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"OBRA is beautiful public policy...." (Omnibus Budget Reconciliation Act)(interview with National Citizens' Coalition for Nursing Home Reform executive director Elma Holder)(Interview)

An interview with Elma Holder, Executive Director, National Citizens' Coalition for Nursing Home Reform

To some in the nursing home field, she is a "holy terror" - out to nail them no matter what they do. To others, she is the prickly conscience of long-term care, pushing them toward agonizing reappraisal and improvement of their services to residents. No matter what she is or isn't, Elma Holder is always there, in the forefront of debate whenever nursing home quality care is at issue. Her career monument is OBRA '87 and its progeny, which she continues to spearhead through their evolution and - some would say - their imminent dissolution. Before assuming leadership of the National Citizens' Coalition for Nursing Home Reform in 1978, Holder came up through the consumer activist ranks, serving with Ralph Nader's Retired Professional Action Group and with the National Gray Panthers' Long-Term Care Task Force. Holder says she is not simply a militant who sees nursing home administration as "the enemy" - if you do well by your residents, you're fine with her. This isn't how she and her Coalition's activities are always perceived, though, and if Congressional Republicans live up to their promise of doing away with OBRA, there will be a sizable cheering section within the nursing home industry. Nursing Homes Editor Richard L. Peck asked Holder what she thought about that, and about other issues.

Peck: What are you views of the GOP's proposals to turn OBRA over to the states?

Holder: It would be a tremendous waste of time, energy and resources. It took at least 15 years to develop OBRA, and it involved people from states and localities throughout the nation; it wasn't something that was just done in Washington. And now we have a law on the books that applies to all of us. To ask the states to do the same thing, or attempt to do so, particularly when resources in many states are already stretched to the limit, is simply a waste. And the worst case scenario is that resident protection will decline.

It is clear, especially with Medicaid dollars probably decreasing if block grants are enacted, that the nursing home industry will fight the development or maintenance of state regulation. And, unfortunately, public efforts to counter this probably won't be strong enough, because public organizations don't have the necessary resources.

Peck: Does the Coalition have a game plan, should all this become reality?

Holder: We do. Of course, we will be resisting any change until the last minute. We plan to participate in Congressional hearings and visit individual Congressmen and Senators to inform them about how and why OBRA was created. But if we lose, we will be working with local and state groups and ombudsmen to develop model legislation for the states. And we will continue to work, as we always have, with quality providers, and to try to share their accomplishments with people in the community.

Peck: What sort of feedback have you had thus far on the new survey and enforcement regulations?

Holder: We have two people involved in the HCFA oversight committees that have been set up, and the committees are identifying problems with the system, as was intended. Certainly, as with any new system, improvements are needed. But we are finding that many in the industry still have the fear of even being cited for a deficiency. Facility resistance and questioning of "deficiencies" and their definition are still driving the system.

Peck: Facilities frequently complain that surveyors often focus on "paper deficiencies" that have no real relation to quality of care. Your comments?

Holder: There is obviously a need for continuous training and reorienting of the surveyors and for more effective leadership by state agencies. On the other hand, resident assessment and care planning are key facets of this process, and maintaining good, clear records is essential to this. This is especially true with the staff turnover that many nursing homes experience. The resident assessment is the only tool the resident has for ensuring good care. It's true that some facilities treat it as a paperwork exercise, but in fact it only makes sense as part of the care planning process. You need good records.

Peck: Do you think facilities should have more leeway to explain cited deficiencies and their response to them?

Holder: Of course, their plan of correction is part of the public record. No doubt, where "paper deficiencies" exist, we need a way to identify them - and we can do so, working together with providers. In fact, we are planning to work with the American College of Health Care Administrators on a project to help consumers better understand the survey report and how to use it responsibly.

Contrary to how some portray us, our focus is not on punishment. Certainly providers who refuse to respond to cited deficiencies should be sanctioned, but this is not our focus. Our focus is on improving resident care, and I suggest that this is what everyone's focus should be. A deficiency means that change is needed.

Peck: Many providers contend that the ideal situation would be a free market, as opposed to a regulated one, in which they would have to respond to consumers, rather than to regulations. What would it take to get the nursing home industry to that level?

Holder: There is so much defensiveness in the industry. If nursing home management would be more open and honest about their problems, the public would recognize this and appreciate their attempts to solve them. Also, involving the community directly in the nursing home would be of great benefit. For example, establishing a resident and family council and demonstrating that management actually pays attention to it would be very helpful; that's the kind of information that gets around in a community. Similarly, a community advisory committee, including community members, Area Agency on Aging representatives and others, would improve community knowledge and understanding of nursing homes.

Nursing homes might also offer more recognition and support to the ombudsman program. No owner or administrator can keep tabs on everything that happens in the facility, and the ombudsman can be very helpful along those lines.

Peck: Speaking of which, the ombudsman program is slated for Congressional cuts. What is your view of that program's strengths and weaknesses?

Holder: There's no question that, since 1975 when the program was started, literally thousands of complaints have been worked out, most of them at the facility level and going no further than that. This has been a great service to residents, families and to nursing homes themselves. They have also served as a tremendous educational resource for the community concerning residents' rights and benefits.

One of the weaknesses is that many states have far too little resources to provide a weekly presence of an ombudsman in every facility, which we feel is needed, or even a monthly presence. The more the ombudsman is exposed to a nursing home, the better he or she understands that facility and what it is trying to do, and the better able therefore to sort out the real problems. Some ombudsmen are viewed as advocacy-oriented, and others, service-oriented. There is no question that there are inconsistencies in implementation across the nation. This could be resolved with more support and more generalized understanding of this program, which is still in the development stage.

Peck: Yet another nursing home complaint is that OBRA is only one piece of the miles of government red tape that they must grapple with every day - OSHA, EPA, and the FDA being other regulatory agencies that come to mind. Do you see any sort of relief or streamlining in sight?

Holder: As a general principle that is a good idea. I have never seen a good analysis of this, and that is something that should be done.

Still, though, when I talk to nursing home administrators, very frequently I find that the "over-regulation" they're talking about pertains to state and local regulations, not federal regulations. Fire safety regulations are another problem they cite, but at least these are continually updated, and providers are a part of that process. But I'm sure there are some state regulations that are 25 years old and are potentially outdated, and states need to review these.

Peck: What about some newer areas of elderly care that some say are under-regulated, such as subacute care, assisted living and home health care?

Holder: Subacute care facilities are going to find that they are dealing with some relatively sophisticated consumers, so if they're not prepared to really deliver the service, they had better not get involved with it. With assisted living, a lot of groups, including AARP, are looking at some form of minimal regulation, particularly since more and more of these facilities are taking Alzheimer's patients. No one wants the regulation to be too intense; they understand that this is a different level of care offering more privacy and independence. But there has to be some oversight. As for home health care, it has never been looked at as carefully as it should be. These agencies are drawing from the same labor pool as nursing homes, and if these aides are not properly trained and supervised, the patients in their homes are just as vulnerable to mishap as nursing home residents, if not more so.

Peck: Money is tight and may be getting tighter, and that has to have a direct impact on quality of care. What are your thoughts on that?

Holder: For one thing, I know that we will always have nursing homes as we know them. I think the subacute care and assisted living trends will play themselves out, because the people needing nursing home-level care will always be there and growing in numbers. Whether or not you call the facility in which they're cared for a "nursing home" doesn't matter; the designation may change, but the needs will remain.

My personal feeling is that the public needs to be educated to plan for these eventualities, and to set aside as much of their personal funds as they can to take care of them. I think the move toward standardized long-term care insurance is a good idea for those who can afford it. But for those who have low income or no income, we still need quality care; we can't have a two-tiered system based on ability to pay. That is where we need sufficient general funding. But I would emphasize the need for increased personal responsibility to the extent possible by those who can pay.

In any event, we believe that in any setting in which care for frail elderly is provided, there have to be standards of quality. OBRA is a beautiful piece of public policy for those living in institutions, and that is the kind of standard we will continue to promote for long-term care in general.

Note: Nursing Homes learned at press time that Elma Holder has resigned as NCCNHR executive director, effective December 31, but will continue as a consultant.
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Publication:Nursing Homes
Article Type:Interview
Date:Nov 1, 1995
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