Nursing homes vary a great deal in the amount and quality of care they provide. One useful way of evaluating them is by applying the competence – environmental press model. When applied to nurs­ing homes, the goal is to find the optimal level of environmental support for people who have rela­tively low levels of competence.

Selecting a nursing home should be done carefully. The Centers for Medicare and Medicaid Services of the U. S. Department of Health and Human Services provides a detailed Nursing Home Quality Initiative website that is a guide for choosing a nursing home based on several key quality factors. Among the most important things to consider are quality of life for residents (e. g., whether residents are well groomed, the food is tasty, and rooms contain com­fortable furniture); quality of care (whether staff respond quickly to calls, whether staff and family

168 CHAPTER 5 are involved in care decisions); safety (whether there are enough staff, whether hallways are free of clutter); and other issues (whether there are outdoor areas for residents to use). These aspects of nursing homes reflect those dimensions considered by states in their inspections and licensing process.

Individuals and families should also keep several other things in mind:

• Skilled nursing care is usually available only for a short time following hospitalization, whereas custodial care may be an option for a much longer period. If a facility offers both types, it may or may not be possible to shift level of care without relocating to another room.

• Nursing homes that only take Medicaid residents may offer longer term but less intensive care levels. Nursing homes that do not accept Medicaid may force the resident to leave when Medicare or private funds run out.

• Ensure that the facility and its administrator are fully licensed, and that a full array of staff training is available on such topics as recognizing abuse and neglect, how to deal with difficult residents, and how to investigate and report your complaints.

• Ensure that the resident’s care plan is put together by a team of professionals, and that residents have choices, can exert some control over their routines and care, and will have appropriate assistance with ADLs and IADLs.

• Ask questions about staff educational levels (including continuing education) and turnover.

Based on the various theories of person – environment interaction discussed earlier in this chapter, the best nursing homes use what resear­chers recommend—a “person-centered planning” approach to nursing home policies (Reese, 2001), especially when working with people who have cognitive impairment (Lawlor & York, 2007). This approach is based on promoting residents’ well­being through increasing their perceived level of personal control and treating them with respect. Taking this approach means such things as residents getting to decorate their own rooms, choosing what they want to eat from a buffet, and deciding whether they want to take a shower or a bath. Person-centered planning focuses on the individual, and does not

use a one-size-fits-all approach. Most important, this approach involves a team who knows and cares about the individual who work together with the person to create the best supportive environment possible.

Such policies are grounded in classic research showing that residents who have higher perceived personal control show significant improvement in well-being and activity level, and actually live lon­ger (Langer & Rodin, 1976; Rodin & Langer, 1977). Nursing homes that use the person-centered plan­ning approach also note major decreases in the need for certain medications (e. g., sleep and anti-anxiety drugs) and soft restraints, as well as substantial declines in the number of residents who are incon­tinent (Reese, 2001). Feelings of self-efficacy are crucial to doing well and have a profound impact on nursing home residents’ functional abilities (Johnson et al., 1998; Reese, 2001).

Although the person-centered planning approach has been around for years, many nursing homes still rely on a traditional approach of rules, routines, and requirements (Robinson & Gallagher, 2008). Perhaps the best way to begin changing the culture from one in which residents are expected to be pas­sive to one that includes them in their own care is to focus on activities related to dining. Choosing what one eats, being able to socialize with one’s friends, and interacting with staff while enjoying a meal is one way to create the level of personal involvement and trust necessary to implement a person-centered approach.

Today, person-centered care is considered a best practice in nursing homes (Dellefield, 2008). Including nursing home residents in the planning of their own care represents a major shift in culture, and is an example of the application of research to practice.