Both the House-passed version of ACA repeal legislation, the American Health Care Act (AHCA), and the Senate’s version currently under deliberation – the Better Care Reconciliation Act (BCRA) – include a particularly debilitating change: a per capita cap system of funding for Medicaid. This change would dramatically cut federal Medicaid funding to states. It would force states to make difficult decisions between benefit cuts, provider payment cuts and changes to eligibility requirements – or all of these in varying measure – in order to balance their budgets.
The LeadingAge Center for Applied Research prepared The Long-Term Care Workforce Crisis briefing paper for the National Commission for Quality Long-Term Care to address long-term care workforce problems affecting frail and disabled older adults in nursing homes, assisted living, other residential facilities and home and community-based settings.
This edition highlights research underway in conjunction with LeadingAge's Center on Applied Research, and models of achieving aging in place in non-subsidized settings as well.
Behavioral health and substance abuse issues can present a major challenge to organizations that house formerly homeless older adults.
Service coordinators in Georgia’s federally subsidized housing properties didn’t have to think very hard when LeadingAge Georgia asked them to name the biggest challenge they faced in serving older residents.
One responsibility landed consistently at the top of the list.
Service coordinators wanted help addressing the needs of residents who have mental health care needs.
“It was very clear that it was a real challenge for them,” LeadingAge Georgia President and Chief Executive Officer Walter Coffey recently told members of LeadingAge’s Housing Plus Services Learning Collaborative. The collaborative is supporting 12 community-based teams as they develop strategies to coordinate and deliver health and supportive services to residents of subsidized housing properties.
It took 2 years for Coffey to figure out how he could help service coordinators in Georgia help their residents. The answer came when Coffey attended a 2008 conference that the Centers for Disease Control and Prevention (CDC) and the Substance Abuse and Mental Health Services Administration (SAMHSA) co-sponsored in Atlanta.
That’s where Coffey learned about PEARLS—the Program to Encourage Active, Rewarding Lives for Seniors.
PEARLS: Problem-Solving to Overcome Depression
PEARLS is designed to help older adults learn behavioral and problem-solving techniques that have been shown to reduce symptoms of depression and improve quality of life.
Individuals who have been trained as PEARLS counselors implement the program in community-based settings. These counselors work one-on-one with a program participant during 8 in-home sessions. A series of follow-up phone calls reinforces program themes and tracks resident wellbeing.
Problem-solving is at the heart of the program, says Dr. Mark Snowden, PEARLS project adviser.
“When you have overwhelming and unsolved problems, you have an increased rate of depression,” says Snowden. “If you can figure out ways to solve problems, the severity of symptoms of depression will, in fact, decrease.”
Participants also work with a PEARLS counselor to develop a plan to engage in activities that interest them and give them pleasure.
“I knew that this was the answer we had been looking for,” says Coffey about PEARLS. “The problem-solving treatment plan is such a brilliant model. It is almost a coaching model where the elder is coming up with the answers of what they can do and what they want to do. There is great potential for it to support our elders, especially in housing properties.”
A psychiatrist-led team trains PEARLS counselors and reviews each PEARLS case regularly. The supervising psychiatrist can also address other causes of depression and, when necessary, will work with the client’s primary care provider to begin more formal treatment for depression.
The Research behind PEARLS
The University of Washington School of Medicine initially tested PEARLS using a randomized controlled trial in community settings, according to Snowden, who is associate professor in the school’s Department of Psychiatry and Behavioral Sciences.
The study evaluated the impact of PEARLS on levels of depression, quality of life and health care utilization of 138 clients aged 60 years or older. Just over half (51.4%) of the study participants had minor depression and the remainder had chronic depression (48.6%).
Half of all participants were randomly assigned to participate in PEARLS, and half were randomly assigned to continue with their usual medical care.
Over 12 months, individuals who participated in PEARLS were more likely than those who did not receive PEARLS to:
- Have a 50% or greater reduction in depression symptoms.
- Achieve complete remission from depression.
- Have greater health-related quality-of-life improvements in both functional and emotional well-being.
- Have lower rates of hospitalization.
Service Coordinators and PEARLS
After Coffey discovered PEARLS at the CDC/SAMHSA conference, LeadingAge Georgia partnered with the Fuqua Center for Late-Life Depression at Emory University to train service coordinators in the PEARLS model.
Service coordinators were initially hesitant to join PEARLS, which they perceived as “very clinical,” says Coffey. But those who decided to participate in the training were glad they did, he says.
“They saw it as a way to really help their residents, to bring them out and engage them in the life of their community,” he says. “Later, (the service coordinators) told us, ‘This is the greatest addition to my job in years’ and ‘This is a skill that is really going to change (residents’) lives.’”
In addition, says Coffey, service coordinators found that their PEARLS training and experience helped them engage more successfully with local health care providers, including residents’ general practitioners.
“They were using the right language,” says Coffey. “They were able to say, ‘I assessed a person this way, and this is what we are learning.’ So they got more respect from health care providers. They got more feedback. They were also a lot better equipped to connect resident with the services they needed.”
From May 2009 through June 2010, Adam Simning conducted 90-minute interviews with 190 residents living in 4 public housing high-rises in Rochester, NY. One in 4 older public housing residents in his study experienced some form of anxiety and depression.
The LeadingAge Workforce Cabinet has spent a year defining the skills sets for personal care attendants, care coordinators and middle managers to deliver effective supports and services.
Now, the Cabinet wants to make sure that nursing homes, home health agencies and housing properties will use those competencies to strengthen their workforces.
The Workforce Cabinet -- a group of educators, state association executives and LeadingAge provider members -- discussed in March strategies and resources that could help LeadingAge provider members create healthy workplaces and improve the workforce.
Creating Healthy Workplaces
During their March meeting, members of the Workforce Cabinet worried that the current economic downturn could make LeadingAge members too complacent about the need to address persistent workforce challenges facing the aging field. The current economic climate has helped to stabilize turnover rates.
But those rates are likely to rise sharply again as soon as the economy recovers.
An Organizational Readiness Assessment could help a LeadingAge member objectively examine its workplace, identify that workplace’s strengths, and assess how it might be improved. Staff members at all levels could use the tool to record their perceptions of the benefits and challenges of working for the organization.
Those responses could then be used to assign a score to the organization’s work environment and culture.
The Cabinet discussed a package of supplementary materials that could be targeted to an organization’s specific score on an Organizational Readiness Assessment. Those resources could help the organization address and resolve any workplace issues that surfaced during the assessment.
“It’s difficult to attract and retain qualified workers unless your organization supports those workers after they arrive,” says Natasha Bryant, managing director and senior research associate at the Center for Applied Research. “A readiness assessment is really the first step in this process. An organization that carries out this type of assessment will be in a much better position to make full use of the competencies that the Workforce Cabinet will release next fall.”
Improving Staff Training
The Workforce Cabinet plans to help nursing homes, home health agencies and housing providers incorporate its workforce competencies into their hiring and training practices. The Cabinet believes that these providers might benefit from:
- A checklist that would outline specific knowledge and skills that workers would need to meet each competency.
- A package of resources that would guide the organization in helping workers achieve the competencies they lack.
“The Cabinet’s primary goal is to make the competencies easy to use so that providers will use them,” says Bryant. “We would like to offer providers an all-in-one package that takes them from the readiness assessment right through to actually using the competencies to hire, orient, evaluate and train personal care attendants, care coordinators and middle managers.”
About the Workforce Cabinet
The Workforce Cabinet held its first meeting in April 2012 and will serve until April 2014.
The cabinet is co-chaired by Barry Berman, chief executive officer (CEO) of Chelsea Jewish Home Foundation in Chelsea, MA, and Frances Roebuck Kuhns, president and CEO of WRC Senior Services in Brookville, PA.
An informal conference call on a recent Friday afternoon convinced representatives of 4 LeadingAge member organizations just how much they had in common.
On the first day of 2011, The New York Times published a front-page article about an innovative palliative care program for older adults with dementia based at Beatitudes Campus, a LeadingAge member in Phoenix, AZ.
The program put the comfort of residents with dementia above all else, even if that meant allowing residents to dine at 2 a.m., eat all the chocolate they wanted, or take an alcoholic “nip at night.”
Two years after that article first appeared, the Palliative Care for Advanced Dementia program—now called “Comfort First”—is spreading to New York City, thanks to the Alzheimer’s Association-New York City Chapter, 3 LeadingAge members and their hospice partners:
- Cobble Hill Health Center in Brooklyn.
- Isabella Geriatric Center in Manhattan.
- Jewish Home Lifecare in Manhattan.
Alzheimer’s Association Role
How did Comfort First show up 2,000 miles from home—and what went into making its cross-country leap a success?
The story begins with the Alzheimer’s Association’s New York City chapter, which has long been seeking ways to improve the way nursing homes care for people with dementia. That quest led to research, the establishment of a Nursing Home Task Force, the launch of an annual conference for local nursing homes, and the hiring of Ann Wyatt as the chapter’s residential care policy & strategy consultant. Wyatt was charged with bringing the chapter’s work with nursing homes to the next level.
Soon after arriving, Wyatt raised the possibility that the New York chapter might want to help New York nursing homes replicate Comfort First. Jed Levine, the chapter’s executive vice president and director of programs and services, says the chapter liked the Beatitudes’ approach because it focused on organizational changes that could be sustained over time.
“Our concern was that this could not just be a training program,” agrees Wyatt. “It really needed to be an implementation program. We wanted to embed process improvements in the nursing homes, not just train frontline staff.”
Wyatt made an early visit to Beatitudes Campus to take the Comfort First training and to confer with the program’s co-directors: Tena Alonzo, director of research at Beatitudes Campus, and Dr. Carol O. Long, principal at Capstone Healthcare.
Over the next year, the new partners designed a multi-pronged replication project with Levine serving as principle investigator. The New York City chapter, in the meantime, put together an impressive group of funders:
- United Hospital Fund.
- The Fan Fox and Leslie R. Samuels Foundation, Inc.
- The Mayday Fund.
- The Milbank Foundation for Rehabilitation.
- 1199SEIU Training & Employment Fund and The Greater New York Education Fund.
- The Caccappolo Family Foundation.
- Matthew Furman and Judy Hecker Furman.
- Daniel and Nancy Finke .
- The Alzheimer’s Association-New York City Chapter.
Research: An evaluation of the training program is at the center of the replication project and the key to spreading palliative care for advanced dementia to other nursing homes in the New York City region and beyond, says Long.
“Great programs have to have evidence-based foundations underneath them,” she says. “The research and evaluation component makes a program real, marketable and practical. Without that research, even the best programs will not be relevant to other organizations.”
The evaluation, which Long is co-directing with Dr. Ed Cisek, director of program evaluation at the New York City chapter, will span the first year of the 30-month project. Long, Cisek and other research partners will assess how the New York City training program has impacted:
- Organizational culture.
- Quality of care.
- Cost and use of medications.
- Operating and care costs. The LeadingAge Center for Applied Research is conducting this evaluation.
- Knowledge about advanced dementia and the beliefs, attitudes and perceptions of staff members.
Training: The training portion of the project began in Sept. 2012 with a 1-day meeting in New York City that introduced Comfort First to leaders from participating nursing homes and hospices as well as other regional stakeholders. A month later, a contingent of program champions from the chapter, and from each nursing home and hospice, traveled to Arizona for onsite training. Alonzo and Long returned to New York City in Nov. 2012 to train frontline and supervisory staff members who weren’t able to attend the Phoenix training. In Dec. 2013, the participants will gather again to focus on how they can spread Comfort First beyond the nursing units where they are currently piloting the training program.
Remote consultations: The New York City and Phoenix teams touch base regularly with their nursing home and hospice partners through remote consultations. These consultations might offer guidance on how to treat pain among nonverbal residents, design comfort-focused activities for people with dementia, or provide comfort foods as part of a liberalized diet.
“We tailor our consultations to the individual organization,” says Alonzo. “We recognize that each organization has its own way of doing things and will also have its own way of changing how things will be done.”
Webinars: The Phoenix and New York City teams are developing a series of interactive webinars that will be broadcast to each of the nursing homes. The first webinar, focusing on pain management, takes place this spring.
The Challenges of Distance
Frequent travel, telephone calls and use of technology like webinars is helping to close the 2,000-mile distance that separates Phoenix and New York City. In addition, the Phoenix team credits Wyatt and Levine with making the New York City replication possible through their local connections and their weekly contact with nursing homes and hospice organizations.
“The Alzheimer’s Association has strong relationships with the nursing homes and the hospices in New York City,” says Long. “So it has been instrumental in building vital partnerships. In addition, Ann is transferring our vision for this program to these organizations through her ‘boots on the ground’ involvement.”
Distance has actually brought a new and beneficial formality to the training program, says Alonzo.
“The webinars must be scheduled,” she says. “We can’t do long-distance consultation on the fly. As a result, some very thoughtful consideration goes into designing the ways we work together. I like that very much.”
Pleased with Progress
Alonzo, Long, Levine and Wyatt are pleased with the progress that their nursing home and hospice partners have made so far in adopting the Comfort First program.
“The work that we do is sacred,” says Alonzo. “It is so exciting to know that we are not alone and that other people can get just as darn excited about all this stuff as we can. Ultimately, people want to make a difference. I get to see that validated over and over again and it never gets old.”
Does the online NurseLEAD training program really improve the skills of nurse leaders in aging services organizations? Over the next year, the LeadingAge Center for Applied Research will be working with LeadingAge Tennessee to conduct a pilot test of the program's effectiveness.