Long Term Care Thoughts

Overview of Nursing Homes in the U.S. and Our New Rural PACE Program

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Aging with Aloha

“Aging with Aloha” a Community-Wide Effort

Dr. Bill Thomas, a distinguished physician and elder care scholar, recently spoke on

Maui

to family caregivers and professional caregivers.  His books including “Lessons from Hanna” and “What Are Old People For?” give us many questions to think about as we plan for services and facilities for frail elders.

Here is one:  “What gift do frail demented elders have for us?”  This is not a trivial question, nor a trick one.  The Maui Long Term Care Partnership has held many meetings in the past few years bringing together consumers and providers from around the island to discuss ways in which to provide long term care options for

Maui

’s age wave in the future.  What has emerged is the concept of “Aging with Aloha”.

The question Dr. Thomas poses to us calls us to consider our human nature.  Instead of “protecting” and isolating frail people who have trouble being present in person time and place we must find ways to integrate them with home and community based services.

For the gift they give is to stimulate the caring emotion in all of us.  As we institutionalize these beings we isolate them from ourselves.  Young people especially are losing touch with older people and so we may be raising a whole generation of children who think only of their generation.  Frail confused people are one of the golden threads that make up the fabric of our society.  As we institutionalize them we unravel this thread from the fabric of our community which is a contributing factor to the supportive community we all wish to live in.

This is one of the reasons that the Maui Long Term Care Partnership has sought to bring high school students interested in health careers to Maui Adult Day Care Centers and Hale Makua.  What we have learned from these students is that they were initially afraid of approaching frail order persons.  But, after the experience of assisting them with craft making, singing, dancing and hearing their stories they have told stories that show that they have much to learn from older persons and that frail, confused elders generate care and concern.  Care and concern for elders is a thread that keeps our community in harmony.  It is even more if this can be an elixir to the isolation, substance abuse and other ills that are plaguing our community.

The “Golden Thread” contributes to “Aging with Aloha”.  As we celebrate the Maui Senior Fair let’s also be mindful of the gift that frail confused elders have for us.  Let’s cherish our Kupuna! ("kupuna" -  a respectful hawaiian term for hawaiian for ancestor)

The challenge of starting a PACE Program

Received word this morning that Hale Makua has been been selected by the Centers for Medicare and Medicaid Services for funding to develop a Program of All Inclusive Care for the Elder (often knows as PACE). The grant of $500,000 is unusual in that it only is released after an application is submitted to the State of Hawaii for a PACE program, the state approves and forwards the application to the Centers for Medicare and Medicaid Services (CMs) and CMS approves the proposal.

So a lot of work is needed to craft a business plan that is feasibible to assume the risk that PACE lays over a PACE provider.  For more information on PACE see:  http://www.npaonline.org/website/article.asp?id=12

Hale Makua's third vision in its strategic plan is to: Create high quality, cost effective services and programs that serve the physical, spiritual, emotional and informational needs of our community. It also fits in with the strategic goals of the Maui Long Term Care Partnership which in part calls for: developing facilities, programs and services that meet the frail and disabled needs and preferences in our community. (see - www.mauilongtermcare.org for more information on the Maui Long Term Care Partnership) < Developing a PACE program is a way to achieve that goal. But it will require developing contractual and other partnership arrangements with local home and community based service providers and physicians to make it work.

This grant is a way to bring those organizations to the table to attempt to create a model the meets the needs and preferences of frail elders and the disabled who qualify for Medicare and Medicaid services in our community.

Quality Requires Resources

My colleague May Akamine, Executive Director of the Ko'olauloa Community Health and

Wellness

Center has been kind enough to keep me up to date on the editorials from Consumer Reports and a new commentary by  Guest written by Mary Jane Koren, M.D., assistant vice president, the Quality of Care for Frail Elders program at http://www.cmwf.org/aboutus/aboutus_show.htm?doc_id=392798&#doc392798.

Once again, you get some good advice on what to look for in a good nursing home and a call to action from consurmers to demand "better quality". Specifically she states: "Consumers must push industry to provide the kind of care America's elders deserve."

In my neck of the woods in our nursing facilities we work on quality consistently. But, we are finding that the strain to improve quality, increase staffing and develop a elder centered culture is caused not be lack of interest or committment but by a declining revenue stream. As costs go up faster than the increase in the infalation factor which Medicaid provides (and this applies to 80-90% of our residents), we find ourselves in a "no win" situation.  Dr. Bill Thomas was here at our facilities last month and he noted that culture change "is very hard work".  Boy, is that an understatment. But we are committed.  What Dr. Koren fails to acknowlege is that the majority of customers in long term care, that is the residents and their families do not pay for the cost of care. And yet, as time goes by customers are more educated, well read and therefore more demanding in what they expect from the nursing home industry.   Nursing homes are the most highly regulated industry below nuclear power. More regulations, more inspections, fines etc will not improve quality in the long run. What is needed is for the nursing home industry, government, consumers and consumer advocacy groups to sit down and re-design the system and the incentives for that system.   More on that later

Beginning

Recently I was challenged to start sharing my thoughts and experience about senior care, especially about challenges, best practices, and where we might be going in the future as we deal with the care of seniors and the disabled.  The suggestion came from Gloria Garvey of the Brand Strategy Group which was helping our organization to look at how to communicate more effectively with various aspects of the community.  So, here, I go.  Let me start by saying that  I hope that what I write here in the "blog" might stimulate some thoughts, ideas, interchange and maybe create some disagreement.  And, since I have never read a blog before, if you know of someone else in the "blog world" that is writing about similar issues, please direct me to their blog page.

I have also lived in Hawaii since I was 17 (I am now 58) and from time to time I might spin some yarn, reminisce or just provide some thoughts about our beautiful state and its people.

Consumer Reports - A scorecard on nursing homes

In the past week Consumer Reports has published an article which rates nursing homes in various states. The report indicated that generally non profit nursing homes (such as Hale Makua) generally provide better care than those operated for profit or by  companies that run numerous nursing homes. I went to the Consumer Reports website and I have to say that their criteria for choosing a good nursing home was better than most. Specifically, "check the ownership, read the  federal form 2567, don't rely on the federal website, visit the home at least twice, talk with the administrator " were all good ideas. The one I like most is to ask to read the 2567 form. This provides both the specific concerns cited by the state survey teams but it also provides the facility's;s response.The federal "nursing home compare" website only provide the general description of the "nursing facilities' deficiencies" but doesn't give you the opportunity to see what the facility had to say in its defense or what it plans to do about it.   I was disappointed when I went  to see which homes were listed for Hawaii in their web report on nursing homes. There were only two listed to consider and one to avoid. Of the two to consider one was actually a continuing care retirement center in a high rise with one floor of nursing home beds.  This facility is primarily for it's retirees  who pay  a $350,000 or more entry fee and $2,000-$3,000 per month to stay there. It's life care.  The other nursing home to consider wasn't a nursing home at all but what Kaiser Hospital called its skilled nursing beds within the hospital. Staffing for long term care beds in hospitals is usually far greater than in free-standing nursing homes.

Do You Get What You Pay For?

Every nursing home in the United States loses money on every Medicaid patient they admit. In Hawaii the difference between the daily cost of care and the Medicaid reimbursement for that care is a loss of $11.40 a day.  Eighty to ninety percent of Hale Makua's residents in its two nursing facilities are Medicaid recipients.  And, as our private paying clients look for care at other  service delivery systems such as retirement centers  and assisted living, we are finding it hard to stay solvent. Our board is working with me on other ideas but I must say that the financial squeeze is tighter than I've ever seen it in the 25 years that I have been here.  Residents and their families have much higher expectation of our direct care staff, our food service etc. etc. And yet most folks do not pay for their care and rely on government assistance. So what's the answer. I'll have some thoughts on this in future blog sessions..... that is.. if I can keep up the discipline to keep writing while doing my real job.