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Below is my State of the Association speech from the 2009 AAHSA Annual Meeting and Exposition in Chicago:
Our members at Selfhelp in New York had a great theme a couple of years ago: “Our past propels us forward.” It conveys how four generations of values and mission are being transformed into contemporary programs to meet changing needs.
As we plan our golden anniversary in two years, I am reading and reflecting on our history. The more I read, the more I realize that our history propels us forward. It all began at Arden House in New York in 1961. Ninety-nine professionals met there to explore the prospect of creating this association. Based on a consultant report written by Dr. Robert Morris of Brandeis University, the Arden House founding mothers and fathers discussed history, values, and principles. Here are selected quotes and paraphrases from that report:
- “The not-for-profit home for the aged was once considered the basic social resource for the aged when individual and family resources failed.”
- That we all “have a sense of responsibility to the community.”
- The “strength of the winds of change” are so powerful that the existing institutions must change in the face of uncertainties with the admonition that “no firm outlines about the status of these institutions can be presented with assurance.”
- The elderly will have the economic power “to choose where and how they live in some independent form.”
- The elderly will be driven by a “search for privacy and a yearning to retain the familiar.”
- The report said we would serve more people in independent settings, yet increased numbers of people with disabilities, including the mentally ill, would require “great attention” from us. It said that we would need to pay special attention to the “flow between home and hospital” so that seniors would not be subject to “arbitrary eligibility processes” instead of “need.”
- The Arden House report predicted development of multi-purpose centers that include “all the various options with “added responsibility for many other services to the elderly outside of an institution.” It said that many homes would change their names.
The report predicted we would encounter competition from many directions, confusion about institutional versus non-institutional roles, anxiety about accreditations and licensing and the extent of government control, backward-looking boards and staffs who hope to recapture the past, skeptical health and welfare planners, reluctant contributors, and, not the least, “our own self doubt” that “we display a lack of confidence in the use of our own knowledge.”
The report said that “none of these problems are insurmountable,” that “boards do learn,” that each crisis is an opportunity, and that “the elderly present very great unmet needs for housing at low cost, for nursing and attendant care, for rehabilitation,” for “opportunities for constructive living.”
The author of the Arden House report asks our founders this basic question: “Can we be sufficiently flexible and imaginative to develop requisite programs and services?”
The report concludes that this body — now AAHSA — be created “to provide a significant medium through which these major issues of our society can be evaluated, solutions tested, and programs supported.”
Subsequently, our founding documents reflect the creation of “a national membership organization of non-profit voluntary and government homes for the aged. It provides its members with a means of identifying and solving problems of mutual concern and that protects and advances the interest of the people they serve.”
So, let our future propel us forward to today and project the next decade.
Today our mission is creating the future of aging services. How effective are we as a significant medium to evaluate the major issues of our society, test solutions, and support programs based on that mission statement?
Certainly, the creation of the Institute for the Future of Aging Services (IFAS) and the development of the Center for Aging Services Technologies (CAST) have created forums in which AAHSA members, in collaboration with businesses, academia, government and foundations, have tested culture change, housing with services models and technology applications.
Evaluation of major issues of our society has produced blue-ribbon thought-leadership bodies like the AAHSA Financing Cabinet, whose work is today at the center of health care reform. I hope you are proud that AAHSA is in a prominent leadership role in health reform.
We have become better-thinking partners with others to address quality. The Advancing Excellence in America’s Nursing Homes campaign is a child of Quality First in collaboration with consumers, providers, professionals, government, and the Commonwealth Fund. Advancing Excellence holds the best promise today for showing that we can create quality improvement in nursing homes.
Back in 2002, your board declared this the Era of Leadership. We concluded that we had no problem that leadership could not solve. We have brought you the best of leadership through the use of some of the best thought leadership concepts available anywhere.
We are overcoming our “lack of confidence in the use of our own knowledge” and “self-doubt” as leaders. Your commitment to shared learning is exemplary and well known. Leadership AAHSA and similar programs in our states are being embraced with enthusiasm and supported by you in so many ways. In fact, the key to leadership development is your personal commitment, colleagueship, mentoring, and shared learning with each other.
Our advocacy is focused on a fundamental advocacy agenda around 5 Big Ideas — most anticipated in the documents pondered by our founders. They are transformational ideas. Advocacy for the right policy for the right reasons is the number one priority we have together. What they called “constructive living” and “the quest for the familiar” we now call culture change.
The “confusion about institutional versus non-institutional roles” is being embraced by most of us. It is not an either-or, but a both-and. And it depends on the needs and preferences of the people we serve. It is a matter of balance and mix. Public policy is certainly beginning to bend toward that balance, though all services are still underfunded. The CCRC and comprehensive campuses abound, as a fulfillment of the vision of multi-purpose centers. In a decade, many of you will be centers for healthy aging, as the term “retirement” fades into the sunset.
The “search for privacy and a yearning to retain the familiar” got lost along the way as we created nursing homes as junior hospitals, with shared rooms and clinical environments in a regulation and reimbursement system not often friendly to our work. Our anxiety about that, as predicted by our founders, is well founded. We’ve learned that regulation doesn’t produce quality. It produces at best, compliance with regulation. People who have the time to understand needs, and help staff learn contemporary practice, produce quality.
We have given inadequate attention to what Arden House highlighted about the “flow between hospital and home.” Siloed business models, perverse reimbursement incentives and poor care coordination have created transfers based on the arbitrary instead of on real needs of seniors and their families.
Studies now show that the human and financial consequences are great because our fragmented system doesn’t handle transitions well. The hopes for improvement actually are found in PACE, hospice, CCRCs, and some Medicare Advantage programs, which start with need, not arbitrary eligibility. We will be cofounding shortly a quality initiative in collaboration with the Brookings Institution and chaired by a highly respected expert to address quality improvement in transitions to minimize the difficulty for consumers.
Even less attention has been paid to the mentally ill elderly, as the founders recognized. Too much loosely prescribed medication, too little geriatric psychiatry and therapeutic relationship training. With the knowledge that late-life depression is severe in the elderly, especially men, we still largely ignore the need. Mental illness is not a character flaw, and like many other illnesses, it does not cure itself.
The founders outline our “responsibility to the community.” We still have it! We enjoy public support — though donors and government can be skeptical and reluctant as the founders predicted — but many of you prove your motivations every single day and those good deeds are too often lights under a bushel.
Make no mistake, however, that the public eye is on us to justify the tax benefits, reputation, and philanthropy we enjoy. Stewardship is front and center. Our story about our responsibility must be made clear — and we need to tell it more boldly.
The founders were right about the strong winds of change and the uncertainty. None of us has a clear path and assurance of success. We never have. Yet, the history shows that we not only survive, but we change, transform, and thrive. You have served your communities on average 3-4 generations — some much longer. Yes, you have changed your names and business plans to reflect the changing need.
We need innovative sources of capital. We have formed a thought leadership group to make recommendation to policy makers about capital. We are a good risk. We use it well and pay our debts. We stand the test of time.
Yes, AAHSA’s founders dazzle us with their prophetic insights. By all measures, AAHSA has 48 years of success. Yet, we are more than homes and services. The founders said we are a medium for innovation to benefit the people we serve. So, what is that brand? What should we call ourselves as we look to the future? Many of you have gone through the exercise of branding and identity.
Your AAHSA board, staff, state leadership both lay and professional, are addressing our brand for the future. We’ve used surveys, discussion groups involving state associations and their leaders. Our brand is about values, innovation, advocacy for policies and programs that reinforce those values.
The values emanate from the voluntary, mission driven sector of every community: for the benefit of the people you serve through, as our founders said, “Opportunities for constructive living.” Next year we will announce our brand plan and promise and possible new name.
Our good friend and colleague Ken Durand, reflecting on the aging process and our missions, AAHSA’s role in our field, said to me recently, “You know, this old age is not only worthwhile, but it is meant to be. Therefore, it is our responsibility to help people get the most out of it.”
What an interesting way to conceptualize what you do for society — help people get the most out of the aging experience. Your brand.
Yes, our future propels us forward. So, I have 5 questions for us to ponder at this poignant time in our history.
- How do we stay focused on the best interest of the people we serve in the midst of today’s pressures?
- How do we communicate to the world that old age is not only worthwhile but meant to be in cultures of youth-oriented?
- How do we define our work together as mediums of innovation — flexible and imaginative — to help people get the most out of the aging experience — even when it is difficult?
- How do all of us create a value proposition with consumers and policy makers to demonstrate we are trusted providers of essential services that society must have and is will to pay for?
- Are you willing to advocated aggressively for transformational change?
The best evidence we can offer that answers each of these four questions positively is the extent to which we can show we are changing lives!
Your association is strong — yet we can be so much more. People expect that of us.
I have the greatest job in the field. I am honored to be your CEO. If there is anything we can do, call me.
The U.S. House of Representatives soon will vote on the Affordable Health Care for America Act (H.R. 3962), a landmark bill ensuring that millions of Americans, will have access to health care coverage they have never had before.
Efforts to make this coverage a reality go back almost a hundred years, through the presidencies of Teddy Roosevelt, Harry Truman, Lyndon Johnson, Richard Nixon and Bill Clinton.
Now it’s down to one measure coming to a vote in the House — possibly in the next week — with a slightly different measure to be taken up by the Senate soon thereafter. Once the Senate and House have taken their initial passes at the legislation, a conference committee will determine which provisions will be in the final version to be sent to the president.
In 2003, AAHSA board members considered the issue of access to health care insurance and gave it a high priority. Earlier this year, the board again reviewed the issue of health care reform and decided that “health care reform is essential now, including long-term services and supports.”
The AAHSA board applied the same criteria for evaluating health care reform proposals generally that had earlier been developed for screening long-term services and supports financing proposals. In both cases, the board called for a national solution to a national problem, as universal as possible, affordable for individuals, fiscally responsible for government, giving consumers choice and control, supporting family caregivers and investing in both quality and talent.
Our initial evaluation of H.R. 3962 indicates that it conforms with many of the principles that our board articulated for health care reform in general, and long-term services and supports in particular. We are examining the legislation’s potential impact through four primary lenses:
- On our residents, clients and their families?
- On our members as providers?
- On our members as employers?
- On those who work in our member organizations?
Impact on Medicare Beneficiaries
We have heard from many members that their residents are extremely anxious about health care reform’s impact on their Medicare benefits. You can reassure them that the House bill makes no changes to their benefits or premiums, and that the program will continue to operate as it does now.
In fact, for beneficiaries, the bill includes several Medicare improvements:
- Filling the so-called “doughnut hole” in Medicare Part D prescription drug coverage.
- Medical home provisions to ensure better coordination of services.
- Improved coverage of preventive care.
CLASS Act Provisions
One of the bill’s most far-reaching effects will be its impact on the future of aging services through the inclusion of the Community Living Assistance Services and Supports (CLASS) provisions. This plan for a new structure to finance long-term services and supports closely tracks the recommendations of our own member-led Long-Term Services and Supports Financing Cabinet.
Looking ahead, our cabinet forecast that the Medicaid program would become unsustainable as the default coverage for the services we provide. We are seeing the truth of that prediction this year as states cut back on provider reimbursements and on coverage of long-term services and supports provided in home and community-based settings.
Both consumers and providers need a more responsible and sustainable source of financing for the services that growing numbers of Americans will need as they age. The inclusion of CLASS provisions in H.R. 3962 is a direct result of this year’s extraordinary grassroots advocacy in which many of you participated.
Last year, no one on Capitol Hill was willing to say “health care reform” and “long-term services and supports” in the same sentence. Our members not only contacted legislators yourselves, but they involved their boards, residents, staff and families as well. The fact that we have come so far with CLASS is largely due to their efforts, and we thank them.
Medicare and Medicaid
In addition to the CLASS provisions, the House bill contains a number of improvements in Medicare and Medicaid. It extends the economic stimulus package’s increase in federal Medicaid matching funds for another six months, through the end of June, 2011. For nursing homes, the legislation contains a new $6 billion in federal Medicaid funds to mitigate under-reimbursement for homes that meet quality criteria. The bill mandates a study of the adequacy of Medicaid reimbursement. It also addresses the flaw in the Medicare prospective payment system that under-reimburses for the care of medically complex residents, many of whom receive their care in AAHSA-member facilities. It renews the caps exceptions process for Medicare coverage of out-patient therapy.
For home care, the bill calls for an evaluation of Medicare margins and would delay hospice reimbursement cuts for another year. The legislation addresses the high cost of health insurance that many of you experience as small businesses by establishing health exchanges with affordable policies and guaranteed benefits. The bill also makes a number of improvements to the federal nurse education program, including increased loan repayment benefits and the removal of caps on awards for nurses pursuing advanced degrees.
The reality is that no legislation will ever provide everything we want and nothing we don’t. Two provisions of H.R. 3926 in particular concern us. One would eliminate the 2010 Medicare payment update for nursing homes and home health care providers as of Jan. 1, 2010.
The other would increase civil monetary penalties imposed for survey deficiencies. The rules under which the legislation will be considered on the House floor do not allow for any revisions or removal of these provisions. The Senate is taking a different approach on both of these issues in the legislation it is drafting, and we are working to make sure that the Senate provisions prevail when health care reform reaches the House-Senate conference committee.
You have two opportunities to learn more about the health reform bills in the next few days:
- Through our participation in the Seniors to Seniors coalition, residents and clients of AAHSA members have an unprecedented opportunity to join other seniors on a White House Conference Call with U.S. Health and Human Services Secretary Kathleen Sebelius to ask questions and learn about how health care reform will impact seniors’ access to physicians, Medicare Part D drug plans, and most important, long-term services and supports. The call is Thursday, Nov. 5, at 5:15 p.m. Eastern. Phone lines are limited, so advance registration is required. Anyone who would like to participate should RSVP.
2. Attend our 2009 Annual Meeting next week in Chicago. There will be numerous discussions in plenary sessions and education workshops to learn and understand health care reform. Our speakers will include Assistant Secretary for Aging Kathleen Greenlee. We hope you will come, gain more information, and share your feedback with us so we in turn can bring it back to Washington to work with members of Congress as they make the final decisions on health care reform legislation.
This is a rare and unprecedented time in the life of our country. We thank the members of Congress for what they have done so far, but we also will continue to work with them toward final health care reform legislation that combines the strengths of measures developed in both the House and Senate.
Stay tuned and stay involved.
A man named Clarence passed away a few days ago.
It was four years to the day after he was rescued during Hurricane Katrina. They found Clarence on the roof of his modest house in New Orleans. You may have seen his story on the news. No family. Nowhere to go. A single soul in search of stability, safety, security and community.
The Katrina response by AAHSA members was immediate, overwhelming and amazing. Member employees, state associations and AAHSA staff joined together to marshal money and supplies to people in Louisiana and Mississippi who were instantly without necessities.
Part of the AAHSA member response was the establishment of a hotline by National Church Residences (NCR), whose CEO, Tom Slemmer, is AAHSA’s board chair. We helped broker needs with available housing throughout the country for older people and employees from the Gulf Coast. Some 900 people, including Clarence, wound up being helped.
Clarence went from the roof of his flooded house to Lakewood Christian Homes in Atlanta. The transition was orchestrated by Brenda Schrader, an NCR service coordinator based at NCR’s headquarters in Ohio.
Service coordinators are increasingly important to the emerging housing with services agenda, and they are an under-recognized group of professionals who help countless people like Clarence every day. Brenda is a poster child for the role. Brenda, and AAHSA’s Leslie Knight, her own brand of “service coordinator” to our members, were part of a great team throughout this unprecedented set of events.
Recently, Brenda wrote Tom about Clarence’s passing. As you read this, think about what it says about Brenda.
“I am deeply saddened after receiving a call at home this morning from Fulton County, Georgia’s M.E. office, informing me that Clarence passed away yesterday. They stated they found my name on a card I sent him, which I assumed was the birthday card I sent last week, but they stated it was a card dated 2007. Let this be a reminder of what the smallest gestures may mean to others. I will greatly miss talking with him and our harassing each other over sports teams…for me, the opportunity and experience assisting Clarence, and knowing him as a kind and gentle person, is something I will never forget.”
The rescue of Clarence — the man on the roof — represents everything great about mission-driven people. For every Clarence, there are millions more in need. For every Brenda, there are countless others with her 24/7 commitment and motivation to help vulnerable people through difficult times.
Your “man on the roof” may be an Alzheimer’s resident who is without family or identity. It may be an impaired senior living in the community, hanging on to home and a shred of independence because of the many other people like Brenda, whose names I wish I knew and could share.
The birthday cards from many a staff member are on tables, in drawers and on the refrigerators of people who kept them because they are such important gestures — however simple and mundane they may seem to the sender.
This weekend, remember that many people on the roof of desperate and difficult circumstances need our help. And celebrate the Brendas and Leslies, and the organizations that create cultures of services to empower them to fulfill a calling to help people like Clarence enjoy a new and better life — because there are people like you and your staff who care so very much.
Brenda, your smallest of gestures had a great impact on Clarence — and on people like Tom and me whom you inspire.
With great appreciation for the labor of all of you, happy Labor Day!
Years ago, a trustee of my former organization said after a couple of years of service, “You know, on the surface this seems like a simple operation, but at the heart of it, this is very complex work, isn’t it?” How true.
The draft House of Representatives health reform bill, H.R. 3200, has a provision to eliminate the Medicare Market Basket update for nursing homes. On the surface, many “Beltway People” assume we can “absorb it.” They base that conclusion on studies that, on the surface, say there’s enough money in the long-term care system.
On the surface, many people don’t like nursing homes anyway, so there are Beltway People who seem to want to keep the pressure on us. They don’t like nursing homes until their family needs a really good one on short notice.
On the surface, many assume quality in nursing homes is bad, so let’s fine homes more and create more regulations. It was Beltway People that created a public reporting system that rates nursing homes like toasters or cafes. It seems simple enough, on the surface. In their wisdom, those “beltway rankers” make large nursing homes with complex patients look artificially worse than they really are.
On the surface, these Beltway People believe that nursing home people can’t be trusted to improve quality, so progress on quality is measured in terms of how bad we are, not how we’ve improved. Despite the fact that reputable entities like the National Commission for Quality Long-Term Care or the Advancing Excellence in America’s Nursing Homes Campaign conclude otherwise.
On the surface, some Beltway People will say Medicare is a federal program and Medicaid is a state program. Some understand the interdependence, but some don’t. So it’s easy to ignore severe Medicaid shortfalls while talking of Medicare cuts.
So, on the surface, it’s all too easy to pay nursing homes less and regulate them more.
That’s the dynamic we face. That’s what’s on the surface.
But, what’s at the heart of it?
First, the heart of nursing homes is care for vulnerable people whose families under stress. Many enter skilled nursing facilities straight from hospitals — some from ICUs, where the reimbursement is several times that of a post-acute nursing home unit. Yet, the care must be close to that of the hospital at the hour of transfer and remain at a high level for some time.
Some people’s needs are straightforward — rehab for a few weeks, then home. Some homes make a niche business of it and therefore, have profit margins. The Beltway People say their margins are too good, so all nursing homes can be cut.
However, also at the heart of nursing homes are very complex patients, with multiple chronic and delicate conditions that require higher staffing, more expensive medications and longer stays. Other “beltway experts” actually say the care for these people is under-reimbursed by Medicare. Most of these facilities are not-for-profits, who traditionally accept sicker people as part of their mission. Our sector plays an important role below the surface, and at the heart.
At the heart of it are people who deliver the care — direct care staff, therapists, nurses and doctors. The experts say the doctors are under reimbursed, and liability costs for everyone involved are out of proportion. The experts also say programs are needed to attract and retrain nursing and other direct care people. In fact, nursing home care — particularly complex care — requires more people with higher qualifications. The experts admit that most nursing home care costs pay for people who provide the care. It’s a people intense sector of health care.
So, at the heart of it, when cuts are made, people bear the brunt of those cuts. The experts know that staffing is the best known proxy for quality. Let’s help the Beltway People do the math: less reimbursement equals less staff equals lower quality.
At the heart of it is that many nursing homes must be all things to all vulnerable persons in many communities — the post-acute unit for the hospital, the Alzheimer’s programs for those who can’t stay home, the outpatient center, the place to live for those whose care needs are too complex and have no home or family, the hospice and the Meals on Wheels program for the county or community.
Often, the nursing home is the place for those who are sightless and out of sight, out of memory and out of mind. Many are people with difficult care needs: those on Medicaid, those with no insurance, even those with undocumented status. The community quietly sends the difficult people to us, especially in inner city and remote areas.
The complexity is that some segments of Medicare part A subsidize other segments of Medicare Part A, which subsidizes Medicaid which must be subsidized by self-pay, providers tax or fundraising.
On the surface, a nursing home is a nursing home is a nursing home. Some patients are profitable, so let’s cut reimbursement for all of them by cutting the market basket. So simple on the surface.
The market basket is an automatic annual two to three percent increase to cover costs of living — mostly people — who need jobs and have bills to pay. The market basket is the only stabilizing, predictable revenue stream to cover other negatives.
It’s time to do the math for Washington. We have a calculation tool that can tell you the effects of Medicare’s cuts on your nursing home. You can quantify those cuts for your legislators and translate these dollars into people to be laid off, programs to be eliminated, patients who’ll have to remain in hospitals, employee benefits to be cut, and in some cases, nursing homes that must be closed or sold.
On the surface in beltway conference rooms, it’s easy to say the “industry” can take a cut.
At the heart of it, though, you must tell your elected Beltway People that eliminating the Market Basket hurts people. Tell them before these cuts became law. Tell them NOW!
Tell them that the not-for-profits in your community are losing money and cannot afford to lose more. Ask them what they think your communities would do without your nursing home. Because we provide the care that is all too easy to misunderstand, and we are all too ready to help when a bed is needed.
That’s the heart of the matter. You’re indispensable to the heart of your community. You must tell that story.
