Paul Willging Says…


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.

The government is of no help whatsoever. Even the databases that result from federally financed programs can’t talk to each other. Home care has its own federally mandated database (OASIS). Nursing homes have the MDS. Even new programs such as PACE (Programs of All-Inclusive Care for the Elderly) are developing unique data collection and reporting systems-again, absent the ability to communicate across the continuum. (And forget assisted living which, based largely on its private funding base, has no mandated or voluntary cross-industry information system.)

Our “perfect” system will, of course, alleviate some of those disadvantages by minimizing the need for transfers across the continuum. Location will be determined by client needs, not by the biases inherent in funding systems or by the issue of affordability. Clients will not be forced into a hospital for an unnecessary three-day stay when all they need is the 14-hour oversight available in a nursing facility. And they will not end up in nursing facilities when home care or assisted living might just as adequately meet their needs. The model we’re looking for will limit the traditional bias in favor of institutional and acute care settings without limiting necessary care. In short, care will be a function of need, not available financing (or so we can dream).

The use of available technology, with an emphasis on information technology, is the third distinguishing characteristic of our model system. Providers too often view data gathering as the domain of government and academicians-and, admittedly, both have their own compelling reasons for collecting information. Like it or not, government oversight has been, is, and will continue to be an indelible part of long-term care. And with oversight comes the demand for data. Traditional academic research, for its part, is important to assess the ultimate success of long-term care systems and programs.

I would submit, however, that “action research,” driven by operational data, is equally if not more important than that conducted by academicians and regulators. It is critical to the success of any long-term care provider, whether institutional or home-based. It is indispensable to quality management, without which no long-term care service program can succeed today. Thus, our model system is data-driven, with data collection procedures in place that recognize the importance of data without overwhelming or distracting caregivers from their primary functions.

Finally, there is the issue of human resources or workforce development. Our model facilitates attracting and retaining essential caregiving and management personnel. Although I’m not sure I would prioritize any of the four characteristics of our perfect long-term care system, were I to do so, human resources has to rank way up there. Buildings don’t provide care. People do. Sufficient numbers of people. People with the requisite skills. And, perhaps of greatest importance, people who really want to provide care. Human resources, skills, attitude-these are the truly essential components of quality.

How essential? Well, if you had to choose just one benchmark distinguishing the stellar community from its competition, what would it be? From my standpoint, as I have long argued, it would be staff turnover. Think about it: If your staff retention levels are high, what does that say about your community? It suggests that management has provided the tools and skills necessary for staff to perform well. It also implies the existence of a “culture of caring,” so critical to good service delivery. While little research shows a correlation between turnover and some of the other indices of quality (survey deficiencies, tort litigation experience, etc.), I’d bet a great deal that the correlations are positive.

So just where are we in this country in terms of a “model” long-term care system? Quite a distance away, unfortunately. Are we customer-friendly? Certainly not as much as we would like or need to be. Are we systemic? Well, providers are getting there, but the total system leaves a lot to be desired. Are we data-driven? Interestingly enough, long-term care, despite the flaws in its data generation capacity and the difficulty of meaningful communication across provider types, is in a lot better shape than other components of healthcare in this country-such as hospitals, for example. Like it or not, long-term care can actually measure outcomes and base its management priorities on improving them. Hospitals are still struggling with the concept. We in long-term care have quality indicators that describe what is actually happening in terms of resident well-being. Hospitals are still working largely with process and structural indicators.

Along with financing, however, it is likely the area of human resources presents the greatest challenge to realizing the model long-term care system. Here the provider community cannot go it alone. Government has to share much of the blame for the staffing shortfalls that occur in long-term care. Indeed, it would be amusing (were it not so tragic) to listen to politicians bemoan the lack of adequate staffing in America’s nursing homes as they blithely overlook the nexus between human and financial resources.

Inadequate staffing ratios are largely a function of inadequate Medicaid reimbursement, in that Medicaid covers the costs of nearly 70% of all nursing home residents. Even if profit margins were zeroed out for all nursing facilities and the resulting dollars used exclusively to augment staffing, the incremental changes would be miniscule. And speaking of reimbursement, assisted living is, unfortunately, tied to the financial vagaries of nursing home care. By representing itself as the low-cost alternative to nursing facilities, assisted living essentially capped its own prices at or below the level of the already inadequate Medicaid rate paid to nursing homes.

So there you have it. Our model exists only in theory, not in practice. While we may be moving in the right direction, we have a long way to go. And until government recognizes its own culpability, the perfect model might never be realized.

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Paul R. Willging, PhD, was involved in long-term care policy development at the highest levels for more than 20 years. For 16 years as president/CEO of the American Health Care Association, Dr. Willging went on to cofound the successful Johns Hopkins Seniors Housing and Care postgraduate program (cosponsored by the National Investment Center for the Seniors Housing & Care Industries), and later served as president/CEO of the Assisted Living Federation of America. He has enjoyed an equally long-lived reputation for offering outspoken, often provocative views on long-term care.

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