Steven Littlehale

Returning from an early morning walk down to the harbor of this sleepy Cape Cod town, it’s hard not to feel hopeful. My geriatric pups Melvin and Theodore couldn’t get enough of the sea smells and feel of the sand under their little Shih Tzu paws.

This distinct sense of hope has carried over from the American Health Care Association’s Congressional Briefing earlier this month, where several hundred owners, operators, clinicians and passionate advocates assembled to take our message to Capitol Hill.

The goal was to displace the negative long-held beliefs about aging services, and the idea that more regulations by people, some of whom have never entered a skilled nursing facility, is the answer.

Armed with data and a palpable passion for quality eldercare, we took to the streets, or more specifically, the Hill, to meet with elected leaders to tell our story. In our data-driven, evidence-based society, this seemed like the right approach.

Our outcomes data tells a positive story about quality improvement, deep personal reflection, and a continuous effort to do better. It highlights that average or even above average is never good enough for our facilities or those we serve.

It’s a gratifying story. You should feel proud, I told myself … and yet I couldn’t help but wonder if we were looking at the right data and telling the right story.

We measure it because we can. CMS’s quality measures, PointRight’s Pro30 rehospitalization metrics, etc. are all National Quality Forum endorsed and, of course, this is a very good thing. These very same metrics are used by payers, regulators and consumers alike. They are incorporated into CMS’s Five-Star ratings and we generally accept them as proxies for what our patients and residents value. And this is where the story, at least for me, starts to fall apart.

Are we measuring the right thing? I struggle connecting some of these outcomes, such as mobility decline or many of the other CMS quality measures, with what I hear from residents and patients in SNFs. Some talk about being respected, the quality of the food, whether caregivers like them, and having their call light answered in a timely manner. Others want to return home ASAP. I have not, however, heard a resident or his/her proxy ask about urinary tract infection or weight loss rates.

As a clinician I know, and you know, that these rates tell an important story, and we should monitor and improve them, but are they telling the most accurate story to represent the voice of the resident? Are they really going to sway public opinion about SNFs? And can someone explain why we seem to be the only segment of healthcare without a mandated standardized satisfaction survey?

The evening prior, renowned reporter and author Carl Bernstein reminded conferences attendees to “follow the money,” the implication being that when you do, you’ll find truth. OK, perhaps not the truth, but insight into your question.

Taking Bernstein’s advice feels somewhat cynical, but this exercise has historically revealed agendas or other influencers. It sure gave me great clarity into the new Patient Driven Payment Model when I was reviewing the proposed final rule!

So where does the money that will ultimately change the opinions of the public and our elected leaders about the quality of care delivered in SNFs lie? In the pockets of a new audience akin to Madison Avenue. Once the Boomers “come a-knocking,” they will reject, well, pretty much everything, forcing all aging services to rebrand. Madison Avenue will be poised to cash in by turning aging into something honored, glorified, revered and, yes, even sexy. I can see the commercials now featuring one of our cherished Hollywood personalities like Sally Field or Diane Keaton walking through the doors of our rebranded facility (which, of course, will not be referred to as a nursing home).

Ultimately, public perception will catch up to the many examples of excellence we demonstrate through our data, and eventually we’ll learn how to broaden our measures to include outcomes that speak directly to our patients and residents. As I remember the passion and confidence demonstrated by my colleagues at the conference, who know they deliver excellent quality care, the gentle sunlight of my early morning walk deepens its intensity, and my conviction that we will prevail deepens right along with it. 

Steven Littlehale is a gerontological clinical nurse specialist, and executive vice president and chief clinical officer at PointRight Inc.