Medical Direction and the Future of Assisted Living

Those who recognize the issues facing long-term care as being systemic will deal with them systematically. Not by trying to alter the environment, but by accommodating to it. And we’re talking here not just about nursing facilities. The challenges facing assisted living are equally daunting. Yes, it is true. Assisted living has enjoyed an almost meteoric rise in public acceptance and utilization. Almost too much so. Its popularity in the long-term care marketplace was such that, for a brief period, supply of the product clearly exceeded demand. Occupancy levels dropped precipitously. And many companies and individual facilities were tossed onto the dustbin of economic history.

But the beauty of free enterprise is that markets do self-correct. Indeed, bankruptcy is very therapeutic (except, of course, for those actually immersed in Chapter 11). It adjusts price, supply, and demand almost painlessly (again, other than for those for whom the pain is very immediate and personal). So, why worry? Well, to understand why you should worry, you have to delve just a bit into the history of assisted living. You have to understand the genesis of its popularity. Yes, assisted living did attract a following among those looking for more palatable long-term care services. But were we really seeing acceptance on the part of seniors (and their families) of assisted living as their product of choice? Or is it more likely that assisted living was seen simply as the lesser of two evils when compared to nursing homes?

Like it or not, what we might really be talking about here is an overwhelming popular aversion to facility-based care, no matter what the setting. Say what you will about public perceptions of nursing homes, the average senior’s aversion stems less from the issue of facility quality than from an unwillingness to confront the realities of aging. A facility whose primary purpose is to deal with the frailties and illnesses accompanying aging is not likely to be embraced by its customers. Forget what it’s called. Assisted living facilities are, after all, not all that different from nursing homes in terms of their customers’ frailty.

I’ve taken my share of brickbats for having offered some years ago a definition of assisted living as “a nursing home with a chandelier.” But the phrase was never meant to belittle assisted living. Rather, it is simple shorthand for the reality that assisted living facilities deal with exactly the same residents as did the nursing home of yore (then called an intermediate care facility [ICF]). Thus, my description of assisted living facilities as “nursing homes.” While assisted living facilities have had to attract residents in a highly competitive market, nursing homes did not—thus the “chandelier.” The customers remain the same—the same level of activities of daily living (ADL) dependencies, the same incidence of cognitive impairment. While preferring the ambience of assisted living over the institutional flavor of the traditional nursing home, most customers still see assisted living for what it really is: a healthcare provider whose purpose lies in caring for the elderly and the needs attendant to aging.

Today’s assisted living resident, has, indeed, become the nursing home resident of yesteryear. The Assisted Living Federation of America’s recently published 2006 Overview of Assisted Living¹ clearly demonstrates the increasing acuity of assisted living residents, while a comparable article by Frederick Decker² at the National Center for Health Statistics shows equally significant changes in the characteristics of nursing home residents. The implications for the future of assisted living stemming from this mutually reflective “morphing” are significant. Assisted living is no longer “hospitality” (assuming it ever was). It is healthcare, pure and simple. Admittedly, it’s healthcare with a difference. Its focus is on the continued independence and empowerment of the customer. But that’s the environment in which services are provided, not the essential nature of the services themselves.

Staff members in assisted living strive to maintain a customer focus; however, that speaks to personal, not professional qualifications. One can dress a wound while paying attention to a customer’s unique and personal desires, interests, and needs, but you’re still dressing a wound and need to have the qualifications that enable you to do so competently. So, where will this new and more professionally qualified staff come from? Probably from the same inadequate pool used by nursing homes to fill their positions. And that doesn’t look promising. Nor is the problem limited to any particular segment of the healthcare workforce. The workforce shortage extends across the entire breadth of function and career, across programs and professions. But let’s focus on the apex of geriatric care—the board-certified geriatrician. Certainly, the need for geriatricians is indisputable.

A report in 2002 by the Alliance for Aging Research³ put some pretty stark numbers on the table. The 9000 trained geriatricians in practice constituted, even then, less than one-half of the 20,000 needed. And, given the geometric growth in America’s elderly population, the 20,000 needed in 2002 will balloon to 36,000 in 2030. Worse yet, the numbers of geriatricians in practice are actually diminishing—and dramatically so. Estimates suggest that there were 1500 fewer certified geriatricians practicing in 2004 than in 2002, a decline of over 15% in just two years.⁴ What does this have to do with assisted living? There is, after all, no regulatory requirement today that assisted living even consult with (much less employ) trained geriatricians. There is not even a requirement for medical direction, at any level of qualification. But given the increasing acuity of the assisted living resident, just how long will (or should) that last? If assisted living does not itself enhance its access to trained medical direction, the states will ultimately do it for them.

As I review the literature regarding the need for more medical direction in assisted living, I’m reminded of Don Quixote as he sets forth on his quest through the Spanish countryside with his trusted companion, Sancho Panza. Readers of Cervantes’ great novel will remember: Don Quixote’s delusions are many. As he attempts to combat the world’s injustices, his imagination transforms windmills into giants, flocks of sheep into enemy armies, and country inns into castles. And, true to the chivalric model, Don Quixote dedicates his actions of valor to a noble love, whom he calls Dulcinea. So, where’s the parallel here? One, certainly, is the injustice of having an increasingly frail long-term care population desperately in need of a dwindling supply of expert medical care. This windmill is indeed a giant, and a formidable one at that.

Another parallel might be the Don’s romantic dedication to Dulcinea. Those who have spent their careers tilting at the windmill of physicians’ inadequate geriatric training display all the nobility of Don Quixote, as they continue to dedicate their energies to upgrading quality of care in America’s long-term care communities. But I fear there is a less encouraging parallel here—one that reflects the real focus of Cervantes’ novel: the often frustrating dialogue between idealism and realism. Our struggle to facilitate the growth and involvement of trained geriatricians in resident care is idealism at its very best. And it flies in the face of anyone’s definition of realism. Certainly, the need for geriatricians is indisputable. The available data is stark enough. But, it gets even worse. We don’t have sufficient numbers of academicians necessary to train even those few medical students who might have an interest in the field.

The Institute of Medicine suggested a conservative need for 2400 academic faculty trained in geriatric medicine.⁵ We have 900. While 75% of the nation’s medical schools offer elective courses in geriatrics, only about 4% of medical students actually take them. And, while 40% of medical residencies offer elective geriatric rotations, again, few residents avail themselves of the opportunity.⁶ (And forget about established programs of geriatric medicine—at last count, only 12 existed in the entire country (four of them in schools of osteopathic medicine). Yet, in the face of this stark reality, recommendations offered by the vast majority of professional associations interested in the problem simply echo the Institute of Medicine that we “develop the capacity to train academic geriatric leaders who will, in turn, train sufficient numbers of physicians (geriatricians and primary care practitioners) to care for our growing population of the aged.”⁵ Way to go, Don Quixote! Way to go, Sancho! Let’s get back to reality. If we in long-term care are going to meet the need for expert medical direction in the field, we need to understand the underlying causes and cure of the supply problem, and not simply “tilt at windmills” with bromides and half-hearted solutions.

We already know the nation “would benefit from an increased supply of geriatricians.”⁴ What we need to know is why medical schools don’t create them. Ask any physician and you’ll get one answer. Ask any student of American medicine, and you’ll get another. And both will be right. Let’s start with the physician’s response: “It’s all about reimbursement.” There is little question that Medicare reimbursement is the single most influential economic force shaping medical practice in the United States, accounting for 27% of all physician income in 2000. Healthcare in this country is not a function of patient need, it’s a function of financing! Because geriatricians limit their clinical practice to older adults, most of their compensation comes from Medicare—and, unfortunately, many of the time-intensive services that geriatricians provide are not adequately reimbursed.

The growing gap between Medicare reimbursement and the actual costs of delivering geriatric care seriously affect the willingness of young physicians to consider careers in this field. And who can blame them? What about our answer from the student of American medicine? Well, he/she might suggest that geriatric medicine is out of tune with the core philosophy underlying American healthcare—the focus on “healing.” American medicine is oriented toward improvement, not decline. But aging is, more often than not, a graphic and sobering reflection of decline. As Vander, Sherman and Luciano⁷ have suggested in their Human Physiology: The Mechanisms of Body Function, aging is “a gradual deterioration in function and the capacity of the body’s homeostatic systems to respond to environmental stresses.” Deterioration? Not the stuff American medicine is made of. And certainly not the stuff to entice American medical students into geriatrics. There is nothing to be ashamed of in either of those responses. What is discouraging is the propensity of many to assume that those two barriers can be easily overcome by “simply expanding capacity.” But, how? I, for one, think we are dealing with systemic barriers that are not easily surmountable.

Reimbursement for geriatric care has not kept pace with the increasing complexity and volume of cases. Is that really likely to change? I served for 13 years in senior positions (including Deputy Administrator) at the Health Care Financing Administration (now Centers for Medicare and Medicaid Services). My advice is: “Don’t hold your breath.” Between 1999 and 2002, total compensation for geriatricians in private practice increased by all of 3.1%―that’s 1% per year—the lowest percentage increase over that period among the 12 specialties surveyed by the Medical Group Management Association. As for the optimistic medical philosophy of American healthcare professionals—the emphasis on the possible rather than the inevitable—I’m not at all sure we can (or even should) attempt to change it.

While it has, perhaps, worked at cross-purposes with the need to grow more geriatric practitioners, it has been the stimulus for much of the innovation for which American healthcare is justifiably famous. So it is time that we stop tilting at windmills and rethink the essential configuration of medical oversight and management in today’s long-term care community. That doesn’t mean supplanting the medical director or substituting for him/her. It simply means recognizing the fact that we might never achieve the goal of filling the unmet need for trained geriatricians, that attempting to do so simply directs our energies toward activities that are likely to be unsuccessful and away from those that might prove fruitful. If we can’t fill the gap with trained geriatricians, let’s better support those we have. To me that means augmenting the supply and use of advanced nurse practitioners—not as a substitute for medical direction, but as an enhancement of it.

Let’s utilize our dwindling supply of geriatricians in roles for which they are uniquely qualified: to lead the geriatric team; to consult on the critical healthcare issues that only the trained geriatrician can handle; to delegate much of the day-to-day care to non-MDs and non-DOs. To focus their specific expertise on those problems that actually require it. And let’s provide the requisite training to colleagues who will work under the direction of the geriatrician as he/she leads that team. There’s really nothing new about the concept. It has its counterparts in physician assistants and pediatric nurse practitioners, who have been around for some years now. In geriatrics, admittedly, the phenomenon is of more recent vintage. Until ten years ago, a nursing focus on the care of older adult patients was sadly lacking. At that time, less than 1% of the 2.2 million practicing registered nurses were certified in geriatrics; less than .002% of registered nurses were geriatric nurse practitioners or clinical specialists; only 23% of nursing schools even had a required course in geriatrics; and 60% of baccalaureate nursing programs had no geriatric-expert faculty.⁸

By 2003, on the other hand, 92% of baccalaureate nursing programs reported that gerontological content was integrated into one or more courses in the curriculum, a remarkable increase from the 63% of schools reporting integration of gerontological content in 1997. Further, many schools that had stand-alone classes in gerontological nursing made them required courses instead of electives.⁸ Progress! Yet, the above notwithstanding, there are still only 3500 certified advanced practice nurses in geriatrics. That’s almost half the number of trained geriatricians, but still woefully inadequate. We need more (but, unlike geriatrics, can actually generate more) as we tackle the problem of enhanced medical direction in long-term care. In a nutshell, we’re talking here about both improved quality and reduced cost—not at the expense of the physician, but collaboratively with him/her. When it comes to geriatric care, increasing use of the GNP combines the best of both our idealism and our realism. And knocks down a few windmills in the process.

The author reports no relevant financial relationships.