Some nursing homes that rely heavily on Medicaid funding have implemented “culture change” or palliative care, a recent study found.1 This finding surprised researchers.

“Resource-poor nursing homes, whose residents rely primarily on Medicaid for their long-term care needs, are known to be of lower quality than facilities that do not rely primarily on Medicaid,” says lead author Denise Tyler, PhD. Tyler is assistant professor of health services, policy, and practice at Brown University’s Center for Gerontology and Healthcare Research in Providence, RI.

Resource-poor facilities often have lower staffing, lower quality of care, and are less innovative than facilities that are not resource-poor. “They often lag behind other facilities in terms of implementing best practices or new programs,” says Tyler.

When researchers previously surveyed over 2,600 nursing homes in 2009 and 2010, they were surprised to find that some resource-poor facilities were implementing two newer practices: culture change, also known as resident-centered care, and palliative care.2 “This study aimed to determine how they were able to do that, considering the financial constraints they were operating under,” says Tyler.

The researchers expected that some facilities would be ahead on both culture change and palliative care. “Our hypothesis had been that if facility leaders had figured out how to implement and sustain one innovative practice, that they would apply what they had learned to other innovative practices,” says Tyler.

Most facilities had increased their resident-centered care practices. None had increased implementation of palliative care practices, however.

“The differences weren’t so much between the facilities and their leaders, but between these two types of practices themselves,” says Tyler.

This was especially related to the intentional diffusion of culture change by multiple stakeholder groups. “Culture change and resident-centered care was being pushed by so many groups, and so many more resources such as information and training were available to nursing home administrators, that it was simply impossible not to get on board,” says Tyler.

This was not at all true of palliative care. “In fact, many facility administrators had trouble even defining what that was,” says Tyler. She says the following are important take-home messages for bioethicists:

Providers shouldn’t assume that goals of care conversations are happening at nursing homes.

“Take the opportunity to have these conversations with nursing home residents and their families when they are in the hospital setting,” says Tyler.

Providers shouldn’t assume that patients’ wishes, identified during goals of care discussions in the hospital setting, are communicated with the nursing home.

“Ensure that systems are in place so that this information is relayed back to the facility when the resident is discharged back to the nursing home,” says Tyler.


  1. Tyler DA, Shield RR, Miller SC. Diffusion of palliative care in nursing homes: lessons from the culture change movement. J Pain Symptom Manage 2015; 49(5):846-852.
  2. Miller SC, Looze J, Shield R, et al. Culture change practice in U.S. nursing homes: prevalence and variation by state Medicaid reimbursement policies. The Gerontologist 2014; 54(3):434-445.


  • Denise Tyler, PhD, Assistant Professor of Health Services, Policy and Practice, Center for Gerontology and Healthcare Research, Brown University, Providence, RI. Phone: (401) 863-3894. Email: