Category Archives: Long term care

Changes to ACA Likely Mean More Pressure on Providers

Patrick Connole

With the Senate in the process of making heads or tails out of the American Health Care Act (AHCA), the bill passed by House Republicans on May 4 to rewrite major parts of the Affordable Care Act (ACA) and to revamp Medicaid funding, the financial analysts are out in force to assess what the proposal would mean for health insurers and providers.

In that vein, a new report by Standard & Poor’s (S&P) examines how two main health care market segments—Medicaid and individual—will be affected, and in turn what this means for payers and providers.

On Medicaid, the AHCA offers a titanic shift for the Senate to consider by putting a per-capita cap on federal funding pegged to beneficiary spending in the base year of 2016. States would have some flexibility to eschew the cap and go with a block grant formula instead, but for the most part the cap model would be in place for the long term care sector’s primary clients among elders and people with disabilities.

The Congressional Budget Office, which has not scored the version of the AHCA that rests with the Senate now, did so in March for a previous iteration of the legislation and said changes to Medicaid funding would result in federal spending reductions of $880 billion over 10 years.

There are also hotly disputed changes in the Republican bill to gradually end the Medicaid eligibility expansion under the ACA.

Analysts Weigh In

S&P said in its analysis that the proposed change in Medicaid funding for the expansion population would trim the number of enrollees in the program over time and “be a real test” for Medicaid stakeholders, from insurers to providers, to states and to beneficiaries.

“The bill shifts Medicaid from an entitlement program to either block grants or per-capita funding, with growth in spending likely to lag health care cost inflation. This will likely force some states either to reduce Medicaid eligibility levels or cut reimbursement to providers to offset the growing burden on state budgets,” S&P said.

In general, S&P said the ACA repeal and replace effort, which certainly will undergo a rewrite of some sort in the Senate, is a challenge for providers.

“We believe that passage of this legislation as proposed would add to credit stress in the not-for-profit and for-profit hospital sectors, which could lead to negative ratings actions over time and ultimately a negative outlook,” the analysts said. This negativity is most noted for safety-net providers that are vulnerable to Medicaid reductions.

“However, the funding reductions the bill currently proposes are spread out enough that an immediate negative outlook for 2017 is not currently warranted, in our opinion,” S&P said.

Joseph Marinucci, senior director, S&P, says it is important to remember that changing Medicaid from an open-ended payment system as it has always been to a capped system leaves the door open for trouble if there is a recession.

“The ACA was designed for recession, with buffers for a bad economy. If there are caps, there is then a stress scenario for states who won’t have the flexibility or federal budget to pay for their Medicaid budget,” he says.

S&P also said that providers are already under operating pressures “from a wide array of factors, including already weaker reimbursement growth, movement to value-based reimbursement, and rising labor costs.” This makes the possibility of a new law to follow—and the changes to Medicaid—an especially tough road for providers to navigate right now, the analysts said.


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The Future of Tech-Enabled Partnerships between Post-acute and Acute Providers

Steven Scott


Steven Scott, PointRight

Whatever may happen to the Affordable Care Act, one thing is certain: The evolution that it created toward accountable and more integrated health care will continue onward, and the collaboration between different types of health care providers will only intensify in the coming years.

Information technology (IT) continues to be central to this effort, but what kind of technology?  Certainly systems that store, manage, and easily retrieve patient data have become state-of-the-art, but a new challenge emerges: turning data volume into value. Business intelligence solutions that affect both quality of care and costs will soon become the bridge across care settings.

It is because data aggregation, data exchange, and analytics are so central to value-based care and to collaboration across care settings that I was surprised this past February when I scanned the audience at the HIMSS conference, considered by many to be the world’s leading gathering of health IT professionals, and saw so few representatives from the long term/post-acute care (LTPAC) profession.  Of the 40,000-plus attendees that gathered over the several days of the program, not very many represented LTPAC providers.

While technology has been a latecomer to a field traditionally focused on the human touch, I certainly don’t believe the numbers are reflective of the LTPAC community’s commitment to leveraging IT solutions to advance quality and deliver superior outcomes. Those of us in attendance were highly motivated and eager to demonstrate to the broader health care universe the vast number of improvements skilled nursing has made thanks to technology adoption.

Post-acute care providers understand that IT has never been more important to the profession—influencing decision making at not only the bedside, but also in the boardroom. To anyone tempted to think technology innovation is exclusive by care setting, look no further than hospital readmissions.

In June 2016, just one year after the American Health Care Association (AHCA) introduced the AHCA Quality Initiative aimed at reducing the number of hospital readmissions within 30 days during a skilled nursing stay, one-fifth of AHCA member centers had achieved a 30 percent reduction in hospital readmissions or lowered their rehospitalization rate to below 10 percent.  These numbers are reported based on our PointRight® Pro30™ measure, a National Quality Forum-endorsed risk-adjusted rehospitalization measure that includes all SNF admissions regardless of payer, rather than Medicare-only data tracked by CMS.

The federal Hospital Readmission Reduction Program (HRRP), created under the ACA, makes lowering readmission a priority, as it penalizes hospitals with readmission rates that exceed the national average.  HRRP shines the light on the interdependence between acute and post-acute providers, a relationship that goes far beyond avoiding readmissions.

As hospitals and health care systems work on improving population health while strengthening their connection to patients and families, having a strong post-acute network in place is pivotal.  This means hospital administrators must have a very strong sense of the quality of the post-acute providers upon which they rely.

Data help tell the story about provider quality.  Hospitals can use analytics to better understand the post-acute facilities in their area that may be most adept at serving certain types of patients.  A patient being discharged with a respiratory diagnosis has vastly different needs than a patient recovering from a knee or hip replacement.

Understanding which facility is right for a particular patient will greatly decrease the likelihood of readmission.

Hospitals and post-acute providers, in many respects, have the same IT challenge, and that is leveraging the data in their EMRs to meet the new challenges of our value-driven health care system.  What is even more interesting is that each provider segment can learn a lot from the other’s data.

Establishing an integrated care continuum will depend on technology-enabled partnerships where data are shared and analytics are used to better serve patients as they move across diverse environments of care.

Steven Scott is President and CEO of Cambridge, Mass.-based PointRight,  which provides predictive analytics solutions to thousands of post-acute providers, hospitals, ACOs, and payers.


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Fault Lines And Frontiers In Person-Centered, Long Term Care Part 3

V. Tellis-Nayak

Robert Murray sat at the desk with three octogenarian fellow residents; they had an air of authority. Across the desk, the young, shy, but confident Angelica Riviera took her seat.
At the Bethel Health and Rehabilitation Center, a meeting of the ages was about to begin: knowledge developed over 300 cumulative years, arrayed against the untested idealism of the 19-year-old Angelica. This was the final meeting where this team of seniors would declare whether Angelica measured up to the certified nurse assistant (CNA) job she was seeking.

Elders in skilled nursing centers recruiting their own caregivers is something you would expect Diane Judson, director of nursing, to initiate. She has a cultivated way of relating to residents. She connects with the person concealed within an aging body; she recognizes the human spirit yearning to be whole, to reach its potential, and to rise above selfishness and to serve others.

The four residents who interviewed Angelica are the Recruiting Council Judson installed over a year ago. As recruiters, they take over after the routine preliminaries and paperwork. They have the final say in CNA hiring. Robert Murray, a victim of Lou Gehrig’s disease, is an active member. He led the interview with Angelica. His amplifier headset muffled his labored words, but Angelica sensed the pathos in the question Murray directed toward her.

Compassion Over Competence

Murray asked her, “Angelica, you see, I am only 42, but I am not a whole person anymore. ALS has crippled me. I can barely move around. I cannot talk with you without this amplifier headset. I was a full person once. I am not anymore. Angelica, as my caregiver, what can you do to make me feel whole again?”

Angelica could not stop the gush of tears. “That is not what I had expected,” Angelica says. “I thought they would ask me about my training, my skills, and my experience. Bob’s question cut through all that I anticipated, it went deep inside me. It told me that what they were looking for was not a CNA. They wanted a caregiver that made them feel like a whole person. I cried.”

Angelica is now a caregiver at Bethel—a happy one. She has a special bond with Murray.
The recruiting elders are uncanny in detecting the kindness an applicant brings to the job. Not all applicants pass the test. Of the 40 or so prospective students or CNAs thus screened by the residents and recruited in the past year, only two have left Bethel: One was hired by Judson against the team’s recommendation—she soon discovered they were right—and the other, although big in heart, fell short on competence.

The “Residents Recruit CNAs” story is as much a tribute to Judson as it is a warning about the gaping lacuna in the person-centered approach in long term care. Not all well-regarded programs that preach or practice humanistic principles capture all the essential elements that make the human person.

Service Is Joy

A history written in blood, sweat, and tears finally brought the world to agree on a lofty vision of the human person; it is now shared by nations, religions, and cultures. That model posits that five innate yearnings define our goals, endow us our inalienable rights, and confer on us our humanity. We have distilled these primal needs and birthright as: to be, to become, to belong, to be your best, to reach beyond.

To reach beyond selfishness and to lift those in need are tendencies to be compassionate etched in our DNA. Adam Smith, the widely misquoted godfather of economists, refers to compassion as a “principle of human nature, the most exquisite sensibility to feel for others.”

Compassion is the most divine of human virtues. It brings blessings not only to the receiver and the giver, but also to the bystanding observer. The science of compassion has documented the beneficial changes in brain, body, mind, and soul.

As a Nobel Prize laureate put it,
“I slept and dreamt that life was joy.
I awoke and saw that life was service.
I acted and behold, service was joy.”
—Rabindranath Tagore

Compassion Spreads its Blessings

The residents in nursing centers know much about the rewards of selfless sacrifice. They were parents, teachers, doctors, lawyers; they volunteered and were good neighbors; they gave. Why should we presume that in their ripe years they desire to disregard life’s lesson, to become self-absorbed and egocentric?

It is rare that the person-centered agenda specifically caters to the noblest human instinct that yearns to transcend, to serve, and to give. Ironically, this is a glaring deficiency in many well-funded programs. However, compassion thrives in innovative practices at many nursing centers.

At Bethel, Judson opened one route to attain fulfillment via compassion. Other people like Judson at other sites have opened different pathways to compassion:
Residents partner with hospice staff; they bring comfort and peace to their dying friends and co-residents.

Residents serve on advisory groups that plan menus and improve layout, décor, and furnishings.

They serve as ambassadors-at-large that facilitate communication, troubleshoot, and spread cheer and smiles.

One nursing center in New Jersey reinstated a resident’s past career role as a judge. She arbitrates disputes and grievances that residents and staff bring to her.

At another Eastern site, a resident with a distinguished career on the stage was helped to turn residents and staff into actors; they put on stage shows for their families, friends, and neighbors.

In a California nursing center, residents make fancy colored soap, market it at fairs and online, and spend the profit feeding the homeless.

Many nursing centers across the nation connect with churches and schools. They host children; encourage intergenerational play; do foster-grandparenting and baby-sitting; and help with homework, writing letters, and so on.

At other sites, residents pass on their skills and wisdom to the younger generation. They teach, mentor, and counsel.

Kindness and compassion are deeply felt urges that seek fulfilment even as our body ages. Compassion spreads its blessings all around. As Judson says, “Seeing residents hire their caregivers is rewarding enough. Sitting on the sidelines, I listen to residents, I understand what they really want. At each session, I learn something new. It has made me a better leader. It has blessed us all, made each of us a better person.”

V. Tellis-Nayak, PhD, is senior research advisor at NRC Health, Lincoln, Neb. He has been a university professor, whose scholarly work has been published in national and international professional journals. He and his wife, Mary Tellis-Nayak, have co-authored a book, “Return of Compassion to Healthcare,” which upholds humanity as the ultimate measure of success. He can be contacted at

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Possible New Federal Medicaid Policies Put Pressure On States

Patrick Connole

With Congress weighing whether to alter how shared federal and state payments work in the Medicaid program under a Republican federal per-capita cap, the possibility of such a shift could leave long term and post-acute care (LT/PAC) providers much more focused on state policymaking moving forward.

That is the thinking of Robin Arnold-Williams, a partner and head of the Medicaid practice for Leavitt Partners in Salt Lake City, Utah, who tells Provider that if a per-capita cap comes to be then states will be faced with enormously tough decisions on “who they are going to cover and for how long.”

Of the many factors playing into how states decide, under a possible cap system, to allocate money to the various populations able to receive Medicaid funding (low-income elderly, disabled, pregnant women, etc.) is the Affordable Care Act’s (ACA) eligibility expansion. What the House Republican bill, the American Health Care Act, currently proposes is that enhanced federal funds, or matches under the ACA, will continue to be paid for enrollees on the books by Dec. 31, 2019.

So, states like Kansas, which is slowly moving forward in its legislature to possibly expand eligibility under the ACA for its Medicaid program, may want to act sooner rather than later in order “to get critical mass” and take advantage of the enhanced match of 90 percent, Arnold-Williams says.

How these state decisions on ACA eligibility directly affect LT/PAC funding is that if a state does or does not take on the more generous federal match and more enrollees, then they may or may not have more money for other buckets, or populations, in need of the capped federal funds.

All of this is very complex to understand, she explains, and will leave state Medicaid offices working overtime if the House Republican bill survives its trek through Congress.

“I imagine there are a lot of Medicaid directors looking at their data and trying to calculate that. That will take some sorting through,” Arnold-Williams says. “There are different per-capita rates for each group: children, adults, seniors and the disabled and the blind. It is one thing to say the money is going to flow to the state in those set per-capita rates by group, but it is quite another thing at the state level to say how that revenue will be allocated.”

An example of the tough math ahead is if you have different inflation costs for seniors and people with disabilities versus children, leaving states to allocate Medicaid budgets for these different groups and services within Medicaid without open-ended entitlement.

Some states, she says, will be more generous and may even weigh keeping their program open-ended with possible tax increases, decrease in health benefits, or other moves to pay for it, but more likely it sets up an intense period of competition between various Medicaid groups when the Republican proposal would go into effect in 2020.

“And one decision point in 2020 will be a state making a conscious decision to roll back ACA expansion in order to manage money better. It is hard to manage expansion and not have new people come on at lower match rate,” Arnold-Williams says.



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Fault Lines And Frontiers In Person-Centered, Long Term Care: Part 2


V. Tellis-Nayak

V. Tellis-Nayak

When did you last notice a doctor sitting at the bedside, totally absorbed listening to the patient’s story? Danielle Ofri, MD, recalls bygone days whenever she talks with admiration of her mentors. They were white, male doctors in starched shirts and bow ties, schooled in lily white settings.

“Their old-fashioned doctoring made them approach the bedside as a sacred act,” Ofri says. “They examined each patient—whether a homeless Ecuadorian alcoholic, a veiled Muslim woman, or a visiting Swiss diplomat—with a thoroughness that in itself exuded respect.”

She speaks of Dr. Spenser, blustering in style but who coached young medics-to-be on compassion. He would drag a metal stool to the exam table, swivel it down to the lowest level, and sit on it with his head level to the exam table. Then he would say, “Whenever you speak to a patient, you seat yourself at the patient’s level or lower. You never hover over them high and mighty. They are the ones who are sick. They run the interview, not you.”

Eclipse Of The Art Of Relating
A kind caregiver whose eyes bespeak concern, whose touch conveys compassion, and whose words reassure, does more than just communicate; kindness and caring speed up recovery and hasten healing more surely than does the cold potency of the formulary.

Institutional medicine is quick to report that 70 percent of the avoidable, massive acute-care damage inflicted on patients is caused by miscommunication. Such analysis is typical of the biomedical mindset—it skirts the real issue; it begs the question.

Advances in communication make the world flatter and smaller, and social contact easier than ever. Why then is miscommunication epidemic in health care? The answer is obvious.

The communication revolution helps us to connect easily, but it does not help us to relate meaningfully. Relations are the soul of health care. But human contact is turning cold and sterile.

The Art Of Listening
Surveys of residents, families, and staff are commonplace in long term care (LTC). But the art of listening is in eclipse. Many policies, regulations, and programs are elegantly designed and aimed to benefit LTC residents. But we sadly watch many of these residents flicker, flame out, or linger on as cooling embers. Too many LTC initiatives are born of logic that is not always in sync with what beneficiaries want and need.

Regrettably, LTC discourse on culture-change is loud in tone, light in theory, and lax in its phraseology. My disappointment sparked a research interest, which in turn resulted in a book I co-authored with my wife, Mary Tellis-Nayak: “Return of Compassion to Healthcare.” Importantly, we reviewed what we had heard from residents, family, and staff in annual surveys—several million respondents over 15 years.

We asked, “Who is the person in person-centered care?” All lines of inquiry converged on the humanist axiom, which we summarized as follows: Five primal yearnings make us human and endow us our inalienable rights: to be, to become, to belong, to be our best, to reach beyond.

History’s March Toward Human Rights
These five “Bs” are what make us human. However, many societies throughout history have not recognized select groups as humans, including women, children, slaves, and ethnic outsiders.

Our forebears paid a heavy price in blood and treasure before reaching a consensus about the humanity that is our ultimate birthright. We believe the five Bs distill the content and spirit that fueled history’s major upheavals—those whose intent was to clarify and ensure that birthright:

  • Milestones in democracy: Magna Carta, Emancipation Proclamation, Women’s Suffrage.
  • Revolutions: American (“life, liberty, happiness”); French (liberty, equality, fraternity); Russian (You have “nothing to lose but your chains”).
  • Religions: Christianity (We are “made in the image and likeness of God”; “People of God”); Hinduism (“Atman is Brahman”); Islam (“All the born are born with the God-given nature”).
  • Caregiver oath: “First, do no harm.”
  • Humanist precept: Maslow, Frankl, Adler (“Our humanity is the measure in all things”).
  • International consensus: 193 signatories to the United Nations declaration of human rights.

The five Bs encapsulate the primal yearnings intrinsic to a person, whatever the context or circumstance. We take inspiration from the great humanitarian, Albert Einstein, who advised, “Remember your humanity, and forget the rest.” We propose that the five Bs serve as a preliminary touchstone for new understanding of human yearnings—especially of those under our care.

The skeletal outline that follows narrowly focuses on LTC residents and is meant to illustrate how the five Bs could be a “GPS” that pinpoints our person-centered destination and guides us on an assured route.

Five Self-Evident, Inalienable Rights

  1. To Be: To live in a risk-free setting, safe, without fear of injury from medication error, abuse, under-staffing, inadequate infection control, substandard wound care. To live without pain and to die in dignity.
  2. To Become: To be respected for your unique self; to participate in care decisions and day-to-day choices; to have ready access to all your health records. To maintain self-reliance and maximize self-care.
  3. To Belong: To lead a fulfilling social life, to bond with caregivers and to be mutually supportive of fellow residents; to stay connected to family, children, animals, nature, and the outside world, real and virtual.
  4. To Be Your Best: To grow mentally and spiritually as a person; to use your skills to advise, to teach, to mentor; to display your talent and use it to entertain fellow residents; to
    find meaning in suffering, and to make disabilities and illness a teacher.
  5. To Reach Beyond: To find joy in serving others, to be part of resident council, of an advisory group that plans menus; to comfort those in pain and in hospice; to be a foster grandparent.

Heed what the residents, families, and staff say, and what they yearn for. Always honor their humanity. That will keep you on the high road in pursuit of life, liberty, and happiness.

V. Tellis-Nayak, PhD, is senior research advisor at NRC Health, Lincoln, Neb. He has been a university professor, whose scholarly work has been published in national and international professional journals. He has conducted research in the United States and abroad, and his major findings have reached a wider public through his writings in trade magazines. He can be contacted at

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Health Policy Change Coming in Waves, Ready or Not

700Patrick Connole

By now, early in the Trump administration, it is clear that any and all policies are up for grabs. But even as issues like immigration and border security can be altered quickly with the stroke of a pen on an executive order, the changes coming to the Affordable Care Act (ACA) and other health care rules and regulations will take longer to unravel—measured in months and possibly years rather than weeks because Congress must act first.

What these reforms will mean to long term care (LTC), post-acute care (PAC), and assisted living is of course not known. If anyone can figure out how Congress will replace the ACA, and what if anything they decide will be to the liking of President Trump, is beyond a betting person’s capabilities. But one expert in analyzing the LTC-PAC universe says even with D.C.-based changes looming, the attention of providers, especially PACs, should not waver from two fundamentals that will survive: to get your clinical house in order and to get your costs down.

This is because the march toward value over volume and the trend for hospitals to tighten their PAC networks is only going to continue, no matter who resides at 1600 Pennsylvania Avenue, says Shawn Matheson, manager for Leavitt Partners. That doesn’t mean, he notes, that Congress and the administration won’t overhaul existing CMS bundled payment and related demonstration pilots. What it means, instead, is that hospitals and managed care payers will be narrowing networks even if policy goes in new directions.

“In the rapid shift to value-based payments, many hospitals and medical groups are shifting referral patterns and creating PAC value networks,” Matheson says. “I see two main ways of change that have brought about these shifts for hospital-to-PAC referral patterns. The first wave began since fiscal year 2013 when the Medicare hospital readmissions reduction program began and the second wave, a much bigger and much more sudden one, began in April 2016 with the advent of Medicare’s Comprehensive Care for Joint Replacement bundled payment program.”

These policies helped put hospitals on alert to partner with top PAC providers, those that demonstrate high-value outcomes, low-cost spend, and clinical specialization in order to reduce readmissions, he says.

“Bundled payments are creating winners and losers in the PAC space,” Matheson says. “Referrals are going to the high-value providers that can demonstrate value, and those actively willing to work on lowering their length of stay.” There is an inherent risk and reward for a PAC provider participating in bundles in that decreasing your costs has to be offset by the volume of referrals from the hospitals,” he says. “The key is to get hospitals to compensate with volume,”

This is happening even as skilled nursing care centers are being left out of some of this planning in favor of home- and community-based care in many cases. The pendulum, Matheson says, will likely swing back to using PAC providers as the first site of care. This is because more and more anecdotal evidence is emerging that too many patients are coming back to the hospital from the home- and community-based settings who should have gone to PAC care first.

With much of the ACA being eyed by Republicans for replacement, there is still an expectation the pay-for-value movement will survive, albeit in some new forms.

“We think bundled payments will continue in the new administration. CMMI [Center for Medicare and Medicaid Innovation], for example, has significant statutory authority to test payment models. We feel like the Trump administration will use that authority to test the models that appeal to them,” he says.

“Indications are favorable for more state control [under the Trump administration], with states implementing programs through Medicaid system bundles and advanced payment models.”

With this attention to new payment models continuing, the onus will be on providers to state their case to acute care entities. The key idea, Matheson says, is it pays for PAC providers “to really reach out to hospitals, MA [Medicaid Advantage] plans, and managed Medicaid to build stronger relationships.” And with that outreach comes the need for hard, cold data showing real outcomes success in an efficient manner. “Data talks in this new environment,” he says.

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Our Humanity— The Ultimate Goal and Measure in Long Term Care: Part 1


V. Tellis-Nayak

V. Tellis-Nayak

The day’s surprise came in the sixth meeting of NRC Health’s marathon series of interviews with clusters of long term care (LTC) residents and families. Life-long experience had prepared my wife, Mary, and me to lead this study. Still, we had not anticipated that so many new twists on old truths would set so many neurons firing full cylinder.

The Resident Surrenders
The surprise came when Marcie, a wizened 94-year-old, narrated the story of her first days at her LTC community. She felt anxious when she first arrived.

“It was not long before I got into the new routine. It came easy, I lowered my expectations.”

Marcie’s words were an electric jolt. I wondered what maledictions would have rained down if trial lawyers, regulators, and advocates were here listening to Marcie? These critics bemoan that LTC communities run on institutional logic; they do not support resident autonomy. Residents all too quickly surrender personal choice. Institutional routine asks new entrants to sacrifice individual lifestyles.

Did Marcie lower her expectations, and thereby surrender her independence? For a true answer, we need to look beyond what advancing age does to our body and see how far, how wide, and how deep its effects echo.

Self-Demolition In Slow Motion
When aging signals, my body starts to fall apart. The self-demolition occurs in slow motion, it is relentless, it spares nothing. Old age disables the body, dulls the best talent, blunts well-honed skills, and clouds beautiful minds. Worse, it chips away my self-image. I desperately grasp at any symbol that prolongs the illusion that I am still self-sufficient and in control.

As I stumble along on my final lap, the prospect of LTC threatens to uproot me and make me spend my last days among strangers. LTC centers are modern-day public symbols of human life at its most undesirable. They broadcast to the world that I am on my last legs; I am of little value, am a drain on resources. My life has no purpose, has no meaning, is not worth living. Many elders try to escape the humiliation and take the exit through suicide, active or passive.

Victories Of The Spirit
The dread prospect that drives many to despair, paradoxically, is also the test that vindicates the resilience of the human spirit. Research offers many a glimpse into human fortitude that can ride out the roughest waves and into the human quest for transcendence in the meanest conditions.

Meditate on the wisdom that shines through in the following findings of good research.
One in four Americans spends some time in a nursing center. One in three dies there after a stay of two years. Two in five of the lucky ones who live to be 85 die in a nursing center.
The 100 elders in 15,000 nursing centers who each year die by suicide, make up a lower rate than the suicide rate for elderly in the community. Half of the nursing center suicides occur in the six months after admission.

Up to 40 percent of nursing center residents and their families rate their satisfaction as “excellent;” 2 percent rate it as “poor.” Their judgment correlates with the state survey

Residents and families praise the staff for their care and concern, for their respectful ways, and for making residents feel safe.

Most LTC staff are satisfied by the quality of their workplace. Their greatest joy is knowing they make a difference in the life of the elders. LTC staff turnover is lower than in many service industries.

Fantasy Versus Reality
Three significant themes run through these scattered findings. First, the image of LTC in the public imagination is a cruel caricature starkly contradicted by the testimony from residents, families, staff, and state surveyors—the most credible witnesses to quality at ground zero.

The negative stereotype adds to the fear and anxiety of many elders. It is particularly unfair to the caregivers who, day in and day out, allay the fears of frail elders and make them feel safe, wanted, and respected.

Although mediocrity dogs LTC, a second underlying pattern shows through. The kindness of staff touches residents and families so deeply that they take in stride the irritants of group living. They do not blame a kind caregiver; they see the rush, delays, and missteps as normal to the give and take of life.

Beth, a feisty centenarian uncovered yet a third truth when she responded to Marcie. “It is like getting married,” Beth said wisely. “You fall in love, you get married, and you fall into reality. Sharing your life with another curbs your independence. You love each other, so you make the sacrifice and live happily ever after.”

You Get What You Negotiate
Our survival instinct has taught us well: When you cannot control the wind, adjust your sails; let not the best be the enemy of the good. Elders know the survival strategy too well: In life, you do not get what you deserve but what you negotiate.

The human spirit is indomitable in its quest for happiness. It adapts, accommodates, compromises, and concedes—shrewd tactics hidden under the guise of surrender. Many fail to recognize the silent victories of human ingenuity.

V. Tellis-Nayak, PhD, is senior research advisor at NRC Health, Lincoln, Neb. He has been a university professor, whose scholarly work has been published in national and international professional journals. He has conducted research in the United States and abroad, and his major findings have reached a wider public through his writings in trade magazines. He and his wife, Mary Tellis-Nayak, have co-authored a book, “Return of Compassion to Healthcare,” which upholds humanity as the ultimate measure of success of any human endeavor. He can be contacted at

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