I asked AC Thompson the questions that maybe you wanted to ask him. He got the fundamental picture of assisted living mostly wrong.
The day after the FRONTLINE assisted living story aired, I reached out to see if I could get an interview with AC Thompson, the writer/reporter/investigator who did the bulk of the work on the series of video and print stories and who you saw on camera.
Last week we talked by phone and I asked the questions that many of you have wanted to ask. At the root of his reporting is a strong negative bias toward assisted living as it exists today. As a result, he got the fundamentals wrong in at least 6 areas:
1. He Believes There Are Big Problems in Assisted Living –My first question to AC was what he hoped to accomplish with this story. He is convinced there are big problems in the assisted living industry that need to be talked about. His believe is just plain wrong.
We deal with a very frail population and must juggle each day the frequently conflicting values of resident freedom and protection. We know, as a for instance, that falls can be all but eliminated using drugs or restraints, but the quality of life price is just too high.
It is not all roses, there are some bad operators and sometimes good operators accidently hire bad employees. The really bad operators are essentially never large multi building organizations, but rather small capitalized mom and pop organizations.
What is perhaps most discouraging is that if I were a researcher and went through the same data that AC used, then compared it with acute hospital data, frail seniors living at home with home health or family members and skilled nursing data, assisted living would be the star player. This would be true in quality of life and resident safety. This current article: “Elderly abused at 1 in 3 Nursing Homes” brings home this point.
2. AC Believes Bigger Fines Would Equal Better Care – When I asked him about this his response was to point out that if a resident dies (as the result of wrong doing on the part of the senior community) in California the fine is only $150. He then asked if I thought a life was only worth $150.
So sure, $150 is really nothing but is $1,000 or $25,000 somehow better? Is it the fines that makes senior communities take great care of their residents? When we look at the skilled nursing industry the one thing we know for sure is that bigger fines generate lots of additional work for attorneys who battle those fines. We don’t know that fines would in fact generate better care.
3. AC seems to believe there should be more Federal oversight of assisted living – It was difficult to figure out exactly what this would look like in AC’s ideal world, but in my conversation with him and on the video report, he talked about the lack of Federal oversight.
This is a huge philosophical difference about the kind of world we want to live in. I do know for sure that more Federal (or state) oversight will cost someone more money and that money will ultimately come out of the resident’s pockets which would make assisted living just a bit less affordable.
AC seems to have a sense that because different states have different rules that this is a bad thing. My view is that this is a great example of how states’ rights are supposed to operate and that if a state and the citizens of that state see a problem (which does not really seem to be the case except maybe in Florida), it is their right, their privilege and their obligation to deal with those problems in a way that makes the most sense for that particular state.
4. AC believes consumers should have more data available to them – This is a tough one for me. On one hand it makes some sense that people should have access to survey results, on the other hand, surveyors are uneven, some are too easy and some too hard. I rather think that consumer review sites like SeniorAdvisor.com, Google Places and Caring.com provide better more trustworthy feedback.
5. AC seems to believe consumers have limited personal responsibility for due diligence – Particularly with the level of assisted living that AC targeted, the care is essentially all paid for out of consumer pockets, which means these resident and their families have the ability and at least some obligation to do their own due diligence. This means they should show up at midnight and check things out.
6. Putting a loved one in assisted living is putting them in grave danger — The one consistent message that emerged from this series was that assisted living was a dangerous risky place for elders.
In talking to AC he acknowledged that there are in fact many good assisted living communities doing a great job of caring for residents and that somehow, that part of the story was never told. He told me that he had a family member who is or was in assisted living and it was a great experience for that family member.
Finally
I have been accused of keeping this story alive because it drives traffic to Senior Housing Forum and there is no doubt that there is some real truth in that charge. But the reason it drives traffic is because people are interested in the story and it in fact brings to the forefront some important questions and issues for our industry.
There are lessons for all of us here. I have believe the story will die a quite death with little if any regulatory consequences, and yet it raises some important questions about whether or not there are some things we can do to lessen the chance of another one of these stories ever happening.
Finally, I think we need to be very careful in saying “Oh that is just an Emeritus problem.” If you are an organization of any size, and you have been operating for any number of years, someone wanting to dish dirt on you . . . could no matter how good a job you are doing could done find disgruntled ex-employees and family members willing to trash you. This is a “there but for the grace of God . . . .” story.
Keep up the good work Steve. As a former editor of several magazines, I was taught many years ago “if it bleeds it leads” and that is the focus of today’d media too.
They do it so they can sell ads, and they see nothing wrong with this.
Even if they get it wrong. And facts–99% of journalists are biased, and come in with that bias before the story is even written.
We know that we are one human error away from tragedy. Dilligent staff screening, solid training, follow up evaluation of learning and skills monitoring all help minimize the risk. Establishing open communication and strong relationships with family members is essential. AND we PRAY God keeps our residents safe.
A story about happy, secure, engaged residents who are served and cared for by kind, caring,capable staff would not generate the buzz that a horror story does!
Kathlern: Great points and I don’t know exactly how to resolve this problem because I actually tell happy stories and they are never as well read as the controversial ones.
Steve
Thank you, Reece, for having providing this much-needed perspective. It’s something I’ve always known and, for some reason, no one talks about it. When will we see a Frontline exposé about the media’s complete disregard for the facts, I wonder.
I try to be as fair as I can, but as civil as I can (though some readers of my last nursing home article thought I went beyond civil . .). That being said we all have biases and it is those biases that make things interesting to read. There is no doubt I have my own and they are reflected in everything I write.
Steve
Thank you for asking the questions Steve. Maybe you caused AC to doubt a few of his beliefs by putting your questions to him. Keep up the good work!
Hi Janis: I suppose it is possible, but I doubt it. I do expect to have further conversations with him, though not likely they will result in additional articles . . . but never can tell.
Steve, thanks for going full circle on this PBS project….I agree with Reece Franklin’s comments and most people understand this phenomenon….it is so unfortunate in today’s media….
Time will tell the real story!
I think AC’s observations are good points — for more thoughts on the benefits of regulation:
http://www.ageinplacetech.com/blog/why-not-apply-federal-regulations-assisted-living
Laurie: Honestly I read your article and it is hard for me to know how to respond. I have spent the last three days at the Pioneer Network annual convention. These people get and advocate for patient centered care. There politics are generally so pro government that I was likely one of maybe a dozen conservatives in the whole world. You would think that given their bent they would be with you, in thinking regulations are the way to go to give residents a higher quality of life. Not true. The live it every day and know that a huge huge huge amount of their personnel budget goes to meet regulatory requirements and that the checklist nature of regulations makes it much harder to provide quality person centered care.
This does not even address the reality that if we had nursing home style regulation it would likely increase the cost of assisted living to the private pay market by 15%-25% and put it out of reach for more people. It would also result in a need for a massive infusion of cash from the government to pay for added costs of this regulation to the building serving the low income population where there is not enough margin and the residents can’t absorb the cost.
Are there problem building out there? Sure, but here is my question to you, a question I asked AC and didn’t get an answer too: In your mind how safe does assisted living have to be in order for you to be satisfied? As safe as skilled nursing? I bet if you did a similar examination of the skilled nursing marketplace you would find the problems described by AC to be tenfold.
You are right on target, Steve. That is why I did not bother attending after reviewing their conference program, etc. Great response that is completely how I feel as well. As long as we allow regulations to choke the system, the system will fail everyone.
Dr. Ethelle Lord
Pioneer in Alzheimer’s Coaching
I am the administrator of a med-size AL. It is always sad that bad news gets the most press coverage. I believe that most facilities are structured to provide the best resident care possible. Federal regulations would make the cost impossible for most people to afford. At the state level, changes/improvements are easier to implement. Because we are human, nothing is perfect nor will it ever be.
I wonder what AC thinks about these exact same things that happen outside of assisted living facilities — such as in people’s homes, for instance. Because they DO happen there and in much greater numbers than occur in assisted living facilities. The (unbaised) American Psychological Association had this to say about elder abuse in nursing homes and other residential settings:
“Most incidents of elder abuse don’t happen in nursing homes and other residential settings. Occasionally, there are shocking reports of staff who abuse residents in their care or of a resident who physically or sexually abuses another resident. Although such abuse does occur, the vast majority of older people living in nursing homes and other residential settings have their physical and emotional needs met without experiencing abuse or neglect.”
http://www.apa.org/pi/aging/resources/guides/elder-abuse.asp
Additionally, over 90% of elder abuse is committed by a family member:
http://www.ncea.aoa.gov/Library/Data/index.aspx
Finally, over 90% of assisted living residents are satisfied with the care they receive and would recommend their community to others:
http://www.ahcancal.org/research_data/staffing/Documents/ALF
http://eon.businesswire.com/news/eon/20130724006010/en
It saddens me that Frontline and ProPublica chose to sensationlize families’ personal tragedies in order to attack an industry that all OBJECTIVE data says is serving the needs of seniors.
David some great links, you have it right.
Steve
Steve- Under #4- you write: “I rather think that consumer review sites…provide better trustworthy feedback.”
We agree, but one challenge (on review sites like Yelp, for example) is that companies can’t respond to reviews, but we recently launched our reviews on RetirementHomes.com, allowing communities to respond directly to reviews. It doesn’t simply mitigate negative reviews- it turns it into an opportunity to sell.
Steve – Thank you for reaching out to interview AC. Good work!
Thanks Shep
Steve
I’m sorry but I totally disagree with you this time, Steve. There ARE big problems in ALF today. Huge problems. People ARE dying through negligence, and are being poorly cared for. There are too many ALFs with insufficient staff to meet the needs of an increasingly sicker and more frail population.
I do not believe that refusing to look at the bad in our industry today is serving anyone well. The corporation featured on the Frontline exposé deserved every word of that documentary and more. They do NOT do a good job, in the majority of the states where they have ALFs. Until we are all ethical enough to say, “yes, there are problems and we are going to advocate to fix them,” we all look like collaborators with the bad operators.
Not all large ALFs are poorly operated, not all small ALFs are well run. Not all not for profits are well run. The point is, that was a responsible piece of journalism and if we all refuse to see that we are doing more of a disservice to our industry than what some here think that documentary did.
Advocate for good laws, enforceable laws, and demand excellence. If we promote mediocrity, and accept it, that is all we will get.
My sincere appreciation for your providing us (me) with the opportunity to comment. I know you don’t have to.
Hi Edie: If nothing else I am committed to an open dialog for two reasons I like it better that no one has all the same points for two reasons:
1. It makes the website more interesting which mean more people read which makes my sponsors happy.
2. These are important issues and when we talk about them and even disagree we learn and get better at caring for our elders.
So I am really glad you have joined the conversation. I would also note that I don’t remove comments because they disagree with my position or the position of other writers or readers, unless of course they were slanderous, obscene or illegal. To this point, after more than two years, I don’t think I have ever deleted a comment except for SPAM.
To your premises:
1. You say there are big problems, and so I have to ask the question I have asked others: what level of risk is acceptable? We have determined with automobiles that they don’t have to be armor-platted which would save lives because the costs are too high. We allow people to drive 65 mph plus even though we know that if we reduced the speed limit to say 20 mph we would save maybe 5 or 10 thousand lives each year. We have really safe aviation, but there are still airline accidents. We could completely eliminate commercial air accidents by eliminating air travel, but we have somehow determined we are at an acceptable level of risk.
So in your mind what level of risk would be right? and how would we pay for the cost to get the risk level down to what you think is acceptable?
I fundamentally disagree that it was a fair article. Even in my conversation with AC he acknowledged that the series does not really ever point out that not all assisted living communities are death traps. Further, there are parts of several of the stories that were not told, that would have made Emeritus look better and more responsible, but didn’t make the cut. Just one example is the clip about 8 hours of training. It turns out there was further explanation that did not make the cut.
I would guess that if you took a 1,000 seniors and their families sat them down to watch the FRONTLINE story then gave them the choice of an Emeritus Community or a typical skilled nursing building most would more than 90% would choose Emeritus.
That being said, we can and should do better. A great place to start would be for the industry (ALFA, ACHA/NCAL, LeadingAge and Pioneer Network) would come together and create some quality guidelines for things like training, staffing and programing that would create in effect a “safe harbor” protection for both residents and the communities that serve them.
Steve
Steve,
Thanks for your thoughts and measured responses. Unfortunately most people view this issue with a ton of emotions. Just like any other industry, there are always issues – it could be systemic, it could be human errors. This is no different from other industries such as hotels, restaurants, fast food joints and retail stores. With the seniors being frail, it compounds the issue further. A major suggestion from many people are that the employees at ALFs can be be better paid. Unfortunately, it leads to increased cost of senior care which nobody seems to realize!
Only other option suggested by the participants in this study is to drive all these seniors to government funded nursing homes. We all know what has driven the health care industry to the current state. Unfortunately the mass media wants to ride on the emotions of the citizens rather than a deep analysis and possible solutions to reduce the issues. For example, we conveniently forget that the more and more Americans are living longer and more sicker as a result. As a participant mentioned in the interview, some seniors are prescribed 10 to 15 medications each time. And don’t talk about the obesity issue which leads to more falls.
While the ALFs are resorting to more training and technology, and help ease the strain on the employees, their is job is not going to be ‘fun’ or ‘cool’ as we are taught by the media and society at large.
Isolation is the biggest problem faced by seniors, which leads to more emotional and health issues. Who is to be blamed for this, except we the society, as sons and daughters of the seniors? We have completely broken the family system in the name of ‘freedom’ and ‘independence’.
Hence assigning the entire blame to the ALFs workers or owners is neither fair nor logical. You cannot provide text book training and avoid all the problems.
After watching the video, it would appear that staff for the most part are doing their best given financial and personnel constraints. Businesses listed on the stock exchange need to prove that they are good investments for their investors – this becomes a huge tug of war between profits and costs, and in this case, resident care. Training of customer facing staff is appalling – shame on Emeritus. They seem to be getting by with spending the minimum and getting the maximum profits. The balance between resident care and profit needs to move more towards the customer………vulnerable populations need better advocates. If this PBS documentary shows the failings of the system, so be it. The presenter did not paint all employees/facilities with the same brush but highlighted some situations that need rectification now.
Hi Steve, Thanks for following up with AC and sharing your conversation with him. I’m glad you brought up point #4 – that people need to have more information immediately available to them. At SeniorAdvisor.com, we wholeheartedly agree with you that senior living reviews are an excellent source of information for both the people looking for a community and the communities themselves. We hope and believe that these reviews will help improve the level of care in some of the unfortunate situations such as those publicized in the Frontline story, but that these reviews will also help the truly great and caring communities that are out there shine and get more attention for their efforts in the public eye.
Hi Steve. It’s been a bit of a challenge to return to this conversation. I had to go into a different link because any other link that lead directly to this page blocked me. Odd.
Anyway, what do I consider an “acceptable” risk level? Something that the ALF would not be initially aware of, or have been informed about by the resident’s physician, or family, or resident. If the resident had never experienced a seizure, then the ALF staff would not be responsible for working to prevent the seizure. However, the care staff would be responsible going forward, and for addressing the need promptly and working with the physician of record to prevent further seizures.
When admitting someone to an ALF it is the responsibility of the family, the resident (where possible) and the ALF to be sure that all pertinent information is collected to be CERTAIN that the needs of the resident can be me. Any good ALF staff will also look at the admission diagnoses and using good clinical judgement evaluate the resident based on the admission diagnoses and the potential prognosis.
Admitting someone with a diagnosis of AD or other ARD must be contingent upon planning for the course of the disease. Admitting someone with Parkinson’s Disease must be contingent upon understanding the general course of the disease. There really is no defense for admitting someone for whom the ALF staff cannot provide care, or with an illness or a disease that cannot be managed by the staff.
I do think the exposé was fair as I stated. The eight hours of training referred to was recognizable to those of us in the industry as the regulatory requirement. Florida has that same regulation. That is the MINIMUM hours required to maintain compliance with the law. Any responsible ALF is going to provide ongoing training of a general content, and additional training for specific issues being faced by the care staff and residents.
Quite bluntly, managing and ALF requires much dedication and constant 24/7 oversight. It requires complete conviction by all parties responsible for the ALF (owner, executive management, care staff… etc.).
Again, I thank you for your providing this forum to discuss this critically important and very relevant topic!
Thank you Steve for keeping this topic alive. You mentioned we have to define what level of risk is acceptable. Life is uncertain and there will always be fuzzy boundaries. People of all ages trip and fall, and gravity always seems to win. For quality of life, the least restrictive environment is recommended, as long as someone is not a danger to himself or others.
I see so many people in nursing homes, getting progressively weaker because they are not allowed to try to walk without assistance because they might fall. Patients who are not incontinent are made to wear diapers because there is not sufficient staff to escort them to the rest room. Patients unable to feed themselves are given G tubes rather than patiently feeding pureed food by mouth. There always seems to be at least one patient who screams all night, necessitating sleeping pills and tranquilizers for those who are not fortunate enough to be hard of hearing. Many people think this is not quality life, and would prefer to take a little more risk in favor of not languishing in an institution.
Government regulation never simplifies anything, but it does always add to the cost (which too many even now can’t afford). Staff who could be providing hands-on care will spend more time on bureaucratic tasks and box-checking. If families start to demand quality care above chandeliers and marble, and if companies make it their priority to provide it, the profits will follow. If a company is willing to cut corners on care to make higher profits, they will lose in the long run.
There is fact #6 many good assisted living communities doing a great job not all are worse but finding the best one is difficult to everyone. One serious problem with Assisted Living is that there are no overriding Federal Regulations as in nursing homes.