Reflections of a nursing home administrator

“I could write a book about that.” How often have you as a long-term care administrator, DON, or other manager said that about the work you do? Not long ago, a nursing home administrator did just that, publishing his “candid reflections” on running facilities for for-profit and not-for-profit operators in Maryland. Long active in long-term care organizations based in that state, including the state chapter of the Wellspring Organization, Elliott D. Cahan decided a couple of years ago to leave the profession and move to Israel. In his book he discusses the challenges posed by the multi-faceted balancing act demanded of administrators, the futility of government long-term care policy, and the unique satisfactions offered by the administrator’s role. Cahan elaborated on all of these points in an interview with Richard L. Peck, former Long-Term Living Editor-in-Chief.

Peck: Why did you decide to write a book about your experiences?

Cahan: There are so many times at the end of a workday when you say to yourself, “I could write a book about this.” But, of course, most administrators don’t have the time. I was able to find the time after retiring.

Peck: How did you get started as an administrator?

Cahan: I graduated college with a B.A. in political science, which taught me nothing other than how to read a newspaper. I like working with people, I like marketing, politics, the law, and human resources and, more to the point, my father served on the licensure board for nursing home administrators in Maryland. Once I asked my father what nursing home administrators do and he referred me to a few to get some answers. One, Gary Hibbs, who became my preceptor, took me to a nursing facility dayroom where the activities director was conducting a music therapy program. I found it very inspiring to see residents participating as best they could and making the most of the life they had left. Gary said that he viewed it as his personal challenge to make sure that residents always maintained their dignity and had something worth living for.

Peck: Your comments in your book, though, present quite a mixed picture—principally, that the administrator’s job is a juggling act. Would you elaborate?

Cahan: All the disparate parties involved in resident care—residents, families, staff, regulators, owners—come at it from different angles, but ultimately, it’s the administrator who is holding the bag for providing the care. Put it another way, it’s like a stack of cards and you’re never quite sure which card is holding up the stack—take away the DON, the nursing assistant, the RN, and will the whole thing collapse? It’s a precarious business. And yet I always found it interesting that Maryland had no requirement for a state surveyor to have worked in a long-term care facility. It’s a job that is more difficult than many people think.

Peck: Would you say that an administrator’s principal focus would be on staff?

Cahan: I think a principal role for the administrator is to clear the way of all red tape and roadblocks so that staff will have an environment for success. If you do this, they will provide good care. You can’t pay the highest wages, although they should be competitive, but basically if you provide an environment where staff feel appreciated and want to show up every day, good care will result. Specifically, that means giving them the supplies, the equipment, including maintenance and repair, and in general eliminating frustration from their daily work.

Peck: By the same token, what do administrators need?

Cahan: They need to be empowered by the owner, the board, and the corporate office. They need more than “sometimes” authority—for example, having no control of the budget but being held accountable for spending nine bucks for doughnuts at a staff meeting.

Peck: How does reimbursement (or lack of it) impact on the job?

Cahan: You’re expected to give Ritz-Carlton care at Motel 6 prices. That’s another juggling act—reimbursement vs. regulation. Maryland had the second highest Medicaid reimbursement rate in the country when I was there, but that could change dramatically every year due to political forces beyond my control. What would I do if I were an administrator today? Probably lose a lot of sleep.

Peck: What’s your view of government policy on long-term care in general—remediable or beyond hope?

Cahan: I had frustration in Maryland when I expected that a new Republican administration coming in after more than 30 years of Democratic control would bring a broader view and much-needed change, but it didn’t happen. Long-term care has to be looked at not just as pieces and parts, as nursing homes or assisted living, but as a broad continuum of services. Policy needs to have a wider range. But the political system in the U.S. today makes it hard to tackle big policy issues.

Peck: Among the more controversial statements you make in your book is that, from a quality standpoint, not-for-profit facilities are preferable to for-profit facilities. Would you discuss that?

Cahan: That probably is the most controversial statement in my book. But I can only go by personal experience. I’ve heard for-profit management of one chain admit that it was all about the quarterly share price, not the residents. At least they were honest. In general, the for-profit chains thought that they would create efficiencies through centralization but it never happened. Also, they went through a period when they bought provider companies at crazy prices, with huge mortgages that operations could never support. It made me wonder whether investors really understood the field, but this had a bearing on quality. I’m not saying this is a hard-and-fast rule—there were for-profit facilities in inner city neighborhoods that offered much better environments than was available at home, and I’ve seen not-for-profits that provided low quality of care. I was just addressing the overall situation with that comment.

Peck: Why did you leave the United States for Israel?

Cahan: Moving to Israel in 2004 was a long-standing dream of ours—we had family connections there. The events of 9/11 certainly impacted that decision. There is terrorism in Israel but 9/11 told us that we weren’t safe in the U.S. either. What’s more, an employee’s husband was carjacked and killed at a local Wendy’s shortly afterwards—a form of terrorism in its own right. We thought it was time to pursue our dreams of moving to Israel. I now run a postgraduate school for religious studies.

Peck: Have you had a chance to compare how Israeli long-term care facilities compare with ours?

Cahan: The reimbursement situation here is similar, but there is less regulation. They have the same range of services and quality and a focus on trying to keep people at home. There is government reimbursement for that and the home services are staffed by many workers from overseas, particularly the Philippines.

Peck: Would you consider coming back to the U.S. as an administrator?

Cahan:

I’ve maintained my license, but we’re very happy here right now. When I hear about the state Medicaid cuts that are being discussed and made these days, I’m happy to be out of it. They’re quite arbitrary, and government decision makers really have no idea of what they’re doing.