He said, she said: Exucutive roundtable; Four providers and a federal administrator weigh in on topics ranging from home-based services to reimbursement and staffing. (Cover Story).

As CLTC editors listened to presidents and CEOs of companies whose services range from skilled nursing and assisted living to various degrees of home care, we formed a strong impression that the services available within the next decade will not be "your grandfather's long term care." As seniors begin to take more control of their lives and the decisions involving their care, the continuum is expanding to include a more varied menu of home-and community-based services. But as one executive told us, home care is not every provider's area of expertise. For the foreseeable future, his company will play to its strength--traditional, facility-based skilled nursing. We hope you will find our roundtable, which includes comments from CMS Administrator Thomas A. Scully, an enlightening snapshot of the industry as framed by the executives who took the time to speak with us.

Len Fishman

President and CEO, Hebrew Rehabilitation Center for Aged (HRCA)

Boston, Mass.

Len Fishman became president and CEO of the Hebrew Rehabilitation Center for Aged in November 2000, following his tenure as president of the American Association of Homes and Services for the Aging (AAHSA). Prior to the AAHSA presidency, he served as Commissioner of Health and Senior Services for New Jersey, where he expanded assisted living and community-based services for the elderly and disabled. Fishman says that his background as public servant and association president helped prepare him for the challenges of running HRCA, which in addition to encompassing the entire continuum of long term care, houses the nation's largest geriatric research, teaching, and training programs.

What has been your greatest challenge since joining HRCA?

Fishman: One of the things that you can't be prepared for until you're actually in the Situation is running an organization that relies very heavily on frontline caregivers who are not given the pay or the respect that they deserve. The lack of equity and social justice really smacks you in the face. It is also challenging to come into an organization that over the years has been regarded, and rightfully so, as a national leader in providing long term care and to say to the senior staff and the caregivers that the future lies in a more balanced continuum. We are the largest long term care facility in Massachusetts. We have 725 beds, and our census runs at nearly 100 percent. But I also know that in the future, more and more of the services we offer will be delivered in the home and in the community.

What role will home- and community-based services play within the next 5 to 10 years?

Fishman: I think that portion of the continuum is going to continue to grow. We have adult day programs at two locations. We have a CCRC that is home to about 400 seniors, and we also have two HUD-subsidized housing facilities and are in the process of purchasing 500-plus units of additional senior housing. That reflects my view--and the board's view--that in the future, supportive housing is going to be a very important platform for delivering care to frail seniors. Our future lies in more housing, more services that can be delivered to seniors in their own homes.

We're dealing now with the first generation in history that has really foreseen its longevity. When my parents retired, they figured that they were going to live maybe for another 5, maybe 10 years. Twenty years later, they were still going strong. They had no idea they were going to live that long. We're now dealing with the generation that knows it's going to be living--or has good shot at living--into its 80s and 90s. And they're beginning to act accordingly, which is why I think you're seeing CCRCs and independent housing with supportive services doing extremely well. People want to know that long term care is being offered when it's appropriate--not that they're being shoehorned into that level of care because it's all that's available.

Lawrence G. Santilli

President, Athena Health Care Systems

Watertown, Coun.

Lawrence G. Santilli, a co-founder of Athena Health Care Systems, became president of the Connecticut-based company in 1990. As president of the Connecticut Association of Health Care Facilities, which represents both for-profit and not-for-profit health care facilities, Santilli has also been active as a lobbyist in Connecticut Athena, with some 4,000 employees, is Connecticut's largest health care employer and operates 24 nursing homes and nine assisted living facilities in New England.

How have you seen Athena Health Care change since its beginnings in 1983?

Santilli: We actually started out with just the ability to manage facilities. We didn't have the capital among the four of us to actually own our own facilities. So we started out with probably five or six homes between 1983 and 1990 and we've grown from there to 24 skilled nursing facilities and nine assisted living.

Do you have plans to expand your assisted living operations?

Santilli: Very minimally in that area, because in Connecticut there's a lot of competition on that end and it's all private [pay]. It isn't funded by Medicaid, so the working-capital needs are pretty exorbitant. But we are planning on expanding the nursing-home side.

Does your company have any plans to expand into home care?

Santilli: No, not at this time. First of all, it's not our area of expertise. Secondly, most of the home care is done by the non-profits in our state.

How has the shortage of health care workers affected your company?

Santilli: For the nursing-home side it's been pretty drastic in certain parts of the state. In the southeastern part of Connecticut, where we have the casinos, it's very hard to get nurses' aides and licensed nurses. The shortage of licensed staff is a major issue throughout the state. We've made attempts at getting nurses from out of the state and out of the country but it's been very difficult.

According to a survey that we published in the May 2001 issue of CLTC, the occupancy rate for Athena nursing homes was 98 percent. What factors have contributed to this high occupancy rate?

Santilli: Excellent staff and excellent physical plants. Our facilities average about 8 or 9 years old, and the quality is excellent. We're here for the long term, so we do everything we can to make sure quality comes first and that the bottom line will fall into place after that.

What is the greatest obstacle that your company has encountered in terms of providing high-quality care?

Santilli: It's the staffing issue on the licensed side. On the nurses'-aide side, it's starting to get a little better because the unemployment rate is starting to spike up a little bit. Right now we're using a nursing pool, and they're not part of our team. That sometimes causes problems on the quality side because they're not answering to us.

What have you been able to accomplish in your role as a lobbyist in Connecticut?

Santilli: It's been an education process for the representatives and the senators. There's a lack of knowledge of our reimbursement system--it's very complicated. I've spent most of my time educating them on that, so that they know where the Medicaid funds are going as compared with guessing why an increase would be needed. Once they know that it's going to the residents and to the quality, it's not a major issue anymore.

How has your company managed to avoid the financial pitfalls that many providers have experienced?

Santilli: We never relied on Medicare as much as the public companies did. We relied more on our quality and routine costs. We didn't go into the ancillary side at all, so we weren't affected as much by that.

Jerry and Kristine Clum

President/CEO and vice president, Comfort Keepers

Springfield, Ohio.

Working as a nurse for Mercy Home Care in Springfield, Ohio, Kristina Clum saw, firsthand, seniors' need for non-medical home care. "I was providing their medical care, but as a nurse, looked at the whole patient. A lot of times people needed to be taken out of their homes and moved to an assisted living or nursing facility because their ADL needs just weren't being met," she explains. In March 1998, Clum and her husband, Jerry, created comfort Keepers--a company that provides non-medical home care--as a home-based business with three caregivers. A year later, they opened a second office in Dayton, Ohio, and in August 1999 they started franchising. Today, Comfort Keepers has 205 offices throughout the United States. Its services range from assistance with meat preparation and light household chores to companionship and help getting to therapy, doctors' appointments, or the grocery store.

What would you say are the most important factors contributing to Comfort Keepers' fast growth?

Clum: Essentially, there are a lot of variables. A lot of things have changed. One is the demographics of the marketplace. In 1974, there were a lot more one-income families than two-income families. A second factor is we live in a mobile society. Twenty-five years ago we just didn't live as far apart from our immediate family members as we do today. Third, our neighborhoods have changed dramatically. We have DVD, satellites, and the Internet to keep us in the house, we don't have the outside support structure we once had.

Then you top off these things with the dramatic increases in medical technology. In the 1900s, the average life expectancy was 47 years. Now, we're pushing 80. The number of people who need our services has changed. People are not going to facilities because they have skilled-medical needs, they're going because they can't get their groceries, get to the doctor's, prepare meals, or do household chores.

In what capacity does Comfort Keepers work with facility-based providers?

Clum: There are situations where, when we go out to meet people, they may be very eager to have care come into their homes. Unfortunately, some of them are at a point where our services are not going to be able to meet those needs. We refer them to facilities in the area with which we have a referral relationship. We work with many nursing homes and assisted living facilities, as well as social workers at the hospitals, case managers, and physicians. If we feel there are other options available that are more appropriate to a client's situation than our services, we don't feel pressed into those directions.

Do you think the U.S. General Accounting Office's recent report on nursing home abuse will make people more likely to seek home care?

Clum: I think it may not be just that report. Changes in the Medicare/Medicaid system have created many challenges for facilities in terms of dollars and cents. One of the things that nursing homes have had to do in response to the changes in the Medicare/Medicaid system is to reduce staffing and have a higher patient-caregiver ratio.

The current buzz in the media is that you see a lot of negatives when it comes to long term care facilities. They don't highlight very many of the positives. Many people are predisposed not to be very positive when it comes to the long term care industry, and everything that is happening in the media today is not helping that attitude. Certainly, to remain in the privacy and comfort of their own home at a fraction of the cost would be the preference for many people.

BY JOYCE PAGAN

Thomas A. Scully

Administrator, Centers for Medicare and Medicaid Services 

Baltimore, Md.

Thomas A. Scully was sworn in as Administrator of the Centers for Medicare and Medicaid Services (CMS) in May 2001. Prior to this position, be was president and CEO of the Federation of American Hospitals, the trade association representing the nation's 1,700 privately owned and managed community hospitals and health systems. As CMS administrator, Scully serves as CEO of the largest health-insurance organization in the world. According to the Department of Health and Human Services, CMS is responsible for $1 out of every $3 spent on health care in the United States and has more than 70 million beneficiaries. Scully took time to speak with CLTC during the Emerging Technologies in Health Care Conference held Nov. 16, 2001, in New York City.

Many providers are saying that home health care is a major growth area in long term care. What is the future of Medicare and Medicaid reimbursement for that option?

Scully: I think reasonable home health is wonderful. In 1992, home health spending was $3 billion a year. By 1997, it was $18 billion a year--that was not reasonable. It's now back down to $10 billion a year. There was an unjustifiable explosion of home health due to some not particularly well-thought-through reimbursement policies, in my opinion, in the mid-90s. We're back with PPS for home health, on a more rational basis with Medicare, working with the states to ensure that we resolve some problems. I think that most seniors, given the choice of being at home or in a nursing home, would pick home. So there's no question that home-based care is growing--it should be. But you've got to do it in a way where you don't create reverse incentives. I'm a huge fan of PACE, which I think is a great program for elderly people. I'm a big fan of Evercare, which is also home-based. It's not that we don't like nursing homes, I just think seniors want to stay at home as long as they can. We have an explosion of people com ing our way in the senior population, so there's not going to be a problem filling up nursing homes in the next 10 or 15 years.

Should there be closer government scrutiny and regulation of assisted living, just as there is with nursing homes?

Scully: It's a totally different setting, and it's going to be a difficult issue as the years go on because the assisted living business exploded. And the perception, arguably, is that it's overbuilt and under-financed. It is hoped that will go back into a much more rational growth rate as well. But the problem is that the assisted living industry built up very specifically not to take public dollars. It's almost all private pay. So the regulatory issues are really state regulatory issues--not federal. I think it's unlikely that we're going to go diving into the assisted living area anytime soon. As the states start to draft assisted living regulation and they ask for our help, we'll certainly consider it. But they are private pay, so I think we have a totally different obligation than when we're paying with Medicare and Medicaid dollars.

BY SUZANNE BILYEU