Bonnie Kantor, Executive Director of the Pioneer Network, Offers Her Thoughts about Geriatric Health Care and Its Future
HP: What drew you to the field of geriatric health care?
Actually, my interest in and passion for changing the culture of aging and long-term care both stem from a very personal experience: my father's death.
He died suddenly when I was only 16 years old. He was 57, the youngest of five children, and the only son. We lived in Rochester, N.Y., and my father's sisters and mother were in New York City. My four aunts decided to protect my grandmother and not tell her that "the love of her life," my father, had died. They thought the news would, in their words, "kill her." My grandmother lived another four years wondering why "her Moishe" never called or visited anymore. She felt neglected; she thought he didn't love her anymore. At that time, I wrote in my diary that I would devote my life to ensuring that no one made decisions for older people because of their age. That no one should take away their rights and act in their stead. I still have the diary. And through my work in the culture change movement and the Pioneer Network, I am fulfilling the promise I made to myself almost 40 years ago.
HP: How has this work affected your life?
When I first considered joining the Pioneer Network, I asked myself what legacy I wanted to provide for my children. I realized that I wanted them to see what a life well-lived looked like. To me, that meant serving others in a way that will make a difference. The Pioneer Network and the culture change movement continually provide me with the opportunity to model my philosophy of life through my work. All four of my children, who are grown and independent, comment on this "living legacy" and how they hope to model a "life well-lived" for their children as well. It was this desire to create a legacy for my children that motivated me to leave academia and join the culture change movement.
The other notable impact is that the line between work and leisure is now blurred, simply because I love what I am doing.
HP: What's new and exciting at Pioneer Network?
As Alphonse Karr stated, "The more things change, the more they remain the same." This is very true of the Pioneer Network — it is only the "how" that is evolving, not the why. While we are expanding our outreach, we never lose sight of our mission, which is to create and support more consumer-focused models of long-term care that embrace flexibility and self-determination, where life is satisfying, humane and meaningful.
From our early-adopter organizations, we know that culture change works on many levels. The philosophy is compelling, the business case supports investment in change, and quality of care outcomes are superior. The challenge before us is to leverage the experiences of these early adopters and change the "norm" so that person-centered care and deep system transformation become usual and customary. These values become what everyone expects in whatever setting the care is provided and wherever the elder lives.
HP: What advice would you give new leaders as they take on responsibilities in the world of geriatric care?
First, I would advise folks to seriously consider becoming leaders in this field, not only because our population is aging, but also because it affords us such a wonderful opportunity to make a difference. I would also remind them of the old adage that "you must do well to do good." We have to remember that our mission is only good if we can make it work in the marketplace. And the only way we are going to make culture change and responsive care the norm is to advocate for state and federal policy changes that will reward and link high-quality and efficient care.
HP: What are among the most difficult challenges facing aging services today? What do you see as possible resolutions to these challenges?
The barriers to providing responsive person-centered care and changing the way we provide care are persistent. Self-determination may result in choices that create tension within the current practice environment. Self-directed work teams challenge traditional roles. Facilities built for a different model can inhibit the creation of neighborhoods within the facility. Furthermore, funding methodologies are inflexible. And yet, the most pervasive barrier of all comes from the lack of a unified will to change by organizational leaders unwilling to take the risk of disruption.
Perhaps, however, the greatest obstacles are those caused by perception, not always reality. For example, while the Centers for Medicare and Medicaid Services (CMS) support the principles and practices of culture change in the physical environment as a fulfillment of the Federal Nursing Home Reform Act of 1987, providers often cite an array of issues that arise when making structural changes or developing new buildings. CMS and the Pioneer Network are partnering to directly address these concerns in a national symposium on culture change and the environment requirements called "Creating Home in the Nursing Home: A National Symposium on Culture Change and the Environment Requirements," which will be held in Washington, D.C., on April 3, 2008. This symposium will provide stakeholders with a common understanding of the issues and potential regulatory barriers while also advancing solutions and seeking national consensus. I would encourage active participation in this symposium by members of Catholic health organizations.
HP: How will long-term health care be different 5 to 10 years from now?
Well, the time frame may be a little tight, but in 10 years, I believe that resident-centered care will be the norm across the continuum of aging. When looking at long-term care options, consumers, patients, families, providers, funders and policy makers alike will be asking "Are the values of choice, respect and self-determination practiced here?" And they will be asking, "Does this organization or provider promote a culture of aging that is life affirming, satisfying, humane, and meaningful?"
In most cases and in most places, the answer will be a resounding "yes." In addition, we will be providing care in smaller living environments. Permanent work assignments and consistent staffing will be the norm, and decision-making will be at the level closest to the person. Hierarchies will be flattened, daily routines will be dismantled, and systems will be in place to allow and encourage freedom and choice.
HP: Looking 5 to 10 years ahead, what should health care leaders be preparing themselves for in terms of the aging population?
Providers should be prepared for a system that focuses on the person, not the locus of care. Care options are going to be very different from those we have today. The transformation of the nursing home is long overdue. The existing product, building, service and system fail to meet the needs of frail older adults, and the families who love them. Costs are high, and states and communities are struggling to support the existing model without compromising quality of care. Within 10 years, organizations will have found new and innovative ways to "create home and community" while still providing quality care to a medically complex population. This will require changes in organizational practices, physical environments, relationships at all levels and new workforce models.
HP: What role might Catholic health care play in the future of aging services?
Catholic health care has a significant leadership role to play in the transformation of the service delivery system. Culture change, deep system transformation, and resident or person-centered care are all concepts and philosophies that go back to the very roots of the Catholic health mission. Person-centered care and caring is nothing new to Catholic health care. In fact, it is its foundation. Being able to model person-centered, responsive, and cost-effective care and caring for the rest of the country is a responsibility that would come naturally to Catholic health care, which has long provided care throughout the continuum. Catholic health care could be a model for making the seamless transitions required as care needs change, providing teaching opportunities for the next generation of providers so that they will be ready to care for our aging population in the most responsive and cost-effective manner.
In the short term, active participation in the CMS symposium in April 2008 would position Catholic health care to lead the way in effecting environmental change throughout the system in a way that meets older adults' needs and satisfies state and federal regulations.
Visit www.pioneernetwork.net for more information on the Pioneer Network.
Bonnie Kantor is executive director of the Pioneer Network, a national organization that advocates and facilitates deep system change and transformation in the culture of aging and long-term care in America. The network, founded in 1997 and based in Rochester, N.Y., is dedicated to making fundamental changes in values and practices to create a culture of aging that is life affirming, satisfying, humane and meaningful. This umbrella organization, which includes professionals from all disciplines of long-term care and aging, has helped change the national conversation from a focus on "what's wrong with nursing homes" to articulating and disseminating a shared vision and set of practices based on the importance of relationships, home and community. As the Pioneer Network begins its second decade, leaders are focusing on the nationwide adoption of resident and person-centered care and on supportive implementation strategies involving more professionals in the field.
Prior to joining the Pioneer Network in 2007, Kantor was affiliated with the Ohio State University Medical Center, developing the school's interdisciplinary specialization in aging, a required home care curriculum for all medical students and the nation's only required clerkship and medical school curriculum in chronic care. As director of the Office of Geriatrics and Gerontology, Kantor brought the organization national recognition as one of the top geriatrics programs in the country, interweaving geriatric medicine into all four years of medical school and resulting in graduates becoming advocates of culture change in aging and long-term care. Kantor received her doctorate in health policy and management from The Johns Hopkins School of Public Health in Baltimore.
The Pioneer Network Focuses on Five Core Goals
1. Focus on the person and his or her loved ones and caregivers. We are reframing the question itself.
We want to move away from discussing the locus of care — it isn't about the nursing home or assisted living or home care, for example. Rather, it is about the person and his or her loved ones and caregivers. We believe that when we focus on certain values — honoring the dignity of each elder and staff person and of creating communities based on strong, loving relationships — many of the costly problems (both in terms of money spent and lives left unfulfilled) will be addressed and eventually solved.
2. Work with new organizations and groups that can influence both long-term care policy and practice.
These new pioneers can join us in spreading and embedding the principles of "person-centeredness" into practice.
For example, through the generous support of the Commonwealth Fund, we have begun working with the American Medical Directors Association (AMDA), to help more physicians understand and embrace these principles.
3. Develop evidence-based core competencies.
We know what quality, resident-centered care should look like, but we need markers that can be taught and guidelines that can be implemented. In fact, in the past, the lack of core competencies has closed the door to some who were unsure how to proceed. Together with AMDA, the Pioneer Network will be creating and broadly disseminating the first set of these markers.
We believe that to implement change throughout our long-term care system, physicians need to know the attitudes, skills and knowledge-base needed to practice resident centered care. Until we can clearly articulate, define and measure these competencies, we can't expect the physician community to actively participate. After we develop these core competencies, we will then work to adapt them for other provider groups.
4. Ensure that education and training in resident-centered care is available for all providers and health profession students at all levels of training.
With some notable exceptions, education and training programs have not embraced the culture change movement and resident-centered care. And I don't think it is their fault.
Many faculty members haven't heard of resident-centered care. They haven't experienced it. There are few teaching materials out there, and few culture-changed training sites that have been identified. What an opportunity we all have in this area.
5. Establish a strong, compelling business case for culture change and deep system transformation.
Long-term care organizations must be able to demonstrate to policy makers, boards, regulators, consumers and investors that resident-centered care is NOT at odds with operational objectives, treatment goals and fiscal allotments. We are working to promote the business case for culture change and suggest potential ways to study and link quality and financing.
—Bonnie Kantor, executive director
Copyright © 2008 by the Catholic Health Association of the United States.
For reprint permission, contact Betty Crosby or call (314) 253-3477.