Turning LTC Upside Down

Peck: As your organization’s recent name change indicates, long-term care is starting to move out of the nursing home to some extent and into more independent situations. What are your views on that?

Fishman: Nursing homes will always be a critical part of the continuum, but we want to get to a place where no one is admitted to a nursing home unless they absolutely have to be, and we’re being very public about it. Bottom line: If we plan our facilities and services in accordance with what seniors want, then we will thrive, even in difficult times. At Hebrew SeniorLife, we are trying to make our system look like the kind of system that seniors, including frail seniors, would design themselves. This means we are expanding at both ends of the spectrum. On the more acute end, we have opened the largest postacute geriatric unit in Massachusetts, and we have opened a medical acute care unit for geriatric patients. This unit provides extended medical and rehabilitative care for seniors with complex medical conditions and/or multiple acute or chronic illnesses. We think that there is an opportunity for an organization like ours to be the lowest-cost and highest-quality provider of long-term acute care and chronic care for geriatric patients in need.

On the other end of the spectrum, we have greatly increased the variety and amount of housing that we offer. For the first time in our history we have many more seniors in housing than in long-term care-an important milestone for us. Overall, then, I think the number of nursing home beds will probably diminish, even as the number of frail seniors increases, because people in this field are catching on to the fact that it is no longer a seller’s market.

Peck: Your organization previously had “rehabilitation” in its name, and now your emphasis is moving toward home-based services. How did you begin to move your organization in that direction?

Fishman: First, the board undertook a planning process that looked at trends here in Boston and around the country. We wanted to design a system that we ourselves would find to be acceptable if we were in need of long-term care. At this point, this means moving in the direction of nursing home alternatives-specifically, in the direction of housing. It is my view that senior housing will be a platform for delivering care even to frail elders in the future.

One of our models is the system in northern Europe, where long-term care is considered, first and foremost, to be a housing issue. In the Netherlands, Denmark, and Finland, for example, it is common to find people whom we would consider to be in need of an assisted living or even a nursing home level of care receiving that care in their own apartment units.

So we start with the housing, which is an apartment unit with universal design, and figure out how we can efficiently bring healthcare and personal care services into that unit. A similar model in the United States would be a CCRC. The reason that it is so appealing to deliver this service in housing is, first of all, it isn’t just “homelike,” it is actually home. Second, because there is a lot of affordable senior housing available, you have a platform that is more economically feasible. One of the big complaints about assisted living is that people without considerable means cannot access it. It is easier to serve those people if you are bringing a rich array of supportive services into HUD housing, and we have done that with our HUD facilities.

Peck: How do you coordinate bringing healthcare services into HUD housing?

Fishman: I will give you an example. We acquired a senior housing building about a year and a half ago that was essentially a senior apartment house. We spent a good deal of time and money creating a lot of community space-things like a library with computers, a den, a fitness and exercise room, a community room for lectures, and a coffee shop. These amenities would be unremarkable in a CCRC, but they are not as common in senior housing, especially where most of the residents are at low- and moderate-income levels. But for us, the hallmark of housing is community. And that means creating community space.

There is a meals program, which is, of course, very important because the first things that an independent senior finds difficult to do are shopping and cooking. Just the fact that we offer meals means that people can live there longer. We have a nurse practitioner available eight hours a day; people can see her even without making an appointment. We have medical office hours in the building. We have social workers who can help arrange for services. We have transportation. And we love the fact that the facility is located in Brookline, a neighborhood that is incredibly pedestrian-friendly, even for frail elders.

When you put all of this together, you have a supportive environment that can keep even frail seniors independent. In fact, some of the people coming into that particular building are transferring from assisted living facilities because they do not want to be in what is still a somewhat regimented environment. They would rather be in a truly independent setting, which our senior housing is.

Then there is personal care; personal care can be delivered in different ways. We have a home health agency that delivers care in some of the housing. In other cases, we use visiting nurse associations or other organizations that provide personal care services.

Peck: To what extent is it realistic for people with ADL needs to transfer to an independent-oriented housing facility? How far will you go in a home-based environment to accommodate these needs?

Fishman: Obviously many, if not most, of the people in assisted living facilities would not be good candidates for living in an independent living facility, even if it had very extensive supportive services. But the answer to your question is, it depends on the condition of the individual and what services are available in the housing. I don’t think we have come close in our field to really pushing the envelope on this.

In the building that I described to you, we are pushing the envelope as far as anyone, and the results are really satisfying. For example, once we completed renovating the community space that I described, the results were better than we expected. In just a month or two since the renovation, the nature of the community in that building has altered dramatically. Whereas in the past seniors basically came downstairs and took their mail and then went back up to their apartments, now there is a kind of pedestrian traffic and critical mass that produces a sense of community-people exercising together, having coffee together, playing cards, taking in a lecture, or just hanging out. It is a whole different environment.

At some point, people need to be in a more intensive environment. In this case, people who live in that building rarely go into assisted living when they leave. They go into long-term care more often, because we are pretty much able to handle the assisted living piece of the spectrum right in the housing.

I will tell you a quick story. When we decided to purchase the buildings in Brookline, I went to each building to talk to the residents and introduce our organization to them. When I asked if there were any comments or questions, the first question I got was, “Mr. Fishman, if I cannot live here any longer, will you take care of me at the Center?” The “Center” refers to our 721-bed long-term care facility. I was little apprehensive about how to answer the question because I didn’t want her or other residents to think that we had bought these buildings in order to fill up our long-term care beds. So, I gave the “politically correct” version of the housing answer, which is to say, “We hope you remain here for your entire life, and we are going to bring in services to support you. But, if you require more care than we can give you here, then of course we will take care of you at the Center, and you’ll get preferential admission.” The room erupted into applause, which was a real shock for me because seniors usually don’t applaud when you tell them they can get on a fast track to a long-term care facility. What I realized at a gut level is that for these seniors, putting our long-term care and our housing together relieved the typical tenant’s anxiety about “what will happen to me if I can’t live here anymore.” None of them wants to come to our long-term care facility, but they are grateful knowing that if they require that level of care, it will be delivered by people who know them and will help them make the transition; it’s like a virtual CCRC for people with low and moderate incomes. Or, put another way, it is like taking two plus two and somehow getting ten, and that is what I think systems like ours should be doing in the future.

Peck: It’s been said that from a technical standpoint, organizing the housing and medical components for something like this is a regulatory nightmare. There is the red tape, for example, of coordinating HUD housing and Medicaid. Was that a problem for you?

Fishman: Generally speaking, it depends on the state you are in. In Massachusetts, there is something called the Group Adult Foster Care program, which is a Medicaid program that will pay for the service component of an assisted living environment, provided the individual is nursing-home-eligible. You have to demonstrate that the person’s need for assistance is equivalent to a nursing home level of care, and then you can access the state payment for the care component. The limiting factor in some states that do this, often, is that the state is not paying enough for the care component of the assisted living package.

For a couple of years now, HUD has been making available nationwide grants of up to a couple million dollars to convert all or part of HUD-financed facilities to assisted living. Some owners are doing one floor, and others are doing the entire building. Again, the limiting factor is whether the state you are in is willing to pay an adequate amount for care.

Peck: So it depends on the states’ willingness to step up to the plate.

Fishman: Exactly. And here is where you confront the conflict between those who see this as a move toward decreasing costs, because you are putting people in a lower-cost environment, and those who express concern about the “woodwork effect”-of costs escalating to meet a host of unmet needs. When I was commissioner of Health and Senior Services in New Jersey, I wanted to make state funding available for the care component of assisted living for people who are nursing-home-eligible and otherwise Medicaid-qualified. The people in our Office of Management and Budget (OMB) fought it tooth and nail. I remember one day one of OMB’s analysts in a rare moment of candor saying to me, “Commissioner, you don’t get it. We like nursing homes because we know that seniors hate them and will never use them unless they absolutely have to.” They assumed that seniors were going to flock to assisted living because those facilities look so pretty.

My contention was then, and still is, that seniors move into assisted living for the same reason they move into nursing homes: because they have no choice. Some event has occurred that makes it impossible for them to live independently. They may enjoy assisted living more, but they do not opt for it just because they drive by one day and say “Jeez, what a nice Sunrise facility!” They go there because it is a matter of necessity.

Once we got over that hurdle with the guys at OMB, the next objection raised was the “backfill” problem. Let’s say you give somebody the choice to move out of a nursing home and into assisted living, with state support at half the per diem rate. People said that, even so, somebody else is going to fill that nursing home bed and get Medicaid reimbursement. I think that argument is much harder to make today, though, because the occupancy rates of nursing homes are relatively low. If there was pent-up demand, the occupancy rates would be higher.

So, I am not a strong believer in the woodwork effect. And at the end of the day, even if there is a woodwork effect, then we should be serving those seniors in a more community-based residential environment.

Peck: Another concern that has been raised about community-based care is that people become more isolated in their homes as they get older. Your thoughts?

Fishman: I think that is a valid concern, but here is my take on it. If the senior chooses to live independently even if, in my view, the life that the individual is leading is isolated and not adequately stimulating, it is still his or her choice. I would rather think of my job as enticing that person into an environment that is more engaging and lively then deciding, against that senior’s will, whether it is in his or her best interest to move. Again, I come back to the senior housing model, an environment where you can have your cake and eat it, too. The senior can have his or her own private space, but also a rich community life if you are capable of providing the necessary programming.

If the only thing you have to offer is a nursing home, then you should not be surprised that the senior is clinging to life in a single-family dwelling, even though the life is isolated and may even be unhealthy.

Peck: Having said all that, how do you envision the nursing home of the future?

Fishman: Well, that is a really hard question to answer. The big question is whether people who are looking at developing replacement plans for nursing homes are going to try to produce a nicer version of the mini-hospital, which is what nursing homes have been essentially up until now, or whether they are going to try to do something that is a more radical departure from the past. Take, for example, the household/neighborhood concept pioneered by, among others, David Green in the Evergreen Retirement Community in Oshkosh, Wisconsin. The Green House Project in Tupelo, Mississippi, is another example, with people actually shutting the nursing home down and providing care to nursing-home-eligible seniors in homes of about ten individuals.

We are in the process of planning a large long-term care facility that will be built upon the principle of households and neighborhoods. Our goal is to create a facility where you will not be able to tell the difference between the assisted living setting and the long-term care setting. That’s still not quite the same as independent housing with supportive services, but that is the direction we are pushing in.

So, back to your question. I think we are at a pivotal time now in terms of institutional long-term care, when a lot of organizations like ours will have to decide whether to essentially throw away the old model and produce something new, or make the old model friendlier and kinder.

Peck: Doesn’t it seem, though, that nursing homes are being pushed in two directions-having to manage more clinically intensive needs on one hand and moving toward more homelike environments on the other?

Fishman: You are absolutely right. It is ironic that we are finally getting around to making nursing homes more homelike at the very time that the people moving into them are in need of more intensive medical and nursing care than ever. But, in designing the facility I mentioned, we have doctors, staff nurses, social workers, and others helping with the design, and I think their general feeling is that nothing about a more homelike environment is going to make it harder to deliver excellent nursing and medical care. It is just a matter of reconceptualizing the environment.

For example, we have 14 geriatricians on staff here, which is more geriatricians than some states have. They make rounds through our current long-term care facility, and the residents and their families love it because doctors are visible on the units and are accessible. But eventually we are going to have to conceptualize the doctors’ intervention as a “home visit” instead of “making rounds” as if you were in a hospital, and right now we are thinking of ways to do that.

It is also interesting that some people predict that lengths of stay in nursing homes will continue to drop until the nursing home essentially becomes an extended hospice. In that case a more homelike environment makes tremendous sense because that is the environment where most of us would want to be at the end of life.

I am hoping that what we are designing will service seniors well into the future. But I am humble enough to realize that the people who designed the building that we are operating today were as smart as we are and had the same goal when they designed it 50 years ago.

Peck: Now for the $64 billion question: How do you envision the long-term care system of the future?

Fishman: I am serving right now on a couple of national panels; one is a National Academy for State Health Policy workgroup called “Making Medicaid Work for the 21st Century” and the other is the National Academy of Social Insurance’s project called “Designing a Long-Term Care System for the Future.” These are inextricably intertwined because financing and the model of long-term care go hand in hand.

But I don’t pretend to know where the long-term care financing system-or, for that matter, the acute care financing system-is going. The one thing that I think is likely to be true is that, no matter what, there will be an increasing emphasis on chronic care and chronic disease management, if only because a relatively small number of Medicare beneficiaries is accounting for a large and disproportionate amount of Medicare expenditures. In my view, the lowest hanging fruit (in terms of reducing cost and improving care) in both the long-term and acute care systems is managing the chronic care of geriatric patients more effectively. We are trying very hard to do that, which is one of the reasons we added the long-term acute care component to our post-acute care component and expanded home health.

We would like ultimately to be in a position in which Medicare HMOs or other managed care entities come to us because we have expertise in managing seniors with chronic conditions in a way that not only delivers high-quality care, but is also cost-effective. Predicting beyond that, though, would be mere speculation.

Peck: And the financing would have to be organized accordingly, somehow.

Fishman: It has to do with capitating the financing and strengthening those organizations that are capable of managing the care and accepting risk in a way that benefits the senior and also saves the system money. There is a way of doing that already-the PACE [Programs of All-Inclusive Care of the Elderly] model is a good example, Medicare HMOs are another, and so is Evercare. So, we are not trying to invent something that does not exist. We are trying to build on something that, as I look around, seems to be working pretty well in other settings.