Many experts have written about culture change and have pointed out the money-less features including putting the resident in the center of the decision-making circle, being more attentive to needs, and treating residents with love, kindness and respect. While these are essential components of person-centered care and culture change, it does help to have some resources to help along the way. Recent studies show that in skilled nursing, differences between Medicaid and Medicare residents do impact culture change efforts.
Payer Mix and Reimbursement Matter
A key finding in a study by Chisholm and others (2018) found that despite the many benefits of culture change (i.e. higher levels of quality care, resident and family satisfaction, and a more home-like environment), there are certain money-related barriers that affect leadership’s decision to implement features of culture change, namely reimbursement form either Medicare or Medicaid as well as the resident population receiving care.
Medicare, Medicaid and Culture Change
According to Chisholm and others (2018) “Nursing homes that rely heavily on Medicaid may have limited financial resources, which can limit the adoption of innovations as Medicaid reimbursement is typically lower than private pay reimbursements”. Other researchers support this and report that nursing homes with fewer Medicaid residents are able to implement culture change. On the other hand, those nursing homes receiving Medicare dollars are more likely to implement more culture change features and practices.
Management in the Middle
It’s no secret that skilled nursing facilities work on very tight budgets and pay a lot on staff, benefits, and food. There are simply fewer dollars to put into culture change innovations. Managers are in the middle of reimbursement, case mix and Medicare or Medicaid, and sometimes private pay, and whether or not to implement the costlier features of culture change, including remodeling, creating better dining and leisure spaces, turning shower rooms into spas and so on. Reimbursement seems to influence management decisions.
Final Thoughts on Culture Change and Money
While there are numerous features and practices involved in culture change which don’t cost a dime, there are many more that rely on major financial investments. Managers have a budget and the cost of doing business in skilled nursing is high while profit margins are very low. It appears to some degree that resident case mix, Medicare, private pay or Medicaid greatly influence the decision “to be or not be” in the world of culture change.
Resources
Chisholm, L. PhD, MSW, et al. 2018. Culture Change in Nursing Homes: What is the Role of Nursing Home Resources? The Journal of Health Care Organization, Provision, and Financing, Volume 55: 1-6.