National Commission challenges the politicians

Bob Kerrey
Newt Gingrich

America’s nursing homes and long-term care facilities face the daunting challenge of instituting sweeping reforms in their operations and approaches to serving long-term care consumers, as a “perfect storm” of events—longer life spans, a growing elderly population and increasing costs of care—threatens to develop into a national crisis.

That is a major conclusion of a report issued early in December by the National Commission for Quality Long-Term Care, headed by former Senator Bob Kerrey (D-Neb.) and former House Speaker Newt Gingrich (R-Ga.), who both called on the nation’s political leaders, including presidential candidates, to address the crisis in their campaigns and party platforms.

“We hope our political leaders and the candidates for President will begin to understand the seriousness of the long-term care problem and that it leads to bigger problems in health care,” Kerrey said during a conference call with journalists. Gingrich expressed the hope that the next president and new Congress will work for a solution when they take office in 2009.

To prepare, the Commission urged Congress to hold hearings in 2008 to investigate and recommend workable strategies to design and implement a new and better long-term care system. It said the President should lead “a multifaceted transformation of the current system” so it can serve consumers for decades to come.

The Commission’s final report focuses on four critical elements: quality, workforce, technology, and finance. It stressed that these areas are interconnected and that success or failure in one area will affect all others, and offered these general recommendations:

  • Quality. The nation can reform the long-term care system by developing innovations that focus on improving an individual’s quality of life and quality of care, including developments for standardized measurements for quality, moving towards a system of consumer-centered care, dissemination of comparative quality information, and supports for family caregivers.

  • Workforce. With a shortage of long-term care professionals nationwide, those who provide care must receive support. That means improving compensation and incentives, providing better training, leadership development and opportunities for advancement, and ensuring respect for the workforce as distinct from the healthcare labor market.

  • Technology. Strengthen federal and industry efforts to develop health information technology and conduct innovative research that enhances consumer independence, while safeguarding privacy, along with open communication and data sharing.

  • Finance. Financing the long-term care system is a national problem that requires a national solution. The system should include ensuring access to quality care for all, affordability for individuals and society, and promoting a shared responsibility among government, individuals, and the private sector.

Three leading long-term care advocacy organizations immediately issued a statement praising the Commission’s work and recommendations. “We believe the policy road map [the Commission] has put on the table today, as well as the plan we will offer in January, will engender a detailed, thoughtful, much-needed discussion of these key issues as the 2008 presidential race unfolds,” said Bruce Yarwood, president and CEO of the American Health Care Association.

Alan G. Rosenbloom, president of The Alliance for Quality Nursing Home Care, said that “adequate, stable funding is integral to ongoing quality improvements,” adding that “substantial structural changes” in the way long-term care is financed are required.

David Kyllo, executive director of the National Center for Assisted Living, said the Commission’s recommendations on quality, workforce, technology, and financing reform “are of major importance across the entire spectrum of long-term care—from nursing homes to assisted living to home-based care.” He said a public discussion “of the most important healthcare policy issues not currently being discussed in appropriate detail” is now essential.

The Commission’s report commended the “Quality First” program sponsored by those organizations and the American Association of Homes and Services for the Aging, a program that offers technical assistance and resources to help providers make quality improvements. The Commission noted that “providers in all segments of the long-term care field have a critical role to play.”

However, “voluntary efforts are only one way to address quality,” the Commission observed. “Providers also have a responsibility to meet existing statutory and regulatory quality standards; doing so is another critical way to help ensure quality.”

The Commission warned that current workforce problems will only worsen unless steps are taken to develop employees at all levels sufficiently to meet future demand. It said population trends show that by 2015 the population aged 85 years and older will increase by 40%, while the native-born population aged 24 to 54 will not increase at all. But population growth issues will only worsen a problem that is already serious, the Commission said. “The negative attitudes about aging and long-term care held by many prospective workers will make recruitment difficult, even for providers that have earned a reputation for quality. Throw in a job description that features a heavy workload, insufficient pay, and inadequate benefits, and the job of recruiting and retaining direct care workers may become virtually impossible. Even today, turnover rates among these workers can be over 75%.”

The Commission said recruitment and retention issues aren’t limited to direct care workers; they also affect professionals such as medical directors, administrators, licensed nurses, and academically trained social workers. There are not enough of these professionals working in long-term care now, the report said, predicting that the situation will worsen.

“Providers need to find ways to attract more of these professionals to the long-term care field, but they also must ensure that these professionals are properly trained and educated, and that long-term care settings take full advantage of the expertise and experience they have to offer,” the Commission said.

Although pointing out that since 1990, nursing homes reimbursed by Medicare or Medicaid must employ a physician medical director, the Commission said that while nursing homes have met the “letter of the law,” they have a long way to go before they fulfill the intent of the requirement—that is, to enhance the medical services available to long-term care consumers.

The Commission said that nurse practitioners could be used to better advantage, that administrators’ and registered nurses’ job satisfaction must be addressed to reduce high turnover, and that compensation at all levels needs to be improved, as does training and preparation of employees to work in long-term care settings. It said that a special federal-state task force should be appointed to lead an initiative in this area.

With its report, the Commission released the results of a national survey, which shows that:

  • Voters recognize the need to reform the system, and most feel the issue has gone largely unaddressed by the presidential candidates.

  • Most voters support a voluntary contribution system for financing long-term care. Almost two in three say they would participate, even up to $50 monthly.

  • The majority of voters have personal experience with long-term care—57% play a caregiving role, either providing care themselves (37%), arranging for or overseeing care (50%), helping to finance their relative’s care (27%), or some combination thereof. About 60% had the experience of having a relative in the long-term care system, and about 25% currently have a relative receiving long-term care.

  • That they or someone in their family will require long-term care within the next five years was believed by 51%, including 61% of voters older than 65 and 53% between the ages of 35 and 64.

  • In yet another manifestation of general popular confusion about the financing of long-term care, 34% think it is Medicare-financed, 22% say it’s directly out of pocket, 20% say it’s Medicaid-financed, 6% look to private health insurance, and 13% don’t know.

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