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This Issue: The Aging Veteran | Table of Contents: Summer 2016 |

A Chat with Our Experts

Promoting resident-centered care in VA community living centers

Dr. Christine Hartmann, with VA and Boston University, studies nursing home safety, the quality of long-term care, and nursing home cultural transformation. <em>(Photo by Ron Strickland)</em>
Dr. Christine Hartmann, with VA and Boston University, studies nursing home safety, the quality of long-term care, and nursing home cultural transformation. (Photo by Ron Strickland)

Dr. Christine Hartmann, with VA and Boston University, studies nursing home safety, the quality of long-term care, and nursing home cultural transformation. (Photo by Ron Strickland)

Dr. Christine W. Hartmann is a research health scientist at VA's Center for Healthcare Organization and Implementation Research (CHOIR) and a research associate professor at Boston University's School of Public Health. Her research focuses on nursing home safety, the quality of long-term care, and nursing home cultural transformation. She uses both quantitative and qualitative methods. Her national service to VHA includes chairing the VHA National Community Living Centers (CLC) Cultural Transformation Steering Committee. VARQU spoke to her about her work on culture change at CLCs.

VARQU: How do VA community living centers (CLCs) differ from community-based facilities?

Hartmann: The main difference between VA CLCs and what is known in most communities as nursing homes is really the centralized structure of the VA system. Whereas community-based nursing homes can be privately owned, part of larger corporations, independent from other such homes, or organized in other ways, in VA we have one system with one set of standards and regulations. That is the reason a lot of things may differ between what happens in VA CLCs and what happens in the community.

Residents of VA's Little Rock (Ark.) community living center take part in a therapeutic
Residents of VA's Little Rock (Ark.) community living center take part in a therapeutic "drum circle" with recreation therapists and volunteers. (Photo by Jeff Bowen)

Residents of VA's Little Rock (Ark.) community living center take part in a therapeutic "drum circle" with recreation therapists and volunteers. (Photo by Jeff Bowen)

VA's CLC residents are mostly male, and residents in nursing homes in communities are mostly female. To a certain extent, residents in CLCs have a different type of profile for their disease states than residents in the community. Those are the main differences that apply across the two settings.

How are VA CLCs constructed, arranged, and staffed?

There are 135 CLCs across the country, including in Puerto Rico, Hawaii, and Alaska. So they are found everywhere. All CLCs are geared right now to focus their care around one care model, called the Holistic Approach to Transformational Change (HATCh) model.

The HATCh model has three different spheres at its center: care practices, work practices, and the environment of care. They all intersect, and CLC residents—the individual Veterans living in the residences—are at the center of the model. Surrounding these spheres are leadership, community, and then the wider context, which includes regulations, standards, and laws.

Much of what happens in the CLCs is grounded in this model. Processes for changing the environment, for example, are led by the CLC design guide, which was published in 2011 and is now being updated. The design guide focuses on the HATCh model, and it changed the ways we do renovation or new construction at CLCs. Every new VA CLC is instructed to follow the design guide, which opens the design of CLC facilities up to becoming person-centered.

Instead of having nursing stations, for example, the guide encourages facilities to develop innovative techniques to allow the best possible care to take place without disrupting a homelike environment for the Veterans who are living there and the staff who are working there. So design helps maximize culture change and the person-centeredness of care.

Interactions among residents and staff and among staff are also guided by the HATCh model. And CLC staffing is guided by meeting the needs of Veterans, both for person-centered care and the services CLCs provide. These services include 24-hour skilled nursing care, respite care, restorative care, and access to social workers and psychologists. So CLCs are staffed depending on the population they serve. That staffing is often different among CLCs: Each CLC provides various services, but all provide a person-centered care environment.

How do CLCs get families involved, and how has that changed over time?

The HATCh model and person-centered care are part of a movement in health care often called "culture change," which is changing the culture at nursing homes away from one that was rooted firmly in a medical model of a hospital-type setting of care. It's transforming nursing homes, and is happening broadly throughout the United States.

We're moving from that medical model-driven culture to a patient-centered care model in which the needs and preferences of those living in the facility drives the care that's provided. VA has embraced this, and actually started the process rather early. In 2004, a cultural transformation steering committee was formed, and in 2008, the names of our facilities were changed from nursing home care units to community living centers.

The guidelines for person-centered care and culture change were incorporated into the CLC guidelines in 2008. In those guidelines, family involvement is heavily stressed. The guidelines are also based on the HATCh model, which stresses community.

Family and friends are near and dear to everyone's heart, and that doesn't change because a person has come to live in a CLC. So we have made changes, such as the elimination of visiting hours in CLCs. Families and friends can come and visit their loved one at any time as they wish.

There are other changes at individual CLCs that have embraced this cultural transformation. Of course, the CLCs—when they were known as nursing home care units—did some really imaginative things even before the new guidelines were implemented. What the policy change did was provide a lot of freedom and support for facilities to make these changes. That definitely included a strong emphasis on encouraging residents and families and friends to interact as much as possible.

Some CLCs now have special rooms that are private areas with sofas and television sets and beds where CLC residents and family members can spend the night together if they would like—or for the residents to invite their grandkids over and have a private space to meet.

So there are all kinds of innovative things going on, and they differ a lot from facility to facility. But what culture change really means is broadening options and focusing everyone on person-centric, person-driven, care.

What are you personally working on, and how does what you're doing benefit Veterans in CLCs?

I have the privilege of working on a number of different projects right now, funded by VA, and they are all focused on CLCs. That is by choice: I have a passion for improving care in community living and nursing homes.

My father spent the last years of his life in a nursing home, and I watched the care he received and saw what happened at the end of his life, when the care he needed and the safety he needed intersected in a way that was not ideal. Watching that unfold gave me a strong passion to improve the quality of care at these homes, especially in conjunction with the staff who work there.

Some of the work I do focuses on safety in nursing homes, and I also work on person-centered measures of care within CLCs—an area I find particularly important.

One of my projects is in an area in which there's a lot of excitement at the moment. We are working with CLCs to improve the person-centeredness of care in two particular aspects related to building relationships: the interactions between residents and staff and the engagement of residents in their lives in the CLCs.

What we've done is developed a structured observation protocol. We've prepared a paper-and-pencil tool to be used as you sweep a room from left to right using observations that last five seconds each. Anyone can use this tool. Housekeeping can use it; nursing services can use it; researchers can use it. It's very simple.

Once you gather the data, what's a little different from other observational tools is that we're looking for the places where things went well. We're not looking at "what went wrong here." We're looking at where things went really well, and why that happened. And we're encouraging staff to have conversations, because it's not just the data but also the dialogue that is important. We're encouraging them to talk with each other about what they've observed, where things went well, and to find what we call the "bright spots."

Staff note little things, for example during dining, such as when one staff person who is obviously doing another task stops by a table to help a resident who is struggling with cutting his food. Or someone makes a point to go out of her way to make sure a resident is comfortably seated. Or a staff person puts his hand on a resident's shoulder and squats down to talk with him, because the resident is in a wheelchair. They're little things that can make a big difference.

We had a site in our project where staff became so focused on finding "bright spots" that a nurse made a "kudos" board on which she noted any bright spots she saw that staff had done. The focus on the positive really changed the environment at that site.

Our project has actually become known as the "bright spot project" at the CLCs we've been working at. We've had such success with these tools, and there's been so much enthusiasm around it that VA Central Office has decided to roll them out nationally. So now we're working on the preparation for the implementation of this program, the program of doing observations and having huddles to talk about the data to find out where the bright spots are, and then spreading the bright spots around. The program will be rolled out nationally in 2017.

We have a large team of wonderful people working together, including Dr. Lynn Snow and others at the Tuscaloosa VA Medical Center, to prepare for that and we're extremely excited about this opportunity.

I work for VA for two reasons. First and foremost, I work to serve those who served, because I have a lot of Veterans in my extended family, and that is what drew me to working in VA. The other reason why, as a researcher, I appreciate working in VA is because I can effect this type of system change. So we're very excited to be able to do this on a national scale. We're honored that our tools were chosen.

Is there anything else VA is doing to transform CLC culture?

The [HATCh] policy really gives CLCs the guidance, and the room, for transformation. CLCs are doing really innovative things. There are some that are being done nationally, such as the nursing assistants initiative, in which nursing assistants are paired with coaches, who are often registered nurses, and are coached to become leaders within their CLCs.

Then there are facility-level initiatives, such as those involving pets. It's very sad to have to give up your pet if you are moving into a CLC. So there are CLCs that have resident pets, like birds, cats, and dogs. But can you believe that there's a CLC that has a giant tortoise? To think of all possible ways to care for the tortoise, they even had to come up with an evacuation plan in case of a hurricane!

The list could go on endlessly. Some CLCs are involved with community programs and other programs to get the residents out of the CLC and doing things they like to do, even if it's as simple as going to a restaurant, which isn't really simple if you use a wheelchair and need to use special transportation. CLCs are making so many things possible, including making some amazing wishes of Veterans possible.

So imagination is the only limit to what CLCs are doing in terms of moving forward, and this is a really exciting time!

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