Environment

Raising the bar in long-term care requires the transformation of the "facility" into a "home." To be more than an institution, nursing homes are challenged to eliminate the use of overhead paging, provide accessible bathrooms, encourage the personalization of resident rooms, and offer private rooms. These four measures reflect a nursing home’s overall commitment to the physical transformation inherent in culture change:

For Consumers

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Private Rooms

To receive the quality incentive point for this measure, an average of at least 50 percent of the facility's Medicaid-certified beds must be in private rooms or semiprivate rooms to which all of the following apply:

  • Each room provides a distinct territory for each resident occupying the room;
  • Each distinct territory has a window and is separated by a substantial wall from the other distinct territories in the room;
  • Each resident is able to enter and exit the distinct territory of the resident's room without entering or exiting another resident's distinct territory; and
  • Complete visual privacy for each distinct territory may be obtained by drawing a curtain or other screen.

The facility must report the number of Medicaid certified beds in private rooms or semiprivate rooms meeting the above criteria on the first day of each month of the calendar year preceding the fiscal year for which the Medicaid rate will be paid and on the last day of the fiscal year for which the Medicaid rate will be paid.  Facilities must report using the Quality Incentive Data Submission Tool no later than May 31, 2014 to be considered for the state fiscal year 2015 rate-setting. Please review the submission instructions.

Relative Advantage

Utilizing private rooms may reduce costs for the facility and the health care system.Studies in both nursing facilities and hospitals have found that residents in shared rooms are at significantly higher risk of nosocomial infections, including C-Diff and MRSA, than those in private rooms. The Commonwealth Fund-supported study, "Exploring the Cost and Value of Private Versus Shared Bedrooms in Nursing Homes, "(The Gerontologist, Apr. 2007), found that 84 percent of the nursing home residents who developed acute nonbacterial gastroenteritis during an outbreak had a roommate. Only 16 percent of those who became ill had a private room.

Utilizing private rooms to lower the infection transmittal rate also may reduce costs for the facility and the health care system. The same study reported that "... infections (primarily pneumonia and influenza A) account for almost 1/4 of hospitalizations of nursing home residents ... Finally, a study conducted in 1994 estimated that the average cost of hospitalizing a nursing home resident to treat pneumonia to be $7,500 (Lave, Lin, Hughes-Cromwick & Fine, 1999). Since most of these infections are difficult and expensive to treat, and increase risk of mortality, this is a particularly significant issue for both patients and the health care system at large."

The marketing of private rooms for residents also may result in revenue gain. With new construction, private rooms are more expensive to build. However, one study found a $23 cost differential in the amount able to be charged for a private room, making it possible to recoup upfront costs in less than four years. "The business case for private rooms is even more compelling if nursing homes have trouble filling beds in shared rooms. It can take less than seven months to recoup the cost of construction and debt service for two private rooms versus one shared room if the second bed in the shared room is vacant," Margaret P. Calkins, Ph.D..

Additional advantages found to result from the use of private rooms, as reported Dr. Calkins:

  • Improved sleep, which leads to fewer falls;
  • Less anxiety;
  • Improved continence;
  • Ease in hosting visitors, especially at end of life;
  • More control over personal territory; and
  • Less staff time managing roommate conflict.

Compatibility

Facilities often utilize empty space to allow for private rooms for residents for whom a private room is desirable due to illness, level of activity or risk of infection. The practice may aid facilities in meeting residents' needs for privacy and dignity. Private rooms may enable residents to make their rooms more homelike and personalized, leading to higher overall satisfaction with the facility.

Simplicity

Use of empty rooms and rearrangement of existing resident facilities often utilize empty space to allow for private rooms for residents for whom a private room is desirable due to illness, level of activity or risk of infection. With occupancy rates in the mid-80 percentiles, facilities with lower census may find it easier to commit to providing private rooms to more residents.

In 2005, the typical nursing home was 29 years old. Many nursing homes will have to be replaced or renovated in the next decade.

"After analyzing 189 bedroom plans and developing a detailed cost analysis, the average cost of construction plus capital costs (debt) of a traditional, side-by-side shared room was found to be $41,012 or $20,506 per person, while the average cost of a private room was $36,515 (2005 dollars). Thus, it costs $16,009 more per person to build private versus traditional shared rooms. Stated another way, it costs $32,018 more to build two private rooms than one shared room. This would seem to support those who say that private rooms are too expensive to build. But taking a life-cycle costing approach, it can be demonstrated that this difference in construction cost is not as great as it might appear. Based on a large national study, the average daily cost of a private room in a nursing home is $23 more than a shared room. If the beds are all occupied, assuming a $23 dollar a day difference, it would take 1.9 years to recoup the cost differential of building 2 private rooms versus 1 shared room. However, if the facility cannot fill a bed in a shared room, the lost revenue is not $23, but $167 per day -the average daily cost of a shared bedroom. At $167 a day it takes only 6.4 months to recoup the construction and debt differential" (Calkins & Cassella, 2007). ("Exploring the Cost and Value of Private Versus Shared Bedrooms in Nursing Homes," The Gerontologist, Apr. 2007)

Trialability

A facility may assign private rooms to residents for whom a private room may be most helpful: those with infections or at highest risk if they were to acquire an infection; residents who prefer a different waking/sleeping schedule than the majority; and those whose speaking or wandering may be disruptive to a roommate.

Observability

Some facilities are built to offer only private rooms. As an Ohio facility administrator described the decision to make their rooms private, "We were built that way to meet the needs of the Boomer population. Shared rooms just won't be acceptable." Others have been renovated or existing rooms have been repurposed. An Ohio facility described their use of previously shared rooms as private rooms as "using a low census and a commitment to private rooms. It wasn't strategic; it just happened. Overall, it's much better."

Resources

Calculating loss of revenue from a semi-private to a private room. These rates are private pay, but give an idea of the revenue stream differential and how it may be applied to residents paying with Medicaid.

  Avg. Daily Nursing Home Rate
Private
Avg. Daily Nursing Home Rate
Semi-private
Cincinnati $222 $191
Cleveland $240 $206
Columbus $218 $196
Rest of State $206 $189
State Average $218 &194

Source: 2010 MetLife Market Survey of Long-Term Care Costs

State Averages: MetLife provides a "State Average" for each type of long-term care service in each state-the average of all rates for all sampled services in the state. In the states where MetLife includes average rates for one or more cities or areas within a state, these averages are specific to those areas.

"Exploring the Cost and Value of Private Versus Shared Bedrooms in Nursing Homes," The Gerontologist; April 2007 ; 47(2):169-83. With Christine Cassella.

"Envisioning your future in a nursing home," Paper presented to the Creating Home in the Nursing Home symposium hosted by CMS and the Pioneer Network in April 2008.

Some of the most extensive research on the use of private rooms in a nursing home setting has been done by Margaret P. Calkins, Ph.D., President of IDEAS Inc., Board Chair of IDEAS Institute and Founding member and Board Member of SAGE.

Eliminate Overhead Paging

To receive the quality incentive point for this measure, the facility must maintain a written policy that prohibits the use of overhead paging systems or limits the use of overhead paging systems to emergencies, as defined in the policy. The facility must communicate the policy to its staff, residents and families of residents.

The point will be awarded to facilities that indicate on the Quality Incentive Data Submission Tool they have adopted such a policy and communicated it to staff, residents and families of residents. Facilities must complete the submission no later than May 31, 2014 to be considered for the state fiscal year 2015 rate-setting. Please review the submission instructions.

Relative Advantage

>Using overhead paging for emergencies only or not at all creates a homelike environment.Using overhead paging for emergencies only or not at all creates a homelike environment. Few personal homes would come equipped with such an institutional feature as an overhead paging system. Noise from overhead paging contributes to sleep disruption and workplace stress. According to Karen Schoeneman and Carmen S. Bowman, in their report, Development of the Artifacts of Culture Change Tool, facilities that have eliminated overhead paging report that "It significantly decreases the white noise throughout the facility, decreases resident agitation - especially for those dealing with dementia, improves the working environment, creates a more 'normal' living environment in the households and increases privacy."

Compatibility

The Interpretive Guidelines: §483.15(h)(1) issued by CMS oblige facilities to provide a safe, clean, comfortable and home-like environment. Importantly, the guidelines call the elimination of overhead paging and piped-in music among the "good practices that serve to decrease the institutional character of the environment." Wireless systems or "other electronic systems" are included in the intent language of the revision to address homes that do not have nurse's stations or use wireless systems.

Simplicity

When a facility adopts consistent assignment of staff (the same caregivers are assigned to the same residents on a permanent basis), the ability of staff to predict and respond to residents' needs is enhanced, limiting the reliance on overhead paging for alerts. One facility eliminating overhead paging said they did so, "... cold turkey. When you have consistent assignments you shouldn't have to page CNAs."

A number of vendors offer electronic paging systems that allow staff members to be summoned by residents or co-workers. See the Pioneer Network's Design on a Dollar for information on inexpensive means of creating homelike environments.

Trialability

Have staff track overhead paging use for a day or a week, including overnight. What kinds of messages are being conveyed and how often? Meet with staff and residents to discuss the possibility of eliminating overhead paging. Ask staff and management about their personal use of overhead paging. What messages are considered critical? How could they be otherwise communicated? What overhead messages could be reduced or eliminated through other means? What should an "emergency use only" policy include? What portable electronic means of communication has staff used (either at your facility or others in the area)? What did they like or not like about those systems?

Ask residents how they reacted to the overhead paging system when they first moved into the nursing home? Are their activities, conversation or rest interrupted by overhead paging?

"[t]ake a 'no overhead paging' holiday and see what happens. How did people adapt? Did they take messages rather than paging overhead for every call? Two-way radios and walkie talkies are inexpensive and readily available for this exercise." - Pioneer Network, Design on a Dollar

Observability

Visit nursing homes where overhead paging has been eliminated. The Person-Centered Care Coalition has solicited mentor facilities through its efforts toward making a more homelike environment available for residents. Sign up for the Coalition's listserv and ask for assistance in making the transition.

"Noise reduction: environments that foster peace and comfort" includes a success story, California Culture Change Coalition.

Resources

Design on a Dollar

Artifacts of Culture Change See items 39 and 40.

"Shh-People Thinking," presented to the National Consumer Voice for Quality Long-Term Care 2009 Annual Meeting & Conference on reducing noise.