Improving quality amid ongoing budget battles

When asked what keeps long term care providers awake at night, Greg Crist, vice president of public affairs for the American Health Care Association (AHCA), succinctly stated, “Reimbursements.”

He continued, “This is a sector that’s constantly underfunded and struggles to make its case.” Yet, Crist contended, there is a strong case to be made for the 16,000 facilities nationwide that serve seniors and disabled Americans … both from a care provision and economic engine standpoint.

The AHCA, with affiliates in 48 states, is the largest trade association in the country representing skilled nursing facilities and post-acute care providers. Crist said his organization advocates on behalf of nearly 12,000 … almost three-quarters … of those facilities and the more than 1 million people for whom they provide care.

Despite systemic and sustained improvements within the industry, long term care providers often find themselves battling an outdated nursing home image, reimbursement trends moving away from residential care, and a perception of poor quality and low patient satisfaction.

An Economic Engine

The long term care industry is a major economic driver in a country that is rapidly aging. “We are the 10^th largest employer in the country,” Crist said. He added that in terms of the overall economy, his industry comes in at 27^th in the nation with an annual economic impact of $529 billion.

Furthermore, he said, the labor-intensive nature of long term care provides employment for millions of Americans. Citing 2009 data, Crist said, “3.1 million direct jobs are sustained by this sector.” He added long term care also is responsible for contributing to another 2.3 million indirect jobs when taking into account custodians, food delivery companies and other ancillary service providers. In total, the industry helps keep 5.4 million Americans working.

Crist also noted that during the current economic turndown, long term and post-acute care has been one of the few industries actually adding jobs. In 2010, he said, the sector added 63,000 new positions.

Growing Demand

The need for post-acute care and residential services is growing, noted Crist. A fact sheet from the AHCA states that every eight seconds someone in the United States officially becomes a senior. In 1900, there were 3.1 million people over the age of 65 in America. In 2011, that number has risen to 40.2 million individuals.

Of course, with increased life expectancy and modern healthcare, many “seniors” are in great health and able to live self-sufficient lives. “The average age of our resident is 87-89 years,” Crist noted. He added that by the time many individuals are in need of residential care, the acuity level is very high. “It’s hands-on, human beings caring for some of the frailest in the country today,” he said.

Furthermore, Crist said the need for services is anticipated to increase exponentially over the next two decades. “The demand for the services for or facilities will only grow … 2011 was when the first boomers turned 65.”

The Question of Quality

Crist recognizes his industry sector suffers from what he called outdated notions of what a nursing home environment is like. “The stigmas of the past are not borne out in the reality of today,” he stated, adding that many facilities now follow a more medical model as dictated by patient need.

He added the industry has acknowledged the need to improve quality and focus on outcomes. Crist said this has been a point of emphasis over the past decade. In fact, in the latest quality report released last month, Crist said the industry as a whole has improved on 9 out of the 10 key quality measures the Centers for Medicare and Medicaid Services uses as basic criterion for five-star ratings.

In addition, last year’s report compared a number of quality indicators over time. Crist said the prevalence of dehydration fell from 0.9 percent in 2000 to 0.2 percent by 2010. Likewise, the prevalence of little or no activity by residents fell from 18.9 percent in 2000 to 5.7 percent in 2010. “Have there been areas that are up? Absolutely. Depression is up. That’s unfortunate, and we need to work on that,” Crist said of the 1 percent increase reported.

Overall, Crist said he feels good about the trends in outcomes and noted that 89 percent of residents and their families indicate they are happy with the services being received. However, he said that number could … and should … continue to improve.

The Funding Conundrum

Stable funding is a chief concern within an industry sector that is cost-driven by labor. “When you think about what we do, it’s primarily care-giving. In order to deliver that care, we can’t use robots and computers. If you go to our facilities, 70 percent of their costs are labor related,” Crist said.

AHCA recently launched “Care Not Cuts,” an informational campaign in conjunction with the Alliance for Quality Nursing Home Care. The purpose of the nationwide advertisements is to increase awareness among federal lawmakers about the role skilled nursing facilities and rehabilitation programming plays in the continuum of care.

Crist said 64 percent of residents in skilled nursing or post-acute care facilities rely on Medicaid with another 14 percent relying on Medicare … for a total of 78 percent of residents receiving state or federal funding to pay for services. Crist maintained this sector of healthcare has already weathered enormous cuts and is running extremely lean.

A study commissioned last year by AHCA with an independent company found Medicare is currently underfunding payments to long term care facilities by about $5 billion annually. It’s critical, Crist said, for those in charge of funding to understand additional reductions in reimbursements isn’t just about trimming dollars but is also about cutting access.

“If you cut back in these major programs, these facilities potentially suffer,” he said. Crist pointed out a facility cannot simply close the doors and send the residents home. “These people need a high level of care.”

While home-based care is often the most economical, Crist said it isn’t a realistic option for many of the residents served. “We’re getting them out of hospitals at far higher acuity levels than they were even 15 years ago,” he said. Crist added that for those in need of residential post-acute care, skilled nursing facilities are typically the most economical option compared to long term acute care hospitals and inpatient rehab facilities.

“Many individuals do not realize that ours is a sector that wants seniors and patients and residents to be in the least restrictive care setting possible,” Crist said. “The unfortunate reality, however, is that many cannot. Our view is there’s a place for home- and community-based services, but they should not come at the detriment of skilled nursing facilities because they both play an equally important role in providing care to seniors.”

Crist said the good news is that healthcare is evolving and adapting to better meet the challenges of changing care demands. “We very much appreciate and understand our place in the continuing care spectrum. When you need the type of care you can’t get at home, there’s a role to play for skilled nursing facilities. We’re not trying to expand that role to encompass care that could be provided at home … but if needed, we want to make sure the dollars are there,” he concluded.

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