Paul Willging Says…

A professional association can serve society

And yet within this environment, trade associations-particularly those representing nursing facilities-have had a tough row to hoe. Working at cross-purposes against prevailing sentiment, they represent an industry as much in need of public support as any I am aware of. And they receive far less. Whether the issue is reimbursement or regulation, lobbyists for nursing facilities seem more than most to be bucking adverse public perceptions. And this despite the uncontested need for their services.

You can imagine my excitement, therefore, when the Health Facilities Association of Maryland (HFAM) decided to take the “high road” in dealing with the nation’s “demographic imperative.” Last month I discussed the initiatives taken in my own county, as authorities there look to facilitate “aging in place.” I spoke of the need for facility management to become conversant with (and accepting of) such initiatives. They are, after all, inevitable, and it’s better to learn how to accommodate them than to oppose them. That’s precisely what HFAM concluded as it responded to the state’s request to restructure Maryland’s long-term care program.

HFAM has been dealing with the Medicaid waiver issue for as long as I can remember. That issue in Maryland has shared the same roots as those in most other states: the need by state government to save public monies. State nursing home associations have reacted to waiver proposals in lockstep precision-arguing, essentially, against the proposals while requesting, simultaneously, more money and fewer regulations (as though that were enough to fix our long-term care “nonsystem.”

HFAM decided on a different tack. To meet current and future challenges, the association proposed a brand new model of long-term care that puts consumers at the center. HFAM believed that long-term care, which for decades has been shaped by funding sources and provider preferences, should instead be driven by the needs, choices, and expectations of the elderly and disabled persons served, regardless of the setting in which they receive care.

Policy makers have just begun taking steps in this direction. Rising demand for choice, coupled with funding constraints, has led to President Bush’s New Freedom Initiative, a nationwide effort to allocate resources more effectively while lifting barriers to community living for people of all ages who have disabilities or long-term illnesses. That initiative has encouraged many states to launch demonstrations and waiver programs that overhaul the delivery of services for Medicaid recipients. It was under this authority that Maryland submitted its own waiver request.

HFAM’s counterproposal to the waiver request actually builds on and complements the emerging public policy shift, basically by introducing four essential components to the long-term care system:

• Customer focus. The primary building block of this new model is the belief that consumers should be the drivers of long-term care. This includes the ability to choose long-term care options in the most appropriate setting and greater flexibility among healthcare providers in changing the way they offer services, all to create a truly customer-focused system.
• Care coordination. The HFAM model is premised on linking the entire senior care system with a common assessment tool that provides a holistic picture of the individual’s needs and preferences, regardless of the setting in which she receives care.
• Data-driven management. To optimize quality and promote robust data collection and sharing among providers, HFAM calls for creating a database that crosses the long-term care continuum and follows individuals from one setting to another.
• Adequate financing. The new model envisions a payment system that identifies, and adequately covers, the total cost of individuals’ long-term care needs, maintains high quality, and remains stable despite budgetary pressures.

And just what is wrong with the current care system? Well, long-term care stakeholders-providers, consumers, and government entities alike-can all identify and agree upon the problems with what we have today, even as we debate the best solutions. HFAM providers believe that today’s long-term care system is fundamentally hampered by a structure that has evolved, to a great extent, in response to the needs, demands, and availability of funding sources. Long-term care suffers from a structural failure to put consumers first.

Medicaid, for example, makes eligibility and level of care determinations for the vast majority (60 to 70%) of nursing home patients. Coverage and financing decisions have shaped the organization and availability of long-term care services along the continuum, stifling consumer choice and creating silos in which each provider type focuses on its own payer-driven rules and procedures, with no system-wide framework for coordinating vital clinical and quality management processes.

In short, the failure to place customers at the center of decision-making, financing, and care-related processes is the central weakness of the current system-and this weakness has generated a cascade of woes. It is the lack of consumer choice that is the current system’s most fatal flaw. The current care model was built around a Medicaid entitlement program driven by financing concerns. This priority affects the structure of Medicaid eligibility, level of care determinations and, ultimately, eligibility for community services. Clearly consumers not only want greater choice than the current system allows, they want the ability to drive the healthcare system, including having control of healthcare dollars.

HFAM supports customers’ right to choose, but recognizes that simply allowing individuals to receive services in the community will not comprehensively address other critical problems in the current system.

The second major concern facing those who would understand long-term care in America is the problem of fragmentation of care. As customers move through the long-term care continuum, they often experience a disjointed system, which does not promote communication, cooperation, or seamless delivery among providers. In its acclaimed report, Crossing the Quality Chasm: A New Health System for the 21st Century, the Institute of Medicine underscored the healthcare system’s poor organization. “Care delivery processes are often overly complex, requiring steps and handoffs that slow down the care process and decrease rather than improve safety,” the report said. “These processes waste resources, leave unaccountable gaps in coverage, result in loss of information, and fail to build on the strengths of all health professionals involved to ensure that care is timely, safe, and appropriate.”

Similarly, the fragmented long-term care system in place today fails to effectively integrate or target services to vulnerable senior and disabled populations.

A third limitation of the current system is the absence of meaningful and coordinated data. Data collection is limited and data sharing virtually nonexistent among care delivery systems. This impedes providers’ ability to leverage data for the purpose of clinical, disease, and quality management. Databases vary in adequacy from one long-term care setting to another and do not interact or intersect. The Minimum Data Set (MDS) used by nursing homes is, for example, wholly separate from the OASIS database used by home health agencies. This perpetuates the silos that fragment the long-term care continuum. As a result, when patients move from one part of the continuum to another, data collection continually begins frustratingly anew.

Finally, the system is known for its unstable financing. The Centers for Medicare & Medicaid (CMS) and the Maryland Department of Health and Mental Hygiene (DHMS) have made it clear that the Medicaid program cannot sustain the growth occurring in long-term care. However, with no alternative funding mechanism available, most patients continue to rely on Medicaid. Insufficient resources for that system, however, create financial instability for providers who care for Maryland seniors. Long-term care customers deserve quality care regardless of where services are rendered, and quality care must be adequately financed.

So, what might the new system look like? HFAM proposes a new long-term care model offering solutions to all four of the major problems with the current system. The four-point model would serve frail, disabled, chronically ill, and indigent populations, the vast majority of whom would be seniors. Disabled from all age groups would also be included.

First and foremost, the new system calls for a customer focus. HFAM believes that long-term care customers should be able to choose the care setting most appropriate for their physical and mental needs, and have input into the delivery of that care. Every aspect of long-term care decision making, service delivery, and related processes should follow the customer’s specific needs, as opposed to the current system that is led by financing.

The federal government has signaled a willingness to fund innovative ideas that give consumers greater choice among long-term care options, and HFAM’s model strongly supports individual choice. To realize that goal, the model also advocates enhanced flexibility for providers, giving them needed leeway to create a truly customer-focused system. HFAM contends that the current federal and state regulatory process stifles innovations that would place customers at the center of the healthcare model. For example, the certificate of need process strictly enforces how beds and space in nursing homes can be used. A customer who receives nursing home care and becomes ready for assisted living may have to leave the facility because it is not allowed to flip beds back and forth between assisted living and skilled nursing requirements. As a result, the customer who has developed relationships at the facility and is comfortable in this setting must nevertheless move-definitely not a customer-focused model.

In an effort to identify strategies and reforms needed to become customer-focused, HFAM recommends a forum, in partnership with the state and consumer groups, to review regulations that affect providers’ ability to operate in a customer-focused model. The forum would give consumers, providers, and regulators an opportunity to develop recommendations together on changes needed to ensure customer-focused care.

The second premise of the HFAM proposal is that the entire senior care system should be linked by a common assessment tool so as to facilitate care coordination. In long-term care, everything is determined by and follows the assessment, including the plan of care, data collection, and quality management. Currently, the assessment tools used by home health agencies, nursing homes, assisted living programs, and adult day care programs are each very different. As a result, the same customer evaluated in different settings would end up with an assessment that is limited in scope and oriented primarily to the setting in which she is currently receiving care. Moreover, the customer has to be reassessed at each level.

A standardized assessment form would produce a holistic view of an individual’s needs, regardless of where she receives services. This assessment would maintain the same format as it follows the customer throughout the system and would be updated as the customer moves across provider types and experiences significant changes in status. By ensuring uniformity across the continuum, the assessment process would become truly customer-focused, producing a care plan unrelated to a particular setting and driven instead by individual needs. The care plan generated by the assessment would also follow individuals through the continuum and be updated as required to accommodate shifting needs.

The process would be streamlined further by designating a single point of entry to the long-term care system, where assessments would be conducted by professionals with the appropriate expertise. This portal, independent from a particular facility or community-based setting, would also serve a case management function, a focal point for helping consumers through a myriad of healthcare decisions.

Obviously, this assessment and case-management system must be dependable, accessible, and adequately staffed. Currently, an appropriate infrastructure does not exist in the community. However, nursing home staff, who have expertise and a congression-ally directed mandate in this area, would be ideally situated to conduct assessments and provide outreach to the community. Tapping the experience of professionals who would want the opportunity to work both in the community and a nursing center (much like the model pioneered in Denmark) would be an effective strategy for building the necessary workforce. In this way, the customer-not the care setting or provider-would be the focus.

HFAM’s third premise is data-driven management. In today’s healthcare system, robust data collection and analysis can maximize care planning, oversight, and quality management. Just as a standardized assessment form that follows an individual across the continuum would enhance care coordination, a common database housing clinical, social, and demographic information from various settings would bolster that same objective.

In HFAM’s model, data collection would begin when an individual entered the long-term care system. Information gathered from the standardized assessment would be collected, entered into the database, and used to create a plan of care that would follow the customer across the continuum. Subsequently, each provider and care setting would build on those data, entering information into a common database, the contents of which, again, would follow and move with the individual. This would ensure that at every step in a customer’s journey through the long-term care system, providers have access to the person’s complete record, history, care plan, and unique needs and choices.

Information that could be tracked in such a single-source healthcare information system would include: eligibility status, covered services, cost-sharing information (premiums or copays), allergies, immunization records, prescription medication (including quantity and date dispensed), diagnosis, service history, lab history, and provider contact information.

As has been noted of late, a continually evolving electronic healthcare record has the potential to provide vast amounts of vital information. To maximize the value of these data for the benefit of consumers, though, providers must have the ability to access them, regardless of where an individual receives care.

A common database, drawing together information from home health agencies, nursing homes, assisted living communities, and adult day care programs, would facilitate data sharing and promote seamless care. Ultimately, this comprehensive overview of each customer would optimize quality and outcomes management, strengthen care planning, and support individual choice.

The database would also be used to track the cost of services delivered to each individual, based on her plan of care. This would help all stakeholders understand, from a fiscal perspective, the cost-effectiveness and efficiency of services provided. It would also make it feasible for national, state, and local governments to plan adequate budgets for meeting long-term needs.

Given the strong interest in the promulgation of health information technology, this database might make an ideal proposal for a federally funded demonstration project.

And finally, financing. Like all other components of long-term care, the financing system should follow customers, regardless of where their care is provided. Currently, the reverse is often true: The financing system determines what services will be funded and in what setting. Individuals must then follow the money to receive care. Perhaps, as in a voucher system, the money should follow the individual instead.

Under HFAM’s model, each individual’s plan of care, drawn initially from the standardized assessment, would detail the mix and intensity of services required for that person. Then, the cost of providing that care could be calculated, using the cost information captured over time in the common database. In this way, each person’s long-term care costs could be calculated, predicted, and budgeted.

On a state and national level, the aggregate cost of plans of care for individuals using services throughout the continuum would reflect the total funding needed to provide quality long-term care. And since those costs would be a function of independently administered assessments, they would be reflective, not of provider preferences, but customer needs. (What a shockingly novel thought!) Whether this funding comes from Medicaid, Medicare, or private sources, payment for long-term care services must be adequate to maintain quality. A dedicated financing source must be established, sustained, and shielded from those annual budget battles in which providers must prove why vulnerable seniors and the disabled are “more deserving” of funds than other healthcare recipients. Inconsistent and unpredictable funding creates insecurity, not just for providers, but for consumers, as well.

To bring security and stability to the system, policy makers may have to look beyond Medicaid for additional revenue sources. Options might include the sales tax, a state lottery, private long-term care insurance, and policy changes to create tax incentives to help seniors maximize the value of assets before they turn to public programs.

The viability of the future healthcare system will depend on our ability to initiate change and embrace innovation. Clearly, the traditional nursing home will play a role in long-term care for many years to come-but the future is a customer-focused model in which choice, decision making, care planning, data gathering, and funding follow the customer. Long-term care providers are well positioned to serve as a resource for this new model, and we should all look forward to working with consumers, advocates, public agencies, and elected officials to advance this concept as we meet the growing demands of the 21st century. To send your comments to Dr. Willging and the editors, e-mail willging0406@nursinghomesmagazine.com.