Last October, the National Quality Forum, a public-private partnership financed by the health care industry to lead quality improvement, convened a commission to evaluate the quality of long-term care and track future improvement. Since February, Vincent Mor has served as academic partner to the committee. Now, as executive director – a still “evolving role,” as he put it – he’ll work even more closely with the group and write any future reports, while remaining in his position at Brown.
PBN: This is an offshoot of the National Quality Forum, which works with industry leaders to set detailed, voluntary standards for quality health care. Is that also what this commission will do with long-term care?
MOR: I don’t think the commission, at this juncture, will get into that level of detail. … It’s at a totally different level. The members represent academic, political constituencies, very knowledgeable experts in various fields – super-educated laypeople, you could say. (But) the commission is being funded by the industry, all three of the major industry associations: the American Association of Homes and Services for the Aging, the American Health Care Association and the Alliance for Quality Nursing Home Care.
PBN: What’s on your agenda at this point?
MOR: We are geared toward having a first-round report in December, sort of at the 30,000-foot level, with a vision of what long-term care could be like in America. It might have some readily implementable legislative (recommendations) embedded in it.
PBN: What are the biggest issues in this field?
MOR: First, work force issues. There aren’t enough people in the field; there are lots of barriers to their being trained and retained, and that becomes a vicious cycle. The fewer people there are, the more overworked are those who remain. And there are some reasonably practical recommendations that could be made to begin to address those issues. There are programs, for example, where physicians who go to work in Indian reservations or other underserved areas have some level of loan forgiveness or low-interest loans. There’s nothing like that for nurses, aides or physicians in (long-term care).
PBN: To what extent do Americans recognize long-term care as an issue affecting them personally? A large share of health care users are elderly, even if we don’t talk of the services they’re getting as geriatric medicine.
MOR: You could just ask (those patients) if they think they’re old and need a geriatrician. I don’t think everyone will say yes; in fact, a lot of people won’t, because they don’t think they have a geriatric condition – they just have diabetes or high blood pressure or whatever.
PBN: Nursing homes are for the sickest, but people don’t seem to think they or their parents will be there. Is that a problem?
MOR: It certainly is. One of the challenges that the commission faces is how to get attention to an issue which is in some respects as important if not more important than Social Security and Medicare. It’s not just about money; it’s about caring and recognition. … For years, people talked about death and dying, and how we deny it, and it’s likely that the same deep psychological forces that apply to dying apply to long-term care.
PBN: It used to be that elderly parents feared that their children would make them sell their house and put them in a nursing home. Has assisted living taken over that role?
MOR: It can only replace it for people who have money to shell out the monthly payment, which is almost always substantially more than the median income of older individuals living alone, but not necessarily more than the income plus some asset if they were to spend it. A lot of people can’t afford it, but there’s still a lot of people in assisted living, and they stay there, on average, about nine to 15 months.
PBN: Where are the rest living?
MOR: The U.S. Census Bureau just came out with a report that said the dominant type of household is an individual living alone, and many of those people are older.
PBN: Is that the reality that we’re going to see in coming years, or is there going to be a shift toward living in group settings?
MOR: Marriott has bet a lot of capital on the fact that as the baby boomers age, when they reach 75, they’re going to want to have upscale residential arrangements to move into, if they have the cash and capital. … You can run a very good business by capturing just 3 percent of the market, because it’s going to be a lot of people.
PBN: Will there be a need for more nursing home beds?
MOR: That is the big unknown. There was the SHAPE report here that said we’re going to need many more nursing homes, but it’s not entirely clear, because the occupancy rates are now dropping across the country. It’s also a question of what do we have to do if we want alternatives to the nursing homes, and how nursing homes are going to change in response to continued pressures for shorter hospital stays. I think a lot of that is up in the air. But there’s no question we’re going to continue to need long-stay, chronic-care beds for very sick people, at least at the level we have now. So the real issue will be how many more roles are nursing homes going to assume?
