Welcome to Session, Where Can We Turn? Case Managers and the Caring Crisis. Today’s presenter is Irving Stackpole. With decades of experience as a healthcare professional, Irving Stackpole has held leadership positions for global organizations, as well as hundreds of consulting clients on five continents as president of Stackpole and Associates Incorporated. Mr. Stackpole has led many cross-continuum collaborations in health and social care, developing recognized innovations in transition of care and social determinants of health in the U.S. and the U.K. Welcome. We look forward to your presentation.
This is Irving Stackpole, and it’s a pleasure to be with you here today. Well, to be here with you virtually for the Case Management Society of America’s annual conference. I was very pleased when CMSA accepted this presentation proposal because I think it’s a rather challenging topic, and it has to do with the role of case managers in the system, the healthcare system in the United States, and really the chronic care system in the United States. And the subtitle, “Case Managers and the Caring Crisis. I’ll try as best possible to define each of these terms as we go along. The objectives for this presentation are: 1. to quantify the unmet need for post-acute and long-term care information and services in the United States, 2. to describe the conflation and confusion among the general public about long-term care, and accessing long-term care, and 3. to list three steps, which I believe case managers and the CMSA can take to help alleviate this problem.
So I’m going to cover in some detail the current situation in providing continuum of care for chronic care needs. So the first step here, we’re going to talk about the continuum of care for chronic care needs in the United States. Sometimes referred to as the continuum of care, this is a category of chronic conditions that receive support and services through various social, medical, and healthcare systems within the United States. Systems which don’t always play nice in the sandbox with each other. I’m also going to talk about demographics which are at the heart of demand, talk aspects of demand, talk specifically about how the needs of an aging population in the United States are being met, and in some instances how these needs are not being met, talk about staffing, a critical issue these days for long-term care in the United States and long-term supports and services, and finally the potential role of case managers in this system overall. I was encouraged to give this presentation because of a personal experience with my family with regards to accessing long-term care, supports and services, long-term supports and services for dying relatives. It was an extremely enlightening process that my family and I went through, even though I’ve been involved professionally in long-term care and social services since 1985, deaths in my family last year, precipitous illness and deaths in my family were eye-opening.
These personal experiences highlighted on a very personal level, where the empathetic and personal – the qualitative aspects of needs – weren’t being met, aren’t being met in this long-term care system in the United States. I hesitate because very often I think that it isn’t really a system at all. There isn’t really much of a system. So let’s take a look.
Let’s talk about demographics. A really boring, white-paste kind of topic. But in fact, demographics is destiny. That’s not my phrase, but a borrowed expression. It says that in our work and the work we do with persons of age, older persons, there would be no markets without the people. And what you see here in this table, this graph, is the live births in the United States from 1910 to 2010. And you can see that the various cohorts or age groups have been labeled. So the GI generation, the silent generation, and the so-called baby boomers, of which I am one. Gen X, the fat group plus the others, which is probably many of you listening, and Gen Y, which is probably also some folks who are listening. What I want to draw attention to is the dip in births, live births here in the United States. From 1925 to 1945, there was a significant decline in the number of live births. As you can see, it looks like quite a sulcus, quite a dip. And this is the result of the Great Depression, as well as the Dust Bowl, which affected a significant swath of the United States. And the net result was that the live births in the United States were, as you can see here from this graph, significantly reduced.
What’s of interest to this is that, of course, this population ages. And I want to draw particular attention to the very sharp dip around 1935, right in the middle of that 20-year period from 1925 to 1945, the severe dip. There, well, if someone was born in 1939, they would be 85 years of age today. 85 years of age is an important benchmark age in chronic care and long-term supports and services, because that’s typically when the demand skyrockets for chronic care services related to age and the conditions of aging. That’s when the demand for chronic care services related to age and conditions of aging. when it really begins to manifest and grow. And indeed, you can see that here in 2024, people turning 85 were born in 1939. And what you’ll notice is that we have just come out of the lowest part of that birth dearth, that decline in live births in the United States. What does that mean? Well, just a few years prior to 2024, say in 2020, the number of individuals who were reached 85 years of age would have been significantly fewer than those who are reaching 85 today. Because if you hold longevity fairly constant, which it generally is, it improves a few months per year, generally each year because of lifestyle and medical advances. The exception to that was, of course, because of the COVID, there was a significant number of additional deaths. But the bottom line here is that we’re coming out of a real decline in live births. And so an abbreviated number of individuals who reached 85 years of age, who would survive to 85, and we’re coming into a period of rather steep growth in the number of individuals who will reach 85 years of age. And the numbers of those individuals, as you can see, are beginning to grow. And if you move just a little farther forward, you can see that by 2030, the number of individuals who turn 85, born in 1945, becomes significantly more. And then after that, it gets even more, as you can see, from the rather steep, precipitous climb in the number of live births after 1945, after the war. There is going to be a precipitous increase in the number of persons of age as well. So the question is, are we ready for this? And my answer is this presentation. So the question is, are we going to be, are we prepared for the chronic care, long-term care requirements of persons of age that will be upon us very soon?
On the demand side, on the demand side of health and social services, I’m going to use dementia, this model of progression of dementia, as a proxy, as a model, for how long-term supports and services and long-term care fit into a span of demand in aging. So individuals age, their requirements, their needs change, the family’s needs change as the person ages and becomes more dependent. And the question is, how are we prepared? Is the current methodology, the current way the United States meets or fulfills these demands, is it fit for purpose? Is it suitable? So in this model of dementia, in this demand span model for dementia, if we look at this, it goes from preclinical Alzheimer’s disease, and I know that Alzheimer’s is a proxy, there are many other forms of dementias, there’s clinical, there’s cognitive impairment with no dementia, there’s Lewy body, there’s a number of different forms, but I’m only using this as a model to show how these, the fulfillment, the services, the supply is met in the demand span. So if you move ahead, you can see that symptoms due to mild Alzheimer’s, this is where symptoms interfere with some everyday activities. So the activities of daily living or ADLs, independent activities of daily living, IADLs, moderate dementias will interfere with those activities.
This is where, behaviorally, these challenges are manifest. It’s there that long-term supports and services are needed for the individual to help fulfill, to help live a healthy lifestyle. In this middle area, very often the individual is living in the community, is living in his or her domicile and is being supported. Some people are being supported by long-term supports and services provided by external agents. Moving on a little further in this spectrum, as the disease progresses, or as the severity of the manifestations of the disease progress, and everybody’s distinct in this regard, there are many different ways that this manifests, the symptoms interfere, the symptoms of the disease manifest in being dependent on many or most, activities of daily living. It’s there, typically, where long-term care is needed. And in speaking about long-term care here, I refer to home health care, Medicare, Medicaid, paid for, supported home health agencies, perhaps other sorts of domestic supports that come in. Very often the families engaged and involved, although for, a growing number of individuals who reach these thresholds, family supports are not available.
Raising the question, are we prepared for this level of increase in demand based on the demographics that I’ve already pointed out? So the long-term supports and services progress into long-term care. Now, the disease has an organic progression.
One of the things that I know professionally and I learned personally is that the support systems do not progress. There is very little interoperability. There’s very little coordination between and among, say a Meals on Wheels program and a home health care agency, or between a home provided physiotherapist and the social supports that are available through a local community support agency, home and community based support agency. There’s very little coordination. So, thus raising the question I raised earlier about whether or not we really have a system here in the United States. In this disease progression, you can see that the individual consumer would need long-term supports and services and then would progress to needing long-term care. And moving still further at the end trajectory of a dementia or other severe neuromuscular, neurodegenerative disorders, an individual would need skilled nursing care, would need congregate care for their ongoing daily, perhaps even hourly support.
Now, some of you are saying, well, what about assisted living? What about independent living? What about congregate housing? These layer in on top here, but the system is so poorly defined and it’s so fragmented state to state, region to region, that there’s really no coordination or interoperability between and among the provision here. But this is basically the model that I’m offering for demand span over a course of an aging individual’s life. So here we see the model in terms of demand. Let’s talk about another view of demand in terms of the needs for long-term supports and services, which are principally provided by community-based organizations. Let’s talk about the prevalence of long-term supports and services for long-term supports and services among community dwelling residents.
These needs break down in an excellent study, which is in the references at the end of the slide presentation, which I hope you’ll access if you want to dig in a little deeper. An excellent report showed that the needs based on race and ethnicity are significantly different. That access to the long-term supports and services and the long-term care system are not easily understood and not easily accessed. And they’re particularly not easily accessed by the Black and Hispanic or Latino communities. As you can see from this, the needs are significantly greater. And as we’ll see going forward, their ability to access is significantly hampered or reduced. So you’ll also notice, I hope, that the need in the rural environments, the prevalence of needs in rural environments are significantly greater than the prevalence of needs in the urban environments. This is going to have an important bearing on availability of services as we move along, and in particular, skilled nursing.
Insurance is a doorway to accessing supports and services at any age, and it’s particularly important as we age among the aging population. Now, this particular study was done among individuals in the United States who were 55 to 65 years of age. Now, that’s quite a bit younger than the population I referred to earlier who were 85. But remember that these individuals are going to progress into being 85, or some significant percentage of them will survive to 85. And further, that these individuals are accessing long-term supports and services through an insurance portal. So the front door to long-term supports and services in the earliest manifestations of the need for services between 55 and 65 years of age, the front door to that in important ways is Medicaid.
This front door is extraordinarily complicated. Those of you who work with Medicaid agencies in any particular region or have had occasion to work between and among state-based Medicaid agencies will understand that the rules, the benefits, the requirements for coverage vary state to state, and they vary significantly. This is not just a problem for individuals trying to navigate the system. It’s certainly a problem for consumers or individuals and other providers.
Consumers relocate as they age, and this can be a real nightmare, a problem for individuals trying to access these services. I mentioned earlier my family situation, and indeed, we encountered this. We had in-laws who were sick. They became ill in Pennsylvania. Then they became precipitously ill. And we, for family-based reasons, relocated them to New Jersey, and oh boy, what a difference a state makes. So the point is, here in this presentation, that the front door, the way to access these benefits is complicated. It’s fragmented.
And case managers are in a distinct position to sort these things out, in part because case managers have been trained in the language and the methodologies necessary to navigate these complex and highly varied, variegated systems. I mentioned earlier about demand and the availability of supply. One of the major issues that we’re encountering in the United States is the unavailability – the growing unavailability – of certain types of long-term care, in particular. And these, the two categories are home care and skilled care. What you see here is a graph of the number of Medicare, Medicaid certified nursing homes in the United States by year from 2018 through July 2023. And what you see here is indeed a declining number of skilled nursing centers. And those of you who have been working in this area for some time, or those of you who will recall the prior demographic chart that showed the birth rate decline that corresponded to a decline in the number of persons 85 years of age or older. And the average age of relocation to a nursing home in the United States is 86.4 years of age. So you’d notice that the number had been going down. And so you’d say logically, well, the number of skilled nursing centers should go down if the number of age qualified individuals is going down, so should the supply of congregate support.
The problem is that the number is going down, not necessarily because demand is going down, but because the economic model has been so constrained, and the number of persons working in nursing centers has gone precipitously down. It plummeted during the COVID period and has not recovered. So both home care and especially nursing care centers, these are suffering a real fatal contraction of workforce. There simply aren’t enough caregivers.
What’s happening is that individuals that are of age, let’s say my mother goes into a hospital for a total hip replacement. She’s got some comorbidities and some other conditions and needs rehab. Home is not suitable for her, so she should go to a rehab for a period of physical rehabilitation. She can’t find a bed. The hospital has difficulty finding a nursing center able to admit my mother for that period of rehabilitation. And it’s particularly difficult because the loss of nursing centers is especially acute in rural areas. So it’s particularly difficult in the Midwest, in the South, other parts of the country. Other places where there’s not density, particularly difficult for hospitals to find placements for patients, consumers being discharged that should be discharged to nursing centers. Now what this is creating is it’s creating this situation where the hospital is not going to keep them because they get penalized. So they’re going to send them where? They’re going to send them home.
And oftentimes the home situation is neither clinically optimal nor optimal socially or optimal physically. So this is resulting in a cascade of negative outcomes in part because of the way the system was built, the way the nursing center system was built, the way the home healthcare system was built, and the way that the long-term supports and services system, home and community-based services, the way they were built. These were all built in very serious silos or bunkers. There’s very little connection between and among these service delivery systems or methodologies, meaning that there really isn’t a system at all. There might be some logic, an interconnection within the congregate care setting, the nursing center setting, and there might be some within home care, there might be some within home and community-based services, but there’s de minimis connections between and among these three service delivery platforms in any given community around the United States. And this is now a problem, and it’s becoming an even more serious problem.
These are three areas or domains of service provision with which case managers, especially those that have been working in long-term care and in chronic care, these are areas that case managers understand and understand very well. And it’s my particular opinion that case managers are in an ideal position to be supported and navigators for consumers and families who are looking for ways to navigate this incredibly complicated service delivery system.
I referenced earlier about human capital, or human resources. And you’ll see here that the relative change in employment based on the pandemic change, as depicted here by Kaiser Family Foundation, which has very good data and excellent reporting, you’ll see here that community care centers for the elderly and nursing care centers for the elderly who are dependent on 24-hour nursing care, these centers, their employment has not recovered. There are a number of estimates, but I believe the most reasonable is that these two delivery platforms have lost somewhere between 280 and 350,000 staff as a result of the pandemic and the lack of their ability to recover from the pandemic and to re-attract workers and workforce. Now, go back, if you would, to the demographics slide that I showed at the beginning and understand that in the United States, we are just at the very earliest stages of a surge in demand for LTSS and LTC. It’s just the beginning. And understand also that the workforce that cares for persons of age has typically been low-skilled women, many of whom are women of color and immigrants, and this workforce has not come back and may be only attracted to come back with significant change. There needs to be some significant changes to the system in order to re-attract the levels of employment required and the additional employment in these centers necessary to care for persons who move along that demand-side trajectory.
So that’s the supply-side picture. I want to point out here, I’m going to jump to some political and economic topics ever so briefly and point out that here in the United States, we spend, the United States spends more than two times the next developed economy on healthcare. As you can see here from the Peterson Institute that the United States spends over $13,000 per capita on healthcare, and the next closest country, Germany, spends $7,000 per capita. So this is a tremendous difference in the amount spent by the United States on primary care and secondary care, that’s hospital care and physician care. In terms of how we compare we spend more on administrative costs and about the average on clinical costs. But as you can see here, the average spend, total spend on long-term care is right around the average, the OECD average. So we’re spending twice as much on healthcare but we’re spending less than the OECD average. That’s the organization of economic developed countries the developed economies. It’s a club of developed economies. We’re not spending the average. This does not auger well for persons of age. There are a number of people who argue quite compellingly and I don’t disagree with them that there can be no better demonstration here in the United States of how we live in an ageist, conservative society.
When we think about this situation, we’ve got a pending surge in demand. Demand is going to increase. The amount of money we spend is really de minimis. We’ve got a highly fractured and complicated system of fragmented delivery platforms. If you step aside from that and look at the consumers, the public, what does the public think? The public wants the government to take care of long-term care. The consumers want the state and federal agencies to deliver on services and to make these services available to them or their family members or the persons they’re caring for. The public wants these things to be available. And the public is quite clear and quite consistent about this.
In a survey done not too long ago by the AP in Newark, 75% of the population wants Medicare to pay, or the government, CMS, to pay for long-term care requirements. That seems pretty overwhelming. And this difference is consistent whether you’re Republican or Democratic. And indeed, it seems to be pretty consistent whether you’re at the upper strata of socioeconomic tiers or in the lower group of socioeconomic tiers. There’s quite a bit of support for the need to make long-term services and care available to persons who need them.. So, why isn’t this happening? Because there apparently is a lack of political will. If you take the time and you read the studies, it’s also clear, at least to this observer, that case managers are in a distinct, if not unique, position to leverage and to navigate these structures within the supply side to make the experience, to make the delivery of care more palatable and more smooth. When you look at what the consumers want, it’s certainly not a surprise that what consumers want is to be cared for in their homes as long as possible. Many consumers, almost 80% of consumers want to age in place. They want to age in their homes. A small percentage of consumers want to relocate to a carefree environment like assisted living or independent living, but that then becomes their home and they want to age in place there, which means that the systems designed to support individuals in their aging, they need to be flexible enough and dynamic enough so that they can be brought to the individual in their home. So consumers are very clear. The market, the consumers, are very clear. I want to age in place. I want to age in place until I’m no longer able to.
For many, many years, my company conducted surveys among case managers and for a very, very well-known, international corporation and conducted almost 45,000 surveys. And what became clear out of this over a number of years as is that not only do individuals in the public not want to go into nursing centers, case managers have a very low opinion of nursing centers as well. To some degree, the aversion to receiving care in nursing centers is the flip side of the attraction of being cared for in one’s home. And of course, it makes sense, all the sense in the world that if you are at home, you’re comfortable at home, you wish to stay at home, for just as long as possible. And there’s also very good evidence that this being at home is also highly supportive that individuals who are able to stay in a comfortable residential situation do better psychologically, behaviorally, and clinical outcomes are better, for the most part.
So what I’ve depicted here for a case management audience, is the highly fragmented, difficult to access, extremely biased system that exists in the United States for delivering care and support to persons of age who need them. Now, I know that some of you that hear this will object. And I hope that some of you will object rigorously enough that you’ll be in touch by email or that you’ll become irate and give me a call. That would be wonderful. I believe strongly that these issues need to be discussed. They need to be discussed far more openly because right now they’re not being discussed or debated. The best we have are policy punishments for outliers in the long-term care sector. And what we have is death by 1,000 cuts in the LTSS supply delivery sector. Home and community-based services are getting trimmed and sliced by state-based governments, which pay the bulk of the costs. And the nursing center, providers are getting trimmed back and punished by politicians who see that there’s a few political points to be gained or some advantage to be taken by punishing the sector. It’s a real problem that needs real attention. If you look at the match between supply and demand, you can see that in the United States we cannot meet the imminent surge in demand.
Moreover, it’s very clear that there is a market for information about how to access care, supports and services and care, and that that market is not being fulfilled.
I understand this at a personal level. My family struggled with learning how to find a suitable, at first domestic, a home care agency, and then ultimately a nursing home for my two in-laws who had different needs, different clinical profiles, and so had different clinical needs. The family had a tremendously difficult time finding resources to direct them, and then difficulty finding providers who would actually accept them. It should not be, it need not be this difficult. And it’s my conviction that case managers are in the right position, this is the right time to take a leadership role. There is no market for empathy in the long-term, long-term care systems in the United States. I’m not suggesting that individuals aren’t empathetic because we are a culture of empathetic individuals. Nobody would look away from or step over somebody because we are a giving society. We are giving, we’re a giving culture. We are a caring culture inside of a capitalistic and political catastrophe, which is the only way to describe the fragmented system here in the United States. And it needs to get addressed. So when you look at the role of case managers, the demand for long-term care, supply of long-term care, I’ve given you a very brief history. Basically, it’s poverty care. The first long-term care, congregate long-term care centers in the United States were poor houses. And that’s how the model evolved. So what’s wrong with this picture? There’s a lot wrong with this picture. What’s wrong with this picture? A lot.
So who can we turn to? This is the question.
The demand is about to surge. Now put yourself in that place. Some of you may have already been there. Put yourself in the place of a family whose mother has just left the stove on for the third time in two months, who has been found by a friendly agent or neighbor out on the street in her bedclothes, not quite clear where she is. Put yourself in the shoes of that family if you haven’t already been there and say, who would you call? Now, unfortunately, many of you listening or perhaps all of you listening will know the answers to that question. You might first say, I’m going to call an ombudsman in the state, in the state Medicaid office. And that would be a terrific initial place to call. You may know that there is an agency in your state, a no wrong door agency in your state that you can contact and inquire about services, programs and supports. But what about the folks who don’t know? What about those who have no idea?
I’ve worked in long-term care since 1985. And I came out of a hospital, professional hospital background and began working in long-term care. And because of that long experience, many of my family members and many of my friends and many of my professional colleagues know that I’ve worked in long-term care fora long time. Because of this, I receive calls on a regular basis from friends, families, professional colleagues asking, “What do we do about this situation with mom?” Or, “What do we do about the situation with dad?” Or, “We need to relocate mom from her third floor walk-up apartment in a Chicago suburb to our home in New Jersey, where she can live in the in-law apartment and have access and a little kitchenette. How do I start?”
If I’m getting these calls, I can only imagine that many of you are getting these calls as well.
We are a culture, a networked culture, and we’re networking on our way. Many people are networking their way to you, case managers, and your training is perfectly proportioned and fit for the purpose of directing this surge in demand for access, this demand for understanding qualification, understanding fit.
Right now, the system access is limited.
The supply is contracting.
And Americans are surprisingly unaware. If you ask an individual who has not been exposed to any of these systems that we’ve talked about, the home and community-based services, long-term supports and services, or long-term care, or even healthcare, if you ask your friend who’s a schoolteacher, or ask your friends who work in the local manufacturing sector, whether they would know what to do, they will take a guess. They will be guessing. And that’s just not a good way to deal with an impending surge. It’s inefficient, and it’s frankly inhumane. So my suggestion is that this awareness needs to be focused on how to access the knowledge and the sophistication that’s available among most case managers, and in particular, case managers who are familiar with the long-term care system such as it is within the United States. Given the age of our culture, I say Americans are surprisingly unaware. People just don’t know. People generally believe, and my company has demonstrated this through lots of consumer research, consumers generally believe that the government takes care of long-term care. That the government, the state or the federal government, pays for and offers support in accessing long-term care. If I need a nursing home, the government will take care of it. And they believe that because they’ve heard through their social networks that, oh, the Joneses down the street, their mom got Alzheimer’s and nobody was able to take care of her because mom was far away. And so she wound up in a nursing center.
That’s what they believe. And the Joneses down the street are no different than us. They’re certainly not well-off or wealthy. They’re middle class or upper middle class like us. But unfortunately, what they don’t see is they don’t see the difficulty, the heartbreak, the disappointment and the extraordinary pain qualitatively that the Joneses went through accessing the services and making arrangements for the services. I will also say, this is a bit of a political commentary, but I will also say that the United States is the only developed economy – the only OECD country – without a federally underwritten long-term care insurance program. We’re the only one. We spend almost two and a half times the OECD average on healthcare, but we spend 46% of the OECD average on long-term care.
That’s just not right. That’s unsustainable in the long term. And we need a federally funded, federally managed long-term care system of insurance in the United States. Now you say, “Oh, we can’t afford that. The demographics are such.” Well, if you look around the world, Japan with the steepest demographic cliff of any developed economy, instituted a federally funded long-term care insurance program about 12 years ago. And if Japan did it 12 years ago, the United States can certainly do it today.
But I digress from my fundamental point about what the general population is unaware of. Maybe these things are correlated. Because the public is unaware, politicians aren’t being moved or spurred into action. In any event, the public is generally unaware of what benefits are available and generally completely unaware of how to access those benefits. I’m conveying the message, case managers are uniquely positioned to be individuals as a professional class to whom the population could turn for information first and then for guidance. Information and then navigation. Information then leads to navigation. Some individuals will need a lot of support and others will need less support. But case managers are uniquely positioned to do that. Society needs it. Society needs case managers to help broker and identify and to help explain to both the provider and the consumer why this is a good match. Sometimes it takes an explanation in the lingo, in the techno speak, case management 101, to broker those connections that lead to service provision. Case managers are uniquely positioned to do that. I don’t believe that there’s any other professional group who has the training or who is better equipped, better positioned to do that. Now, in order to accomplish this, what is it that case managers need? Well, it’s pretty simple. Case managers, the ones I’ve worked with, are extraordinarily empathetic. They understand the system is fragmented. They understand that individuals and families need support. They need help navigating this fragmented system. What case managers need is a structure for how do I set this up? How do we set this up? How do we make arrangements to buy insurance if we’re going to become navigators in a community? How do we set this up? So case managers need help and support in establishing the networks and the support systems that they can deliver this information and this navigation in local communities. And ultimately what that means is that they need to get paid. So how do case managers get paid for these services? Well, initially, unfortunately, they get paid from private sources.
Individuals and families who can afford the benefits of a case manager’s knowledge and understanding of a local state-based or community-based support network systems, how to match up the insurance coverage that the individuals may have, how to uncover insurance coverage that an individual or a couple or a family may have of which they may have not been aware. Case managers can do that kind of thing. And there are some who have established private sources or private practices in order to do that, but they need support. And I believe strongly that the Case Management Society of America is in a position to do that, to provide the kind of guidance and structures of fulfillment, I’ll call it, for establishing businesses, securing insurances, how to create marketing, everything from how to create a marketing plan to how to create a website.
Because the elder system in the United States is fragmented and broken. Case managers are in a distinct and I would say unique position as a professional class to be able to address that. And that, I believe, is a significant challenge.
To end with a quote from Albert Einstein, we created this sitiuation in the United States, over a series of several decades, we created this incredibly Willy Wonka chocolate factory of a long-term care system. And this system is the process of our thinking, our legacy thinking. We can’t change it without changing our thinking. And that is my challenge for you, the case managers, the case managers of America. And I hope that this has provided some grist for that mill and that you will indeed move forward and provide the desperately-needed service to the hurting individuals and families that you encounter and that you find through your journey. Thank you very much. I truly have enjoyed this presentation. I hope it’s raised significant questions. And I look forward to your feedback.
My hope is that this information has been of interest. You’ll be in touch. If I’ve struck a nerve, I hope you’ll be in touch, as I said earlier. Please do be in touch. This is my email address and my phone and WhatsApp. So I’ll look forward to hearing from as many of you as have the opportunity.