More Home, Less Nursing
Advocates want to make nursing homes more comfortable and humane, with home-like amenities and resident-centered care. And they’re looking to NFPA for leadership on the code changes that can help make it happen.

NFPA Journal®, January/February 2010

By Alan R. Earls

One size does not fit all. That’s the message of a movement called "culture change," which aims to individualize the care and well being of nursing home residents across the country. Instead of two or more people to a room, with each room furnished almost identically, culture-change supporters seek rooms that are as individual as their inhabitants, with personal belongings treated not as threats to efficiency and care, but as key elements of residents’ health and happiness. Rather than a single large dining area that serves uniform, institutional food, culture-change advocates envision smaller, more home-like eating and kitchen areas serving a greater variety of food, and that may even involve residents in the food preparation. Even the term "nursing home" is subject to a phase out in favor of names like care community or life center. Advocacy groups such as Pioneer Network and Society for the Advancement of Gerontological Environments (SAGE) hope to push culture change beyond the early adopters and into the mainstream, essentially reshaping the landscape of nursing home care.

Garden Spot Village in New Holland, Pennsylvania, for example, is a facility that closely mirrors the ideals of culture change. Instead of a large building with double loaded, long corridors, many elders now live in small groups within separate, self-contained "households," each with its own food preparation center. "The new facility has helped us to transform the culture," says CEO Steve Lindsey. "Our model used to be paternalistic, but now we push most decisions down to the residents and the people working with them."

Those changes may make for a more caring and comfortable living environment, but they can also conflict with the current provisions of the codes, especially NFPA 101®, Life Safety Code®, according to Robert Solomon, NFPA department manager for building and life safety codes. As a consequence, culture-change advocates are proposing a series of revisions to NFPA 101, including provisions that would allow smaller kitchens and more home-like appliances to be used rather than the larger industrial-style commercial cooking equipment; evaluating the means-of-egress requirements to reflect the use of the corridor as a gathering place by allowing functional furniture, such as chairs, in hallways; allowing wall decorations in resident rooms where the facilities are sprinklered; and allowing gas fireplaces within the facilities as long as they conform to the code’s requirements for heat producing appliances.

While acknowledging the complexity of the code issues involved, Solomon lauds the goals of culture change. "In thinking about the kind of facility I would want my parent to be in, or where I might want to be someday, the culture-change vision is much more appealing than the typical institutional nursing home with two people in every room, regimented schedules, and limited activities" he says. "I believe the revisions that culture-change advocates seek in NFPA 101 can eventually be accomplished without compromising safety."

Culture change 101
Bonnie Kantor, executive director of Pioneer Network, describes culture change as an effort to move away from an institutional model and toward a more consumer-driven care model that embraces flexibility, self determination, and the wishes of elders and their families. "If I had to define culture change in one phrase, it would be that the person comes before the task," she says.

Pioneer Network began in 1997, when a small panel of professionals got together to advocate for person-centered care; the group quickly became the umbrella organization for the movement, and is one of the most prominent groups in the reform effort today. Kantor traces the start of the culture-change movement to the Nursing Home Reform Act included in the Omnibus Budget Reconciliation Act (OBRA) of 1987. "Up until then, evaluation of nursing homes was based on a purely structural approach that looked at facilities and staffing," Kantor says. "OBRA shifted the focus to actual clinical outcomes and measures of quality of life."

To make culture change a reality, however, requires changes in the way nursing homes organize care in the physical environment, their modes of staffing, and the buildings and facilities they use—and that’s where Kantor and others see a need to look at the influence of the Life Safety Code. She believes that in a growing number of cases, NFPA 101 may be having unintended consequences by constraining legitimate efforts to enhance resident quality of life. Solomon says this is not by design, but simply because a new model is emerging and the code needs to consider how that model will work while still maintaining the goals and objectives of the code.

This was one of the issues examined in detail at a symposium held in 2008. The event, "Creating Home in the Nursing Home: A National Symposium on Culture Change and the Environmental Requirements," co-sponsored by Centers for Medicare/Medicaid Services (CMS) and Pioneer Network, allowed Solomon, representing NFPA, to hear about the goals of the culture-change movement. In turn, people involved in long-term care were able to hear from Solomon about the fire safety goals and objectives of the Life Safety Code. "I think they were surprised and impressed that NFPA has a technical committee dedicated to the health care occupancy environment," Solomon says. "They even applauded when I said that I was confident that the NFPA committees could figure out a way to use something other than the heavy-duty, industrial-style cooking equipment n these new types of facilities. That was a first."

Based on the process begun at that meeting, a task force was formed by Pioneer Network to study the code ramifications of culture change, and the group has submitted numerous proposals to NFPA for potential inclusion in the 2012 edition of the Life Safety Code.

Kantor says the effort to develop the proposals has emphasized consensus and a transparent, public process. "We are seeing this relationship as a growing one so that the submissions or proposals are ones that have, if not complete unanimity, at least broad support," she says. Meanwhile, last April, partly in response to the 2008 conference, the CMS issued new guidelines related to culture change and living environments. In particular, CMS mandated a new survey process that provides a more complete appraisal of quality-of-life initiatives "so that all nursing homes are being assessed consistently along these lines," says Kantor.

"While the culture-change movement is intended to create self-directed living environments and to empower residents and front-line staff, it is never intended to do so by making an unsafe environment," says Kantor. "So the safety element that NFPA is focused on is vital, and we would never advocate lowering those standards."

Growing impact Nursing homes are a $100 billion industry, and that figure promises to increase in coming years as the population of Americans 65 and older increases. In 2004 there were an estimated 36 million Americans over age 65, according to the American Health Care Association (AHCA), with that figure projected to grow to more than 63 million by 2025. AHCA data for 2006 indicates that the nation is served by about 15,800 nursing home facilities housing some 1.5 million residents, a number AHCA projects will grow to nearly 7 million by 2050.

Based on a recent study by the Commonwealth Fund, Kantor says she believes culture-change principles are now embraced wholly or in part by more than half of the nation’s nursing homes. That support has yet to translate into substantial physical changes in nursing home facilities, Kantor adds; she estimates that only about 1 percent of new nursing home construction conforms to the tenets of culture change, while about 5 percent of facilities have made what she calls "substantive cultur- change transformations in organizational and physical environments." Kantor says aligning culture-change ideals with the Life Safety Code is a critical step forward, because it will provide what she describes as "certainty and clarity" to developers interested in building to culture-change standards.

Among the converted is Skip Gregory, bureau chief for the Office of Plans and Construction at the Florida Agency for Health Care Administration and a member of the Pioneer Network Life Safety Code Task Force. Gregory says he combines his role as regulator with advocacy for culture change; when he returned from the 2008 Pioneer Network and CMS conference, he vowed that his office would not be an impediment to culture-change efforts.

Gregory says his organization had generally applied the Life Safety Code under the guidance of the state fire marshal and of the CMS at the federal level. However, after the conference, Gregory says he worked with Pioneer Network and with people from across the country to change Florida’s building code regulations "so that we would not only permit this kind of design but make the household model the new minimum standard." The proposed changes made smaller, home-like facilities the standard to which new construction and rehabs would need to conform. However, notes Gregory, "If a site could not accommodate that kind of structure, we also provided for variances to allow a more traditional approach."

While the idea received support from the Florida Association of Homes and Services for the Aged, he was unable to sell the Florida Healthcare Association on it. The proposal was withdrawn. "Without support from both groups I knew it wouldn’t succeed," he says. Gregory says he was surprised by the opposition because he was convinced his proposal left enough flexibility to address the concerns of nursing home operators. He suspects some operators feared that new culture-change-oriented facilities would pull customers from their existing nursing homes. "Although companies have learned how to make a profit despite big problems like staff turnover, this proposal represents something new," Gregory says. "They aren’t sure they know how to make a profit under culture change."

But Gregory says culture-change efforts continue in Florida. "We have many architects who are trying to do this within the limits of NFPA 101," he says. His department has sponsored a competition at architectural schools across the country that is expected to yield ideas for turning traditional medical-model nursing facilities into culture-change facilities. "This coming spring there’s another revision cycle for the state building code, and I fully expect to propose another set of revisions," he says.

Implementing culture-change principles can be challenging for architects, but the problem isn’t just with the Life Safety Code, notes Vernon Feather, principal of SFCS, Inc., an architectural firm in Roanoke, Virginia, that specializes in nursing home designs. Regulations can be a slippery slope, he says. For instance, the requirement that nursing home kitchens use bulky and expensive commercial-style stoves doesn’t always come from the Life Safety Code, Feather says; it can be a local requirement as well. "But once you’ve got a commercial range, NFPA 101 does require that you have a commercial-type hood," he adds. "Taken together, those things can be barriers to new designs and can raise costs."

Feather, who is also a member of the Pioneer Network Life Safety Code task force and chairman of the Kitchens and Cooking subcommittee, says those regulatory impediments can make it too easy to stick to the institutional-model status quo, which presents problems to many residents. "One of the keys to culture change is to normalize food service, because in the institutional food model, we see people losing weight and becoming detached from their environment," he says. By contrast, he says, giving people access to a kitchen can help them maintain the rhythms of their daily lives.

Thomas W. Jaeger, president of Jaeger & Associates, LLC, a Great Falls, Virginia, consultant to the nursing home industry, supports culture-change initiatives and believes the nursing home industry will eventually embrace the model. "They understand that their primary purpose is to improve the quality of life for residents, and that the institutional model may not do that," he says. In the same breath, however, Jaeger points out that health care facilities are the second-most-regulated facilities in the United States, right after nuclear power plants—meaning that a habitually cautious industry isn’t likely to change overnight.

Still, change can happen, Jaeger says, citing recent responses to the H1N1 virus as an example. "The nursing home industry now allows infection control using alcohol-based hand rubs at every patient room door, which can amount to several gallons of flammable liquid along a hallway," he says. "But we are accepting that risk in order to better fight the greater risk of infection. When it comes to culture change, we don’t want to open a Pandora’s Box, but I think it is perfectly acceptable for a residential nursing home to accept a little more risk to improve the quality of life. We do it in our own homes every day."

Alan R. Earls writes on technical and safety topics and is based in Franklin, Massachusetts.