Frequently Asked Questions

From a Consumer's Perspective

Compiled by the Massachusetts Advocates for Nursing Home Reform (MANHR)

1. What is Culture Change?

Culture Change (also known as person-centered care or resident-directed care) transforms the long-term care medical model to one that nurtures the human spirit, as well as meeting medical needs, based on these principles

  • Resident Choice promotes individuality – nursing home residents make choices based on life-long habits, not facility schedules.
  • Relationships between residents and staff are at the heart of quality care, and involve family/friends to create a community.
  • Management Style focuses on teamwork, collaboration, and group decision-making.
  • Environment gives comfort, includes personal belongings, creates neighborhoods, and includes access to the outdoor world.

2. What is the history of the Culture Change Movement?

For more than a decade, a small group of early pioneers in the long-term care field have worked to fundamentally change the values, practices and culture of their organizations to create places for living and growing rather than for declining and dying.  In 2000, these reform leaders from around the United States established the Pioneer Network ( as the umbrella organization for the Culture Change movement.  In recent years, this movement has been expanded to include home and community-based services.

3. What are some of the benefits from Culture Change?

  • Resident benefits: life with dignity, choice, and self-determination, and improvements in physical and mental health (e.g. reduction in: depression, incontinence, pressure ulcers, etc.)
  • Staffing benefits: higher employee satisfaction, less employee turnover, reduction in use of temporary agency staffing, decrease in staff injuries, etc.
  • Additional benefits: higher family satisfaction with quality of care and life of their loved ones; improvements in facility regulatory compliance, etc.

4. What are some examples of Culture Change approaches?

  • Consistent team assignments to care for residents (see #5-How does Culture Change affect nursing home staff?).
  • Care practices built around the preferences of the resident, including waking/sleeping, meals, bathing, etc.
  • Personalized care plans written in “I” format, encouraging residents to make decisions on all aspects of their care. E.g. Instead of “ambulation 2X/day”, a care plan would say, “I like to walk.  My favorite times for walking are after lunch and dinner.”
  • Actively engaged families who are sought out for visits, family councils, care input, etc.

5. How does Culture Change affect nursing home staff?

  • Relationships between staff and residents are at the heart of care.  Systems and structures are developed to support these relationships by focusing on person-centered care, rather than task completion.
  • One Culture Change approach that honors those relationships is through consistent assignments in which teams of staff work together with groups of residents on an on-going basis, rather than rotating assignments.

6. Are Culture Change approaches in violation of CMS or state regulations?

The Centers for Medicare and Medicaid Services (“CMS”) and the MA Department of Public Health (“DPH”) are committed to working with facilities to find innovative ways to allow the implementation of Culture Change.  The essence of Culture Change fulfills the mandate of the Nursing Home Reform Law (OBRA’87) by allowing nursing homes to be responsive to individual resident’s needs and creating an environment in which residents thrive.

  • The MA Culture Change Coalition was initiated in 2005 to foster Culture Change in MA facilities.  Participants in the Coalition include a wide-range of long-term care related organizations.  The Massachusetts Advocates for Nursing Home Reform represents residents, their families/friends, Family-Run Councils, and other advocates in the Coalition.

7. What if a nursing home is unwilling to implement Culture Change?

It’s important to acknowledge that it will take some time to achieve widespread Culture Change.  It is expected that facilities ignoring the movement toward person-centered care will be at financial disadvantage with lower occupancy rates, higher CNA turnover costs, etc.  It is therefore anticipated that market forces will eventually force those facilities to move toward Culture Change.  Promoting education about Culture Change is essential to spreading Culture Change throughout the nursing home industry, and you can play an important role by educating yourself and others on the benefits of Culture Change.

8. If Culture Change is so good, why is there resistance to it?

Changes to any existing system can be difficult and carry with them a certain level of resistance.  Professionals schooled in a long-accepted medical model are being asked to look at their duties and care practices from a different perspective.  Even though Culture Change approaches are beneficial, the evolution of change creates additional questions and concerns on the part of professionals which can impede the process.

9. My facility has some Culture Change activities, but why hasn’t overall care improved?

Some facilities fall into the trap of implementing Culture Change activities on a superficial level.  What can be missed is the meaning behind those activities, even though the activities are positive - such as community involvement, memorial quilts, etc.  True Culture Change involves a change in the attitude and philosophy of management and staff to be centered around the needs and well-being of the resident.

10. Is Culture Change expensive to implement?

Some facilities may decide to make expensive renovations to install “neighborhoods” as one of their Culture Change goals.  However, such sweeping changes to the physical plant are not required to implement Culture Change approaches which are rooted in management styles and staff attitudes.  In general, there may be some consulting costs and other minor costs related to changes in services.  These costs have been viewed as minimal and are offset by savings from a decrease in staff turnover rates and improvements in the well-being of the residents.

Furthermore, a 2007 study spearheaded by the Pioneer Network (conducted by Amy Elliot, Ph.D.) suggests that transformation from a traditional institutional model to one that embraces Culture Change improves quality, without a detrimental effect on cost - thus supporting the business case for providers.  Key findings of the study showed that in comparison to conventional facilities, Culture Change homes had better quality of care outcomes, fewer survey citations, and higher per bed income and operating margins.

11. Will Culture Change work in a diverse, urban setting?

Culture Change has been successfully implemented in nursing homes in large cities with diverse demographics, as well as in small facilities in rural settings. Size and location are not the driving forces for implementing Culture Change, but the commitment of staff to the well-being of residents is.

Examples of successful Culture Change in two diverse nursing home settings:

  • The Maine General Rehabilitation and Nursing Center in Glenridge, portrayed in the American Health Quality Association Culture Change documentary, is in a rural, close-knit community.  The documentary, “Culture Change in Long-Term Care:  A Case Study", can be obtained through the production company: ImageWorks 619-239-6161.

12. How widespread is Culture Change?

The MA Culture Change Coalition has implemented regional forums to educate MA nursing homes on various aspects of Culture Change and to support facilities already on the Culture Change path.  Currently, approximately one-third of Massachusetts nursing homes are involved in these forums, with the number and interest growing in the state.  Also, on a national level, there are over 30 statewide culture change coalitions in various stages of development around the country.