Riverview Lutheran Care Center, a skilled-nursing center near the Spokane River on Upriver Drive, strives to offer a homelike alternative to traditional institutional facilities.

The center participates in the Pioneer Network, a nonprofit coalition of nursing-care interests that promotes an ongoing person-centered transformation of institutional care that provides residents more control over their lives, says Patrick O'Neill, president and CEO of Riverview Retirement Community.

The network's philosophy recognizes the need to change institutional care to help nursing-home residents avoid feelings of loneliness, boredom, and helplessness, O'Neill says.

A large component of that philosophy minimizes top-down bureaucracy and encourages putting as much decision-making authority in the hands of patients and the people closest to them as possible, he says.

Such decisions include ordering meals from a larger menu selection than most nursing homes offer, says Dan DeBoise, director of nursing at the facility. The center has a large kitchen staff that aims to meet all residents' wants and needs in a restaurant-style dining area, he says.

"Meals are a central activity," he says. "We're trying to enhance that experience."

The center also offers a variety of planned and spontaneous activities and entertainment options that residents can participate in if they wish.

A popular room for entertainment is the Fireside Lounge, in which residents can hold small gatherings or watch movies or sports events on a big-screen TV near an electric fireplace.

Many patients enjoy the center's resident dogs, cats, and birds, which interact with them and help promote feelings of connection to the center, DeBoise says.

Homey features that also promote patient connectivity at the center include generous amounts of warm-toned wood trim, and walls decorated in a palate of pastel colors, DeBoise says. Quaint street signs on walls and doorways are named for birds, flowers, and pleasant weather conditions.

Lately, on casual Fridays, many of the 100 employees at the care center wear blue-and-white jerseys with the number 15 under a crest of five stars. It's not an institutional uniform, but rather an expression of celebration.

Riverview is the only nursing home in Washington state to receive a five-star rating in each of the three qualifying categories from the Centers for Medicare and Medicaid Services, DeBoise says. Also, it's one of only 13 in the country to receive 15 stars each quarter for a year, he says.

"It validates what we already know," DeBoise says. "Quality is ingrained in what we do."

All skilled-nursing facilities that accept Medicare and Medicaid funding are graded quarterly under the federal rating system, which was developed in 2008 to help consumers compare skilled-nursing facilities, he says.

The rating categories cover health inspections, staffing, and quality measures, each of which can earn up to five stars. Quality measures include 10 clinical and physical areas, such as changes in the patients' mobility and prevalence of pressure sores.

DeBoise says the 15-star rating is difficult to maintain, and Riverview's main control of it is through its staffing.

Patients at the center receive an average of five hours of nursing attention a day, he says, adding that the average nursing time per patient per day for similar-sized skilled-nursing centers is 3.4 hours.

"In order to provide more care, we have to provide more staffing," DeBoise says.

The base rate for residents ranges from $294 to $341 a day, which doesn't include special services, physical therapy, medications, and personal needs.

The center has been financially self-sufficient under its current staffing level, and there's no plan to change it, DeBoise says. Its 2009 revenues totaled $8.7 million and its payroll totaled $4.4 million.

The 75-bed facility, which opened in 1967, is part of the 28-acre Riverview Retirement Community, at 1801 E. Upriver Drive.

In addition to the care center, the community includes Riverview Terrace independent- and assisted-living apartments and Riverview Village independent-living homes. The care center, Riverview Terrace, and Riverview Village are nonprofit affiliates supported by the congregations of 22 Lutheran churches in the Inland Northwest.

Riverview Terrace, which was built in 1959, connects to the west side of the care center, and has 100-assisted living units and 45 independent-living units. Riverside Village consists of 153 independent-living, buy-in cottages and multi-unit residences constructed in phases between 1985 and 2009, and those units are mostly to the north and east sides of the care center.

Residents on the campus have priority for admittance to the care center, although it also accepts residents from the community.

Most patients are Medicare age, but the facility has treated patients as young as 17 years old.

The center serves an average of 15 to 20 Medicare patients at any given time, O'Neill says. The rest of the beds are occupied by patients requiring long-term care, which is funded through private payers, insurance, and Medicaid.

Most Medicare patients are admitted for rehabilitation following an injury or illness that required a hospital stay of at least three days before coming to the center. Medicare pays the center's full rate for the first 20 days and patients pay a portion after that up to 100 days.

"Our goal for rehabilitation is to get people to their level of functioning (as it was) prior to the injury," he says.

Medicaid reimburses at a fraction of the cost it takes to care for somebody, O'Neill says. The care center wrote off $1.3 million in charitable care in 2010, up from $1.1 million in 2009.

O'Neill says he's expecting the Medicaid gap to increase due to anticipated cuts in state funding.

"Going forward, it will be a challenge," he says. "We know what it costs to do this. We know that state funding is going to be going down."

A third of the beds at the center are in a memory-care wing, which was dedicated in 1998. The wing is separated from the rest of the center only by a waist-high gate that opens with an electronic keypad.

The gate is effective, yet less upsetting than a solid locked door would be to patients with dementia, DeBoise says.

"We've never had a patient wander away," he says.

The memory-care wing also has residential-like kitchen and laundry set-ups. They aren't so much for practical purposes, but to provide sensations of hominess, DeBoise says.

Many memory-impaired residents are calmed down by tasks of folding laundry or the smell of cookies in the oven, he says.

O'Neill says a big part of nursing care is taking care of the patient's family as well.

"It's stressful coming, going, and visiting," he says. "If we see family members stressing, we might have a therapist give them a massage."

O'Neill says the center also helps families, as well as patients, cope with end-of-life care.

"A full-time chaplain here works with families to help them through the grieving process," he says.

DeBoise says the center regularly looks for ways to improve.

"Being innovative is not new for us," he says. "We take a hard look at ourselves every few years."

He says employees there enjoy working under the Pioneer Network's philosophy.

"We celebrate what we do all the time," DeBoise says.