Transition to Person-Centered Care in U.S. Nursing Homes: Medicaid Reimbursement Policies and Nursing Home Attributes Associated with Culture Change Adoption

Objective: To obtain data on culture change (CC) adoption in U.S. nursing homes (NHs) and examine how NH characteristics and states' Medicaid NH reimbursement policies are associated with adoption. Methods: In 2009/10 we surveyed NH Directors of Nursing (DoNs) and Administrators (NHAs) at 4,149 NHs (i.e., a stratified, proportionate random sample of U.S. NHs); contact was achieved at 3,693 NHs. Cooperation rates were: NHAs: 60.8%; DoNs: 59.5%; and Both: 49.5%. Survey questions focused on CC constructs of physical environment, resident-centered/directed care, and staff empowerment. Responses were summed to create domain scores. A composite score was created by equally weighting domain scores and summing these proportions. Using CC scores merged to NH survey data (OSCAR) and other survey responses we conducted descriptive and multivariate linear regression analyses. All analyses were adjusted for survey nonresponse. Results: 85% of U.S. NHs reports some adoption of CC practices, but there was substantial variation in the extent of adoption. (CC scores ranged from 9.4 to 98.4, out of 100.) Multivariate analysis showed that for-profit NH's and those with higher proportions of Medicaid and Black residents have worse CC scores; those with lower DoN, nurse and aide turnover have better scores. In states with Medicaid pay-for-performance systems (with components focusing on person-centered care), composite scores were significantly higher (coefficient 7.1; p<.001). Implications: State policies supporting person-centered care (NH CC) appear to increase adoption, controlling for other organizational characteristics. However, further research is needed to disentangle the causes/effects of the relationships observed in this study.