Toward Person-Centered Care.

Based on an interview with Robyn I. Stone, Doctor of Public Health, Executive Director, Institute for the Future of Aging Services, American Association of Homes and Services for the Aging

Although the percentage and the sheer volume of elders and people with disabilities living in the United States in the 21St century is increasing, their distribution will vary across the country; the Floridization of the country will happen in pockets. Thus, when I think of long-term care, I don't think of a one-size-fits-all recipe. The diversity in terms of demands on the need for services, providers and systems of care is going to vary tremendously. I think that the future of long-term care is, therefore, really in the options offered.

We are not going to be seeing nursing homes going away. They are already serving a fairly high acuity level resident, and I think that trend will continue. Beyond that we will see the need for an array of residential care options, including affordable assisted living for modest and lower income people who are receiving sets of services that meet their needs beyond housing. Much of the assisted living today has been pretty long on housing and short on services. That really needs to change.

I envision a long-term care system that tries more to address the continuum--not necessarily from just a bricks-and-mortar, mergers-and-acquisitions perspective, but more from a needs-based, person-based and family-based perspective. It might be that a lot of the services are going to be provided in the home. Long-term care will really be built around the community.

There are going to be sets of services and providers that are flexible enough to adapt their provisions to the needs of a variety of people and a variety of families. That's a very different model from what we have today. Part of the reason is that we are so driven by reimbursement, which has created "silos of care." I am hopeful that we will begin to really take a hard look at our reimbursement policies for long-term care in the future and try to make them more flexible.

That doesn't, of course, deal with the fundamental issue of how we're going to finance this. While I would like to see a full-scale, mandatory, public long-term care program like they have in Germany, Japan and Austria, I think we will continue to see incremental change and a patchwork of public/private strategies.

I do not believe that long-term care insurance will cover more than a niche market unless we can get a very strong group market going, and that doesn't seem to be happening. There will have to be a combination of private, out-of-pocket and public resources, and providers will have to figure out how to be flexible and creative within that.

I think the argument of nursing homes vs. home-based/community-based care is spurious. We need a combination of all of those things. Three things need to happen--a more cohesive financing strategy, good delivery models and people trained to do the work. The problem is how to get there.

We need health and long-term care professionals and paraprofessionals who are properly trained to meet the needs of a fairly diverse elderly and chronically disabled population. That's everything from geriatric training at the medical, nursing and social work school levels, to much better training and ongoing in-service for the paraprofessional workers--assuming we can find them.

This is not just a crisis now because of the booming economy. Even if the economy were to go a little bit south, we still would have an issue of getting good, interested and committed people to do jobs that are not the most pleasant and that, at least today, have not been very well paid or supported.

Another part of the short-term future involves subsidized housing. There've been some small victories on Capitol Hill in terms of combining housing with services through the Medicaid program. I think we're going to see some experimentation with that over the next two years.

I also think that over the next two years we'll see continued dialogue in Congress about the future financing of long-term care. There seems to have been a significant bipartisan interest in using the tax code to help with financing, which is an incremental change, obviously. Clearly a lot of states are experimenting with different models of long-term care. In fact, states are really where the real action is in long-term care right now.

We've certainly gotten tremendous feedback regarding the future of long-term care from the AASHA membership since I arrived in July. They have been extremely excited about the formation of an institute that is trying to look at the future and not just dealing with the day-to-day or short-term policy crises. We are already working with a consortium of nursing homes in Wisconsin, the Wellspring Alliance, to focus on their model of quality care and the possibility of replicating it. We've also received significant interest from many of our CCRC members, who would like to explore ways of targeting the CCRC to a more modest income population.

In general, there's an interest among the AASHA membership in trying to go back to their roots--their mission-driven orientation, the importance of being part of the community and the fact that they came out of a community. It's what we're all about in terms of trying to develop more person-centered, family-centered care. You can't do that if you're not part of a community.