The Benefits of Culture Change in Nursing Homes-Obtaining Nationally Representative Evidence

Despite face validity and regulatory support, empirical evidence of the benefit of culture change practices in nursing homes (NHs) has been inconclusive. We used rigorous methods and large resident-level cohorts to determine whether NH increases in culture change practice adoption in the domains of environment, staff empowerment, and resident-centered care are associated with improved resident-level quality outcomes.

We linked national panel 2009-2011 and 2016-2017 survey data to Minimum Data Set assessment data to test the impact of increases in each of the culture change domains on resident quality outcomes.

The sample included 1584 nationally representative US NHs that responded to both surveys, and more than 188,000 long-stay residents cared for in the pre- and/or postsurvey periods.

We used multivariable logistic regression with robust standard errors and a difference-in-differences methodology. Controlling for the endogeneity between increases in culture change adoption and NH characteristics that are also related to quality outcomes, we tested whether pre-post quality outcome differences (ie, improvements in outcomes) were greater for residents in NHs with culture change increases vs in those without such increases.

NH performance on most quality indicators improved, but improvement was not significantly different by whether NHs increased or did not increase their culture change domain practices.

This study found that increases in an NH's culture change domain practices were not significantly associated with improved resident-level quality. It describes a number of potential limitations that may have contributed to the null findings.