For the past few weeks I have been using ChangingAging to ask some pretty basic questions inspired by the theme #DisruptAging. Perhaps the most important of these is: “If Americans want universal access to services for elders that provide higher quality, greater dignity and more choice– why haven’t they appeared?”
In Part One of this series I discussed my frustration with my twenty years of asking (as nicely as I knew how) for the Long Term Care industry to reform itself by embracing person-centered models of care. In Part Two I presented “Tiger,” the aggressive, pro-active approach to change that I will be using to guide my work going forward.
In this third installment I am going to describe the contours of a post-nursing home world and how we can get there.
The Tiger strategy defines two barriers that are currently preventing the much needed and long overdue disruption of the long-term care industry.
Let’s start with the people we are serving. Almost all of the elders and families first engage with the long-term care system shell-shocked, overwhelmed and knowing very little about the breadth of options that are available to them or the rights they possess.
We can say whatever we like about the power of the free market to create quality and choice but people who feel helpless and alone in such a way are incapable of exerting effective pressure on incumbent long-term care providers.
This “market failure” explains why archaic models of care continue to dominate the field even though innovators have developed a range of person-centered, evidence-based alternatives to conventional practice. The spread of innovative models has been and is being stifled by local monopolies of providers who are protected by Certificates of Need. They face limited local competition and enjoy an ever-growing demand from our aging population. Most disturbingly, they are actively co-opting the rhetoric of person-centered culture change… but not the practice.
Creating the change we all need and want will require us to pull two levers simultaneously.
1) Activate, engage, educate, organize and support elders and their families– at the local level. We can initiate a new era of local, community-oriented engagement that is based on the millennia-old idea of the “Friendly Society.” This type of community-based mutual-support organization has long been relied upon by people around the world when confronted by the twin plagues of powerlessness and social isolation. Friendly societies played a key role strengthening communities during the upheaval of the industrial revolution. AARP originated in the mold of a friendly society for retired teachers. Today, the Village to Village Network is creating hundreds of community-based friendly societies nationwide. Tiger can help us to create a new generation of Friendly Societies that are dedicated to increasing the ability of people to understand, navigate and advocate for change within the constellation of aging services being provided in their communities.
2) Create healthy competition in local markets so that incumbent providers are compelled to compete with evidence-based, person-centered, 21st-Century models of care. The local monopolies that dominate long-term care need a good stiff dose of Healthy Competition. Fortunately, it is in our power to foster this kind of competition because we understand and can replicate 21st Century models of care. We can create alliances that advocate for, facilitate the creation of and help to capitalize new models of care in underserved communities.
I am willing to put my trust in well-informed consumers choosing among high quality options in a free and open marketplace. How about you?
Let me know if you’d like to be part of the conversation – I’m heading on the road starting in April to visit 30 cities by the end of the year and I hope to see many of you along the way.
Just found this. It’s been three years since comments. Any change?
While I fundamentally agree with Bill’s solution the one comment I would have is that regardless of whether or not the state requires a CON. Skilled nursing does not represent a free market failure. I am not so bold or brash to say free market is exactly the right way to go for skilled nursing, but regardless, with the payment and regulatory system we have today any resemblance to free market is purely coincidental.
Steve Moran
http://www.seniorhousingforum.net
In your 30-city tour, are you coming to Seattle?
Speaking as a well-informed consumer, I have noticed a few ways in which the marketplace of senior living and services is not a “level playing field” for consumers in Washington State, as described below, and I have become involved in communicating with other consumers so we can do what consumers have always done well – make a marketplace more efficient.
First, nothing in State law requires assisted living facilities to make advance disclosure of all services and all charges to all customers BEFORE a customer occupies a unit, leading to unwelcome and costly surprises about extra charges, or about gaps in services that must be filled through hiring in-home service agencies. Extra moves AFTER learning about extra charges or service limitations are costly, and also may trigger the very real health care phenomenon known as “transfer trauma.” Without complete advance disclosure of charges and service limitations, seniors burn through their resources faster than planned, perhaps finding themselves on the slippery slope of “the Medicaid-spend-down.”
Second, our State’s certificate of need (CN) laws (70.38 RCW) and regulations (WAC 246-310) do even more harm than protecting sub-standard nursing homes from competition.
CN regulations define two different types of nursing homes – one type is a CCRC nursing home, available only to occupants of a continuing care retirement community’s independent/assisted living units after a five year transition period, and permitted to give “priority admission access” to CCRC residents during its first five years. A CCRC nursing home is excluded from being eligible for a Medicaid contract with the State. The other type is a public nursing facility, equally available to all. This type of nursing facility must have a Medicaid contract with the State.
Elderly individuals are “baited” with the features of “priority nursing home admission access” and “exclusive nursing home access after five years” to execute lifetime agreements to finance the construction and operation of CCRCs. In two recent applications, the CCRC operators, once well-capitalized and financed by lifetime financing agreements with elderly residents and depositors, have attempted to use the Certificate of Need process to “switch” what the elders are financing from being the CCRC nursing home they agreed to finance, to being a public nursing facility….. without notifying CCRC residents or depositors that such a switch, if approved by the State, would eliminate their priority admission access, and exclusive access after five years.
Why would the State be willing to use its authority to approve such a “switch,” not requiring it to be informed to all CCRC residents and depositors? Only after “the switch” may the State use the mandatory Medicaid contract to place its local Medicaid-eligible clients in the brand-new facility that elderly CCRC residents and depositors were baited to finance as a private facility. One of the two recently attempted “switches” was successfully executed; the other was not, after residents woke up, smelled the coffee, and requested that the management call off “the switch.”
I admit to have acquired a very geeky understanding, for a consumer, of our State’s Certificate of Need laws and rules, and the harm to elders that may be cranked out from their mechanics, also of the harmful disclosure gaps permitted by assisted living licensing laws.
I work in non-medical home care which, for better or worse, is largely unregulated here in Ohio. While staying in your own home as you age may not be the best choice for everyone, it’s certainly one of those options that most people prefer over a long term care institution. But it is too expensive for a huge segment of the population to even consider since the costs are not covered by most health insurance nor medicare or medicaid. And we have a heck of a time convincing discharge planners to inform patients that going from the hospital right into the nursing home is not their only choice. But how do we include this staying at home option as part of the list of choices available to everyone instead of just a select few? Hope to see you in Cleveland Dr. Thomas!
I am ready to enroll in this cause, Bill.
After 78 years, my wish if I had a magic wand would be to change the prevailing attitude regarding elders making them ‘objects’ (for care,for concern, for profit, for storing away) to an attitude of recognizing that this ever-growing population can be the greatest resource we have.
You are a terrific spokesperson, a leader,let’s get the critical mass!
Arthur Rashap
[email protected]
I would add a 3rd lever: Find a way to make genuine, strength-based, person-centered care communities financially attainable to each person and organization. Period. I’ve seen the problem occurring on both ends: People on Medicaid can’t afford (or are denied from) communities due to their financial status AND Strong, supportive, well intentioned communities feel that person-centered care staff to resident ratios are risky and not-profitable (even for nonprofits!). Currently, staffing ratios are set so profits can be made over persons served. How do we beat this hurdle of money over matters? When can Aging Services afford a 3:1 or less staffing ratio, if not less, without praying for volunteers and families to assist? How do we reconstruct the Aging Services financial structure to make both residents adequately served and organizations adequately staffed?? This would indeed be part of my dream aging service world. Back to you – friend!!!
I know a model that costs 15% less per person per day than traditional SNF care in a community setting. Without bureaucratic and unnecessary administrative costs the cost per person would plummet to 25% less. Best part. It pays critical staff a living wage. Did I mention It’s your model courageously pushed to the max? Communities should be outraged at how their Medicaid dollars are being used. That said, disrupting aging is risky business in my business. I hope some day they’ll listen.
Rebecca, Inquiring minds want to know… What is this model?
I am actively involved in advocating for senior co-housing models with a wide open mind.
Sarah, It’s a Green House Home (TM) in a mixed housing suburban community with a very pure shahbazim model..but it is licensed separately from my traditional home because of CMS angst about survey, which carries some extensive cost structure burden (don, administrator, separate audits, cost reports,etc…) You can contact me via http://www.StJohnsLiving.com to discuss further.
Hi Rebecca, the StJohnsLiving link here does not work fyi. Sarah, I am very interested in Co-housing models and as a former director of an adult day center, I would love to collaborate on ideas to make Dr. Thomas’s Friendly Society idea a reality with you both. Let’s talk*