Transformation Gives Impatient Author Hope

"I think it's a little like asking people, 'Would you rather be at home or an inmate in prison?' Whereas if you said, 'Would you rather be at home or live in a community with people who care about you?' Then people might respond differently."

- Beth Baker

After four years of researching for her new book, Old Age in a New Age: The Promise of Transformative Nursing Homes, freelance writer Beth Baker is hopeful but impatient.


Hopeful, because she's learned nursing homes can become real homes that provide a life worth living for frail elders.


Impatient, because of the slow-to-change majority of long-term care providers entrenched in the old institutional model.


"I get impatient when people who I feel should know better are not embracing culture change wholeheartedly," she says in an interview with Action Pact.


Though acknowledging the practical difficulties of deep change, the real impediments, says Baker, are cynicism about the abilities of elders and their caregivers, and lack of imagination about "how it could be."


"I can't tell you how many times I've heard, 'That might work for assisted living but not in a nursing home because [the elders] are too far gone,' and, 'Aides at our home couldn't possibly do that,'" she tells Action Pact.


Her book adeptly dispels these myths, citing both anecdotal successes and the latest scholarly research.


Baker, a former dialysis technician and a regular contributor to the Washington Post Health Section and the AARP Bulletin, visited more than 20 nursing homes across the country and interviewed countless residents, caregivers, administrators, advocates and gerontological experts.


As an outside observer, she confirms what culture change enthusiasts within the industry have said all along: most conventional nursing homes are unhealthy for residents and caregivers alike.


"If I had to go into a traditional nursing home, I would be devastated," Baker tells Action Pact. "The loss of autonomy, privacy and control; the feeling of being marginalized or warehoused... would devastate anybody."


Her urgency for change is motivated in part by her grandmother, "an extremely fun-loving, lively person," who quickly "lost her spark" after moving into a "good" nursing home some 25 years ago. More recently, her mother was temporarily admitted to a nursing facility to recover from a fall. Ironically, her daughter's book had just rolled off the presses.


"She was in bed reading my book, saying, 'Oh this is exactly as you describe it,'" recalls Baker.

A Grim Future For Boomers

By the time Baker, now 55, is likely to need a nursing home, she may find the prospect even more devastating than today unless there are swift and sweeping changes.


Plagued by shortages of caregivers and exorbitant turnover rates for staff, nursing homes are on course to double their resident populations in 20 years or so with aging baby boomers. The number of Americans with Alzheimer's disease also is projected to double by 2025, according to the U.S. Census Bureau, Alzheimer's Association and National Center for Health Statistics.


"Working short [staffed] will probably become even more common," Baker states in her book. "There are simply not enough people willing to take jobs that are so stressful, pay so little, and are so little respected."


Studies link short staffing to increased risk for falls, pressure sores, incontinence, dehydration and malnourishment for residents. It also adds stress for workers who must pick up the slack while already scrambling to maintain assembly-line efficiency.


Meantime, caregivers typically must also deal with:


  • Rigid, hierarchical management structures that diminish workers' sense of self-worth,
  • Risk of physical assault from residents and their family members (aides working in long-term care represent the occupation most at risk of workplace assault, according to the U.S. Bureau of Labor Statistics),
  • A resident population that is more frail and needs more medical care than residents of bygone eras (thanks to options like home health care and assisted living for healthier elders), and
  • Inadequate staff training.


Is it any wonder that caregivers are leaving in droves? Annual turnover for nurse aides is 70 percent nationwide (above 100 percent in 10 states) and almost 50 percent for nurses, according to Baker's research. There is scarcely time for staff to learn residents' names, let alone address their true social needs.


"I didn't fully appreciate before writing the book how interwoven the lives of aides and residents are," Baker tells Action Pact. "That simplistic saying, 'you can't have a happy resident without happy workers,' is really true."


Most nursing home caregivers enter the profession with the best of intentions, but whether their intentions come to fruition or frustration depends more, Baker believes, on the work environment than on individual character.


A Very Welcome Surprise

The good news: Staff and residents alike are blossoming in the transformed nursing homes Baker visited.


Slumping, characterized by the disengaged elder with vacant eyes, drooling mouth and collapsed body, is essentially nonexistent. Staff turnover in homes well along the road to change is low, often under 20 percent in those Baker investigated. (She cautions that turnover may increase in the first stages of transition, as some workers are uncomfortable with change and the added responsibility it brings.)


Though enthusiastic about culture change, Old Age in a New Age avoids Pollyannaish conclusions: "Transformation is not a magic elixir. Residents will always face trial and losses. But every place I visited held stories of hope," notes Baker.


Representing a variety of social models (resident-directed, person-centered, regenerative, household, Eden Alternative, Green Houses and Wellspring, among others), each home is unique, yet founded on many of the same principles.


"I felt like transformation is an idea whose time had come because I discovered people doing similar things around the country who didn't even know each other. It's like the ideas were percolating out there independently," she says.


Characteristics shared by all the successful models she visited are:


  • Strong leadership and commitment to change by administrators and other formal decision makers. ("Without courageous leaders willing to take risks on behalf of the people who live and work there, [change] ain't going to happen," Baker tells Action Pact.)
  • Cultures that encourage interpersonal relationships among staff, residents and family members.
  • Commitment to creating a real home for residents and restoring to them as much autonomy as possible.
  • Change from top-down, hierarchical management to a team approach and worker empowerment.


She was astonished to learn transformed nursing homes need not cost more to operate than the old model.


"Everyone assumes if it is a good quality home, it must be for rich people. [Learning otherwise] was a very welcome surprise," she tells us.

Overcoming Societal Delusions

So why aren't more conventional nursing homes boarding the transformation bandwagon?


Even more important than the attitudes of individual operators and boards of directors is society's "delusional denial of aging and death" and the idea that old people are a drag on society with nothing valuable to contribute.


"As long as our society views young adulthood as the pinnacle of life stages, elders will not live in places any of us would want to be," Baker's book concludes.


Still, Baker is optimistic that the culture change movement will grow to provide a lot more options by the time she may need a nursing home.


"What is impressive about this movement is its commitment to all elders, including those who depend on Medicaid. Only by supporting universal access to a life with dignity, no matter our age, income, or frailty, they suggest, will we truly transform the culture of our society," concludes Old Age in a New Age.

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