The very best part of attending LeadingAge are the conversations.
Yesterday’s general session speaker was Atul Gawande who talked about the US healthcare system as it is today and what it could be.
The very best part of attending LeadingAge are the conversations. Yesterday’s general session speaker was Atul Gawande who talked about the US healthcare system as it is today and what it could be.
Here are a few snapshots from his talk:
- The world of aging care and healthcare seem to be separate but they shouldn’t be.
- Medical care has been about hospitals in the center and home and family on the periphery. This puts distance between healthcare and the goals people have for their lives.
- The source of the problem in healthcare and care of seniors is complexity.
- It is rare when patients really get all the right care they need. If they are lucky it happens 50% of the time.
- The most expensive care is not the best care. Often the best care is the least expensive.
- Taking a systems approach to healthcare would provide better care, lower costs and happier patients.
- To make our healthcare system work better, we need to have people who do not normally work together, start working together.
- We need to go back and look at goals that people have, then integrate services, housing, homecare, senior housing, hospitals to meet those goals.
- The goal should be to give people the best possible day they can have that day!
Why We Are Doomed
Over the course of the last two and a half days I have had the opportunity to chat with a number of individuals who play a role in how care and services are delivered to seniors and how those services are paid for. One of the questions I like to ask is this: Why is it that Assisted Living does not play a role in caring for seniors with significant medical needs? The short answer is that it is “because Medicare doesn’t pay for it”. This is true up to a point, except that once a senior is enrolled in a Medicare Advantage program or a PACE program this no longer true. Yet, it does not seem to even hold a serious place on radar of any of the payer sources I have talked to. Even worse, it does not seem to something seriously considered by those who are providing these services.
Imagine these two very real scenarios:
1. A low income senior lives at home in subsidized housing. Because they live alone, they don’t get adequate nutrition, they don’t do a great job of taking their medications and they are lonely. As a result, of this suboptimal living condition, the negative factors collide and they end in an ambulance to the hospital where they rack up thousands of dollars of charges, paid for with government dollars, or to bring it closer to home, our tax dollars. After a several days in the hospital, they return home until the next episode. Over the course of a year this one individual will rack up a hundred thousand dollars or more in hospital and physician charges. Or . . . they could move into a great assisted living community where the social and ADL deficits would be eliminated saving buckets of dollars and improving the resident’s quality of life. – – – – “Often the best care is the least expensive.”
2.A low income senior has an acute medical event that triggers a legitimate unavoidable hospital stay. After a week or so, the senior is discharged to skilled nursing where they continue to improve. After their Medicare days run their course, the patient who still needs supportive care, becomes a custodial patient with their care being paid for by Medicaid still in the nursing home.
The glaring question that never gets asked is this: Would it be possible to place this person in an assisted living community where the quality of life would be better and the cost lower? – – – – “Often the best care is the least expensive.” Ultimately the reason this situation will persist is because it works well for the providers even though it is to the detriment of society and seniors. Steve Moran
Why does assisted living not fill the role? Because AL was developed as a SOCIAL MODEL, not a medical model. In my state, there is little regulatory oversight yet ALF’s get Medicaid reimbursement if they participate with CBA, and the acuity level is very high – equaling skilled care in many instances. Skilled nursing facilities are over regulated/ over-penalized while assisted living here continues to be under regulated and many residents are not monitored adequately. I got out of ALF ops because residents were UNSAFE with the staffing levels provided in a model not designed for high acuity, non nursing. It used to be a social/wellness model. Now they are no more than private pay nursing homes. The earlier targeted population now lives unsafely in retirement apartments. All for census….sad. I surmise liability insurance rates will begin to rise as care lapses increase.
From LinkedIn Groups
Group: Senior Housing Forum (www.seniorhousingforum.net)
Discussion: Why We Are Doomed to Mediocrity in Caring for Seniors!
Steve– Awesome article and so true. In short I would class it as Preventative Maintenance as you do on your car, house and personal health. Along with that it’s the scarey word “change”! Along with that, insurance will not cover birth control to prevent unwanted pregnancies and would rather cover the child’s next 18 years of life!!
Thank you for sharing!!
Posted by Barb Przybylowicz
From LinkedIn Groups
Group: Executives in Long Term Care
Discussion: Why We Are Doomed to Mediocrity in Caring for Seniors!
We must take advantage of the latest technology in maintaining good health to our aging population. So much care cost can be avoided by keeping people more active.
Lets start a discussion sharing ideas.
Ernie Hoffman
Posted by Ernie Hoffman
From LinkedIn Groups
Group: Senior Assisted Living Sales, Marketing & Operations
Discussion: Why We Are Doomed to Mediocrity in Caring for Seniors!
Well said Steve.
Posted by Jay Banks
From LinkedIn Groups
Group: Senior Advisory Board
Discussion: Why We Are Doomed to Mediocrity in Caring for Seniors!
Great insightSteve. Also, have to push for aging in place at home with services. If medicare would pay for a grab bar installation, they would save millions in fall costs.
Posted by Pam Pressel
From LinkedIn Groups
Group: Executives in Long Term Care
Discussion: Why We Are Doomed to Mediocrity in Caring for Seniors!
The sad thing is that existing technology(relatively expensive) can be used at home and SNF/LTC by simply treating both the nternal and external medicine issues of wound patients. Our NPWT days are decreased by 75%, dressing change frequency decreased 50%, cost per dressing decreased 50% with 94% healed and improved.
It can be done.
Posted by Lamont Dorsey
Were turning a page in US history where the aged are going to be a challenge due to better medications and advancements in medical technology. The complexities are overwheming and have beed adresses with a bandaide not a long term plan that anyone agrees to or understands. Your comments are very good but whats the long term solution?
From LinkedIn Groups
Group: Senior Housing Forum (www.seniorhousingforum.net)
Discussion: Why We Are Doomed to Mediocrity in Caring for Seniors!
I especially like the statement “Taking a systems approach to healthcare would provide better care, lower costs and happier patients.” As a Human Factors & Systems specialist, whatever a human interfaces with is a system and should be designed to produce the best performance to accommodate the human’s capabilities.
That’s the approach Make My Home Fit takes in respect to the home environment and fall prevention/independence. The home environment should be able to accommodate its resident’s abilities (or lack of).
Posted by Cyndi Schmidt, MS HF&S, CAPS
John you ask a great question. I can tell you that I am beginning hear stories of people or organizations that are at least beginning to make some progress in addressing the problem. I am convinced that some developer ought to to some of the states that are essentially broke (CA, IL) with a radical proposal that would provide better care and reduce costs.
The reason for broke states, is that they are desperate for solutions and could very well be open to a radical solution.
From LinkedIn Groups
Group: Senior Housing Forum (www.seniorhousingforum.net)
Discussion: Why We Are Doomed to Mediocrity in Caring for Seniors!
Jack: “In fact today’s structure favors just the opposite of better care at lower cost. The incentives favor more tests, more MD visits”
I recently told my own primary care doctor that I couldn’t come in every 3 months when I needed Rx refills. He would either have to refill when pharmacy calls or I would just not get them filled.
However, when it comes to Mom’s Dr visits, I’m afraid not to take her. Taking her to the Doc involves two 90 miles round trips for me since she lives 45 miles away and her doc is in town near me. She gets frustrated with having to go for petty things as well.
Posted by Cyndi Schmidt, MS HF&S, CAPS
From LinkedIn Groups
Group: Senior Housing Forum (www.seniorhousingforum.net)
Discussion: Why We Are Doomed to Mediocrity in Caring for Seniors!
Cyndi, it’s good to have your confirmation. This is the “emperor has no clothes” aspect of healthcare “reform” in America. If the focus had simply been on the need for universal coverage, the outcome might have been more constructive than the confusing mishmash of new micromanaging that we’re beginning to experience.
Posted by Jack Cumming
Hi Steve,
Interesting points raised by Dr. Gawande.
I have a bit of technical question, when you say: <blockquote cite="…Medicare doesn’t pay for [assisted living]…except that once a senior is enrolled in a Medicare Advantage program or a PACE program this no longer true." It seems like you are saying that at times, assisted living can be covered.
Could you speak a bit more to that issue? What are ways that families and seniors can get covered for assisted living? How can Medicare Advantage and PACE be accessed to cover those services?
I ask, in particular, because coverage for assisted living was a recent question asked at MyAgingFolks.com
Thanks,
Jordan Rosenberg
Founder | MyAgingFolks.com
Expert Medicare and Medicaid Support
Hi Jordan:
You ask a good question. I am going to try to do this in bullet fashion for clarity.
– Medicare never pays for assisted living (as a general rule)
– If a senior enrolls in a Medicare Advantage Program (Senior HMO, PACE, ACO) those organizations then receive the Medicare dollars and are responsible for providing healthcare (but not housing). If a senior had need for skilled nursing services, it would be allowable for those organizations to pay for that care in an assisted living community or a skilled nursing facility. Normally this would would be for no more than 100 days, but in fact rarely if ever happens at all.
– Finally there is something called a Medicare Waiver Program, that has been adopted by some states and how it works varies quite a bit from state to state. These program is for people who are eligible for both Medicare and Medicaid. Many of these people who need only intermittent skilled nursing services end up in nursing homes, for lack of any other place to be cared for which is an expensive proposition. So in these cases the a portion of the money that would have been paid through the medicaid program can be channeled to an assisted living community. There are two important keys here. The state has to have a waiver program and the resident has to need some type or types of skilled nursing services.
I hope that helps. I will also post this at your website. – Ops – – – Guess I won’t post there. Not going to do so if I have to pay to help you.
Steve Moran
From LinkedIn Groups
Hello, yes we are. As long as we maintain present staff to bed ratios you can send them to 1,000 hours of culture change training and the culture will not change. It is a myth that they can work that much better, that much faster, serving those they now must underserve by virtue of the staff to resident ratio. These ratios will remain the same because greedy, fast buck investors, many of whom are health care professionals themselves want a large and quick ROI. Since profit comes before needs of those being served first comes the profits 10-30%+, then comes the building, then comes with what is left over the services, service providers, their pay and the of course the managers.
nursing homes are now being forced to do what they should of done by themselves years ago, reduce the number of residents on psychotrophic drugs. In fact the sameness of one home to another is not an accident – it is the lowest common denominator and still get your bed full. And unfortunately full beds are not the hall mark of great service and smaller staff rations, the represent good marketing, and persuasive marketers. It is very bleak, indeed. At least, this is what I think and feel.
Richard
From LinkedIn Groups
Group: ADVANCE for Long-Term Care Management
Discussion: Why We Are Doomed to Mediocrity in Caring for Seniors!
So how does change occur? Enforcing federal guidelines for staff ratios? And does increasing staff ratios insure better care? The federal guidelines for regulating nursing homes have been in effect since l990….and they are by and large great regulations, but the surveyors need to cite facilities not following them, especially the Quality of Care, which covers it all. If the one regulation were folllowed to the letter, resident care would improve, as staff ratios would have to increase to follow the regulation. Instead of culture change seminars, fall prevention seminars, seminars need to be held on that regulation, teaching staff again how to do real comprehensive assessments, hold real care plan meetings and find out what is really wrong with the residents, focus on meeting all those needs and actively change the care to attain the highest physical,mental and psychosocial well- being for all residents. If that regulation were followed to the intent, all care would improve.
Posted by MARY HARROUN
Steve, we welcome your post at MyAgingFolks.com. No fee is involved in answering questions at MyAgingFolks.com. Though if you wanted to market your practice more fully, there is a charge. That type of professional marketing, though, doesn’t seem to be what you do.
Jordan
To more fully answer your question in CA, as I only work here, the Assisted Living Waiver Program (ALW) is a program utilized by Medi-Cal (MediCaid in the rest of the country). It is active in, I believe five counties at this time. See below
for additional information,
http://www.canhr.org/factsheets/rcfe_fs/html/fs_alw.htm
Within the approved counties, RCFEs, licensed Residential Care Facilities for the Elderly which are our “board and cares” or “assisted living communities” choose to participate. Medi-Cal supplements the clients income and these facilities try to operate on a shoe string typically. Therefore, they are not as able to provide the surroundings or service as those who focus on profits first. There is much truth to what was said about the corporate mindset and the sea of greed in this “caring” industry. The needs of those who are under served has just begun to appear. We as a society are in big trouble. However, I will save that for another time. I just wanted to provide you with specific information. Best regards.
From LinkedIn Groups
Group: Senior Real Estate Network
Discussion: Why We Are Doomed to Mediocrity in Caring for Seniors!
A pound of prevention….. that is all we need to do but Medicare will continue to cover the fracture but not the prevention.
The denial by our elderly as well is a problem. How many simply say, not me!
Posted by Pam Pressel
From LinkedIn Groups
Group: ADVANCE for Long-Term Care Management
Discussion: Why We Are Doomed to Mediocrity in Caring for Seniors!
Thank you for this discussion. I wish the Leading Age conferences were not so expensive for an independent provider like myself. I believe that we are doomed to mediocrity AT BEST. And that is because we don’t take seriously the Commandment “Honor thy father and thy mother”. We don’t come close to it, sad to say. As Richard Taylor suggests, our values are up-side down.
Posted by Donna Newman-Bluestein
From LinkedIn Groups
Group: Senior Real Estate Network
Discussion: Why We Are Doomed to Mediocrity in Caring for Seniors!
safe housing is paramount as well as any other quality of life factors
I know many of you realistically have other pressing issues on your mind at this time but please don’t forget this often neglected task for your families protection.
CPSC Urges Consumers to Change Batteries in Alarms This Weekend When Changing Clocks for Daylight Saving Time http://www.cpsc.gov/cpscpub/prerel/prhtml13/13027.html
Stay Blessed and the very best to all in Our Nation during these trying times…remember we’re AMERICANS!
Posted by BARRY ADAIR
From LinkedIn Groups
Group: Senior Real Estate Network
Discussion: Why We Are Doomed to Mediocrity in Caring for Seniors!
Great points and example Steve…Thanks!
Posted by Roy Barker
From LinkedIn Groups
Group: ADVANCE for Long-Term Care Management
Discussion: Why We Are Doomed to Mediocrity in Caring for Seniors!
Afraid I have checked it out, both here and in NJ. Thankfully the local Alzheimer’s Association and Pioneer Network conferences are not as prohibitive.
Posted by Donna Newman-Bluestein