For Culture Change Coalitions and State Survey Agencies, hopefully working as collaborators, there are five important and interrelated recommendations based on the experience of the Individualized Care Pilot.

1. Ensure the mandated regulatory process promotes compliance with quality-of-life regulations. The State Survey Agency (SSA) can accomplish this by training surveyors to recognize and enforce compliance with federal and state quality-of-life regulations and through clear communication with providers regarding the meaning of the regulations. 

■ Training surveyors includes assuring they understand the spirit and detail of quality-of-life regulations, are familiar with what individualized care practices look like in action, are prepared for typical surveying scenarios that can be problematic, examine personal attitudes about quality-of-life regulatory issues, and become aware of the power of the questions they ask and the relational manner in which they ask them. The SSA communicating about the meaning of the regulations includes creating transparent and open lines of communication with providers regarding the regulatory facts and being available to answer providers’ questions.

2. Create educational collaborations or connections between the SSA and the Quality Improvement Organization (QIO), or other qualified partner, to assure that providers have the resources needed to implement individualized, resident-centered care practices in keeping with regulatory expectations.

■ When providers in a state or region can openly communicate about any perceived regulatory barriers to implementing new practices and are supported by the SSA in their quality improvement efforts, there is excellent potential for systemwide change. The SSA’s participation in an education-regulation partnership is a powerful way to accomplish that. It is a pragmatic format in which to offer resources to providers at all levels of interest and readiness for the journey from institutional to individualized care. QIOs have the quality improvement expertise and resources to be an excellent candidate to partner with the regulatory authority.

3. Promote opportunities for providers to share their successes, challenges, and solutions so that others can benefit and credibility about new practices grows.

■ Resource sharing or cross-pollination among providers regarding culture change practices is a valuable activity for a culture change coalition, the SSA, the QIO, local trade organizations, or, preferably, all of them in collaboration. Systemwide change depends ultimately on providers having confidence in the economic and pragmatic benefits of new practices. There is no better way to convince a provider that a change is doable and financially viable than hearing it from another provider.

4. Inform residents and families of their regulatory right to quality of life in nursing homes, including the SSA routinely informing them during the survey’s group interview. Coordinate information for consumers with the Ombudsman’s office and other key advocates. Explore ways to involve consumers in understanding and exercising their rights.

■ Culture change coalitions and SSAs need to find ways to respond to a key finding of this project: that nursing home residents often did not know they had the right to choices of schedule or a personalized environment—or did not want to “rock the boat” by asking for what they wanted. The educational handout developed by Rhode Island SSA and distributed routinely at the group interview during surveys is a step in the direction of addressing that lack of knowledge. Any SSA can replicate it. But larger efforts to inform consumers at the national, state, and local levels are needed, and coordination of those efforts among all key players is required.

5. Change state regulations and application processes to support individualized, resident-centered care, if needed.

■ The SSA and culture change coalition members need to work together to examine existing state nursing home and long term care regulations for obstacles to culture change practices and to support legislation to remove them. At the same time they must, when appropriate, propose and garner support for new regulations. The question of whether federal regulations alone are sufficient to define and ensure quality of life for nursing home residents is a key topic for all members of culture change coalitions. State licensing application procedures can be updated, as well, to include clear expectation of individualized, resident-centered practices.

Source: Individualized Care Pilot Toolbox, Rhode Island Department of Health, Recommendations and Dilemmas