As long term and post-acute care organizations desire to make the shift toward person-directed care, the neighborhood model is a likely first step of the journey. Neighborhoods are a smaller unit of the larger skilled nursing center that is made up of elders, stakeholders, and family members who live, work, and visit in that area.
This parallels the outside community, in which people live and work in smaller, more compact areas that make up a larger network.

In 2011, leaders at Signature HealthCARE, a long term and post-acute care (LT/PAC) organization with 117 locations across the country, made the decision to start a transformation process that would eventually lead it to the development of this model of care. Leaders created clear goals to destroy institutional silos, transform the entire organizational design, and build systems that breed accountability and transparency.

Signature’s leaders realized that a new approach focused on developing leadership, agile teams, communication, education, quality improvement, and measuring progress would be the keys to overcoming obstacles in the path before them. Prepared for the challenge, they began to devise a strategy that they hoped would drive them toward person-directed care.

Getting The Basics Right

The key tenets of a successful transformation to the neighborhood model included creating smaller areas for elders to live in, high team engagement through a team leadership model, ensuring decisions are made closest to the elder, and an atmosphere of home, among many more.

In traditional skilled nursing centers, decisions are made for everyone by the management team. In a team leadership model, decisions are made closest to the people they affect. This means that the people who work on the neighborhood as nurses or nurse assistants are empowered to make choices that impact their lives. This creates engagement among all staff as well as improves customer service through faster response times and stronger relationships.

In this model of care, the elder truly becomes the center of attention. In other words, everything that
happens within the community involves the elders and coincides with their choices, desires, and goals.

Many leaders are interested in beginning a person-directed care journey but often give up because the work it takes to achieve those goals can be overwhelming in the whirlwind of LT/PAC. That is one reason it is so important to develop leaders who can carry the mission and vision forward. They can stay the course to realize the person-directed care goal amid changing dynamics.

Investing in Leaders

In order to realize a team leadership model, Signature created its Pinnacle program. This is a career ladder program geared toward certified nurse assistants (CNAs). Through this program, CNAs are rewarded for learning new skills, achieving new certifications, and assuming informal leadership roles.

For example, Pinnacle graduates will have led team huddles, neighborhood meetings, and performance improvement projects on their neighborhoods.

Signature also invested in a variety of educational experiences, including an administrator in training program, as well as a customized school for administrators, directors of nursing, and other key leaders for leadership development. The organization also recognizes leaders who display exemplary work each calendar year by naming them Champions.

Champions give back by becoming mentors to new leaders, serving on agile teams, or helping with special project development areas. The emphasis on leadership development creates a culture with a focus on service, innovation, and continual self-improvement. As a result, many Signature leaders are also CNAs and participate in the organization’s days of activating its “service program,” in which corporate and regional leaders volunteer in various roles that impact elders’ daily lives.

This might mean that some work shifts as nurse assistants, some may use their passion for decorating, gardening, or other hobbies to spend time with elders, while others may volunteer for special service projects such as remodeling an area in the nursing center to make it more appealing.

The Agile Team

The organization realized early on that many LT/PAC leaders fail to align with each other or create sustainable partnerships to impact overall culture. To address this issue internally, Signature launched an agile team framework to engage employees of all levels in key decision-making projects.

Agile teams, a term coined in the technology industry, are cross-functional teams dedicated to specific projects to innovate within the organization at a faster pace. The use of agile teams has helped Signature break down departmental and corporate silos by bringing together individuals with varying skills and knowledge bases.

Within the organization, agile teams have been responsible for things such as clinical innovations, program development, and problem solving. For example, the implementation of team huddles and the organizational design of the neighborhood model were created by agile teams.

Hardwiring Communication

For the shift to the neighborhood model to truly take place, a defined process for communication must be in place within the neighborhood itself. Signature leaders recognized that in many instances, department leadership teams were receiving the bulk of the education, yet direct caregivers still were not being given all the tools needed to make execution of the neighborhood model a reality. It was evident that the traditional ways of educating team members through all staff mandatory inservices in existing educational systems were lacking luster and appeal and could even be considered outdated in the fast-paced world of health care.

It was time to create something new, something that would appeal to a new generation of employees. It
became clear that the team huddle would be the vehicle in which communication practices would be born.

An agile team quickly went to work to develop a team huddle process that engaged employees at all levels. The team huddle engages everyone in the nursing center because it is attended by people at all levels of care. This means that department leadership teams go out to the neighborhood unit to be part of the daily communication process. Nurse assistants are also trained and encouraged to lead the team huddles, which further empowers them to become leaders on the neighborhood.

Huddles Embed Care

Team huddles were standardized with a five-minute micro learning sequence that embeds person-directed care learning principles into the daily routines of the organization. The learning sequence includes a descriptive method of breaking down the education piece into what, why, how, who, and a key take-away. Some of the topics covered include person-directed care, person-directed dementia care, and leadership techniques.

For example, when learning about recognizing unmet needs in people living with dementia, the learner would discover what an unmet need is, as well as how to identify and meet that need. The learner would also have a quick overview of why people living with dementia communicate in various ways, such as they might be hungry, need to use the restroom, or simply feel uncomfortable with something. The key take-away would be a one-sentence overview of the lesson. The education topic repeats for seven days in each huddle so that everyone has time to reflect.

The team huddle also serves as a communication tool on the neighborhood to communicate important changes and news. The micro learning offered in the team huddle is also discussed during daily leadership meetings. Additionally, the education ties back to the organization’s Sacred Six Values: compassion, integrity, teamwork, respect, positivity, and patience.

The team huddle quickly became one of Signature’s company standards for communication and team engagement. The impact of the team huddle is felt through the fostered teamwork and faster problem solving by the neighborhood team to impact the lives of elders and their families daily.

Keeping Quality Improvement Fresh

With the team huddle in place, the organization wanted to continue to highlight process improvement and quality control on the neighborhoods themselves. The next logical step was to teach CNAs to use root-cause analysis and tracking to help solve key problems. The tool in which they do this is known as a Quality Service Expansion Team (QUEST) board.

The QUEST board is a daily project management tool in which CNAs track outcomes related to specific measures for their communities. For example, CNAs tracked falls in some locations and were able to identify causes and prevent falls overall. The QUEST board engages all care staff in a visual reminder of measures being tracked as well as overall process improvement methodology.

With so many programs in place, Signature needed a way to track and measure implementation of the neighborhood model. To support this idea, the leadership team created a visual scorecard called The Transformation Tree.

A Transformation Tree was hung in each community, which was given the opportunity to earn a total of 53 leaves. Each of those leaves represents key steps and goals that are important to the community’s elders and stakeholders and also provide momentum toward the organization’s vision for person-directed culture development.

For example, communities could earn leaves for eliminating overhead paging, adding pets to the community, and making environmental improvements such as adding a chapel or general store to meet elders’ needs.

Integrating person-directed care methodology throughout an organization can be done. However, it requires foundational efforts to be made before any lasting change can take place. Those foundational efforts warm up the environment and inspire confidence in local leaders for deeper systems change. While a vision to change is beautiful, it requires persistence and strategic planning to become reality.
Angie McAllister is director of quality of life and culture change at Signature HealthCARE. Read her blog at, and follow her on Twitter at @angiemcallister.