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Service Delivery Innovation Profile

Creation of Households Program in Nursing Home Improves Residents' Health Status, Reduces Staff Turnover, and Boosts Demand for Services


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Snapshot

Summary

Meadowlark Hills, a retirement community, renovated one of its facilities so that residents can live together in group households and become more independent. An architectural redesign replaced the standard nursing home layout (e.g., long hallways, nursing stations, one large dining hall) with six "households" with 12 to 25 beds each. Each household has its own living room, dining room, kitchen, porch, and patio, as well as staff that attend to residents' medical, dietary, and housekeeping needs. Residents choose when they wake up and go to sleep, when and what they eat, and the activities in which they want to participate. The change in approach led to improvements in residents' health, a sharp decrease in staff turnover, and a significant increase in demand for facility services, all without raising operating costs.

Evidence Rating (What is this?)

Moderate: The evidence consists primarily of pre- and post-implementation comparisons of resident and family satisfaction and engagement, staff turnover, and occupancy rates/waiting lists.
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Developing Organizations

Meadowlark Hills
Manhattan, KSend do

Use By Other Organizations

Nursing home officials from 42 states and 14 countries have visited Meadowlark Hills seeking ideas they can apply at their own facilities. Each Friday, the campus is open for informational tours to long-term care professionals and the general public.

Date First Implemented

2001
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Patient Population

Age > Aged adult (80 + years); Vulnerable Populations > Frail elderly; Age > Senior adult (65-79 years)end pp

Problem Addressed

The traditional nursing home model often provides a poor quality of life for residents and an undesirable work environment for staff that leads to high turnover.
  • Unpleasant environment for residents leads to a decline in health status: Facilities frequently resemble hospitals, with long, sterile hallways and centralized nursing stations. Residents have little control over their lives, with staff determining when they wake up and go to sleep, when and what they eat, and what they do during the day. Many residents become bored and depressed, which leads to cognitive and physical decline.1
  • Unpleasant environment for staff leads to high turnover: This model also creates a negative work environment for staff, who may have little opportunity to get to know the patients. Many nursing home staff become disenchanted with their jobs and quit. Annual turnover at conventional nursing homes typically ranges from 70 to 100 percent.2

What They Did

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Description of the Innovative Activity

Meadowlark Hills, a retirement community, implemented a households program by redesigning the physical space within living areas and revamping policies, procedures, and staffing, with the goal of creating an environment where residents feel as if they live independently in their own homes. Major aspects of the new approach include the following:
  • Redesigned living areas: Meadowlark Hills was divided into six living areas, known as "households," with each being home to 12 to 25 residents. Each household has a living room, dining room, kitchen, porch, and patio. In six of the eight households, residents have their own bedroom and bathroom. In two households, residents share the bedroom and bathroom with a roommate. A number of features make the households similar to typical houses or apartments:
    • Privacy and independence: Each household has a doorbell, so (like anywhere else) visitors cannot walk in unannounced.
    • Pleasant design: Large windows and strategically placed lights provide an inviting view of the area's mountains. In addition, Meadowlark Hills has an aviary and an aquarium.
    • Opportunity to decorate: Residents can decorate households with plants, paintings, and other items. Residents may have pets, including cats and dogs.
    • Own identity: Each household was named after individuals (e.g., "Starkey" and "Honstead") whose donations helped fund the renovations and expansions.
  • Control over daily schedules and activities: Residents control their own activities. They decide when they want to wake up, bathe, and go to sleep; when and what they want to eat; and what activities they will participate in. Residents have a number of options for activities, including the ability to go to the onsite hair salon or see a physiotherapist. In addition, Meadowlark Hills maintains several vans and small buses, enabling residents to arrange to leave Meadowlark Hills to engage in activities such as shopping, seeing a movie, or going out for dinner.
  • Self-directed work teams for each household: Each household has its own permanent staff consisting of a nurse, a nurse's aid, a cook, and a housekeeper. These positions are staffed in 3.6 to 3.7 hours per resident day. Instead of being limited to prescribed set of tasks, all staff handle a broad range of responsibilities. For example, in addition to dispensing medication, a nurse may help with cooking and doing light housekeeping. Having a permanent staff allows employees to get know residents as individuals, including learning about their personal preferences (e.g., preferred wake-up time, favorite foods, and health issues).
  • Continuous improvement: Meadowlark Hills holds ongoing meetings, known as "learning circles," during which staff, residents, and family members discuss ways of addressing a particular problem. Whoever has the most expertise in the subject matter leads the session. Learning circles are critical to enhancing residents' quality of life.

Context of the Innovation

Meadowlark Hills is a nonprofit retirement community in Manhattan, KS. The 126-bed facility that implemented the households program serves residents who largely function independently but sometimes need assistance. The average age of residents in the continuing-care retirement facility is 89, with approximately 40 percent of residents receiving Medicaid. In addition to the facility turned into households, the community's 40-acre campus includes three other types of housing: independent living apartments, garden homes, and cottages for the most active residents; assisted living suites for people who need moderate help preparing meals, bathing, dressing, and moving from place to place or taking medications; and assisted living memory support residences for residents with Alzheimer's disease or other forms of dementia. The overall average age of residents living within all of the facilities on the campus is 81.

The creation of the households program at the 126-bed facility occurred as part of a larger redesign and expansion of the entire Meadowlark Hills campus, which occurred from 1997 to 2001. Another expansion of the campus was started in 2008 and was completed in 2009. The original redesign was inspired by the organization's new chief executive officer, whose mother had been a resident of a nursing home facility. Dissatisfied with the institutional feel and the effect it had on his mother's health, he decided to push for an improvement in the traditional nursing home living environment. The overriding goal was to create an environment in which residents direct their own lives, enabling them to continue to grow as individuals.

Did It Work?

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Results

The creation of the households program improved clinical outcomes for residents, increased job satisfaction among employees, and increased demand for Meadowlark Hill's services, without raising overall operating costs.
  • Improved outcomes for residents: Staff observed residents who had previously been inactive and vacant eyed reengage socially as a result of the households program. Survey results as well as informal feedback from residents and families showed that their satisfaction levels increased. Residents' families became more engaged in life at Meadowlark Hills as a result of the redesign.
  • Increased job satisfaction and reduced turnover: Staff turnover was reduced by 50 percent compared with turnover rates before the redesign, and staff indicated that they were more satisfied. Before implementing the household model, staff turnover at Meadowlark was approximately 80 percent. Within the first year of the redesign, the staff turnover rate decreased dramatically and has continued to do so—currently, staff turnover at the facility is 30 percent. In addition, Meadowlark Hills has increased its opportunities for employee career advancement, growth, and promotion.
  • Constant costs: Despite the improvements, ongoing operating costs at Meadowlark Hills have held steady. The ratio of number of staff per resident has remained constant because, although the number of residents has increased, so has the number of employees (78 in 2000 vs. 370 in 2007).
  • Enhanced reputation, leading to wait lists and ability to raise prices: Since the redesign at Meadowlark Hills, more people in the community have wanted to live there. In 1997, about 12 percent of beds were vacant; by 2008, the facility was completely full with a 300-person waiting list. The increased demand enabled the facility to raise its prices. The additional revenue more than covered the nonoperating costs required to implement the new model (e.g., architectural redesign and additional training).

Evidence Rating (What is this?)

Moderate: The evidence consists primarily of pre- and post-implementation comparisons of resident and family satisfaction and engagement, staff turnover, and occupancy rates/waiting lists.

How They Did It

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Planning and Development Process

Key steps in the planning and development process include the following:
  • Formation of planning committee: The director formed a steering committee of 12 formal and informal leaders of the Meadowlark community, including department directors, board members, and staff members, to investigate potential changes that would eliminate as many medical/institutional features of the facility as possible. The committee, which met monthly for several years, solicited ideas from residents, family members, staff, vendors, and community members via focus groups; conducted demographic and financial feasibility studies; and developed a strategic plan. The original steering committee eventually formed focused action groups, which are ongoing, of Meadowlark residents, staff members, family members, and community members. These action groups address specific topics important to the community, such as dining options and learning circle topics.
  • Architectural redesign: In 2001, the facility was redesigned to eliminate institutional features and make the living environments into group households. In addition to the redesign of the living areas (described previously), key design changes included replacing the hospital-style nurses' stations with rolltop desks and eliminating the stainless steel transport racks, medicine carts, and beeping wander-guard alarms.
  • Training: All employees received training to broaden their skills to areas outside their typical expertise. The training was conducted by professionals outside of the Meadowlark Community and addressed core competencies, such as listening, critical thinking, and empathy. Staff were trained in small groups, and it took approximately 1 year to have all staff trained in each core competency.

Resources Used and Skills Needed

  • Staffing: The new households program was implemented with existing Meadowlark staff.
  • Costs: The facility redesign cost roughly $1.5 million, whereas initial training costs for employees at this facility were approximately $80,000. After approximately 3 years, these costs were offset by increased profits due to the facility's higher occupancy rates and prices.
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Funding Sources

Funding for the expansion (which included the facility redesign to create the "households") came from the issuance of industrial revenue bonds ($27 million) and donations from community members ($3 million).end fs

Tools and Other Resources

Meadowlark Hills benefited from its membership in the Pioneer Network, a nonprofit coalition that works to improve conditions in nursing homes. More information is available at: http://www.pioneernetwork.net/.

Adoption Considerations

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Getting Started with This Innovation

  • Do not be hemmed in by preconceptions: Nursing home leaders are often reluctant to make major changes, fearing that "it can't be done" or that government regulators will object. In Meadowlark Hills' experience, regulators greeted the planned changes with enthusiasm and encouraged further innovation.
  • Connect with like-minded leaders: Although most nursing homes still follow the traditional medical model, a small but growing number have adopted new approaches. Meetings and discussions with the leaders of these facilities (e.g., those active in the nonprofit Pioneer Network) can generate ideas for reforming a facility.
  • Articulate the vision in nonbureaucratic language: In building support for change, describe the new vision in direct language that everyone can understand. For example, comments from Meadowlark Hills' chief executive officer included easily understood statements, such as, "It's not like a home, it is home," and "A retirement community should be a place to continue to grow, not a place to come to die."

Sustaining This Innovation

  • Seek continuous improvement: Meadowlark Hills' use of "learning circles" provides an open atmosphere that encourages staff and residents to suggest changes that can improve quality of life for residents at the facility. A key to the success of these meetings is the ability of anyone with expertise in the subject to lead the discussion, regardless of his or her educational background or job title.
  • Involve the community: Encouraging visits from community groups, volunteers, and the media helps make the facility more vibrant, raises awareness of what life is like in later decades, and often leads to good suggestions on how to improve residents' quality of life.

Use By Other Organizations

Nursing home officials from 42 states and 14 countries have visited Meadowlark Hills seeking ideas they can apply at their own facilities. Each Friday, the campus is open for informational tours to long-term care professionals and the general public.

More Information

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Contact the Innovator

Lonnie Baker
Chief Executive Officer
Action Pact Development, LLC
2505 Anderson Avenue, Suite 202
Manhattan, KS 66502
(785) 323-3878
E-mail: Lonnie.baker@meadowlark.org

Innovator Disclosures

Mr. Baker has not indicated whether he has financial interests or business/professional affiliations relevant to the work described in this profile.

References/Related Articles

An archive of news articles and videos about Meadowlark Hills is available on the facility's Web site:
http://www.meadowlark.org.

Footnotes

1 Boyd CK. The Providence Mount St. Vincent experience. Journal of Social Work in Long-Term Care. 2003;2(3/4):245-68.
2 Boyd C, Johansen B. A cultural shift. Resident-directed care at Providence Mount St. Vincent in Seattle places elders at the center of the universe. Health Prog. 2008;89(1):37-42. [PubMed]
Comment on this Innovation

Disclaimer: The inclusion of an innovation in the Innovations Exchange does not constitute or imply an endorsement by the U.S. Department of Health and Human Services, the Agency for Healthcare Research and Quality, or Westat of the innovation or of the submitter or developer of the innovation. Read more.

Original publication: August 18, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: August 13, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

Date verified by innovator: August 06, 2014.
Date verified by innovator indicates the most recent date the innovator provided feedback during the annual review process. The innovator is invited to review, update, and verify the profile annually.