ADVERTISEMENT
Nutrition 411: Wound Healing in the Era of Long-term Care Culture Change
Patients in skilled nursing facilities (SNFs) have seen institutional life change dramatically over the past several years. SNFs, often called long-term care (LTC) communities, operate under vastly different guidelines than traditional acute care hospitals. Although patients average a 3- to 4-day length of stay, LTC patients often reside in the facility for years, frequently until their death. This necessitates a different approach to care and a more homelike environment. A culture change revolution has taking been shape for several years and is gaining speed.
Understanding related changes can help healthcare providers (HCPs) treat patients and their wounds more effectively.
Defining Culture Change
Today’s LTC patients and/or their surrogates are actively involved in making decisions about their living environment, medical care, and lifestyle choices. This is part of a phenomenon known as culture change. The Pioneer Network (www.pioneernetwork.net), one of the country’s largest organizations that advocates for radical changes in the culture of aging, has spearheaded much of this movement. The group defines culture change as, “The transformation of older adult services, based on person-directed values and practices, where the voices of elders and those working with them are considered and respected. Core, person-directed values are choice, dignity, respect, self-determination and purposeful living.”1 The concept of culture change embraces the patient’s right to make decisions, including the right to refuse medications or treatments, which, in the process, increases the patient’s satisfaction with his or her quality of life. In fact, patients are referred to as residents, not patients, referring to the fact that the healthcare facility is their permanent residence. Some SNFs have embraced the concept completely, while others are just embarking on these changes. But it is clear that culture change in LTC is here to stay.
The adoption of person-directed care is a catalyst for modifications in LTC communities. These changes may include modifications to the physical plant to make the facility home-like rather than institutional, procedural changes such as including the patient’s input in development of a plan of care, and alterations in day-to-day life such as changing medication times to better suit a patient’s sleep schedule or encouraging residents to dine when they choose. Not every person likes breakfast precisely at 7:00 am, so why should this be the only schedule available to residents in LTC?
Patient-centered Care
Meal-related choices are important parts of individualized care and self-directed living for several reasons, but primarily because dining is such a significant part of daily life for most LTC residents.2,3 Many facilities offer their residents dining choices based on individual life-long patterns and history, as well as current preferences. This may include, but is not limited to, open dining times, self-selected menus, buffets, family-style dining, and snack bars or 24-hour accessible pantries. The concept of individualizing or liberalizing diets (as opposed to providing restrictive therapeutic diets)2 is common in LTC today and works hand-in-hand with the culture change movement.
Because LTC is highly regulated by the Centers for Medicare and Medicaid Services (CMS), providers must find the delicate balance between meeting each patient’s medical needs and adhering to the regulations that govern LTC. The CMS regulations embrace all aspects of patient-centered care and culture change. Providers are expected to actively seek a resident’s preferences and choice regarding all important aspects of life, such as waking, eating, and bathing.4 Facilities are required to respect a resident’s right to make his/her own decisions.4 Exercising such rights means that residents have autonomy and choice to the maximum extent possible regarding how they wish to live their everyday lives and receive care. Among these rights are the right to choose a physician and treatment, participate in decisions and care planning, and refuse treatment.4 In the event a resident refuses a treatment recommended by a provider, it is up to the provider to educate the patient and/or his/her surrogate on the risks and benefits of such decisions and to document accordingly in the medical record.
Honoring choices must include variables such as balancing risk with benefit, evaluating individual decision-making capacity, and including resident advocates or surrogates if necessary or appropriate. A patient’s right to make choices become more complex in persons with a cognitive deficit. According to the Pioneer Network, even if a person may not be able to make decisions about certain aspects of life (eg, driving a car), that doesn’t mean he/she cannot make choices about other aspects such as dining.3 The Pioneer Network suggests that all decisions default to the person. A recent study5 found that the person-centered approach demonstrated potential as a nonpharmacological intervention for addressing behavioral symptoms, which is a common issue in patients with Alzheimer’s disease or other forms of dementia. 
The Effect of Culture Change on Wound Healing
All aspects of a patient’s care, including treatment of wounds, are affected by culture change. For example, many wound care professionals and other HCPs may be surprised to find patients with diabetes or heart failure who do not follow a therapeutic diet. In the past, therapeutic diet orders were standard treatment. Within the culture change environment, this automatic restriction is given a second look. The reason for this is twofold: many patients prefer a regular diet and in the process thoroughly enjoy their meals, which leads to better meal consumption; there is not much credible evidence to support the use of therapeutic diets in elderly patients.2 Elevated blood glucose levels may slow wound healing, but typically they are managed by medications rather than diet changes in this particular population.6 To promote wound healing, patients are offered a nutritious diet but have full choice over what foods items they eat. This choice is especially evident in communities that offer buffet dining or self-selected menus. If patients choose to avoid high-protein foods associated with wound healing, the staff can encourage the best food choices, but the final decision is up to the resident. Similarly, fortified foods or high-calorie/protein oral nutrition supplements might be ordered if they are needed, but each patient also has the right to refuse them. A patient also may decline wound care treatments or procedures that medical professionals deem necessary; the provider must document these decisions in the medical record.7 In accordance with the culture change model, the term noncompliant is considered outdated and is generally replaced with terminology reflecting a resident’s right to make choices. Table 1 outlines additional terminology changes in this environment.
One of the goals of person-centered care is to provide the same caregivers for each resident as often as possible. Newer facilities might have small neighborhoods of a few rooms with a central living area. In this situation, the same staff might prepare meals and snacks, bathe and feed residents, and launder their clothes, and in the process develop a personal relationship with their patients. When caregivers know a patient well, they often can provide important input regarding a patient’s habits and willingness to accept changes in routines or treatment that might be needed for wound healing.
Practice Points
Ideally, LTC community staff members should know each resident well. The staff should develop a rapport and a history with the residents they care for and know their choices and habits over time, including what treatments and interventions have been ordered and refused in the past. Patients in LTC facilities should have regular access to a registered dietitian (RD) who can evaluate their wound(s), make nutritional recommendations, and monitor them periodically. Food and fluid intake is easily observed, and poor intake can and should be addressed quickly. The effects of new treatments can be observed on a daily basis. Routine care planning is best conducted by an interdisciplinary team, which provides a variety of perspectives and professional opinions on each patient’s plan of care. Medical specialists should take advantage of an insider’s perspective and consult with the LTC facility staff for input on a patient’s lifestyle, choices, and treatment goals. This type of communication and involvement is perhaps the best way to achieve goals and obtain the best medical outcomes.
The attitude and environment of LTC is shifting. Many LTC residents now live in an environment where a patient’s rights and choices drive the care provided. Quality of life is important, and patients’ decisions to maintain their quality of life are respected. Providers who aren’t familiar with the current culture of change and the regulations in LTC may question a patient’s medical regimen for wound healing, which should be patient-centered. Although nutritional care and other interventions are important to promote wound healing, patients retain the right to refuse. Clinicians must respect these rights but also strive to educate, inform, and guide. All discussions and efforts should be fully documented in the medical record and communicated to other team members.
Working together used to refer only to the staff; these days, it includes the patient, a win-win situation for all.
Nancy Collins, PhD, RD, LD/N, FAPWCA is a registered dietitian based in Las Vegas, NV, and founder and executive director of Nutrition411.com. For the past 23 years, she has served as a consultant to healthcare institutions and as a medico-legal expert to law firms involved in healthcare litigation. Liz Friedrich is president of Friedrich Nutrition Consulting and Associate Director of Nutrition411.com. Correspondence may be sent to Dr. Collins at NCtheRD@aol.com.
1. Pioneer Network. What is Culture Change? Available at www.pioneernetwork.net/CultureChange/. Accessed July 31, 2012.
2. American Dietetic Association. Individualized nutrition approaches for older adults in health care communities. JADA. 2010;110(10):1554–1563.
3. Pioneer Network Food and Dining Clinical Standards Task Force. New Dining Practice Standards, August, 2011. Available at: www.pioneernetwork.net/Data/Documents/NewDiningPracticeStandards.pdf. Accessed August 23, 2012.
4. Centers for Medicare and Medicaid Services. State Operations Manual, Appendix PP - Guidance to Surveyors for Long Term Care Facilities, Revision 70 (1-7-11). Available at www.cms.gov. Accessed July 31, 2012.
5. Butack OR, Weiner AS, Reinhart JP. The impact of culture change on elders’ behavioral symptoms: a longitudinal study. J Am Med Dir Assoc. 2012;13(6):522–558.
6. American Medical Directors Association. Diabetes Management in the Long-Term Care Setting Clinical Practice Guideline. Columbia MD:AMDA 2008. Available at: www.amda.com/tools/guidelines.cfm. Accessed August 23, 2012.
7. American Medical Directors Association. Pressure Ulcers in the Long-Term Care Setting Clinical Practice Guideline. Columbia, MD: AMDA 2008. Available at: www.amda.com/tools/guidelines.cfm. Accessed August 23, 2012.
