in terms of image, none of it will mean a thing if nursing homes aren't willing to, first of all, take a hard look at themselves in the mirror, and then react to what they see there. You need to be honest about your own image before you can fix it.
The benefits of public relations, however, can be much more far-reaching. Presenting a positive image helps facilities recruit and retain employees. This, in turn, helps minimize staff turnover, which can also lead to better quality care. From a marketing standpoint, when a nursing home is seen in a positive light by the community, the home is also better able to attract residents and volunteers. Public relations has the added value of assuring residents' families that loved ones are being properly cared for. Simply put, public relations is smart business.
Demographic trends, managed care, and increased competition from alternative providers are dictating, now more than ever, that nursing homes pay closer attention to their public image and actively shape that image as a positive one. Nursing homes need to stand out from the competition and identify the positive role they play in the community. Whether it is a concerted public relations campaign run by a full-time professional staff or a part-time effort taken on by a marketing or admissions director, public relations can make a significant difference in all of this.
A key component of any public relations effort is getting to know the local news professionals -- editors, reporters, and news directors -- who determine what will and will not make the newspapers and the 11 o'clock news. Nursing homes should not wait until a crisis to introduce themselves to the media. Instead, they need to make a special effort to establish an ongoing relationship with the reporters who specialize in the coverage of health care, aging, and other issues related to the industry.
Nursing homes should educate the media and, through it, the community about their facilities, the type of care and services they provide, and the type of residents they serve. For some nursing homes, that's the difficult part, because distrust of the media can lead to the misconception that silence is the best policy. At times, however, "no comment" will get a facility nowhere, or even worse, to a place it does not want to be. While there may be times when a nursing home should choose not to speak to the media, an ongoing strategy of silence will likely elicit suspicion and hinder future public relations efforts.
There are various media avenues a facility can take to have its voice heard in the community. Local weekly newspapers may have space for a column about life and activities within the community. Writing letters-to-the-editor or an opinion/editorial column offers other vehicles for sharing the home's perspective. Another way a nursing home can offer the press and the public a truer picture of the facility is to host an open house, with media representatives invited. A nursing home may even be able to contribute feature articles or photos of key events to its community newspaper.
Often times, nursing homes are so focused on caring for their residents that they spend little time telling others of the good works they do. To be effective in public relations, nursing homes must create, and certainly take advantage of, opportunities to promote themselves. Staff should be mindful of events at their nursing home which may be of interest to the general public and, therefore, the media. Innovative programs, human interest stories, and special celebrations are all chances for facilities to show themselves off.
A few examples of nursing homes that have made an impact through their public relations initiatives are shown below.
18 Steps Toward Image Enhancement
1. Conduct a study of your market and your competition every two or three years. Have the study conducted by someone who can remain objective. Know what your strengths and weaknesses are. Improve on your weaknesses. Build on your strengths.
2. Always keep your name out there in the community. Always place particular emphasis on new programs you are developing.
3. Build relationships with your local and state elected officials. Have them visit your facility (most are especially willing around election time).
4. Choose one or two charity groups (e.g., Alzheimer's Association, Arthritis Foundation, feeding the homeless, emergency assistance for flood or hurricane victims). Raise money, or donate staff time.
5. Know your residents and their families. (For example, I conduct monthly family dinners for new admissions and their families.) Make key staff available to answer questions.
6. Know your employees. Try to get to know as many as possible on a first-name basis. Performance evaluations offer a good opportunity to get to know them a little better.
7. Implement a customer service program as a regular part of your general orientation for new employees. Stress that their job is to care for residents, and if they don't do this, we have no jobs.
8. Set up a marketing plan and set goals. Hold regular marketing meetings (monthly or semi-monthly).
9. Become more involved in your trade association and serve on a committee. Change committees every year. Expand your horizons.
10. Attend educational programs. Become more knowledgeable about our industry. Bring ideas and programs back to your facility and educate your staff.
11. Listen to your staff. Survey them at least annually on what they like and don't like about working at your facility. Build on that information. Keep current and competitive with wage structures in your area.
12. Have department heads set three or four goals for their departments each year. Review the goals in a group or individually each quarter.
13. Encourage new ideas from your staff. Build on them.
14. Send resident satisfaction surveys to families semi-annually. (Sample survey forms are available from the American Health Care Association "Quest for Quality" program.)
15. Follow up with discharged residents at one week, one month and six months post-discharge to see how they are doing. Make sure that they have the home-and community-based services that they need.
16. Network with other administrators. (ACHCA is an excellent forum for this and for educational support.)
17. Consider having an Administrator-in-Training at your facility. Develop a reputation for preparing administrators for the future.
18. Be survey-ready every day of the year.
Mary Kemper is Public Relations Specialist for the American Association of Homes and Services for the Aging (AAHSA). Before joining AAHSA, she worked at the Virginia Association of Homes and Services for the Aging. She is working on a public relations guidebook for nursing homes and retirement communities and is looking for success stories such as those told below. If your nursing home has an example of good public relations, she would like to hear from you. Send your information to Mary Kemper, AAHSA, 901 E. Street N.W., Suite 500, Washington, D.C. 20004-2037.
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|Date:||Nov 1, 1994|
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