Forecast: the unrecognizable nursing home.

Industry-oriented futurists see a new institution forming

Last year may have been a bellwether year for nursing homes. Not only was long-term care actually included in a President's health care reform package, but in shape and substance the proposal reflected some powerful new trends just beginning to take hold. Suddenly -- for better or for worse -- the future of the long-term care industry became clearer. Whatever happens to the specifics of the Clinton plan, the trends point to a nursing home industry virtually unrecognizable from today' s. That seems to be the consensus, anyway, of some knowledgeable industry observers interviewed by NURSING HOMES Associate Editor David Patterson, who asked them to assess the Clinton plan, the prospects for industry growth and the challenges nursing homes face to achieve it. Laura T. Fain, RN-- Director of Nursing for the Leesburg Regional Medical Center Nursing Center, a 120-bed facility in Leesburg, Florida, with 40 beds dedicated to sub-acute care.

Health Care Reform Legislation: "I'm concerned that the elderly and borderline elderly--those who are 60 or 61 with chronic illness and who do not qualify for Medicaid--are being left out. These are people nursing homes serve and who are getting no attention in the Clinton proposal. Their needs have to be looked at, especially after they have left a nursing home and are still in need of long-term care in the home. I don't see the health care reform proposals addressing these people."

Growth: "Sub-acute care is where the real growth is going to be. Health care reform is going to push patients out of hospitals faster and they will be going to nursing homes where they can get the short-term care they need for less cost than in a hospital."

Challenge: "Training a nursing staff to handle sub-acute care patients is the biggest challenge I face as a director of nursing. In a slow week we have ten to 12 admissions for sub-acute care, in a good week 50 or 60. We are turning our 40 sub-acute care beds over very rapidly. Some times patients are here for only two or three days getting intravenous antibiotic treatment or chemotherapy. My nurses need to be good at providing those treatments and at working with patients who are going to be here for a very short stay. It is a lot different working with a patient who will be in and out than with one who will be here for long-term care. When I interview people who come in to work for me now, I am choosing those who have acute care experience and the skills I need for sub-acute care."

Leslie S. Libow, MD -- Chief of Medical Services of The Jewish Home for Aged, New York City, and Greenwall Professor of Geriatrics and Adult Development at Mount Sinai Medical Center, New York City.

Health Care Reform Legislation: "The most important thing from my point of view would probably be achieving appropriate payment for physician time linked to nursing home work -- the time spent seeing the patients, meeting with the family, and participating in the care team. This needs to be done in order to encourage physician involvement in nursing home care."

Growth: "Sub-acute care is obviously the growth area, but even more specifically I see it as rehabilitation programs for disabled persons in the community. That is the most natural area for nursing homes to develop. It is, however, going to require a change in their commitment, their staffing patterns, and their relationships with managed care referral sources."

Challenge: "Treating increasingly challenging patients with diminishing reimbursements is the challenge for nursing homes. Those patients will require a level of care between that of today's nursing home and a hospital. The label of nursing home is going to make it harder for institutions to get the level of reimbursement they need to provide the level of care those patients require." George Molloy -- President of M&M Associates, a consulting firm that specializes in teaching marketing strategies to nursing homes.

Health Care Reform Legislation: "All that Clinton's proposal has done is to duck the issue of long term care. They have to realize how important nursing homes are. Instead they have just ignored them. It's hard to identify an issue pertaining to nursing homes that should be addressed by the reform process when nursing homes have been totally left out in the cold."

Growth: "Specialized care. That's where the biggest growth is going to be. The nursing homes that can move away from the image of the custodial home for little old ladies with blue hair are the ones that will survive and be successful. Health care reform is going to change the relationship between nursing homes and providers of care. Managed health care executives and HMOs are going to enter into agreements with nursing homes, but only on their terms. They're going to be asking nursing homes if they can take the high acuity patient out of the hospital and put him or her in a bed. And they're going to be looking for nursing homes that provide the specialized services these patients need at a price that fits under new rules and guidelines."

Challenge: "The biggest challenge will be to finally understand how generalized marketing strategies will have to be radically altered to attract and keep specialized patients and very demanding customers--the HMOs, Alliances, and managed care executives. In the '70s nursing homes confused marketing with PR. The '80s forced them to understand the difference and to develop market strategies. Now in the '90s they will have to understand that they can't use those same market strategies to sell specialized care services. The customers and the product will be different from the past and they require different strategies. Selling is different from marketing just like marketing is different from PR. Nursing homes are going to have to sell themselves, and they are then going to have to be able to deliver the new services they have sold at a price that keeps the new customers and pays the bills." Donald N. Muse -- President, the Policy Research Group.

Health Care Reform Legislation: "There needs to be adequate reimbursement for nursing homes in any health care reform legislation. The American Health Care Association's Quality of Life proposal provides for this, but the Clinton proposal is silent about it."

Growth: "Sub-acute care -- getting high-care patients out of hospitals and into nursing homes -- is absolutely the wave of the future. Hospitals are going to be under price pressure to move people out. The danger for nursing homes is that hospitals will set up their own sub-acute care facilities. Nursing homes will have to beat the price of the hospital-run sub-acute care units." Challenge: "Nursing homes are going to have to meet competition at both ends of their spectrum. Hospitals will be setting up sub-acute care facilities and competing at that end, while home health care attacks the low end. Meeting that dual competition is going to be the challenge."

Richard L. Thorpe -- Executive Vice President of the American College of Health Care Administrators.

Health Care Reform Legislation: "The first thing we need to do is do away with any notion of reducing Medicaid and Medicare funding. If those funds are seriously reduced it will go right to the heart of what nursing homes are involved in, and it will be counter-productive. Funding is still the issue. It always has been and continues to be so."

Growth: "Growth is going to come from the opposite ends of the spectrum. First will be the extension into sub-acute care. Many nursing homes are already into it, but haven't realized it. They are offering higher than ever levels of care to higher than ever acuity level patients, but are not being reimbursed in a way that reflects it. At the other end of the scale is assisted living. Nursing homes need to expand the services they offer outside the walls of their buildings."

Challenge: "The challenge is going to be to appropriately structure the role of the nursing home to provide economical, high-quality long-term care that will span from the acute care environment all the way to assisted living. As the market continues to stratify and as the resident's independence, autonomy, and perspective become more and more important, the nursing home of today will have to project itself into the year 2000. The whole idea of autonomy and individual, home-based, non-institutional solutions to problems is going to continue to grow politically more attractive. Nursing homes are going to have to meet these reasonable consumer demands, but this will be more expensive. Forget all the noise being made over government-motivated health care reform -- the real driving force is the consumer."

Joan Warden -- Founding Executive Director of the National Association of Directors of Nursing Administration/Long Term Care (NADONA/LTC).

Health Care Reform Legislation: "While proposed health care reform addresses the needs of expectant mothers, children, citizens who cannot afford medical care, community health, and home health for the elderly, the issues of the institutionalized elderly and the chronically ill in the nation's nursing facilities have not been addressed. True, the acuity level of 'patients' in our nursing facilities has risen sharply and will continue to rise as sicker and sicker 'patients' are received from the hospital setting. And with this rise in acuity, nursing facilities are hard pressed to provide quality care for those patients. But the health care reform legislation must provide for the acquisition and training of staff to care for the institutionalized elderly and chronically ill of this nation."

Growth: "The nursing home of tomorrow -- and that tomorrow has already begun -- will be a place for the more acutely ill patient. Specialization will become more apparent. Facilities specializing in head injury, pediatrics, Alzheimers, re-hab, AIDS, etc. will become the norm, as opposed to a mixture of chronically ill patients. Multi-level facilities should continue well into the future. I would anticipate that with this 'specialization' will come increased interest from medical professionals, nursing professionals, and other disciplines regarding long term care. Naturally, this will be welcomed." Challenge: "From the nursing administration standpoint, a big challenge that we will be lacing almost immediately is the challenge of orienting a 'new breed of nurses' into long-term care facilities. With the down-sizing of hospitals, resulting in graduate nurses being unable to find jobs in hospitals and therefore returning to the market, directors of nursing must be prepared to properly orient these health care professionals. There will be a need for orientation of student nurses, acute-care nurses and other nurses returning to the market to the requirements of long-term care. And each level will need a specific type of orientation."