TOOLS
for Change
VOL. 1 NO. 2
APRIL 2011
Positive Outcomes of Culture Change —
The Case for Adoption
Pioneer Network is committed to studying how adopter outcomes translate into more quantifiable metrics and to
benchmark those metrics with national data. The goal of this work is to accelerate adoption and support implementation
and sustainability by articulating the operational linkages between person-centered care, quality of care, and financing —
The Case for Adoption.
Recent evidence demonstrates the positive outcomes of culture change. In general, this evidence can be categorized
into four broad impact areas: organizational, quality of care, staffing and life engagement.
Examples of Organizational Impact: Increased levels of occupancy; Increased percentage of private pay census;
Reduction in the use of agency staff; Increases to operating margins; Improved market position; Waitlists for residents;
Strengthening of outside community support (donations) and volunteers.
Examples Quality of Care Impact: Improvements in quality indicators most correlated with person-centered
principles including use of restraints, weight loss, falls, agitation, pressure ulcers, medication use, time in a bed or chair and
re-hospitalizations.
Examples of Staffing Impact: Reductions in turnover (leadership team, clinical, front-line staff ); Low or no use of
agency staff; Fewer “call-offs” or sick days; Increased levels of staff satisfaction formally (surveys) and informally (verbally
to peers and leadership); Active understanding of culture change and person-centered principles by the majority of staff;
Formal recognition of employees for excellence in person-centered care; Self-motivation, critical analysis, and problemsolving by front-line staff to incorporate person-centered principles.
Life Engagement: Increased levels of resident satisfaction formally (surveys) and informally (verbally to peers and
staff ); Resident choice in daily activities and routines (measured by care plans); Increased levels of engagement especially in
residents with chronic health conditions or dementia (measured by MDS 3.0); Emphasis by residents and staff on relationships
and community; descriptions of the organization as “home” or “family.”
Examples of Pioneer Network’s findings to demonstrate these outcomes are highlighted below.
OCCUPANCY
Mean Occupancy Rate
by Implementation Years
100
■ Early Adopters
■ <5 Years Implementation
■ National Average
95
Adopter homes have a statistically significant higher occupancy
rate (longitudinally — suggesting consistency) than the
national average.
• The green line represents that early adopters (sustained for
nine years or more) maintain, on average, occupancy rates
9 points higher than the national average. With a 100 bed
assumption and private pay rates, 9 occupancy points
equates to $719,415 in potential additional revenue (based
on the 2009 MetLife Nursing Home Survey equating private
pay rates to $79,935 a year).
90
85
80
2005
2006
2007
2008
2009
2010
• The yellow line represents mid stage adopters implementing for 5 years or less. Occupancy has consistently been rising for
New
York
Occupancy Percentage
this
group
post-implementation.
An increase of occupancy by 3 points (with the 100 bed private pay assumption) equates
100to an additional $239,805 in potential yearly revenue for this group of homes.
95
Case
studies99
confirm these findings:
90Occupancy Rate
93
100
85
Teresian House Occupancy Versus NY and U.S. Average
■ USA ■ NY State ■ Teresian House
100%
95
80
97%
90
Adopter
Non-Adopter
94%
85
80
100
Providence Occupancy Percentage
Case Study Adopters National
95
96
90Denver Occupancy Percentage
100
85
95
REVENUE
80
90
91%
88%
New York Occupancy Percentage
85%
100
1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
95
99
93
entitled “Occupancy and Revenue Gains from Culture Change in Nursing Homes: A Win-Win Innovation for a
A recent study 93
Adopter
Non-Adopter
New
Age
of
Long-Term
Care,” found
positive outcomes and revenue
gains from culture change adoption1. Experts in culture
85
85
90
90
change were asked to identify facilities that “best exemplified homes engaged in sustained culture change innovation.” This
80
80
defined as homes engaged in change for two years or more
in key areas of care practice, environment, and workplace.
was
78 group of similar homes on two variables: percentage of beds occupied, and revenue
Adopters were compared with a control
Adopter
Non-Adopter
Adopter
Non-Adopter
per bed per
day. Data are from
2004, pre-culture change, and 2008, after
adopters had been
engaged in culture change for
at least two years.
1 A.Omaha
E. Elliot, “Occupancy
and Revenue
Gains from Culture Change in Nursing Homes:
A Win-Win Innovation
for a New
Age of Long-Term Care,” Seniors
Occupancy
Percentage
Providence
Occupancy
Percentage
Housing & Care Journal, 2010 18(1):61–76 : http://www.nic.org/NicStore/p-352-2010-seniors-housing-care-journal.aspx
100
100
95
95
90
90
TOOLS for Change
96
90
2
Key Findings
• From 2004 to 2008, nursing homes in the adopting group experienced a modest but significant improvement in
occupancy compared with the control group. Both groups had occupancy rates of 86 percent before culture change
was implemented in 2004, but by 2008, the occupancy rates of adopter homes increased to 89 percent, while those
in the control group remained at 86 percent.
Occupancy
Rate significantly for adopter homes when compared with control-group homes. Implementing culture
• Revenue increased
100Occupancy
Rate in an additional $11.43 per bed per day for a 140-bed nursing home. This translates to an additional
change resulted
100
95
$584,073 in revenue per year for the adopter home.
95
90
MARKET
POSITION
90
85
Below
are examples of statistically significant competitive advantage (as measured by occupancy) for adopter homes in four
85
80
major
cities. Data are from Nursing Home Compare 2010 and represent Medicare certified SNF’s and CCRC’s located within
80 city limits. Cities chosen are those markets where adopter homes represent 15% or more of beds in the Nursing Home
the
Study Adopters
National
CompareCase
database
(to establish
a relevant comparison).
Case Study Adopters National
Denver Occupancy Percentage
100Denver Occupancy Percentage
New York Occupancy Percentage
100New York Occupancy Percentage
100
95
100
95
95
90
90
85
95
90
93
93
99
99
90
85
93
93
85
80
85
80
80
Adopter
78
78
Non-Adopter
80
Adopter
Denver
adopter beds = 20%
(487 out of 2477 total )
Adopter
Non-Adopter
Denver adopter organizations = 25% (6 out of 24 total)
Non-Adopter
New York
adopter beds = Non-Adopter
24% (1,355 out of 5,662 total)
Adopter
New York adopter organizations = 15% (3 out of 20 total)
Omaha Occupancy Percentage
100Omaha Occupancy Percentage
Providence Occupancy Percentage
100Providence Occupancy Percentage
100
95
100
95
95
90
95
90
90
85
85
80
90
85
89
89
90
90
85
80
Adopter
80
80
Non-Adopter
Adopter
Non-Adopter
80
96
96
Omaha adopter beds = 17% (455 out of 2665 total)
Omaha adopter organizations = 14% (3 out of 21 total)
80
Adopter
Non-Adopter
Adopter
Non-Adopter
Providence adopter beds = 30% (356 out of 1199 total)
Providence adopter organizations = 25% (3 out of 12 total)
TOOLS for Change
3
PRIVATE PAY CENSUS
Data supports that adopters experience an almost 1-to1 correlation between increases in private pay and decreases in
Medicaid occupancy.
% Change Medicaid Occupancy
from 2004 to 2008
% Change Private Pay Occupancy
from 2004 to 2008
0%
-1%
6%
-2%
-3%
5%
4%
-4%
-5%
3%
-6%
-7%
-8%
-9%
2%
1%
Percent of High-Risk Residents
with Pressure Sores
■ Adopter ■ National Average
15
Adopter
Adopter
National
6
National
5
12
4
9
3
6
CLINICAL OUTCOMES
2
3
1
Pioneer Network continually tracks clinical outcomes of adopters and finds consistent, positive results. Below are longitudinal
0
examples.
Percent
Percent
of High-Risk
of High-Risk
Residents
Residents
with with
Pressure
Pressure
SoresSores
15
15
12
12
9
9
6
6
3
3
0
0
0
2007
■ Adopter
■ Adopter
■ National
■ National
AverageAverage
2007 2007
2008 2008 2009 2009
2008
2009
Percent of Residents
Physically Restrained
Percent
Percent
Who Who
SpentSpent
MostMost
of Time
of Time
in Bed
inor
Bed
Chair
or Chair
6
6
■ Adopter
■ Adopter
■ National
■ National
AverageAverage6
5
5
5
4
4
4
3
3
3
2
2
2
1
1
1
0
0
■ Adopter ■ National Average
0
2007 2007
2008 2008 2009 2009
2007
2008
2009
Percent
Percent
ofAside
Residents
of from
Residents
the substantial benefits to residents from these reductions, there are obvious cost implications as well.
Physically
Physically
Restrained
Restrained
AHRQ estimates that the average pressure ulcer-related hospital stay extends to between 13 and 14 days and costs between
6
6
■ Adopter
■ Adopter
■ National
■ National
AverageAverage
$16,755 and $20,430, depending on medical circumstances.
5
5
4
4
2
Culture change is a process not a program. Quality of life, a decreased % of time spent in a bed or chair and fewer
3
are inherent in this person-centered process. Although quality programs such as Advancing Excellence are making
restraints
great
strides in reducing these outcomes nationally, adopter homes have achieved these outcomes for over 10 years.
2
1
1
0
0
3
2007 2007
2008 2008 2009 2009
TOOLS for Change
4
4%
4%
3.5 3.5
3.0 3.0
99%
99%
80 80
2.5 2.5
60 60
2.0 STAFFING
2.0
12 12
87%
87%
40 40
1.5 1.5
ce
8
8
6
6
7%
7%
Examples of staffing impact from case studies are below (view full case studies at www.pioneernetwork.net/Providers/CaseStudies/).
4 4
1.0 1.0
20 20
1%
1%
0.5 0.5
2
Teresian House
0.0 0.0
0
U.S.
U.S.
Average
Average
Providence
Providence
Teresian
House
Staff
Longevity
Teresian
House
Staff
Longevity
0
Providence
Providence
1.2 million
2005
Position
PositionAverage
Average
Years
Years
of of
Service
Servi
10 10
10-15
10-15
yrs.yrs.
8
8
6
■ 1<year
1 year
26%
■<
26%
■
1–5
years
34%
■ 1–5 years
34%
5–10
years 16%
16%
■■
5–10
years
■
10–15
years
■ 10–15 years
8%8%
■
15+
years
16%
■ 15+ years
16%
9%
9%
6
5-10
5-10
yrs.yrs.
4
4
2
2
0
0
2%
2%
2006
0
2007
0
60%60%
Nursing
Nursing
0
2009
0
Nursing-CNA
Nursing-CNA
$1,000,000
$2,000,000
Rehab
Rehab
Services
Services
Housekeeping
Housekeeping
U.S.U.S.
Average
Average
Laundry
Laundry
0 0
3 3
6 6
12
87%
50%50%
12%
10
50%50%
8
40%40%
40%40%
6
7%
30%30%
4
20%20%
30%30%
20%20%
2
10%10%
U.S.
Average
0
47%47%55%55%
56%56%
0 0
Administration
Administration
0
2008
Nursing
Nursing
Administration
Administration
1-51-5
yrs.yrs.
Providence
Providence
U.S.U.S.
Average
Average
1.5 million
2004
15+
2008
2008
Percent
Percent
Long-Stay
Long-Stay
Residents
Residents
15+
yrs.yrs.of of
Who
Who
Lost
Lost
TooToo
Much
Much
Weight
Weight<1<1
yr.yr.
2
0 0 Staff
U.S.
U.S.
Average
Average
Dollars
Spent on Agency
Providence
Providence
St.Percent
Vincent
Providence Mount
2008
of Long-Stay Residents
e Occupancy
Whose
Ability
About
In and
Percentage
Percentage
of of
Staff
Staff
Turnover
Turnoverto Move
Percentage
Percentage
of of
Staff
Staff
Turnover
Turnover
Around
Their
Room
Got
Worse
Before
Before
Culture
Culture
Change
Change
After
After
Culture
Culture
Change
Change
%
12%
12%
10 10
10%10%
U.S. Average
36%36%
36%36%
43%43%
35%35%
11%11%
12%12%
20%20%
14%14%
16%16%
Providence
0 0
1989
1989
1990
1990
1991
1991
1998
1998
1999
1999
2000
2000
2001
2001
2002
2002
2003
2003
2004
2004
2005
2005
2006
2006
Position Average Years of Service
Administration
Nursing
Nursing Administration
ff Turnover
nge
Nursing-CNA
Rehab Services
Housekeeping
Laundry
0
3
6
9
12
15
TOOLS for Change
5
3.8
Overall satisfaction with communication
A staff member coordinated my stay
Wesley Village
3.9
Wesley Village CNA Turnover
The staff listened to what I said
3.9
80
Visit
www.pioneernetwork.net/Providers/CaseStudies/Wesley/
The staff talked with me
to view the Wesley Village case study
70
60
0
3.8
70%
50
1 40
2
3
4
5
30
20
18%
10
Overall Satisfaction
(Short-Stay Rehab)
0
Wesley Village U.S. Average
98%
98%
While quality of life is the most important outcome of culture change and person-centered care, resident
satisfaction is one
Resident Satisfaction
Would recommend to a friend
Satisfied with overall facility
proxy for this measurement in nursing homes. Below are examples from case studies(view full case studies at
0
10%
http://www.pioneernetwork.net/Providers/CaseStudies/).
20%
30%
40%
50%
60% 70% 80% 90% 100%
Providence Mount St. Vincent
Satisfaction with Clinical Care (Short-Stay Rehab)
3.9
3.8
4.0
3.9
3.9
3.9
3.8
Facility provided me with "best available" medical treatments
My pain was well controlled
I was treated with dignity
I was confident that staff knew their jobs
Staff were able to answer my questions
Nursing assistants were technically skilled
Overall satisfaction with clinical care
0
4
Recommendation of the Mount
3.8 3.7 3.7 3.9 3.7
3.6 3.8 3.6
4
3.6 3.7 3.6
1
2
3
4
5
3.7 3.9
Score
3
2
1
Nov
Dec
Oct
Sep
Aug
July
June
May
Apr
Mar
Feb
Jan.
Dec
Nov
0
3.6
3.7
Additional Resources are available at
Staff Responsive to Concerns
http://www.pioneernetwork.net/Providers/Case/
4
3.8
3.5
3.4
3.6
3.7
3.8
3.6
3.7
3.7
3.6
3.6
3.8
2
Made Possible with Support from The Commonwealth Fund
1
Dec
Nov
Oct
Sep
Aug
July
June
May
Apr
Mar
Feb
Jan.
Dec
0
Nov
Score
3
Pioneer Network in Culture Change
230 E. Ohio Street
Suite 400
Chicago, IL 60611
Phone: 312-224-2574
Fax: 312-644-8557
[email protected]
www.PioneerNetwork.net
TOOLS for Change
6