The “culture change” movement seeks to get these facilities to alter their physical layout and their caregiving practices to create homelike environments where residents are seen not as passive recipients of care but as individuals with control over their lives.

Nursing homes that embrace the new philosophy are letting residents decide when to bathe, eat and sleep; allowing them to organize their own activities; and redesigning nursing units into small “households.”

Advocates say residents in such homes are happier and healthier; the employees have more job satisfaction; and giving care this way even costs less.

And baby boomers who need long-term care will expect no less, said Julie Boggess, chief executive officer at the Bethesda Home, on the Northwest Side. “I became an adult in the late ’60s; I’m real accustomed to doing things my way, and I’m not very apologetic about it,” she said.

She doesn’t even like to speak of “allowing” residents to sleep late. “It’s not for us to give them that freedom,” she said. “They should have it.”
But until Bethesda began adopting culture change two years ago, they didn’t. And at many nursing homes, they still don’t.

The idea is not new. The Pioneer Network, a national umbrella group of nursing home providers and consumer advocates, has been promoting it since it was formed in 1997.

Yet only 25 percent of the nation’s nursing homes say they have “for the most part” embraced culture change, according to a 2007 survey by the Commonwealth Fund, and only 5 percent say they have done so “completely.”
Nursing home operators, who are under tremendous pressure to cut costs, are often afraid that culture change would be too expensive, said Robert Mayer, president of the Chicago-based Hulda B. and Maurice L. Rothschild Foundation, which supports culture change. In fact, he said, flexibility is more cost-efficient.
And there is little pressure from consumers, he said; there are so few “culture change” homes that most people don’t know they exist.
Even nursing home operators who want to make the changes find it hard. “Nursing home rules make it very difficult to do a lot of this stuff,” said Kirk Riva, vice president for public policy of the Life Services Network of Illinois, a trade organization.

The experience of the Bethesda Home illustrates the challenges.
Janet Meyer, the home’s director of nursing, had proposed a single change: letting residents sleep late. But “that’s a bigger deal at a nursing home than you might think,” she said.

Mealtime practices had to be changed to accommodate late risers. Housekeeping had to be done more flexibly to avoid waking residents for vacuuming.

Most challenging, the morning medication system had to be changed. Nursing homes traditionally give out medications during a two-hour period. But if residents were allowed to sleep late, Bethesda could no longer give morning medications only between 8 and 10.

So the home made another change: Residents could get their morning medications any time between 6 and noon, by individual request.
Nurses struggled to adjust. “We just couldn’t understand how this could possibly work,” said Mary Sobus, a nurse at Bethesda for 19 years.
Other practices were loosened too. At staff meetings, administrators told employees that they needed to be flexible and perform caregiving tasks like bathing when residents wanted them.

Staffers objected that some shifts were now doing more work than others. And they were so accustomed to being evaluated based on their efficiency that they were afraid of being downgraded for showing flexibility.

Even some residents and their families protested. Family members told administrators it was unfair to expect nurses and aides to accommodate individual schedules. Residents worried that if they didn’t get their morning medications at the precise time they always had, their health would be harmed.

At the home’s annual inspection, surveyors initially objected to the new medication system, Boggess said, but ended up approving it, along with Bethesda’s elimination of nursing stations. Removing nursing stations is another common element of culture change; the stations are reminiscent of hospitals.
There are regulations in place that make such changes difficult or impossible, said Melaney Arnold, spokeswoman for the Illinois Department of Public Health. But the department is willing to waive some regulations – like the requirement of a nursing station – as long as a home conforms to their intent.
And the department is trying to ease the burden, Arnold said; officials are going through the regulations to see which ones can be changed.

“We are open to and support the concept of changing nursing homes to be more homelike environments,” she said.

The new system at Bethesda prompted several nurses to quit. But Sobus became a believer.

Giving out medications individually can be more time-consuming, she said, but “you’re relating to people on a little different level,” she said. “You’re actually consulting with the resident.”

Bethesda resident Tillie Ohl, 91, a confirmed late riser, is delighted. “They used to call me to wake up at 6:30,” she said. “I wanted to kill them.”

But on this day, “I just got up at 11 o’clock,” she said happily. “I really slept like a log.”

Several other Chicago-area nursing homes have adopted aspects of culture change. Three Crowns Park in Evanston redesigned its units into small households with common kitchens and living areas. At Sunny Hill Nursing Home of Will County, a group of residents interviews and helps choose new hires. If the residents turn thumbs down, “the department head has to go out and get somebody else,” said Becky Haldorson, the home’s assistant administrator, who is also president of the Illinois Pioneer Coalition.

Such homes are in the minority – but not for long, advocates say.

The Health Reform Act passed in March calls for conducting demonstration projects at nursing homes to establish the best ways to effect culture change. So many organizations and government agencies are now working toward culture change that “everything is in place for widespread dissemination,” said Bonnie Kantor, executive director of the Pioneer Network.

Boggess hopes so. “Let’s see if we can make it better for my generation,” she said.