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Paul Willging Says...

February 1, 2005
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The Best LTC Model Has Yet to Be Implemented

The best LTC model has yet to be implemented I'm amazed at how much research has gone into developing the ideal long-term care system-and how little progress has been made. The literature is replete with distressing descriptions of the dysfunctional circumstances with which most Americans in need of long-term care services are confronted, as well as equally depressing suggestions as to how far we have to go in achieving the "perfect" system. Yet from the seemingly countless years of trial and error and millions of research dollars, we have developed a sense of the basic outlines of effective long-term care. And a few essential themes present themselves. They can be grouped, I would suggest, into four elemental categories:

  • Our model system is customer-focused.
  • It provides care through a system that is accessible, coordinated, and appropriately financed.
  • It has available to it the latest technology, with an emphasis on information technology.
  • It has access to adequate human resources who possess both the requisite skills and attitude necessary for delivering stellar care.

Let's start with the customer. As has been stated numerous times in this space, there is more than enough evidence to suggest that a provider who fails to focus on the customer is doomed to failure. What are the distinguishing attributes of the customer-focused system? First, procedures are in place to facilitate customer involvement and independence-and include involving him or her in care-planning and care-delivery processes. The bottom line is an emphasis on the customer's uniqueness within the system, not just as another "case," but as a real human being, with his or her own particular needs and preferences.

And we can't overlook family. More than half the residents in long-term care communities (be they in nursing or assisted living facilities) suffer from some form of impaired cognition. In such cases, families are every bit as important as residents. Is their involvement sought?

In November, I discussed my own family's experience in trying to find the right location for Mom, as her increasing frailty surpassed the ability of her assisted living community to care for her. As I write this column, I'm on one of my bimonthly visits to her new residence. Before I even left my home in Maryland, I had a call from the community's marketing staff asking if, during the course of my visit, I would like to join Mom for the facility's afternoon "high tea." I said yes. I was going to be in the building anyway, and I thought it might be fun. After I arrived (grossly underdressed, given the spectacular sartorial resplendence of the residents), I was asked by the director of nursing if I would like to sit in on Mom's care-planning conference scheduled for the next day.

For this particular community, that was nothing out of the ordinary. Whether a social function or care delivery, the focus was on the customer or, in this case, the customer's family. My involvement was seen as critical to their ability to appropriately care for Mom.

What about service delivery, the second of the four categories? This determines the essential nature of the community's (or system's) caregiving capacity and processes. Important is the degree to which the provider applies a truly geriatric approach to service delivery. Three considerations are worth focusing on: access, coordination, and financing.

Accessing long-term care can be the first and, often, the most formidable challenge facing those in need. Americans have religiously avoided even thinking about long-term care until the specter of frailty has already made an appearance in all its frustrating immediacy. By then, it's often too late to conduct a studied analysis of available (and appropriate) options. The issue of initial points of entry can be particularly baffling to the first-time user of long-term care services. Ostensibly, many communities offer the resources of a state department of aging or an AAA (local area agency on aging) as a repository of useful information. But, I would wager, few Americans are familiar with these valuable resources. The model system therefore will do its best to familiarize potential clients with the availability of such agencies.

The model system will demonstrate the ability to coordinate care once the system has been accessed, and it will do so in as seamless a fashion as possible. We are all familiar with the basic prerequisites of good assessment and care-planning programs: that they be comprehensive, holistic, and current; that they emphasize all aspects of geriatric care delivery (physical, mental, and psychosocial), with a particular emphasis on the critical linkages among the three; and that systems exist to ensure effective inter- and multidisciplinary care based on that assessment.

Unfortunately, the system's ability to translate the benefits of such systems across the continuum is all but nonexistent. In Mom's case-having resided in five separate communities over the course of 15 years-no systems were in place to ensure that assessments and plans of care were transferred from location to location. Thank God she had loving children who made sure that this was accomplished.