In the previous article the passive-aggressive personality was mentioned as individuals that often engage in passive activities such as tardiness, lateness, procrastination, and obstructive efforts that are very disruptive to the workplace. What is interesting is that these individuals often enjoy the frustrating reactions that they provoke in others.  These individuals will frequently manifest these types of negative and obstructive aggressive activities very early after being hired. However, because of the insidious nature of their aggressive behavior, failing to demonstrate the overt features of many forms of aggression, many individuals fail to pick up on the destructive nature of this type of behavior until it is too late.       

Essentially, being aware of how aggression can manifest itself on a passive-aggressive level can be instrumental in ridding the workplace of individuals with these types of traits before they become part of the entrenched working environment. Since many long-term care environments are unionized and membership often is solidified after 90 days, picking up on these individuals early and weeding them out of the environment is imperative.

Furthermore, as was stated, these individuals often thrive on the response that they provoke in others. The reactivity from others that they achieve from their passive and obstructive aggressive activities feeds their personality needs. Although it is easier said then done, failing to be reactive, and failing to be taken into their manipulative web of passive aggressive tendencies often thwarts what they lust for most, the frustrating and over-reactive response from those that they aggress towards in a passive manner.  Therefore, being firm yet non-reactive, will often help to address the concerns that this type of personality poses.                 

The narcissistic personality, often coming off with an over-inflated sense of self-importance, has a very fragile ego that often attempts to avoid any type of issue or event that may challenge their sense of self-worth. Their grandiose sense of self and exalted since of entitlement makes them an utterly individualized entity of pomposity. Here again, they are destructive to the larger team environment. They need to be reigned in quickly and their behavior addressed. 

However, in addressing these individuals, it becomes imperative to not become overly confrontational. When this happens their delicate sense of self becomes insulted to the point that they lead a counter-attack against the person that is confronting them.  They fail to listen to anything that is constructive and react to the apparent threat that is posed to their fragile sense of self. Therefore, addressing their behavior aggressively and confrontationally will only lead to a lose-lose conflict, leading to nothing productive for either party.     

The paranoid personality is the third personality type that was mentioned in the previous paper and will again be addressed here. Their widespread suspicion of others, and their lack of trust make them a formidable challenge. Their maladaptive suspicious nature makes them feel that they are always needing to be on the defensive for fear that someone may unduly threaten them in a myriad of ways. Their lack of trust in their environment makes them react with accusations against others that may range from racism or sexism, to harassment or imputed violent accusations. Please do not mistake or misconstrue these statements.

I am not saying that all individuals that make these accusations as such have a paranoid personality. However, those with a paranoid personality will often assert these accusations when no firm reality basis for their existence. They engage in an autoplastic adaptation, which means that to deal with these perceived psychical threats they alter their perceptions to fit their ill-conceived mental constructs.

In dealing with the paranoid personality, one has to avoid engaging in a confrontational battle of trust. Since lack of trust and suspicion are the catalyst for their worldview, it becomes difficult, if not impossible, to make them the trusting team player that you need for success in your long-term care environment. It is often a terrible reality, but these individuals are often a highly litigious threat.  They are just a slight push or pull away from filing suit over some issue. They need to be closely monitored and all your "i"s need to be dotted and your "t"s crossed in dealing with them. This is not to say that all individuals that present themselves in your organization with this type of personality will inevitably lead your facility to court. However, depending upon the level of their personality issues, the probability for such behavior does deserve watching and may even entail the need for frequent legal counsel to help address many situations that they will bring to your attention.         

It becomes apparent that there are some very interesting, yet challenging, personalities that can wreak havoc on the long-term care environment. This paper reexamined three personalities from the pervious paper, but it looked at some further consequences as well as brief strategies of intervention that can be used to address these personality issues.  However, this brief article far and away fails to provide a voluminous array of interventions that can be used. The topic and its complexity fails to lend itself to a complete discussion in the limited space available for this article. That being said, the reader should still be able to come away with a general knowledge and some rudimentary skills that can better enhance their ability to deal with these problem individuals as they arise in their long-term care environments. It is my hope that the reader will come away with a better understanding of individuals with passive-aggressive, narcissistic, and paranoid personality traits, as well as how to address these individuals and the many challenges they may present in long-term care settings.      

We are all quite different, and all of us come to the workplace setting with different personalities.  Long-term care is no different. It brings individuals of different skills, education levels, temperaments, and in particular personality types to the organizational setting. Some individuals come in with a more introverted, placid personality, while others come to the milieu with a more extroverted, gregarious personality. 

Furthermore, the adjustment level of certain individuals also demonstrates great levels of variability.  Some individuals come to the workplace with a very stable personality while others have highly volatile, unstable personalities. It is addressing this latter element that will briefly be focused on in this paper. Whether we have come to be aware of it or not, many of the issues that are found in long-term care deal with addressing different personalities with varying levels of stability. So it becomes important to understand how certain personality characteristics can lead to problems that are found in the long-term care environment. 

One personality type that often is found in organizational settings that leads to many problems are individuals that have a passive-aggressive personality type. In reality, this is not a current diagnostic classification in the Diagnostic and Statistical Manual of Mental Disorders. However, behavioral scientists are well aware of this personality and administrators and other long-term care professionals, some of whom may also harbor this personality, have witnessed the impact of this type of personality. 

In fact, this is actually a type of aggression that is one of the most dangerous forms of aggression. This person is often the individual that is often agreeing with you while circumventing the organizational climate any time they get the opportunity. They will demonstrate a façade of feigned compliance when in reality they are contravening the organizational climate in their own manipulative ways. They are destructive to the team structure that is needed in a health care setting by superficially stating they are team players while they are at the same time attempting to split staff and drive a wedge in the team environment. The underlying aggressive nature of their personality is so insidiously subtle that is destroys the morale of others, fostering a consecution of destructive emotions in others in their immediate environment.     

With the passive-aggressive personality instead of expressively asserting their aggression, they do their destruction by failing to do many things instead of actively or directly engaging in aggressive behavior. In long-term care environments these individuals assert their aggressive nature through being tardy or showing up late for work and their assignments, procrastinating on particular projects and tasks that need to be completed, or engaging in intentional forms of inefficacy. Since their passive-aggressive tendencies inflict pain to others that have to cover for them in their work, do the work that they continue to put off, or enhance their performance to make up for the reduced efficiency of the passive-aggressive person, it quickly leads to an epidemic dissatisfaction found among other workers.        

The narcissistic personality is another personality that can wreak havoc among a long-term care team. Generally speaking, successful work teams in long-term care settings have to subordinate their own needs and interests to the interest of the larger team environment. This is very difficult, if not impossible, for the person who has highly narcissistic personality traits. The major reasons relate to the fact that the very traits that make up this personality type run counter to successful team building. These individuals often hold a grandiose view of their own self-importance. They are very individually centered, consumed and preoccupied with attaining their own success. They often hold strong feelings of entitlement, and furthermore they have an insatiable need to be admired. Moreover, their tendencies to exploit others to advance their own self-interests, express themselves in an arrogant manner, as well as being deficient in their ability to empathize with others, make them the ideal "anti-team" member.          

As many of those who have worked in long-term care have witnessed, these individuals are also quite destructive toward enhancing a stable organizational environment. In any health care environments, where the emphasis has to be on the patients or residents, these individuals are so involved in their own self-aggrandizement that they lose sight of those who they are serving, as well as those that they have to work collaboratively with to achieve the results of the organization. Many of us have met physicians, nurses, administrators, therapists, as well as nurse assistants that have held this false sense of self-importance. Furthermore, many of us have witnessed the difficulty in working with individuals that exude such an exaggerated sense of self-worth. 

Finally, many of those in long-term care have been on the receiving end of the narcissist's wrath when they have criticized these individuals. Because of the importance they place on their grandiose view of self-importance, they are very sensitive toward criticism that is directed toward them. 

The last personality that will be discussed here is the paranoid personality. As is evident by its name this person has a widespread suspicion of others and their behaviors. They have great difficulty feeling secure and building a sense of trust with others due to their suspicions. They feel that others may be belittling them or engaging in unwanted attacks against their character. Often normal behavioral interactions that others place very little emphasis on will spur ruminations among the paranoid personality that individuals are targeting them in some manner. Their pervasive suspicion leads to feelings of resentment, ill-will, and a general unease with others, who are often viewed as a threat to them in some manner.        

Here again, one can see that these individuals can be quite destructive to a long-term care environment predicated on cooperative team efforts and trust. These individuals are often unable to invest the significant level of trust needed in cooperative team efforts and this in turn leads toward the paranoid personality frequently isolating themselves from the larger social environment.  In an environment predicated on social interaction with workers, residents, and family members, these individuals stick out like a sore thumb. Their destructive nature rests on the inability to trust others and react against those that they perceive are attempting to attack their character.           

Although only three personality types were examined here, there are others that can be instrumental in destroying staff morale and inhibiting team development. However, this paper only focused on these three types of personality. It should also be mentioned that these are not the norm and most individuals, even those that are frequently labeled as "trouble-makers" hold more stable personality traits. Nevertheless, it is important to take note of those individuals that may hold passive-aggressive, narcissistic, and paranoid personality traits.  I

ndividuals that have these types of personality traits can be quite damaging to the organizational environment. In addition, because these features are enduring by the very nature of personality, they are often not just your ordinary trouble-makers or discontented worker. They hold a persistence toward disruption that continues to interfere with the functional nature of the long-term care environment.          

Therefore, although this paper did not speak about intervention, which is a much more sophisticated issue, it is important for long-term care professionals to understand the personality makeup of certain individuals, and in particular, those individuals that may hold a persistent disregard for the workplace and team environment and lead to a contagious turmoil that contaminates the morale of the long-term care environment. Although these individuals are more the exception than the norm, when they do make their appearance, they often hold a detrimental and destructive impact on the organizational behavior of the long-term care environment.  

In team building, especially in the long-term care environment, the administrator is very important toward leading this effort. Their leadership is important toward sensitizing other team members to the importance of teamwork and successful team building. Furthermore, by taking the lead and demonstrating the importance of team building they lead by example, so that others are able to see how seriously building a successful team is to the facility. With the administrator being the vanguard in this effort, the importance of the team is established.

Given that the team is an important entity for administrative success, what are important characteristics for team success? In this article only a couple will be examined. However, from the perspective of this writer, the ones that will be mentioned are viewed as invaluable for a successful managerial climate.

Probably the most important element for a team to achieve is trust. Without trust all further team-building elements are lost (Lencioni, 2002). Trust is a driving force for everything else that follows.  Therefore, trust becomes the base or substructure for everything else to be built on. Just as a house needs a solid foundation for the walls, the floor and the roof to remain firm and to maintain a safe and secure environment, the team also needs the same type of solid foundation. Without it, everything else that may go into the team building enterprise will eventually fail.           

Why is trust important for work team in a long-term care environment, or for that matter, any work environment? Quite simply, the team members have to feel a sense of unity and understanding among all its members. When individuals have trust in each other, they also develop a knowledge and understanding of the individuals that are part of the team. They learn to anticipate other team member's thoughts; they learn to feel a sense of camaraderie; they come to understand the strengths and weaknesses of each of their members; and furthermore, they learn to adopt an inextricable sense of unity. 

When trust is established individuals come to feel a sense of security that team members are all on the same page, feeling a sense of openness with each team member, as well as working in an interdependent fashion. When trust is established on this level it results in the quarterback knowing where to throw the pass, knowing their receiver will catch the pass, even though they may not be able to see their receiver. Although the team in the long-term care environment is not a football team, the same basic principles of trust apply.

However, for a team to build trust, they also have to subordinate some level of individuality.  This is difficult, especially in our culture, which places a premium on individuality. Being raised in a culture that has fostered individuality and independence, many individuals in our society have scorned the team, which often undermine these very important tenets that have been engrained in us from a very early age. The very nature of the team, its interdependence, often vies with the independence and individuality that is so dominant in our culture. 

Another difficult problem that is often faced in building trust is that it exposes the individual to a sense of vulnerability (Lencioni, 2002). Trust in predicated on individuals having more intimate knowledge of their team members. However, when others have more knowledge about you, it can also make individuals feel more vulnerable. Individuals often avoid vulnerability by not investing in highly trusting relationships on a team level. This façade of invulnerability is a critical element that has to be addressed when building trust in the team-building approach. 

After trust in the team has been established, other levels of team building can follow. One important element that needs to be addressed at this point is conflict. Many individuals come to view conflict as always being negative. However, quite to the contrary, conflict can be positive. Conflict is often feared and avoided within teams (Lencioni, 2002). However, rather than fearing conflict, it should be embraced by the group. 

However, conflict can only lead to positive results after trust among group members has been established. If a group fails to have some level of open conflict among its members, the group can become static, apathetic and non-responsive (Robbins & Judge, 2007). At this point it should be mentioned that conflict does not mean involving oneself in contentious interactions and damaging arguments. This is exactly when conflict becomes unproductive.  Productive conflict acknowledges differences as well as acknowledges an openness to address these issues in an open forum.                     

Conflict can also help to illuminate the differences found in the team and help to also shape and define many issues that are often ignored by a false sense of harmony in the group. Too often this false sense of harmony leaves many individuals feeling they are on the same page, when in reality nothing could be farther from the truth. Conflict helps to interject a level of intellectual stimulation toward important problem solving that often fails to exist when individuals accept a false sense of harmony on the team level.    

Hopefully I successfully demonstrated the importance of team building in this paper. The team is so very important for the success of any organization, and the long-term care environment is no exception. However, team development is hard work. Although two basic principles were introduced in this paper, trust and conflict, which appear quite simple, the development of these team principles is more difficult than it appears. 

For successful teams to exist both principles have to be present. Moreover, both principles have to be inculcated into the team mindset, which can only be completed through daily reinforcement. For this to be successfully completed it is dependent upon a leader to be mindful of its importance and to sensitize other team members of its importance as well as to make team building and development part of the daily agenda. It is important to remember that in almost every phase of life, constructive and functional teamwork brings about superior results.  Therefore, recognize the importance of the team not just passively, but actively, and act on its daily development. 

                                                            References

Lencioni, P. (2002). The five dysfunctions of a team: A leadership fable.  San Francisco, Jossey-Bass.

Robbins, S.P., Judge, T.A (2007).  Organizational behavior.  Upper Saddle River, NJ, Prentice-Hall.

Nursing home surveys are frequently anxiety provoking for the staff. Not many individuals welcome others coming into their facility with the intent to play close scrutiny to the environment. This is quite similar to individuals experiencing someone who comes into their home and walks around, looking for things to find, such as a real estate agent, a perspective home buyer, or a nosy neighbor.  In both cases it infringes upon our normal comfort zone that leads to a level of anxiety that is not normally found in the daily milieu. 

However, this type of oversight, regardless of it being anxiety-provoking, it is a natural part of nursing home administration and the regulatory environment that exists in long-term care. Furthermore, all administrators will eventually encounter a situation, where they feel that certain citations are not justified. In this case what should the administrator and their staff do?

The survey environment can be a very emotional situation. Staff or often at ease, on edge and frequently feel like they are walking on glass. In other words, it leads to a tension-filled environment during the survey. This tension is accentuated when citations are given and magnified even further when certain citations are provided, which are felt to be unjustified. Moreover, often administrators feel that there are only two alternatives to deal with this situation: swallow your pride, take the citation or in other words, do nothing, or get into a contentious challenge with the surveyor(s). 

The former is chosen due to the mindset of thinking that if a challenge is mounted, the surveyor will cite even more and with a greater vengeance. The latter is chosen on the basis of frustration, pride and provincialism, with the attitude of “who are these people to come into my building, take it over, and tell me what to do and what is wrong.” This is no new revelation and all administrators and administrative staff have felt both of these feelings at one time or another. 

However, in reality, most citations that are given out are justified. Additionally, most good administrators know this and if they have been doing their job well, have been closely in touch with their facility and their quality indicator reports, and understand the survey process, will not be surprised by the citations that are received by the facility. Furthermore, most surveyors are not vindictive, but are usually doing their job in an appropriate manner. This being stated as human beings, mistakes can be made, by administrators, staff, as well as surveyors. Therefore there are times when citations are given out that may not be appropriate and need to be addressed. 

In the first scenario above, it was stated that many administrators would just let the citation go unchallenged, no matter how inappropriate they may view it as being. A major problem with this “let sleeping dogs lie” approach is that if the administrator feels that a particular citation is unjustified, most of the other administrative staff will also view it as unjustified. If the administrator fails to challenge an unjustified citation, the staff will view the administrator, who is the leader of the facility, as a person who feels helpless, powerless, as well as being a person who is unable or unwilling to address an issue that they feel strongly about and that needs to be remedied. This does not fit well with the leadership role. 

Conversely, in the second situation, when and administrator addresses the situation due to their pride, frustration, and provincialism, they will often come to lose sight of the problem. Their anger and frustration with the citation escalates into a contentious interaction with a surveyor(s), leading to a situation that will accentuate ill will and bad feelings between the administrator, their staff, and the survey team. The hubris of the administrator now leads them to feel that they are being a true leader by getting into the face of the surveyor and confronting them on the perceived inappropriate citation. The “I am not going to let them push me around” thinking is self-serving, failing to take the good of the facility into consideration, and fails to target the problem at hand.

So where does this leave us?  The administrator as the leader has to avoid moving to either extreme. First, it is appropriate for an administrator to address issues that they feel are not valid. Second, to address the issue they have to do it factually. Finally, the demeanor of the administrator should address the issue cogently and in a professional manner. No person likes to admit to errors in judgment. Keeping this in mind, addressing the perceived error has to be done in a manner that will avoid what is psychologically called “reactance,” where individuals attempt to protect their sense of self from threats against it, and therefore react outwardly toward individuals that threaten their sense of self. Therefore, when a perceived inappropriate citation is challenged, it should be done so between the team leader and administrator, in private, to protect the threats against a person’s self that can be augmented when challenges are done in public.                             

When a survey is done, after the exit is completed, there is usually a period of time in which the administrator can challenge an inappropriate citation in what is often referred to as a level one informal dispute resolution. Although surveyors will frequently want to leave the facility and get back to the office, it is quite appropriate to advance your level one informal dispute resolution privilege and speak to the team leader in private about any concerns you may have regarding a citation. Doing so in private, in a respectful and professional manner, will usually quell the likelihood for reactance. 

There is a school of thought that one should never speak to surveyors by themselves and they should always have someone else present. However, in this situation, it is probably best for the administrator and the team leader to meet in a dyadic, one-to-one private meeting. Again, this helps to protect each person’s sense of self, and it limits the probability for reactance to happen. Furthermore, phrasing the problem in a language that does not attribute blame or incompetence, placing the surveyor on the defensive, is very important to eliminate reactance. This is very important for establishing a rapport in which further evidence could be provided to the survey team to assist in addressing perceived inappropriate citations. In most cases the survey team will allow you to submit information the following day to demonstrate compliance.

However, if you have failed to build rapport, develop a level of professional trust, as well as nurture their need for respect rather than vilification, you have lost your case before you could even provide substantive supporting material.           

It is important to recognize that surveyors can and do make mistakes. Even though most citations are justified, there are situations when particular citations should be challenged. The administrator as the leader of the facility needs to understand the need to challenge a citation that they may view as an egregious error in judgment. If such a citation does exist, it is quite appropriate to mount a challenge. However, as this article has discussed, there is a way to do this and the means for challenging a citation is often more important than the end that one seeks. If the correct means is not implemented, the end that one seeks will never come to fruition. Please feel free to comment on this subject matter.  

During this year, a year in which our country will elect a new President, health care has become an important part of the agenda. Liz Rosto in her post entitled Decision 08, writes about the issue of heath care and the apparent lack of emphasis given to long-term care, especially through many of the major candidate’s policy advocacies. This appears to be an interesting phenomenon, which has not just appeared during this current election season, but has existed in past elections as well. 

Although the amount of our Gross Domestic Product spent on health care is approaching 15 percent, with an expectation for it to climb to 17 percent by 2012, most individuals fail to apparently want to acknowledge the important contributions of long-term care to the GDP. With the burgeoning older adult population being a very important part of the electorate, an electorate that votes at higher levels than any other part of the population, you would think that politicians would not only focus on acute care, but long-term care as an important issue that needs to be addressed. Although the focus on changing the health care system is definitely important, to fix many of the deficiencies that currently exist in the system itself, it is important to recognize that these problems also extend to long-term care. However, it appears that many of the health policies that are frequently spoken about politically fail to address long-term care issues.      

What appears to be an inherent contradiction here is this: Although politicians are aware of the importance of courting the older adult vote since they currently make up 13 percent of the population and have the most solid voting records of any age group, most fail to acknowledge a very important health care concern found in many families and among many elderly as it relates to funding and the provision of health care found in long-term care. Although the stereotypes of the elderly being a predominately nursing home bound population are false (in reality, only 5 percent of the elderly population is in nursing homes at any given period of time), long-term care will continue to have an important place in the American health care system. 

It is estimated that there is a 70 percent likelihood that individuals in society will spend some time within a long-term care environment at some point in their lives, which includes home bound care (Gleckman, 2007). Furthermore, as many more long-term care facilities are becoming extensions of the acute care environment, especially for rehabilitation purposes, it becomes almost unfathomable to understand why the political environment often gives minimal to no attention to this area.

Total Medicaid costs for long-term care as a percentage of the GDP has increased from 0.7 percent in 1975 to 2.1 percent in 2003 (Gleckman, 2007).  Furthermore, in 2000, the amount of long-term care expenditures that were part of the approximately 14 percent that made up the GDP was equal to 1.3 percent and it has been increasing.  In fact, Medicaid and Medicare expenditures that are part of the GDP have been increasing.  Moreover, public payment sources such as Medicaid and Medicare make up 60 percent of long-term care payment with another 23 percent of the payment coming from out of pocket expenses (Walker, 2002). When you couple this with budget constraints being placed on many long-term care programs and anxiety over the drying up of the coffers that support many long-term care programs, both on the state and federal level, one has to wonder why advocates for the elderly have failed to make this a more prominent concern to be addressed by politicians on both sides of the aisles in the 2008 political races.    

So where does that leave us in the 2008 political race not only for the Presidency, but also for many other congressional offices that will be up for grabs. Unfortunately, it appears that long-term care will continue to be treated as the redheaded stepchild of health care policy.  Possibly the most vociferous advocate of health care in the current presidential contest is Hillary Clinton and even Mrs. Clinton fails to address long-term care on a substantive level. It is without doubt that escalating costs, physicians forced to practice defensive medicine, escalating third party insurance costs, as well as too many individuals failing to get preventative care, or failing to be insured or underinsured is a national crisis. However, one needs to add to this the problems found in long-term care as part of the national health care system crisis as well.   

Long-term care has to be recognized as part of the larger system of health care that exists in the United States. Yet, as has been evident, most politicians know very little if anything about the concerns faced by older adults, and in particular, the concerns that are faced by this population in long-term care. Therefore, not only is the national crisis in health care problematic since it often fails to address the long-term care part of our health care system, but it is exacerbated by the lack of knowledge by those who hold the most advantageous positions in our society to address this issue. With congressional subcommittees on aging having existed for some time, one has to wonder whether these committees have helped to educate the political faction on these very important issues? 

With a plethora of elderly age groups in existence to address the concerns of the elderly, one has to wonder why they have not placed greater political pressure on our country’s politicians? And with the increasing level of the population that is currently over 65 years of age, a part of the population that is increasing quickly and have concerns about long-term care issues, one has to wonder why they as a group have not continued to place increasing pressure on the politically powerful to address many of their concerns in this area?

The above are all important questions that need to be addressed and addressed quickly.  With each election that goes by, and with each year of failed response, the elderly population continues to grow. Along with this will be long-term care needs that will continue to increase. As our country continues to sit on the issue with little or no response, and as the older adult population continues to increase concomitantly with their growing long-term care needs, a growing lag between these two areas also will continue to increase. As the lag continues to increase between elderly needs and political response, our country sits on a powder keg that can and will explode. Prior to getting to this point, where our country has to mobilize into an emergency mode and reactive response, the American people and their political representatives need to forestall this growing crisis by acting proactively and with prudent foresight.        

                                                            References

Gleckman, H. (2007/April).  Medicaid and long-term care: How will rising costs

affect services for an aging population, An Issue in Brief: Center for Retirement Research, Boston University: April, no 7-4,

Gleckman, H (2007/June)  Financing long-term care: Lessons from abroad.  An

Issue in Brief: Center for Retirement Research, Boston University: June, no 7-8

Walker, D.M (2002/March 21).  Long-term care aging baby boom generation will

increase demand and burden on federal and state budgets.  Testimony made by Comptroller General of the United States General Accounting Office Before the Special Committee on Aging, U.S. Senate.

Health care administration is not an easy job. Decisions have to be made and often these decisions rely on more than just one person. In the long-term care environment many decisions are made within a team framework. The administrator, along with the director of nursing, rehabilitation director, dietary and activities directors, maintenance supervisor as well as many other important administrative team players hold important positions in the decision making process. 

However, there are times when decisions become compromised within group situations.  Teams can be an incredible asset to assist in making important decisions, but also the important significance of bringing people together into a team situation can also lead to problems. One of the major issues that can compromise decision making in teams within the long-term care health setting in what is referred to as Groupthink. 

Groupthink, a concept that was developing by Irving Janis (1982), is the propensity for group decision making to become hindered within decision making groups, regardless of whether they are in health care settings, large fortune 500 corporations, or even in Presidential cabinets. It does not just happen to people that are of modest intellect, but also among the brightest individuals as well.

For instance, groupthink has been implicated in such large-scale events as the Bay of Pigs invasion, the entry and escalation into Vietnam, as well as even our decisions to enter into our country’s current Iraq war. In all these cases there were reservations about the final decisions that were made that were never raised, acknowledged and properly evaluated. If decisions of such magnitude, affecting our nation on such a large scale, made by individuals who are intelligent and knowledgeable in their respective areas can become compromised, one can only guess how often it happens daily in more common situations. Although no exact number can be given, it can be stated that groupthink is quite pervasive, happening in most, if not all, organizations daily. 

What are the symptoms of groupthink? Two key symptoms are an assumed consensus and a feeling of group unanimity. What this means is that often many individuals will not say anything or express their opinion because they feel that everyone else is in consensus with the group. Since they feel that everyone else is on the same page and share a consensual opinion, many will fear speaking about any reservations they may have with a particular idea or plan. If team members feel that they should express themselves on a particular issue, but feel that there is a unanimous opinion and shared consensus among the other group members, that is often enough to inhibit them from getting involved in expressing important opinions. 

To prevent this it is important for the administrative staff to know about these endemic group forces that can lead to an inhibition toward full-team participation. Furthermore, the administrator should often encourage other group members to express their opinions, reservations and even possible dissenting opinions. Once the administrator becomes aware that individuals within the team meetings appear to be “shutting down,” it is at this point that the administrator should ask for opinions and even dissenting opinions. This may sound problematic since most administrators do not what to hear dissenting opinions. This does not mean they should encourage contention, but healthy disquisition on what other views may exist and what weaknesses may appear in the existing plans and ideas that have been presented to the team.         

There are other important characteristics of groupthink. For instance, placing pressure on team dissenters is often a problem that is faced with groupthink. Since dissenters may be viewed as problem individuals that are failing to be cooperative team members, individuals will often not want to raise a dissenting opinion. There is often a misconception about the group or team. Many individuals feel that if dissenters exist they are not good team players and anything they say should not be given any weight and disregarded. Unfortunately, this often leads to the glossing over of many important opinions and views that are raised. Moreover, if individuals feel that they will be looked at in a negative light and that their opinions will not be given any credence, this will lead to pressure for them to not raise any dissenting opinions.

What is also important to mention is that many team members often fear dissent due to group norms that develop dealing with not questioning the leaders or by leaders, such as the administrator or director of nursing shutting down any conversation or differences in opinion. It is not uncommon for leaders to nurture a view of themselves as an omniscient individual that is the prevailing expert in what they do. Soliciting opinion is often viewed as a weakness due to a perceived lack of knowledge. With this comes the intolerance toward opinions that differ from their own. 

Therefore leaders, especially those that are easily threatened due to feeling insecure in their position or with their knowledge, attempt to minimize dissent. In so doing they delude themselves toward thinking they have enhanced the solidarity of the group as well as protected their status as the undeniable expert for the facility. Ultimately, attempting to enhance their power and control by shutting down or disregarding opinions from other team members enhances the likelihood for groupthink to insulate itself into the team decision-making process.                        

What is interesting about groupthink is that it is a ubiquitous component of groups and teams at all levels. Unfortunately many individuals think that they would never act or behave in such a manner and that they are too much of an individual to be influenced by such group forces. Only individuals that are easily led can fall prey to such a problem.  However, as has already been stated, no one is necessarily immune to groupthink and the problems that it brings. It has been shown that even bright individuals, involved in extremely important decisions that involve the national welfare of our country can fall prey to groupthink.

However, possibly the greater sin in not necessarily falling prey to groupthink, but denying its existence or its ability to effect you and your decisions. In fact, groupthink often breeds feelings of invulnerability by the group members and it is often these same feelings of invulnerability that lead individuals to be quite insidiously influenced by this prominent group force that can lead to potentially destructive team decisions (DeLamater & Meyers, 2007).     

Although team decisions are important within any organization, and long-term care team decisions are no different, one has to recognize that team decisions can also go awry. In long-term care groups or teams, decisions are often part of the daily culture of the organization. Although many individuals have increasingly encouraged teams and team building as an important and effective part of long-term care management, one has to also realize that the team in itself does not work automatically. Team administrative management is an important factor for good long-term care administration.

However, teams have to be used effectively to maximize the decision-making process.  As is evident, being aware how the decision making process can be thwarted through groupthink will become an important administrative skill toward preventing this type of process from leading to potentially destructive team decisions. Realizing that no individual or team is absolved from groupthink’s influence will help administrators make better use of the team and the potential that teams hold for making very sound and informative decisions.    

                                                            References

DeLamater, J.D., & Myers, D.J. (2007).  Social psychology. Belmont, Wadsworth. 

Janis, I.L.(1982) Groupthink. Boston, Houghton Mifflin.

The level of information that one has to makes decisions in health care settings often differs dramatically in any one situation. Decisions are often incumbent on the level of information that is available to the decision makers. Administrators face these issues daily when making decisions.  Therefore, it is important for administrators to realize that decision-making is not a one-dimensional process. Although individuals often think of decision-making as “taking a stand” and “being decisive,” the complexity of decisions is predicated on more then these common trite explanations; the type and amount of information that lends itself to administrators and the administrative staff has to also be taken into consideration.    

For instance, in understanding the complexity of decisions, one has to evaluate whether you are dealing with a “programmed” or “non-programmed” decision. Programmed decisions occur frequently. Because they occur frequently there are often well-developed types of procedures and rules that guide decisions in these areas. Take for instance dealing with disciplinary actions dealing with employee absenteeism or tardiness. The administrative staff often deals with these issues frequently and quite commonly. Since this is a recurrent issue, decisions rules in this area are not only explicitly stated, but also implicitly determined. Even dealing with routine survey issues that administrators face are frequently programmed, especially for those administrators who have been involved in long-term care for quite some time. 

Conversely, non-programmed decisions are encountered in situations that happen less frequently and are more unusual. Often there fails to be well-established decision rules for dealing with these issues, and because of their less frequent occurrence, administrators often face greater levels of ambiguity in addressing these concerns. Because of the unique situations that are frequently part of non-programmed decisions, the lack of routinization that is part of programmed decision-making leads to a comfort zone that is much less secure for many administrators.

The problem of dealing with abuse, fires and evacuation, or being informed that there needs to be an immediate abatement to an immediate jeopardy citation leads to the need for insightful decisions that are not part of one’s daily, routinized decision-making ability. This may lead many to ask the question, is this not the fault of the administrator since they were not prepared? The answer to this question is even the very best administrators cannot anticipate every contingency, and even though you may have layers of policies that in some way, shape or form, address many of these issues, the reality of the situation always supersedes simulation and paper policies. 

Also, even though long-term care environments share a great deal of similarity in what are programmed and what are non-programmed decisions, there are also inter-facility differences.  For example, facility A may deal with a high level of acuity as it relates to issues of bariatric residents. Emergent issues related to bariatric residents may be quite routinized and part of their daily programmed decision-making strategies. However, facility B may have a lower acuity and they may not deal with the needs of bariatric residents as routinely as facility A. Therefore, if facility B has a bariatric resident that becomes severely compromised, the decision rules may be more ambiguous due to not having to frequently deal with this type of issue.

So what is a programmed decision in one facility may actually be a non-programmed decision in another. Administrators have to be aware of many of these common facility-to-facility programmed decisions as well as the variances that are found between facilities that lead to non-programmed decisions to be encountered.                

Health care decisions, regardless of being programmed or non-programmed, can also exist under conditions of certainty, uncertainty and risk. In some cases the decisions that are made exist under conditions of certainty, in which the outcomes and alternatives to particular outcomes are known. In this condition administrators have a clear understanding of the alternatives and how each alternative will impact the health care facility. In most conditions it is clear that if they have $30,000 to spend for capital improvement and two areas need improvement, the kitchen and physical therapy, then what is spent on the kitchen becomes and opportunity cost to physical therapy. If $20,000 is spent on the kitchen it is clear that only $10,000 exists for physical therapy enhancement. 

With conditions of uncertainty there is not enough information to make a clear decision and understand how making a decision will influence alternative outcomes. Under these circumstances some individuals will guess at what they “think” is the right decision.  Administrators often like to use the “based on my years of experience argument” to justify their decisions on a lack of information. In reality this skewed type of thinking just does not happen in health care, but in all phases of our lives. However, in a case when one is dealing with lives, the must prudent means is often to seek more information to act and decide in a prudent manner. 

However, probably the most difficult decisions that are faced are those that incur some probability of risk. In reality, many decisions that administrators face are probabilistic in nature, where they are unable to know with certainty what outcome given actions will have after decisions are made.  Under these conditions of risk there is often enough information available to the administrator to make informed decisions based on a level of probability. However, just because you decide to make a decision based on an 80% probability that the payback period will be six months or less or that there is an 80% probability that instituting a wage increase will reduce nursing turnover by 50 percent does not mean that it always will. 

In addition, it is very common to make decisions based on probability but to delude ourselves into thinking that the probability will become the actual occurrence. Psychologically this helps use feel better about decisions that often incur risk. However, just because the probability of a penny being either heads or tails is 50% and that it has turned up heads on the first toss, does not mean that the probability for it to be tails on the second toss increases. The probability still remains at 50 percent.        

For many, decision-making appears to be a clear and easy process. However, as been addressed in the preceding paragraphs, decisions hold a level of complexity that is often not recognized. Long-term care administrators face many different types of decisions and it is important for long-term care professionals to understand that decision-making is more than just an arbitrary and capricious enterprise. Yet, understanding about the decision-making process, the types of decisions that are often incurred by long-tem care professionals, and the challenges they face in dealing with this very important task, will help professionals deal with the unending conundrum and anxiety that is part of decision-making. Therefore, decision-making is a skill that can be improved by being cognizant of the types of decisions that one is presented with, the common problems that exist in making decisions, as well as recognizing your strengths and weaknesses in this area.   

                                                         References

Moorhead, G. & Griffin, R.W. (2004). Organizational behavior: Managing people and

organizations.  Boston, Houghton Mifflin.

Plous, Scott (1993). The psychology of judgment and decision making.  New York,

McGraw-Hill.

Rajagopalan, N, Rasheed, A.M.A. & Datta, D. K. (1993). Strategic decision processes:

Critical review and future directions.  Journal of Management, 19(2): 349-384

Nursing home administration entails being aware of the macro social, economic and political forces that shape the daily life of nursing home administration. This is not an easy task since these forces are constantly changing and influencing the nursing home environment on a daily basis. An administrator has to be aware not only of the changes in the internal environment of the facility, but also the changes that exist outside of the facility.

One way to evaluate these changes regularly is to use the PEST analysis or sometimes referred to as the STEP analysis. The PEST analysis is an acronym for political, economic, social and technological changes that need to be evaluated so that the administrator can understand how these external forces may impact their nursing home environment.   

The political environment outside of the nursing home is constantly changing. As any administrator knows, the news briefs that they receive from their state agency as well as the Centers for Medicare and Medicaid create a substantial amount of paperwork that needs to be read, addressed and acted on.  However, other political areas that may not be directly related to the nursing home industry may also formidably impact their environment.

Political candidates elected to offices, state and federal budget deficits, political petitioning and logrolling, to name just a few have powerful effects that at first blush may not be directly related to nursing home care, yet nevertheless have a powerful impact on the nursing home environment. Furthermore, political agendas, both overt and hidden, have powerful effects in shaping the lives of those that reside in nursing care facilities as well as those who are employed by these facilities.  

The economic factors need to be examined as well. Again, it is not only the direct economic factors aimed at the long-term care industry that influence this environment. One must also examine the indirect economic factors that are prominent in the state and national landscape as well. Not only are the microeconomic factors involved in the long-term care industry something that needs to be examined regularly but also the impact of other macroeconomic factors in the larger state and national environment have to be given close scrutiny, too.

Because large-scale economic decisions made on the state or national level do not typically just influence a particular part of the population that they were initially intended for, the reverberation of these economic decisions may affect other areas as well, such as nursing facilities. Economists call this “externalities,” or the impact that economic decisions have on other, often unintended, areas. Therefore, when fiscal or monetary policies change at the federal level, and tax rates or interest rates are impacted, or reallocation of the state budget is established, the general consumer and larger businesses are not the only area that is economically impacted, but the impact can also be felt in the long-term care industry as well. 

The social landscape has a powerful impact that also needs to be considered.  Social forces affecting long-term care can come from advocates for change, studies that have come to demonstrate areas that need to be addressed, demographic factors that place the long-term care environment under scrutiny, geographic factors that may influence nursing home populations as well as other sociological phenomenon that are relevant and need to be given notice.

The Institute of Medicine’s 1986 report was such a major social force that drove the changes in the modern nursing home industry, leading to the passage of the OBRA regulations that have had a wide-scale influence on the current state and federal regulatory environment for nursing care facilities. Social movements and social forces do not always have to be so prominent, but can also be more subtle. The current nursing shortage, coupled with the shortage of nursing instructors, is and will be a significant social force that needs to be grappled with currently, and in the years to come. Moreover, the current aversion for many physicians to specialize in geriatrics and long-term care, even though the population of older adults is increasing and will continue to increase, is another formidable challenge that long-term care facilities and the older adult population in general will have to address in the years ahead.        

Finally, possibly no other force is having a profound impact on health care in general, and the long-term care environment in particular, as is technology and technological innovation. Franz Boas, the famous anthropologist, stated that no other force changes culture to any greater degree than the technological innovations found in cultures. In years past the nursing care environment was prominently viewed as a low-technology, “rest home” environment.  It was an environment predicated on an almost exclusive labor-intensive environment directed toward providing care for the daily living of residents in these environments.

Today, however, the nursing care environment has taken on the role of a more technologically advanced environment, often being viewed as a post-acute continuation for hospital stays. Rehabilitation equipment that involves short-wave diathermy, electrical stimulation, and other rehabilitative equipment that mimics that found in hospital environments is frequently also found as well in nursing care facilities.  Furthermore, advanced pulmonary equipment, dialysis areas, and neurological testing and rehabilitation are also found in these environments as well. This is just to name a few of the technologically sophisticated practices that the administrator needs to be aware, and often needs to address, daily.   

It becomes a very difficult task to be aware of all the changes that are happening all the time.  Furthermore, it is unrealistic to believe that any one administrator will know every change that is happening and that will impact their nursing home environment. At a time where administrators have enough on their plate managing the internal factors within their nursing care facility, is it realistic to have them also be aware of the external environment as well? The answer to this is that it is not only realistic, but mandatory. Nursing home administration means not just managing the internal confines of the building, but managing and anticipating the trends and factors on the outside that will influence their building as well. 

Again, to reiterate, no nursing home administrator can possible know and anticipate all of the factors on the political, economic, social and technological levels that will influence their daily administrative lives.  However, using the PEST analysis regularly will allow them to understand some of these forces and how they will impact many administrative decisions that they need to make as part of their daily administrative duties.       

What being a PEST, as stated in the title of this article, allows administrators to do is take a regular role in managing the forces outside of your building. Many will say that there is nothing you can do about what happens outside of your building on the community, state or national level. Although there may exist some kernel of truth to the previous statement, holding this idea exclusively it nothing more than “managerial fatalism.” As an administrator you cannot control everything that takes place outside of your facility. However, there are many things that you can influence that may be forestalled or minimized by the proper environmental scanning and the information obtained through a PEST analysis. 

Even things that may not be amenable to change through administrative intervention, if properly acknowledged and known about in advance, can be managed appropriately to avoid more deleterious effects on the nursing care facility environment. Much administration, especially in health care and long-term care, is “anticipatory administration,” which good administrators engage in daily. It allows them to use the information that they have obtained from a scan of their outside environment and put relevant procedures in place to address any issues and obstacles that they may anticipate in the future. 

Therefore, pay attention not only to the internal environment, but to what is happening outside of the walls of your building.  Be a PEST! 

A very common question that is often posed to me is, ”What type of leadership or management style do you have?” The question is often posed as if there is one correct style that exists. Moreover, there has been a substantial amount of studies done on leadership and management styles to lend a scientific understanding to this question, yet they really do not provide any definitive answer to which, if any, style is best. 

A scenario that continues to stick in my mind happened a few years ago. I was listening to an administrator presenting on this particular topic during a conference. I sat and listened hoping to get some insightful tips from an experienced gentleman in this area, but as I listened I heard him state, something to the fact that nursing home administration and leadership is not a democracy, but a dictatorship. 

That word dictatorship immediately gained my attention and I remember looking up very quickly from the agenda I had been reading. He continued to elaborate and as I sat there listening, I could not help but place a broad smile on my face. I felt that I was attending a presentation that was being given by a totalitarian dictator rather than a long-term care administrator. Upon leaving that session I found myself asking, “why would they let this person present and what educational value did his presentation serve?”  I must honestly admit I have no firsthand knowledge of how successful this administrator was in his profession, but I do feel sorry for young, impressionable administrators using him as a mentor.  Providing a “one management style fits all” was to me, patently absurd. 

In my 27 years of health care I have witnessed others who felt it was necessary to establish themselves on a Machiavellian level. Some have been successful, but most have not, and one of the reasons that this type of leadership style will fail if used exclusively is that it shuts down important and necessary lines of communication and input. Unless you are omniscient, which I have never found any human being to be, you need input and open lines of communication. Dictatorial mannerisms will shut communication down very quickly, prevent others from approaching you and help to isolate yourself from the staff that you depend upon. 

I have also seen the other extreme exist, where an administrator fails to be able to take a stand or provide any direction, remaining in what appears to be a perpetual state of equivocation and ambiguity.  As a leader and administrator, you will not always be correct in the decisions that you make, nor is it realistic to believe that you will be. However, constantly failing to take a stance, or having a difficult time taking a stance, is ultimately destructive. Here again, I recently became aware of such a problem, and listening to the consecution of events made my jaw drop. In this case the health care administrator had difficulty resolving an issue with a recalcitrant business office personnel. She wanted to meet with this particular employee to discuss the issues and the administrator and the business office staff member in question became involved in an e-mail exchange where the administrator kept asking for a time to meet with her and the business personnel kept saying she would not meet with her. 

Beyond this being insubordination one has to ask, “Why did the administrator tolerate this type of behavior?” If the administrator had any doubts about her being causative in the office problems, the insubordinate demeanor that was demonstrated in this exchange with the administrator should have helped to validate the problematic nature of this employee. 

At the time of this writing, nothing has been done about this employee and the problem has now spread further in the work environment, creating an unnecessary inflammation that could have been prevented.  However, since the administrator could not take a firm stance, she became an administrator only by salary and title.

I have found that there is no one single successful style that will work in every situation, at every facility, with every group of personnel, and on every occasion. However, I do feel that exclusive extremes on either end of the leadership and management continuum also doom the leader in this area to failure.  A nursing home administrator has to be involved, engaged and aware of the people they work with, the residents and the issues they face, the family problems that exist, as well as the myriad of other factors found in their facility. Therefore I feel the following is a list, which is not exclusive by any means, of important features that individuals need for leadership and management of long-term care environments. However, more important is for the administrator to establish their own way of administering that they find as successful and comfortable.  Avoid attempting to mimic others and establish your own administrative identity. The following is a personal list of qualities that I feel are important for long-term care administrators.  

1. Lead with integrity and always err on the side of what is right—I am not sure if anything is more important. Your integrity as a person is emblematic of who you are. It sets the agenda of what others will expect of you and what you expect of them. As a professional your life inside and outside of the facility follows you and the integrity that you hold will set the standard of your administration, not to say your life. 
2. Remain close to your environment, talking with staff, family members, residents, etc.  This helps to build trust and camaraderie. It also helps to proactively address issues before they even start.  
3. Manage by walking around. Much work has to happen in your office. However, make some time in the day to move around your facility, staying close to what is going on in the immediate milieu. 
4. Develop your own style of management and leadership. Do not attempt to mimic others just because it works for them. They often have different personality characteristics and different situations that do not lend themselves to be carbon copied. 
5. Communicate and listen (not just hear) effectively. Remember, listening is an active process that involves you, as well as others, in the communication process.   
6. Take a stance and do not equivocate. If you are wrong, swallow your pride and learn from it.  However, sitting on the fence and waiting for a great, definitive revelation to come about or hoping that the problem will work itself out will often lead to disaster. Remember, we all err, but erring by omission, not doing anything, often creates larger problems. Think your decisions out to the best of your ability and act on them as well as learn from them, whether you make the correct decision or the wrong decision.               
7. Take action decisively on issues that present themselves to you. Furthermore, do not just be a reactive manager, but work toward being a proactive manager. 
8. Establish yourself as being receptive toward others and their ideas. You do not always have to agree with them, but you should be respectful and listen, as well as provide feedback on whether you think their ideas are viable or not. 
9. Be realistic in your management approach and your project undertaking. Do not attempt to delude yourself toward thinking that you can accomplish everything. A person who thinks of himself or herself as an omniscient and omnipotent leader only deludes themselves. Do not be fearful of introducing small changes that are incremental and may be more realistic, leading to positive results.  Know your resources and abilities, and watch out for the “change the world” mindset. 
10. Empower your workers and create a smart working environment. Your workers need to know that you trust them and respect their abilities to oversee their areas. This does not mean that you should alienate yourself or dissolve your responsibility. It does mean you should empower and create a trust among your employees, and be an informed leader through close interaction with your employees.     

The long-term care landscape has changed and will continue to change. One of the greatest changes that have been found in long-term care is in census, or the residents that are found in long-term care, often referred to as resident mix. As census has changed, so has the social and economic impact found in long-term care, and the implications in this area will continue in upcoming years. Therefore, some of these important changes will be examined to highlight the myriad of social and economic factors that are involved in census change.

Census has always been a driving force for maintaining a financially viable facility. Furthermore, administrators are always examining revenue, expenses, cost control measures, RUG score utilization, and reimbursement rates for Medicaid, Medicare, and third party insurers to find where their facility stands at any given period of time financially, and to understand how the economic landscape will influence their facility in the future.  Census and occupancy rates have always been one of the first things that are examined. Moreover, traditionally nursing care facilities were driven by a census and demographic profile that was typically made up of those over 65 years of age. For the most part, a great deal of this population still exists, but change is happening and will continue to happen for long-term care facilities. 

Although seventy percent of nursing care reimbursement comes from Medicaid, in years past this was almost an exclusive reimbursement for those elderly that needed continued nursing home care and exhausted the rest of their financial resources. However, today the demographic profile of many nursing care facilities has shifted and more members of the younger population have now entered the resident mix in nursing homes. There is an economic exchange here that has also happened, which has led to a net financial loss in many instances.   Not only are older adult Medicaid recipients being replaced by younger Medicaid recipients, older adults often come to the facility with Medicare after a qualifying hospital stay where younger individuals, many of whom are poor, come to the facility with no Medicare or private third party insurance prior to being established on Medicaid. So the net result is not a one-to-one redistribution, but a financial loss of Medicare or other third party payment that often is part of the early stay for many older adults.          

As demonstrated above, one can see how social changes in census can have a powerful impact on the economic factors found in the nursing home industry, and in particular, on the financial climate of any one nursing care facility. Also, some long-term care facilities have attempted to place themselves into a rehabilitation niche, to take advantage of short-term rehabilitation and extend themselves as post-acute care facilities. For some this has worked, capitalizing a both a younger and older adult population that will come to them with Medicare or very good third party reimbursement. However, for many facilities, and in particular many inner-city or rural area nursing homes, facilities that are often older and are reliant on hospitals providing them with poor older and younger residents, the social changes in census have a powerful impact on the financial status of these facilities. 

Many of these facilities are unable to take advantage of better financial resources that certain residents in suburban facilities have at their advantage. When this is coupled with older buildings that have greater primary and preventative maintenance costs and a higher percentage of Medicaid to Medicare/private insurance residents, it should be clearly understood why many of these nursing care facilities are very financially strapped. 

However, even the suburban nursing care facilities are starting to feel the economic impact of the social changes in census. Because the nursing care environment is quite competitive, with many facilities competing over the same residents, and since any empty bed is a major cost for the facility, many suburban facilities are also now taking younger residents, something that they often would not have done in the past. As the competitive market for Medicare and private third party payers has increased, concomitantly with the need for some level of cash flow to cover those empty beds and also forestall further reductions in Medicaid payments for not being at a certain census, many facilities now need to accommodate to the new resident mix that is found in their census. 

As the mean age of many nursing care facility’s census has been reduced with the addition of younger members, the economic impact of dealing with a more diverse age population with often markedly different clinical profiles also needs to be considered. Accommodating the needs and acuity levels of all age groups with the level of heterogeneity that is presented in a facility can lead to heightened costs for staffing, training, supplies, therapeutic invention and medications, just to name a few. This, mixed with many states having to make budget cuts that can affect the reimbursement rates for Medicaid, can lead to a very problematic financial situation for nursing homes. Regardless of facing strict cost control measures, it is often easy for the needs of a heterogeneous age-based nursing home population to grossly extend their costs that far and exceed the ability to even break even.