I found this at the Pioneer Network. They have a GOLD MINE fields’ worth of really good ideas, actual case studies and advice on how to implement culture change in nursing homes.

THIS particular article is about a nursing home in Massachusetts- and the really worthy CNA Career Ladder Program. Very detailed.

Sponsoring Organization

Loomis House is part of Loomis Communities, Inc., a not-for-profit organization that operates three communities in Massachusetts.

Setting

Loomis House, part of a continuing care retirement community, is a 92-bed skilled nursing facility in Holyoke, MA.

Target Group

The culture change effort affects all employees, and career ladders are in place for housekeeping and foodservice employees as well as certified nursing assistants (CNAs). However, this profile focuses on the initiative as it affects CNAs.

Start Date

Loomis House began its initiative by launching a basic CNA career ladder in April 2000.

Here are the details:

Objectives

Primary goals:

* To improve the facility’s ability to retain CNAs.

* To improve care by creating an environment that is responsive to residents’ needs.

* To make the most of each dollar spent on staffing (e.g., spend more on training and less on temporary staffing and recruiting).

Secondary goals:

* To give qualified CNAs more independence, authority, and ability to effect change.

* To increase partnership with families in the care of their loved ones.

* To provide residents with continued opportunities for personal growth.

* To provide outreach to the community, developing or strengthening community ties.

Key Components

The following components affect CNAs most directly:

Continuing education and career advancement. Loomis’s CNA career ladder, which is supported by a curriculum developed specifically to meet the facility’s needs, has three basic levels:

* CNA Level 1 includes the core course of study for state CNA certification plus specialized training in ergonomics. This track is open to Loomis employees who aspire to work as CNAs but joined the staff to work in other departments. Typically, Level 1 graduates secure immediate placement on Loomis’s caregiving team.

* CNA Level 2 provides continuing education with an emphasis on rehabilitation, dementia care, and ‘soft skills’ as determined by individual and staffing needs.

* CNA Level 3 covers leadership skills, mentor training, and a 30-hour physical assessment program.

In addition, some higher-level CNAs choose to take specialized coursework to become a neighborhood coordinator or peer mentor, and mentoring is available to CNAs who aspire to become licensed practical nurses.

Finally, diverse specialized training is also available, including Introduction to Computers, American Sign Language, Time and Stress Management, and Communication. Classes are held onsite and offsite at training partner locations (primarily community colleges).

Resident-centered ‘neighborhoods’ led by direct-care workers. As a first step in its shift from a medical model of care to a resident-centered culture, Loomis divided each of its two stories into two neighborhoods, each serving 20 to 25 residents. At the same time, it created a new position for experienced CNAs: neighborhood coordinator.

Currently, four CNAs hold this position, one assigned to each neighborhood on day shift. Each acts as a frontline manager for her neighborhood, handling tasks such as scheduling direct-care workers and fielding questions from family members. Neighborhood coordinators also oversee the weekly review of each resident’s care plan and help ensure that needed documentation has been secured. Neighborhood coordinators report to the Director of Nurses. As of spring 2004, Loomis management was working to add neighborhood coordinators on all shifts.

In effect, this new position is another step on the career ladder. As of early 2004, one nursing assistant in the position had earned her GED with Loomis’ help and was about to begin studying to become an LPN. Staff who want to pursue a GED are offered peer tutoring and preparatory classes on site. They also receive a copy of PLATO, software that supports GED-related training modules and simulates testing.

Flexible scheduling by CNAs. Neighborhood coordinators are responsible for scheduling their fellow direct-care workers. Flexible scheduling done by a peer fosters teamwork and camaraderie as well as a feeling of control.

Flexible scheduling also fosters culture change at Loomis in other important ways.

First, workers see flexible scheduling as a benefit and a sign that management is tuned into their personal needs.

Flexible scheduling also makes it easier for employees to pursue the classes they need to climb the career ladder. Creativity and flexibility in scheduling help assure coverage while workers are attending class.

Open-door policy. All supervisors have an open-door policy designed to invite collaboration and foster communication between direct caregivers, licensed nursing staff, and managers.

Results, Outcomes, Evaluation

Interest in the career ladder program is high. As of early 2004, there were 11 graduates of Level One, more than 50 of Level 2, and 28 of Level 3.

As the culture has shifted and CNAs have received professional training, the facility has begun to achieve its principal goals.

In part, Loomis measures its success by its reduction in expenses related to direct caregiver staffing, including overtime, recruitment, and temporary staffing (agency fees). In 2000, before Loomis began its initiatives, annual expenditures in these categories were $11,600 for recruitment, $96,253 for temporary staffing, and $24,726 for overtime. Overtime costs stayed fairly level in 2001 and 2002 but dropped to $9,470 in 2003, a 62 percent decrease. Recruitment costs rose in 2001 and 2002, reflecting interim costs related to training, before dropping to $9,800 in 2003, the level at which Loomis management expects it to remain. Costs related to temporary staffing dropped steadily and dramatically, totaling just $2,904 in 2003. These decreases amount to savings of $110,000 in 2003 compared with 2000.

In addition, Loomis’s annual turnover rate has dropped 53 percent, from 85 percent in 2000 to 45 percent in 2003.

Finally, Loomis has taken on a leadership role in promoting culture change in other Massachusetts nursing facilities. Ultimately, Loomis hopes to develop a curriculum/career ladder approach that can be replicated at low cost in other facilities in the state.

Lessons Learned

Basic ‘soft skills’ training is essential to a career ladder program. At Loomis, leadership-oriented classes are some of the most popular and effective courses. Without such training, direct-care workers are not able to develop essential skills such as conflict resolution and understanding human behavior.

‘Adult learner’ techniques, such as participatory learning and opportunities for discussion and problem solving, have proven to be popular and effective at Loomis.

And finally, the costs:

The initial CNA career ladder was funded by a $5,000 grant from the Holyoke Chamber of Commerce in 2000, which was used to purchase career ladder curriculum and training tapes. Later that year, Loomis received the first of four grants from the Massachusetts Extended Care Career Ladder Initiative (ECCLI), a state-funded program that funds workplace education for direct-care workers in long-term care. The first ECCLI grant was for $25,000.

In 2002, Loomis took on a new role as ECCLI grantee, accepting a charge to lead a consortium including two other nursing facilities in the state. As consortium leader, it was granted $380,860 to be shared by the three facilities and their training partners (i.e., local community colleges and other trainers). Subsequently, the consortium received a supplemental grant of $173,508. Last year, the consortium led by Loomis was awarded an additional $144,590 to be divided by the three facilities.

As outlined above, costs for overtime, recruitment and temporary staffing dropped significantly from their 2000 levels, producing savings of $110,000. Management expects that lower levels of spending in these categories will continue. These savings cover the modest pay raises achieved by workers as they step up the career ladder (30 cents/hour for each rung achieved) and provide funding for additional training.

All costs associated with coursework and curriculum development have been covered by the grant.