Date of Award

May 2017

Degree Type


Degree Name

Doctor of Philosophy



First Advisor

Brian K. Schermer

Second Advisor

Gerald D. Weisman

Committee Members

Josef Stagg, Margaret P. Calkins


Culture Change in Long Term Care, Environments for Aging, Household Model, Nursing Homes, Organizational Theory, Pragmatic Case Study


As part of the culture change movement in long term care, nursing homes are transforming into person centered living settings that reject the previous medical emphasis that dominated the industry. The household model is one approach to achieve this goal by systemically altering the traditional nursing home’s organization, routines and physical setting with an emphasis on recreating familiar, domestic places for its residents. The household model is hallmarked by three key characteristics: 1) the creation of a smaller functional group of residents within the nursing home that is delineated by the environment (24 residents or less) with the 2) intent of replicating familiar daily life patterns and routines found in a home aided by a 3) decentralized staffing structure working as a team that supports a family atmosphere. While the household model has high face validity for benefiting residents, staff and family members, there is limited empirical evidence in the literature. Since nursing homes have a scarcity of resources, embracing culture change and the household model incurs a degree of risk. Yet, no business case for the household model exists to inform interested providers. This dissertation begins to fill this gap by exploring the monetary issues related to planning, creating, and operating and evaluating the household model in long term care.

The approach to this dissertation was a pragmatic case study design to compare three innovative providers that pursued culture change and adopted the household model in the mid 2000’s. Utilizing a mixed method approach, a total of 42 informants were interviewed, archival records and floor plans were analyzed, informal observations were conducted, and an instrument was developed to access the affordances of the environment for each household. A conceptual framework was developed to organize the information which emphasized the resource system for the three cases.

Case based reasoning for the cost and values for the household model offer the following key findings:

1) All three providers were highly respected and rated organizations before culture change, but adopted the household model due to a moral imperative and not a financial need.

2) The providers shifted from a task based organization to one that focuses on the person and their location (i.e. The Households).

3) Providers engaging in culture change utilized significant resources to train all staff on campus in person centered care, conduct tours, hire consultants and host meetings to generate a common understanding among stakeholders. However, most of these costs were not tracked.

4) Resident quality indicator outcomes were not conclusive for the three cases, but do demonstrate a trend of improved psychosocial factors and behaviors.

5) Providers strove for cost neutral goals. However, staff to resident ratios increased and compensation methods for staff with versatile roles increased costs due to reimbursements for job enlargement (e.g. salary to hourly or certifications required).

6) Providers did not perceive the model to be any more difficult or costly to operate and believed there were opportunities for cost savings.

7) Material costs might increase due to a learning curve for the model, but offering residents a choice comes with some associated costs and the potential for waste without vigilance.

8) All three providers had higher daily rates compared to regional and state benchmarks and lower hours per resident day ratios.

9) Efficiencies within the operating the household model did not result in a reduction of staff, but a degree of organizational slack that was utilized to focus on the residents’ quality of life needs.

Case based reasoning also provides guidance for attempting to measure the costs and values of the model utilizing a retrospective pre-post comparison. Key findings include:

1) The socio-economic context (e.g. state policies, organization composition, economic outlook and resident characteristics) for the three cases impacts the monetary outcomes (e.g. staff turnover, revenue, etc.) for the organization, which made comparisons challenging.

2) Due to the nature of culture change, comparing the results of satisfaction surveys might not illicit a change as new routines of the household became reified as the cultural norm.

3) Providers only measure what was necessary, and are not always able to provide specific costs when the nursing home was part of a larger organization.

4) Conversion to households, which requires capital expenditure, was often accompanied with other changes that impact revenue, such as an increase in private rooms or the creation of a short term rehabilitation unit with higher Medicare reimbursements.

Although not the intent of a pragmatic case study, the theories of Neo-Institutionalism and conceptualizing the built environment as a resource to reinforce Place Identity were common themes in the findings.