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Long Term Care on the Brink; Saving the sector

Long Term Care on the Brink; Saving the sector September 22, 2020

Marketing, research and business development consultant in healthcare, human services and senior living.

Long-Term Care on the Brink; Saving the sector

Date: 22nd September 2020
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    Long Term Care on the Brink; Saving the sector

    Irving Stackpole

    We are concerned about long-term care. I’ve made the statement here that it’s on the brink and I’ve also used the term saving the sector. I don’t presume to save the sector myself, but the language is carefully chosen. Long-term care as we know it in the United States and the U.K. and certain other places is indeed on the brink and it needs to be saved today in this time. We’ll talk a little bit about the current situation, importantly about recovery and what’s the likely path for recovery. We’ll talk about the structures and long-term care programs and long-term care technology and data. We’ll talk about staff culture outcomes and finally, economics.

    So, the current situation is indeed a crisis. It’s a crisis within a crisis. Crisis, by definition, is an event with an adverse impact on certainly at an individual level, but importantly organization, its customers, consumer and its brand. We need to talk about saving and salvaging what we need in long-term care, because the brand I would argue that the very brand itself, long-term care has been damaged, is currently damaged, and we need to do something about it. I want to talk first about recovery. After the covid-19 crisis, the likely recovery models will be impacted by the depth of the decline. It’s worse in certain sectors, in certain segments and in certain geographies. It’s worse than in others but the depth of the decline, the length of the decline and the shape of the decline is important. I see two basic binary choices for different markets, one where the segment is rebuilt and recharged. Scenario two is that the sector is ravaged and relegated to a second-tier factor or component in the health care and social services models, primarily in the US and the UK.


    I want to present in terms of recovery, let’s look at a couple of ways that markets can recover. There’s just no doubt that as the result of the pandemic, there has been a loss of revenue in long-term care centers and in among long-term care providers. With some potential exceptions, but fundamentally and especially for congregate, long-term care, there has been a decline in revenue. There have been declines in occupancy and the number of individuals using the service and there’s been a decline in access to staff. So how do you look at these declines and how do you project recovery? Well, there’s a few ways.


    In this very simple model, there you can see the blue line here reflect. So, I’m saying that the recovery models are critical for looking at how we will recover, how the sector might recover, this is extraordinarily important for planning. It’s extraordinarily important as we look at limping from day to day, many of our clients are making it by on emergency interventions, by government and in many cases, by personal financial interventions.

    So, it’s important to look at how these markets, how the demand might recover. One of the models that you can see here is a gradual recovery that looks like a U shape. And then there’s another less robust return and then a slower return. Indeed, we’ve modeled these out for this sector, for skilled nursing. We wonder whether or not the sector will recover in this pattern, more like a Nike swoosh and have extended this out to October 2021, trying to trend the recovery in part based on anticipated access to a vaccine and other public health measures interventions.

    But the question is the variance between what we see here in acceptance or penetration. Will we ever get that back? What are the factors that will allow the congregate seniors care market to return for assisted living, which has not suffered as badly as skilled nursing or nursing homes, the return will be closer, will come closer to pre covid metrics? The question remains, can we return to previous levels? what will that look like? How much of that pre covid market will we get back? The recovery might or could look like this.


    We can see these are economic metrics that are used to map recovery in markets. These measures look at primarily in Europe, but the model is what’s important here. We can see this stutter step pattern in the recovery as markets open up and locked down. I understand in the U.K. that in parts of Europe, the interventions are returning to Lockdown’s. My concern is that very similar things will occur here in the United States as we either have exacerbations of the quote unquote, first wave of the coronavirus or indeed a second wave. So, the pattern of recovery is tremendously important because it gives us a window into the timing and what to expect in the not-too-distant future. For the changes we’re going to be talking about, for the interventions we are, it is possible to create intervention. We needn’t exclusively look to the government or look to Big Brother or large corporations to bail us out.

    There are small, meaningful changes that that can be made. I believe that that’s what this dialog is all about. We need to stop relying on pages and pages of governmental intervention as rip it up and start over again. I arbitrarily deconstructed the long-term care sector into structures, and I know that isn’t relevant to those of you in domiciliary care or home care. Structures are important to congregate long-term care, which is a major part of the markets, the segments, programs, which applies to everybody, technology and information, media, production, culture, outcomes and finally, economics.

    With regards to the structures, the original property plant and equipment accounting used before public health, before it became a popular public health term, most nursing homes in the United States, most of the built environment was built between 1960-75 as part of the Hill Burton Act. Since then, there’s been a surge in construction around assisted living, which is why assisted living seems to be the model that people prefer for structured environments in congregate long-term care.

    Since then, since roughly the late 90s, there’s been very little reinvestment, especially in nursing homes is capitalization has been extracted. The federal government has withdrawn fiscal support for the structures, for the property, plant and equipment. The result is that we have physical plants that were built in the 60s and 70s that haven’t been updated, haven’t been significantly upgraded. And the question I’d like to ask audiences and clients is, would you stay at a Hilton or a Marriott that hadn’t been renovated in 40 years? I don’t think so. Its people don’t want it. It’s an unattractive model. We’ll talk more about that.

    In terms of the culture, what do we need? We need a far wider array of built structures than is generally currently available, we need large ones like college dormitories with today’s college dormitories, not the kind that I had when I was in college and in the 1960s. We need large college dormitories with attractive common spaces. My niece is a professor at a liberal arts college and she likes to say that there’s a battle of student unions. How can we make our student union before covid more attractive than the other colleges student union? This battle applied to college dormitories as well. So those newer college dormitories are indeed the kinds of structures that will be attractive to certain consumers. We also need medium sized structures, 70, 80 units in a physical congregate space, and we need small units like mansions for small groups of related or unrelated individuals. These are sometimes called naturally occurring retirement communities. I can’t keep up with the lingo. I think that label has been changed and the model is Golden Girls. There was a famous article in The New York Times last year about the Golden Girls being the new model.


    Supply studies have been all about the market research into what we need in terms of physical supply has all been about benchmarking, and there’s very little about qualitatively what consumers want. It frankly, it’s been about what investors can extract from the market. The real value development in the sector and has for some time is the real estate, which is why we have real estate investment trusts prop. Those involved in the markets at all is because of the underlying value in the real estate. Telecommunications and information infrastructure is needed and clearly the sector needs access to the capital. Why don’t we get what we need?

    Well, access to capital, a skilled nursing center, a nursing home in the UK just doesn’t have access to capital. How would you borrow 3 Million Dollars to upgrade your infrastructure and convert your twin bedrooms or four bedrooms to single beds, suites with all suite showers and bathrooms? How would you do that? You need capital. You need access to capital. And I’m suggesting that we need a new federal Hill Burton act modeled after what occurred in the nineteen sixties. The other reason we don’t get what we need is, frankly, the segments, the market segments have been too busy competing with each other and I refer to that as eating each other’s lunch. We’ve also been focusing on profit, not on the future of the segments overall. Frankly, we have not taught our consumers how to differentiate and get how to navigate the very complicated long-term care environment and importantly, providers.

    That’s all of you. Many of you, we don’t bargain together. This makes no sense to me. The fragmentation in the sector is not serving us. We need to create a single agenda, a single voice, in order to affect some of the meaningful changes that are clearly needed in the sector. Really, do we need Prop Co? The original model was to attract investment money, investment grade money into the sector to bring capital in. My suggestion is that there are many ways in which that model no longer serves. It no longer serves what the segment really needs and what the sector needs in order to survive.

    Then we get to programs, It’s just a mess. There are vocational programs versus need based programs. There are programs that focus on the community, their focus, their programs that focus on the home. There are programs that focus on congregate. There are programs that focus only on nursing and exclude the other allied health or other social sciences or behavioral health needs of the consumer. It’s a really a rhetorical question. We understand how it got this complicated and in the references that you’ll see attached to this slide deck is really a terrific article that I would commend you all called Failure to Thrive by a colleague who wrote How We Got Here and how we got into the situation that we’re in. What do we need? What we need, I would say, is we need a system that provides screening and triage who needs what, and we need that screening in order to determine who needs what, and we need the triage to figure out to help the consumers and their adult children navigate the system.

    So exactly what does mom need? Maybe she only needs a handy person to install a guardrail, a grab rail and build a small ramp or shorten the steps and then triage. Help Grandma find those services. The second piece is we have a model now that is so complicated, in part because the financial system has strived to control payment in order to control costs, in order to manage activity in the sector. Controls have been placed on activity which in many ways restrict the ability of providers in the sector to collaborate to work together. It makes no sense.


    There’s extraordinary fear about being in violation of stark regulations in the United States is extraordinary fear about losing contracts with local authorities or offending penetrating the barrier between health and social services in the UK. None of this makes any sense whatsoever. Don’t fit the person to the patient, understand what the person needs and then figure it out and make clear choices. Credit default swaps. If you’ve ever seen the movie The Big Short, I commend it to you. Even better. The book by Michael Lewis. Credit default swaps, which are incredibly complicated, are way simpler than the choices that consumers and their adult advisers have with regards to long-term care.

    Let’s move on to technology and information services. The status of technology and long-term care is nothing short of abysmal. The technology as it exists now is completely focused on with very few exceptions. There are exceptions, but very few is completely focused on reporting, recording and regulatory fulfillment. It’s not focused on staff efficiency. The technology exists and the staff is supposed to. Participate is supposed to adhere, is supposed to comply with the insertion of the technology into the system rather than the technology adapting to what the staff say are their preferred models of working.

    This raises the question of staff efficiency. I argued pre-covid as passionately as I could that efficiency was going to be the mantra for long-term care going forward for the next 5 to 7 years. It’s still critical and it’s especially critical given that we’re about to see record levels of losses in staff. That is to say, we’re going to have a hard time filling position. If you aren’t already, you certainly will. We need subsidies for the technology because long-term care providers operate at extremely small margins, have very small amounts of cash on hand. The days of cash, outstanding days of cash on hand are very small for most providers. So, who can afford it? And we can’t get access to capital. We need we need to get our priorities straight, make sure that we’re placing more value on our grandparents than we are on tomatoes at Kroger.


    We need personal emergency response systems, the legacy systems. Philipps the Lifeline were hospital based. They were highly centralized. Geographically, we need an internet of long-term care. We need interconnectivity between and among legitimate health electronic health records and not simply small-scale records producing regulation compliance programs. I won’t mention any providers names and we need interoperability. We need something like what’s referred to in the literature as ambient assisted living ways that the technology can actually help grandma help our aging consumers, whether they’re in their home, whatever their whatever their domiciliary pattern is. Where are they? Can we help them where they are?

    The means of production is our staff. Well, there’s unpaid and there’s paid caregivers. The data on this is truly frightening. Who’s going to care for our long-term care consumers today and who’s going to care for them in the future? Tragically, this conversation in the United States and in the U.K. and other places has been politicized about immigrants and about workforce work rules, minimum pay. I believe, is a real disservice to the demand, the need for motivated, loyal, committed carers in long-term care environments. The second question that I have here, who wants to work in long-term care, given what has occurred with the pandemic? There needs to be some really sophisticated research done to identify the psychographic profile of those heroes who really did hang around in long-term care and who remain committed to serving the aged consumers, aged and disabled consumers, the most vulnerable people in our society.

    We need to understand who wants to serve them, and we need to figure out ways to bring more of them into the workforce and to keep them in the workforce. We need these sources today and we’re going to need these sources tomorrow. I have a few suggestions about that means of production staff in long-term care they’re about and here in the United States, they’re about 4.5. There were about 4.5 million.

    These measures, this data is from the Kaiser Family Foundation these metrics are already changing before our very eyes. We need to watch them very, very carefully as we see how the pandemic is impacting the willingness to continue to work and the actual ability of consumers to continue to work in long-term care. It’s such an important issue.


    So there really are those who want to work in long-term care. My belief is that it will take at least one generation to remove the stigma associated with long-term care. I believe that we need a federal long-term Care Jobs Act that will redirect the resources of the training system. The job retraining system in the United States is a similar system in the U.K. We need to retrain unemployed individuals after they have been screened for the loyalty components that I referred to previously.

    We need to screen out for people who are merely being opportunistic, find individuals who will remain motivated, and we need to train them in ways that that training will stick and give these individuals a career path so we could use existing training centers. The final point is we need to subsidize at a federal level, perhaps federal plus state. We need to subsidize salaries as retention incentives in order to keep people in the long-term care market, in the long-term care sector. Those of you who have been in long-term care centers have been in thousands of them, you know that they can be wonderful places, rewarding places, but they are also very challenging places in which to work. The consumers are often demented. Consumers have physical and physiological patterns that are very difficult to work with, challenging to work with. It’s incredibly important, very important to focus on the staff and the people, which gets to the issue around culture.

    The culture in long-term care, as I attempted to depict with this hallway in the wheelchair, can be nothing short of depressing. As I mentioned, the infrastructure, especially for nursing homes in the United States and the U.K., was constructed 30, sometimes 40 years ago or longer. It was built on the efficiency of the staff and it was built on a hospital model. There are long corridors, straight corridors with doors off of either side and rooms. And this may be convenient for the staff and the movement of equipment and staff, but it certainly doesn’t create an attractive environment, an environment which for especially for long-stay residents, is very conducive to comfort or to ease of living.


    The outcomes, clinical results from long-term care are only part of the story, certainly in-home care and in long-term care in the United States, as well as in nursing homes in the U.K., the NHS in the UK, CMS in the United States and other national services measure the clinical results, the outcomes in long-term care. However, I want I seriously wonder, is that really that certainly critical. But is that the total story quality, as much as this word has been maligned, is the degree to which a service is free of defects, which means that quality reporting programs such as has been promulgated by CMS in the United States and the NHS in the UK, it’s only half of the equation. The question is, what about consumer satisfaction? What do they want? Is this what they need? Is this what their families want? And if they don’t know what they want, why aren’t we teaching them? Why aren’t we in the sector taking responsibility for explaining the long-term care sector to our prospective consumers? I don’t understand it, but I think that leads us into what it is that we can do to modify to help change the environment.

    Finally the economics so that direct and indirect costs of providing services to elderly consumers. Through organized long-term care in both the UK and the US have been short changed, it’s been neglected for at least 30 years, maybe longer. The. In the United States, the Medicaid system, which supports 65 percent of persons in long-term care centers and is both the state and the federal program, it’s means tested, which means one needs to be poor in order to qualify for Medicaid. It can’t afford long-term care. The state budgets are groaning under the pressure of Medicaid payments, and it’s only going to get worse.


    Post covid Medicare in the United States backed out of this business, backed out of the long-term care business 30 plus years ago because it didn’t want to be responsible, didn’t want to be on the hook for what it saw coming down the road, which is a large increase in costs. Medicare is only responsible for a small percentage, 10, 11, and certainly no more than 12 percent of the costs of long-term care. Consumers, the public, many of them still believe that the government will pay for it when we survey and we’ve done tens of thousands of surveys in countless marketplaces around the United States on behalf of governments and associations and even state agencies, we find that consumers, the age qualified consumers and their adult children, their adult advisers, they all think that somehow the government will pay for it, which is one of the reasons why long-term care insurance never took off and never exceeded market penetration of 12 percent.

    There’s almost that many people think that the government will pay for it and by one estimate, there’s almost 500 billion dollars annually in non-paid. Care offered by family and friends and relatives to consumers who never show up on the government payroll systems or whose care is supported and supplemented by family and friends. This is a huge issue, a growing economic system that’s about to completely implode. There’s waste maldistribution and significant lack of collaboration and fragmentation.

    I want to make note here, especially that this issue of waste is particularly emerging during the covid recovery as the media looks to explain why so many people have become infected in long-term care centers and why so many fatalities have occurred, why a disproportionate share has occurred in long-term care centers. And it’s all too easy to blame point fingers at bad operators. The number of bad operators pales in comparison to many other segments, many of the sectors that are supplemented by federal direct or indirect payments. In long-term care, most providers want to do the right thing. Most providers are committed to the consumers and the residents that they serve. This issue of waste is a convenient distraction from the underlying brokenness of the economic model and long-term care.

    So, regarding economics, here’s some ideas as to what we might do. It’s mind boggling that in the United States there is no federal insurance for long-term care. This needs to be seriously adapted, adopted as a program, it would mitigate several of the perverse incentives in the United States around long-term care, like spending down your assets or distributing your assets prematurely and indiscriminately in order to qualify for Medicaid. Federal insurance for long-term care should protect the assets that individuals and families have developed, while at the same time offering real security, real security to families and consumers themselves. Funding for long-term care. We need a small increase.

    These are my suggestions, a small increase in the Medicare payroll deduction and a small premium, small premium with the means test on parts A, C and D in the Medicare programs. This is a I mean, a small it’s a politically sensitive issue, perhaps, but anybody that’s qualified for part A Part C and D can really afford a small premium for those services that would go to fund a federal insurance program for long-term care, make private long-term care insurance fully deductible, and more importantly, create a long-term care risk pool in each state, similar to what the Affordable Care Act did for the state, the state programs to sell health insurance.

    We should require participating long-term care health insurance programs to spend some small percentage of their premiums on education and communications, to teach the public how to navigate the long-term care system, because if the public doesn’t get smart about this, we’re going to have continued problems with misallocation and people accessing parts of the system for which they’re inappropriate and others not having access at all.

    The next steps, I believe we’ve included the discussion about the current situation, I think we need to create, in my opinion, a community of action. I would call on all of you who are listening today to participate in that community of action, which is involved in effective dialog. That’s what leaders do. They step forward. They talk about the issues in an honest, unbiased way. If you have biases, if you’re with a rete and you’re listening to this program, then step forward and have the conversation about how your knowledge about accessing capital can serve to benefit the segment. There’s certainly no problem in the world with enterprise solutions and profit, but we need to identify and implement serious changes to the long-term care system. It’s really an existential issue. We’ve created this system. We’ve created this long-term care process, and it can’t be changed without changing the way we think about it. So that’s the presentation for today. Thank you all for your patience. And I’ll look forward very much to your questions.


    Question: Lots of nursing homes and other places go out of business? How can we make sure we survive?

    Irving This is extremely important and unfortunate question to have to ask. But there are nursing centers, especially those in rural or semi-rural areas, that really are necessary. They are in hospital lingo, safety net nursing centers. There can and should be state based. Focus on looking at those nursing centers and finding ways. I know there’s currently money available through the federal government looking at ways to not only keep them afloat for the time being, but to find sustainable sources of revenue or income of some kind over the long haul so that they survive. And some of the suggestions I’ve already made may contribute to that. The other thing is that for those nursing centers that are in a genuinely competitive marketplace environment, though, it’s critical that those centers.

    Take charge of the narrative and begin to step forward and talk about the services they provide, the consumers they serve, the programs they offer and begin responding effectively to issues that arise out of this crisis, such as deaths, such as infections rates and the legacy issue of why our center experienced the pandemic in such a tragic way.

    This is all part of the very first webinar that we presented called Crisis Communications, and I would recommend that all to you for review.

    But how we respond as individual providers and as a sector in a marketplace area, state based, leading edge, state-based health care associations, state-based home care organizations, these associations and organizations can and should be helping their individual providers develop communications with their marketplace in order to work through this this difficult time. There will certainly be. In the United States and in states and in specific marketplace areas and in the U.K., there will be care homes and nursing homes that will reach existential levels of occupancy, utilization and support. There’s just no doubt about it. There will be contraction. And the next program that we’ll be talking about, we’ll be talking about what happens on the other side of that, because in roughly 20, 30, there will be a resurgence in demand based on the aging of the leading edge of baby boomers in both the UK and the US. And how the supply adapts to that demand will be critical.

    Question: Can you comment on Medicare plans, extraction of revenue from the SNF sector?

    Irving Medicaid managed care is a bad idea, which keeps coming around over and over again, Medicaid managed care didn’t work in the 80s, it hadn’t worked in the 90s, and it’s not going to work now. Medicaid managed care basically says that we, the state, which is responsible for administering state plus federal moneys to providers of Medicaid beneficiaries. Basically, this says we, the state, think that if a private provider. It’s more competent at this than we are. This private provider, this private insurance organization or its spinoff is more competent. The first point to be had is that maybe they are, but that competence could and should, in my opinion, be brought into the state because this long-term care is not a profiteering exercise, although profit can be made.

    It’s not a profiteering exercise. Fundamentally, it’s a responsibility of the state to care for and support its most vulnerable individuals. Second point is that the. Private agency that operates that it just dispenses the Medicaid funds are incentivized to dispense as little as possible. And while you can create rules and regulations about this at the bottom, at the end of the day, the more the agency, the private agency receives and the less they dispense this gap, this medical loss ratio, that’s their profit. And while I have nothing against profit, this system is so extraordinarily broken that that. Intervention at this point is, I believe, a perverse incentive. The Accountable Care Organization is something different. Accountable care organizations are an attempt by the federal government to drive value in. Health care, we all know that health care in the United States is at least twice as costly as every other developed nation.

    One of the ways that the government and many governments are attempting to do this is to introduce value based health care, and there’s nothing wrong with that. The problem is that the way this particular organization, Axios and other Value-Based Health Care organizations, the way they’re organized is they put somebody at the top of the mountain. In the case of the United States, most of it is hospital organizations, hospital groups.

    So, a hospital is now the ACOR agent in a particular marketplace area, and they dispense the money to all of the providers in that caring for persons covered by the FDA so they are incentivized to control the costs, limit utilization. All of that is good. The problem is that it’s a race to the bottom. Once you have controlled the costs and controlled the utilization, what’s left, what are the incentives for this administrative function in the health care system? What incentives are left are left? I know there was one attempt, but I don’t think there are any currently. Unfortunately, what’s left for them is scraps, and I believe it’s a race to the bottom. In the U.K., right, there is a similar sort of model with its own particular wrinkles, but the real question is, are they only extractive? Do they actually help administratively to control utilization? And are they the best model for controlling utilization? I hope I answered the question. It’s a good question. It’s a complex subject.

    Question: How can you successfully persuade people to be financially accountable for their family members that require long-term care? Many refuse to acknowledge that ownership of the challenge and responsibility.

    Irving Yes, this is what a great question and I’m going to start the response to that question at the at the philosophical level. By saying that. There is no freedom without responsibility. We would have no freedoms if we as citizens don’t take responsibility and what’s occurred in long-term care are a set of perverse incentives. So these perverse incentives have created a responsible in some measure, some for some portion of the rotten economic infrastructure in long-term care.

    The in principle there really is. No action that individual provider can take to teach consumers, to teach families to take responsibility for the financial component of the care of their family member. There are many families, and I hear these stories talking to our clients all the time. There are many families that step right up and say, whatever mom needs, we’re going to take care of it. Whatever grandma needs, we’re going to take care of it. I have dear friends who have driven themselves to the edge of bankruptcy in order to care for aging parents and relatives. The rate of bankruptcy in the United States for health care based on health care, the rate of bankruptcy is stunning and it’s going to get worse.

    Question: How do we teach families to be responsible?

    Irving I think there’s an interesting question, how do we remove the perverse incentives in the system in order to then create a sense where? Consumers feel that they can access a system, that they’re going to be treated fairly, that the family members are comfortable, that while those who have enough will share in the costs, those who don’t won’t be driven to the brink of bankruptcy or indeed right into the crater of bankruptcy because mom fell, broke her hip and wound up in a nursing home. So, the question is a principled one, an important one. And unfortunately, I don’t believe that there is a way for individual providers to address the issue. I just don’t think there’s a way for us to do it.

    Question: So the transition of care from hospital to nursing home is very hot. Do you have any ideas on how to better the communication between the hospital, the nursing home?

    Irving That, too, is an excellent question. And I can tell you that this is one of the bright lights in long-term care and specifically in nursing home care in both the U.S. and the U.K. with the pandemic has done is it has dramatically opened up the world of telehealth. Telecommunications have been available for a long time. We are all here in Zoom and there’s a lot of you using Zoom now in ways that you wouldn’t have used before covid. And I’m deeply grateful for that, by the way. The same is true in long-term care, best in class before covid worked with nursing centers, which had 50, 70, in some cases 100 admissions a month. If you think about that into a long-term care, these were short term care consumers discharged from hospitals for brief periods of rehabilitation, wound care and the like in a skilled nursing setting and in those best-in-class centers. There was great telecommunications links between the discharging hospitals and the long-term care providers, and they would be, in some cases, weekly or biweekly teleconferences to review cases, review care plans, talk about discharges, talk about complications, etc. These communications have terrific impacts on unnecessary 30-day readmissions to hospitals and on the competency of the long-term care staff. This telecommuted these telecommunications tools that are now being proliferated and now being used by long-term care providers much more widely. These are game changers, and they will dramatically improve the communications components between and among long-term care providers that congregate care, including home care, as well as pharmacy and discharging hospitals.

    Question: What do you mean by take charge of the narrative? How can we do that?

    Irving What I mean by that is historically long-term care providers and the associations that purport to represent them. These systems have not had a public facing communications agenda. And when they did, it was nothing significant. There was no significant investment that’s we are now paying for that in many ways. Providers that want to have good relationships with the media want to have good relationships with the age, income, asset qualified consumers and advisers in their marketplace areas, providers who want to have good relationships can’t do it overnight.

    There’s no flipping a switch and making it happen. It takes determination and it takes a program of regular communication, understanding how to frame communications so that the positive is maximized and the negatives which are in there will occur are minimized. How to respond to media inquiries, how to handle a crisis, a death or an untoward event, fire violence in the nursing center and that that impacts domiciliary care or home care providers. There are ways to handle these things. And because long-term care providers have never done it, there’s very little skill set.

    I would refer you all to the Crisis Communications webinar. It talks about how to build that kind of skill set and how to build the systems so that we are responding to inquiries from our communities and managing the narrative, stepping out in front of these issues to communicate with our public, our audiences in advance, communicating with them about new developments, communicating with them about changes in programs, communicating with them about personal interest stories. And there are dozens. And I hope that you’ll see more of them coming through in the media and the market marketplace areas as we progress in this in this post covid period.

    Question: What you describe in aggregate seems to represent a significant and radical departure from the post-acute model of care that has emerged over the past five decades, particularly the presence of competitive forces and profit that exists in the system. How do we get the kind of change that you are describing to start?

    Irving OK, how do we get the changes? I think the changes are being forced on us. And as I said at the beginning of the presentation, I see two potential scenarios. One scenario is that the sector, long-term care, all of it will be renewed, refreshed, recharged, reconsidered, reconfigured, new sources of investment, new sources of operating systems, new sources of income. It’ll all be transformed. Because of the existential crisis we are in, we are in a crisis where a significant portion of the long-term care supply base. Currently bankrupt and is only being supported by force federal investment, and if we don’t fix it, we’re going to lose it. And if we lose it, then we’ll have to have a transformational dialog about what to put back in its place and my sincere prayer and I mean that literally is that we don’t just reproduce the jerry-rigged system that we’ve got now. The other part of the question had to do with the competitive forces that were put in place. Over the last 40 and 50 years, those competitive forces are the product of very short termism, very short term thinking about controlling payments and controlling utilization. Look at this, Mrs. Stackpole, who’s an 85 year old woman who falls and breaks her hip both at home and breaks her hip and gets. Sent to the hospital.

    She has a hip replacement done because she’s got otherwise them being a little overweight and having Type two diabetes, she’s really fine. She’s managed quite well. She goes to the hospital. She has her hip repair. She goes to maybe she goes to a skilled nursing center previously, briefly, and then she goes home back to her house with home care. Mrs. Stackpole in that episode will have been exposed in the United States and the UK, less so in the UK, especially in the United States, to five to eight different payment slash regulatory systems, several of which, like the pharmacy system, the D and E, the durable medical equipment home medical equipment provider.

    Possibly the hospice provider and the skilled nursing provider, many of which can’t talk to each other, it’s prevented by the regulations if mitigated against by the regulations. There are ways around it, but most people don’t struggle with it. It’s too complicated. It’s so over the past 40 or 50 years, the competitive environment has built up around that. And the same is true in many parts of the healthcare market. We’re only talking about long-term care, which is a small slice, a relatively small slice of an enormous two point eight trillion-dollar sector. These factors can and should be to use the term that Edwards Deming coined the systems need to be rationalized, there should be a rational connection between and among the pharmacy service providers that take care of Mrs. Stackpole, there should be a rational connection between the social services that evaluate Mrs. Stackpole appropriate return to home, whereas currently it is in the UK. But currently there is no such thing in the US. None of this makes any sense. And it’s it’s the product of this jerry rigged, micro focused attempt to control utilization, control payment and therefore superimpose regulatory measurements and metrics on top of that intent systems. We need to fix it.


    Stackpole & Associates is a marketing, research & strategy consulting firm focused on healthcare and seniors’ services markets. Irving can be reached directly at

    Marketing, research and business development consultant in healthcare, human services and senior living.

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