Oriente John Caliari had a choice in the second-floor dining room of the Presbyterian Medical Center, a 200-bed nursing home in Oakmont: ham or pizza.
The 76-year-old Penn Hills resident, who is recovering from paralysis of his legs and arms, could look over those and other lunch options at the buffet steam table before the employee in high chef's hat dished them out.
With a staff member taking his beverage order at tableside and the aroma of warm bread filling the room, it was much like the restaurants he was accustomed to outside the nursing home.
"And you can go back for seconds," the retired machine operator said. "They don't hold you back."
Best of all, even though he was in a wheelchair and dependent on others for help, Caliari could decide what he wanted on the spot.
It's a too-novel concept in too many nursing homes, where short-staffing and mediocrity create a rigid, lifeless environment, a joint Pittsburgh Post-Gazette/KDKA investigation has concluded.
Yet, critics of the industry and some pioneers within it are trying to push nursing homes to nurture healthier, happier patients through a movement called "culture change."
Just as important, they say, is overhauling the work atmosphere so that bottom-level employees feel like valued members of a team instead of the ones who end up with all the menial tasks. At the Presbyterian Medical Center mealtime, nurses and supervisors and plainclothes staff stood alongside nursing aides taking food orders and serving meals.
The dining changes are among the first steps in a transformation dubbed "From Hallways to Households" for the nursing home, part of the Presbyterian SeniorCare system.
"We're coming into a period of rethinking the system," said Presbyterian SeniorCare President Paul Winkler. "It's more than changing a building. It's a leadership philosophy that needs to be instilled."
More dramatic innovations are already in use in other parts of the country.
At the Live Oak Living Center in El Sobrante, Calif., every resident and staff member available joins in an hourlong group meeting at 10:15 a.m. daily to air problems or celebrations. Live Oak co-executive officer Barry Barkan calls it a "regenerative community" designed to avoid leaving anyone languishing alone in a room, a common problem.
Nursing homes have made progress in the past decade, he said, with "a recognition that people must be treated as whole people, that people shouldn't be shot up with drugs and tied down. ... But in terms of what you may want for your mother or yourself, we need some radical change in the system."
Slow in coming
The culture change trend has reached relatively few homes, and it can be hard to pin down. It embraces various facets and goes by different names -- regenerative communities, the Eden Alternative, Wellspring model, resident-directed care and more.
Whatever it's called, it can't always be proven that it makes a difference in patient health. Culture change proponents point, however, to the depressing atmosphere and high staff turnover in most of today's nursing homes as evidence of need for change.
They say the generation raised in the Depression and World War II era might tolerate regimentation in group living quarters near life's end, but not so the independent-minded baby boomers who will replace them as nursing home residents in the decades ahead.
The Eden Alternative, adopted by 300 nursing homes over the past decade, is built on relieving facilities of "the three plagues" -- loneliness, helplessness and boredom -- said Dr. Bill Thomas, the Sherburne, N.Y., geriatrician who founded Eden.
It and other culture-change philosophies "all share an idea that the elders themselves ought to have a voice in what goes on, and what their life is like," Thomas said.
"Second, they believe that as management does unto staff, so staff will do unto patients. There's a very bad history of relations between management and staff, and the negative actions are played out all too often against the people who live there."
The third key principle of culture change, Thomas said, is to make the nursing home more attractive and homelike, rather than institutional. That typically means adding plants and animals and, if possible, making dining rooms smaller and creating more comfortable community spaces.
The biggest transformations have been in nonprofit homes, where administrators feel freer to try approaches that can't be guaranteed to enhance the bottom line.
Three years ago, Sandra Wright, administrator of Somerset Patriot Manor in Somerset County, returned invigorated from a three-day Eden seminar. The facility, owned by a nondenominational Christian organization, has been revising its atmosphere and appearance ever since.
"The problem with a nursing home is that everything is so traditional. There's a time to shower, a time for medicine, a time for bingo. Is that what we really want for ourselves?" Wright mused.
"Your management has to commit to overcome the plagues -- by providing more companionship through animals, plants and children, by providing spontaneity and variety and avoiding such routine in daily lives."
Patriot Manor created 14 volunteer teams, run by front-line workers instead of administrators, to help address various issues: measuring quality, raising money, public relations, caring for plants and animals, welcoming children.
Physically, vinyl plastic furniture typical of an old institution was replaced with bamboo rattan signifying more cheery, casual living. The staff began using walkie-talkies instead of the hospital-like paging system. Fish and birds became residents of the facility, which is working its way up to dogs and cats.
While the overhaul is not complete, it's been enough that Wright said staff turnover has dropped in three years from 87 percent to 9 percent annually, while resident occupancy is at 98 percent.
"We always had a good little facility, but if something's obsolete, you need to move on," Wright said. Residents' medication use, moods and participation in activities will be measured to see if the changes have been medically effective.
"We're looking for a decrease in depression -- that's numero uno," Wright said.
Seeing a need to improve
It makes sense that Presbyterian SeniorCare would be looked to as a regional leader in trying new approaches; Woodside Place on its Oakmont campus has been viewed as a model for progressive dementia care since opening in 1991.
But across the parking lot, Presbyterian Medical Center has been a traditional nursing home since the mid-1980s. Officials realized through focus groups of managers, staff, families and residents last year that they weren't much better than anyone else at offering patients any flexibility or sense that the facility belonged to them.
So changes began, starting with second and third-floor dining areas that have been converted for restaurant-style dining. Imposing nursing stations that dominated the view of anyone stepping off an elevator have been recessed into a quieter presence. And employees now have permanent instead of rotating assignments, so they can get to know patients better.
"Everything we're trying is really very simple," said Fatemeh Hashtroudi, the nursing home's executive director. "To ask a resident 'Do you want peas or do you want carrots?' is not rocket science."
Staff members say they can tell the difference in the improved appetites of residents, as shown by reduced orders for Ensure, a calorie supplement.
Still to come are conversions of unused rooms at the end of 120-foot hallways into cozy desk, snack and coffee space where employees and residents will find it easier to mingle. And the first and fourth floors of the medical center will eventually see changes, based on what's learned from floors two and three.
Not everything about such changes is easy.
Aides say that some supervisors have chafed at doing the same work as they do in serving meals. Staff members may hesitate to take permanent assignments, in case they're stuck with difficult residents. Some employees are cold to the idea of letting patients pick when to take showers, which can disrupt other plans for the work shift.
"When you have change, it's always rough at first," said Becky Gardone, a Presbyterian Medical Center direct-care aide for five years, who's seeing happier residents. "It's good for their mental state to have the opportunity to decide some things for themselves instead of always somebody else telling them."
In a much smaller way, the revamping in Oakmont is modeled after a $17.5 million conversion of an 88-year-old nursing home operated by Fairport Baptist Homes Caring Ministries, in Fairport, N.Y.
Fairport Baptist spent its money -- more than 10 times as much as Presbyterian SeniorCare has budgeted for alterations -- to get rid of its 40-bed to 60-bed nursing units. Residents are grouped instead in households of nine to 12 members, who make decisions jointly while getting to know one another and staff intimately.
The Rev. Garth Brokaw, president of Fairport Baptist, said dangerous falls and wanderings have declined as residents learn one another's tendencies and help the staff. Weight loss is less of an issue because people choose their food and snacks and eat them in a small room meant for socializing.
The nursing home has 10 dogs, eight cats, a child care center and toy cupboards for young visitors.
"We really tried to create rampant normalcy," Brokaw explained.
How money is saved
It's hard to say if such culture change is the future of nursing homes, since relatively few have embraced it. It requires nurturing from management in an era of high turnover among administrators as well as staff.
Mary Anne Kelly, executive director of the Southwestern Pennsylvania Partnership for Aging, said effective change has to alter how employees approach both their work and residents, though some facilities try to fake it by just adding a couple of animals -- the "fur and feathers" approach.
"A lot of nursing homes have thrown in a bird and a plant as a marketing tool," Kelly said.
Industry officials say other financial pressures are making regular operations difficult, aside from the potential cost of altering buildings to accept some of the concepts or even taking on new bills for cat food or veterinary expenses.
"There are lots of creative things being done that have significant potential, but the broader issue is that we've been under-resourced for a while," said Alan Rosenbloom, president of the Pennsylvania Health Care Association, which represents many for-profit nursing homes.
His association has been pushing another improvement that he says could provide tangible benefits. Industry officials want the state Health Department, which regulates and sanctions nursing homes, to analyze and distribute more "best practices" data showing successful methods of reducing weight loss, pressure sores and restraint use, among other improvements.
The Health Department is taking a modest step in that direction, conducting a new study in which nursing consultants regularly visit 10 homes to offer advice intended to reduce depression and improve each individual's ability to perform basic tasks. If the suggestions work, they could be disseminated broadly.
But for the most part, state and federal regulators have left it to the industry to figure out how to improve itself. No rewards from government exist for facilities that perform well on inspections or maintain the health of residents better than competitors.
The best prize for nursing homes providing quality care and treating people well is probably the money they save on reduced staff turnover and avoiding empty beds through their reputation in the community.
Sandy Ransom, a researcher at the Texas Long Term Care Institute, said a two-year study she conducted of homes adopting the Eden Alternative in that state documented a 44 percent reduction in staff absenteeism.
That translates into ample savings on overtime costs and use of agency temporary help. The study also found reductions in behavioral problems, pressure sores and bed-bound residents.
The findings persuaded Ransom to become a leader in Eden training herself, in the belief that it shows how residents' immune systems work better when they're happier.
Culture change advocates believe such findings will multiply if facilities place more emphasis on patients' desires.
"You can still [operate a nursing home] the old-fashioned way, making sure people are receiving their medicine and food and having some activities," Ransom said, "but I wouldn't want to live there because I would have absolutely no autonomy as a resident."
Tomorrow: Becoming a better-educated nursing home consumer.
Gary Rotstein can be reached at grotstein@post-gazette.com or 412-263-1255.
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