Autonomy for nursing home residents
In 1991, Dr. William Thomas took a part-time job as medical director in a nursing home in upstate New York. Thomas, who trained in emergency medicine, had no aspirations to pursue a career in long-term care. But his outlook changed when he found that his strictly medical approach with residents wasn’t improving their health outcomes or quality of life.
“I came to the realization that to take good care of older people, it wasn’t enough to give them the right pills or the right tests,” said Thomas, now a professor of aging studies at the University of Maryland. “Those things were necessary, but not sufficient.”
What the medical model was not addressing, Thomas learned, was the loneliness, boredom and helplessness many of his elderly patients experienced in the typical nursing-home environment.
So Thomas began to change his approach. He brought in pets as companions for the residents. The more engaged patients became in caring for the animals, the less withdrawn they were with caregivers.
Thomas received a grant from New York state to pilot a model project for a nursing home based on 10 principles he developed from his experience. Those principles included creating a “human habitat,” allowing patients regular contact with animals, plants and children. The project got patients and nursing assistants involved in daily decisionmaking and eliminated set schedules for residents to wake up, eat or bathe.
“We’re talking really simple stuff,” said Chris Perna, CEO for Rochester, N.Y.-based Eden Alternative, which grew out of Thomas’ pilot “If
project. an elder wants to get up late one morning, the nursing assistant can allow them to sleep in.”
The original model was called the “Dementia Project,” which Thomas, along with his wife, Jude, developed over three years into a model that could be taught and replicated in nursing homes throughout the country. In 1994, they renamed it the “Eden Alternative,” which has become an international not- for-profit that provides education, training and consulting to more than 300 nursing homes in the U.S., Australia and Europe. Over the years, the model has expanded to independent living communities, adult day care, hospice and home healthcare settings. Thomas’ approach was outlined in his 1996 book, “A Life Worth Living.”
Staff at facilities that seek to adopt this approach go through a three-day training course, with a required minimum of 25% of staffers participating. Those staffers then go back to their facilities and teach their colleagues the Eden Alternative’s principles and practices.
It can take three to four years for the typical facility to fully implement the model. Perna said the biggest challenge is to get a sustained commitment from owners and administrators to implement the changes. “Culture change is extraordinarily hard work and requires a very persistent effort over a period of time,” Perna said. “But there’s no arguing with the effectiveness of it when the right ingredients are in place.”
Data collected in 2011 from nursinghome providers using the Eden Alternative model showed the average occupancy rate of Eden-trained nursing homes was 93%, compared with the national average of 86%. The average annual turnover rate of licensed practical nurses at Eden-model facilities was 16%, compared with the national average of 39%. Average annual turnover of nursing assistants was 26%, almost half the national average of 42%.
Staff at Eden Alternative facilities stay longer because they are “able to do what they got into this profession to do, which is to provide real care,” Perna said. “It’s not just running around with a clipboard. The focus is on the people who are being cared for.”
A 2013 study published in the journal Clinical Interventions in Aging found the Eden Alternative model was associated with “significant improvements in residents’ levels of boredom and helplessness.” Another study published in 2007 in the peer-reviewed journal Federal Practitioner found that accidental falls and assaults by patients residing in the dementia unit at the VA Pittsburgh Healthcare System fell significantly following adoption of the Eden approach.
Dr. Christian Furman, vice chair of geriatrics at the University of Louisville School of Medicine, said that since the Eden Alternative model has been adopted at four nursing homes affiliated with her school over the past 10 years, she has noticed a reduction in depression and pain issues and an overall improvement in their quality of life. “It’s been great at our facilities,” she said. “We’re able to treat their pain, and they’re not going back and forth to the hospital.”
Thomas said the Eden Alternative strives to change institutional culture by changing the stories nursing-home staff tell each other about what they’re doing. “The new story we started to tell is that long-term care is devoted to helping people grow,” he said.