Needed to cope with managed care.

Anyone who has been a nursing home administrator for more than a few years has seen immense changes taking place in our health care system. These changes are ongoing. with no end in sight - and probably the most profound of them is the rise of managed care. Nursing homes have not been caught up in this as rapidly as some other health care sectors, but managed care involvement is increasing, particularly with the growing interest in non-hospital-based subacute care. Thus, for most of us in nursing home administration, learning to be managed care-responsive is only a matter of time.

My time, in fact, arrived not long ago. I am based in one of the most managed care-active localities - San Jose - in one of the most managed care-active states in the nation - California. For the past 2 years, our managed care contract has been one of the mainstays of our 58-bed skilled nursing facility. This has required use of a new set of administrative skills and attributes.

They are quite different from those that were, and remain, paramount for the administrator involved in traditional long-term care. In extended care, residents often become like "family" and are treated as such. The administrator and staff performs a "social service" role in maintaining residents' function and dignity for as long as possible, and works with family and relatives, as well, in attempting to meet their needs. With managed care, the administrator's responsibilities are both broader and more intense.

First and foremost, the administrator in this new environment must be open to change and find satisfaction in coping with it. He or she should recognize the competitive situation in which managed care is placing our facilities, and should enjoy the challenge,. An administrator who finds all this to be unappealing may be in for a difficult future.

Second, the administrator has to put the "customer" first - and have a much broader concept of "customer." As I see it, the customer runs my facility, and I operate it to meet, and possibly exceed, the customer's goals. The "customer," however, is not only the resident and family, but the discharge planners, case managers and utilization review staff associated with HMOs and hospitals.

One must be proactive in meeting their needs. I can't sit back and wait for good results or for complaints to arise; it is my business to actively seek out their opinions and experiences regarding our services and try to react accordingly. Under managed care, we are indeed in a competitive situation with other facilities, and unhappy customers can easily find others to contract with when contract renewal comes up.

We need negotiating skills, now more than ever, so that we can continue to provide quality services at a price reasonable to everyone. To successfully negotiate such an agreement, we need an in-depth understanding of our business, and a clear idea of what we can and cannot do. We need, furthermore, an in-depth understanding of our market and its needs, and the extent to which we can realistically meet them and still stay in business. We need to build sound business relationships with our new partners, such as the HMOs, because these will be critical to our continued growth.

I am fortunate in that the Guardian Foundation, our multi-facility owner, has given me and my fellow administrators local autonomy in negotiating contracts and in developing and marketing our services. Guardian recognizes that nursing homes are local businesses, with marketing and service considerations specific to our localities. For an administrator associated with a chain, recognition of the need for autonomy would seem to be essential.

There are clinical implications, as well. We in the nursing home industry will find ourselves held to stricter standards of clinical performance than perhaps we were in the past. In line with this, we will have to develop an understanding of the "critical pathway" between diagnosis and outcome - i.e., the most effective and cost-efficient course of treatment possible within the resources available. And we will need to document those outcomes effectively - outcomes, by the way, not only at discharge, but for months post-discharge, to show whether our residents/patients are having to return to nursing homes or hospitals for further expensive care, and the reasons why. (These outcome studies will be useful, of course, not only as managed care "report cards," but as internal reviews prompting continuous quality improvement.)

As we become more entrenched in sub-acute care services, we administrators are required to serve as team leaders of various interdisciplinary teams - indeed, more disciplines working together under one roof than ever before. We will have to make sure that they work well together, and this will require new and informed leadership skills.

If I were asked to sum up the new skills and attributes needed by today's nursing home administrator, I would say openness to change and sensitivity to the needs of the customer. Whatever our personal predilections may be, we will have to be more open to others' needs and wishes in accomplishing our basic mission. The administrator who sits in "lonely eminence" will require considerable good fortune to succeed in our health care system as it is evolving.

I wish I could say that there was some quick and formal way - a course or a class - that would readily teach us these skills. My experience has been, however, that formal instruction, while useful, doesn't ensure that one's behavior will change back on the job. Much of this must come in the form of on-the-job training (most definitely, for example, outcomes analysis), and much of it can come from mentor relationships. We should seek out and try to learn from professional colleagues who have already met these challenges and have had some success in coping with them. Our new openness to others might well begin with developing this sort of relationship. From this we can learn to not only survive, but thrive, as today's health care revolution comes to nursing home care.