Green House Blog

LeadingAge: Enough is Enough

By: Larry Minnix

LeadingAge President and CEO

What will it take for the nursing home to gain the respect it now deserves?

The nursing home continues to be treated like the illegitimate child in the health care family. Yet, it is an essential part of every community. Just ask any family when the hospital says you have a short time to find a nursing home bed. Or, ask any person caring for someone at home when incontinence, sleep problems or dementia can no longer be managed in the family home.

Granted, nursing homes are the place no one wants to be. We all understand that, dont we? Yet, when we need one, we really need one — and we want the best nursing home we can find. None of us wants to worry about where our loved one lives or what happens to them when were not around.

But society doesn’t trust nursing homes. In fact, we are just emerging from an era of mistrust exemplified by over-regulation, punitive public oversight, and constant battles over reimbursement. Why is that? There are many reasons. The underlying one is our denial about aging for ourselves and our loved ones.

I will never forget a Wesley Woods board member’s story of a corporate executive whose mom lived with his family. His wife kept telling him that mom had problems. He traveled a lot and had the attitude that his wife never liked his mom anyway and “mom is just fine.”

The corporate couple had a formal dinner party, including his boss. The boss’s wife asked where the powder room was. The hostess pointed to the hall door. The boss’s wife opened the door and there stood mom with no clothes on and no idea where she was. The corporate son finally had to admit mom had a problem and needed to be in a nursing home. Denial is a powerful force. None of us wants to think that we are aging, our parents are aging or that we may need a nursing home.

Two other reasons for society’s suspicion include past reports about poor quality and investigations into financial practices. The headlines of those dark days painted all nursing homes with the same brush, unfortunately. So, why does this happen? And more important, what do we do about it?

When I took the position as your president 10 years ago, I was confronted with the opinions of the U.S. Department of Health and Human Services (HHS) secretary, senators from both parties as well as others that the nursing home field had not taken responsibility for its own quality.

The Centers for Medicare and Medicaid Services (CMS) administrator at the time said to a large audience of our members, You are not going to get anywhere with less regulation and better reimbursement until you take responsibility for quality.

A tough message, but much truth to it. Not that we produced bad quality, but we had not taken responsibility for improving it and being transparent about our results.

So, we charted a course for quality improvement in collaboration with two other organizations who have nursing home members. The strategy is called Quality First, which ushered in the era of self-responsibility for nursing homes. Most nursing homes joined the initiative and the results show it.

Quality First spawned other quality activities, including the Advancing Excellence in Americas Nursing Homes Campaignthe most effective nursing home quality improvement program in the country in terms of results.

We now enter the next era of quality, which will be defined by outcomes, demonstrative value and transparency. It will be a more sophisticated era because thats what consumers need. Accountability will be immediate and constant.

The culture change movement has been a big help in creating more appealing settings to live including developing healthy atmospheres through programs like Pioneer, Wellspring, Eden, The Green House Project, small houses or neighborhoods.

They show great promise in improving quality of life for residents, families and staff.

Our research through the LeadingAge Center for applied research has been at the forefront of studies that prove success. To their credit, CMS’ quality division supports culture change and quality improvementa strong public-private partnership approach.

Yes, we are making progress in this self-responsibility era. Many nursing homes are doing a better job than those sensational headlines of a decade ago. You are telling your story more effectively. You are doing so through better annual reports, transparent reportseven through social media.

Recently, I saw a news clip of a member who had done a great “bucket list” event for a resident who is dying. The newscaster, obviously inspired by the story, stated something like: If you have to live in a nursing home, wouldn’t you want to live in one like that?

Though we have a ways to go, the self-responsibility era resulted in a minimum of new punitive regulations and a relatively stable reimbursement environment…until now.

Enter today’s pressing dilemma: the national budget deficit.

A member just wrote me an email message. He knows his state is one of the worst in terms of Medicaid reimbursement, yet he believes Medicaid is bloated with fraud and abuse. He wants to know how LeadingAge can advocate for no Medicaid cuts and protest Medicare cuts when our country is going broke. He sees that his state has hundreds of nursing homes that seem to stay in business on poor reimbursement. How could that be? Perhaps hes asking the wrong questions.

Here is my response: since the advent of human commerce, some people have made money delivering poor quality products, services and by cheating. His state has a history of quality scandals from which people became rich, and which prompted major national legislation that we all now live with.

My guess is that some providers still make money on poor quality while good providers need contributions to make ends meet. Still others create services that produce margins to help offset Medicaid, including Medicare. And, I know that some are thinking about closing their doors.

The real questions are these:

How do we define a decent quality of life in nursing homes for frail and vulnerable individuals and the people who work there?

How do we calculate the cost of providing that high quality care?

What should be our personal responsibility to cover these costs and how do we help people insure or plan for them?

And what should the public pay through our collective benevolence of taxes and charity to help poor people?

These questions represent the public discourse that needs to take place at every family kitchen table, in every state house and throughout the halls of Congress. We have a population that is aging, has multiple chronic problems to be addressed and has public and hidden costs that affect every state budget and most every family pocketbook.

These unprecedented dynamics can no longer be addressed with a return to the era of more regulations and arbitrary cuts like those that CMS announced, many states have just imposed and that some members of Congress are trying to advance. Another cycle of arbitrary cuts will inevitably lead to a new dark era of quality we dont like, regulations we don’t need, schemers who make money off of bad quality, tort lawyers and good providers who throw in the towel.

We have seen this cycle before. We’ve had enough of it. It is time to pay for quality. Enough of the crazy, arbitrary and capricious Medicaid and Medicare budgeting!

Let’s define quality.

Pay providers to deliver it.

Assure competition through value and transparency.

Root out the cheaters and send them to jail.

Create a self-planning model like the CLASS Act so people can take more responsibility for their own futures.

Make sure the genuinely needy get help.

Pay the direct-care people livable wages, benefits, respect, and training.

And go to bed at night knowing your mother is well cared for.

Let’s make the nursing home a legitimate part of our health system where quality is an automatic public expectation, not a risky venture to be feared by all and punished when it does not measure up.

As one of our colleagues exclaimed after these recent reimbursement cuts, enough is enough!

Here is how that will happen:

Continue your hard work on quality improvement, culture change, innovative services, ethical business practices and transparency. This is the only path to progress! And punish only those who dont deliver.

Tell your policymakers about the success of your work and the impact of arbitrary cuts. Tell them where legitimate savings that improve quality can be achieved.

Tell your story of the great people who care for the most vulnerable every day and why they are one of the best investments in quality outcomes in all of health care. You have the thank-you letters, accolades and outcomes to prove it. And, tell them why your nursing home is absolutely an essential part of the health care family in every community.

Dont let policy makers recreate the darker era. Enough is enough!

We have made real progress!

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