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The Nursing Home Reform Act, passed in 1987, established quality standards for nursing homes nationwide, emphasized the importance of quality of life, and preserved residents' rights. In the culture change model, which has gained momentum over the past decade, seniors enjoy much of the privacy and choice they would experience if they were still living in their own homes. The Commonwealth Fund 2007 National Survey of Nursing Homes In the past decade, there has been growing awareness of culture change among professionals and providers in the field, but the extent to which nursing homes across the country have adopted a resident-centered culture is still unknown. The questionnaire was administered to directors of nursing who were asked about three domains of culture change: resident care, staff culture and working environment, and physical environment. Although survey results are mixed regarding the degree to which nursing homes report they have adopted resident-centered practices, findings indicate a hopeful picture about the potential for deep, systemic change within the industry. Furthermore, the survey shows that in facilities that incorporate some aspects of culture change, the more culture change initiatives that are under way, the greater the benefits in terms of staff retention, higher occupancy rates, better competitive position, and improved operational costs.
Using self-reported data from directors of nursing, we categorized nursing homes that participated in the survey as culture change adopters, culture change strivers, or traditional nursing homes (Figure ES-1).
In general, nursing homes have been most successful at increasing residents' involvement in decision-making, and there is some evidence that management is accommodating collaborative and decentralized decision-making to empower direct-care workers.
Culture change adopters are more likely than traditional facilities to implement resident-centered care approaches. Fifty-eight percent of culture change adopters allow residents to determine their own schedules, compared with only 22 percent of traditional nursing homes (Figure ES-2). Nearly two-thirds (64%) of culture change adopters implement bathing practices that are more resident-centered, while only 37 percent of traditional nursing homes do so. Seven of 10 culture change adopters report that residents are involved in decisions about their facility, but only one-quarter of traditional nursing homes (27%) involve residents in such decisions. Overall, just over half of nursing homes (53%) provide staff with leadership training opportunities but only 15 percent indicate that they currently enable direct care workers to create self-managed work teams and only 14 percent currently cross-train staff to play several functional roles (for example, housekeeping, nursing, food service, and activities) to serve a variety of resident needs. Among culture change adopters, one third (32%) support self-managed work teams yet far fewer traditional homes do so. Fifty-nine percent of culture change adopters include direct care workers and residents on the senior management team, compared with only 24 percent of traditional nursing homes. Culture change adopters are more likely than traditional homes to consistently assign the same aides to residents (86% vs. On average, nursing homes report that only 8 percent of residents currently reside in neighborhoods and only 1 percent live in households. Only 16 percent of culture change adopters report they are currently breaking down large units into smaller operational units and only 7 percent have eliminated large nursing stations, which are often given prominent placement in the center of the unit in institutional-style nursing homes.
While more nursing homes are making the dining experience resident-centered, progress in this area is still slow.
Nearly half (46%) of culture change adopters report they have changed how meals are served. The more culture change principles are embraced, the greater the increase in staff retention and occupancy rates and the greater the decrease in operational costs. Among facilities that are engaged in some aspect of culture change, 78 percent currently implementing seven or more culture change initiatives report that culture change has improved their competitive advantage in their market area. Another 60 percent of nursing homes that are currently implementing at least seven or more culture change initiatives report improved occupancy rates, while only 44 percent with three or fewer culture change initiatives under way reportthis improvement. Half of nursing homes that are most engaged in culture change report that staff absenteeism decreased; in contrast, only one-third of nursing homes with three or fewer culture change initiatives under way report this improvement in staff absenteeism.
The Commonwealth Fund 2007 National Survey of Nursing Homes finds that while many nursing homes are aware of the "culture change" movement, progress has been slow in transforming long-term care facilities from institutions to homes.
The mission of The Commonwealth Fund is to promote a high-performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society's most vulnerable, including low-income people, the uninsured, minority Americans, young children, and elderly adults. When Wisconsin’s Department of Health Services (DHS) decided to implement Music & Memory’s personalized music program in 100 long-term care facilities in September 2013, officials were hopeful that the initiative would improve residents’ quality of life. One year later, the evidence is persuasive: Wisconsin has moved from tenth to fourth place among all 50 states in a national effort to reduce use of antipsychotic drugs in nursing homes.
According to DHS’s Kevin Coughlin, the 100 nursing homes represent about a quarter of all facilities in Wisconsin.
Research, in partnership with the University of Wisconsin-Milwaukee, is underway to provide a rigorous assessment of program benefits for residents. Even before the data were published, evidence of the program’s success persuaded DHS Secretary Kitty Rhoades to champion Music & Memory, not only across Wisconsin, but also to her state executive counterparts nationwide. Response to Music & Memory at the facility level has been so enthusiastic that DHS is bringing the program to another 150 long-term care facilities this fall. Following Wisconsin’s lead, Ohio and Utah are launching their own statewide Music & Memory initiatives, and other states are expressing significant interest in bringing personalized music to their long-term care facilities.
While the program targets nursing homes, it has had a ripple effect for other long-term care settings in the state.
The state’s substantive commitment to making personalized music available to long-term care residents means “it’s being woven into the fabric of best practices,” says Tom Hlavacek, executive director of the Alzheimer Association’s Southeastern Wisconsin chapter. Founded in 2010, MUSIC & MEMORY? is a non-profit organization that brings personalized music into the lives of the elderly or infirm through digital music technology, vastly improving quality of life. Many factors go into a decision about where to place a loved one in a nursing home—compassionate care, excellent medical support, cleanliness, a supportive social environment and affordability are often top of mind.
But a recent survey indicates that access to personalized music has also become a priority for people seeking appropriate long-term care for a relative or themselves.
Most respondents (83 percent) would favor a nursing home that offered residents iPods with individualize playlists versus a similar nursing home that did not. Half of respondents would consider moving outside their city to find a nursing home that offered residents iPods, with 8 percent willing to move out of state. More than half of respondents would spend more money on a nursing home that offered residents personalized iPods. With person-centered care becoming the new gold standard in long-term care, personalized music provides a simple, cost-effective means to enhance residents’ quality of life.
The majority of respondents were either “extremely likely” (29 percent) or “very likely” (24 percent) to favor an iPod-integrated nursing home. As personalized music in long-term care becomes more widely available, Executive Director Dan Cohen hopes this therapeutic option will become so accessible that no one would need to travel far to find it. Perhaps most striking, more than half the respondents indicated they would be willing to pay more for a long-term care facility that offered musical favorites on iPods. For long-term care administrators weighing the costs and benefits of implementing a personalized music program, the results present persuasive evidence that the program can offer a distinct marketing advantage to attract more residents. These findings are consistent with another trend identified in the survey: The majority of those seeking nursing homes favored programs that keep residents mentally engaged. In short, as we age, the survey results suggest that ensuring quality care for the mind as well as the body is becoming a much higher priority for long-term care consumers.
At hundreds of Alive Inside screenings around the country this summer, we’ve heard from audience members who are inspired to get involved and promote MUSIC & MEMORY? in their home communities.
We asked some of our friends in the field to share what has worked at screenings they’ve help to promote. Letitia Jackson, Vice President of Corporate Engagement for Senior Star in Tulsa, Oklahoma, says venue owners have been key to promoting the screenings.
Letitia also connected stakeholder organizations, such as the Tulsa Alzheimer Association chapter, with venue owners to get out the word about screenings. Venue owners served as event MC’s, and also introduced the Q&A session after the screenings.
Steve Garwood, a Music & Memory volunteer in California and a 40-year music industry veteran, made calls and sent emails to his network of palliative care and nursing home contacts to invite them to showings in Encino and San Louis Obispo.
That effort drew a number of health care professionals who were inspired by the film and shared their reactions with facility management the next day.

3) Prime the audience for a Q&A session, and use ice-breaker comments to open a dialogue. The evidence continues to mount: Musical favorites can bridge the divide between hopeless isolation and joyful social engagement for people with Alzheimer’s and other dementias and cognitive challenges. That adds up to significantly reduced stress for caregivers, who get a boost from seeing their loved ones uplifted by the music, as well as time to recharge. The findings were a welcome surprise for Sabrina McCurbin, iPod project coordinator for AST.
AST’s iPod Project, conducted in collaboration with MUSIC & MEMORY?, is targeted at persons with ADOD living at home and their families, as well as those living in care facilities.
Offered free of charge to persons with a formal diagnosis of dementia who live in Toronto (or if their caregivers reside within the city), the program currently enrolls 1,300. The caregivers also found that personalized music helped them to accomplish activities of daily living.
Powerful as these findings are for home- and community-based care, the report emphasizes that residents in long term care settings may have the greatest potential to benefit from personalized music. For Sabrina McCurbin, the report reinforces AST’s goal to expand the iPod Project and build more links to the Toronto community. It’s the iPods that help bridge the gap of generational distance and fear about Alzheimer’s. Just one of many anecdotes, now bolstered by solid research, for McCurbin, about the value of the iPod Project. Whatever the organizational structure, all share a common experience: Favorite music makes a world of difference for residents, their families and the professionals who care for them.
Even for young children, sharing music and helping to identify musical favorites can be a meaningful way to stay connected with a loved one at the end of life. Generating a playlist has become an essential part of resident intake for some hospice programs. Leadership buy-in to Music & Memory is always a crucial aspect of creating a successful program, whatever the care setting. To have music available for residents, especially when they are in their rooms for many hours toward the end of life, has been a great gift. A sophomore at Tuckahoe High School in Eastchester, member of Troop 353 and guitarist with the high school band, Alejandro made a compelling plea before December concerts at both his high school and the local William E. As of March 1, when his donation drive ended, Alejandro had raised $1,300 and collected 38 iPods and 850 CDs of all kinds, including pop, Big Band, classic and alternative rock.
Now that he has collected all the donations for Music & Memory, his next step for his Eagle Scout project is to meet with administration of the nursing home he has identified, with help from a parent in his school district who was inspired by his effort.
The money Alejandro raised will help pay for the MUSIC & MEMORY? Certification Program for the site, although he will also ask the facility to contribute some to the training, so they have a vested interest in the project.
Although he has until he turns 18 to earn his Eagle Scout rank, Alejandro doesn’t intend to wait that long to complete his Music & Memory project and hopes to finish by the end of the school year.
Bent over her wheelchair, eyes closed, Ella would all-too-easily melt into the background of the dining hall at the Orzac Center for Extended Care and Rehabilitation. Chris, who loves “playing guitar, hopping and singing” with residents, brought Ella into her music therapy groups, where the octogenarian became an active participant. It would take, on average, three sessions a week for two to three weeks, 40 to 50 minutes each session, for the residents to realize there was music in the headphones. Chris has also introduced iPods to short term patients, using generic playlists of different popular genres, such as Big Band music or hits from the ‘50s and ’60s.
Founded in 2010, Music & Memory is a non-profit organization that brings personalized music into the lives of the elderly or infirm through digital music technology, vastly improving quality of life. Since learning to use and enjoy her iPod, this woman now resides on a dementia floor with Russian-speaking staff and participates in group and individual programs. However, despite enactment of this law, serious concerns remain about the quality of care provided to residents in the nation's 16,000 nursing homes. Residents' needs and preferences come first; facilities operations' are shaped by this awareness. In 2007, The Commonwealth Fund conducted a nationally representative survey of nursing homes to learn more about the penetration of the culture change movement at the national level and measure the extent to which nursing homes are adopting culture change principles and practicing resident-centered care. Specifically, the survey examines whether nursing homes have adopted practices that make care more resident-directed, that engender a work environment that fosters staff autonomy and decentralized decision-making, and that alter the physical environment to make their facilities look and function like a home, rather than a hospital.
Four or five years ago, few nursing homes were familiar with the term "culture change." Today it is recognized by and familiar to almost all providers. As the awareness of these and other competitive and operational advantages becomes more widely known, it is likely that many more nursing homes will begin to shift toward making the changes in human resource management, the physical environment, and care delivery that are the hallmarks of resident-centered care.
Only 5 percent of nursing homes report that the definition of culture change or resident-directed care "completely" describes their home.
The 25 percent of nursing homes in this category indicate that the definition of culture change describes their nursing home "in a few respects" or "not at all" but leadership is "extremely" or "very" committed to adopting culture change.
The remaining 43 percent of facilities that fall into this group say that the definition of culture change describes their nursing home "not at all" or only "in a few respects" and the leadership is only "somewhat," "not very," or "not at all" committed to the adoption of culture change (Figure ES-1). However, very little organizational redesign has penetrated the field and very few homes have changed their physical environment to support culture change. The survey finds that there is wide variation among nursing homes in terms of the choices and autonomy given to residents and in providing environments that are resident-centered (Figure ES-2). Overall, a minority of nursing homes have undergone organizational changes, such as supporting a team approach for workers or cross-training staff, which makes the organization less hierarchical and empowers direct care nursing home staff. Very few nursing homes have renovated their traditional nursing units into "neighborhoods"—smaller functional areas that can include common community and dining areas—or "households," which are small home settings with a full kitchen, dining room and living areas for 25 or fewer residents and their dedicated staff. As nursing homes become more engaged in culture change and adopt more of its associated practices, staff retention, market competitiveness, occupancy rates, and operational costs also improve (Figure ES-3).
In contrast, only 54 percent of nursing homes that are implementing three or fewer culture change initiatives report such an improvement.
Nursing homes that are considered strivers—that is, they are not yet culture change adopters, but have leaders who are committed to culture change and resident-directed care—are similar to the culture change adopters in their ability to provide resident-directed care.
But with the examples and best practices gleaned from the culture change movement, nursing homes can begin to make the necessary changes to improve the quality of life for their residents and staff.
The Music & Memory program is one of the alternatives to medications implemented by Wisconsin nursing homes to reduce unnecessary prescribing of antipsychotic drugs to residents.
Funding for Music & Memory’s certification program comes from the Centers for Medicare and Medicaid Services (CMS) Civil Monetary Penalties fund, comprised of financial penalties for accreditation shortfalls. While the first round of 100 nursing homes began the Music & Memory initiative with equipment for 15 residents at each site, more than half of the facilities have now expanded their programs to include more residents. Half those surveyed indicated they would be willing to drive a long distance or even move beyond their city to have access to a long-term care facility offering personalized music—27 percent would be willing to search within their county, 15 percent would look statewide and 8 percent would even be willing to commute or move out of state. Statewide initiatives in Wisconsin, Utah and Ohio to bring MUSIC & MEMORY? into their nursing homes are channeling the iPod-based program into the best practices mainstream. Of the respondents, a total of 84 percent said it was either “extremely,” “very” or “moderately important” to enable older residents to stay mentally agile. Personalized music provides a humane, uplifting and fine-tuned approach to holistic, person-centered care in nursing homes—one well worth pursuing and paying for.
Although the round of theatrical releases is now over, in coming months the film will become available for licensed screenings at community venues.
Paul Williams, a team of researchers affiliated with the University of Toronto conducted the report and discovered some additional benefits of personalized music: Caregivers at home, who are often exhausted by their responsibilities for loved ones with ADOD, gain a much needed respite when the ones they care for listen to musical favorites. The program also provides support for staff at MUSIC & MEMORY? Certified Care Facilities in the city.
Participants receive an iPod loaded with their musical favorites, chosen with help from family and friends, and a pair of headphones.

Providing the iPod during activities that might otherwise cause agitation, such as meals, traveling on public transportation or during household tasks such as vacuuming, served to calm their loved ones.
A comparison of responses on the Caregiver Distress Scale between the beginning and end of the three-month study period uncovered two statistically significant results: Caregivers felt more able to engage socially.
Given the prevalence of advanced Alzheimer’s and other dementias among nursing home residents, there are simply more opportunities to help more people. But the report concludes that “this low cost intervention offers a range of potential benefits with little risk of harm. Next steps may include engaging additional community partners, such as adult day programs, memory clinics serving those with early stage dementia, and family doctors. Currently, a core group of 10 helps weekly with developing playlists, loading iPods and providing administrative support. One teen volunteer told McCurbin that he brought his grandmother an iPod loaded with her favorite music.
Settings vary from dedicated hospice facilities to hospice services within nursing homes to hospice care in private homes. According to hospice professionals at MUSIC & MEMORY? Certified Care Facilities, speaking on a recent conference call about best practices, kids enjoy sharing the gift of music with their grandparents, especially when they can meet in a private room and listen to songs together. Families have the opportunity to share more personal background about their loved ones’ favorite music and activities as teens. Conference call participants noted positive feedback from caregivers and family members, who appreciate how the personalized playlists bring joy back to their loved ones while also giving the caregivers a much needed daily respite.
Deirdre Downes says her facility was able to get significant funding by sharing stories with board members about how personalized music has benefited residents. Social work student interns shared videos that they had made of residents and stories about how the program was implemented. That approach garnered a five-figure gift from a board member that will enabled the facility to purchase iPods for all residents as well as hire part-time help to set up the program.
According to Alejandro, only 4 percent of Boy Scouts earn the rank, which requires demonstration of leadership and organizational skills by completing a service project that helps others.
Any money left over from the donation drive will go toward purchase of additional iPods and music. Legally blind, with dementia, she sat quietly, a solitary figure who rarely, if ever, spoke. The first time Chris tried to play gospel music for her on an iPod, it took 50 minutes for Ella to respond at all.
She would sing along to all the music, shake her hand-held rhythm instrument, and even talk to other residents–something she had never done before. Chris says the iPods have helped other residents with dementia to become more engaged, as well, with time and repeated exposure to their musical favorites. Chris has no doubt that listening to favorite gospel music made her final years at the Orzac more humane, meaningful and fulfilling. Struggling with a cognitive impairment and a language barrier, she seemed inconsolable and would only communicate with Russian-speakers one-to-one. Assistant Director Irina Elentukh helped the woman put on headphones and listen to her new personalized playlist.
In fact, many long term care facilities that have graduated from Music & Memory’s webinar program report similar turnarounds for residents.
To improve the quality of care and the quality of life for nursing home residents, a growing movement, known as "culture change," is working to deinstitutionalize long-term care and radically transform the nursing home environment. To this end, nursing home residents are given greater control over their daily lives—for instance, in terms of meal times or bed times, and frontline workers—the nursing aides responsible for day-to-day care—are given greater autonomy to care for residents.
A representative sample of 1,435 nursing homes was surveyed between February and June 2007.
If the first step to change is awareness of a problem and the availability of an alternative, then the field of nursing home care is indeed poised for transformation. An additional 25 percent indicate that their nursing home "for the most part" fits the description of a culture change. About 30 to 40 percent of all nursing homes report they are currently implementing some principle of culture change that fosters resident-directed care, including allowing residents to determine their own daily schedules, practicing resident-centered bathing techniques, or by actively involving residents in nursing home decisions. But, direct care workers are more likely to have leadership opportunities and be authorized to make decisions about delivering resident care in nursing facilities that self-identify as culture change adopters.
Even culture change adopters have difficulty altering their physical environments to make facilities more home-like. They also demonstrate that they are moving toward being the type of facility that empowers workers, provides direct-care workers with leadership opportunities, encourages decentralized decision-making, and allows staff to make decisions about resident care. For a screening in Ohio, the state’s Department of Aging helped promote the program with key information and links on their letterhead as handouts. Not only does the music calm their loved ones; the caregivers also gain peaceful time to focus on daily household tasks or their own personal needs. The recipient, caregivers and family members also have access to a social worker for support, group activities and other services. They also reported that their caregiving responsibilities created less of a negative impact on their personal life and health than before their loved ones had access to personalized music. McCurbin says the volunteers range in age from 14 to 60, with the teens coming from public high schools to fulfill community service requirements.
As one conference call participant noted, “When we get them involved in creating a list for the resident, there is much more joy in the process. Committed to improving the lives of elderly in NYC, Julio introduced his son to Concetta Tomaino, a Music & Memory board member and Director of the Institute of Music and Neurologic Function.
Gradually, however, as she recognized the songs, she began to sit more upright in her wheelchair. Short-term patients sign an agreement to replace the iPod if it is lost and are typically able to use the devices on their own with some basic instruction.
In addition, the physical and organizational structure of facilities is made less institutional. A total of 31 percent of surveyed nursing homes are considered culture change adopters (numbers do not add because of rounding). Indeed, culture change strivers reported significantly more positive responses on all measures related to improving staff working environments, compared with traditional nursing homes. Senior Star helped spread the word about upcoming screenings on their Facebook page with a share campaign.
When he placed the headphones over her ears, she looked in his eyes and smiled at him the entire time the music was playing. That visit inspired Alejandro to learn more about Music & Memory, and to conceptualize his Eagle Scout service project. Large, hospital-like units with long, wide corridors are transformed into smaller facilities where small groups of residents are cared for by a consistent team. These findings reiterate the importance of a committed leadership for encouraging culture change.
Findings From The Commonwealth Fund 2007 National Survey of Nursing Homes, The Commonwealth Fund, May 2008.

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