A talk with Paul R. Willging, PhD, President and CEO, Assisted Living Federation of America. (Assisted Living Review).

Last April the Assisted Living Federation of America (ALFA) made big news with the appointment of Paul R. Willging, PhD, as its new president and CEO. Although Willging was coming off a two-year stint as director of the groundbreaking Seniors Housing & Care postgraduate training program at Johns Hopkins University, for the previous 15 years he had become known as a formidable battler for long-term care interests as president and CEO of the American Health Care Association (AHCA), one of the national organizations of nursing homes, and as one of the founders of AHCA's National Center for Assisted Living (NCAL). Now, returning to the Washington wars, he faces major challenges in advancing the cause of both ALFA and of assisted living, in general. Recently he reviewed his plans and concerns, both near and long term, in an interview with Nursing Homes/Long Term Care Management Editor Richard L. Peck.

Peck: What do you see as your principal immediate challenges in assuming leadership of ALFA?

Willging: I see the major mission internally as stabilizing the organization and focusing it on its critical competencies--the work that it does best--while setting aside other activities that don't relate directly to this work. The major external challenge is to guide the regulatory fervor that appears to be developing across the country in a direction that doesn't run counter to the purpose and spirit of assisted living.

Peck: Let's take those one at a time. Would you elaborate on what you mean when you say you want to stabilize ALFA?

Willging: As with any turnaround situation, you need to look at costs and at possible revenue enhancements. ALFA relies for its primary sources of income on a field where resources are already very tight.

Peck: Regarding tight resources, some say it's a matter of waiting for an overbuilt market to catch up with itself for things to loosen up a bit.

Willging: You really can't wait for something to happen--there's always the chance you won't be around when it does. It's a better idea to position the organization to be able to take advantage of the situation when the market does turn around.

Peck: As for external challenges, you point to the threat of federal regulation as being of primary concern. How do you see this?

Willging: The bottom line for our organization is maintaining a regulatory environment in which assisted living can do what it does best: focus on customer service. Assisted living can't do that if it is bedeviled by the same kind of regulatory environment facing nursing homes. I'm not saying that government doesn't have an interest in regulating when it is as deeply involved in financing a product as it is in nursing homes. Not that the government does such a great job of regulating nursing home quality--but it does have a right to specify what nursing home care should look like because it's paying so much for it. That's not the case with assisted living, which is largely privately financed and dependent for success upon customer service.

Recently, Sen. Hillary Rodham Clinton (D-N.Y.) complained about the "hodgepodge" of regulations governing assisted living throughout the 50 states. My immediate response was, "And? What's the problem with that?" Why shouldn't a service geared to consumer preference be regulated at the local level where the customer lives and the bills are paid?

Peck: Some have said that the threat isn't great, that federal regulation of assisted living is less likely to happen because policymakers don't want to repeat the "disaster" of nursing home regulation. Is that a factor?

Willging: I think that most policymakers I talk to do mention that as a factor. Unfortunately, however, there are other groups who have become so attuned to the federal system--it's what they grew up with and feel most comfortable with--that they believe this is the only conceivable answer to perceived problems in assisted living. They miss the point: Every choice made by a regulator is one less choice available to the consumer. And it is customer choice that we are trying to preserve.

Peck: Earlier you alluded to increasing "regulatory fervor." What did you mean?

Willging: Recently a multiorganizational Assisted Living Work Group (established by the Senate Special Committee on Aging) proposed some preliminary regulatory guidelines that looked a great deal like nursing home regulations. Just one example: The draft guidelines required that all leftover food be reheated to 165[degrees] F before serving. The issue here is not the appropriate temperature for leftovers. It's whether we want to apply to assisted living the same process-oriented regulations that so constrain nursing homes.

A better direction would be to focus on outcomes--in this example, a focus on avoiding foodborne pathogens, contamination, weight loss and the like. In the case of nutrition, for example, we already have local health departments that keep tabs on process and procedures, just as they do with restaurants (And I don't believe anyone is proposing the federal regulation of restaurants). In assisted living, the emphasis should be on enhancing the enjoyment of the dining experience, while avoiding adverse clinical outcomes.

Peck: Don't assisted living providers, though, have at least one window of vulnerability to regulation-the "aging in place" issue, which focuses on promises made, resident and family expectations, licensure issues and the like?

Willging: I think the industry has come to see that aging in place has to be more than a marketing mantra. Providers know that two things have to happen: (1) full disclosure. While the resident and the family want aging in place, and we want the resident to age in place, everyone has to be clear from the start about the facility's capacity for delivering the requisite care and the discharge policies that reflect that capacity. (2) If the facility wants to accommodate these growing needs, it has to be willing to add capacity--whether more staff, increased network connections with home healthcare, adult day care or both, etc.

Peck: The assisted living arm of AHCA, NCAL, began under your AHCA tenure. What sort of relationship do you foresee between NCAL and ALFA?

Willging: I look for it to be collaborative and cooperative. I have a strong sense that the interorganizational competition of the past was of no use in advancing the best interests of long-term care. I've run the largest long-term care organization in the country, and I see no need to create another empire. I think we have a chance now to create a whole that is greater than the sum of its parts by bringing organizations together to work on common interests.

I know it sounds "pie in the sky," but I think cooperation among the major organizations is eminently doable. For example, I think one of the strongest of the major long-term care organizations in the field of research is the National Investment Center for the Seniors Housing and Care Industries (NIC). Well, why does every other organization have to replicate NIC's research? What barrier would there be, for example, to launching more joint projects, both with the NIC and the other three long-term care organizations (the American Association of Homes and Services for the Aging, the American Seniors Housing Association and AHCA)? What if all five of the major organizations, for example, pulled together in generating industry data through more timely and comprehensive surveys? The likely result would be dramatically increased response rates and commensurately more reliable data.

I'm not saying that anything like this is going to happen tomorrow, but as long as I'm not asked to sacrifice the essential interests of my members, I'll do whatever it takes to advance the larger cause of the profession, even if it sometimes falls outside the limits of our own organizational boundaries.

Peck: What did your years in academia, specifically the Johns Hopkins program, teach you about long-term care?

Willging: I think the two years at Johns Hopkins gave me a chance at developing a broader perspective. For example, I developed a feeling for how the consumer looks at his or her long-term care choices and makes decisions based on perceptions of value. In that context, I became more aware of nursing homes' inability to focus on customers in any creative way, because so many administrators feel that regulatory compliance has to take precedence. Attempting any sort of innovation in this punitive environment scares them (and rightly so). The threat of something like this happening to assisted living scares me, and that fear is the primary reason I accepted the ALFA presidency.

For further information, contact ALFA at [phone], fax [phone] or visit www.alfa.org.