Culture change practice in U.S. Nursing homes: prevalence and variation by state medicaid reimbursement policies

Abstract

Purpose of the study: To estimate the prevalence of culture change practice in U.S. nursing homes (NHs) and examine how state Medicaid policies may be associated with this prevalence.

Design and methods: In 2009/2010, we conducted a survey of a stratified proportionate random sample of NH directors of nursing (DONs) and administrators (NHAs) at 4,149 U.S. NHs; contact was achieved with 3,695. Cooperation rates were 62.6% for NHAs and 61.5% for DONs. Questions focused on NH (physical) environment, resident-centered care, and staff empowerment domains. Domain scores were created and validated, in part, using qualitative interviews from 64 NHAs. Other NH covariate data were from Medicare/Medicaid surveys (Online Survey, Certification and Reporting), aggregated resident assessments (Minimum Data Set), and Medicare claims. Medicaid policies studied were a state's average NH reimbursement rate and pay-for-performance (P4P) reimbursement (including and not including culture change performance measures). Multivariate generalized ordered logit regressions were used.

Results: Eighty-five percent of DONs reported some culture change implementation. Controlling for NH attributes, a $10 higher Medicaid rate was associated with higher NH environment scores. Compared with NHs in non-P4P states, NHs in states with P4P including culture change performance measures had twice the likelihood of superior culture change scores across all domains, and NHs in other P4P states had superior physical environment and staff empowerment scores. Qualitative interviews supported the validity of survey results.

Implications: Changes in Medicaid reimbursement policies may be a promising strategy for increasing culture change practice implementation. Future research examining NH culture change practice implementation pre-post P4P policy changes is recommended.

Keywords: Culture change; Medicaid policy; Nursing homes; Pay-for-performance.

Figure 1.

Culture change implementation reported by nursing home directors of nursing: 2007 and 2009/2010. *Implementers in 2007 survey included facilities where culture change completely or for the most part describes the facility. For 2009/2010 survey, implementers included 12% that reported culture change “completely changed the way they care for residents” in all areas of the organization and 19% that reported culture change “completely changed the way they care for residents” in some areas of the organization. 2009/2010 percentages are rounded. The 2007 pie chart is from Doty et al. (2008). **Strivers also included nursing homes with no implementation but with leadership reported to be extremely or very committed to implementation.

Figure 2.

Average culture change domain scores by director of nursing’s response to culture change implementation question.

Figure 3.

Average qualitative interviewer rating (0–5) of culture change domain implementation by director of nursing response to culture change implementation question.