Response to Rozzini and Trabucchi

Response to Rozzini and Trabucchi To the Editor: We appreciate Drs Rozzini and Trabucchi raising some of the questions we often hear from skeptics of the culture change movement, and are grateful to have the opportunity to respond. Drs Rozzini and Trabucchi express skepticism as to whether a revolution is indeed occurring. We believe (as Dr Rozzini and others may not) that successful culture change facilities represent a paradigm shift from a custodial, medical approach to one that is dynamic, joyful, and quality-of-life enhancing. The transformation in the structure and processes of care is so radical that we feel the term ‘‘revolution’’ is justified. The sad thing is that few physicians and other medical providers appear to fully appreciate how different this approach can be when fully implemented. We agree that the geriatric model of medical care addresses syndromes—such as falls, dementia, and incontinence. However, the physician is almost never the first person to encounter these syndromes as they develop; instead it is the staff and family members who are better situated to anticipate and abort adverse outcomes before they unfold. By changing a facility’s hierarchical structure—for example, by providing consistent assignment and empowering residents, families, and staff—culture change aims to address problems before they happen. The idea is to be proactive rather than reactive to our residents’ syndromes, and in this respect we see culture change as an enhancement of the geriatric model, in which the responsibility and authority are broadly shared rather than resting solely with the physician. This by no means implies no role for physicians or other medical providers. Indeed, they must be full partners, invested in this new model of care and even more active than in the medical model. Medical providers need to not only be up-to-date on geriatric medicine, they must also be responsive to (and patient with) requests of residents, families, and staff, and to serve as supporters and educators to a far greater extent than is required by the medical model. In a culture change facility, the medical director and other providers are truly members of an interdisciplinary team, and not the sole leaders who dictate care. In the United States, residents and families are increasingly demanding this approach.

JAMDA-January 2010

Physicians or other medical providers who fail to educate themselves about this model may find themselves at a loss when engaging the interdisciplinary team. We recognize that our comments relate primarily to what we have seen and experienced here in the United States, and that Dr Rozzini’s clinical work setting may be different. We would like to acknowledge the intense economic stress that is accompanying the ‘‘graying’’ of society, of which Italy and other European countries are seeing firsthand. We empathize with the widespread resource restrictions facing longterm care advocates, and hasten to add that we here in United States are experiencing similar challenges. But as advocates for our patients, we cannot fail to act because the system is imperfect or our resources less than optimal. Our residents are living their last days under our care—let’s finally empower them to make it their home while still optimizing their medical care. E. Foy White-Chu, MD Hebrew Senior Life/Beth Israel Deaconess Medical Center/ Harvard Medical School Boston, MA William J. Graves, BS St. Camillus Health Center, Whitinsville, MA Sandra M. Godfrey, RN St. Camillus Health Center, Whitinsville, MA Alice Bonner, PhD, RN Massachusetts Senior Care Foundation, Newton Lower Falls, MA Philip Sloane, MD, MPH Cecil G. Sheps Center for Health Services Research, Chapel Hill, NC DOI:10.1016/j.jamda.2009.09.012

LETTERS TO THE EDITOR 79