Top aging care experts on Thursday floated a vision of regional centers of experts affordably advising seniors and their families on where to continue their healthcare upon discharge from a hospital.

In their ideal scenario, dedicated offices and their staffs would be supported by a combination of public, private and employer-based money. It would reflect a long-term healthcare industry that has the patient’s best interest at heart, even if it means recommending care at someone else’s facility.

This scenario was presented in a report released Thursday by Nexus Insights, a think tank advancing the well-being of older adults through innovative models of housing, community and healthcare. 

“Where Am I, Where Do I Go: The Missing Entry Point to Long-Term Care Solutions for Older Adults and Their Caregivers” sprang from a week of discussion among an elite group of industry stakeholders in February 2022. Included in the host committee besides Nexus Insights founder Bob Kramer were: David Grabowski, PhD, Harvard Medical School professor; Caroline Pearson, senior vice president of healthcare strategy, NORC at the University of Chicago; Sarah Thomas, CEO of Delight by Design/MezTal; and Anne Tumlinson, CEO of ATI Advisory. Some 20 other key stakeholders either took part in the event or were interviewed before it.

The report lays out a blueprint for both policymakers and the private sector that is the product of eight months of work. It addresses “the current challenges that older adults and their families face in finding and understanding the resources and supports available to them and to identify ways to help them access those programs and to identify potential elements of a navigation support system.”

Kramer said the report’s ideas are urgent because the country’s main public sources of healthcare funding — Medicare and Medicaid — are moving from volume-based to value-based.

Robert G. Kramer headshot
Nexus Insights founder Bob Kramer

“Skilled nursing more than ever has to recognize it’s not about fighting to get people to come to their setting and holding on to them as long as possible so they can bill as much as possible. It’s rather demonstrating they’re very much part of a larger continuum and for many skilled providers that means an opportunity to think about their customer and resident in a much broader sense than when they’re in their building,” Kramer told McKnight’s Long Term Care News Thursday.

Insurance plans for seniors have an incentive to break what Kramer calls “the vicious cycle” of people getting caught in a revolving door into hospitals and ERs.

“They also have an incentive to make sure that people are getting the right care in the right place at the right time,” he said.

He said an example of the all-too-common nightmare the report is calling attention to is: 24 hours before a hospital discharge, the hospital gives the patient and their family a list of places to go to, with only a day to choose.

“They don’t know what they need, and the family is in a panic,” he said. “What does Mom really need?”

Breaking down walls

Kramer suggests that part of the current challenge begins with a siloed point of care system.

“If they’re interested at all in the transition, it’s only to say, ‘Well, we found a bed for Mrs. Jones,’ but they’re not there to counsel the family, to say, ‘This is what you need to expect over the next six to 12 months, this is the kind of help and support you’re going to need, this is the kind of setting, therefore, that you may want to consider,’” Kramer said. “There’s nobody there doing that.”

He related a story of a friend whose mother entered a skilled nursing facility from a hospital and within two days had calls from three officials: a care coordinator from the discharging hospital, a Medicare Advantage representative, and a staff member from the facility where she was.

“All three gave conflicting advice and it was clear they never talked to each other,” he related. “Absolutely no coordination. How are we supposed to know what to do when three experts tell us three different things?”

Skilled nursing providers should concentrate on the fact that potential residents need better guidance, and if that guidance means the patient may not stay at their facility, that’s a better outcome for the industry overall.

“Ultimately, the skilled nursing provider will win if they are seen as having the best interest of that patient at heart, and not desperately wanting them in their building and staying as long as possible,” said Kramer. “You have not only knowledge but you’re connected to all parts of the continuum and committed to Bob’s mom getting the right care at the right setting at the right time, and it may not be your building.

“Yes, there’s a time and a place for her to live with us, but our common goal is to keep her from bouncing back and forth to the hospital. and we want to break that vicious cycle of the revolving door of the ER and the hospital where each time that person comes out weaker and with a lower quality of life.”

Public, private-pay and employer-based programs must work together by combining their infrastructure, experience and delivery models, he added

“Employer-based options have a lot more promise because they’re much more customized, personalized and patient centric,” he said.