Download Long-Term Care Issue Brief Change AGEnts

TheJohnA.HartfordFoundationChangeAGEntsInitiativeacceleratessustainedpracticechange
thatimprovesthecareofolderadults.ItdoesthisbyharnessingthecollectivepowerofTheJohnA.
HartfordFoundation’sinterprofessionalcommunityofscholars,clinicians,andhealthsystemleaders.
InDecember2015,nearly100JohnA.HartfordFoundationChangeAGEntsgatheredinPhiladelphia,
PAtoidentifychallengesandopportunitiesforimprovingcareofolderadultsinseveralcaresettings
andissueareas.EachgroupworkedtowardidentifyingactionableareasforJohnA.Hartford
FoundationChangeAGEnts,theFoundation,andcolleaguesinthefieldtopursue.Thebriefbelow
representsthesummaryoftheInstitutionalLong‐TermCaregroup'sproceedingsandshouldinform
futureworktocreatewidespreadandsystemicchangesinthecareofolderadults.
InstitutionalLong‐TermCare
Inthe1999OlmsteadDecision,theU.S.SupremeCourtupheldtherightofindividualstoreceive
careinthecommunity,asopposedtoaninstitution,wheneverpossible.Thisdecisionhasenabled
significantgrowthinarangeofhome‐andcommunity‐basedservicesforolder
people.Nevertheless,nearly1.5millionpeople,mostlywomenandtheso‐calledoldest‐old,still
resideinskillednursingfacilitiestoday.Improvinginstitutionallong‐termcarecontinuestobea
challenge,asthebroaderhealthcaresystemevolvesandskillednursingfacilitiesstrugglewith
staffing,carequality,andpaymentissues.
TheissuegrouponInstitutionalLong‐TermCaremetastheCentersforMedicareandMedicaid
Services(CMS)consideredaproposedrulethatwillupdateregulatorypoliciesgoverningthe
provisionofcareinlong‐termcarefacilities.AccordingtoCMS,theConsolidatedMedicareand
Medicaidregulationshavenotbeensystematicallyreviewedandupdatedsince1991,despite
considerablechangesincase‐mix,residentacuity,andconditionintensity,aswellasaplethoraof
qualityofcareconcerns.
Againstthisbackdropandtheopportunitiesitsuggests,thegroupcoveredawiderangeof
issues—somedirectlyaffectedbytheCMSreview,othersfocusedonrelatedtopics.Notably,there
wasrecognitionthatinstitutionalorresidentialcaretodaymustbeunderstoodwithinabroader
carecontinuumthatincludesacutecareandhomeandcommunity‐basedservices(thetopicof
thefinalissuebrief).Theworkahead,therefore,isnotjustaboutenhancingwhathappensin
skillednursingorrehabilitationfacilities,butaboutimprovingallkindsoflong‐termservicesand
supportsforolder,frail,chronicallyandseriouslyillpeople.
Challenges
Severalmajorlearningsandassociatedchallengesemergedfromthegroup’sdiscussion.These
included:

Confrontingageismandnegativestereotypesoflong‐termcare.Therewasarecognition
amongthegroupthatageistattitudesimpedeourabilitytobuildsupportforarangeof
improvementsinthecareofolderadults,bothinlong‐termcarefacilitiesandinother
places.“Whoamonguswantstogrowold?”askedonegroupmember.Theseunhelpful,
ingrainedstereotypesareamplifiedinlong‐termcare,wherethegeneralpublictoooften
viewslong‐termcarefacilitiesandtheirstaffnegatively.
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
Promotingculturechangeinskillednursingandotherlong‐termsettings.Traditional
nursinghomes,manyformedinthemiddleofthelastcentury,createdneededresidences
andservicesforolderpeople.Theseinstitutionalsettings,however,evolvedintoplacestoo
oftendesignedaroundschedulesandprocessesthatmattermoretothefacilitythanthe
olderadultswhoresidethere.Duringthelast15years,thePioneerNetwork,theGreen
HouseProject,andothershavestarteda“culturechange”movement,seekingtocreate
institutionallong‐termcarethatisbasedonperson‐directedvaluesandpracticesand
wherethevoicesofolderadultsandthoseworkingwiththemareconsideredand
respected.Improvingcareinthiswayinvolvesadiversesetofpracticalreforms.Group
membersnotedseveralexamplesofpracticalreforms:consistentassignment,shift
huddles,useofstafflearningcircles,involvingcertifiednursesaides(CNAs)incare
conferences,andfosteringfacility‐widecommitmenttoongoingqualityimprovementsthat
enhancethepatientexperienceandliftthestandardofcare.

Promotingsubstantiveworkforcereform.Centraltoimprovedcareforolderpeoplein
institutionalsettingsaretheclinicalandothersupportstaffwhoworkthere.Turnover
remainsasignificantissue,withsomeestimatesofaverageannualturnoverratesfor
registerednurses(RNs),licensedvocationalnurses(LVNs),andCNAsrangingbetween55
percentand75percent.Creatingopportunitiesforcareeradvancementandleadership
development,improvingpay,developingcertificates/certificationforaides,andensuring
24/7RNcoverageinlong‐termcarefacilities—allrepresentstrategiestoimprovethe
supplyandretentionoflong‐termcarecliniciansandstaff.

Managingsafetyvs.autonomy.Whileperson‐directedcareisacriticalgoalforinstitutional
long‐termcare,residentsandfamiliescanneverthelesshavediscordantviewsonwhatthat
means.Familieswantsafetyfortheirlovedones.Residentswantautonomyandchoice.
Long‐termcarereforms,includingthoseseekingculturechange,mustbalancethistension
tocreatesettingsofcarethatmeettheneedsandgoalsofolderadultsandtheirfamilies.

Needforapracticechangechampion.Previousreforms(e.g.,“HandinHand”fromCMS)
includedhelpfultoolkits,buttherewasinsufficientattentionpaidtowhowouldchampion
theseeffortsandhowthechangeprocesswouldbemanagedatindividualfacilities.
Practicechangeinitiatives,includingthoseledbyJohnA.HartfordFoundationChange
AGEnts,mustensurebuy‐infromtheDirectorofNursingorChiefNursingOfficerand/or
administrativeleadershipsothatevidence‐basedprogramsareimplementedina
meaningfulway.
Opportunities
Whilethechallengesfacinginstitutionallong‐termcarearesignificant,severalideasforpositive
actionemerged:

RespondingtothefinalCMSruleonlong‐termcare.TheJohnA.HartfordFoundationChange
AGEntsandotherpracticechangeadvocatesshouldbeinvolvedindevelopinginterpretive
guidelinesbasedonwhatemergesasthefinalCMSrule.Inparticular,regulationsfocused
onimprovingperson‐centeredcareshouldbeacknowledgedandpromoted.Beyondthe
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CMSruleitself,thereisaneedforamechanismthathelpscareprovidersinlong‐termcare
facilitiesstayinformedabouthowchangingregulationsaffectdirectcaretoolderadults.
Researchers,educators,healthplanadministrators,andfamilieshavesimilarinformation
needsoftheirown.Creatinganonlineresource/setofresourcestokeepthefield(and
ChangeAGEnts)abreastofawholerangeofpolicydevelopmentsinlong‐termcarewould
yieldsignificantbenefits.

Developingacompellingandsharedchangevision.Whilethereareasignificantnumberof
peopleandgroupsintheChangeAGEntscommunityandbeyondworkingonthisissue,the
groupnotedthatthereisnot,atpresent,acompelling,comprehensivechangevisionthatis
widelyacceptedandcancreateasenseofurgencyaroundimprovinglong‐termcare.This
gaprepresentsapowerfulopportunity.

ShapingqualityimprovementeffortstobenefitfrompopulationlevelpaymentsthroughACOs,
bundledpayments,value‐basedpurchasing,andothercapitatedarrangements.Financing
issuesforlong‐termcareremaincritical.Howcanpaymentsbestructuredtopromote
bettercare?Whatisthebestwaytoalignvaluepropositionssotheyworkbothforhealth
caresystemsandlong‐termcarefacilities?Therearemanyqualityinitiativesandmodels,
butlessunderstandingofwhatthefinancialreturnoninvestmentisforsystemsand
payers.Developingthesebusinesscaseswillbecriticaltomovingusefulchangeforward.

Advocatingfor24/7RNCoverage.Thereisthepotentialtoinstitute24/7RNcoveragein
long‐termcarethroughacurrentbill,H.R.952—“PutaRegisteredNurseintheNursing
HomeActof2015.”Thereisaguidingcoalitionbehindthislegislation,butassistanceis
neededtocommunicatethevision,generateshort‐termwinsthatwilldrivebipartisanand
bicameralsupport,andcontinuemomentumtodevelopbackingforthislegislation.
Drivingmovementtoperson‐centeredcare
Thechallenges—rangingfromconfrontingageistmisperceptionsaboutlong‐termcareamongthe
publictoreformingworkingconditionsinfacilitiessotheyattractandretainthebeststaff—are
formidable,butsoaretheopportunities.ThenewregulationsthatemergefromtheCMSreview
presentatremendousopeningforTheJohnA.HartfordFoundationChangeAGEntstodrive
movementfromoutdatedinstitutionalsolutionstoperson‐centered,homeandcommunity‐based,
long‐termservicesandsupportsforolderadults.
InstitutionalLong‐TermCareIssueGroupParticipants
JTaylorHarden,RN,PhD,FGSA,FAAN(SeniorRespondent)
NationalHartfordCenterofGerontologicalExcellence/GSA
AngeliaBowman,MS,MSPM(Facilitator)
HartfordChangeAGEntsInitiative
TheGerontologicalSocietyofAmerica
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GenaSchoen(Notetaker)
HartfordChangeAGEntsInitiative
TheGerontologicalSocietyofAmerica
HeatherAltman,MPH
UNCSchoolofPublicHealth
CarolWoodsRetirementCommunity
EricaAnderson,MA
TheNationalCommitteeforQualityAssurance
EvelynDuffy,DNP,AGPCNP‐BC
CaseWesternReserveUniversity
JackieEaton,PhD
UniversityofUtah
SharonFoerster,MSW
MaineHealth
CathyLieblich,MA
PioneerNetwork
WhitneyMills,PhD
MichaelE.DeBakeyVAMedicalCenter
BaylorCollegeofMedicine
GinnyPepper,PhD,RN
UniversityofUtah
TeriRound,BSN,MS,RN,NE‐BC
OklahomaUniversityHealthScienceCenter,
CollegeofNursing
HarryStrothers,MD
MorehouseSchoolofMedicine
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