ADVANCE Perspective: LTC : Nursing Home

Guest Blog: An Idea Whose Time Has Come

Liz Rosto — Tue, 17 Nov 2009 17:07:00 GMT

The following is a guest blog from Kevin R. McMahon:

Multi facility nursing home organizations have a fairly standard arrangement that centralizes the operating authority over individual nursing facilities in a regional office. The regional office through operational directors oversees the operation of individual facilities. Facility administrators in this arrangement report directly to a regional director.

While the division of operational authority between the regional and the facility varies widely the regional is universally viewed as the ultimate source of decision making authority.

When this authority is widely accepted and acknowledged by other regional staff (consultants and the sort) as well as facility staff the power and authority of the facility administrator and management staff is undoubtedly diminished.

This situation can easily become an incubator for passivity and detachment on the part of the facility administrator and management staff. When this attitude is fully evolved the administrator and management staff may come to adopt a world view that says things like, "It's your business" (I just work here), "It's your problem" (I have no incentive to think or solve it for you), "It's your decision" (I am resigned to interminable processing and being spoon fed the answer), "It's your world" (The experts at "corporate" will explain our world to us).

Obviously these are extreme views. However, I would posit that variations on these views run as an undercurrent through the minds and worlds of facility managers who are micro managed to varying degrees by regional office staff.

On a good day the end result of these attitudes is the normal cynicism and disenchantment that runs rampant through the world of business. On a bad day things can go horribly wrong and facility managers can and do loose their jobs. Ultimately resident care and services are adversely affected and the forward progress of the facility is stymied.

At one point in my career I worked for a company that experimented with an alternative arrangement to the centralized regional model for controlling the operation of far flung nursing centers. I came to refer to myself and other administrators fortunate enough to work in this situation as Independent Operators. I have come to the realization that this arrangement makes a lot of sense on many different levels in many different organizational contexts.

The Independent Operator concept hinges on an administrator who has shown an inclination and ability to work without the close and direct supervision of a regional director. They are provided with broad operating parameters and expectations and allowed to move their facility toward these goals by exercising independent judgment. Their decision making authority would mirror that of the regional director in the traditional model.

The Independent Operator would report to an individual (not the Regional Director) who would act as the representative of the owner of the facility (Owner's Rep). The mindset of the Owner's Rep would be akin to that of a banker making ongoing assessments about whether to continue the funding for the facility being run by the Independent Operator. In this case the decision by the Owner's Rep is whether or not the Independent Operator continues to be employed operating his/her building.

The main advantage of the Independent Operator concept is the opportunity to energize and empower the Administrator and the management team in his/her building to achieve success in meeting financial and operational goals.

The central aim is to move the management team in the facility to a world view that says things like, "This is my (our) business", "This is my (our) problem", "This is my (our) decision", "This is my (our) world". By making this subtle but ground shaking change in attitude the management team in the facility can truly bring their creativity to bear on problems, react quickly to situations, and use their indigenous knowledge and insights into people and situations on the ground to guide their actions and decisions.

In addition to the above, the Independent Operator concept would provide a career path for capable administrators who enjoy being an administrator and the personal connectedness that comes with being in a facility. It would also serve as a recruitment tool as companies strive to hire the best and the brightest.

Finally should an Independent Operator not meet the expectations of the Owner's Representative and a change is indicated this decision becomes much more palatable for all concerned. When I worked as an Independent Operator I was at peace with the possibility of being terminated because it was my decisions and actions that would have precipitated this action (not the decisions and actions of others from the regional office).

The concept of Independent Operator need not be an all or nothing proposition. One possible strategy would involve the identification of current Administrators who could operate as Independent Operators. These individuals would be assigned a new person to report to (Owner's Rep) and start charting their own course within the operating parameters spelled out for them.

Going forward Regional Directors could be offered financial incentives to hire and train Administrators capable of becoming Independent Operators. This would allow the culture of the organization to change over time to one that esteems independent thought and action.

In the traditional centralized regional model the authority given to facility staff is limited and not commensurate with the ultimate accountability demanded. The Independent Operator model seeks to more closely align the accountability required of facility managers and the authority given to do their jobs.

The Independent Operator concept is by no means a panacea. It is, however, an attempt to take full advantage of the existing management talent in nursing facilities while at the same time attracting self starting, creative, and independent thinking/acting individuals into the field of long term care administration.

Kevin R. McMahon the administrator at the Merriman, Akron, Ohio, part of the Provider Services family. He can be reached at kmcmahon@the-merriman.net.

Caught in the Middle

Liz Rosto — Fri, 30 Oct 2009 13:11:00 GMT

A new study from PHI, a national non-profit organization working to strengthen the health care services workforce, reveals that less than one-fifth of Massachusetts direct-care workers (nursing home assistants, home health care aides and personal care attendants) are enrolled in employer-sponsored health insurance plans.

The primarily reason for the lapse in coverage is that it's too costly. The study found that most employers in this sector offered insurance but their direct-care employees did not enroll.

The reason: many workers are caught in a bind. If they are offered employer-sponsored health coverage, direct-care workers, whose wages primarily come from public programs such as Medicare and Medicaid, cannot access Massachusetts' less-expensive subsidized health insurance programs.

This scenario is all too common for low income workers. They don't make enough money to afford health insurance, but they make too much to qualify for public assistance. We all know that a strong work ethic is valued in American society, so why are these workers being left behind adn what can we do to change it?

"While considering proposals to expand access to health care coverage, Congress must heed what we learned from the Massachusetts model: it has done nothing to lower the cost of employer-sponsored health coverage, making it prohibitive for low-wage, direct-care workers and their employers," PHI government affairs director Carol Regan said in a press release.

Nationally, there are 3 million direct-care workers and the number is projected to grow to 4 million by 2016, becoming thenation's single largest occupational group.

In Coverage for Caregivers: Lessons from Massachusetts Health Reform, researchers recommend the following provisions should be included in health reform legislation:

Support the inclusion of a national, publicly operated health insurance option.
Allow all eldercare/disability service employers access to the proposed insurance "exchanges" or "gateways" regardless of size.
Ensure adequate federal subsidies to low- and moderate-income workers and their families.
Expand Medicaid to include all individuals earning up to at least 133 percent of the federal poverty level.

Futile end-of-life care

Maureen Salera — Fri, 16 Oct 2009 17:42:00 GMT

Two new studies from The New England Journal of Medicine indicate that nursing home residents may be receiving futile care measures at the end of their lives.

In one study, doctors examined health records of 3,702 nursing-home residents across the nation who started dialysis between 1998 and 2000. While the average age was 73, many had other health problems, including diabetes, heart disease and cancer. Within the first year, 58 percent died and 29 percent declined in their ADL ability.

The second study followed 323 people with advanced dementia from nursing homes in the Boston area. Their average age was 85 and they could not recognize loved ones or walk or talk. One out of four died within six months and half died during the 18 months they were followed.

As this article points out, experts agree that these two studies point back to the need for more palliative care in nursing homes.

Proper Handwashing Technique

Liz Rosto — Fri, 16 Oct 2009 14:44:00 GMT

With the H1N1 virus lurking in our office (so far, one confirmed case), experts agree that aside from vaccination, the best defense is thorough handwashing. Check out this video from the Washington Post that shows proper handwashing technique.

We hear these messages all the time, but truthfully, we could all probably do a better job following through. In fact, a recent Australian study found that three out of ten men and one out of ten women didn;t wash their hands after using the restroom.

On a related note, did you know yesterday (October 15) was Global Handwashing Day? www.globalhandwashingday.org

Dialysis May Do More Harm Than Good

Heather Simons — Thu, 15 Oct 2009 20:34:00 GMT

A study published in The New England Journal of Medicine questions whether dialysis is the best treatment for nursing home patients. As reported by USA Today, more than half of older nursing home residents die within a year of starting dialysis and "nearly another third experience a significant decline in their ability to perform simple tasks, such as feeding themselves."

Study authors said they hope the results will encourage health care professionals to engage in "open and honest discussions" with residents about the risks of the treatment.

For frail elderly nursing home patients, permanent kidney failure "is like metastatic cancer with rapid deterioration and short life expectancy," [says Peter Aronson, Yale University nephrologist]. "The results of this study should inform end-of-life planning for such patients and encourage consideration of alternatives to dialysis, such as palliative care" to relieve symptoms.

Read the full article here.

Reliable Nursing Home Information Lacking

Heather Simons — Tue, 29 Sep 2009 15:52:00 GMT

Reliable information on the quality of nursing homes is hard to come by these days, according to an article in the Los Angeles Times.

Currently, a Web site called Nursing Home Compare, which was created by the Centers for Medicare and Medicaid Services in 1998, provides information on nursing homes, from characteristics of residents to staffing and quality. But the Web site has been criticized since its inception over a decade ago.

Legislation included in a health care reform bill could revamp the site, making it more accurate and comprehensive:

That legislation, the Nursing Home Transparency and Improvement Act, would require the site to provide more precise data on staffing ratios and facility ownership, and improve and accelerate the complaint process. It would also require the Department of Health and Human Services to scrutinize the site to ensure the information provided is clear to consumers.

The bill has long been awaited by advocates of nursing home reform.

To read the full article, including shortcomings and assets of the government-run Web site, click here.

Report Outlines How Health Reform Will Help Seniors

Heather Simons — Fri, 04 Sep 2009 18:54:00 GMT

A recent report at HealthReform.gov outlines exactly how health insurance reform, if passed, would strengthen health care for seniors and long-term care residents. "America's Seniors and Health Insurance Reform: Protecting Coverage and Strengthening Medicare" outlines, step by step, why the current health care system is ultimately unsustainable and why a reformed health care system would prove beneficial for everyone.

The report included the following ways to reduce health care costs for seniors:

Eliminating overpayments to Medicare Advantage plans could save the Federal government, taxpayers and Medicare beneficiaries $177 billion over the next 10 years.
Waste, fraud and abuse lead to an increase in Medicare costs for all seniors; reduction in these discrepancies could save $1.3 billion over 10 years.
Rising drug costs prevent seniors from taking their medication regularly; health care reform would cut drug costs by 50 percent.
Prevention of chronic illness, such as obesity, in people of all ages can decrease Medicare costs down the road.

To read the rest of the article, including more reasons why the current health care system is on shaky ground and how health insurance reform will improve access to care for seniors and long-term care residents, visit the HealthReform Web site here.

Is the Five-Star Rating System Effective?

Maureen Salera — Thu, 16 Jul 2009 18:12:00 GMT

The debate about the effectiveness of the CMS Nursing Home Compare Web site--with its five-star rating system--rages on, according to an article that was posted on The Washington Post online.

Industry experts suggest that the rating system doesn't accurately portray the care given in nursing homes. To address these contentions, CMS is opening a dialogue with the industry, patient advocates and states about changes, including the way the system measures quality of care. For example, nursing homes that specialize in pressure ulcer management and pain have more patients with those issues, and that can skew the homes' ratings, according to the industry.

What do you think of the rating system? How do you feel it has impacted your facility?

Employment Trends

Adkins-Ali Carrie — Wed, 15 Jul 2009 13:37:00 GMT

Many health care employers are working to improve their employer status to attract workers when the economy improves, according to a press release from Career Builder.

33 percent are outlining potential career paths for current and future employees
33 percent are offering more employee recognition programs
28 percent are offering more flexible work schedules
20 percent are revising job listings to emphasize a positive work culture
18 percent are revising recruitment materials
26 percent are revamping their company career sites.

This release runs counter to other articles I've been reading that say many employers are using the recession to crack down on "unnecessary" retention tools and re-establish a more traditional culture.

What trends are you seeing at your facility?

Obama supports program that would cover long-term care costs

Maureen Salera — Fri, 10 Jul 2009 15:47:00 GMT

This week, President Obama gave his support to creating a program to help families struggling with long-term care costs, the Associated Press reports.

The voluntary insurance program, sponsored by Sen. Edward M. Kennedy of Massachusetts, would pay a daily cash benefit of at least $50 that people could use for various in-home services or nursing home expenses, according to an online Boston Globe article.

Kennedy's own Senate health committee will include the long-term care provisions in its version of health care legislation. But the Congressional Budget Office is warning that premiums will not be enough to cover benefit costs after the program has been operating for a few years. Plus, Republicans said that the program could cost $2 trillion over the next 75 years.

Still, Obama's support could persuade lawmakers to take a second look at Kennedy's idea. In a letter to Kennedy released this week, Health and Human Services Secretary Kathleen Sebelius said that Obama believes the long-term care program should be part of a health care overhaul.

As Kennedy envisions it, workers and their spouses would be able to enroll in the insurance program for a monthly premium of $65. People would have to pay premiums for at least five years before they could claim benefits, and they would have had to be working at least three of those years.

Hospice in long-term care

Maureen Salera — Fri, 05 Jun 2009 17:31:00 GMT

A little more than a year ago, I wrote an article about integrating palliative care into nursing homes. My research and my sources seemed to agree that end-of-life care wasn't anywhere near where it needed to be in long-term care. In fact, in some long-term care organizations, palliative care had no place at all. Others were trying, but there was still a lot of work to be done.

I'm now writing another story on hospice for an upcoming issue of ADVANCE so I was eager to see if this has changed. I started out by looking for long-term care providers who have somehow integrated hospice services into their continuums of care. My preliminary research indicates that an increasing number of senior living providers across the country are somehow getting involved in hospice.

I have a lot of questions for these providers so keep your eyes out for their answers in an upcoming issue of ADVANCE. In the meantime, feel free to comment on your experience with hospice.

Boost Morale Now

Adkins-Ali Carrie — Wed, 13 May 2009 13:05:00 GMT

In the current job climate, many companies are using the climate of fear to cut back on morale-boosting costs and activities. Employees don't need morale to stay with your company, the thinking goes, because they have no choice.

But in the article "Employee Engagement - How to Navigate the Most Difficult Economic Times since the Great Depression," Sonya Sullins, founder of Human Capital Management Institute LLC, explains that boosting morale right now is vital.

"It is clear that disengaged and actively disengaged employees pose a risk to any employer, negatively affecting nearly every facet of your organization, including occupancy, resident care, customer devotion and, of course the bottom line," she writes.

Read the article here.

Nurturing a Love That Lasts

Liz Rosto — Tue, 12 May 2009 14:24:00 GMT

Happy National Nursing Home Week 2009!

The theme of this year's event, sponsored by AHCA/NCAL, is "Nurturing a Love That Lasts." Using the person-centered care philosophy, long-term care staff and residents nurture each other's minds, bodies and spirits.

What are you doing to honor national nursing home week?

For more information, see AHCA/NCAL's planning guide.

Mice-on-Resident Violence

Adkins-Ali Carrie — Fri, 01 May 2009 13:11:00 GMT

A news item about a mouse-on-resident attack in an Australian nursing home is hitting the U.S. media. Tales of mice chewing off residents' ears are, we can only hope, extremely rare, but certainly stir up a lot of attention and fear.

Do you think the U.S. long-term care community should respond to this news report on a national level? How about a local level? Have you heard from any of your residents' families inquiring about your rodent control program?

Start Preparing for National Nursing Home Week

Maureen McAndrews — Tue, 31 Mar 2009 16:12:00 GMT

National Nursing Home Week, scheduled for May 10-16, is fast approaching. This year's theme is "Nurturing a Love that Lasts," according to the American Health Care Association.

For ideas on how to celebrate in your facility, visit AHCA's planning page.