Looking into the future is always risky, if there’s any interest in being accurate.
Those of us working in long-term care are aware, many of us painfully and acutely aware, that we have the combined crisis of occupancy, revenue, unavailable labor, and of declining public confidence. The path long-term care is on doesn’t seem to be sustainable. My purpose here isn’t to further agonize over the sources or root causes of this crisis but to try to understand what’s possible for the sector.[1]
The body of research, typically applied to urban planning, into comparative historical analysis and critical junctures is instructive in understanding what’s possible.[2] These models present us with ways of understanding how institutional change occurs and what’s likely for the long-term care sector.
Incremental or disruptive?
Based on critical juncture analysis, “… there are two general modes of institutional change: incremental and more or less continuous adjustment and adaptation; and critical junctures of sudden and transformative change.”[3] For example, the passage of the Social Security Amendments of 1965[4] (SSA) represent a disruptive change based on political, social, and economic crises at the time. The Amendments were intended to protect the aged, children, and other vulnerable persons from destitution and hardship; a clear and present memory among the legislators and the public at that time. And the institutions and systems that the SSA created have been extremely durable and long lasting, despite the fact that they are now, in many ways, no longer fit for purpose.
The changes we’ve seen since 1965, which effect long term care are incremental changes brought to us through the institutions created by or empowered through the SSA. Considering this type of incremental change, there’s no doubt that LTC will continue to see more accretive regulatory pressure to mandate staffing, moderate prescriptions, master contagion, and mitigate loneliness through dictates about access to the consumer.
My questions here are: Where will this lead the sector, and; Are we nearing the point (or perhaps there) where more incremental change is refractory to meaningful results? An affirmative answer to the latter might lead to a critical juncture.
Are We at or near a Critical Juncture?
Critical junctures are types of social, political, and economic disruptions, which can occur in relatively brief periods, and where previously stable institutions are transformed and new approaches – new pathways – established. Critical juncture is the point at which the social contract can no longer be fulfilled, available alternatives are evaluated and choices are made based on the unacceptability of the current situation.
Is the current crisis (a nexus of problems) sufficiently painful and unacceptable to prompt substantial changes to:
- How CMS regulates (political);
- How capital is formed and invested in the sector (infrastructure);
- How intermediaries pay for services (economic);
- How the public sees long-term care (social);
- Substantially increase the technologies deployed (technology);
- The body of jurisprudence (legal), and / or;
- Make the sector environmentally more sustainable?
American society overall is racing away from the experience of the pandemic and its related issues as fast as possible. The deaths and failures of our long-term care institutions are already receding from the public consciousness. The publicly acknowledged inadequacy of the direct care workforce is morphing into discussions about labor actions such as strikes and walkouts, shifting the rhetoric away from the underlying inadequacy (demographic, immigration, status & economics) toward less relevant planning topics. One of the critical ingredients to critical junctures (apologies for the play on words) is a widespread acknowledgment that the current institutions aren’t working, and that the publicly identified problem is intractable by the solutions at hand.
The health and social care “systems” in the United States are so extraordinarily fragmented that few understand how to navigate them. So-called cross continuum collaborations are local, uphill battles.[5] Among the best (disruptive) outcomes for nursing homes would be to become fully, federally integrated with other healthcare and social care providers in the US healthcare “system.” This would require a harmonization and rationalization of regulations and legislation, which would truly be disruptive.
Another fundamental fracture in the aging services infrastructure in the US is where care occurs. There are generally two venues: Institutions (nursing homes and hospitals), and; Home. The latter might be an apartment, standalone house, or even an assisted or independent living residence. The public has finally become aware that hospitals are the deadliest places in which to receive care.[6] Most nursing homes were built before the era of Certificate of Need requirements are decades-old and decrepit. What’s needed is a new Hill Burton act to rebuild them.
Inadequacy of the direct care workforce in long-term care may also be another dimension leading to what could be a critical juncture. For decades, the inadequacy of the direct care workforce for the imminent search in age-qualified demand has been recognized. The political fixes include; depoliticize regulations around nurse qualifications and bring back nurse and caregiver Visas. Such changes would increase the supply, while relying very heavily upon established institutions to monitor quality and outcomes. The underlying demographics is like the looming, biggest part of an iceberg beneath the surface of public attention.
What if we lost 30% capacity?
Inadequate workforce in both institutional and home-based care, changed behaviors among consumers, increasingly profiteering intermediaries, slow adoption of technological efficiencies and inflationary pressures are forcing nursing homes to close, and home health agencies to delay, ration or decline starting services. While home care agencies are more supply/demand elastic, nursing homes in particular are having a hard time, with many of them on the brink of fiscal collapse (“zombies”). If the current political, economic, social, and legal quagmire isn’t enough to bring the sector in the US to a critical juncture, would losing 10%, 20%, or 30% of our capacity precipitate real change?
Even if the capacity remains as is, by 2040, by back of the envelope estimates, the US will be short 3,000 to 4,000 nursing home beds, and unable to staff 6,000 to 8,000 home care visits. Significant increases in the number of age qualified consumers starting in 2030 will create increased demand for capacity for which the US is unprepared.
As the situation evolves without major change, more nursing home and home health agency capacity is lost, leading to backed up hospitals, leading to negative political attention, leading to more punitive media attention, and regulatory pressure.
Change in the Social Contract
In considering this environment, the crisis we are in and what’s possible, in particular, looking just a little farther down the road, consider the following questions:
- Will baby boomers’ children (Generation X and Millennials) accept the maddeningly complicated, fractured means of supplying long-term care to their aging Boomer parents?
- Will they tolerate the erosion of their inheritance, the largest inter-generational wealth transfer in history, to pay for long-term care?
- How will Xers and millennial’s respond to declining/ unavailable/inadequate/unacceptable supply as they attempt to find support in services in this extraordinarily complex institutional environment?
While we may not be at a critical juncture, the signs of the crisis are all around us and even bigger challenges are looming just around the corner. In the past, changes in the social contract, such as the Social Security Amendments of 1965, have occurred as a critical juncture to create new capacity. Those of us working in the sector, while navigating incremental change must be alert with policy alternatives when the opportunity arises for a new social contract in long-term care.
Join us February 23, 2023 at 12 pm ET for Beyond the Predictable to the Possible in Long-Term Care: Rethinking the Future of Aging Services with Irving Stackpole & Dr. Michael Wasserman
To download a PDF of this article, please fill out the form below.
[1] If the reader would like to go over some of these precipitating factors, please see: Fatal Contraction: Healthcare Adjusts to a Shrinking LTC Sector, https://bit.ly/3iNb6e0.
[2] Sorensen, A. Taking critical junctures seriously: theory and method for causal analysis of rapid institutional change, Planning Perspectives. 2022
[3] David, “Clio and the Economics of QWERTY”; Pearson, Politics and Time
[4] https://www.ssa.gov/policy/docs/ssb/v28n9/v28n9p3.pdf
[5] See: Bridging the Divide: Transitions to Cross-Continuum Collaborations in Healthcare
Bridging the Divide: Transitions to Cross-Continuum Collaborations in Healthcare
[6] The pandemic has raised public awareness regarding the rapid rate of contagion within all institutions, hospitals included. The public seems generally unaware, however that iatrogenic deaths in hospitals are routinely over 200,000 per year making hospitals far deadlier by almost any measure than nursing homes.
Irving Stackpole is President of Stackpole & Associates, a marketing, market research and training firm at www.StackpoleAssociates.com. He can be reached for consultations directly at: istackpole@stackpoleassociates.com or at +1-617-719-9530.