Training the greatest performers on earth.

Long-term care facilities and circuses have much in common. This analogy is certain to raise some eyebrows, but consider the similarities. The ringmaster of a circus oversees separate rings, each with its own actions and activities, just as an administrator monitors nursing, financing, physical plant and other departments in the organization. Like circuses, long-term care facilities attempt to keep all the people--in this case, residents, families, staff, financial resources and the government--happy. But, while a ringmaster usually has performers to help run his show, long-term care administrators are not always so lucky.

Indeed, administrators themselves must be multiskilled performers. Walking the tightrope of regulatory compliance, they must also jump through hoops of customer satisfaction, staffing issues, ethical concerns and negligence lawsuits; dodge the finicky actions of elephants (Republicans) and donkeys (Democrats); and juggle their home and work lives, all the while continuing to chase after up-to-date knowledge.

Thankfully, under the long-term care Big Top, there is help to be found: Several organizations are prepared to help wearied managers gain some measure of control of the acrobatics of administration.

The Assisted Living Federation of America (ALFA) is one such group. "Because assisted living is a new industry," explains Barbara Shoemaker, director of marketing for ALFA University, "many people have not had the benefit of training specific to assisted living. Having the opportunity to take courses developed specifically for assisted living helps explain the 'philosophy behind the practice,' giving administrators a perspective that is very, very helpful." To that end, ALFA University offers many courses for administrators to advance their skills, including a 47-hour "Management Library," a self-study, self-paced course with an open-book exam that, if passed, leads to voluntary ALFA certification in assisted living administration.

The American College of Health Care Administrators (ACHCA) also offers certification for administrators of assisted living homes, as well as for nursing home and subacute facilities. ACHCA even collaborates with ALFA to offer the Assisted Living Boot Camp. "It's like a 101 college course that takes participants through at least a 201-type level of understanding of the assisted living industry," explains Mary Paspalas, ACHCA chair-elect.

Colleges and universities have developed programs that specifically deal with long-term care management. The Wertlieb Educational Institute for Long Term Care Management at The George Washington University has a graduate-level certificate in long-term care administration (Table 1 ),a master's degree in health services administration and various continuing education programs. Other options include an MBA focusing on health services administration, a doctorate of public health and for those with less far-reaching educational plans, three-week intensive courses focusing on specialized topics, such as law and policy and long-term care. According to Nancy Alfred Persily, MPH, director of the Wertlieb Institute and associate dean for Undergraduate and Continuing Education at The George Washington University School of Public Health and Health Services, an undergraduate program focusing on long-term care administration was in development at press time.

Saint Joseph's College of Maine also has a long-term care administration program through its Long-Term Care Management Institute, offering a certificate (Table 2) and bachelor's degree in long-term care administration, in addition to a master's in health services administration. All three can be earned by taking courses online, but a two-week on-campus session is required to earn the degrees. According to Institute Director John Pratt, American nationals living in places such as Saudi Arabia, Guam and Saipan (part of the U.S. Commonwealth of the Northern Mariana Islands) have taken the Institute's online classes; some anticipate returning to the United States to pursue careers in healthcare or long-term care administration.

(The latest academic entry in the field, Johns Hopkins University, is starting its new "Seniors Housing & Care Program" this month; see "NIC on Financing," p. 40.)

Other organizations use the Internet for training, as well. ALFA University anticipates having several courses online by April 1. Paspalas says AGHCA currently does not have courses online, but its Web site offers information on its sessions. The ACHCA site also has a Peer-to-Peer section that allows administrators to communicate with each other, and AGHGA is considering ways for administrators to earn continuing education units (CEUs) online. (Many are eligible to earn CEUs by reading Nursing Homes/Long Term Care Management and taking the test at the back of each issue.)

The Wertlieb Institute, according to Persily, plans to have selected gerontology and long-term care management courses online this summer; students eventually will be able to take most- if not all-courses for the graduate certificate online.

All of these programs share a common purpose: to develop effective leaders for the long-term care field, providing formal instruction in matters that previous generations of administrators had to acquire on the job. And they know the characteristics of a good administrator when they see one.

Persily emphasizes that administrators should have their fingers on the pulse of their organizations and get to know their facilities-not be isolated in the office. Her colleague, Wertlieb Institute Assistant Director Susanne Matthiesen, adds, "People who embody the characteristics that we see as being ideal for an administrator are those who really reach out to a variety of organizations in long-term care," by being involved with accreditation boards, state associations, mentoring programs, etc.

Pratt believes good leaders will recognize areas where they need help and take the time for training: "One of my big gripes with a lot of administrators is when it comes around toward the end of the year and they suddenly need another four or five CEUs to meet their licensure, they'll just go out and get any of them, not in some area where they could improve."

Shoemaker notes the need for strong communication skills among assisted living administrators: "The assisted living administrator has to communicate effectively with staff, residents and families. Assisted living generally has a lower staffing ratio than other long-term care environments, so the administrator ends up with the role of chief communicator. Families are often absorbing the costs of assisted living care and expect a high degree of input. Residents also tend to be more active and involved in communicating their wishes. Juggling all the expectations of staff, residents and family members makes good communication skills essential."

With so many responsibilities and, particularly in the nursing home arena, fiscal restraints and regulatory demands, some wonder why anyone would choose to become a long-term care administrator. John Pratt understands. He sits on the Education Committee and Board of Governors of the National Association of Boards of Examiners of Long Term Care Administrators (NAB), and notes that NAB has been so concerned about the drop in people taking the licensure exam that NAB has formed a marketing task force. However, while acknowledging that it has been increasingly difficult to convince people of the rewards of being an administrator, ACHCA's Paspalas emphasizes that "increasingly difficult doesn't mean impossible."

The situation is not totally bleak. "Even though there has been a great deal of negative press regarding institutional care of the elderly, GW has done very well," says Wertlieb's Persily. "We've been able to double the number of students in the long-term care administration program." And experienced people already in long-term care are far from being written off. Persily's colleague Susanne Matthiesen emphasizes the importance of looking within the long-term care field to find potential administrator candidates: "We shouldn't just be focusing on bringing new people into the field, we should also be considering how we can build upon the skills, knowledge and experience of people already in the field." ACHCA's Paspalas adds that not all training needs to be formal: "Somebody said to me at our Winter Marketplace meeting, 'You know, we don't always need some paid expert to come in on a topic. Sometimes we just need an opportunity to sit down and talk to each other and share some ideas,' which is training."

By taking the time to further their education and training, and help each other, administrators can prove that they are indeed among the greatest performers on Earth.

Curriculum for the Graduate Certificate in Long Term Care Administration (offered by The George Washington University/The Wertlieb Educational Institute for Long Term Care Management)

* Aging and Disability: Needs and Services (3 credits, online Summer 2001)

* Managing Long Term Care Programs and Facilities (3 credits, online Summer 2001)

* Organization and Management of Health Services (3 credits)

* Health Economics and Finance (3 credits)

* Human Behavior and Human Resource Management (2 credits)

* Wertlieb Institute Topic Courses (four required, 1 credit each)

* Management of Assisted Living, Continuing Care Retirement Communities, & Independent Housing for the Elderly

* Current Issues in Federal Long-Term Care Policy & Law

* Improving End-of-Life Care

* Development, Finance & Operational Issues Affecting Providers: A Comprehensive Look at the Long-Term Care Continuum

* Alzheimer's Disease Care: Organizing Policy, Program & Practice

Curriculum for the Long-Term Care Administration Certificate (offered at the undergraduate level by Saint Joseph's College of Maine/Long-Term Care Management Institute)

Core Courses

All required (3 credits each)

* Introduction to Long-Term Care Administration

* Introduction to Health Care Accounting

* Aging in America

* Long-Term Care Law & Regulations

* Human Resources Management

Capstone Courses

Students select one (3 credits)

* Nursing Home Administration

* Assisted Living Administration

* Home Health Care Administration

From Hospital to Long-Term Care: Warren Slavin

You're out of your mind.

What are you doing?

You're smarter than that!

These are the type of responses that Warren Slavin received when he made a "crazy" jump from hospital to long-term care administration in 1976. "[long-term care administration] was viewed as a second-class career," Slavin explains.

Intrigued by the possibility of helping a Catholic nursing facility build its services, Slavin intended to return to hospital administration after a short stint as a long-term care administrator. But his plans changed because "I found a very rewarding career in long-term care." In fact, he ended up staying at the Catholic home for 13 years. Now he is president and CEO of The Hebrew Home of Greater Washington, a not-for-profit complex that includes 558 nursing home beds, 500 units of independent living, 37 units for assisted living, an outpatient medical clinic and a nonskilled home health service.

He cites interaction with residents as a major reason why he stayed in the field: "I found that I liked being closer to the people that I serve...Being in hospital administration, I never got to know anybody I was serving. Their stay was very short, and my interest was on the service I was providing rather than on the people I was serving."

However, he points out he special challenges that nursing home administrators face: "I think for the typical nursing home administrator, it's in some ways probably a more difficult job than the typical hospital administrator because the nursing home administrator doesn't have the same resources. He might not have a human resources department or purchasing department-he might have to do all that himself. So nursing home administrators face a wider scope of activity, although, the organizations tend to be smaller therefore the financial responsibilities are less."

Having a strong administration background, which includes years of experience and an MBA in healthcare management from The George Washington University, and having been in long-term care for more than 20 years, Slavin emphasizes the need to regularly update one's skills. To that end, Slavin says that every year he exceeds the number of CEUs he needs for relicensure, and he takes advantages of opportunities for further learning, such as recently becoming a certified Eden Alternative associate. Recognizing the importance of lifelong learning, Slavin says, "The value of education, both formal and continuing education, becomes more important in an environment such as the one we have today, which is so rapidly changing."