Assisted Living in the Limelight

On Tuesday, Frontline aired a program entitled "Life and Death in Assisted Living" that focused on one Seattle-based, for-profit provider. Larry Minnix, President/CEO of Leading Age, our national association of not-for-profit providers responded with this post: Making My Blood Boil: Frontline Expose on Assisted Living by Larry Minnix Published On: Jul 31, 2013   If you did not see the Frontline exposé about an assisted-living company, it is a must-see for boards of directors, senior management, and staff of our organizations. If you are like me, you will feel powerful, mixed emotions about the Frontline PBS episode. You will feel horrified about the human tragedy that is portrayed. You will be angry because you know that many people watching — and beyond — will assume that all assisted living is similar to the Frontline depiction. You will feel defensive of good providers who do not deserve to be painted with the same brush that the company in question is painted. You will, initially, be angry with the media for doing a hatchet job that doesn't portray balance. You also may have the impulse to blame policymakers and regulators for making the services program too complicated or too lax. You may even blame various associations for allowing bad actors to function in the service-delivery world. After all, nursing homes have been under this kind of microscope for years. Who Is Responsible? But, who is really responsible for such stories, and what do WE plan to do about it? Here is my take: The corporate executives interviewed by Frontline blamed residents with Alzheimer's disease for unpredictable behavior. They blamed staff for being human and making mistakes. They even blamed families for understanding the negotiated risk of putting a loved one in an assisted living facility instead of placement in the “dreaded nursing home.” They blamed everyone but themselves, except for issuing the now common “we’re not a perfect company” message too often used in similar situations of corporate scandal. But, the thing that made my blood boil the most is that what happened to these residents should not happen to anyone! And no one should be treated the way that these employees were treated! The core failing of a company with multiple problems, violations of state regulations, and lawsuits is a corporate culture based on fundamentally poor values. Laced throughout all of the interviews by former employees and family members was a hidden value of greed over compassion and competence, covered by layers of sweet icing of the trappings of nice facilities. The Achilles' heel of assisted living is that those who are in it for the money know how to sell sizzle but offer very little steak. Long-term care leaders have, for years, fretted over this potential. Many of us have complained that assisted living is admitting and keeping residents that they can’t care for. These facilities play on the public psychology that families will gravitate to the nice wall sconces, winding staircases, secure gardens, and public-relations trained admissions staff who know that, as one investor-owned chain marketing person told a friend of mine, "if you get them to cry, you know they will buy." Assisted Living Has the Right Ideas Assisted living is an important program in the buffet of options that should be made available to seniors and their families. It has all the right ideas: Familiar and homelike setting. A culture of hospitality. A program and environment that appeals to the interests and strengths of residents who have impairments. A supportive approach to families. Flexibility to design services around the needs and interests of residents. Assisted living has also enjoyed a relatively regulation-free hand to prove that this sector can self-govern using market-based principles without heavy-handed government intervention. LeadingAge, and our colleague associations in collaboration with consumer groups, have worked over a decade to help define standards that could follow in overseeing assisted living at the local level. Many states have recognized the need for additional standards and training for dementia care, including Illinois, Minnesota, Montana, New York, Oregon and Washington. National groups, such as the Center for Excellence in Assisted Living (CEAL), have been working on best practices in dementia care in assisted living. Assisted living represents the chance to show that professional and sector self responsibility can be effective — a state of public trust that nursing homes, even with big improvements in quality, do not yet enjoy. Let us hope that the Frontline exposé has not irreparably derailed that privilege. Unfortunately, regulation is often driven by bad actors who take advantage of the circumstances in which they find themselves. In this case, we cannot let that happen! So here's what we need to do…and stand for! Assisted Living Providers: Make Sure Your House is in Order First, we need to make sure our house is in order. Take the Frontline video and ask yourself these questions: What are our admissions and discharge policies and procedures? What are our staffing levels? What kind of training and development program do we have for direct-care people? What are our quality standards and how do we know we’re achieving them? To whom are we accountable for what we deliver, and how does the public know our values and results? If you find yourself feeling or discussing the tension between filling beds and delivering good quality, you need to have a serious conversation with your board of directors and senior management staff. You should do this because Frontline has exposed that when greed trumps compassion, bad things happen and residents and many others get hurt. Evaluate Your Culture Second, evaluate your culture. Indicators of healthy cultures begin with staffing. Yes, all of our research points to the fact that staffing is the best proxy for quality in nursing homes and assisted living. In fact, the most trusted and supported staff in your organization should be the direct-care people on the night shift between Saturday evening and Sunday morning. Here are some questions to ask: When was the last time you checked in with those people to see how things are going? When was the last time you made rounds on evenings and nights or weekends? Do you have staff satisfaction surveys as well as resident and family satisfaction surveys? Do you act on the results? Do you disclose those results to your board and to the public? Do you have a culture of ongoing learning opportunities in the arena of contemporary clinical care as well as the often difficult dementia care arena? Quality-Improvement Programs Third, do you have a continuous quality improvement program in place beyond the cosmetics of it? Any crafty manager can produce numbers. Not everyone knows how to produce quality and how to measure it. In less-supervised settings like assisted living, continuous quality improvement is even more critical because of fewer leadership and supervisory people available everyday, 24/7. Does your continuous quality improvement culture include nonpunitive, anonymous mechanisms to report incidents or negative dynamics? Public Oversight Fourth, are you active with policymakers, regulators, and consumer groups to make sure that the proper, transparent public oversight is in place. It is not sufficient to defend what we do, however good we may be. We must go on offense about constantly improving standards that can be publicly disclosed. Are you advocating for policies in your state that assure disclosure about owners and access to them — even stockholders. In the not-for-profit sector, ownership accountability is local and transparent. With publicly traded or privately owned organizations, the public often does not know who's behind the curtain. Are you advocating for mechanisms that oust ineffective leaders and management — and even governing boards and owners? We have been working with the Centers for Medicare and Medicaid Services (CMS) on how to deal with chronically bad performing nursing homes. The long-standing tradition has been to punish them, fine the owners, or close them down. In recent years, we have suggested that punishing residents, families, and employees by closing down a bad actor is punishing the wrong people. Instead, we believe that managers and owners should be relieved of their responsibilities and replaced with competent and compassionate governance and leadership. You see, the Frontline exposé was not generated by the fault of the disease, the residents and families who cope with it, the employees who try to deliver care in a high-pressure situation, or nosy media or hungry lawyers. No, the Frontline exposé results from a failure of leadership. And, it is our responsibility to advocate for corporate structures that are driven first by quality, which should result in business success whether you are a not-for-profit or a for-profit provider. In the next few days, the Frontline story will develop broader public-relations legs — or not. It could result in the next OBRA 87 — or the flames could die down quickly. In either case, we cannot treat the Frontline exposé as a temporary public-relations crisis, because we all know that assisted living is an accident waiting to happen if we do not take responsibility aggressively for quality and what should happen to people who don't produce it. No one should be subjected to what we saw on Frontline. Quality should be an automatic public expectation. Let’s do something about it. Organizations like the one in the Frontline episode make my blood boil — and they should make your blood boil as well! But, if we don’t address the underlying issues involved, we will have no one to blame but ourselves.  

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