Person-centered care represents the most essential feature of culture change in national models, such as the Eden Alternative. Advancing Excellence highlights the principle that “person-centered care promotes choice, purpose, and meaning in daily life.” And as nursing homes, as well as assisted living centers, are increasingly caring for elders living with various stages of dementia, the Pioneer Network, among other groups, is focused on person-centered dementia care.

Regulation is often seen as a barrier to person-centered care in nursing homes; however, it can be argued that regulation offers the most direct avenue for widespread culture change across the industry. Voluntary initiatives provide the critical step of developing and testing culture-change processes and how to implement them among committed organizations. They also provide the tools to articulate and evaluate these processes from a regulatory perspective.

QIS offers some of these rudimentary tools based on the knowledge base available when person-centered care was designed a decade ago. The resident and family voice became much more central in surveys such that nursing home staff and surveyors began to focus on the resident’s perspective—a first step toward more person-centered care.

Specific QIS questions are aimed at choices, dignity and respect, and participation in care planning decisions, for example, all of which are central to person-centered care.

But what about person-centered care for the growing number of nursing home residents with dementia?
In its most recent Survey and Certification (S&C) letter 14-22-NH; April 18, 2014, the Centers for Medicare & Medicaid Services (CMS) said that it is “undertaking a pilot to more thoroughly examine the process for prescribing antipsychotic medication, as well as other dementia care practices in nursing homes.” This pilot is intended to build on the CMS National Partnership to Improve Dementia Care in Nursing Homes, an interim report attached to S&C letter 14-19-NH; April 11, 2014.

The program focuses significantly on reducing antipsychotic use, but more broadly on “implementing person-centered care practices, individualized care plans, and enhanced resident and family engagement.”

In S&C letter 13-35; May 24, 2013, that provided new surveyor guidance for Quality of Care (F 309) and Unnecessary Drugs (F 329), CMS listed person-centered care as the first principal of dementia care. CMS also recognized the need for considerable training for surveyors to understand this standard and provided training videos to meet this need. Enhancing the QIS process to more fully explicate and assess standards for persons with dementia should be a high priority for CMS.

Providing person-centered care, however, requires a cultural shift in the care for residents who are able to direct their care and services, and those with dementia who cannot.

Relationships between staff and residents are critical in order to support residents in preserving what is meaningful in their lives. The physical environment has to be comfortable and manageable, whether it is like the Greenhouse project, in neighborhoods, or some other physical design. All of these are measurable, but require informed development of more explicit regulations that can provide impetus for culture change.

Andy Kramer, MD, is a long term care researcher and professor of medicine who was instrumental in the design and development of the Quality Indicator Survey (QIS).