Culture Change in Long-Term Healthcare

Instead of residents, call them elders. Instead of units, call them neighborhoods. And put your money where your mouth is. Indeed, the transformation from a hospital model to a hospitality model has a name in eldercare. “Culture change” is the national movement for a conversion of the institutionalized system of care to person-directed values and practices. Community-based settings are key to this culture change.

To grandmother's house we go:  “We’re changing the environment into home life. It’s no longer sterile. It doesn’t have a hospital feel to it anymore. If you come into one of our neighborhoods, it’s like walking into your grandmother’s home,” says Daphne Gulick, senior director of food services at Masonic Village at Elizabethtown in Pennsylvania.

Culture change here is reflected both in the environment and on the plate. The long-term care building houses 450 beds. In a construction project that’s ongoing until 2014, Masonic Village is knocking down walls, creating open, homey spaces.

Nurses don’t sit at a hospital-like station, but instead can be found at a home office-style desk. Residents no longer eat in a central dining room with 449 other residents. Instead, each neighborhood of 45 or so has its own “country kitchen.”

Inside these kitchens, combi ovens are being installed, continuing the re-therming functionality needed, but also including the ability to roast turkeys, for example, adding more home-style cooking to each neighborhood.

That neighborly feeling: Lutheran Community at Telford in Pennsylvania also follows a neighborhood model. The dining rooms have become more intimate, dropping from 75 to 25 residents. “With the neighborhoods, you have a closeness. Staff gets the chance to talk to residents more and find out about individual preferences. It’s a richer experience for the residents,” says John Kopyar, general manager of dining services with Cura Hospitality at Lutheran.

To create a homier atmosphere, each of the three dining rooms has a small kitchen attached. Now, although most of the food is still prepared in a centralized kitchen, there’s the capability to cook some items, like burgers, pizzas and muffins, on each floor.

“It’s closer to home cooking,” he says. “They can smell the pizza, the muffins. Smelling good food stimulates the appetite, which is an important part of the puzzle here.” Another upside to the small kitchens on each floor is that they contribute to the enrichment of an eldercare facility stay. As a scheduled activity, residents can bake breads, muffins and cakes in these more intimate, wheelchair accessible mini kitchens.

Have it your way: One of the key components to the culture change movement is person-directed values. This is expressed in both the culture of care as well as the food culture. And just as customization is king in other foodservice segments, the same is true here.

“We are restaurant-quality driven, but we work in a unique environment. I tell my line cooks that they need to know how to cook broccoli 16 different ways,” says Duane Leitzel, director of dining services at the Village at Penn State Retirement Community, State College, Penn. “We customize every single order based on what they like. On the tickets, our modifiers are in red ink. We have a lot of red ink on those tickets.”

Portion sizes are smaller than they used to be, reflecting both a societal trend and a demographic reality. Proteins are four to five ounces. Each meal time sees four courses: cream- or broth-based soup, salad, four main entrées, six sides (three vegetable, three starch), featured dessert, fruit, sorbet and ice cream. The menu features a chef’s daily feature, which Leitzel says adds to variety but also keeps his chefs engaged and helps him manage food cost. “This is not institutional food,” he says. “It’s local, fresh and innovative.

He also notes that the demographic is changing, and the elders coming in have different expectations. “They demand quality, flexibility and choice.”

They also demand quality of life, and that speaks to the culture change in eldercare. “The new model sees an emphasis on informed choice,” says Linda Roberts, R.D., Academy of Nutrition and Dietetics liaison at the Pioneer Network, based in Chicago. In foodservice, this is reflected in a liberalization of food restrictions. “The question we ask now is, ‘What would they do at home? How can we give them pleasure with their food? There’s a big emotional piece with food that is very important here,” she says.

An elder (what residents are now called within the Pioneer Network) is given information on making the most medically sound choices, but ultimately they can decide on a number of food-related issues. One example is sodium. The elder might have been advised to follow a lower-sodium diet, but a saltshaker is still available on tables in the dining room. Or an elder with compromised swallowing function might not take well to a thickened-liquid regiment—despite the risks of drinking regular liquids. “They get to make the informed choice and guide their quality of life,” says Roberts. “When we try to restrict diets too much, many elders just stop eating. We want them to be healthy and happy.”