Culture Change and Quality of Care among High Medicaid Nursing Homes: Does Earlier Implementation Matter?

Context: High Medicaid nursing homes are under-resourced and associated with lower resident quality of care. Culture change initiatives, a movement to transition nursing homes to more home-like environments, are a potential process to improve residents’ quality of life and care. Objective: To examine how the number of years of implementing culture change initiatives is associated with nursing home quality among high Medicaid nursing homes in the US. Methods: The study used national survey data from nursing home administrators (n = 348) merged with secondary data sources for the year 2018: LTCfocus.org, Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility Quality Rating Program (SNF QRP), and the Area Health Resource File. The dependent variable was the nursing home quality star rating obtained from the CMS SNF QRP. The independent variable represented the number of years of implementation of culture change initiatives. Data were modelled using an ordinal logistic regression with state-level fixed effects (n = 339). Findings: Compared to nursing homes with no culture change/one year or less implementing culture change initiatives, those with six or more years had increased odds of having a higher star rating. Facilities with two to five years of implementing culture change initiatives did not significantly differ from nursing homes with no culture change/one year or less implementing culture change initiatives. Limitations: The culture change measure was self-reported by nursing home administrators. Implications: Results suggest that a more extended implementation period of culture change initiatives may be needed to see quality improvements among high Medicaid nursing homes.