Forecast: the "sociable" nursing home.

Report from the American College of Health Care Administrators "National Futures Symposium"

There was a time not long ago when nursing home owners and managers might have been considered to be among the last of a breed -- the good old American rugged individualist. They provided "rest homes" for those who could afford it, and the service offered was limited only by their own business ingenuity and sense of decency. For the most part, nursing home operators answered only to their residents, residents' families and their own consciences.

Obviously, those days are fading fast. Aside from their well-known, and steadily accumulating, burden of regulation, nursing homes are being pushed into a new environment of social cooperation and responsibility -- so social, in fact, as to be almost chummy. More and more, it seems, they will be working with other providers in the so-called "continuum of care." More and more, they will be faced with having to respond to demands for more personalized resident services. And, more and more, they will be be lining up and comparing themselves with each another in quality-of-care follow-up audits.

These "more and more's" were the trends that almost everyone agreed upon among those who presented at the American College of Health Care Administrators' recent "National Futures Symposium." For example, Dennis Codner, Study Director of the futurist "Project 2010," discussed the predictions offered for that year by "Delphi panels" of academics, government officials, providers and businessmen. What did they foresee for long-term care? Aside from an increased burden of illness among the elderly, continuing labor difficulties and constantly tight budgets -- nothing earthshaking there -- they saw:

-- a new generation of seniors -- better educated, more well-off financially, more "consumerist," but with less family support -- demanding high-quality service;

-- more "public-private" partnerships, starting with some growth in private long-term care insurance, but evolving to an expanded Medicare-type social insurance program, i.e., the "public" becoming the senior partner;

-- more coordination of long-term care services of all kinds, including but not limited to nursing homes;

-- more accountability for cost-effective care, with capitation being the primary mode of payment, case management greasing the wheels, and managed care running the show.

Dr. Robert Kane, Professor of Long-Term Care at the University of Minnesota School of Public Health, added his own prognostications, some but not all of them a veritable echo of the Delphi experts'. He foresaw elimination of the dichotomy between community and institutional care; a "bundling" of hospital and post-hospital care financing, as opposed to today's "Balkanization" of such funding; and more emphasis on resident autonomy. But he also added a new thought: that residents who remain "environmentally responsive" will be housed separately from those who are not (i.e. the chronically vegetative). This would involve, for nursing homes, an uncoupling of the concepts "nursing" and "homes." Residents would receive whatever specialized health care services they needed while living in environments meeting their personal standards of quality of life. For many of today's cognitively intact living in nursing homes, he said, having to share facilities with the cognitively disabled represented a severe decline in quality of life.

This comment prompted rumblings from the audience, and one administrator responded that, in his view, nursing homes' mission was to serve as a community for all those in need. To Dr. Kane, this was propagating the "mythology of happy togetherness"_most cognitively intact residents, when asked, would not choose to live in this way. "We have to begin to think about the configuration of the sites in which we treat these people."

Dr. Donna Infeld, a professor at the George Washington University School of Management and Policy, served as an official commentator on Dr. Kane's remarks. She broadened the issues -- and raised serious questions about them. "What about AIDS patients? Those with tuberculosis? Pediatric cases? The developmentally disabled? The mentally ill? Can we in long-term care specialize our care for these groups? Or will we end up with so much fragmentation and redundancy?"

There were other potential problems -- for example, there could be more competition for funding, rather than coordination of it. Also, attempting to integrate a variety of long-term care services could produce more headaches than it resolved. For example, she noted, hospitals that own nursing homes have often felt frustrated in attempting to manage this unfamiliar mode of care, and have had availability problems, as well (as she put it, "full is full, whether you own it or not"). Furthermore, under managed competition, might not nursing homes be relegated to providing specialized post-hospital care, with their more social service aspects being farmed off to other providers? And, with "bundling," will reimbursement be adequate for all levels of care?

Dr. Infeld, in short, sounded like someone who has had experience with public policymaking.

Still, if youth is any guide to the future, there's little for futurists to worry about. A pre-conference "Young Leaders" meeting involving 32 long-term care administrators with less than 5 years' experience, issued its own report. All in all, the participants seemed very comfortable with the predictions of the 2010-Kane scenario. Indeed, the youngsters were so broad-thinking that they reported failure in coming up with a common definition of "long-term care." They were anxious, they said, to avoid the connotation of simply caring for the chronic needs of the elderly. There was much more to long-term care than that, but in attempting to define that "much more," they had found that commonly agreed-upon terms eluded them.

Some of the experienced administrators in the audience found their report frustrating. Were the kids thinking too much and overcomplicating things? Or was their uncertainty a sign of recognition of the wider, but still ill-defined, mission of tomorrow's nursing home?