University of Minnesota Long Term Care Resource Center
http://www.sph.umn.edu/hpm/ltcresourcecenter/
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Hulda B. and Maurice L. Rothschild Foundation logo

 

The Rothschild Foundation and Culture Change

The Founding President of the Foundation is Robert Mayer, PhD.  
http://www.culturechangenow.com
The Hulda B. and Maurice L. Rothschild Foundation is a private national philanthropy with primary interest in improving the quality of life for elders in long term care environments. The Foundation was created under the will of Hulda Rothschild and came into being at her passing in 1980, at the age of 102. It is the only national philanthropy exclusively committed to culture change in long term care in the United States.

Program Description [TOP]

The Rothschild Foundation is committed to resident-centered relationship-based long term care, integrating elders and their families into the design, planning and programming of skilled nursing homes. If we are to truly improve the way we support and care for elders, they and their families must be an integral part of that service delivery system. Rothschild is presently working with providers, consultants and national organizations to rethink the culture, built-environment, and process of developing skilled nursing homes. The Foundation employs a number of strategies to further its objectives.

Model Programs [TOP]

The Foundation was responsible for the design and development of the Waud Family Resource Center of the Bowman Health Center at Rush University Medical Center in Chicago. As a part of its program of inpatient recovery and rehabilitation services, Bowman provides residential apartments for elders. The Waud family-friendly environment offers a variety of information sources, both electronic and paper, for families to explore issues of the elderly in a comfortable, non-threatening setting.

The Foundation created one of the few private/municipal partnerships, in order to work with the City of Evanston to develop an award-winning enabling garden for the Levy Senior Center. The garden and horticulture program, based on principles of universal design, are created to actively engage elders in a wide variety of programs supported by a rich sensory environment and a beautiful communal space.

Convenings [TOP]

The Foundation’s first support for a culture change conference was in 1998, when it helped to introduce an Eden Alternative workshop for the first time to the Chicago area, “Our Common Ground.” A year later, it supported a much larger presentation of “Learning from Hannah”, featuring Bill Thomas and the Eden Alternative, held in a theater in downtown Chicago and drawing several hundred interested participants.

In 2001, the Foundation attended the Second Pioneer Network National Conference in Rochester, NY and was sufficiently impressed that it offered to sponsor the Third National Conference in 2002 in the Chicago Area. The Network advocates for and facilitates deep system change in our culture of aging. Much of their work has its roots in nursing home reform. At the time, there was virtually no visibility for the culture change movement in the Midwest, so it was a way to create some visibility. This third Pioneer Network Conference, held in August, 20002, attracted 699 participants. There is now an active Illinois Pioneer Coalition. The Foundation has been a sponsor of every Pioneer Network Conference since.

Also in 2004, the Foundation helped introduce culture change to a broader audience by sponsoring a special culture change track at the American Society on Aging Conference in San Francisco, featuring nine sessions over three days, discussion circles and an exhibition booth. It also featured a special role play which was a comedic look at nursing home administration, which has been replayed at several other conferences.

Recognizing that many organizations with roots in acute care have missions and values which parallel those of culture change in long term care, the Foundation has begun to convene important representatives from these fields, including in 2007 Planetree, the Center for Health Design, the Pioneer Network, and the Institute for Family Centered Care. The Foundation was the sponsor of the Continuing Care track at the Planetree National Conference in Chicago in 2008, and of the Planetree Continuing Care Council.

Media [TOP]

The Foundation funds media, when the potential impact is wide-ranging. For example, the first video describing the Green House Project and documenting the historic relocation of elders from their traditional nursing home to a Green House received Foundation support. A video which introduces the SAGE Principles (Society for the Advancement of Gerontological Environments), received Foundation backing. “Design Innovations for Aging and Alzheimer’s”, a guide to design for maintaining independence by Betsy Brawley (2006) was also supported by the Foundation.

In 2010, the Foundation provided support for the development of a Primer designed to increase the availability and effectiveness of arts programming in long term care, in conjunction with the IDEAS Institute and the Society for the Arts in Healthcare. It also initiated development of a Leadership program, including a DVD,  that will demonstrate the advantages of provider/family/elder/patient partnerships in healthcare, in conjunction with the Institute for Family Centered Care.

National Competitions [TOP]

In 2002, the Foundation announced the first national competition for skilled care program and design. The Creating Home & Building Community Award, which was a $100,000 grant, was designed to assist a skilled nursing facility that is remodeling or replacing their physical environment to become more resident-centered. It was awarded in 2003 to the Garfield County Hospital and Long Term Care in Pomeroy, Washington, which is pioneering a number of new management processes in long term care such as rapid cycle decision-making and the balanced scorecard.

In 2007, the Foundation announced a second competition, Creating Home & Building Community II: The Urban Experience. Designed to recognize up to two nursing homes in the exploration of new approaches to creating more resident-centered, relationship-based models appropriate for an urban setting with $50,000 in support, the award was made to Isabella Geriatric Center. Located in New York City, and with 705 beds, Isabella is evidence that size and location are not barriers to culture change.

Research [TOP]

In 2005, the Foundation announced a new research initiative, Comparing State Regulations Affecting Nursing Homes: Implications for Culture Change and Resident Autonomy. This two-year research project resulted in the collection, classification, analysis, and comparison of over 50,000 pages of state and federal regulations that affect nursing homes, including those specific to health and safety.  Information collected is available in a searchable web site, NHRegs Plus, containing all state nursing home regulations and related materials. This information is now being actively utilized by over 30 state culture change coalitions around the country to advocate for regulations more supportive of resident-centered care, with support from the Foundation. A 2010 grant will add state-based waivers to the database.

Regulatory Reform [TOP]

We take it for granted that a very significant approach to moving culture change forward today is regulatory reform; the concept of revising existing regulations such that they support rather than inhibit quality of life for elders, while at the same time preserving the safety and security that they are designed to secure. How quickly we forget that this is still a relatively new vehicle for advocacy, and the genesis of how this approach was launched.

Prior to 2004, a small number of foundations had been supporting the culture change movement, though in a wide variety of ways, including the Commonwealth Fund, Picker, Retirement Research Foundation, RWJ Foundation, and the Hulda B. and Maurice L. Rothschild Foundation. Strategies included support of research, media, model sites, competitions, and new training programs, just to name a few. However, none of these appeared to be able to impact wide areas of the field. The number of homes actually involved in some sort of meaningful change remained very small.

Staff at the Hulda B. and Maurice L. Rothschild Foundation had been informally discussing the lack of progress in moving culture change into the mainstream with industry leaders for some time. The question posed was, “What are the real barriers to culture change?” While the answers were wide ranging, one of the most frequently cited common denominators was regulations. There appeared to be a myriad of complex, overlapping jurisdictions, and rigid regulations which seemed to stymie providers, caregivers, families, residents, and designers/architects alike. Regulatory barriers to household kitchens, hallway seating, and room decoration were frequently mentioned.

It was also clear that a perceived barrier existed between the regulatory community and providers. Few, if any, regulators were present at industry meetings such as AAHSA and AACHA, and they were frequently vilified by those in the provider community. Yet, it was clear that regulators cared as deeply about the welfare of elders as providers. They simply viewed their responsibilities through a different lens.

NH Regs Plus[TOP]

In an effort to better understand regulatory issues, the Rothschild staff quietly invited a small group of regulators to a private foundation-sponsored dinner at the Pioneer Network Conference held in Kansas City in August, 2004. At that dinner, it was pointed out that both the regulatory and provider communities were interested in quality of care for residents. They just approached the issue differently. In the interest of building some communal bridges, the Foundation offered grant support for the regulators in their work, if they could articulate what form that help might take. After several hours of discussion, the regulators agreed that a good beginning might be a database which contained the nursing home regulations for all 50 states. The issue was that each state’s regulations were substantially different from every other state. Many were not available on the internet, and even those that were, were not cross-referenced in a user-friendly way. So, a regulator who wished to identify which state regulations were most progressive in a particular area in other states, for example, was stymied.

In response to this request, the Rothschild Foundation sent a request-for-proposal to several consultants and academic centers in 2004. A grant was then awarded to Rosalie Kane and Lois Cutler at the University of Minnesota in 2005 to upload all nursing home regulations onto a single searchable database on the web, and cross-index them so that they could be readily searched by common issues such as dining and bathing. And describe significant differences between the states. The website, NH Regs Plus, containing approximately 50,000 pages of state regulations, was completed and debuted at the 2006 Pioneer Network Conference, and made available at no charge on the web.

As numerous stakeholders, including state culture change associations and Authorities Having Jurisdiction (AHJ)s, began to utilize NH Regs Plus, they found many ways to bolster their advocacy efforts with data from the website. More than one state advocacy group drafted model state nursing home regulations based on a search for the best language available. Data from the site was used to bolster arguments for regulatory change in many cases. At the same time, more than a few providers began asking, “What about all of the other regulations governing the nursing home industry?” Apparently, it is the second most highly regulated industry in the United States behind nuclear energy.

National Life Safety Code[TOP]

In response, the Foundation provided support along with Commonwealth Fund and others, for a Symposium in April, 2008 in conjunction with the Pioneer Network and CMS, Creating Home in the Nursing Home: A National Symposium on Culture Change and the Environment Requirements. The purpose of the Symposium was to address building design systems, processes, and environmental features which required alteration in order to create a real sense of home in a nursing home. A day of presentations at an open meeting was followed by another day of invitational workshops to develop specific recommendations.

Amongst the recommendations arising from the Symposium, was a suggestion that the National Fire Safety Code be reviewed for possible revisions to better support quality of life for elders. In response, in January 2009, the Foundation provided a grant to the Pioneer Network to convene a national task force to address such changes to the Life Safety Code. Months of work resulted in the submission of four discrete proposals to the National Fire Protection Association, which have now been adopted for inclusion in the 2012 edition of the Life Safety Code. These changes would allow residential kitchens open to the corridor with a more modest fire suppression system; allowing corridors and hallways to include fixed seating; allowing greater flexibility for decoration of resident rooms and hallways; and providing for use of gas fireplaces which are open to sleeping areas.

2014 Guidelines for Design and Construction of Health Care Facilities[TOP]

On April 1, 2009, the Foundation in conjunction with the Center for Health Design, hosted an Organization Roundtable: Bridging Acute & Chronic Care, held in conjunction with the Environments for Aging Conference. The purpose was to create opportunities for leading professional and non-profit associations in the healthcare, long term care, and design industries to promote and support each others’ work and to partner on projects that advance the design of built environments for aging. One of the key recommendations of this group was to develop key design recommendations to the 2014 Guidelines for Design and Construction of Health Care Facilities, in use by architects in 44 states but which do not contain consensus recommendations for aging. Another recommendation was to support specific research designed to enhance options for built environment design regulation. A third recommendation was to explore the possibility of revising the Americans with Disabilities Act.

On November 11, 2009, a Roundtable was convened by the Foundation and the Center for Health Design with representatives of 12 organizations to further refine strategies for approaching revision of the Healthcare Guidelines. The group recommended three approaches: white papers, research and specific recommendations for the 2014 revisions. On June 17, 2010, another meeting focusing exclusively on the Healthcare Guidelines was convened with 17 experts to draft specific changes to be incorporated in the Guidelines revisions, to be submitted in 2011. These were reviewed at another meeting in March, 2011. Changes in nine separate categories were identified, and templates created which will be transformed into Issue Briefs/White Papers for submission to the Healthcare Guidelines Revision Committee.

In May, 2011, the Foundation commissioned the Center for Health Design to conduct some additional research in support of the changes to the Guidelines, specifically to create a Resident Safety Risk Assessment. This will serve as a broad evaluation framework for key design areas that impact resident safety in three residential settings- skilled nursing, assisted living, and memory care. Existing research that supports the relationship between design and safety outcomes in these settings will be identified.

Yet another effort to develop coordinated and comprehensive proposals for residential health care guidelines as a part of the 2014 Guidelines for Design and Construction of Health Care Facilities, is a three day conference to be convened in September, 2011 by the Facilities Guidelines Institute with support from the Rothschild Foundation. This meeting will essentially coordinate all of the recommendations received and compile them into a separate document, apart from hospitals and ambulatory care facilities, concentrating just on residential care.

ADA[TOP]

The Americans with Disabilities Act Accessibility Guidelines (ADAAG) initially issued in 1991, were primarily based upon the physical challenges encountered by returning Viet Nam veterans. These guidelines, based on the physical strength of a younger population, according to researchers, are not well-suited to an increasingly older and more frail community with a wider range of physical and cognitive disabilities. In fact, it has been suggested that adhering to this code may in fact do more to promote disability in elders than to ameliorate it. An often cited example is toilet transfer and grab bar configurations, where non-ADA compliant designs. In 2010, the Foundation in conjunction with the American Institute of Architects, initiated discussions around how to recommend selected ADA modifications to make the ADAAG more supportive of quality of life for elders in long term care settings. A January, 2011 grant to Georgia Institute of Technology is supporting research specifically into alternative grab bar configurations.

Dining Clinical Standards[TOP]

In May, 2010, Creating Home in the Nursing Home II: A National Symposium on Culture Change and the Food and Dining Requirements, brought together a national group of experts under the auspices of the Pioneer Network to understand how the dining experience can better support self-directed living. After the Symposium, the Foundation and Pioneer Network created a Clinical Dining Standards Task Force to create clinical dining standards for each of these groups: physicians, nurses, occupational therapists, pharmacists, dieticians, speech therapists, CDC and FDA. This task force met in March, 2011 with representatives of nine professional associations, CMS and CDC, and their recommendations are now being circulated for support by those professional associations.

International Code Council

In conjunction with the Pioneer Network, the Foundation is supporting an International Code Council (ICC) national task force to submit person-centered changes to be incorporated into the next edition of the ICC codes in 2015. These codes include the International Building Code (IBC), the International Fire Code (IFC) and the International Mechanical Code (IMC). A first meeting of this task force was held July 8, 2011. Some of the initial changes to be recommended will include the approved changes to the National Life Safety Code.

Lighting[TOP]

In 2012, the Foundation expects to commence work with a new lighting task force in conjunction with the National Institute of Building Services (NIBS). This group will recommend specific lighting levels to be incorporated into existing regulations for elder communities that currently only refer to “adequate” or comfortable” levels of lighting.

State Coalitions[TOP]

In August, 2008, the Foundation supported a first meeting of state culture change coalitions at the 8th Pioneer Network Conference. This day-long session focused on follow-up activities to the Symposium, to explore which might be undertaken at the state level by the existing 33 state culture change coalitions. They shared current activities, strategies and ideas for furthering culture change. A June, 2011 strategic planning retreat of coalition representatives continued the dialogue around opportunities to work together.

(7/14/11)