See Part One for an explanation of how I came to understand that a new strategy to disrupt long-term care was called for.
Everyone knows what happens when an inventor builds a better mousetrap– the world beats a path to her door. Except when it doesn’t. Sometimes the incumbents of a particular market don’t want or need something better. The status quo is good enough and the decision to adopt any innovation entails extra work and new risks that are likely to disturb an otherwise stable business proposition. This is the case for most of the long-term care industry. Buoyed by astonishingly low expectations and a reimbursement system that literally pays them for making their patients sicker and weaker, nursing homes represent the one part of our health care system that has seen little substantive change in more than half a century. People don’t buy 1960’s style phones, furniture or cars. They do, however, buy 1960’s era institutional long-term care.
[Footnote: Residents are physically restrained less and, it must be said, chemically restrained more than they used to be.]
Over the past five decades a complex system of supervision and regulation has emerged which is designed to minimize the most egregious failures of the long-term care system. That system was founded upon a decision to think about, regulate and penalize nursing homes in isolation from each other. The regulatory system also adopted a “catch and release” philosophy that emphasizes the work of restoring poorly performing facilities to compliance. The result is a system that everyone dislikes. Providers often feel that they have been singled out for unfair treatment. Regulators become frustrated with the endless cycle of sanction and correction. Elders and their families feel trapped in a broken system that is not serving their needs.
It can be different.
My undergraduate degree was in Biology and although anatomy, physiology and microbiology were among my favorite courses I also enjoyed studying population biology. It was there that I first encountered the idea that herds of wild animals need predators in order to stay healthy. Consider, for example, a herd of 15,000 buffalo roaming the plains with nary a predator in sight. Now imagine that this vast herd is being followed by an enormous team of veterinarians all of whom are dedicated to treating the weak and the sick and returning them as soon as possible to the herd at large. Viewed from the perspective of the individual buffalo this scenario is something close to heaven. From the point of view of the herd, however, it is a disaster of epic proportions.
Predators selectively remove individuals who are weak and sick. Under ordinary circumstances, the strong and healthy have little to fear because predators focus their attention on the weak and the sick. Wolves help keep the herd healthy by removing sources of infection. They help to strengthen their prey by ensuring that weak and malformed individuals do not live long enough to pass their defects on to the next generation. This arrangement is both cruel to individuals and vitally important to the herd.
America’s long-term care system has about 15,000 facilities. Few of them are exposed to anything more than token competition. Meanwhile the industry as a whole is surrounded by an army of consultants and regulators who are dedicated to correcting the flaws of the poor performers and returning them to the general population as soon as possible. We can think of them as a herd that lacks any natural predator. Worse, the ecosystem they occupy ensures that the weak and sick remain as active participants in the industry. This perspective helps explain why even though some individual facilities can and do provide exceptional care, the long-term care “herd” has been, is and will remain disease ridden and highly dysfunctional.
Let’s apply the insights of population biology and wildlife herd management to long-term care and see where they takes us.
What if: State Medicaid authorities and licensing boards stopped coddling the dangerous incompetents and started revoking the licenses of chronic poor performers? Imagine the difference it would make if every state committed to revoking the licenses of the 10, 30 or 50 worst nursing homes within its borders– and they did so every single year. Year after year after year.
What if: CMS stopped begging nursing homes to adopt evidence-based approaches to care and started applying an institutional “death penalty” to the industry’s laggards and dullards? Imagine the newfound interest that the remaining facilities might exhibit toward approaches to care that might protect them from falling into the bottom of the heap.
We need to thin the herd.
Although this policy would be radically unpopular with poor performing nursing homes (and the trade associations that represent them) it would be good for elders and it would greatly benefit the industry as a whole. People want and deserve access to long-term care that is rooted in 21st Century science rather than 19th Century paternalism. Talented professionals need to be able to work for better organizations if they are to rise to their full potential.
For those who ask: “How do you propose to abolish the nursing home?” Here is my answer. I will align myself with a new species of predator, one that delights in preying upon the worst that the long term care industry has to offer. A Tiger is the most cunning, the most daring and the most aggressive when she is hungry. Are you hungry for change? I am.
The time has come to let the Tiger roar.
In Part 3 I explore the contours of the post-nursing home world.
Greta Lee says
If more people were aware of what elders experience in nursing homes, there would be a greater call for change. My siblings wanted my mother to be placed in a nursing home because they thought she would be safer and better cared for than living on her own with twice daily caregiver visits. I resisted. She resisted more strongly. Then she fell and broke her hip. From the hospital she went to a nursing home. I went with her and spent every day with her, thinking I could go back home once she knew where she was and adapted. Instead I discovered that nursing homes are hell for people with mild dementia. One night she fell beside her bed and had to be returned to the hospital for a transfusion. She had dehydration induced hallucinations (I called a nurse friend who explained to me what was going on), became sleep deprived and was in a constant state of confusion. I could go one with horrors she experienced when I wasn’t there but expect people who read this blog are aware of them. I also hated being in the nursing home with her. It was noisy and busy. I had to prevent her from getting up while two nurses aides could be rounded up to help her go to the bathroom. The only time we were happy was when we sat outside and watched the trees. If I had left her there, this formerly happy, fun woman would have ended up in the “memory care” unit. It was a real wake-up call for me. After two weeks I moved her to a small residential care place somewhat like a green home. We furnished her private room with her furniture and her paintings. The staff have time to talk to her. But I also hired her two previous caregivers to visit her everyday. They have been crucial for her health and happiness.
I just wish there was some way to reach all the children with elders in need of assistance to let them know that a nursing home is not going to make your parent safer, healthier or happier. When people start demanding alternatives, then those alternatives will become more numerous and thrive.
Robert Barnes says
Let’s apply the insights of population biology and wildlife herd management to long-term care and see where they takes us…
Tiger eats “bad” long term care facilities.
Displaced residents apply for admission to surviving “good” facilities.
Good facilities are full or nearly full so only a few residents get in.
Remaining residents are left to die in jungle.
Only the strong survive.
I emphatically disagree that most of the long term care industry has not changed in 50 years and is disease ridden and highly dysfunctional. Like our facility, the majority of facilities I visit are blessed with loving, caring staff that are mission driven. We are focused on continuous improvement to enrich the lives of those we care for. Thank God for the regulators that monitor conditions and provide incentive for those facilities that need to improve rather than tossing them to the wolves! Fortunately, humans have evolved and improved beyond a model of wildlife herd management. We can actually care for those that are sick, rather than leave them behind to be devoured.
Rebecca Dutton says
As an occupational therapist who worked in a nursing home and then had a stroke I agree with you. My April, 2014 post on safety precautions is one example of how institutions put being sued above clients’ quality of life.
Tom Rowan says
I have been involved in aqspects of LTC for many years as a spiritual care provider. In my roll, I act often as an advocate for the elderly challenging the status quo. It is a position I find essential yet tough to do without support. My latest experience was knowing two male patients in the hospital who had been in an associated nursing home. They each “behaved poorly” in the nursing home and are now barred from returning. The behavior that gained a sanction? Speaking up for themselves. The elders are crying out. We need to listen to them and change this situation. I am in.
At Ford says
A well-crafted and thoughtful post, Dr. Thomas. While I agree with much of what you say, let me point out that the “dangerous incompetents” and chronic poor performers in LTC keep their licenses because they are usually the only places that take Medicaid residents with heaviest care needs (behavioral as well as physical) for the pittance the government pays. The reimbursement rates do not come near to covering the costs of these residents, and the numbers of younger residents with higher acuity and social service needs are growing. Methink the tiger needs to pay a visit to a few politicians, too.
Carole Harrington says
One of the things that bothers me the most about the nursing home business is how on-going physical and occupational therapy are tied to Medicare funding and patients are only alloted so many days. We give the patients therapy to get them able to transfer and ambulate, but don’t follow up with any therapy to maintain these skills once these patient’s medicare days are up. What is the point in helping these people if we are only going to abandon them once they achieve some functional normalacy. We need to focus more on preserving functional abilities.
Also from the perspective of a care-giver, I would like to point out that there is a practical reason for the institutional existence of nursing homes. Because as a society so many people exist as single solitary individuals without the support of family or community or the financial resources to afford individualized care. Or in many cases their families are either physically or emotionally unable to care for them. As an aging individual, I want to maximize my health, functional abilites and opportunities for creative involvement. But who or what will be there for me when my physical and emotional resources fail me? In the same way that I feel that de-instititutionalizing the mental health industry brought challenges to our society, I feel we need to consider the potential ramifications that a de-institutional nursing home industry will bring.
Finally the mentality and attitude we need to be truly effective in this day and age! I know you will have lots of support! I am roaring with you!
Paula Frakes says
We need a “wake up” call to help culture in general start to “Face Aging”! We are all getting older and the demographics do not lie about what is now on our doorstep. I understand what Dr. Thomas is saying but I also am concerned about the Assisted Living Industry. I see AL buildings be put up very quickly across my community here in the Twin Cities of Minnesota, but often with little concern for how the people that live and work in these facilities will really be connected to the community and live a quality of life that is any different than what we offer in traditional LTC nursing homes. Little thought is put into how the residents and workers will have access to the outside and nature that is so beneficial to them. Also access to transportation and the community at large in terms of intergenerational opportunities to engage in their lifestyles. I see many of the senior housing projects going up as mere “warehousing” and “creating another silo” away from the rest of life. I would like to see more plans that incorporate intergenerational living and relationships with our aging population. Plans that also incorporate access to the outdoors and nature indigenous to the area with walking paths and landscaped gardens that allow greater access for people of ALL ages and abilities. Plans that incorporate regular opportunities to engage with younger people of all ages. I think “smaller” is better too. I like the Green House concept but where it is smaller and fits into existing neighborhoods and incorporated into the life around it.
We need to stop dividing people up by age groups and start mingling and relating across the generations once again! The reality is that “informal” care by family friends and neighbors is how a broad number of our elders are really cared for…how can we better support that network!??
Just a few thoughts that I have been mulling over myself….and wondering in what ways I can be a bigger part of helping to make the change I wish to see??!!
Kavan Peterson, Editor, ChangingAging.org says
Terrific comments Paula! I couldn’t agree more. In his new book Being Mortal, Atal Gawande tells a sad tale of the evolution of Assisted Living from a visionary concept helping elders stay in community to the reality today — rapidly growing, corporate, for-profit institutions much as you describe. We need urgently need more community-based, intergenerational options for aging.
Janis Deets Nowak says
Oh My!!! I fear for the future of elder care!
If you had asked me yesterday “who are the three folks who care most about: the elderly; the disabled; the cognitively impaired; here in the United States?” – I could not have come up with a better answer than Martin Bayne, Bill Thomas and Steve Moran.
Imagine my surprise when I receive an email this morning from Laura the Nurse who says “This article in the Senior Housing Blog is really interesting. My issue with it seems to be that if I go by what is being written about, I don’t think I understand person directed care. I would really appreciate your take on it.” They are caught up in a discussion about abolitionists and tigers.
Laura hit the nail on the head! This war between our elder-care heroes (Martin, Bill and Steve) has little to do with our residents (or you or me). Elder care should be a battle for individuality. Creating a culture in which each person receives the care they desire is a little scary. Often, it differs from our own opinion about what someone needs. On occasion, it doesn’t meet the requirements of the law. Sometimes, it is not so pretty. This is what person directed care looks like.
Lucky you! If you are not “institutionalized” you can make choices. Maybe you smoke. Maybe you eat too much. Maybe you don’t socialize. No wonder you do not want to enter a long-term care environment!
So what is this argument between Martin, Bill and Steve really after? They are all good men. All extremely well-intentioned. What are they looking for? Here is a thought….
I am going to leave the world of assisted living for a moment because I think there might be some answers outside our silos (Steve Moran, you encouraged us to step outside). Have you heard of Cynthia Ong and the work that she is doing in the environmental field? Cynthia, is the executive director and CEO of Land Empowerment Animals People (LEAP). Cynthia was frustrated by the development-conservation polarity (the struggle between those who want to develop land and those who want to conserve land). The push-pull, the good guy-bad guy attitude on both sides did not seem productive to her. So she founded LEAP “to facilitate partnerships and projects across sectors and hemispheres based on a core belief that real, robust, and resilient solutions are found in connection and relationship with each other.”
Now I am going to steal her ideas, paraphrase and adapt to the business of assisted living…
• The regulatory/provider arrangement is an old frame, which no longer serves us.
• The regulatory/provider framework pits us against each other, constrains us in us-them dynamics, makes one right or better and the other wrong or bad, and the divide is a chasm. It is a disconnect – which keeps our solutions partial, oftentimes conflicted and always limited.
• Our current mindset is not going to cut it in the world with huge numbers of people over 80, many without the resources to care for themselves.
• Even for those with resources, where are the caregivers going to come from? The proportion of elders to youngers is increasingly tipping toward toppling.
• We need to put our attention and energies into connecting dots, issues, people, groups and sectors. We need to create spaces for conversations about the future that include the elderly, the needy, the carers, the regulators, the payers and the providers of service.
I’m still stealing ideas here….
• We are invested in our constructs, the patterns and formats by which we engage, and their underlying assumptions.
• We roll out the same old processes and get the same results.
• We stay in our corners, interact with people like ourselves, compete amongst each other for finite resources.
• We build campaigns that say if only the other corner would change their ways everything would be fine and the world would be better.
Do you find any of this intriguing? We talk a lot about what we don’t want to have happen: we don’t want people to fall; we don’t want people to be isolated; we don’t want people to run away. Perhaps we should shift our focus and ask what do we want to have happen?
Even my concluding remarks are Cynthia’s words: “The challenge is to get ourselves out of the way, stop thinking it’s all about us, scrutinize, question our assumptions and constructs, and work hard and smart to redesign and recalibrate. Radically different results – which are what we need – are going to take radically different approaches and processes. If we continue on the tracks of business-as-usual, government-as-usual with the elders silently screaming in the margins (ok, elders was a substitution from the words she used). I’m afraid we are not going to make much impact on our own trajectory.”
Let’s start working together and looking for the win-win! We can do this!!!
Gregory Bator says
Your approach is vicious, simplistic, and oddly antithetical to your prior work. Do I have this right? Isolate the weak and eliminate them from the system. Then others will improve based on fear of becoming the next victim.
And what reforms do you envision to replace administrative due process? Is it something more akin to what was described in yesterday’s NYT? http://www.nytimes.com/2015/02/01/world/asia/taliban-justice-gains-favor-as-official-afghan-courts-fail.html?src=me&_r=0
Is your indictment limited to nursing homes? Does your tiger approach include the assisted living industry?
I have witnessed the growth of the assisted living industry over the past 30 years. Assisted living is an industry still in its early teen years. At its core are a dedicated crew with a positive approach. The network of community based supports before and during an assisted living residential stay are growing exponentially. An inherent barrier to improving assisted living though is money. Frankly, we are not prepared as a society to pay the true cost for excellent care.
If only every worker was an angel satisfied to earn $9-11 per hour to provide tender care. We are fast approaching, if not already there, a quality care worker crisis. Paying deserving wages to attract a quality career path care professional faces a struggle. The battle typically pits the ‘company’ versus the worker. I don’t buy this equation. Well run companies today run on thin margins. Customers/families experience sticker shock at today’s assisted living prices. The real battle is in informing customers/families the cost of care needs to go higher to create a career care system.
Frankly, I am not sold on your about face tiger driven approach. Your prior path was rooted in the belief that understanding and training would release the generous human spirit. My personal path runs parallel. I believe that one of the best ways to attack the growing need for quality personal care is to remain healthy, happy, and dignified. I’ve rooted every one of my 110 Graceful Aging shows in the belief at least one life is improved with each viewing in some way.
The problem as you are presently viewing it seems to say ‘if we can only rid the world of the bad guys, everything will be better.’ Our market place driven economy is the strongest system in the world. It has flaws ,no doubt. Yet, I will take the market place approach to driving improvement over a bludgeoning approach.
Hi Greg — big fan of Graceful Aging, you guys do great work. Thanks for weighing in, we want to spark a serious dialogue. I agree with you that our society is unwilling to view caring for our elders as the worthy investment it truly is. But I think you missed the point. First, you’re conflating compassion for people with compassion for facilities. Second, Bill’s point is that the long term care system is flawed exactly because it is not market-place driven. Much the same can be said for the health care sector as a whole, but the long term care sector in particular desperately needs competition. Why shouldn’t outstanding, proven alternative models like The Green House Project compete directly with poorly run, often-cited institutional providers? Why shouldn’t we advocate changes that make the system more competitive and accountable? And I certainly don’t share your rosey view of the Assisted Living industry. It’s ironic that you tout a model originally designed to do exactly what Bill proposes to the nursing home industry — wipe it out! Ask Keren Wilson what she thinks of Assisted Living today.
Gregory Bator says
Thanks for your kind words and response. I understand the value and purpose of radicalizing positions to energize change. I have enjoyed Dr. Bill’s reflective and inspiring approach. I have never been a fan of a scorched earth policy for change. This incredible surge in persons of great age is now upon us. We are talking about ourselves.
I am not ready to blow up the system. I am also unwilling to cast the care industry into good versus evil. The industry is much more nuanced and sophisticated, even though it is only in its early years to be labeled so simply. Our generation will not live long enough to rebuild a system that will be ready to attend to our needs should they arise in our lifetime. Realistically, we must improve and strengthen the existing systems. A system flexible enough to attend to differing needs and abilities with career minded, trained sufficiently paid professionals is what we need.
Sadly, state and federal budgets continue to place reduced value on protecting and serving our most vulnerable populations. I feel that the tiger approach is falling trap to a mentality of ‘if we only get rid of the bad guys, everything will be good.’ While the nursing home horror stories exist and are reprehensible, they are outweighed by the respectful care more individuals actually receive. The adage ‘don’t throw the baby out with the bathwater’ resonates in this discussion.
The solution to better care in any setting begins with the person involved. Have we planned for our own needs as we age. Have we saved adequate funds for our own needs. If not, shame on us. We have relegated our future to a system underfunded and over burdened.
The solution is to eliminate the belief that some mystical “they” are causing our problems. I am not comforted that “we” are better than “they”. We ordinarily become someone else’s they.
The solution is that we must take responsibility for ourselves. Our surging population is ourselves. I want to remain healthy, happy, and in my own home. Have I put shower bars in my shower stall? Have I thrown out rugs without non-slip backing? Have I taken a driver improvement course? Have I stopped looking at my texts while driving? If not, we may end up like they.
Thanks for spearheading this important conversation. Vigorous thought moves life forward.