By KIM VAN OOSTEN
ST. LOUIS — As Catholic acute care providers continue to anticipate and prepare for the implementation of health reform and the aging of the U.S. population, they should turn to long-term care providers for insights, since long-term care providers have critical expertise to share when it comes to meeting the needs of older people. That is according to presenters at a first-time CHA Long-Term Care Mission Leader Seminar held here in late October.
"There's work long-term care providers have been doing for years related to home health and other areas of care that is going to make a big difference going forward for care management, quality management and goals related to rehospitalization," said Brian Yanofchick, CHA senior director of mission integration and leadership development.
The Patient Protection and Affordable Care Act established Medicare reimbursement penalties for hospitals that have relatively high readmission rates within 30 days of a senior's discharge. Experts view the short-term readmission rates as a proxy measure of care coordination, and according to a report recently by the Dartmouth Atlas Project, the nation isn't doing so well in that regard. The report said that one in six Medicare patients is rehospitalized within 30 days of discharge.
Yanofchick explained that the challenge of preventing readmissions to hospitals will require a more collaborative effort between acute care and long-term care facilities to assure that patients maintain and improve their conditions after discharge.
Julie Trocchio, CHA senior director of community benefit and continuing care, shared other long-term care issues Congress looked to address when it passed health reform, including:
- The difficulty of navigating among the medical and social programs, payers and providers in the long-term care system.
- Bias towards institutionalized care over care in the home.
- Long-term care being positioned as a welfare program.
- Nursing home quality problems.
- Workforce problems (turnover, training, insurance status).
Trocchio said the Affordable Care Act is not perfect, but it addresses ministry goals of improved health care access and quality, prevention orientation, responsible financing, cost-effectiveness and being patient-centered.
To prepare for the challenges ahead related to the implementation of the Affordable Care Act, she told attendees to "get the facts" on the aging trends in their communities, and to learn how and whether their quality ratings and hospital readmission rates make them a preferred partner for hospitals. Too, Trocchio said, partnership will be the new norm, so organizations must consider partnering to innovate and obtain grants.
Benedictine Health System's Steven Chies recommended that all long-term care providers familiarize themselves with tools such as Medicare's Minimum Data Set resident assessment instrument, which enables long-term care providers to undertake a comprehensive physical, psychosocial and psychological assessment of all their residents. Such quality measures will be important to success under health care reform. Chies, a senior vice president of long-term care operations, is based in Benedictine's Cambridge, Minn., office.
Escalating costs
Seminar presenter Richard Jackson said the U.S. is not alone in confronting the challenges of a graying populace and it is actually in a better position to do so than many Western democracies.
Jackson is a senior fellow at the Center for Strategic and International Studies in Washington, D.C., where he directs the Global Aging Initiative, a division studying the long-term implications of demographic changes.
Citing portions of the center's "Global Aging Preparedness Index" report, Jackson noted that most of the concern, especially in the developed world, is focused on the rising cost of government benefit programs. He explained that most developed countries have expensive pay-as-you-go public pension systems that were put in place decades ago when workers were abundant and retirees were scarce, but which now have been rendered unsustainable by the collapse in birthrates and the steady rise in longevity.
Some countries are beginning to raise retirement ages, especially by closing down no-penalty, early-retirement options. Workers in some European countries have been eligible to collect full benefits in their mid- to late-fifties. At the same time, governments in many countries are trying to expand existing funded pension systems or jump-start new ones in an effort to fill the income gap left as governments scale back benefits.
Jackson noted that the U.S. is now the youngest of the developed countries, in terms of its population age balance, and thanks to its relatively high fertility rate and substantial net immigration, it is projected to remain the youngest. He said the U.S. has notable handicaps of a low personal savings rate for retirement, an extraordinarily expensive health system and a political culture that finds it difficult to make trade-offs.
At the center of the U.S. health reform debate was an imperative to "bend the cost curve." Jackson said that it's a fallacy to think that improved efficiencies achieved by health reform will be enough to slow health care cost growth. Instead, society will need to make choices about the way it spends its limited resources. There is a "fundamental delusion that pure efficiency gains can ultimately control health care costs," he said. Even if all the waste could be eliminated in health care, ultimately three factors will continue to drive up the cost:
- New technologies that create new demand for medical services
- The understanding of "good health" as a subjective standard that is rising over time
- The fact that limits are harder to set as people become more knowledgeable about treatment options
"As a society, we have to ask how many of our resources we want to devote to ourselves when we're older and how many we want to devote to our children and something that comes after our lifetime," Jackson said.
Long-term care mission leaders describe their daily challenges
Mission leaders at long-term care facilities face a distinct set of challenges, according to attendees at the Long-Term Care Mission Leader Seminar.
Several said they find it difficult to understand and appropriately respond to varying interpretations of church teachings by bishops, in relation to end-of-life care, and in particular with respect to nutrition and hydration.
Another challenge is addressing the moral distress employees can suffer when trying to ensure the safety of residents while also trying to provide them with the autonomy they want. Resident falls can detract from the organization's overall quality level and can counter its goals to promote dignity by giving residents a greater sense of independence.
Long-term care mission leaders also have challenges assisting staff who face verbal abuse by family members of residents.
Eileen Malo, interim chief executive of Bon Secours New York Health System of Bronx, N.Y., said mission leaders can help staff to empathize with family members and the powerlessness they may feel in the face of a loved one's impending death. Long-term care leaders can train the staff to defuse tense situations by showing compassion and encouraging families to articulate and process emotions such as anger and fear of death.
Malo said mission leaders awaken an understanding among staff members of their importance in caring for residents, families and each other. "There's a calling that many of our staff have answered and may not even know they've answered ... to help the most poor and vulnerable," she said.
Seminar presenters said that to address these challenges, it is important for ministry facilities to keep staff engaged in the mission and to acknowledge their contributions to resident care.
Sr. Patricia Talone, RSM, CHA's vice president of mission services, said that people caring for seniors must have a personal and lived spirituality and the courage to stay open to others. She said that spirituality should ground and express itself in prayers and Liturgy, recognize the importance of sacramental presence, appreciate the reality of death and diminishment and provide time for quiet and personal prayer.
"In working with seniors ... you understand that these are people who are close to God and who can have a transformative power in our lives if we are open to them," she said.
"There is joy, laughter, tears — it is a tremendous richness to be able to journey with these people," Sr. Talone said.
— Kim Van Oosten
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