• Denise A Tyler, Renée R Shield, and Susan C Miller.
• Center for Gerontology & Healthcare Research, Brown University School of Public Health, Providence, Rhode Island, USA; Health Services Research Program, Providence Veterans Administration Medical Center, Providence, Rhode Island, USA. Electronic address: Denise_Tyler@Brown.edu.
• J Pain Symptom Manage. 2015 May 1;49(5):846-52.

ContextStudies have found that nursing homes (NHs) that rely heavily on Medicaid funding are less likely to implement innovative approaches to care, such as palliative care (PC) or resident-centered approaches commonly referred to as "culture change" (CC). However, a nationally representative survey we previously conducted found that some high Medicaid facilities have implemented these innovative approaches.ObjectivesThe purpose of this study was to identify the factors that enable some high Medicaid NHs to implement innovative approaches to care.MethodsWe conducted telephone interviews with 16 NH administrators in four categories of facilities: 1) low PC and low CC, 2) low PC and high CC, 3) high PC and low CC, and 4) high PC and high CC. Interviews explored strategies used to overcome barriers to implementation and the resources needed for implementation.ResultsWe had expected to find differences between low and high NHs but instead found differences in NHs' experiences with CC and PC. Since the time of our national survey in 2009-2010, most previously low CC NHs had implemented at least some CC practices; however, we did not find similar changes around PC. Administrators reported numerous ways in which they had received information and assistance from outside entities for implementing CC. This was not the case for PC where administrators reported relying exclusively and heavily on hospices for both their residents' PC needs and information related to PC.ConclusionPC advocates could learn much from the CC model in which advocates have used multipronged efforts to institute reform.Published by Elsevier Inc.

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