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The future is predictably unpredictable

May 1, 2008
by Paul Willging
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I talked last column about alternative approaches to financing long-term care. And I admitted that the suggestions offered were, at best, problematic (at least in the sense of political viability). So, let's get serious. Let's talk about more realistic change. Let's discuss the major national policy issues that affect long-term healthcare as it is today and will likely operate in the future.

And let's do that based not on the sometimes biased agendas (and always political pronouncements) of trade associations. And even less on the always distant and sometimes irrelevant musings of academics. In fact, let's take a shot at the best (or worst) of both worlds. The National Commission for Quality Long-Term Care might provide just such a perspective.

For those unfamiliar with the organization, the National Commission is a nonpartisan, independent body charged with improving long-term care in America. Its appointed commissioners reflect a diversity of experience in government, academia, quality improvement, and long-term care. Its founding and continuing benefactors were and are, admittedly, the nursing home trade associations (the Alliance for Quality Nursing Home Care, the American Association of Homes and Services for the Aging, and the American Health Care Association). However, the Commission contends that none of these organizations have input into its activities nor do they exercise prior review of what it publishes. My sense is that its contention is buttressed by the fact that the organization is housed in the highly respected New School of Social Research (in New York City) and functions independently under the leadership of its executive director, Doug Pace.

Remarks offered by Mr. Pace early this year (at a meeting of the Center for Excellence in Assisted Living) will form the outline for my own prognostications. In his remarks, Doug suggested four primary areas of concern facing long-term care: quality, workforce, technology, and financing. The charter of the organization he heads, interestingly enough, focuses on six areas, adding cultural transformation and individual empowerment. I suspect, however, that Doug feels (as do I) that these last two are essential prerequisites for quality improvement and need not and should not be treated separately.

Since these four (or six, if you will) elements make up the Commission's “road map for reform,” let's take a long look at what's actually possible and/or likely in the 12-month time frame set by the Commission for its immediate efforts. And the answer is, I fear, very little.

Let's start with technology, largely because I'm not even sure why it's on the list. Not that I have anything against enhancing the application of technology to industry functions. I'm just not all that sure that the potential inefficiencies stemming from a dearth of technology rank all that high in the pantheon of industry challenges. Nothing against computers, you understand (insofar as “technology” alludes to them). But computers don't give baths. (Not that a hoist, another form of technology, isn't a helpful aid in completing that task.) Nor is our problem the lack of data. The nursing home industry, for example, has access to a more powerful database than any other sector of healthcare, i.e., the Minimum Data Set (MDS). The problem is that the profession just doesn't use it very aggressively (outside of regulatory self-protection, that is).

Herein lies the real challenge for technology (or, at least, information technology). Not that the databases don't exist, it's just that they don't talk to each other. It's all but impossible to have a seamless transition across the respective “silos” of long-term care as long as there is no electronic and portable health record to facilitate that transition.

However, while this might not be the most challenging of the issues facing long-term care, it turns out to be the one most likely to show some meaningful progress over the next 12 months. I've written already (Nursing Homes/Long Term Care Management, April 2006, p. 20) about a project undertaken by the Health Facilities Association of Maryland to develop a common assessment tool for long-term care (a prerequisite for a common health record). The Centers for Medicare & Medicaid Services has launched its own process for developing a Standardized Patient Assessment Tool (endearingly referred to as CARE, or Continuity Assessment Record and Evaluation). My own university, operating what the Hartford Foundation has referred to as the most comprehensive long-term care continuum in the nation, has initiated a “Senior Strategy,” with the geriatrically focused electronic health record as its essential foundation.

None of these activities is without underlying significance. It's just that none of them address the other three issues on Doug's list—the ones that, if not dealt with, will threaten the very existence of the industry. Let's move on to one of those more intractable issues.

Let's move on to quality. But let's also not forget that the quality issue cannot be confused with regulatory concerns. The latter are a function, not a reflection, of the former. Or haven't we learned anything from decades of experience with skilled nursing facilities?