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It is a privilege to recognize those in the industry whose advocacy, attention to detail, innovation, leadership, and understanding serve as an inspiration to others in long term care. This year's five honorees have set new standards in the quality of resident care and lifestyle. We are sure their mark will be an indelible one, and that their impact will continue to be felt for a long time.


He made a list, checked it twice

"I GOT THE BUG TO INVESTIGATE THE PROBLEM of inappropriate drug usage among the elderly back in 1987," recalls Mark H. Beers, MD, executive director of Geriatrics and Clinical Literature and editor-in-chief of The Merck Manual for Merck and Co. Inc., Whitehouse Station, N.J. "While researching the use of psychoactive medications in nursing homes for my fellowship project in geriatrics," he explains, "I immediately became fascinated by how problematic this issue was and by how much a person could do--with the right provisions--to remedy the situation."

Since then, Dr. Beers has conducted a mountain of research on using medications safely in the elderly and developed a nationally recognized tool that has been instrumental in protecting the well being of seniors around the country. "When I first got into this area," he notes, "I discovered there were no good criteria regarding which drugs are considered most harmful to older adults." During his investigation, Dr. Beers brought together a panel of experts who compiled a list of medications that they believed were most troublesome for the elderly, a list that he subsequently transformed into what is known today as the "Beers Criteria."

This highly acclaimed medical checklist considers approximately three dozen classes of medications that pose a risk to seniors and includes suggestions for safer alternatives. These guidelines have been used by numerous researchers for evaluating the status of prescribing to the elderly, according to Dr. Beers. "Merck-Medco Managed Care, the pharmacy benefit manager subsidiary of Merck, also has built this list into the computerized drug utilization review systems it uses for more than 9 million patients over age 65," he adds.

But the usefulness of the "Beers Criteria" didn't end there. A few years ago, HCFA proposed that Dr. Beers' list could be used to help the government monitor appropriate prescribing habits in nursing homes around the country. "Prior to this, HCFA had been evaluating only the use of certain psychoactive drugs," he says. Today this checklist is the heart of a HCFA survey system used nationwide to assess appropriate drug usage in nursing home facilities and to provide key information back to prescribers about safer drug alternatives.

To those who use the "Beers Criteria," and to the elderly protected through its use, Dr. Beers is a Santa Claus of sorts. His tool is a precious gift that has inspired the government, professional societies, and the public at large to work harder to ensure drugs are used appropriately among our senior citizens. In other words, Dr. Beers adds, "my list stimulates people to take the time to check that medicines are not being overused or underused and that the very best ones are selected."

Dr. Beers continues to consult with groups on numerous research projects, including one that highlights relationships between medical conditions in the elderly and the drugs they use. He also is working with outside academics to update the "Beers Criteria" for the third time since its inception. "The success of this list makes me very happy," Dr. Beers admits. "It means a lot of older people out there are getting the benefit of medical therapy while avoiding drug toxicity. Isn't that what it's all about?"


Government guardian of nursing homes

BACK IN 1995, THE DEPARTMENT OF HEALTH and Human Services issued the toughest nursing home regulations in the history of Medicare and Medicaid. While these reforms have led to measurable improvements in the quality of care provided to nursing home residents in this country, the Clinton Administration believed this story could not end there. In July 1998, the Health Care Financing Administration (HCFA) launched the Nursing Home Quality Initiative and the driving force behind this project ... Nancy-Ann DeParle, administrator of HCFA at the time.

"When I came aboard as administrator, the President and I addressed his concern that while nursing home care was better than before, it still wasn't as good as it should be across the board," recalls DeParle. "Fewer residents were being placed in restraints and the use of sedating drugs had diminished, for example, but a significant number of facilities remained noncompliant for long periods of time."

With DeParle behind the wheel, the Nursing Home Quality Initiative was set in motion. Thanks to this multifaceted program, the Administration has worked hard with the states to improve their nursing home inspection systems and to crack down on facilities that repeatedly violate health and safety rules. Furthermore, consumers now have access to comparative information about nursing home quality via survey results published on the Internet. The inspection process also has broadened its focus on prevention of bedsores, malnutrition, and resident abuse.

As part of this initiative, DeParle and coworkers at HCFA conducted a study this past summer revealing "the first definitive data on the strong relationship between quality nursing home care and the quality and level of staffing," she contends. "Additionally, we worked with industry leaders and nursing home representatives to determine how to improve employee training levels and other aspects of their jobs." According to DeParle, this investigation may be the first step toward an official minimum staffing level requirement in nursing homes. She adds, "Now it's up to the Bush Administration to decide if this research, and other elements of our quality initiative, warrant further attention."

DeParle also has been cited for her integral role in extending the life of the Medicare Trust Fund as part of the 1997 Balanced Budget Act (BBA). She was heavily involved in negotiating the final agreement for extension of this fund and responsible for its implementation at HCFA. While DeParle is well aware that many folks in the nursing home industry believe the BBA was a bad thing--as it included reductions in payment to virtually every health care provider in the country--she argues to the contrary. "The new prospective payment system for Medicare was tough medicine ... many nursing homes saw their reimbursements reduced," she admits. "But these changes were absolutely necessary as the Medicare trust fund was scheduled for bankruptcy in 1999. Today it is solvent until about 2030." What's more, DeParle says, Congress and the Administration made some adjustments to the system in 1999 and 2000 to ensure adequate payments to these facilities, especially for staffing.

DeParle's recent departure from HCFA has freed up her time to assume perhaps her most challenging job to date-that of full-time mom for a 22-month-old and a newborn. Will she ever return to government to help further the cause for improved public health? Only time will tell. Nevertheless, she will long be remembered for her steadfast dedication to improving life for members of our graying population.


Transforming the culture of aging to holistic care

THE LIGHT BULB WENT ON IN ROSE MARIE Fagan's head back in 1992 during a nursing home visit for the Long Term Care Ombudsman Program at LIFESPAN, an organization that provides direct advocacy and care services to older adults in the Greater Rochester, N.Y., area.

"I had never been in a nursing home before," Fagan recalls. "I was shocked by what I saw in terms of resident inactivity, apparent depression, and minimal social interaction between residents and caregivers who were working frantically to do the right thing." On that eye-opening day, Fagan decided "there had to be better futures for people who have contributed so much to their communities, their countries, and their families" and that she would do everything in her power to recreate nursing homes as places for living, rather than for decline.

This personal promise sparked a series of Rochester community forums, also fueled by the new OBRA regulations, which brought together providers, regulators, advocates, residents, and family members to talk about fresh approaches to nursing home life. In planning these forums, Fagan discovered other people from around the country also working to recreate nursing homes. Eventually, these visionaries created the Nursing Home Pioneers, a national grass-roots movement to change the culture in these homes.

The first meeting of this group took place in Rochester in March 1997. Fagan received a grant to coordinate this gathering of the four founding Pioneer experts and 30 other forward-looking leaders. She also co-authored the widely disseminated final report of that historic occasion, "conveying the important message that what anchors us all together is a common set of values and principles," she says. "We vowed then and there to keep searching for kindred spirits who knew in their hearts that things could be different for our elders and to form a national movement."

Indeed, this pledge has paid off. In Rochester, August 1999, the first national Nursing Home Pioneers conference, "Frustration to Pride," convened 365 participants from 23 states. The conference focused on transforming nursing homes from a medical to a more holistic care model. "We asked people to envision care that addressed the mind, body, and soul of residents and to recognize the importance of treating people as individuals who could reach their highest practicable level in a homelike setting," Pagan explains.

When the group's focus broadened from nursing homes to the whole continuum of long term care, its name was changed to the Pioneer Network. Its mission: to advocate and facilitate deep system change and transformation in the culture of aging in America.

As current director of LIFESPAN's Nursing Home Culture Change Project and executive director and primary spokesperson for the Pioneer Network, Fagan continues to share her ideas about nursing home culture change with people coast to coast. "It's imperative that we create a meaningful role for older Americans, value their contributions in all living arrangements, ensure their autonomy, and honor their 'personhood' wherever they live for as long as they live," she concludes.


Rocking the boat in the name of quality

NEIL ROBERTS WAS ONCE ASKED, "IF YOU could snap your fingers and make one wish come true that would change the quality of care in nursing homes, what would you wish for?"

His response: "That everyone would volunteer to work in a nursing home two hours a week for 10 weeks in a row. Only then," he contends, "would people begin to value quality care, understand what quality is all about, and recognize that quality is alive and well in many nursing homes around America."

Neil Roberts has worked for Wesley Health Care Center Inc., a skilled continuum of care nursing facility in Saratoga Springs, N.Y., since its inception 28 years ago. From day one, he has become increasingly interested in educating the industry about true quality indicators and the importance of high-quality care in long term facilities. Today, as CEO/administrator of Wesley and chairman of the board of the New York Association of Homes and Services for the Aged (NYAHSA), Roberts takes his message on the road, touting the importance of resident care beyond baseline necessities and the need for better quality measures. "Cleanliness, healthy food, good pain management, proper use of restraints and medications, etc., are essential elements of good care," he notes. Without proper relationships between staff and residents and families, however, genuine quality is in danger."

Much of Roberts' public speaking revolves around his concern over the current HCFA survey process, which he feels not only fails to identify quality but also threatens the very essence of quality by undermining staff morale. "Sure, the process identifies errors," he says, "but with the assumption that the absence of errors indicates residents are receiving quality care." He continues, "Once errors are found, we need to ask the right questions." Roberts believes the current system only penalizes and never rewards. "Yet what I see, by and large, are people of good will trying to do a good job." Negative reinforcement, as a regular diet, is extremely counterproductive, he adds.

While Roberts says he's not being disrespectful of the Government, he believes "HCFA and its surveyors are taking the wrong approach," and through his public speaking hopes, eventually, to get the "powers that be" to consider revamping the system. In the meantime, Roberts told CLTC he will continue rocking the boat--growing knowledge among members of the NYAHSA and promoting best practices through direct advocacy with legislators, training programs, the Internet, and any other tool that proves valuable, he says, "all in cooperation with other caring, innovative people in the industry."

In a nutshell, Roberts says, "HCFA's survey process measures the word 'nursing' but doesn't even scratch the surface of the word 'home,' the part of care that matters most to residents and their families. That's the kind of care we provide at Wesley," he asserts, "and the kind of care that our older or chronically challenged loved ones deserve as they require long term attention."


A spiritual leader for seniors

AS A RABBI AND FOUNDER OF THE SPIRITUAL Eldering Institute in Boulder, Colo., Zalman Schacter-Shalomi has had ample opportunity to share his personal philosophy with others and to help seniors in the community appreciate its important message. "Every life matters immensely," he says. "Every well-lived and completed life helps in healing the world."

A multi-faith organization, the Spiritual Eldering Institute is dedicated to recognizing the spiritual dimensions of aging and conscious living, endorsing the importance of one's "golden years," and helping people harvest their life's wisdom to transform it into a legacy for future generations. Through vehicles such as workshops, conferences, books, and enlightenment from strong role models, elders are taught to savor the positives that accompany their advanced years (e.g., personal mellowing, increased spirituality, intelligence through life's lessons) and to accept negative aspects of aging, such as physical and mental frailty, and rejection or apathy from the community.

The impetus to establish the Institute came to the rabbi as he approached the "autumn years" of his own life. "We live in a youth culture where most people entering the final chapters of their lives are essentially invisible to the rest of the world," he told CLTC. Furthermore, while models mapping out the best routes to personal and spiritual satisfaction are available in abundance to people throughout their younger and middle-aged years, he continues, "such guidance is, for the most part, unattainable to the elderly community."

Eventually the rabbi realized the increased sedentary lifestyle accompanying his advanced years gave him the opportunity to extend his consciousness and to call upon more contemplative means for personal contentment. "I began gathering meditative strategies from numerous sources and meeting with small groups of friends to share life review, recontextualize past events, and come to terms with mortality." Thanks to the rabbi's hard work, keen insight, and altruistic nature, the Institute has been available to members since the late 1980s. While the group's objectives might sound overly profound on the surface, the rabbi believes this organization has been a wonderful support system for the elderly, all of whom, according to the rabbi, "have special powers to confer blessings."

In addition to his affiliation with the Institute, the rabbi is recognized for his work in his past position as holder of the Wisdom Chair for Naropa University, also in Boulder. This post afforded him numerous other chances to accentuate the importance of spiritually focused contemplative education and practice for the elderly to attain optimum peace of mind.

Nancy E. Trotto is a freelance writer based in Totowa, NJ.
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Publication:Contemporary Long Term Care
Date:Jun 1, 2001
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