The future is predictably unpredictable

I talked last column about alternative approaches to financing long-term care. And I admitted that the suggestions offered were, at best, problematic (at least in the sense of political viability). So, let’s get serious. Let’s talk about more realistic change. Let’s discuss the major national policy issues that affect long-term healthcare as it is today and will likely operate in the future.

And let’s do that based not on the sometimes biased agendas (and always political pronouncements) of trade associations. And even less on the always distant and sometimes irrelevant musings of academics. In fact, let’s take a shot at the best (or worst) of both worlds. The National Commission for Quality Long-Term Care might provide just such a perspective.

For those unfamiliar with the organization, the National Commission is a nonpartisan, independent body charged with improving long-term care in America. Its appointed commissioners reflect a diversity of experience in government, academia, quality improvement, and long-term care. Its founding and continuing benefactors were and are, admittedly, the nursing home trade associations (the Alliance for Quality Nursing Home Care, the American Association of Homes and Services for the Aging, and the American Health Care Association). However, the Commission contends that none of these organizations have input into its activities nor do they exercise prior review of what it publishes. My sense is that its contention is buttressed by the fact that the organization is housed in the highly respected New School of Social Research (in New York City) and functions independently under the leadership of its executive director, Doug Pace.

Remarks offered by Mr. Pace early this year (at a meeting of the Center for Excellence in Assisted Living) will form the outline for my own prognostications. In his remarks, Doug suggested four primary areas of concern facing long-term care: quality, workforce, technology, and financing. The charter of the organization he heads, interestingly enough, focuses on six areas, adding cultural transformation and individual empowerment. I suspect, however, that Doug feels (as do I) that these last two are essential prerequisites for quality improvement and need not and should not be treated separately.

Since these four (or six, if you will) elements make up the Commission’s “road map for reform,” let’s take a long look at what’s actually possible and/or likely in the 12-month time frame set by the Commission for its immediate efforts. And the answer is, I fear, very little.

Let’s start with technology, largely because I’m not even sure why it’s on the list. Not that I have anything against enhancing the application of technology to industry functions. I’m just not all that sure that the potential inefficiencies stemming from a dearth of technology rank all that high in the pantheon of industry challenges. Nothing against computers, you understand (insofar as “technology” alludes to them). But computers don’t give baths. (Not that a hoist, another form of technology, isn’t a helpful aid in completing that task.) Nor is our problem the lack of data. The nursing home industry, for example, has access to a more powerful database than any other sector of healthcare, i.e., the Minimum Data Set (MDS). The problem is that the profession just doesn’t use it very aggressively (outside of regulatory self-protection, that is).

Herein lies the real challenge for technology (or, at least, information technology). Not that the databases don’t exist, it’s just that they don’t talk to each other. It’s all but impossible to have a seamless transition across the respective “silos” of long-term care as long as there is no electronic and portable health record to facilitate that transition.

However, while this might not be the most challenging of the issues facing long-term care, it turns out to be the one most likely to show some meaningful progress over the next 12 months. I’ve written already (Nursing Homes/Long Term Care Management, April 2006, p. 20) about a project undertaken by the Health Facilities Association of Maryland to develop a common assessment tool for long-term care (a prerequisite for a common health record). The Centers for Medicare & Medicaid Services has launched its own process for developing a Standardized Patient Assessment Tool (endearingly referred to as CARE, or Continuity Assessment Record and Evaluation). My own university, operating what the Hartford Foundation has referred to as the most comprehensive long-term care continuum in the nation, has initiated a “Senior Strategy,” with the geriatrically focused electronic health record as its essential foundation.

None of these activities is without underlying significance. It’s just that none of them address the other three issues on Doug’s list—the ones that, if not dealt with, will threaten the very existence of the industry. Let’s move on to one of those more intractable issues.

Let’s move on to quality. But let’s also not forget that the quality issue cannot be confused with regulatory concerns. The latter are a function, not a reflection, of the former. Or haven’t we learned anything from decades of experience with skilled nursing facilities?

Indeed, one might argue (as I’ve hinted already) that the emphasis of most nursing facilities has been, unfortunately, on meeting government regulations, not on enhancing quality. Just as facilities have fallen short in assuming that as long as they adhere to regulations, they are meeting an acceptable standard of care, so too has the government helped perpetuate confusion regarding the distinctive nature of those two functions. The result: True quality has received little attention from regulators or operators.

Long before the term “defensive medicine” became part of our vocabularies, nursing facilities performed “defensive senior care.” As they established policies and procedures designed to satisfy regulations, they emphasized avoiding regulatory problems, not enhancing the quality of care. Of course, the resident was the one affected. The government went even further by painting the facility unable to meet its procedural standards as “criminal” and began to mete out appropriate “punishment.” This process created environments that were incapable of retaining competent staff on which, of course, quality care depends.

With facility staff worried more about the annual government survey than about the resident, they give little—if any—thought to improved approaches to patient care. Staff resources end up being survey-oriented, rather then resident-oriented. This orientation violates a basic principle of total quality management: to experiment with alternative approaches to improving customer satisfaction. The current system rewards only those who conform to currently accepted approaches to “quality,” those required by the “system.” And the current system severely punishes those who stray from the processes it so precisely articulates.

Admittedly, assisted living, in its initial manifestations at least, focused more on the “true” customers (the resident, not government) and attempted to meet (if not, in fact, exceed) their expectations. But assisted living essentially blew its own chance of spearheading a new paradigm for quality. It might well have promulgated its own industry-wide procedures to enhance and demonstrate quality and accountability before succumbing to governmental requirements. It chose, rather, to attempt an accommodation with the very regulatory paradigm foisted off on nursing homes. In state after state, the flaws in that strategy are becoming increasingly clear. Someone in the industry must have failed to read George Santayana on the repetition of history ignored.

So, where does that leave us as far as quality is concerned? Well, quality is actually going to have to stem from an application—industry-wide—of the very concepts that Doug Pace (and I) would have left off his list, if asked—concepts that form a critical part of the Commission’s “road map to reform”: cultural transformation and individual empowerment. Suffice it to say, all approaches to quality management—call them by their generic names (TQM or CQI) or by their branded versions (Wellspring or Pioneer)—begin and end with the customer as well as with focused and empowered caregivers. And the associations have, to their credit, mightily pushed this concept, beginning in July of 2002 with promulgation of their respective “Quality First” campaigns.

Quality First was designed and is still described as “a commitment to performance excellence in quality of care and quality of life” by the long-term care community. The voluntary initiative reflected a publicly articulated pledge on the part of the long-term care profession to establish and meet quality improvement targets in order to “heighten quality and accountability.” The first of the seven principles supporting the campaign reflects a heavy emphasis on Continuous Quality Improvement (CQI). And, if successful, it was anticipated that, by 2006, six key outcomes could have been expected.

These included: (1) continued improvement in compliance with federal regulations, (2) demonstrable progress in promoting financial integrity and preventing occurrences of fraud, (3) demonstrable progress in the quality of clinical outcomes and prevention of confirmed abuse and neglect, (4) measurable improvements in all Centers for Medicare & Medicaid Services Continuous Quality Improvement measures, (5) improved consumer satisfaction with services (as measured by rates on consumer satisfaction surveys), and (6) demonstrable improvement in employee retention and turnover rates.

The stated purpose of those outcomes was a simple one: to “strengthen the confidence and trust of the public and other key groups” in the services provided by America’s nursing facilities. And did we get there? Probably not. There are as yet little data to show substantial success in achieving any of these initial benchmarks. Absent persuasive data, the Congress, duly unimpressed, continues to engage in its traditional, punitive approach to regulating nursing home care. One need look no further than legislation such as the “Nursing Home Transparency and Improvement Act of 2008,” introduced on February 14th by Senators Chuck Grassley (R-Iowa) and Herb Kohl (D-Wisc.). Same old, same old: “Improving nursing home care requires constant vigilance,” Sen. Grassley said. “Some problems keep coming up. They need to be fixed [by regulatory means] so nursing home quality continues to improve and stay improved. More transparency, enforcement [emphasis added], and staff training are all needed. That’s what our bill addresses.”

So, why hasn’t the new initiative worked? Why do the Grassleys still reign supreme? Probably because of a mind-set so deeply ingrained among policy makers and the American public that much more drastic action will be required than that reflected in the self-directed promulgation of “Quality First.” I don’t care how well-meaning the campaign was and continues to be. It is largely seen as a self-interested industry undertaking, the role of the National Commission notwithstanding. Even the National Commission pays only lip service to the consumer (with Bill Novelli, CEO of AARP, listed as one of the commissioners. Interestingly enough, not even that slight nod to the customer is reciprocated. Go to the AARP Web site and search for the National Commission. Result? Nada).

What it will take to wake up policy makers is a truly joint initiative, including both industry and consumers—and including them in a meaningful enough way so as to actually impress the Congress. And maybe, just maybe, a truly joint exercise might focus on two issues of equal importance to both parties: workforce and financing. The inadequacy of staffing levels is a concern long raised by consumer groups, but they have always recognized that additional staff must be paid for, particularly given the critical nexus between workforce and quality.

I can’t think of two issues more likely to unite consumers and the industry in a common undertaking. But to successfully confront the Congress and actually force it to act, both parties will have to give in order to get. It will not suffice to simply claim unity of purpose. It will have to exist. And both parties will have to sacrifice to get there.

Consumers will have to recognize that: (1) most providers are well-meaning, and (2) that they are in a better position to manage facilities than are consumers (or the Congress, for that matter). That said, providers, for their part, are going to have to acquiesce to financing and reporting mechanisms whereby additional dollars can actually be tracked through to the staff caregiver’s pocket. In short, the coalition will have to display an element of trust sorely lacking in most of its political discourse to date. But, if created, such a coalition will be hard for the Congress to resist.

Nor need that alliance be limited to the financing of additional manpower. Some point to general financing, not just financing additional staff, as the real issue confronting long-term care. Certainly, it is easy to suggest that the “silver tsunami” portends a future crisis in seniors’ healthcare. But is the problem really that serious? Is it truly systemic? Are we definitely heading toward a catastrophe, or are there other factors that suggest the future may not be so calamitous after all?

I, for one, would suggest that financing long-term care is less a reflection of systemic problems (i.e., “apocalyptic demographics”) than it is simply one of political will. But political will is and will remain in short supply as long as consumers and providers dissipate their energies by fighting each other. In the last analysis, the issue of society’s ability to absorb the cost might well be more a question of the desire to do so rather than one of economic capacity. The issues, in my view, can be resolved, but only through meaningful and joint action by the involved stakeholders.

So, let’s get on with it!

Paul R. Willging, PhD, was involved in long-term care policy development at the highest levels for more than 20 years. Dr. Willging served for 16 years as president/CEO of the American Health Care Association, was President/CEO of the Assisted Living Federation of America, and later 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 Industry). He is currently Associate Director of both the Johns Hopkins Medical School’s Division of Geriatric Medicine and Gerontology as well as the Johns Hopkins Center on Aging and Health. He has enjoyed an equally long-lived reputation for offering outspoken, often provocative views on long-term care.

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