What Healthcare Reform Should Learn From Long Term Care

Anyone working on healthcare reform should spend some time observing how a great long term care provider does their job. Long term care providers already think and act in ways that the rest of the healthcare system needs to adopt in a post-reform world. But I suspect the wisdom of long term care is not being brought to bear in the debates on healthcare reform. As our national attention span always gravitates to hospital and acute care settings when we think “healthcare,” long term care is rarely given a seat at the strategy table, is often relegated to an “afterthought” discussion, and is even dismissed by many as “not real healthcare.” This is especially sad and ironic given that one of the biggest issues for healthcare reform in terms of the cost/quality issue is how to care for seniors differently and better in the midst of the age wave and needed changes to Medicare.

In my job, I spend a lot of time with long term care providers of all kinds. Sometimes doing formal fieldwork in assisted living facilities and CCRCs. Sometimes working on policy issues around Medicare and Medicaid. Sometimes just calling providers up to learn from them about their needs and the needs of seniors and families. Today, I had the pleasure of speaking to—and learning from—the leadership conference of the Oregon Alliance of Senior & Health Services (http://www.oashs.org/), a group of not-for-profit long term care and senior service providers in my home state. These are the people who serve on the front lines of caring for our parents and grandparents when we can no longer manage that care ourselves—often with little pay or appreciation or respect—but with lots of quality and compassion and commitment. (In fact, I am writing this in the car on the way home from the conference…but don’t worry…Ashley is doing the driving!)

And here is why I told them that the rest of the healthcare continuum should be paying more attention to how they, as long term care providers, view the world:

1) Quality First: The majority of long term care providers operate from a principled and heartfelt passion of delivering quality care for the seniors they love. No one goes into this business (and most of them don’t like to think of it as a business) to get rich, but because they are enriched by serving seniors. This industry has many of its roots in faith-based missions, where quality and compassion supersede ROI and the business of care. I’m not claiming some utopia wherein these providers don’t struggle with hard financial and business issues every day, but they know how to strive and drive for quality because it is foundational in their orientation to care. 

2) Holistic Orientation: Long term care providers have to care for all of the life needs of their elder residents—sometimes for decades for an individual. From addressing basic needs like housing and nutrition to healthcare needs like medications and disease management and mental health to high level needs like social engagement, entertainment, education, and spirituality for their residents, long term care providers already think and act in holistic ways that the rest of the healthcare system is struggling to deal with. The current medical home movement and the push for someone to act as a primary care “champion” for patients across all the specialists they see is something that long term care providers have been doing naturally for decades. This holistic orientation is a strategic advantage for them in a post-reform world.

3) Continuum Thinking: You can see many sectors in healthcare starting to realize that they must diversify their services and revenue streams in order to survive—that they need to serve more parts of the continuum of care with their clinical and campus assets. Again, long term care is ahead of the rest of the pack—in fact, we have them to thank for the notion of a “continuum of care” as those providers came to realize that they needed to diversify their services from just nursing homes to many other “flavors” of care: assisted living, adult day and foster care, independent living, continuing care retirement centers, and more. Long term care has already diversified its knowledge and service delivery capacity, much as many other healthcare sectors will need to do in a world that pays more for quality and outcomes instead of just the number of face-to-face visits.

4) Care Coordination: One of the hottest topics in healthcare reform—and a core tenant of the Obama administration for reform—is that we have to do a better job on the coordination of care. This relates to #2 above. Long term care providers already routinely practice as coordinated care teams by virtue of the holistic care they provide. In fact, they can’t operate without care coordination. Other parts of healthcare would do well to see how long term care does this so successfully—as well as learn from the mistakes that long term care has made—as they try to coordinate care across locations, departments, and needs for a resident whose needs change dramatically over the years.

5) Value over Volume: Perhaps the most radical part of the Senate and House bills in consideration is the shift of payment for healthcare from the volume of face-to-face visits to so-called “bundled payments” or “value over volume” or “quality over quantity.” While these payment paradigms may be troubling and new to physician groups or nurses or hospitals, this is already “old hat” for long term care providers who are most often paid in “bundles” (small bundles, if we are honest with ourselves) and then have to figure out how to manage quality care that isn’t based on # of visits but on outcomes.

6) Incorporating Family and Friends: The long term care community—again, by virtue of the kind of care it delivers—has long found ways to incorporate family members and informal caregivers into the mix of their services. They realize that it if they are to be successful in their mission of quality care, they have to “recruit” this informal care workforce into the care team. Families come into their facilities expecting to know what is going on—and, since those families are often paying out of pocket for some or all of these care services, they demand “transparency” and “quality” at every turn.

7) Home Orientation:  Lastly, and it should be no surprise to anyone who has read much of what I have posted on this blog, I want to celebrate the fact that long term care providers have a “home” orientation in their care. It is their job to create a home for their residents—whether in an independent living apartment or a skilled nursing facility. And many pioneers in long term care are already exploring how to use technologies to deliver their care services virtually and to the traditional homes of their residents. These providers “get it” that the future of healthcare in America is to move care capacity, services, and expertise into the community and into the home—not to leave all of that “locked up” in a campus that someone has to travel or move to. This is not to say that long term care facilities will or should go away—only that they will add even more nodes to the continuum of care in which they serve.

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Long term care today is very different than it was even 10 years ago. It is an industry that began reforming itself because of its quest for quality, its heritage in faith based compassion, and its need to adapt to the demands of changing demographics. And they are in the midst of reforming themselves again as they contemplate what it means to serve Baby Boomers, who will likely be a very different kind of “senior” than those of the past. But I believe long term care providers still live under a false, antiquated stigma of “nursing home” horror stories that are fodder for sensational news sound bites but are the rare exception, not the norm. In many ways, our cultural imagination and assumptions about long term care have not caught up with the realities of what is really offered today.

I don’t mean to suggest that long term care providers don’t have problems, don’t make mistakes, or that they have all of the answers for healthcare reform. And in full disclosure: I work side by side with many long term care organizations from non-profit boards I sit on to my commitment to CAST (www.agingtech.org) and its parent, the American Association of Homes and Services for the Aging (www.aahsa.org). But the reason I choose to spend my time with these long term care folks—aside from the fact that they are wonderful, fun, compassionate people—is that they offer a glimpse of what healthcare reform must ultimately accomplish: better quality care, at lower cost, with holistic, coordinated care in the home becoming the norm. We should not relegate long term care to an afterthought in our national strategy for healthcare reform. We should learn from the wisdom of those who care for our elders. They—and the seniors they serve—are at the heart of our grand challenge to reinvent care as we know it.