GUEST PERSPECTIVES.

This month, Ian Cordes, a Florida-based consultant involved with the state's professional associations for nursing homes, assisted living, DONs and medical directors, and a man who literally grew up in the field, reflects on how times have changed during the past 30 years--and (at least in his state) not for the better. Questions were posed by Editor Richard L. Peck.

You've become nationally known as a consultant during the past decade, but how did you get started with the field in the first place?

It was our family business. I remember as a kid back in the 1970s visiting my dad's nursing homes in Montreal, Canada. I remember that the nursing homes were very small; they were essentially private rooms in converted mansions, and those rooms were gorgeous. It looked like assisted living, but it wasn't. These people were very sick and even bedridden, and we provided them with active care.

In 1980, I moved to West Palm Beach, Florida, where I did a little bit of everything in nursing facilities, including administration, bookkeeping, housekeeping supervision, maintenance supervision and so forth. I remember that the first facility I worked in had been converted from a hotel built in the 1920s, and it was a tough building to run. Any building of that age has inherent structural limitations for what you're trying to do as a nursing home provider.

In those days, the early '80s, we called residents "patients." The state mandated in the mid-'80s that we start calling them "residents" to get away from the medical model, but in fact all that changed was the name. They really continued to be patients, in view of the care they needed--even more so in the '90s, as their acuity became greater.

I think that good nursing homes have always provided relatively sophisticated medical care. The chief difference today is that more nursing homes are specializing, whether it be providing vent care, child care, AIDS care or what have you.

What was your response to OBRA '87?

By the time the regulations were issued in 1990, I had become a consultant. So while I didn't have direct, hands-on experience with OBRA, I did make some observations. One was that OBRA required an incredible amount of information gathering, which was both good and bad. Often it was a distraction from the facility's primary mission of taking care of people--it diverted attention, staff and resources toward meeting these intense paperwork compliance requirements. As for quality of care, the recent Institute of Medicine report noted that quality of care appears to have improved during the 10 years the OBRA regulations have been in effect, although it doesn't state that there's a connection between the two.

What are some trends that you've seen developing throughout the 1990s?

Aside from the trend toward clinical specialization that I mentioned, I'd say an important one has been the development of better educated and more qualified administrators and DONs. Various new certifications have come about, including ones from the American College of Health Care Administrators (ACHCA), the Assisted Living Federation of America (ALFA) and the National Association of Directors of Nursing Administration (NADONA). This has provided a tremendous boost to making long-term care a well-informed profession. Another major trend, of course, has been the evolution of facility ownership from mom and pops to big national chains--our company was one of those that sold--but since then, the pendulum is swinging back to more regional forms of ownership as chains have gone bankrupt and/or moved out of the state.

How are these new regional companies faring in Florida's tough environment these days?

Several of them are working very hard trying to decide whether they can stay in business. As the requirements constantly tighten, reimbursement is not keeping pace. And then there's the liability insurance climate. Florida's nursing home law has a huge loophole that encourages attorneys to sue nursing homes ad nauseum. As a result, there are so many insurance companies pulling out of the state that you're lucky to find coverage. And if you do, premiums have increased from 100 to 1,000%. This has nothing to do, by the way, with whether you run a quality nursing home. So now you have the insurance industry pointing at the attorneys, and the attorneys pointing at the insurance industry, and nursing homes pointing at everyone and paying through the nose.

We need tort reform, that moves the industry away from the legal standards of strict liability and toward that of negligence, such as applies to the hospitals. The state legislature is going to give tort reform a try for the third year in a row. And I think that this is the year that, if nothing is done, the consequences will be very severe in terms of financial failure and closed nursing homes. The legislators just might have been waiting for this crisis to happen. In any event, this year's legislative session will tell a lot.

Do you think Florida is a bellwether state in showing the future of long-term care?

I've heard it said that Florida often leads the nation by 5 to 15 years in showing the trends in services for the elderly. I think in the case of the insurance crisis applying to other parts of the country, a lot depends on how individual state laws are written.

There are other areas we can look at, though. For example, the nursing home industry continues to cope with bad press. I'm really getting tired of seeing the folks who work in these facilities being put down in the media, particularly by the attorneys these days.

I think my peers in the nursing home industry need to become more active and more visible; they need to meet with the legislators, network with the community and so forth. This just isn't happening enough, either in Florida or throughout the rest of the country.

Ian Cordes is president of Corecare, West Palm Beach, Florida.