The Sitrin Model: Changing the culture of long-term care delivery
When visualizing a facility providing long-term care, what normally comes to mind are resident rooms lining hospital-like hallways, central nursing stations, and large institutional dining rooms. Pebble Partner, Charles T. Sitrin Health Care Center, has developed the vision to see beyond this traditional method and is changing the culture of long-term care to allow its residents to live in real homes, rather than in the standard institutional setting. After successfully providing long-term care for nearly 60 years, Sitrin has recently changed the way healthcare is delivered in New York with the opening of its new long-term care homes.
As a Pebble Partner for more than six years, Sitrin has collaborated with nationally recognized architects, interior designers, researchers, and related professionals affiliated with The Center for Health Design. These experts promote healing environments in healthcare and have evidence-based research to support their conclusions. Their influence has resonated in Sitrin's design-built environment and solidifies its position as a model for future development in New York.
The new Sitrin Model-the first approved by the New York State Department of Health-provides comfort and a true home environment for residents. It represents an entirely unparalleled approach that will dramatically alter the concept of long-term care. The transition of these skilled nursing beds from the traditional institutional model to the residential design will improve the quality of the healthcare system in Sitrin's region of New York by creating a design-built environment that responds to today's consumer demands, as noted by “A Plan to Stabilize and Strengthen New York's Health Care System, Final Report of the Commission on Health Care Facilities in the 21st Century.”1
This Pebble report identifies the national megatrend indicating that consumers increasingly are expressing a strong preference for noninstitutional alternatives to nursing home care. The paper further notes that consumers, and in particular baby boomers (born between 1945 and 1964), value living independently and typically shun institutional care arrangements. Sitrin's homelike design with private resident rooms and bathrooms support the demands of today's consumer and respond to the Commission's vision for quality services. Furthermore, delivering skilled nursing care in a more homelike setting has been modeled in various projects throughout the United States. Professionals in the healthcare industry have recognized the clinical and psychosocial benefits of this service platform.
Widespread access to this type of skilled nursing care is currently not available in Sitrin's region. However, Sitrin has more than 15 years of experience delivering care in a similar setting through its Office of Mental Retardation Developmental Disabilities (OMRDD) Intermediate Care Facility (ICF) houses and is best positioned to replicate this service model for its skilled nursing residents.
Building a new model of care
Nine residential Cape Cod-style homes have been built, and were opened and fully occupied in June 2009. The homes are located on their own parcel of land on Sitrin's campus. Twelve residents live in each of eight houses, and 14 live in one. Each resident bedroom is private with its own private bath, independent lift system, large flat-screen TV, and a view of the landscaped grounds. The homes also have large kitchens with family-style dining rooms where residents and staff eat meals together. The living rooms are also spacious, with fireplaces to provide areas for gathering with one another, or with family and friends. The new environment was constructed to maximize the delivery of resident-centered care.
Expected benefits of this alternative care delivery model include improved resident, family, and staff satisfaction; decreased staff turnover; reductions in resident depression and weight loss; improved resident continence; decreased agitation and fewer behavior issues; and increased family visits. Also, individuals previously dependent upon wheelchairs are up and walking, due to shorter travel distances in each house.
The cluster of homes are anchored by a large community building, giving residents and their families a comfortable place for visits, celebrations, holidays, and other activities. Heated, covered walkways ensure convenient access to all of the homes for residents and staff. The views of the landscaped grounds in a beautiful wooded area provide opportunities for outdoor activities that are not possible in most nursing home settings. Convenient outside access consists of merely opening the door, whereas in typical institutional settings, residents live on multiple levels and rely upon staff to help them exit the building via elevators, which are often crowded. Many have to wait for available elevators, as they are also utilized by employees making regular deliveries to various areas of the building.
Residents are exposed to an abundance of natural light in the new homes due to the attractive large windows in the main living areas, which has proven to be essential to their well-being. To ensure each resident has an opportunity to take pleasure in the outdoors, each home has easy access where residents can enjoy the sunshine or relax under a covered walkway, whichever they prefer. Additionally, each home has a multipurpose room where rehabilitative services such as physical, occupational, speech, or recreational therapies are offered.
Safety was another goal of this project. There are design features that the Sitrin Model has also incorporated to protect resident safety. All resident rooms are private and each one has a Horcher Unilift system that travels from bed to the bathroom to an individual's personal wheelchair, allowing residents a safer and more dignified manner of transport. In addition, these lifts provide safety for staff by preventing back injuries and protecting them against falls, compared to manual transfers. Sitrin's decision to include the Horcher Unilift system was based upon evidence such as similar findings of Peace Health, a Pebble Partner colleague. Sitrin hopes to reap the benefits shared by Peace Health which included reduction in incidence and severity of injuries to patient caregiver staff; decrease in patient falls, skin tears, and abrasions; increased patient comfort, security, and dignity during transfers; promotion of patient mobility and independence; enhanced toileting outcomes and increase in continence; as well as improved job satisfaction, staff efficiency, and increased empowerment of nursing staff.2
The Sitrin Model also incorporates advanced technology, including electronic medical records, a nurse call system that works through a pager direct to the caregiving staff, and environmental control units (ECUs). Residents do not have to hear bells ringing during the day or at night while they are resting, ensuring that the homes remain quiet and comfortable.
According to Break Boundaries of Burlington, Kentucky, a leading producer of ECUs, these units allow individuals with disabilities or those with limited mobility or motor skills to control dozens of devices throughout their living environment.3 Individuals with diagnoses including Multiple Sclerosis, ALS, Huntington's disease, spinal cord injuries, traumatic brain injuries, or paralysis can control their television, stereo, fan, telephone, lights, bed controls, nurse call, and computer with the ECUs. Each unit is set up for the individual need of the resident, and has the flexibility to be controlled by touch, voice commands, a head mouse, or via a switch that can be controlled by using almost any body part movement, including the blink of an eye.
Using ECUs in long-term care provides the highest level of independence, and those with limited movement do not need to rely on others to adjust their bed, call a family member on the phone, or turn off their lights. In turn, this allows caregivers to increase productivity by not having to perform mundane tasks, such as changing the television channel, going from room to room to shut off lights, or dialing or answering phones for residents. Nothing can give a resident more pride and satisfaction than being as self-reliant as possible.
Furthermore, the increased application of technology, an electronic medical record system, and ECUs allow staff to have more time with residents. It is anticipated that the technology will change the culture of Sitrin, while dramatically cutting costs.
Building the evidence base for long-term care
Along with designing and building this model, Sitrin is also conducting research to formalize and educate individuals on the benefits of this new environment for long-term care.
Topics of study include the perception of quality of care issues held by the residents and their family members. In particular, the researchers will examine quality of life domains, including emotional, social, and physical well-being. It is estimated that visits from family members will increase due to the more homelike environment, and spacious visiting areas. Since the residents' move from Sitrin's institutional setting to its long-term care houses took place in June of 2009, researchers are currently collecting postoccupancy data with the expectation of research outcomes to be finalized by the end of 2009.
In addition, Certified Nurse Aides (CNAs) provide a great deal of the daily human contact and care for the geriatric resident. CNA interactions with residents are thus decisive in determining both their clinical well-being and daily social context. Other direct care members of the healthcare delivery team also greatly impact the lives of residents. Postoccupancy staff satisfaction surveys will be completed by the fall of 2009. Findings will be shared at the upcoming Health Design conference, which will be held in October of this year.
Sitrin's research would not be complete without collecting data on the satisfaction of the staff in the new cottage-style environment. Retaining qualified staff is quite challenging in the healthcare field, therefore, the Sitrin Model was built not only to improve the quality of life for long-term care residents, but also to improve the quality of the work environment for its employees.
Research is taking place in other areas as well, such as medication errors. Sitrin is determining if the new environment of 12 residents per home leads to fewer medication errors and less usage of psychotropic medications.
The Sitrin Model is the only one of its kind in its region and hopes that it will serve as a prototype for other long-term care facilities throughout New York State. As a preeminent healthcare provider, Sitrin will continue to seek innovative solutions to meet the medical, social, recreational, and support needs of those it serves, with respect, dignity, and fiscal responsibility. HD
For further information, visit http://www.sitrin.com.
- “A Plan to Stabilize and Strengthen New York's Health Care System”. Final Report of the Commission on Health Care Facilities in the 21 st Century. December 2006.
- Joseph A. and Fritz L. (2006). “Ceiling lifts reduce patient-handling injuries.” Healthcare Design 6 (1): 10-13.
- Break Boundaries, Burlington, KY. 2009