The diagnosis of “failure to thrive” describes a multifactorial state of decline, which is often the result of chronic concurrent diseases and functional impairments.
Long-term care certainly warrants the diagnosis, “failure to thrive”. This is due to many factors, described clearly by Brendan Williams’ Failure to Thrive? Long-Term Care’s Tenuous Long-Term Future. Most of these chronic conditions can be described as political, fiscal and cultural neglect
With 40+ percent of the COVID-19 related deaths in the United States and Europe occurring in congregate long-term care (~80% in Canada), decades of underfunding, neglect and negative cultural stereotypes have tragically converged. The reality of this carnage is inescapable, and cannot be glossed over with politics, public relations or (even worse) grim resignation.
Before COVID-19, the sector endured widespread economic and operational problems. Now, nursing homes and assisted living residences, have lost occupancy & utilization, have lower revenues and face immense staff retention and recruitment obstacles. And in spite of the fact that this is a situation concocted almost entirely of political neglect, these same politicians call for review and reform, goaded on by ersatz public interest groups and media outlets who see an opportunity to leverage the situation for their own ends.
This will further add to the uncompensated direct and indirect costs of these already underfunded healthcare system stepchildren. And we haven’t yet seen the tide of litigation, which is bound to swell as guilt-ridden and angry families seek to take revenge for the deaths of tens of thousands of their relatives. This collision of circumstances will certainly drive a steep increase in bankruptcies and closures, removing even more nursing homes and assisted living residences.
Most of the inventory in congregate senior care is unattractive, inaccessible and/or unaffordable. Systems for regulation and payment have been cobbled together over decades with little or no concern over what the consumer wants, true efficiency, operational outcomes, or quality. Government funding sources have empowered or contracted with various intermediaries (local authorities, state agencies and private claims management companies) to help manage payment and control utilization. Or developers have focused on “cherry-picking” higher income, wealthier prospects, leaving the so-called middle market and poor to fend for themselves.
The result is a hodgepodge that costs too much, includes perverse incentives, and is almost impossible to navigate. As developed economies reel from disproportionate COVID-19 related deaths among the elderly in congregate care settings, isn’t it time to look past old models, which weren’t working anyhow, and start afresh with creative ideas and 21st-century innovation? From an ethical point of view, the vulnerable elderly and disabled in our midst deserve better. The post-World War II Baby-Boom cohort is entering their 70s and could overwhelm the existing age care & support systems. From an economics point of view, we need to do something to bend the cost curve. The system, to put it bluntly, cannot survive unless we take bold steps.
On Wednesday, November 18th at 11:00 AM EST, join me as we look at what might be done to cure this failure to thrive. We’ll take a brief look at how we got to such a precarious point, what individual providers can do now to survive, and chart a new course for the long-term care sector.
Saving long-term care includes:
- Facts v. fantasy – the sector is full of incorrect information and enduring myths about the demographics and psychographics of ageing. We’ll bust several myths about the number of age-qualified consumers, as well as their perceptions about what they want. (Spoiler alert – these answers are not the ones you’ve heard elsewhere.)
- Measure what’s left after COVID-19 – we will look at how much “fear” will change the markets, and how much supply is likely to survive
- Structures – the property plant & equipment in most congregate, long-term care settings is old and unattractive. Recent additions of purpose-built assisted living and other types of properties stand in contrast to the “Fawlty Towers” properties. Most owner/operators don’t have access to capital markets and would not be able to make the debt payments for the kinds of upgrades that have been put off for 30+ years. Imagine staying in a hotel that hadn’t had more than a paint job for 30 years? You get the picture.
- Programs – most of the programs in long term care aren’t at all designed to meet the needs and desires of consumers or their families, but are, instead, designed to restrict government funding to a specific class of individuals and/or to monitor and control payment through utilization measurement. For example, in the US, a typical 85-year-old who needs post-operative care will be covered by 5 or more different programs, including nursing home, pharmacy, medical equipment, physical therapy, home health care as well as home & community-based services. None of these talk with each other and very often actively compete with each other.
- Technology – technologies, including “ambient assisted living” are currently available to enable surveillance and physical safety of consumers in their homes. Remote patient monitoring, digital health and telehealth solutions have clear returns on investment and (because of SARS-CoV-2 / COVID-19) are meeting with widespread acceptance and adoption. Public health principles applied in long term care (relabelled as social determinants of health) are finally being applied in risk-based experiments and demonstrating their importance to improving health, safety and lowering overall costs.
- Information infrastructure – grocery stores have better technology than most congregate care centers. Why? Because the sector has been embarrassingly neglected by policymakers and politicians for decades. Country-wide investments in health information technology (HIT) for things like telemedicine and electronic medical records in the US and the UK have specifically excluded congregate long-term care.
- Outcomes – the minimum data sets required of and recorded by long-term care centers are just that – minimum. There is no data about the overall outcomes of care. Even where the data about clinical conditions is recorded, (e.g., PDPM, PDGM), unlike hospitals, and medical practices there’s no attempt to measure customer or consumer satisfaction.
- Economics – how will care be funded? The most important component of any long-term care operating budget is labor. The human resources needed to care for vulnerable elderly represent 60 – 80% of every long-term care Operating Statement. These individuals are often poorly paid, foreign workers at the bottom rung of the socio-economic ladder. Why? Because operators are paid as little as possible, based on the “heads in the beds” or the (truly perverse) insurance or pension category of the consumer. A few bad actors aside, long-term care workers are paid so little not because of greedy owners but because the system doesn’t allow the owners to pay them more!
We need to save the sector, and the current COVID-19 crisis is an inflection point where thought-leaders can and should step up and speak out. Join us, speak out for change and become part of the dialogue.