Staff is at heart of "culture-change" revolution

Third in a series.

Today's column is part of a series based on a speech I gave last month to an association of long-term care providers. It's about an extraordinary new paradigm in eldercare called "culture change."

Last week I wrote about resident-centered care provided in intimate, homelike environments, and even in nursing homes. Today's column addresses another key ingredient: treating caregiving staff with respect and a sense of accountability that has long been missing in the industry.

Because staff is the heart and soul of all eldercare, the most important leg of the culture change — what's truly revolutionary — is its ability to hire, train, and retain high-quality, caring aides and nurses.

For decades, many care providers have paid lip service to this notion. However, the outcomes reflect something different: 60-to-80-percent annual turnover in most care settings, low job satisfaction, poor wages and few benefits, no career ladders, and jobs that go unfilled for months.

Imagine: 78 million boomers — the largest block of babies born in American history — will soon be old, just as a steep drop-off of younger people becomes a permanent fact in the labor force. Who will care for them if nobody wants the job?

Here's why I think culture change offers us something better:

Staff typically rotates among clients in eldercare. Under culture change, they have permanent assignments from day one, allowing caregiver and care-receiver to get to know each other and develop a relationship. This results in more consistent care, caregivers look forward to coming to work to see how "their people" are, absenteeism drops, job turnover drops and caregivers take more responsibility.

Staff training includes ongoing mentoring by seasoned staff. Covering both caregiving and leadership skills, direct care workers are able to rise in the ranks and have real careers, and learn to be good supervisors — one of the big missing links in eldercare.

The hierarchy so typical of health care is flattened under culture change, meaning everyone answers call bells and performs other needed functions, rather than wait for the right category of person to come along. Aides have more decision-making responsibilities and accountability.

One of my favorite examples of this took place at the one nursing home in tiny Pomeroy, Garfield County, as it embarked on culture change. Surveys showed residents wanted home-style cooking on demand. Unfortunately, the kitchen and dining room weren't set up to accommodate this. So one weekend when the director was out of town, the staff gutted the kitchen, built a new counter in the day room (where everybody gathers), and bought and installed a new stove. By breakfast on Monday, residents were ordering what they wanted to eat and watched it being cooked, even helping with the cooking.

Research shows the results of this new paradigm can be dramatic: staff turnover plummets from, say, 60 percent per year before culture change to 20 percent afterward; many fewer staff call in sick each day; there's a more efficient use of staff and resources and much higher satisfaction by residents, families and staff.

In fact, staff satisfaction is a key predictor of family satisfaction in eldercare and vice versa. I can attest. I visited my parents for eight years — six in assisted living, two in a nursing home — and learned a great deal about their internal workings, and failures, by listening to the people who cared for them.

In 2002, the American Association of Homes and Services for the Aging (AAHSA), a national association of primarily nonprofit eldercare providers, created Better Jobs Better Care (BJBC), a four-year, $15.5 million research and demonstration project funded by the Robert Wood Johnson Foundation and the Atlantic Philanthropies. Its purpose: to support policies and practices that reduce caregiver turnover. The conclusion, according to the January-February 2007 issue of AAHSA's journal, futureAGE, is that culture change works (you can read its findings at www.aahsa.org, then scroll down and click on "BJBC").

Bottom line, there may be higher initial costs to get started — because it's a change and a dramatic one. But in the long run, there are significant savings. The most important savings come from hiring, training and retaining good caregiving staff.

Here's why: Every direct service worker who quits a job in eldercare costs the employer $2,500 in direct costs, such as advertising and training of their replacement. Even more dollars go down the drain in indirect costs: vacant shifts, lower quality care, slower care, loss of new admissions, stress leading to errors, stress leading to injuries and a bad reputation. Consider the revolving door of 60-to-80-percent turnover, and it's obvious there's a better way of doing business.

For all of our sakes, culture change is a revolution that's long overdue and, I hope, will become permanent.

However, there's a big problem: It's not going mainstream. It's not spreading like wildfire in an industry desperate for change. A few brave souls have embarked upon it, but not nearly enough. Next week I'll talk about why.

Liz Taylor's column runs Mondays in the Northwest Life section. With 30 years experience in the field, she writes and lectures on a host of aging topics. E-mail her at growingolder@seattletimes.com or write to P.O. Box 11601, Bainbridge Island, WA 98110. You can see all of her columns at www.seattletimes.com/growingolder/.