Long-term care 2002: what next? A Nursing Homes/long term care management panel discussion.

While 2002 hasn't exactly been a banner year for the long-term care field, there have been hints of better times ahead. A very busy Congress has found time to focus on key issues of interest, including reimbursement and staffing, and controversial--and often painful--issue of nursing home quality assurance has received a second look from federal officials attempting to improve the process. So what should insiders make of all this? Recently Cleveland, Ohio-based long-term care attorney Alan E. Schabes convened a teleconference of some of the top players in long-term care policymaking-and a representative owner-operator who, like most readers, is on the receiving end. Here's how they view the field, this year and beyond.

Schabes: What are the most significant operational and regulatory challenges in the short term (six months) and long term (one to three years)?

Weiss: For the short term on the operational side, staffing. How to use staff well and empower them so that everyone is on the decision-making team. For the long term, how to use technology to extend the facility's clinical capacities. Specifically on the regulatory side, how to operate above the floor set by regulations and to use quality benchmarks that consumers can understand and use. Unfortunately, we don't have the tools for that right now.

Abraham: I concur that staffing is the short-term challenge, and that's across the board: nursing assistants and other ancillary staff, as well as professional personnel, with use of background checks in recruitment and then effective retention. On the regulatory side, yes, staying above the bar is important--but the bar shouldn't move! We need a more consistent enforcement of the regulations; federal officials recognize this, but the message doesn't seem to be getting across to the states. In Ohio, for example, we have an adversarial and punitive survey process, which leads to a negative mindset, and the facility has to fight just to get back to a level playing field. CMS (the Centers for Medicare and Medicaid Services) has a bully pulpit for this, but they just don't use it.

Hogan: On the operational side, I'm in awe of the demographics. Everything indicates that the demand for staffing is going to go way up, but I see nothing coming in on the supply side. So I would say the short-term challenge is retention--keeping turnover down and empowering staff, as Suzanne said. The long-term challenge will be recruitment; we're going to have a lot more jobs than people to fill them under the current situation. As for the regulatory challenge, I've been around and around the political battlefield with Sen. Charles Grassley (R-Iowa), CMS and state surveyors, and I'm convinced that we providers have to learn to be advocates for the resident louder and better than anyone else. Once we stop making it politically popular to beat up on nursing homes, that's when governments and regulators will get serious about focusing on improving quality rather than punishing people.

Bortz: I'm not sure everyone will like to hear this, but the key--above everything else--is perception. When it comes to regulatory issues, families, communities, reimbursement, etc., everything ties back to perception. Are we or are we not important--and I'm referring not only to long-term care, but healthcare. The perception so far has been controlled negatively by politicians and by the media. We have 1,100 employees in our homes, and the people who work with us are proud of where they work. Yet they go out into an environment where people will say, "How could you work there?" And that's a problem.

It will be a problem until the real story is told and people's expectations are addressed honestly. If a 90-year-old person in poor condition comes into your facility and she expires after four or five months, does that mean the facility did a bad job? Not if the facility kept her comfortable and provided good service, and the person passed away surrounded by family--that is not a negative outcome.

Following the lead of Dr. (Chip) Roadman (president and CEO of the American Health Care Association), I've made a point of bringing local political and community representatives into our facilities. Without exception, their perceptions were changed.

Schabes: Getting back specifically to the issue of staffing, what have any of you seen as effective ways of dealing with the shortage at least over the short term?

Bortz: A lot of people point to loosening the criteria for immigration as a solution. I hate to beat a dead horse, but people in this country just don't want to become nurses. Getting back to perception, they just don't see healthcare as being a good choice. As long as that's true, immigration boils down to being the only answer.

Hogan: I tend to agree. I spend a huge amount of time on immigration issues in Washington. I think, though, that's more a short-term avenue than a real solution. We really need a cultural change in this country that shows America that these people are true heroes, on the side of the angels. I've had several conversations with officials at HHS whose job is to get people off welfare--and that's their full-time job. Meanwhile, we have hundreds of thousands of positions open where we can train people, put them on a career ladder and get them off welfare. Our priority should be to find people at home and train them. Then we have to emphasize retention.

Schabes: As far as immigration goes, do you think that the current antiterrorist environment will pose a problem with this?

Hogan: Yes, but it is not unsolvable. We do recognize, however, that to have true homeland security, you have to know who is in your homeland.

Weiss: I agree with Mike that immigration has some limited possibility as a near-term solution to nursing home staffing. We're also working with the State Department on helping some refugees fit into the picture. One must have some concern, though, about bringing in healthcare workers from other countries and leaving those countries short.

Let's focus again on recruitment and retention, which are two separate but related problems. The best recruitment tool is word of mouth. As for retention, Mike is right; we need a culture change, and part of that is training, giving people sufficient enough skills that they feel good about what they do. There must be career ladders, because these jobs should never be seen as dead ends. We need empowerment--for example, some facilities allow the staff to schedule its own time and have found that both turnover and callins are reduced.

People have to feel that their time is well spent. Technology can help--for example, the use of handheld computers allows staff to prepare more accurate and complete charts. Staffing at all levels needs attention in this regard.

Abraham: Some major relief would be provided using single-task workers. We should also encourage specialized training for CNAs, medical technicians and so forth, to allow for more effective use of available staff. Then we should go the. next step and promote teamwork among all these workers. In nursing homes, we deal not only with healthcare, but with a variety of social and economic factors, all with the goal of enabling the resident or patient to go home. That all-encompassing approach is what makes us successful, not just filling slots to meet arbitrary staff ratios.

Schabes: Do you think we'll see federally mandated staff ratios in the not-too-distant future?

Hogan: I think that's highly unlikely, largely because of the current budgetary environment. AHCA supports optimal staffing standards if they are fully funded. If nursing homes can pay wages on par with hospitals, that will enable us to better recruit and retain staff. But the price tag for that is high--more than $15 billion a year. I can assure you that no one in government places that high a priority on this in today's budgetary environment.

Weiss: I agree that full funding is the issue. But there's another dimension to this. I hope that minimum levels won't be seen as an answer. The recent report from CMS made it very clear that we don't know enough about nursing home staffing patterns and how they relate to care. We need to pay attention to the new staffing models out there--the Wellsprings, the Pioneers, the Eden Alternative and more--and understand what they're telling us.

Abraham: I agree, we don't have enough of this sort of information yet. I worry, though, that in dealing with a regulatory or union-oriented political environment, staffing standards will be imposed without having been tested regarding their impact on quality of care.

Bortz: Whenever I hear the word "quality" in these discussions, I just cringe. Delivering good care is what we are paid to do. The trouble with defining "quality" is that there are so many variables involved. Ohio pays around $150 a day, while Kentucky pays $120, yet the quality in all our homes in both states is about the same. I would rather focus on patient satisfaction. Fortunately, we are more than 50% private-pay, so our families dictate the quality they expect, and we try to abide them. Many providers, though, feel overwhelmed simply trying to keep up with charting issues that have no impact on quality of patient care at all. How many people quit our field out of total frustration because of this? As a provider, you can be cited for issues involving one patient, and for that your reputation can be totally destroyed.

Weiss: I agree, that's an accurate portrayal. At AAHSA, we frequently get calls from members saying, "My surveyors just left, and so did my DON." There is widespread frustration that people just aren't being recognized for the good that they do.

This is one excellent reason staffing ratios are inappropriate. As of now, we haven't explored best-management practices. You can have two nursing homes in the same area, with the same staffing resources and reimbursement, and one is doing a good job and the other isn't. We have to understand better why this is.

Schabes: That is a good segue to my next question: It seems as though the long-term care industry has done little to improve its image for the general public, and as a result regulations seem to be almost exclusively punitive. I think we all agree here on the need to change the public's perception of nursing homes. So what do we do, internally and externally, to achieve this?

Hogan: It's really all about attitude. I sort of take offense, though, at the comment that we haven't done much to improve our image.

Schabes: Just trying to evoke a response....

Hogan: I know, but we and AAHSA have worked hard at this, and your question indicates that we have a lot more work to do. I think we're going in the right direction; in fact, AHCA right now is promoting TV spots featuring Olympic gold medallist Jimmy Shea calling long-term care nurses "heroes," and so on. But I think it'll be a gradual process. Since the Grassley hearings and the Clinton administration's nursing home initiative, I think we've managed to show that, for example, malnutrition does not necessarily mean poor care, and that providers are dealing with a lot of co-morbidities in these elderly residents. These providers don't need punishment; they need help. We're saying this on Capitol Hill every day, and it should be expressed at the local level, as well.

Weiss: I know that our members are sick to death of having others tell their story and not telling it well. Among our members--and I'm sure among AHCA's, as well--we have residents and families with good stories to tell, and we are determined to have these stories told.

Bortz: I love what you're saying. I know I've been inspired by Dr. Roadman on the perception issue. But I don't think providers are making the same broad-based efforts on this that the associations are. Facilities have to spend the money to advertise, for one thing. We also have to keep asking, why must we have an antagonistic relationship with government; why not a partnership? All of us--providers and government--have the same goal: patient and family satisfaction. But until government joins forces with providers, it's not going to happen.

Abraham: Apart from my position at NASPAC, I'm also an operator. We have had a family business in skilled care for more than 30 years. I see how the people representing us in Washington have to walk a fine line. Sen. John Breaux (D-La.) is one of the sharpest people out there and has been very encouraging, but Suzanne is right--we need to get the good stories out there to the powers-that-be. If we turn our backs for a second, we could go down the Grassley road. Providers simply have to step up to the plate.

Bortz: I think the associations have done an awesome job of moving us in the right direction.

Abraham: I agree. But we need to involve our providers more in coming to the Hill and sharing their stories.

Like Barry said, "quality" is a scary thing to hang your hat on, because it's a moving target. You need to look at the end result: patient satisfaction that is measured quantitatively.

Schabes: With all the talk about the Medicare cliff--automatic cuts of more than $1 billion for postacute care--what kind of situation are we looking at in nursing homes this fall?

Weiss: So far there has been a lack of appreciation on the Hill that this is serious and real. I don't think facilities will cope without that money--residents won't be able to receive proper care and, for that reason, won't be admitted in the first place. And, of course, it is hypocritical to talk about minimum staff ratios while you're cutting funding.

Bortz: I just got our corporate report for 2001. Three of our six facilities lost money on Medicare last year--and these are the three newest, most up-to-date facilities we have, offering many of the amenities, such as homelike surroundings and spacious rooms, that people are asking for. It's just that the capital costs for this type of facility are high. Older facilities might survive the Medicare cuts, but they're not doing that much Medicare business to begin with.

Hogan: My job in Washington is to put this issue in the starkest terms. After the last cuts, we saw more than 1,500 facilities declaring bankruptcy. While it's true that most of these were in corporate chains filing Chapter 11, you don't get two shots at Chapter 11. Meanwhile, a lot of the "mom and pops" refinanced and restructured their debt, but you don't get a second shot at that, either. With the next cuts, we'll see Chapter 7s and closures. AHCA has commissioned independent studies showing that facilities currently are barely making ends meet; with the Medicare cuts, and with chronically low Medicaid on top of that, more would be unable to provide care. Under conditions like that, patient access and quality would be threatened in the nursing homes of America. Politically, especially in an election year, I can't imagine that happening.

Abraham: I agree that without something being done, a lot of the "moms and pops" aren't going to survive this time; it won't be just the chains. I'm optimistic that this won't happen--but I'm scared, anyway.

Moderator: Alan E. Schabes, Esq.

Benesch, Friedlander, Coplan & Aronoff, LLP 

Joseph Abraham

Legislative Director, National Association of Subacute/Post Acute Care

Barry Bortz

President and CEO, Carespring Health Care, Cincinnati, Ohio 

Michael Hogan 

Director of Legislative Affairs, American Health Care Association

Suzanne Weiss

Senior Vice-President for Advocacy, American Association of Homes and Services for the Aging