Volume 51 | Number S1 | February 2016

Abstract List

Barbara Bowers, Tonya Roberts Ph.D., R.N., Kimberly Nolet M.S., Brenda Ryther M.S., R.N., , Patrick Brown B.S., Lauren Cohen, David Grabowski, Susan Horn Ph.D., Sandy Hudak, David Reed, Sheryl Zimmerman


To develop a conceptual model that explained common and divergent care processes in Green House () nursing homes with high and low hospital transfer rates.

Data Sources/Settings

Eighty‐four face‐to‐face, semistructured interviews were conducted with direct care, professional, and administrative staff with knowledge of care processes in six organizations in six states.

Study Design/Data Collection

The qualitative grounded theory method was used for data collection and analysis. Data were analyzed using open, axial, and selective coding. Data collection and analysis occurred iteratively.

Principal Findings

Elements of the model created significant opportunities to identify, communicate, and respond to early changes in resident condition. Staff in homes with lower hospital transfer rates employed care processes that maximized these opportunities. Staff in homes with higher transfer rates failed to maximize, or actively undermined, these opportunities.


Variations in how the model was implemented across homes suggest possible explanations for inconsistencies found in past research on the care outcomes, including hospital transfer rates, in culture change models. The findings further suggest that the details of culture change implementation are important considerations in model replication and policies that create incentives for care improvements.