Caring For Our Elders

The Open Mind
Host: Richard D. Heffner
Guest: Dr. Robyn I. Stone
Title: “Caring For Our Elders”
VTR: 11/06/02

I’m Richard Heffner, your host on The Open Mind. And many years ago when I was a young man with a young family and was doing a public television program called “The Problems of Everyday Living”, my wife pointed out to me that anyone and everyone could know just what was going on in our private lives simply by taking note of my guests and the subjects I chose to discuss with them on the air … from toilet training to disciplining our kids, to problems at school.

And I guess nothing changes very much. For here we are today talking once again about the problems of everyday living, not of children this time, to be sure, but of the aging, particularly of nursing facilities and of frail elders. Few of us will escape that real concern whether for our parents or, let’s face it, prospectively for ourselves.

And as a recent National Public Radio report had it, most news about the nursing home industry is bleak …poor care, overworked staff, aides who abuse the residents. Yet NPR could focus this time on good news; news from the Commonwealth Fund on a recent report of its Picker/ Commonwealth Program on Qualify of Care for Frail Elders. The Report, a positive evaluation of the so-called Wellspring Model for Improving Nursing Home Quality.

And I can turn now for an explanation of the Wellspring Model to its principal evaluator, Dr. Robyn I. Stone, Assistant Secretary for Aging in the Clinton Administrations Department of Health and Human Services, and now Executive Director of the Institute for the Future of Aging Services. Asking her just how we can go now from sad to glad.

Stone: [Laughter]

Heffner: What makes this a good report?

Stone: Well, what makes it a good report is that we know it’s a model that works. Wellspring is a provider model that was put together by a group of folks about nine years ago to try to improve quality in a set of nursing homes in the middle of Wisconsin. And they did it partly because they were trying to position themselves for the managed care market, and when managed care didn’t happen in Wisconsin, they realized that they had something unique. And that was an alliance of forward thinking folks who wanted to improve the quality of care and the quality of work environment for the folks that were employed there. And so what they did was to combine a series of clinical training modules, care resource teams, a GNP, a geriatric nurse practitioner who sort of did the trouble-shooting and a … creating an alliance of, of CEO’s, Directors of Nursing and Nurse Coordinators who work together to empower the staff from the front line to top management. And they’ve been doing this now for nine years.

Heffner: And it works?

Stone: It works. I guess the message that I like to send is that it’s a “work in progress.” What we found was that all of the facilities, in some way, shape or form were committed to this. But there were always glitches. As somebody told me when we were interviewing them, “it’s like going on a diet, you don’t go on it and then go off of it.” And so rather than thinking about these models as things that actually work, I think we have to think about them as things that become the norm of how we live our daily lives … whether it’s in a nursing home, whether its in assisted living … whether it’s in a home care setting. You have to constantly be working on it, that’s why we call it “continuous quality improvement.”

What we did find was that over time the Wellspring facilities looked much better on some very important measures … higher retention rates, lower turnover rates …

Heffner: Of employees.

Stone: Of employees, particularly the front line work force and the RNs. In addition, lower deficiency rates in terms of what the surveyor and certification folks do at the State level. Every year nursing homes go through that kind of a process. And the Wellspring group, on average, looked better over time than other facilities in Wisconsin. So we have some concrete evidence, what I like to call the “evidence base” behind this model that has been going on for a relatively long period of time.

Heffner: How do you explain the fact that this is something new and that, in fact, we have so mis-treated the frail elderly.

Stone: I don’t think it’s something new. You know, we use the words, “this isn’t rocket science”, although I’ve actually talked to some rocket scientists who say this is probably more “rocket science” than what they do. It’s not new; it’s just that in some ways it’s so simple that it’s complex. What we’re really talking about here is a combination of creating a knowledge base for people who do the work in nursing homes. Give them the tools to do critical thinking and create a work environment where they are nurtured and coached and mentored and supported. That is not a new concept. These concepts go back a long way and it’s the kind of work environment that anyone would want to live in. And, in fact, we probably have a lot of nursing homes that have been doing this over the years.

We have a whole group of nursing homes called the Pioneers. These are forward thinking folks who have been doing job redesign, different kinds of clinical and management training, paying attention to things like how we communicate with each other. This has been going on for a long time. The problem is that these tend to be the exceptions rather than the rule …

Heffner: Why?

Stone: Because it’s difficult. It is … nursing homes are a very, very difficult environment. Think about it. First of all these are places where people live, where they get services, but they also live there. So we’re talking about a care environment basically in people’s homes. Very, very frail. Very, very co-morbid individuals, folks who have a lot of complexity to their problems; generally folks who are on nine, ten … sometimes 15 medications simultaneously. And, at the same time, who’s providing the services for them? Individuals who at the front line are some of the lowest paid folks in the United States. On average about $7.50 an hour, the rates are higher in New York and higher in some other parts of the country, but it’s a low wage occupation with an incredible amount of pressure put on these folks constantly. Many of whom have already multitasked, probably three times before they got to the nursing home in the morning, or in the evening … so …

Heffner: What do you mean? Multitasked?

Stone: They’ve had to make arrangements for childcare, many of them had to take three buses to get to the job; they’re dealing with a lot of personal problems at home. So, so they bring all of that to bear on the work that they are doing in the nursing home … very, very complex set of tasks which they are involved in. These are not just “butt wipers” by the way. These are folks who have to pay attention to all the signs of problems among the elderly living in these places. They’re the eyes and the ears; they’re the “high touch” of the care industry. And so we put a lot of responsibility in the hands of people who are not being paid, generally and frequently, a livable wage. And who are expected to do miracles in environments that are extremely difficult. So, while it is … these are simple concepts that we’re talking about in terms of creating a living, wonderful work environment for these folks and giving them the tools to do it, it’s very difficult to actually make it happen in practice.

Heffner: Now, you see, I went from sad to glad.

Stone: [Laughter]

Heffner: And now you’re making me go back the other way. You’re talking about how difficult it is.

Stone: Well …

Heffner: On, on the one hand you say, “you don’t have to be a genius to figure this out.” On the other hand, you seem to be saying at least given the resources we’re willing to put in now, it’s tough … maybe too tough.

Stone: I agree. I think it is very tough. Without getting into all the complications around “who’s to blame” … where we point the finger, because the finger has to be all over the place. I would start by placing the finger on our society in terms of what we value in care-giving, what we value in terms of providing assistance to our elders, to people with chronic disabilities, and are we willing, as a nation, as a society, to invest in good quality?

Heffner: You seem to be saying the answer is “no” to that question.

Stone: Well, I mean if you start with looking at what our, what our rates … what we pay our general rates for … on the public side … for this investment … our Medicaid rates, which is a primary payer for many of these nursing facilities, is very, very low. And many would argue that it’s not sufficient to actually staff in a way that is critical for these nursing homes and other settings as well. So, we start with that. We add on top of that that these are … these are jobs, whether they’re the front line, whether they’re RNs or whether they’re physicians and other health professionals, these are not jobs that are valued. And so what has happened is we have a real leadership gap in long-term care. We’re not attracting the best of the best. We’re not attracting folks who are committed to a caring environment. And so we don’t have leadership to really sort of set the standard for the kinds of environments, the kinds of tools we would really like to make available. And it becomes a vicious cycle. So then we end up with these horrible, horrific stories in the media …

Heffner: MmmmHmmm.

Stone: … that feeds on itself, and then the blame goes to the front line, because obviously they’re the ones who have the most hands-on experience with elders living in nursing homes every day. And you get caught in this maelstrom and you can’t pull yourself out. What Wellspring has done, what a number of these other Pioneer homes have done …the examples … if you want to look at the Eden alternative, if; you want to look at the folks who are doing a fabulous peer mentoring programs with the frontline staff … I mean there are lots of examples of really good programs out there. They have been able to pull themselves out of the maelstrom within the current constraints.

And I would argue that they are the exception rather than the rule. But what we can do is use them as examples of what can be and try to begin to focus on what I call “Centers of Excellence” rather than always looking at the negative.

Heffner: But you talk about models … you also make it seem as though until we finance the care of the frail elderly, models aren’t going to make that much difference.

Stone: I think that we have to address these issues simultaneously. My view has always been that in this country, clearly, our nursing home field, long-term care field, was really driven by financing. If you look at the evolution of the nursing home … pre-1965 …pre Medicare and Medicaid … we basically had homes for the aged. These were benevolent societies; these were other kinds of altruistic organizations that came together to basically support their communities, because there was nothing else.

In ’65 with the advent of Medicare and then Medicaid, we basically had financing mechanisms and a whole industry evolved around that. Now what we have to do is sort of turn everything on its head, and say, “you know what, we need to get back to some of the values that we had in those old homes for the aged.” Because in many ways they were caring institutions, but we need to bring them in to the 21st century. We need to have the resources that are required to, to recruit and retain a staff from the CEO, Administrators, RN’s, Directors of Nursing, front line staff, dietary maintenance all across-the-board. We need to help them to create environments that encourage people to stay and to like what they do and to learn from their experiences and we need to support that. And right now we don’t have an environment where that happens. What we have … what has evolved is a fairly mediocre set of settings with a very heavy regulatory orientation that really doesn’t allow for innovation and that really also doesn’t support performance based on quality.

Heffner: Why do you say “heavy regulatory”?

Stone: Because of a lot of the problems which are very, very clear … we have had a history of very significant disasters in long-term care, particularly in the nursing home setting … we have evolved a, a very significant regulatory system. In fact some would argue that if hospitals were regulated as strongly as the nursing homes have been regulated, we would see some more serious issues with the hospitals. And I think we are beginning to see that now. So …

Heffner: Are you saying that regulation leads to inadequate …

Stone: No. I am saying that regulation needs to be balanced with other interventions that look at how we can promote quality. And we haven’t been able to strike that balance. To my mind, they’re a sort of … there’s a three-legged stool – there’s the financing which means that we have to have at least money that is enough to really at least set the, set the standard … to pay for the standard. We need a regulatory structure that makes sure that the bad apples, as much as possible, are out of the picture. And we need other incentives and tools that actually help us to promote the best quality that is possible and we need to bring all of those things together.

And, in my judgment, what we have done is to have, in general, under-funded a system, have focused substantially on a lot of bad apples, and because of that have set a regulatory system that has basically “lowered the bar”. All you have to do is meet those regulatory standards. What the, what the Wellspring folks have done and what the Pioneer folks have done and what a lot of the other folks who are really trying to do things differently, they have raised the bar for themselves. They have said, “the regulatory standard isn’t enough. We need to go above that.” And, and what I, and some of my colleagues in the Commonwealth Fund have been interested in is trying to figure out “how do we make that bar the norm, rather than the exception?”

And, it’s not going to be just money, it’s not going to be just regulation, it’s not going to be just putting out new models for people, or current models for people to look at. It’s going to have to be a combination of those things. And, in addition, I would argue that we’re going to need leadership. Just like we need leadership in this country, we need leadership in long-term care. We need to cultivate new people, we need to cultivate people in our medical schools, in our nursing schools, in our management schools, who really understand this as a caring profession … not just as a real estate deal and who are acknowledged, both financially and from a value base. And right now if you try to get a geriatrician, a geriatric nurse practitioner, a good nursing home administrator, people who are really trained in this area … we have a hard time finding them. We’re not turning them out in our schools, we’re not paying them well enough to make it worth their while, and so we’re, we’re really … you know, it’s sort of like the elephant … it, you know, it’s this big elephant and it all depends on what side the elephant the blind man is touching. And we’ve really got to touch all of them.

And this is why, to go back to your question about complexity … that’s what makes it so complex?

Heffner: What about other people? Other countries?

Stone: Other countries have probably done a better job in … or at least have been more systematic in their financing. Mostly, if you look at a lot of the Western industrialized countries, and I’m talking now about Germany, Austria, France, Japan … they have made some very intentional choices to, to develop a … basically a social insurance approach to the financing of long-term care. Which basically means that with a combination of taxes, premiums, public pensions and private contributions, they have basically built a system of financing for their long-term care program.

We are a country that is … the sort of the incrementalist at heart. Sort of a combination of strong community values, but also rugged individualism. When you put those things together, what we have is a hodge-podge of, of financing. So, on the financing side we are not as … we are not as comprehensive and not as systematic as many other countries.

On the other hand, I think we are probably no less … we aren’t worse than other countries in terms of our delivery system. All the, all the countries are struggling with the same problems around delivery. And that is the quality issue is a, is a bear. We all have countries that are aging. Remember that in 1965 we weren’t … when Medicare and Medicaid evolved, we weren’t dealing with the magnitude of the demand that we see today.

Longevity is a mixed blessing. People are living longer, but we have a lot more chronic disability; we have a lot more people who are living past the age of 85, which is really the trigger for long-term care needs. The majority of folks who are requiring long-term care are 80 and over. And so we have higher, higher, higher level acuity in many of our nursing homes today; people who are really sick. They are sick as well as needing social supports and a residential environment. And so when you combine all these things, it’s putting a lot more pressure on our system. We can’t get by with mediocrity.

Heffner: You spoke before about leadership. And I was intrigued to note that you had received, at one point, in your career, a Claude Pepper Award …

Stone: Right.

Heffner: And I think of Claude Pepper as one of those great political figures, who were largely concerned with the question that you’ve devoted yourself to.

Stone: Yes.

Heffner: The elderly. Is there any counterpart to a Claude Pepper in government today?

Stone: I don’t think so. I mean … interestingly I’ve been in this now for almost 30 years … I’m in my early 50s … I’ve aged … I’ve aged with this field. And in the sixties and seventies there was incredible enthusiasm around these issues. My cohort of folks who got into this business were incredibly committed. And were really motivated by people like Claude Pepper, like Arthur Flemming, sort of the grand old guys of gerontology and aging. And what is interesting and I think sort of ironic is that as we’re aging, and as we are just about to see this incredible exponential boom in the aged … between 2010 and 2030 we’re going to see a huge … a 76% increase in the aging of our population.

Heffner: 76%?

Stone: This is, this is when we will really begin to see the huge boom. Just as we’re on the cusp of that, I sense more pervasive ageism than we’ve had in the past 20 years. So that we don’t have leadership. We don’t have a value set that really values aging. And consequently, we’re, we are in … you know we could say this is grim … I always look at it as the opportunity. The opportunity that we have here is … the demographic imperative is there. And baring some kind of pandemic that wipes us all out … all of us have already been born … so the aging is there … the demographics are there …

Heffner: And I find that hard to understand because we’re voting and people constantly talk about the AARP and its political moxie. You talking about aging … ageism … that that’s growing.

Stone: Yeah. I mean …

Heffner: How do you reconcile it?

Stone: Well, this is how I reconcile it. That as we have larger groups of people who are actually getting close to this, the fear factor grows. And while we have a lot of wonderful rhetoric around successfully aging and honoring our elders, and what have you, the reality is, is that at an individual level it’s a very frightening thing. And aging is equated in most people’s minds with decrepitude and death. And so the larger the group of folks who are actually beginning to face this, the more fear we have. And so, you know, we basically, it’s not going to happen to me … I mean there’s a collective notion around aging, but the individual notion doesn’t merge. And, and I think that that is one of the reasons that we have …look at the media. Look at the attention to anti-aging. The language, the vocabulary is not about embracing aging, it’s about anti-aging. And …

Heffner: What do you mean by “anti-aging?”

Stone: What do we talk about when we talk about drugs to, to allow us to live longer? We don’t call that age enhancing … we call it “anti-aging”. There’s a whole field of biomedical research that has evolved around anti-aging. Look at the cosmetics field. And you well see the language is about anti-aging. And I, I use that as an example only because vocabulary is very important for us. It’s a symbol of what is underneath, what are the underpinnings. And I believe that there … because there is a pervasive ageism in this country, it is reflected in the vocabulary that is used. And ultimately it gets translated into what we are willing to invest in the infrastructure … going back to why we haven’t invested … not just money … I’m talking about also investment in human capital, which isn’t all about money. It’s all about where we are putting our resources to develop the capacity to actually take care of people who are becoming chronically disabled.

Heffner: I’m so interested in you use the word “fear”. We’re “fearful” of it, so we look the other way?

Stone: Yeah.

Heffner: Well …

Stone: … we look the other way, until of course, everybody …

Heffner: We’re there …

Stone: … everybody hits the crisis … it’s almost … it’s probably one of the … after childbirth … it’s one of the most ubiquitous activities. Everybody has either personally, or indirectly an experience with long-term care. And it is the conundrum for those of us who have been in this for so long that there is this tremendous cognitive dissentience between what we know, on the personal level, and what we have been able to do on a societal level. Hope … I have incredible optimism that with this huge wave of folks who are entering the aging world the Baby Boomers … both as people who are aging themselves, and also who, who now have family members who are really experiencing these issues, that we will see a new wave of advocacy and a strong constituency for some kind of societal support for this.

Heffner: And I suppose that’s the best place to end the program on that optimistic note. I, on the other hand, keep thinking of Maurice Chevalier, and the song ….

Stone: [Laughter]

Heffner: … “I’m glad I’m not young anymore.” Thank you, Dr. Stone, for joining me today.

Stone: [Laughter] Thank you very much.

Heffner: And thanks, too, to you in the audience. I hope you join us again next time, and if you would like a transcript of today’s program, please send $4.00 in check or money order to The Open Mind, P. O. Box 7977, FDR Station, New York, New York 10150.

Meanwhile, as an old friend used to say, “Good night and good luck.”

N.B. Every effort has been made to ensure the accuracy of this transcript. It may not, however, be a verbatim copy of the program.

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