Why Resident, Staff Autonomy Should Be at Center of SNF Policy Decision Making

Why Resident, Staff Autonomy Should Be at Center of SNF Policy Decision Making
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Policy decision making – especially around infection control and prevention – needs to be more inclusive as the sector moves forward. Namely, residents, their family members and direct care staff need to have a seat at the table when it comes to broader decisions on policies.

This all starts with a cultural change in long-term care, according to a report published by the Rand Corp., a nonprofit institution focused on helping improve policy and decision making through research and analysis.

Researchers suggest operators emphasize resident and staff autonomy, referencing small-scale policymaking models that could be expanded for wider adoption.

Twenty-three stakeholders provided input for the project, including residents, direct care staff, clinicians and researchers, along with administrators, consumer advocates and long-term care associations.

Lori Frank, co-author for the report, said she wanted to expand on the idea of ​​culture change and policy decision making after the National Academies of Sciences, Engineering and Medicine (NASEM) report was released in April.

“It had such a ripple effect in terms of the whole health care ecosystem,” added Frank. “Through amplifying the points about culture and adding in some of what we found through our work, we can really expand the potential transformative impact of that report.”

Participatory governance, researchers said, or a hybrid of select stakeholders and operational leadership, are policymaking models needed to ensure policies meet the needs of residents.

Researchers outlined three policy decision making models: petitionary representation is more traditional, with administrators and owners bringing concerns to officials. Participatory representation is on the opposite side of the spectrum, with all stakeholders bringing concerns to government officials.

“If you have different voices as part of that governance structure, then you’re likely to see different things, think about things differently, and come to a more rich set of conclusions in any policy-based decision,” said Frank.

A hybrid model is somewhere in the middle, which has a mix of select stakeholders, family members and residents, along with administrators and staff that come together to bring policy recommendations.

“Maybe there’s an in-between way where we can begin to collect this input directly from residents and from family members, maybe using some of the infrastructure that’s already in place,” added Frank. “There are family councils and resident councils that could be a leg up.”


The sector has already seen an increase in family and community group participation during the pandemic, when visitation was nonexistent or severely limited during Covid surges.

Policy decision making should take system-wide pressures into account too, researchers said. Regulation realities, financial management and staffing “must be acknowledged” in cultural changes.

Leadership is critical to moving the needle on cultural change, researchers added, setting the tone for staff action and resident well-being.

“Across all of the many, many people we spoke with, there was real consensus about the importance of within facility leadership,” said Frank. “A lot of this was spurred on by my own experience with my mother-in-law and assisted living. It was so fascinating to hear … [everyone] point to the importance of leadership within the facility for setting the tone and for enabling different types of conversations that can support these types of decisions and this type of culture change.”

Operators must spend more time on leadership training, according to the report, and “fund examinations” of communication between staff and management.

Through such examinations, researchers said, age, gender, race and ethnicity can be assessed relative to collaborative decision making.

Other examinations should look into balancing individual preferences for infection prevention as well as community-level needs and requirements for those in long-term care, researchers noted.

In other words, residents’ autonomy should be considered in infection control policies.

“If there’s going to be a lockdown, or, these are my last few years of life and I choose to hold this birthday party with my family, is there any way to get my preferences entered into that conversation?” asked Frank.


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