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Just as the Green House Project® announced the completion of the nation’s 100th Green House home in September, Seniors Home & Care Journal published an article concluding that the Green House model’s operations are “comparable in cost to traditional nursing homes as well as nursing homes that are implementing other culture change practices.”

The article, “Financial Implications of The Green House Model,” explains that several published studies have already shown that the Green House Model of licensed nursing homes “provides significant and sustained satisfaction and clinical improvements when compared to traditional nursing homes,” but that questions remain as to the model’s initial and long-term financial viability.

The authors review past studies on the financial performance of the Green House Model and report on two recent studies that look at the 1) costs of Green House administration and organizational staffing, and 2) environmental costs, overall financial performance, and benchmarks of Green House homes.

The first study found that the total estimated personnel costs of the Green House homes and traditional models are “essentially equal.”

While there is an increase in the number of full-time direct employees in the Green House homes compared with traditional facilities, this increase is offset by a reduction in the number of both administrative and support staff (housekeeping, laundry, and food service staff), the authors report.

Shahbazims’ Larger Role Reduces Other Costs

In the Greenhouse model, the certified nurse assistants known as Shahbazim are responsible for the tasks of these support staff in addition to their typical direct-care duties.

The authors attribute the reduction in administrative full-time employees to the increased role of both the nursing staff and the Shahbazim who coordinate care and maintain patient records in the Green House model rather than having unit secretaries or charge nurses do so.

The second study compares the overall costs — including food costs, plant operations, ancillary costs and administrative expenses — of Green House homes to traditional nursing homes. It also compares their capital costs, both per square foot and per unit.

In this study, the authors conclude that the capital costs of the Green House homes are equivalent or less than similar culture change models but higher than traditional facility designs. They note that the increased occupancy and more private-pay days that are associated with the Green House model may offset these capital costs.

Tripling the Number of Green House Homes

The Robert Wood Johnson Foundation, a partner of the Green House Project, announced the organizations’ mutual goal of tripling the number of Green House homes in the next three years.

PHI, also a partner with the Green House Project, has worked with the project to imbed its Coaching Approach^SM in the educational offerings for all Green House staff, including the formal leadership team, nurses, and the self-managed work team of Shahbazim.

– by Deane Beebe

The National Fire Protection Association (NFPA) has revised its Life Safety Code handbook to include provisions in the health care occupancy rules that support making nursing homes more home-like environments.

Four proposals recommended by the Pioneer Network to “create home in the nursing home” have been included in the 2012 edition of the NFPA 101^® Life Safety Code^®, according to a statement by the national culture-change organization.

The proposals that have been adopted, with some restrictions and providing that certain criteria are met, are:

• Kitchens serving no more than 30 residents will be permitted to be open to the corridor and other spaces, and either residential or commercial stoves or cooktops may be used.
• Furniture may be provided in corridors.
• Combustible decorations will be permitted in resident rooms, corridors, on doors, and in common space.
• Gas or electric fireplaces will be allowed to be used in smoke compartments that contain sleeping rooms, but not within individual sleeping rooms.

The Pioneer Network plans to advocate for the federal Centers for Medicare and Medicaid Services (CMS) to also accept these revisions, followed by states.

New Dining Practice Standards

Additionally, the Pioneer Network has proposed new Dining Practice Standards (1.4 MB pdf) that “support individualized care and self-directed living” for people living in nursing homes.

The proposed food and dining standards, such as individualized nutrition approaches and a diabetic/calorie-controlled diet, “reflect evidence-based research available to-date as well as current thinking which is in some cases in advance of research,” a press statement from the group explains.

The Dining Practices Standards have already been agreed to by 12 national clinical standard setting organizations, including the American Association of Long Term Care Nursing and National Association of Directors of Nursing Administration in Long Term Care.

The Pioneer Network is planning to submit the Dining Practices Standards to CMS as well as to the U.S. Food and Drug Administration, Centers for Disease Control, and the long-term care community, and anticipates that CMS “will refer to these new agreed-upon standards of practice within [their] long-term care interpretive guidance where they fit.”

– by Deane Beebe

A set of 20 proposed quality measurements for Ohio nursing homes includes three related to the staffing of direct-care workers.

Many of the 20 measurements are also designed to make Ohio’s 900 nursing homes more person-centered.

The three staffing-related measures require nursing homes to:

• maintain a written policy mandating consistent assignment of state-trained nursing assistants (STNAs);
• demonstrate an STNA turnover rate at or below 65 percent; and
• document that STNAs who are primary caregivers attend and participate in at last half of their nursing home’s resident care conferences.

The full set of proposed measures (pdf) was submitted to the Ohio legislature on September 1 by the Nursing Facility Quality Measurement Subcommittee of the state-appointed Unified Long-Term Care System Advisory Workgroup.

The subcommittee included advocates for the elderly, nursing home representatives, and state officials and legislators.

“Consistent assignment and low turnover rates among direct-care workers have been linked to high-quality care, cost efficiency, and strong satisfaction rates in nursing homes,” said Bonnie Kantor-Burman, the director of the Ohio Department of Aging and a subcommittee member.

“We made sure to include those concepts in our 20 measurements to help ensure that Ohio’s nursing home residents receive the highest quality care possible,” she added.

Focus on Person-Centered Care

Many of the quality measurements are related to the concept of person-centered care, which promotes the dignity and autonomy of the person receiving care.

Some of the measures are based on whether residents are allowed to make their own decisions regarding their sleep schedule, dining preferences, bathing frequency, and room décor.

Other measurements are tied to overall clinical outcomes — such as the facility’s rate of pressure ulcers and urinary tract infections — as well as the results of resident and family-member satisfaction surveys.

The Nursing Facility Quality Measurement Subcommittee designed the measurements to be evidence-based and easy to quantify.

Measurements Tied to Medicaid Payments

Nursing homes that fulfill at least five of the 20 measures will be rewarded with a slightly higher Medicaid payment. Those facilities will receive $168.84 per Medicaid bed day, compared with $152.40 for those that fail to achieve five of the measurements.

The subcommittee, however, says in its full set of proposed measures that it “assumes that every nursing facility will receive the full quality incentive payment.” Furthermore, the subcommittee “strongly believes” that all 20 performance measures are achievable.

The state legislature will vote on the proposed measurements by the end of the year; they could take effect as soon as July 1, 2012.

– by Matthew Ozga

Three brief stories on direct care:

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Pioneer Network Extends Early Bird Registration

The registration deadline for the Pioneer Network‘s 2011 National Conference has been extended until Tuesday, June 7.

This year’s conference will take place in St. Charles, Missouri, from August 1-4.

The Pioneer Network is a leader in the culture change (pdf) movement and an advocate for person-directed care.

Effective June 27, Peter Reed, Ph.D., M.P.H., will take the helm as the organization’s new executive director.

Visit the Pioneer Network website to learn more about the conference and to register.

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Fund Created for Nursing Home Employees Hit by Tornado

The Missouri Health Care Association (MHCA) has established a charitable fund and grant program to help employees and their families who suffered damage from the devastating tornado that ripped through Joplin, Missouri, on May 22.

At least 10 nursing home residents and one employee were killed in the tornado, and three Joplin nursing homes are no longer habitable, according to McKnight’s Long-Term Care News.

More information on the fund and information on how to donate is available on at the MHCA website.

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Consumer Voice Publishes New Guide on Choice and Advocacy

The National Consumer Voice for Quality Long-Term Care launched Piecing Together Quality Long-Term Care: A Consumer’s Guide to Choices and Advocacy, a national guide intended to:

• educate older adults and people with disabilities about options for long-term services and supports;
• empower consumers to become self-advocates for quality long-term care; and
• provide information and resources to assist people currently living in nursing homes to move back into the community.

The Consumer Voice has also created a document to assist groups that want to develop state-specific guides. Kansas, North Carolina, and Virginia have already published guides for consumers in their states.

– by Deane Beebe

Many nursing homes and home care agencies are lobbying for an exemption from a health-reform mandate requiring employers to offer health coverage to employees beginning in 2014, according to an article published in The New York Times on May 15.

The article by Robert Pear cites PHI research stating that 26 percent of direct-care workers in nursing homes and 37 percent of home care workers lack health coverage.

Under the terms of the Affordable Care Act, employers with 50 or more full-time employees would be required to offer affordable, comprehensive health coverage, or risk facing a penalty.

Long-term care industry groups say that many nursing home and home care agencies cannot afford to pay for their employees’ coverage unless Medicaid and Medicare reimbursement rates are increased, Pear reports.

Others, however, say that the uniquely dangerous work done by direct-care workers is a strong argument in favor of mandatory coverage.

“It’s scandalous to have nursing home employees taking care of people when they themselves lack coverage and go without care,” said Charlene Harrington, a professor at the School of Nursing at the University of California, San Francisco.

Defending the Affordable Care Act in the article, PHI Director of Policy Research Dorie Seavey says, “This assistance could significantly increase coverage among direct-care workers.”

The Times‘s piece has since been cited in these and other articles:

• Connie Schultz, a columnist for the Cleveland Plain Dealer, trails a local direct-care worker, who says she is anxious about what will happen to her job if Medicaid is cut.
• New America Media commentator Paul Kleyman takes a deeper look at The New York Times‘s article.

– by Matthew Ozga

Florida State Capitol in Tallahassee

Florida direct-care workers and nursing home residents will feel the effects of the dramatic budget cuts passed by the state legislature late last week.

The budget calls for a 6.5 percent cut to Medicaid reimbursement rates, which amounts to approximately $187 million in cuts to Medicaid-funded nursing homes.

Florida’s Republican-dominated legislature passed the budget bill in the early-morning hours of May 7.

Staffing Requirements Lowered

To offset the budget cuts, state staffing requirements for nursing homes will be lowered.

The minimum number of daily hours of care provided by certified nursing assistants (CNAs) will be lowered to 2.7 hours, from 2.9.

Overall, nursing home residents will be required to receive a minimum of 3.6 hours of daily direct care from nurses and CNAs combined, down from 3.9 hours.

In the past, Florida had “stood out as one of the few states that made a commitment to staffing its nursing homes near the level we know is necessary to provide basic care and services — 4.13 hours per resident day,” said Janet Wells, director of public policy at the National Consumer Voice for Quality Long-Term Care.

Wells continued:

It is devastating that the legislature has gone back on that commitment on the false premise that reducing staff will save the state money. Hospitalization to treat pressure sores, dehydration, broken bones, and other medical conditions related to understaffing will offset any savings gained from firing nurse aides who make $11 an hour.

Staffing Reductions and Budget Cuts Criticized

The reduction in state-mandated staffing hours means that nursing home residents will get “less assistance with their basic living activities,” thus degrading the quality of care they receive, said Terry Bucher, the director of education at the Florida Professional Association of Care Givers.

The 6.5 percent budget cut will also likely require nursing homes to cut direct-care workers’ hours — or lay them off entirely — just to stay afloat economically, Bucher added.

“Many of these direct-care workers are single heads of household; thus the [economic] ripple effect is difficult for them…in an economic time that has already left their families struggling,” she said.

Governor Expected to Sign

Gov. Rick Scott (R) is expected to sign off on the legislature’s budget within the next several weeks, observers say.

The Florida budget will also cut Medicaid support for hospitals by a larger-than-expected 12 percent, or $510 million.

– by Matthew Ozga