Monte Levinson, MD, Vice-President of Medical Affairs, Presbyterian Homes.

In commemoration of its 50th anniversary, Nursing Homes/Long Term Care Management has invited several long-term care experts to comment on how the field has evolved during that period. This month, Monte Levinson, MD, vice-president of medical affairs for Presbyterian Homes, speaks from a perspective of 37 years in long-term care, including a stint as president of the American Medical Directors Association (AMDA). Presbyterian Homes is an Evanston, Illinois-based not-for-profit operator of six retirement communities, which include on their campuses independent living, assisted living, adult day care, medical and rehabilitation care, and long-term care facilities. It serves more than 1,600 residents with a staff of more than 600. Dr. Levinson reflects on the more humble beginnings of the field and offers opinions on what has happened since in an interview with Nursing Homes/Long Term Care Management Editor Richard L. Peck.

How did you start in long-term care, and what was it like back then?

Dr. Levinson: I started in 1963 as a private practitioner in general internal medicine with patients in the nursing home; it was simply a part of my practice. Back then the care was primarily custodial. The physician would check to see that everything was progressing in a satisfactory manner, but was not expected to provide active treatment or rehabilitation or a cure. Now the typical nursing home is virtually a hospital for the elderly, providing active rehab, IV therapy, infectious disease treatment and more.

Hasn't the criticism been, though, that physicians haven't taken an active enough interest in these facilities?

Dr. Levinson: That's a very typical comment. Today's society complains that doctors don't do this and don't do that--and yet my doctor is a great guy! This negative perception is fostered by people feathering their own nests as physician-bashers and long-term care-bashers. There has always been an interest by many physicians in caring for the frail elderly.

When did the medical director become a formalized position?

Dr. Levinson: That was in the mid-1970s. Because of the work of some in Congress and the National Citizens' Coalition for Nursing Home Reform (NCCNHR), legislation was adopted requiring that the medical director be a physician. Before that it was thought that nurses and administrators could do the job, but with the progress in medical care for the elderly, it was thought that a physician was needed to provide the appropriate level of service. Today the role of the medical director has been enhanced by the demands of the rules and regulations set by the Health Care Financing Administration (HCFA).

What impact has OBRA '87 had, in your view?

Dr. Levinson: I have always been a fan of the Minimum Data Set (MDS), at least in concept, if not in execution by the federal government. Acquiring the information it calls for is not only worthwhile, it's necessary; you would have chaos without it. I think, though, that the MDS is being used for purposes that weren't intended for it.

For example, I'm not sure that you can correlate it with assessing quality of care or, more recently, with targeted surveys, for the simple reason that it's based on self-reporting. There's always an element of doubt raised by that methodology. Then there's the Prospective Payment System (PPS) tying in the MDS with Resource Utilization Groups (RUGs),which according to a recent report aren't working and may never work. RUGs do not reflect the comorbidity that is so common in the elderly. You don't have the simple cause-and-effect of, say, a broken leg for a young person. With the elderly you can have, for example, coexisting congestive heart failure and chronic obstructive pulmonary disease, and the treatment for one worsens the other. As a physician, you can only attempt to set a balance in these situations, treating neither as well as it could be, but helping the patient to function a little better a little longer. This is impossible to measure adequately with the RUG system.

What about the OBRA survey process?

Dr. Levinson: I think the surveyors should be educational and consultative in their approach, not punitive. Yes, they should hold facilities accountable, but they shouldn't be punitive unless it becomes obvious that, despite consultation, things haven't improved. The fact that someone has broken a hip or takes 12 medications is not necessarily meaningful in itself. I happen to have a respiratory infection right now for which I'm taking sufficient medications to make me a survey outlier. Does that mean I have a bad doctor? Does it mean I'm addicted to drugs? No to both questions--you have to take the context into account.

I can't leave off without saying that I'm a little sick and tired of the self-appointed guardians of the elderly. People are going to die in nursing homes--that's unavoidable, and the issue is, "do you treat them with respect, dignity and good medical care," not "did they lose weight." There's a tendency to focus on individual poor performers, and to condemn everyone for the actions of the few. This is a harmful way to approach long-term care.

Do you think that inadequate reimbursement has had some bearing on creating these negative impressions of long-term care?

Dr. Levinson: Perhaps it's the other way around. It's strange how we're called upon to increase the wages of our lowest-paid employees--which we should do, in order to attract a better class of employee and avoid having the hospitals raid them away from us--and yet at the same time funding is being reduced. I'm not sure how you make that work.

Part of it goes back to impressions created by some in Congress and by self-serving organizations that make a habit of focusing on the worst. You go to a congressional hearing and see photographs of someone's loved one covered with pressure ulcers or lying in feces with a fractured hip, while people who actually work in the field have no credibility. In sum, it's a put-up job and doesn't generate much support for the field.

On a more positive note, you help preside over one of the more noteworthy long-term care campuses in the United States. Some say the campus approach is the wave of the future for long-term care. How have you seen it change over the years?

Dr. Levinson: I think the development of the CCRC philosophy has been very appropriate, i.e., your ability to function determines where you live but, when you need more help, you don't have to be uprooted from your community to receive it. I will concede, though, that my friend Monsignor Charles Fahey has a point when he says, "CCRCs are for the healthy, wealthy and wise." That's why it is very important that you have those services readily available and affordable to residents as they age.

Let's move up the ladder of the continuum--do you think that, as some have envisioned, all those services can be provided in the home?

Dr. Levinson: I think that's a canard. No nation can afford a series of one-bed nursing homes. With today's medical advances, people are living longer, but they are also living longer with considerable frailty. This has a significant impact on families who often, for very good reason, can't bear up under their caregiving responsibilities.

What about assisted living?

Dr. Levinson: This is a niche market that, historically, was created by the negative impressions of nursing homes. "This is not a nursing home!" the assisted living people say. The initial real estate and hospitality developers have done well in bringing nice people into beautiful surroundings. But what happens when the residents age in place, as they inevitably will? Where will they go? How will their needs be met? The facilities will begin to evolve into nursing homes in their own right, and the question becomes, how will management deal with this? As it stands now, assisted living is an artificial creation. The good thing is that nursing home operators have learned about creating more homelike environments that ultimately benefit residents and families.