Building a State Coalition for Nursing Home Excellence

Abstract

Purpose of the Study: This article describes the successful evolution of a state coalition for nursing home excellence that brought together organizations that had once worked in silos to improve the quality of care through the implementation of culture change for Arkansas’ 240 nursing homes with 27,700 residents. Design and Methods: The Coalition was established in 2004 when stakeholders were invited to participate in a retreat to explore how they could come together with a common goal to improve the care of older Arkansans. These stakeholders were encouraged to bring their organization’s perspectives to the Coalition and determine ways to work with others. The continuous refinement of the Coalition’s activities involved revisiting goals of the Coalition, assessing the need for other stakeholders, identifying gaps and overlaps in quality and culture change programming, and providing feedback to Coalition members. Results: The Coalition stakeholders had the leadership to articulate and mobilize others around a common vision of improving quality of care in nursing homes through culture change. Over time, the Coalition members developed a willingness to share resources and to speak as one voice. Implications: Stakeholders from diverse organizations and governing bodies can come together to complement each other’s work and collaborate on programs to build a better system of care for the frail and elderly persons across a state. The success of this statewide effort lends support for policies that encourage regional coalitions of providers to improve care.

Rahman and Schnelle (2008) have described the historical development of the Culture Change Movement, and the American Association of Homes and Services for the Aging (AAHSA & IFAS, 2008) has provided a toolkit of exemplary state activities. The Pioneer Network tracks state-level culture change coalition activities and includes reports of these activities on their web site (https://www.pioneernetwork.net/Coalitions/Coalitions/). Currently, there are 37 state culture change coalitions and 36 regional coalitions that represent a smaller geographic region of the states. Coalitions vary in size and participation. Coalitions also vary in activities. Most coalitions conduct educational programs and networking meetings. Many coalitions also engage in public policy advocacy through grant funding or support from Federal Civil Monetary Penalty funds. Despite these variations, a commonality of coalitions is their ability to bring together people and organizations with diverse interests to support a shared agenda. Although the California Health Care Foundation has reported the results of interviews about the value and impact of the California Culture Change Coalition (Cheek, 2011), little has been described about state culture change coalitions from an organized framework of coalition development. Therefore, this article describes the process of developing a state Coalition, the Arkansas Coalition for Nursing Home Excellence (Coalition), some of the Coalition’s activities and accomplishments, the data provided to Coalition members as feedback, and the members’ evaluation of the Coalition’s effectiveness over the last eight years.

Development of the Coalition

Over the years, long-term care stakeholders, including professional, government, and interest groups, have formed interest-based organizations to improve services on both national and state levels. National level organizations include the American Health Care Association (AHCA), the National Association of Directors of Nurses Administration (NADONA), the National Association of State LTC Ombudsman Programs (NASOP), the National Association of State Survey Directors (NASSD), and the National Coalition of Citizens for Nursing Home Reform (NCCNHR). Similar organizations have also been established at the state level. However, these multiple organizations in Arkansas most often worked in silos, did not effectively communicate with each other, and therefore had not found a common ground to work together to achieve common goals. Further, most of the organizations did not include stakeholders from outside long-term care.

This lack of communication and collaboration meant that multiple uncoordinated demands put on nursing homes made it more difficult for them to focus on quality and culture change. For example, there was often tension between government agencies charged with oversight, facility associations charged with day-to-day management, and advocacy groups charged with addressing significant concerns about care. In addition, training and quality improvement initiatives were often duplicated, leading to inefficient use of scarce resources.

Concerns about the competing demands being put on Arkansas’ 240 nursing homes with 27,700 residents (Arkansas Department of Human Services, 2012), the sometimes adversarial relationships among the multiple stakeholders interested in culture change and quality care, and the less than efficient use of training resources to achieve these goals led three nurse leaders (two from academia and one from the nursing home industry) to initiate efforts to build a state coalition of between 22 and 24 organizations interested in improving the quality of care in Arkansas’ nursing homes. The development of this Coalition is discussed using the seven stages described by Florin, Mitchel, and Stevenson (1993): mobilization, establishment of an organizational structure, development of capacity for action, planning for action, implementation, refinement, and institutionalization.

Mobilization

The first step in mobilization by the three nurse leaders was holding a retreat in which the idea of developing a Coalition was discussed with representatives from nursing home advocacy groups and legislators from across the state of Arkansas, as well as a representative from a national nursing home organization. The retreat was facilitated by a representative from a nonpartisan, independent health policy center that serves as a catalyst for improving the health of Arkansans. At the retreat, a consensus was reached that there was sufficient common ground and will to form a Coalition to address culture change and quality of care in nursing homes. The Coalition leaders assembled a group of stakeholders to participate in the process and secured their commitment to a long-term initiative. The initial stakeholders included 22 people from organizations and other entities with interest in long-term care, including providers, payers, state regulators, consumer advocates, representatives of state and national legislators, the Governor’s office, nursing home organizations, and the Chamber of Commerce and the community. These agencies and associations as reflected in Table 1 were expected to bring their perspectives to the Coalition and to commit to a long-term initiative.

Table 1.

Types of Agencies and Their Purpose Represented in the Coalition

Type of agency	Agency represented	Purpose
Quality improvement agency	Arkansas Foundation for Medical Care	Improve the effectiveness, efficiency, economy, and quality of services delivered to Medicare beneficiaries.
	Arkansas Innovative Performance Program
Provider agency	Arkansas Health Care Association	Represent 93% of long-term care providers in the state with legislature. Provides educational programs for health care professionals and staff in long-term care facilities.
	Arkansas Health Care Foundation
	Arkansas Assisted Living Association
State agency	Arkansas Department of Human Services, Office of Long Term Care	Provide licensure and surveys of long-term care facilities in the state. Approves certified nursing assistant programs also.
	Arkansas Department of Human Services, Office of the Long Term Care Ombudsmen	Advocate for the rights of long-term care residents, train volunteer ombudsmen, and provide educational programs.
	Arkansas Attorney General’s Office, Consumer Protection Agency	Receive complaints from consumers on care in long-term care facilities and other groups.
	Health Care Policy Advocate from the Governor’s office	Provide information to group about state issues regarding funding and changes in policy.
Nursing home/Assisted living owner	Privately owned nursing home and assisted living facilities	Implement culture change in homes and provide perspective on challenges related to survey of homes.
	ConvaCare, Southern Administrative Services, Southridge Village
Consumer organization	Alzheimer’s Association	Provide information and support to persons with dementia and their caregivers.
	Alzheimer’s Arkansas	Provide information and support to persons with dementia and their caregivers.
	Arkansas Advocates for Nursing Home Residents	Advocate for the quality of care and life for Arkansas residents in long-term care facilities.
	Arkansas State Chamber of Commerce	Serve as the primary business advocate on all issues affecting Arkansas employers.
Professional organization	Arkansas Medical Directors Association	Represent medical directors, attending physicians, and others practicing in the long-term care continuum.
	Arkansas Association for Long Term Care Nursing	Advance excellence in the specialty of long-term care nursing.
	Arkansas Gerontology Association	Improve the options, choices, and opportunities of mature Arkansans by convening public and private groups and individuals to share information and increase the knowledge and skills of members.
	Arkansas Association of Directors of Nursing Administration/Long Term Care	Advocates for Directors of Nursing Administration and Registered Nurses in Long Term Care
	Academy of Consultant Pharmacists	Empower pharmacists to enhance quality of care for all older persons through the appropriate use of medication and the promotion of healthy aging.
	Arkansas Chapter National Gerontological Nursing Association	Represent nurses providing care of older adults across diverse care settings.
	National Association of Health Care Assistants	Assure the highest quality of care is provided to the nation’s elders living in nursing homes.
Resident	Lakewood Nursing and Rehab Center	Represent the perspective of a nursing home resident.
Advanced practice nurse	Works in private nursing home and has free clinic also	Represent issues facing Advanced Practice Nurses in the workplace.
Politicians	U.S. Congressman/Senator local representatives	Represent the congressional offices and provide updates on any national health issues.
	Arkansas House of Representatives Health Policy Committee	Inform coalition on current issues effecting older adults and long-term care.
Academic institution	University of Arkansas for Medical Sciences • Donald W. Reynolds, Institute on Aging • Hartford Center of Geriatric Nursing Excellence, College of Nursing • College of Medicine, Department of Geriatrics	Represent the three areas at the university who have strong interest in care of older adults and quality in long-term care.

Establishment of Organizational Structure

After the retreat, the three nurse leaders agreed to serve as coleaders for the now Arkansas Coalition for Nursing Home Excellence (Coalition). The coleaders Beck and Beverly were from the academic setting and Moody was from the provider setting.

The Coalition coleaders (Beck, Beverly, and Moody) established an organizational structure for the Coalition with input from the stakeholders that included a coordinator for communications and a recorder. Cochairs and working groups were established later after setting the mission and goals. The organizational support for the Coalition was provided by the academic setting in the hope that this would bring a sense of impartiality to the members.

Development of Capacity for Action

The development of capacity for action included development of the following vision and mission for the Coalition:

Vision.

Create nursing homes in which the elderly, frail, and disabled people will experience the highest quality of life.

Mission.

Change the course of care in nursing homes by addressing immediate and long-term needs. Long-term care for those who require nursing home settings will be

• person centered to respond to unique conditions and choices,

• adequately staffed by a well-trained, empathetic, well-compensated workforce,

• community based to engage rather than isolate, and

• technologically advanced.

The development of capacity also included informing Coalition members about national- and state-level initiatives on which the Coalition could focus. For example, because one of the Coalition leaders was a member of the National Commission on Nursing Workforce for Long Term Care, she was able to share the Commission’s recommendations for practical steps to recruit and retain a skilled and experienced nursing workforce to care for frail elderly and disabled people. Likewise, a Coalition leader was on the Steering Committee for the Advancing Excellence Campaign, and she shared the goals and activities of this Campaign. Coalition organizations were also able to educate Coalition members about national- and state-level activities. For example, the quality improvement organization for the state provided the Coalition’s stakeholders information about the areas in which the Centers for Medicare and Medicaid were focusing for quality improvement.

Planning for Action

Using the new vision and mission for the Coalition, the following goals related to changing the culture of the nursing home environment were established.

• Goal 1: Implement person-centered care in nursing homes in Arkansas.

• Goal 2: Support person-centered care by systems in place to sustain continuous quality improvement.

• Goal 3: Implement person-centered care by an interdisciplinary team that is knowledgeable, empathetic, and cost effective.

• Goal 4: Evaluate the quality measures and cost–benefit outcomes of person-centered care as implemented in Arkansas.

Implementation

Activities of the Coalition focused on person-centered care and stakeholder meetings were used to determine the best way to implement measures to improve person-centered care. Many of the Arkansas Coalition’s activities are detailed on the Pioneer Network’s web site and therefore are not reported here in detail. However, we have grouped the activities of the Arkansas Coalition into some overarching areas that may be helpful to other culture change coalitions, and they are briefly described here. These areas are (a) joint promotion of educational programs; (b) coordination to prevent duplication; (c) collaboration between the university and public sector; (d) influencing policy; (e) mobilizing all members; (f) rapidly responding to opportunities; and (g) hosting of national meetings.

Joint Promotion of Educational Programs.

When the Coalition began, many stakeholders were sponsoring their own activities and were not aware of similar activities that other organizations were sponsoring in the same parts of the state and on the same topics; there was little cross-organization publicity. As members of the Coalition grew to know each other and the goals of the multiple organizations, leaders of organizations began to feel encouraged and supported in their work. Any event that was held by an organization in the Coalition was branded with logos from all the major organizations in the Coalition, and each organization helped to publicize the events of other organizations.

For example, members of the Coalition were involved in marketing the Medicaid performance program’s monthly statewide conference calls and educational programs funded by the quality improvement organization, the Ombudsman program, and others. The Coalition also hosted the national Advancing Excellence Campaign’s consistent staffing webinar, provided support for awards to physicians from the state medical directors’ organization, and provided support for awards to certified nursing assistants from the state advocacy organization. Through collaboration with the state nursing home association’s educational foundation, the Coalition provided a promotional partnership to their Resident Art Program. Coalition members also encouraged the development and establishment of the foundation’s Administrator in Training program, Director of Nursing training, Activity Director Certification, and four other long-term care services trainings.

Coordination Among Stakeholders to Prevent Duplication of Effort.

Nursing homes often felt confused and overwhelmed by the multiple, sometimes overlapping activities to address quality improvement. The state quality improvement organization provided participating long-term care facilities with tool kits and training in areas of needed improvement. In 2005, another quality improvement group was funded by Medicaid to provide training in Medicaid-certified nursing homes, and they were invited to join the Coalition. Their work focused on identifying the top 10 survey deficiencies in the state and providing training in a train-the-trainer environment to improve care. At the same time, a new, broad-based national coalition, the Advancing Excellence in America’s Nursing Homes (Campaign), was launched to improve quality. Because this new campaign had goals and strategies similar to the Coalition, including building on and complementing existing quality and culture change activities, the members of our Coalition agreed to participate.

At stakeholder meetings, these three groups reviewed the long-term care facilities they were working with in various regions of the state to make sure there was no duplication of effort. Thus, facilities were not approached by multiple groups with the same goal, resulting in a more efficient use of resources.

Collaboration Between the University and the Public Sector.

One of the most important features of the Coalition was the establishment of partnerships between academia, regulatory agencies, and organizations focused on quality of care. Examples of these are listed subsequently:

1. The Hartford Center for Geriatric Nursing Excellence at the University of Arkansas for Medical Sciences became the logical home to the Arkansas Advancing Excellence Campaign (AR AEC) because this group was already providing administrative support to the Coalition. The AR Advancing Excellence Campaign identified a program to improve communication skills between nursing home staff, residents, and family caregivers as part of the Coalition efforts to promote person-centered care. The Partners in Caregiving-Cooperative Communication Between Families and Nursing Home Staff was developed by the Cornell Gerontology Research Institute (Pillemer et al., 2003).The AR AEC and the Coalition formed a work group to implement the program across the state. Over 100 people, including attendees from 41 nursing homes and assisted living facilities, family caregivers, professionals and paraprofessionals, attended the program. They were trained as trainers so that they could take the program back to their homes or regions. After the initial training in May 2009, the Coalition partnered with the University’s statewide initiative, the Arkansas Aging Initiative (Beverly et al., 2007), which provides geriatric care in local communities across the state through Centers on Aging. The Directors of Education in the local Centers scheduled 17 Partners in Caregiving training sessions and trained 462 nursing home employees in 137 different homes, amounting to 60% of the nursing homes in the state. Thus, the Coalition was able to take advantage of the affiliation with the University and the statewide infrastructure (Beverly et al., 2007) provided through the University’s seven Centers on Aging.

2. The Coalition mission on improving the workforce in long-term care led to discussions among three Coalition stakeholders (the Hartford Center for Gerontological Nursing Excellence, the AR Health Care Association, and the Arkansas Foundation for Medical Care) to secure funding for two Robert Wood Johnson Partners in Nursing grants to bring CNAs, LPNs, and RNs into nursing programs in order to strengthen the long-term care workforce. Both awards required matching dollars, which were secured from Coalition partners.

3. Because of the relationships established with the state survey agency, Coalition leaders from the University were able to nominate a surveyor from the agency to the Geriatric Nurse Leadership Academy, an 18-month leadership program within the international nursing honor society (Sigma Theta Tau International). The Coalition believed that this program would improve the relationships between the state survey agency and nursing home facilities by promoting a more collaborative relationship and helping the nurse workforce better understand rules and regulations.

4. When workforce needs were reviewed, a significant need for advanced practice nurses in nursing homes became apparent. The College of Nursing at the University decided to expand its geriatric nurse practitioner track to meet the new national requirements for the Adult-Gerontological primary care nurse practitioner. The long term care provider association and the state workforce services each contributed funding to support a PhD faculty member for this track. Again, relationships that had been developed played a key role in helping partners understand the need to strengthen the long-term care workforce and identify ways in which they could contribute.

Influencing Policy.

Coalition members are well aware that policy changes are sometimes needed to achieve the Coalition vision. Therefore, Coalition members have remained vigilant about policy-related activities nationally and at a state level. The Coalition has actively worked to have a voice in policy making. Numerous states use civil money penalties to improve the quality of nursing home care (Tsoukalas et al., 2006); in 2008, the Arkansas state survey agency requested permission from the legislature to add to the activities for which civil money penalty dollars could be used. Once the legislature approved expanded program uses for civil money penalties, the state survey agency awarded funding to staff the AR AEC. More recently, the Medicaid division of the AR Department of Human Services has engaged in a Balancing Long-Term Care initiative to place more individuals needing care in community-based settings rather than nursing homes. Members of the Coalition have actively participated in discussions leading to policy changes focused on quality improvement, staffing, and universal assessment. As a result, Medicaid leaders have invited Coalition members to participate in discussions to shape policy.

Mobilizing All Members.

In 2008, the national Advancing Excellence in America’s Nursing Homes issued a challenge to recruit/sign up nursing homes in each state to participate in programs and select goals for work. The Coalition members went into full gear and worked together to determine the best way to get nursing homes involved. They divided up the list of nursing homes, placed calls, e-mailed, and blast faxed information to owners/administrators and directors of nursing to encourage them to sign up and select goals to focus on for the next year. By the time the enrollment period ended, Arkansas had a 100% sign-up. At the first national campaign meeting in Dallas, the Arkansas representatives were honored for this accomplishment.

Sign-up was not the endpoint however. A Coalition subcommittee developed a plan to track the goal achievement and have ongoing communication with the homes. The group developed window clings and certificates to hang in the front of facilities demonstrating their participation in this national campaign.

From 2007 through 2010, Coalition members supported an array of culture change activities, participated in implementation of legislative, financial, and state regulatory changes, and administered the AR AEC satisfaction surveys.

In 2006, members of the Coalition collaborated to bring Nancy Fox, the Executive Director of the Eden Alternative to expose not only facility workforce but also community members, state surveyors, vendors, facility owners, home health agencies, and the public to the Eden Alternative. Initially, training was held to introduce the 10 Principles of the Eden Alternative; then more training was conducted to help participants become Eden Alternative Associates. One-day seminars were held in five locations, with attendance averaging 130 representatives from diverse groups. Lead representatives of the Coalition promoted the events.

The Arkansas state survey agency sponsored a significant surveyor attendance, and other provider organization members hosted Eden Alternative Associate training and set stellar examples of this continuing collaborative atmosphere. The number of Eden Alternative Associates trained around the state has now reached over 200. In 2011, an Eden Alternative Associate Alumni meeting was sponsored by the AR AEC with funding from the Office of Long-Term Care and over 200 people attended. The State Survey Agency Director supported training for every survey supervisor, making Arkansas the only state in which all survey supervisors were Eden Associates. There are now six Eden Alternative Educators in the state, two of whom are in the state survey agency.

Both the AR Advancing Excellence Campaign and the focus on the Eden Alternative to achieve culture change are examples of Coalition members working together to produce outcomes that would not be possible without coordination and collaboration.

Rapidly Responding to Opportunities.

Over the life of the Coalition, many opportunities have emerged to secure funding to achieve the goals of the Coalition. The relationships developed among Coalition members have made it possible to successfully apply for state and federal funding, often with very short notice. One such example was a request for proposals from the U.S. Department of Labor for funding to Mississippi Delta counties in multiple states, including Arkansas. The funding provided for the purchase of computers, printers, and furniture to create learning labs for CNAs, LPNs, and RNs employed in long-term care. The learning labs were assembled in space provided by the nursing home. Currently, there are six learning labs in Delta counties in north and south Arkansas. Additionally, telehealth equipment was purchased for two of these facilities to provide increased access to geriatric health care and subspecialty care. Without the rapid buy-in and quick response of nursing home owners, this funding would not have been secured.

Our relationships with Arkansas workforce services have provided several opportunities to strengthen the long-term care workforce. The Coalition, with leadership from the Hartford Center for Gerontological Nursing Excellence, developed a 3-hr course in geriatric nursing supported by Arkansas Workforce Services. The course is an elective in the College of Nursing, UAMS, and provides an example of college-level expectations for students wishing to pursue a college degree.

This course has been taught to over 100 individuals ranging from CNAs to registered nurses working in long-term care. Additionally, Arkansas Workforce Services provided 10 computers to the Coalition for use by students taking the course. In 2011, the Coalition participated with Arkansas Workforces Services to write a proposal to the U.S. Department of Labor addressing the registered nurse shortage through workforce development. A total of almost $5 million was awarded to 2- and 4-year nursing programs, with $3 million awarded to the College of Nursing, University of Arkansas for Medical Sciences for baccalaureate education with the requirement that 30% of students in the program be in the long-term care workforce.

Hosting of National Meetings.

Because Coalition members have been involved at the national level and have support for hosting national programs, two national programs have been held in Arkansas. In 2007, the National Ombudsman Resource Center awarded the National State Long Term Care Ombudsman conference to the Arkansas Office of the State Long Term Care Ombudsman, as a direct result of support from the Coalition. Coalition members also negotiated for the International Pioneer Network Conference held in Arkansas in 2009. Coalition members realized during this event that the level of trust and understanding of each other and of each group’s agendas had grown substantially since the initiation of the Coalition. Stakeholders used a team approach to represent Arkansas’ culture change efforts to over 1,200 conference attendees from around the globe.

Refinement

Continuous refinement of the Coalition’s activities has involved revisiting goals of the Coalition at least annually, assessing whether other stakeholders needed to be invited into the Coalition, identifying gaps in educational programming, and providing feedback to Coalition members. Because the Coalition’s focus is on improving the quality of care in nursing homes and all of the nursing homes in the state agreed to focus on improving four quality measures (pressure ulcers, restraints, chronic pain, and acute pain), periodic feedback has been provided to Coalition members on these measures with data as shown in Table 2, from the web site of the Advancing Excellence in America’s Nursing Homes Campaign.

Table 2.

Arkansas and National Data on Clinical Quality Indicators for 2007–2010

	Pressure ulcers	Physical restraints	Chronic pain	Acute pain
2007
Arkansas	12%	11%	3%	14%
Nation	12%	5%	4%	21%
2008
Arkansas	11%	6%	3%	13%
Nation	12%	4%	4%	21%
2009
Arkansas	10%	4%	2%	12%
Nation	11%	3%	3%	19%
2010
Arkansas	10%	3%	2%	11%
Nation	11%	3%	3%	19%

Notes: 2007–2010 are fourth quarter data from the publically reported NH data from the Advancing Excellence in America’s Nursing Homes web site. Arkansas data were not excluded from the national data.

When the Advancing Excellence Campaign began collecting data in 2007, the percentage of Arkansas’ nursing home residents with pressure ulcers was close to the national average of 12%. However, the Coalition believed this should continue to be a focus given the importance of reducing pressure ulcers and their effects on quality of life. By 2010, the rate had been reduced to 10%. In 2007, the national average for physical restraints was 5% compared with the state average of 11%. This became a focus of educational and quality improvement efforts of many of the Coalition stakeholders. The state average was significantly reduced by 2010 to 3%. In 2007, the national average for chronic pain was 4% compared with the state average of 3%. By 2010, the state average was reduced to 2%. In 2007, the national average for acute pain was 21% compared with the state average of 14%. By 2010, the state average was reduced to 11%. Providing these data to Coalition members and reviewing them at Coalition meetings allowed members to see that progress was being made in achieving the goals of quality care and to better target the educational activities of Coalition members.

Because Coalition members also had ongoing concerns about the number of complaints to the state survey agency and hoped that concerted efforts to improve quality through culture change would lead to a reduction in complaints, complaint data were extracted from the Arkansas Department of Human Services, Office of Long Term Care to provide feedback to Coalition members. In 2004, the number of complaints was 1,279. By 2011, the number of complaints was 862, a 33% reduction (see Figure 1). Although we cannot assume that the changes in the four quality indicators or the reductions in the number of complaints were a direct result of the Coalition’s activities, the data did provide positive reinforcement for Coalition members and direction for targeting education and advocacy activities.

Figure 1.

Reported nursing home complaints in Arkansas from 2004 to 2011.

Refining the activities of the Coalition has also involved observation and informal evaluation of the Coalition by the members, including interviews with members and requests for input from members about the Coalition’s effectiveness in written responses.

A 16-item Coalition Sustainability Self-Assessment survey, adapted from a published sustainability questionnaire (Caring Connections, National Hospice, & Palliative Care Organization, 2008), was sent in 2011 to 22 members of the Coalition via Survey Monkey, and 17 members responded for a response rate of 77%. They were asked to respond to 16 statements on a 4-point Likert scale of strongly disagree (1), disagree (2), agree (3), or strongly agree (4). The results of the survey indicate that members take pride and value the work of the Coalition (3.5), believe that the work remains focused on the mission (3.4), and are generally satisfied with the activities and outcomes of the Coalition (3.4).

At the conclusion of the survey, members were asked to list the two most important outcomes of the Coalition. The major responses were that (a) multiple organizations from across the state had come together as partners in the care of seniors and were no longer competitors, (b) these organizations now worked closely on nonduplicative, coordinated training programs for staff, (c) working relationships between stakeholders had been formed and strengthened, (d) open communication was occurring among stakeholder organizations, and (e) culture change was being embraced by long-term care facilities across the state.

Institutionalization

A Coalition also has a responsibility to do succession planning. Because Coalition members have voted to continue their work, the original coleaders are identifying talented long-term care nurses from academia and industry who are interested in providing leadership for the Coalition. The support of the Coalition is also part of the sustainability planning for the Hartford Center for Geriatric Nursing Excellence, so that the Coalition can continue to be housed in and administratively supported by a neutral party.

Discussion

In general, the organizations that joined the Coalition have shown the capacity to be good Coalition members. They have had the leadership to articulate and mobilize others around a common vision, an understanding of their organization’s strategic niche, and good interpersonal skills. Coalition members have been able to articulate the value they brought to the table and to express what they wanted from the Coalition. Over time, the members have developed a willingness to share resources, identify conflicts between their organization and the Coalition, share power/credit, and speak as one voice.

Initially some organizations in the Coalition were very critical of current care in Arkansas’ nursing homes. However, although the Coalition recognized the need to improve care, it seemed more productive to focus first on the positive aspects of care and to work together to find solutions to problems. The members of the Coalition learned to tolerate disagreement while keeping a clear focus on what was already good about Arkansas’ nursing homes and how they could improve. The Coalition leaders were able to bring diverse members together to create and sustain a vision, prioritize activities, make decisions, and provide direction. The Coalition has also demonstrated adaptive capacity by monitoring what was occurring in long-term care and responding to changes that occurred within member organizations, as well as external changes. Various organizations have assumed a leadership role in Coalition activities depending on the technical needs required for these activities.

Coalition leaders and members believe that bringing all interested parties together with common goals promotes change effectively and efficiently. Initially, there was sometimes a fairly tense atmosphere among the diverse Coalition participants. For example, at some meetings, particular groups sat together, there was a tone of defensiveness when different groups addressed one another, and at an early seminar, two participants displayed such negative emotion toward another group that some participants left the seminar. However, over time Coalition leaders created a neutral environment for representatives to express their ideas and tackle perceived weaknesses, and we were able to become “automatic” partners and communicators desiring to include all groups in an occurrence.

Today, Coalition members do not hesitate to support each other with new ideas to enhance care and better serve our most vulnerable Arkansas citizens. Although stakeholders stay true to their specific membership, barriers such as lack of trust, defensiveness, and resentment toward each other have been softened as a direct result of sharing, partnering, and participating in a positive environment facilitated by the Coalition.

The Coalition has learned many lessons that have influenced our development, successes, and limitations over these last eight years. These lessons include the necessity for (a) a clear vision and mission, (b) a strong small group of champions who provide leadership, (c) identification of critical key stakeholders, and (d) a defined structure that provides the opportunity to move the work of the coalition forward.

1. Clear vision and mission: The first order of business of the newly developed AR Coalition was to develop a vision and mission. This process helped group members coalesce around a shared vision and develop a mission that identified the efforts needed to achieve the overarching vision.

2. A strong small group of champions who provide leadership: The coalition began because of the passion of three nurse leaders for improving the quality of care and quality of life of nursing home residents in Arkansas. It was this passion that prompted the three to develop the Coalition and engage stakeholders in the work. A group like these three champions is critical to develop a coalition, keep it moving forward, set the agenda for coalition meetings, and be an ongoing catalyst for a successful coalition agenda.

3. Identification of critical key stakeholders: We conceptualized stakeholder membership in a very broad sense and believe that involving multiple diverse stakeholders from across the state was important to the success of the Coalition and allowed various initiatives to move easily in and out of the purview of various stakeholders as needs and funding changed.

4. A defined structure that provides the opportunity to move the work of the coalition forward: The Coalition has functioned through ongoing strategic planning that involves all Coalition members. The work of the Coalition has always focused on quality of care and quality of life issues for our older adults in nursing home care but is now being broadened to include all long-term care settings. This will continue to be a top priority because as the number of older adults continues to grow exponentially, quality issues continue to be of paramount concern. The Coalition has also decreased duplication of efforts and thus made the state’s culture change activities more efficient.

Coalition members decided in 2012 to change the name of the Coalition to the Arkansas Coalition for Excellence in Long-Term Care and Services to be more inclusive of home health, assisted living, and memory care centers. Thus, new stakeholders will be added as appropriate, such as the AR Home Care Association, representatives of the Assisted Living Association and perhaps a home care professional. A coalition has an ongoing responsibility to keep asking the question “Is everyone at the table who needs to be there?”

Implications

As noted in the Community Tool Box from the University of Kentucky (Rabinowitz, 1994), goals that focus on system-wide change and collaborations and require a variety of expertise are particularly well suited for coalitions. Therefore, federal and state initiatives focusing on achieving system level change might consider offering technical assistance to groups wanting to form coalitions to achieve this change. Another policy change might be a stipulation that organizations receiving federal or state funding for training are required to form a coalition of major stakeholders who are invested in the success of the training. As with our Coalition, such coalitions could result in less overlap and duplication of efforts and thus better use of state and federal funds.

Funding

This work was supported by the John A. Hartford Foundation and by a research grant, 1UL1RR029884, from the National Center for Research Resources.