The synergistic interplay of philosophy, place, program, and policy: Learning the art of the possible from small-house nursing homes

Developing and sustaining group residential settings that support autonomy and better quality of life (QOL) for older people with substantial disability and functional impairment is a persistent challenge. Fueled since 1995 by the Pioneer Network in Long-Term Care (Koren 2010), the culture change movement for nursing homes (NHs) has made strides in promoting individualized person-centered services in NHs and empowerment of both residents and direct-care unlicensed staff. But some critics lament the enthusiastic embrace of its vaguer tenets (Rahman and Schnelle 2008) and some question the evidence base for culture-change activities (Shier et al. 2014). Meanwhile, institutional living erodes residents' QOL and their sense of identity.