For example, take the story of Poland native Barbara Latasiewicz who suffered a stroke in September 2009 and was taken by ambulance to Adventist La Grange Memorial Hospital in Illinois. Latasiewicz suffered paralysis on one side of her body, but eventually became well enough to leave the hospital. However, more than two years later, the 62-year-old was still in the hospital.

"She hasn't needed to be in this acute facility for a long time," explained Richard Carroll, the hospital's chief medical officer.

Carroll said that Latasiewicz belonged in a skilled nursing facility where she would receive a more appropriate rehabilitation, but she had no way to pay because she had no insurance and was an undocumented resident with no access to government safety-net programs like Medicaid. Without payment, no facility would take her.

Her care cost the hospital $1.4 million, when a skilled nursing facility would have been a fraction of the cost. The hospital had to swallow that debt, went to court and was finally granted permission to send Barbara to a medical facility in Poland. 

This situation is unique in that Barbara was an undocumented resident. Most Americans would be covered by Medicare or Medcaid. But by going back to Poland, Barbara left behind most of her family. When patients are not sick enough for acute care, but cannot afford long-term care and have nowhere to go, what do you think is a reasonable solution to the problem?

The following is a guest blog from Anthony Cirillo, FACHE, ABC:  

With all the interest in patient/resident experience, a new study in the Archives of Internal Medicine shows that an overemphasis on satisfaction could have unintended consequences.

In fact, while satisfied patients used the ED less, they also had the highest mortality rates, highest admission rates and used the most healthcare resources. This is important to know, as non-hospital providers become bedfellows with hospital partners. In a world of ACOs, bundled payments and punishment for readmissions, providers are increasingly tied to their hospital partners and others in the continuum of care.

It is important to recognize that service not be confused with medical decision-making and what is right for the resident/patient.

It seems that "frequent flyer" patients naturally become attached to their provider and that bond probably leads to higher satisfaction, perhaps more so than with first time patients.

The article notes that physicians whose compensation is linked to patient satisfaction might deliver more discretionary services leading to harm. Satisfying an experience may not necessarily be solving the healthcare problem.

Brenda Sirovich, MD, from the Department of Veterans Affairs Medical Center in White River Junction, Vermont, in an accompanying invited commentary stated: "Practicing physicians have learned - from reimbursement systems, the medical liability environment, and clinical performance scorekeepers - that they will be rewarded for excess and penalized if they risk not doing enough.... It is time that we, as a profession and as a society, take responsibility for controlling this unrestrained system, by working to overcome the widespread misconception that more care is necessarily better care and to realign the incentives that help nurture this belief."

With so much emphasis on culture change and person-centered care, it would not be surprising that the nursing and assisted living industry gets caught up in creating the super-satisfied resident, patient and family member. Fine dining, honoring preferences, treating people with dignity, having upscale furnishings, beautiful landscapes and more are all laudable. But at the core, we are in the health care business and health is what we need to make sure we remember.

Is making the healthcare experience better contributing to the better health of residents? In most cases of course it does. But we should pause to consider this study and also consider how we make our care partners accountable. After all that patient/resident is touched by many people and entities.

Anthony Cirillo is the about.com expert in assisted living. A speaker, health care consultant, senior advocate and blogger, he consults with long-term care facilities and is available for management retreats and association keynotes. He is the author of "Who Moved My Dentures?" His company, Fast Forward Consulting empowers organizations to change the healthcare experience and leverage it in their marketing. For more information go to More atwww.4wardfast.com.

We've compiled our top 10 favorite tweets from accounts we follow on Twitter. Be sure to follow ADVANCE for Long-Term Care Management by going to　@ADVANCEforLTC!

@CambridgeCap - Interesting statistic: 40% of residents of residential care communities are assisted with three or more activities on a daily basis.

@AdvanceLTCJobs - New #LTCjob! Director of Nursing: CECG Health Care is a leading nationwide employment firm having many dynamic …http://t.co/zYq9xOrU  

‏@EverydayHealth - The fat gene, identified: http://t.co/RX7gjXSy

 @SandyAlz - Protecting your gray matter from Alzheimer's can be a fishy proposition. http://t.co/Kqmcd4nM

@SunriseSrLiving - Celebrate the warm weather with our Quadrangle community's Crab Cakes recipe! http://t.co/5dYiUabx

@LeadingAge - 196 days until Election Day #PEAK12

@AGE - Eating Berries Might Help Preserve Your Memory. http://t.co/HxUxYY6s

‏@ahcancal - We learned some good news this morning: CMS will be issuing an Update Notice on the FY 2013 SNF PPS... http://t.co/iFjoGavj  

@ALFA_Online - Survey Results: Overwhelmingly–Residents of independent & assisted living feel as if they are getting good value for $ http://t.co/WxMWvbLr

@Eldercare911 - Set boundaries to avoid family disruptions at work http://t.co/nccSD6pi

The following is a guest blog from Anthony Cirillo, FACHE, ABC:

The Affordable Care Act has freed up $3 billion in grant money available to states looking to keep elderly and disabled individuals out of long-term care facilities. New Hampshire will be the first state to receive a grant.

"No one should have to live in an institution or nursing home if they can live in their homes and communities with the right mix of affordable supports," said Cindy Mann, director of the CMS Center for Medicaid and CHIP Services.

No matter how much the industry fights, it is inevitable that people want to age-in-place. My argument has been that there will always be people that need the acute level of care offered by skilled nursing facilities. And while I still believe that as a society we do not take self-responsibility, where chronic disease is rampant and obesity becoming the epidemic du jour, it is also true that technology and support services are increasing at such a rapid state that perhaps people with acute needs can age in place.

Of course there is still a lot of confusion in the industry and coordination of services is far from ideal. So perhaps the industry has some time to figure out their next move.

Some already have by moving into the rehabilitation business. And while hip and knee surgeries are predicted to grow phenomenally, not every person will need skilled rehabilitation care and more of this will move to outpatient setting.

Then with the number of nursing homes almost triple that of hospitals, not every skilled provider will be a fit for a hospital. In the era of accountable care, culture fit, patient experience and clinical quality will be the indicators that hospitals will use to pick their skilled nursing partners.

I see three scenarios.

First, there will be more mergers and acquisitions as well as facility closings.

A select few will excel in the rehabilitation arena.

And a visionary microscopic few will understand that they need to extend their brand by developing service and product offerings that cover more of the continuum of care.

Still, many will do nothing and one of these scenarios will occur naturally. I see it on the hospital side of my business. While many hospitals are becoming leaner and improving quality, few are preparing for an inevitable shift to wellness, bundled payments and the reality the empty hospital beds, long talked about, will indeed be the norm.

Where do you fit?

Anthony Cirillo is the about.com expert in assisted living. A speaker, health care consultant, senior advocate and blogger, he consults with long-term care facilities and is available for management retreats and association keynotes. He is the author of "Who Moved My Dentures?" His company, Fast Forward Consulting empowers organizations to change the healthcare experience and leverage it in their marketing. For more information go to More atwww.4wardfast.com.

We've compiled our top 10 favorite tweets from accounts we follow on Twitter. Be sure to follow ADVANCE for Long-Term Care Management by going to　@ADVANCEforLTC!

@ahcancal - AHCA applauds CMS initiative on reducing antipsychotics. Dr. Gifford: "As care providers, we need to listen."　http://t.co/MOP1nMul

@Caring - Boomer caregivers assisting seniors w/ medications: 55% tracking to avoid missed doses; 50% giving pills, injections　http://t.co/8VHcFUS8

@LeadingAge - Our LeadingAge This Week newsletter is online:　http://t.co/qifTeEVs

@ALFA_Online - #ALFA2012　Conference Session Highlight: The Rise of the Food Network & its Effect on Resident's Dining Expectations http://t.co/ciofnLhh/ohttp://t.co/ciofnLhh/t_blank.

@ACHCA - Connect with LTC leaders on ACHCA's members-only Peer2Peer network. Discussions cover topics impacting LTC today.http://www.achca.org/index.php/component/content/article/36-join-or-renew/69-p2p-resources

@RetirementMedia - Advantages of City Living For Retirees, Atlanta - Chicago - Dallas, Phoenix - more City Retirement Living　http://t.co/UIt2Rtfm

@HealthCareGov - The ACA makes medications more affordable for Seniors -- David, pharmacist from PA. Watch David's　#MyCare　story: http://t.co/yQyC6eLv/ohttp://1.usa.gov/HkWKHA/t_blank

@Eldercare911 - RT　@PattyGrace　Dementia, From the Inside: new film attempts to see life through the eyes of someone w Alzheimer's.　http://t.co/AQVsc6Tm/ohttp://t.co/AQVsc6Tm/t_blank

@DrOz - Physical exercise is the most important predictor of a long, healthy life. Check out my 7 min workout:　http://t.co/rTOJ79Sf/ohttp://bit.ly/w1q7Im/t_blank

@SeniorALFs - Three Couples Re-New Their Wedding Vows at Assisted Living Facility: Three married couples in an Inland Valley http://t.co/mXktD9FK/ohttp://bit.ly/Hj3JMo/t_blank

The following is a guest blog by  Brian M. Clifford, Esq.:

"We're guaranteeing homecare workers minimum wage and overtime pay protection. We are going to make sure that over a million men and women in one of the fastest-growing professions in the country don't slip through the cracks. We're going to make sure that companies who do right by their workers aren't undercut by companies who don't. We're going to do what's fair, and we're going to do what's right.." - President Barak Obama, December 15, 2011.

The Fair Labor Standards Act ("FLSA") exempts from the Act's minimum wage and overtime provisions domestic service employees who are employed to provide companionship services for individuals who (because of age or infirmity) are unable to care for themselves. The United States Department of Labor, which is charged with implementing and enforcing rules under the FLSA, has issued its proposed rule changes that would provide minimum wage and overtime protections for roughly two-million workers who provide in-home services for aged and infirm persons. The proposed rules are to be codified at 29 C.F.R. § 552 et seq.

OLD RULES

Under the old rules, workers who performed companionship services were exempt under the FLSA. "Companionship Services" was defined as fellowship, care, and protection for a person who, because of advanced age or mental or physical infirmity, cannot care for his or her own needs. The old rules did not clearly define the tasks that may be deemed exempt companionship services and allowed both third-party employers, as well as the individual or household employers using the services, to take advantage of the exempt status. The DOL has noticed that a growing demand for long-term in-home care has led to a substantial growth of the in-home care services industry. The DOL's analysis predicts that the industry will continue to grow 50% between now and 2018. The DOL states that the current rules are outdated because "workers who today provide in-home care to individuals are performing duties and working in circumstances that were not envisioned when the companionship services regulations were promulgated."

NEW RULES

The two important purposes of the new rules are to more clearly define the tasks that may be performed by an exempt companion and to limit the companionship exemption to those employees who are employed only by the family or household using the services. First, the new rules define "companionship services" as the provision of "fellowship" and "protection" for persons that, because of advanced age or physical or mental infirmity, are unable to care for themselves. "Fellowship" is now defined as engaging the person in social, physical, and mental activities, including conversation, reading, games, crafts, walks, errands, appointments, and social events. "Protection" is now defined as being present with the person in their home or to accompany the person when outside of the home to monitor the person's safety and well-being. The new rules also include a provision limiting the amount of "incidental" services that a companion may do for the aged or infirm person to 20% of the total hours worked in a week. The rules provide a non-exhaustive list of services that would be considered incidental services including: dressing, grooming, toileting, driving, feeding, laundering, and bathing. Incidental services do not include personal services benefitting others within the household other than the aged or infirm person and do not include medical care for the aged or infirm person. The rules state that medical care includes, but is not limited to, catheter and ostomy care, wound care, injections, blood and blood pressure testing, turning and repositioning, determining the need for medication, tube feeding, and physical therapy. Exempt companions may remind the aged or infirm person of appointments or a predetermined medicinal schedule.

Second, the new rules mandate that companions employed by third-party employers, such as staffing agencies and health care providers, will no longer be able to claim the exemption under the FLSA. This applies even where the employee is jointly employed by the third-party employer and the individual or family using the services. On the other hand, the individual or family employer may assert the exempt status if the employee meets all of the new requirements even when a joint employer relationship exists with a third-party employer.

WHAT TO DO AS AN EMPLOYER

The first major change more clearly defining "companion services" will likely affect both third-party employers and individual or family employers in the same manner. Both types of employers will need to assess the services and tasks performed by their employees to determine whether the employee is exempt under the new rules. Moreover, both employers will need to track the hours spent on incidental services to ensure that their employee is not spending more than 20% of the work week performing those incidental services. Individual or family employers do not need to worry about wages and hours worked if their employee is only performing "companion services" and performing less than 20% of incidental services.

The second major change, which restricts third-party employers from claiming the exempt status under the FMLA, places a significant burden on third-party employers. Now, third-party employers must track the total number of hours worked by companion service employees to ensure they are being paid the proper wages for the hours worked, including any overtime compensation. Merely maintaining a work agreement with these workers will not be sufficient under the new rules.

The following is a guest blog from Anthony Cirillo, FACHE, ABC:

I had an opportunity to read the draft of the National Alzheimer's Plan. And I thought for the most part it was comprehensive in its approach. I was dismayed a bit by what I perceived to be a lack of emphasis when it came to the family caregiver.

Here is the section I question:

Strategy 3.B: Enable Family Caregivers to Continue to Provide Care While Maintaining Their Own Health and Well-Being

Even though informal caregivers usually prefer to provide care to their loved ones in their home or other community settings, eventually the round-the-clock care needs of the person with Alzheimer's disease often necessitate nursing home placement. While they are providing care, supports for families and caregivers can help lessen feelings of depression and burden and help delay nursing home placement.

Examples of actions to further support informal caregivers are identifying their unmet support needs; developing, disseminating and expanding interventions; and highlighting supports during crisis situations.

It almost sounds dismissive. Are they suggesting by using the word "prefer" that the proper setting for the Alzheimer's patient is not at home? And while it recognizes that support for the caregiver is needed when they are caring for a loved one at home, it does not seem to recognize that care for the caregiver does not stop there.

Just because someone with Alzheimer's moves to a more acute residential setting does not mean that the burden for the caregiver lessens. In fact it increases. Diligent caregivers are the reasons why some nursing home residents do well while those without advocates sometimes don't.

As one example, according to a policy brief by the University of California, Los Angeles, Center for Health Policy Research, the estimated 6 million informal caregivers in California show serious psychological distress and negative health behaviors.

According to UPI.com, the study finds:

• 25.5 percent of middle-age caregivers are more likely than older or younger caregivers to binge drink.
• 16 percent are more likely to smoke and 30 percent are more likely to be obese.
• Caregivers of all ages who reported serious psychological distress were 208 percent more than non-caregivers to smoke.
• Nearly one-third of middle-aged caregivers are single, divorced or widowed, and more than two-thirds hold down full- or part-time jobs.

The National Alzheimer's Plan should recognize that caregiving is a full time responsibility that unfortunately does not end until a loved one passes. And some caregivers precede that loved one in death.

And, it is the responsibility of every provider in the aging services sector to care for the caregiver. There is a myriad of resources out there. How are you as an aging services provider plugged into the resources that can help caregivers in your community? You should be.

Anthony Cirillo is the about.com expert in assisted living. A speaker, health care consultant, senior advocate and blogger, he consults with long-term care facilities and is available for management retreats and association keynotes. He is the author of "Who Moved My Dentures?" His company, Fast Forward Consulting empowers organizations to change the healthcare experience and leverage it in their marketing. For more information go to More atwww.4wardfast.com and www.anthonycirillo.com.　

If you hold happy hours at your assisted living or CCRC--as many high end comunities do--do you monitor how much alcohol residents consume? A new study from the University of Pittsburgh reveals that nearly 70 percent of older adults in assisted living communities drink alcohol, and more than a third drink on a daily basis. This behavior could lead to safety issues, such as wandering and falls, and health concerns for those with diabetes and high blood pressure.

The following is a guest blog from Anthony Cirillo, FACHE, ABC:　　

The for-profit versus not-for-profit debate - research continues to suggest that higher quality is associated with the not-for-profit sector. In reviewing studies from the last year, consider this. (editors note: Read a column on this: http://long-term-care.advanceweb.com/Columns/Gerotalk/Study-Finds-Largest-For-Profit-Nursing-Home-Chains-Providing-Lesser-Care.aspx)

A study by the University of California at San Francisco research team led by Charlene Harrington, RN, Ph.D., and backed by the Service Employees International Union, suggests that lower levels of nursing staff in large for-profit nursing home chains have resulted in substantially lower quality of care when compared to government-owned or non-profit nursing homes.

Researchers compared staffing levels and facility deficiencies received by the United States' 10 biggest nursing home chains, versus facilities run by five other types of ownership groups. Between 2003 and 2008, the for-profit facilities had fewer nurse "staffing hours," researchers said. The 10 largest nursing home chains received 36 percent more deficiencies from regulators, according to the study. Additionally, the for-profit sites received more deficiencies after being purchased by private equity groups than before the purchases.

Next.

According to the Centers for Medicare and Medicaid Services (CMS), as reported in the American Journal of Infection Control, CMS cites 15 percent of nursing homes each year for deficiencies in infection control. Infections contribute to more than 380,000 deaths annually among nursing home residents, and cost estimates associated with such infections can reach as high as $2 billion.

Researchers analyzed eight years of data, looking for infection control, or F-Tag 441, citations. The number has actually trended upward, increasing from 12.87percent in 2000 to 17.31 percent in 2007, according to the study.

Interestingly enough, researchers say that infections rates correlated strongly with low staffing levels and nursing homes' for-profit status.

Next.

The Center for Medicare Advocacy recently evaluated Special Focus Facilities (SFFs) from the list released by CMS. It concluded that self-reported quality and staffing information from nursing homes categorized as Special Focus Facilities is unreliable and should not be published on Medicare's Nursing Home Compare website.

According to the report, the overwhelming majority of SFFs (45 of 47 facilities, or 96%) are owned on a for-profit basis.

The Center compared the star ratings for a sample of SFFs, evaluating the ratings for health surveys (independent outside reviews), staffing (self-reported), quality measures (self-reported), and composite ratings. The Center hypothesized that SFFs would report high levels of staffing and high quality measures.

All SFFs had low star ratings on health surveys. However, SFFs reported considerably higher nurse staffing and quality measures, resulting in higher star ratings on those two domains than on the health survey domain.

With a move to aging in place and less acute settings, it is only natural that some natural selection take place. I would envision chronic SFFs eventually close as the marketplace demand goes down and consumers become savvier about shopping for care.

Reports like this do not help the industry a whole lot. What baffles me is that I seldom read about the industry's response to the research. And that is particularly baffling when more and more research comes out against for-profit facilities in an industry dominated by them. This is your public relations at stake, your brand. Unfortunately people can poke apart an ad campaign by pointing to the myriad of studies continuing to suggest that for-profit nursing homes have poorer quality. And of course going with that is the unspoken - for-profits only care about the money.

While I do not believe that, remember we are working with perceptions out there. And the long-term care arena has a huge image problem especially in the for-profit sector.

Anthony Cirillo is the about.com expert in assisted living. A speaker, health care consultant, senior advocate and blogger, he consults with long-term care facilities and is available for management retreats and association keynotes. He is the author of "Who Moved My Dentures?" His company, Fast Forward Consulting empowers organizations to change the healthcare experience and leverage it in their marketing. For more information go to More at www.4wardfast.com and www.anthonycirillo.com.　

We've compiled our top 10 favorite tweets from accounts we follow on Twitter. Be sure to follow ADVANCE for Long-Term Care Management by going to @ADVANCEforLTC!

@NAD0NA - 2012 Long-Term Care Salary Survey on ADVANCE for Long-Term Care Management　fb.me/IC2ix0Wy

@seniorhomes - Mild Memory Problems May Be More Common in Men　bit.ly/z8eC9P

@SandyAlz - Activities to share with your Dementia or Alzheimer's loved one - Alzheimer's Support　bit.ly/aOFBya

@AlzGA - Government seeks $1 Trillion campaign against　#alzheimersbit.ly/whycPK　video via　@CBSNews

@LeadingAge - Interested in the latest news on assisted living and retirement communities? Our January newsletter is online:　bit.ly/w6syys

@ahcancal - What's the State of Long Term and Post-Acute Care in your state?ow.ly/8Dw2Z　#ltcstate

@PtSafety1st - Nutrition and Hydation week: a taste of patient safety. 23-29 Jan 2012. Find out more　bit.ly/vf1coh

@BrookdaleLiving - Wish of the Week: JC, a resident of Sterling House Medical Center, is a lifelong diehard NASCAR fan! Check out his wish　bit.ly/yViynp

@ALFA_Online - The Senior Living Art Showcase has 108 submission from incredibly talented residents! Thank you to all participants!　alfa.org/art

@AlvaroF - Q&A on Online Course: How to Be Your Own Brain Fitness Coach in 2012: We have received many excellent questions ...　bit.ly/zESbfl

Why has the long-term and post-acute care (LTPAC) market been slower than other providers to adopt and implement electronic health records (EHRs)? One reason is that, unlike most physicians and hospitals, long-term care providers do not qualify for the significant financial incentives offered through the American Recovery and Reinvestment Act (ARRA) if they adopt certified EHRs that meet the meaningful use criteria of the Department of Health and Human Services. 

Nonetheless, we in the LTPAC community have other, equally compelling incentives to adopt EHR systems that can improve the quality and cost-effectiveness of care and also meet the increasing demand to share patient care information with other providers.  

Once we make the decision to convert our paper records into electronic ones, how can we be sure that our EHRs also will meet federal meaningful use criteria?  One way is to consider an EHR that is certified by the independent, not-for-profit Certification Commission for Health Information Technology (CCHIT®), which has developed the first EHR certification program specifically for the LTPAC market. 

The voluntary work group that developed the CCHIT Certified^® program was co-chaired by the president of the National Association for the Support of Long-Term Care and included LTPAC providers and other clinicians, HIT developers and other industry stakeholders, and consumers. 

CCHIT Certified products meet and exceed federal requirements and CCHIT's core LTPAC certification is applicable to all LTPAC providers. There also are optional add-ons for skilled nursing facilities and home health.

What are the benefits?

If we choose wisely, EHRs can offer LTPAC providers a number of important benefits, including: 

• Easier access to patient diagnostic, treatment and demographic information
• Automated alerts that allow staff to respond quickly to changes in a patient's condition
• Time savings in documenting care, obtaining patient records, processing physician orders and reading care givers' notes
• Greater ease in tracking quality indicators
• Improved documentation that may support higher research utilization groups (RUGs) and increase reimbursement.
• More rapid information exchange that can improve diagnosis and treatment, enhance coordination of care and streamline transactions with payers

What to look for in an EHR.

The basic qualities to assess when choosing an EHR are: 

• Functionality - what the product "does," such as the ability to create and manage electronic records for all your patients, as well as automate the workflow in your facility.
• Interoperability - how the product exchanges information with other products, such as the IT systems of physicians and hospitals.
• Security - the product's ability to protect your patients' privacy and provide secure and easy access for authorized providers.

Preparing for the future.

Interoperability between your EHR and those of other providers is particularly important as we prepare for the new health care system that is rapidly becoming a reality in the U.S. - one where care is integrated, coordinated and seamless.  We must have the tools needed to share information with physicians, hospitals and other LTPAC providers and to participate in partnerships with hospitals, accountable care organizations and health information exchanges. 

While there are many EHRs on the market from which to choose, it's important that we choose wisely.  The systems we invest in should be tested and certified against industry and government standards and support the needs of our patients, both now and in the future. 

Whatever products we choose, it can take up to a year to research and fully implement an EHR system.  The time to get started is now. 

The following is a guest blog from Anthony Cirillo, FACHE, ABC:　　

A survey by the American Association of Nurse Assessment Coordination reveals that overall job satisfaction has dropped among long-term care workers. It may be related to MDS 3.0 assessments that are taking longer to complete. Job satisfaction dropped an average of 10 points between 2009 and 2011.

That surprised me in light of My InnerView results that show increased staff satisfaction. But here is what really bothered me. Nearly 60% of survey respondents were nurse assessment coordinators or MDS coordinators, directors or assistant directors of nursing, administrators, corporate directors/consultants and reimbursement specialists. In other words, these are high-level positions in the organization.

When there is dissatisfaction among leadership that is bound to affect morale and satisfaction down the line.

According to Kevin Eikenberry, a leadership coach, "Dissatisfaction is simply a state where people wish something was better or different. It's a sense that the status quo isn't comfortable or in the best interest of that individual or group. Leadership is about moving people towards a result, an outcome or a goal. If the present situation was perfect, there would be no need for leaders - the status quo would be creating perfect results. Since there is no "perfect" and nirvana exists only in fiction, leaders are required.　 And the leader's work is to move (or lead) people towards something better."

That is great if you are not in a leadership role in the organization. You look to your leaders for answers. But what if the leadership is also looking for answers? Who leads the leaders?

According to Gallup, effective leaders are scarce. And leaders who are effective in leading other leaders are even rarer. And John C. Maxwell offers this - "To add growth, lead followers. To multiply growth, lead leaders."

I don't have an answer here. But I do know that in a time of increased regulation and decreasing reimbursement, dissatisfaction can thrive. And when it infects the top of the organization it can spell doom. Perhaps there is some natural selection and weeding out that has to take place in the industry. That will leave the organizations that have a thrive mindset to care for our seniors. And if they bring that kind of attitude to the table, well that is where I would send my mom.

Anthony Cirillo is the about.com expert in assisted living. A speaker, health care consultant, senior advocate and blogger, he consults with long-term care facilities and is available for management retreats and association keynotes. He is the author of "Who Moved My Dentures?" His company, Fast Forward Consulting empowers organizations to change the healthcare experience and leverage it in their marketing. For more information go to More at www.4wardfast.com and www.anthonycirillo.com. 

As 2011 comes to an end, many of us are reflecting on the year's accomplishments and shortfalls. As tradition holds, many of us are also examining what we can resolve to do better in 2012.

I try not to limit myself to one single resolution, but to improve as many aspects of my life as I can. USA.gov lists the most popular New Year's resolutions, and provides these resources to help you achieve your goals.

• Drink Less Alcohol
• Eat Healthy Food
• Get a Better Education
• Get a Better Job
• Get Fit
• Lose Weight
• Manage Debt
• Manage Stress
• Quit Smoking
• Reduce, Reuse, and Recycle
• Save Money
• Take a Trip
• Volunteer to Help Others

We've compiled our top 10 favorite tweets from accounts we follow on Twitter. Be sure to follow ADVANCE for Long-Term Care Management by going to @ADVANCEforLTC!

@LeadingAge - We live to fight another day! RT @ctffox: #CLASSAct remains safe from repeal for rest of the year ow.ly/8027t

@Caring - How to Handle Holiday Travel & Celebration Problems for People w/ Alzheimer's & Other Dementias: bit.ly/hiA7Fl #ALZcare　#eldercare　

@DrOz - One in four people feel lonely over the holidays. @YouBeauty has six ways to help you avoid this isolated feeling. bit.ly/swl2kl

@Disabilitygov - Arthritis Pain Reliever - learn about the benefits of physical activity & how much exercise is recommended 1.usa.gov/tn531A

@USATYourLife - Brain stimulation may help some stroke patients usat.ly/rLm9oT

@AARPPA - You're making me sick (and other reasons you should wash your hands) aarp.us/szEGuj

@carecompliance - There has been an increase in the number of young nurses entering the profession, but is it enough?　alfa.org/NewsBot.asp?MODE=VIEW&ID=2144

@GracefulAging - Get More Yin for Your Yang: #TaiChi Graceful Aging Video bit.ly/tc9NNl

@ahcancal - Nursing facility providers receive a lump of coal this Christmas - $6.3B in #Medicaid shortfalls ow.ly/80xw2 #carenotcuts

@aegistherapies - Boosting your heart health isn't all about your cholesterol ow.ly/7ZB0W