It’s in the Numbers

Jul 26

Photo courtesy of Menno Haven - mennohaven.org

IT’S IN THE NUMBERS

Case Study Shows Households Improve Quality of Life for Residents

by Keith Schaeffer

The Household Model is standing as a remedy for the institutional ills of conventional long-term care is bolstered by data from a recent case study at Menno Haven, a not-for-profit retirement community in Chambersburg, PA.

Among other benefits, the numbers point to greater autonomy, choice, and community, less incontinence, and fewer challenging behaviors for residents after moving from Menno Haven’s conventional nursing home into households. Resident satisfaction is up and turnover for nurses is down (although turnover for CNAs increased initially), all at a slight increase in operating expenses.

“Some qualitative concepts are not easy to measure, but I think we saw enough to believe that the model really does impact people and is worth the investment,” says Hugh Davis, Menno Haven President and CEO.

Davis is lead author of the case study, “Adoption of the Household Model Improves Nursing Home Quality,” published in the January/March 2023 issue of Journal of Nursing Care Quality. It examines the Menno Haven households’ impact on residents, staff, and operating costs. Davis used the study for his Doctor of Nursing Practice (DNP) dissertation at Duke University.

Other authors include Menno Haven Chief Operating Officer Roger Beins and Administrator Roz Burke; Ryan Decort, Internal Medicine Specialist in Chambersburg; Carolyn Hart, Dean of Nursing at Coker University; and Eleanor McConnell, Duke University Associate Professor in the School of Nursing. Support from McConnell and others at Duke University “helped put up the guardrails and statistics … needed for this type of qualitative research,” says Davis.

The Model

The newly built skilled living home (so named to reflect the emphasis on living rather than nursing) opened in March 2021. There are three households – two with 20 residents and one with 16. Each household has a kitchen, dining room, living room, and private resident apartments with bathrooms. They connect to an easily accessible community core that features a library, ice cream parlor, exercise room, gathering room, and chapel.

Households are staffed by permanently-assigned versatile workers, most of whom are certified CNAs who also provide non-nursing services like activities, cleaning, and meal preparation – or whatever the resident needs in the moment. The new staffing structure increases the direct care hours residents receive, from 3.5 to 4.12 hours per patient day.

Scheduling is based on residents’ individual desires about when to wake up, how to spend their day, and when and what to eat. Hence, each household has its own personality.

“Martin House residents like to get their families involved … love to play bingo almost daily and exercise three times a week,” says Burke. “Bumbaugh House loves to play games and cook for each other. Residents in Lehman House … do not care to do many group activities … (they) like to spend time in their rooms.”

When there were complaints that some families were monopolizing the sunroom, “we took it back to the residents, and they, rather than staff, decided how they wanted the sunroom to be monitored,” she adds.

For Davis, one of the more significant changes was “creating a life around the dining room… the smells and bringing some of the activities around the production of food or recipe. Also, access to outdoors, the screened-in porches and courtyards.”

The Transformation

The five-year transformation to households began in 2016 and involved all stakeholders: management, front line staff, residents, and family members, with firm backing from the Menno Haven Board of Directors.

A team of architects and other professionals with expertise in the Household Model were assembled and met with staff from every level. Together, they envisioned the new model and redesigned the organizational structure, workflows, and job descriptions to align with the planned physical environment. There were numerous meetings with residents, families, and the resident council to discuss planning and building layouts.

Much attention was given to detail in designing the building to empower residents, such as window and mirror placement to accommodate the view from wheelchairs, amber lights that don’t interfere with sleep, minimized distances from bedrooms to common living spaces and the outdoors, and elimination of all signs of institution.

Staff practiced inside a mockup of the new household bathrooms before they were constructed to ensure that the layout was consistent with the new model of care.

Action Pact partnered with Menno Haven for two years to assist with learning, envisioning, action plans, and facilitating high involvement of the entire campus.

Additional expertise was acquired with Beins and Burke joining the Menno Haven management. Beins had helped establish one of the nation’s first Household Models at Meadowlark Hills in Kansas; Burke was familiar with households through her involvement with the Pioneer Network.

Beins left a “high quality organization” that wasn’t a Household Model to join the Menno Haven transformation. “The most impactful time in my career was making that transition at Meadowlark Hills, and the opportunity to be a part of that again was intriguing,” he says.

He found the transition at Menno Haven far more challenging than at Meadowlark Hills 20 years ago. “Back in the day, we didn’t have the staff turnover,” he says. “The same people went through the whole process together.”

Momentum at Menno Haven was lost with the frequent turnover of Directors of Nursing early on, and the COVID pandemic caused construction delays, prolonging the transition.

“I knew that's the kind of care I wanted to deliver to our seniors,” she says.

Outcomes for Residents

Nonetheless, the final analysis conducted six months after moving into the new skilled living home showed improvements in 14 of the study’s 17 measures compared to the data three months prior to moving.

The measures included five QMs devised by Centers for Medicare & Medicaid Services, the Artifacts of Culture Change (ACC) tools, family and resident satisfaction, staff turnover, and daily operating costs.

The post move-in analysis showed an average improvement of 45 percentage points in all five ACC domains, up from 40 to 85 percentage points (resident-directed life: +32%; being well-known: +23%; home environment and preferences: +46%; family and community: +40%; leadership and engagement: +64%).

There were improvements in four of the five CMS Quality Measures with decreases in worsening independence (-7%), declining activities of daily living (-11%), behaviors affecting others (-12%), and low-risk loss of B/B continence (-13%).

On the downside, the fifth QM revealed a slight increase of seven percentage points in the number of resident falls, possibly indicating that greater independence comes with more risk.

Family satisfaction remained at 100% while resident satisfaction improved from 93 to 100%.

An outcome difficult to quantify but apparent to the naked eye was how, after moving into the households, residents who previously stayed in their rooms were coming out and dining in the community – even while residents in many other nursing homes were reluctant to leave their rooms due to risk of exposure to COVID.

“To see the residents’ faces, seeing them interact and having a different type of life, we knew we were doing this right and that the residents were winning,” says Burke.

Turnover

LPN and RN turnover fell by seven and four percentage points respectively, but CNA turnover increased by 29 points, from nine to 38 percent. Exit interviews revealed that some long-term CNAs resisted their expanded role as versatile workers.

“It was like, ‘I'm not going to clean toilets or do activities, I just want to care for the residents,’” says Burke.

The stress of adapting to a changed environment was another factor in turnover.

“You go into a new building where you have to find everything again, and you just changed jobs (from regular CNA to versatile worker),” notes Beins. “But I also think you can't rule out the stress of COVID on the healthcare workforce being a driver of turnover.”

When undertaking the journey to households “you really need to think about it from the perspective of a CNA, because I don't think you can escape the stress that it's going to put them through,” adds Davis.

Burke believes the CNA retention rate is improving as new hires join the organization, fully aware of their versatile worker responsibilities.

Menno Haven has two conventional nursing homes besides the skilled living households.

“The turnover performance in the Household Model is a standard deviation above -- meaning to the good -- above the organizational mean, and the other two (conventional) skilled nursing homes are a standard deviation below the organizational mean,” says Davis. “So there’s a big gap, and we’re currently seeing a much better turnover performance in the Household Model than in the traditional.”

Operating Costs

There was a net increase in operating costs of five percentage points due to a 16-point rise in wages, which was partially offset by a 36-point decrease for supplies, medications, activities, and food. Food costs plummeted because residents eat what they want, resulting in less waste. Other costs decreased due to greater efficiency afforded by the Household Model.

As for the wage increase, “We wound up allocating more hours of care to the residents,” says Davis.

“We lost a little of the economy of scale,” adds Beins, “The efficiency of working with 30 residents is different with 20 and 16.”

Additional Benefits Not Reported

Some culture change initiatives, such as letting residents sleep in, were implemented in the old building early in the process. During that time, “depression and weight loss (among residents) just went away,” says Davis.

However, those results were outside of the timeframe of the analysis and were not included in the report. The pre-move and post-move analyses occurred during the pandemic.

“We didn't want to bring any comparison in from a pre-COVID time (that might corrupt the results),” he explains. “Because of that, I think there were some good effects from the model that our study was not sensitive enough to pick up.”

“I think as the model matures, we will have even more positive results than when we originally measured,” Davis concludes.

Amanda Chan