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BOOK REVIEW |
Department of Sociology and Gerontology/Scripps Gerontology Center Miami University Oxford, OH 45056
Scripps Gerontology Center Miami University Oxford, OH 45056
Managing Long-Term Care, by Connie J. Evashwick and James Riedel. Health Administration Press, Chicago, IL, 2004, 228 pp., $68.00 (cloth).
The Continuum of Long-Term Care, 3rd Edition, edited by Connie J. Evashwick. Thomson Delmar Learning, Clifton Park, NY, 2005, 459 pp., $78.95 (cloth).
Thirty years ago, the book Last Home for the Aged (Tobin & Lieberman, 1976), based on the premise that once a person was admitted to the nursing home it was his or her final place of residence, was required reading for graduate students interested in long-term care). A review of recent research done in Ohio, which mirrors national trends, paints a very different picture. After three months, 46% of all those admitted to Ohio nursing homes remained as residents; and, after six months, just over 30% remained in the facility (Mehdizadeh, Nelson, & Applebaum, 2006). The "last home" has become a short-term, rehabilitation facility for the majority of those admitted. These shorter-term stays, lower occupancy rates, and other changes in nursing homes have been coupled with a dramatic expansion of assisted living facilities and in-home service programs, making long-term care a different entity than the one written about three decades earlier. Rapid changes in the system, combined with dramatic demographic shifts, means that long-term care has become a large, fragmented, and diverse system, with varying goals and responsibilities. Today, long-term care is difficult to even define, making questions about how to manage such a system fraught with difficulties.
The two books reviewed in this essay do a good job of identifying the complex components of long-term care. Questions about financing, staffing, quality and regulation, environment, coordination and integration of care, structure, family involvement, ethics, leadership, and management are examples of difficult issues that need to be addressed in thinking about organizing and delivering long-term care. Each of these issues presents considerable challenges for policy makers, organizations delivering services, and consumers.
What Is the Financing Strategy?
Many of those challenges arise from the fact that the financing strategy in long-term care happened by default, rather than by plan. Unlike acute health care, which, despite its substantial problems, does have a philosophy that employers have a responsibility to provide health insurance, the financing of long-term care has never been based on a specific philosophy or strategy. Medicaid, which did not even cover the nursing home intermediate care benefit when it was first passed, now pays for almost two-thirds of all residents. Long-term care expenditures under Medicaid, which include both nursing homes and home and community-based waivers, have become one of the largest line items in the majority of state budgets. Ironically, this rigorously means-tested Medicaid program results in older people, most of whom had never received welfare assistance, living their final years as wards of the state, while at the same time creating a financial hardship for most states and bringing criticisms from providers about inadequate funding. So, the program does not appear to be working well for any stakeholder group today, and—because of projected demographic patterns and cost increases—it appears to be unsustainable in the future.
Workforce Issues
Another challenging issue discussed in these two books involves workforce. Long-term care is labor intensive with most consumers needing personal assistance. The work is often difficult and is typically provided by workers with limited educational experience and training who receive relatively low wages and limited employee benefits. Documented turnover rates of long-term care workers range between 45% and 100%, varying by setting, region, target population served, work structure, and wages and benefits (Stone & Weiner, 2001). Competition for workers across various sectors of the service economy creates further staffing challenges. Shortages of nurses, especially, add to the array of workforce issues faced in the long-term care arena.
Other Challenges
Quality and regulations, integration of care, culture change, and numerous other issues round out the topics discussed in these two volumes. Both books do an admirable job of describing long-term care and the multitude of challenges faced in making such a delivery system work. And herein lies the paradox in these books designed to improve long-tem care management. On one hand, many of the problems faced in managing long-term care are outside of the spectrum of management. An irrational plan for financing, inadequate support for workers, bad regulations, funding and quality monitoring systems that focus on providers rather than consumers, and uncoordinated service systems are not individual organizational problems and thus require systemic solutions. It is our diverse and disconnected funding sources that are most responsible for our fragmented, fractured system of health and long-term care. As The Continuum of Long-Term Care, by Connie Evashwick notes, well over 80 federal, state, and local programs finance health and long-term care in America, and this does not count private insurance. Many administrators and managers know how to assemble a comprehensive, integrated continuum of care, they just can't figure out how to cover it financially because of the tangle of regulatory and private- and public-sector health insurance.
On the other hand, even within the constraints of the current system, there is wide variation in the quality of long-term care providers. How are some organizations able to experience very low turnover, while others operating under the same financial and regulatory circumstances are not? How have some organizations been successful in empowering consumers to make decisions about the services and supports received, while others do so minimally? The answer, to some degree, lies with leadership and management.
Thus, we are left with a difficult balancing act in looking at these books. We need to recognize that system constraints are huge and that long-term care will never be a model system until the overall issues are addressed. However, there are many management tools and strategies that can and should be addressed that can improve current efforts.
Management and Leadership
If we believe that management and leadership can make a difference, then these books make an important contribution, particularly to students of long-term care. While administrative experience, especially regarding management, is critical, Managing Long-Term Care, by Connie Evashwick and James Riedel, provides a comprehensive, concise, and coherent look at management that should prove valuable to those preparing for long-term care oversight in a rapidly changing, increasingly complex environment.
While the clarity of the writing makes Managing Long-Term Care all the more inviting, the apparent complexity and enormity of the skills needed for good management in long-term care settings—as put forth in the introductory chapter, "Leadership and Management"—may cause some students to wonder what they have got themselves into before entering the reassuring chapters that follow. In the introductory subsection termed "Management Competencies," the authors share 10 somewhat daunting but valuable competency areas deemed essential for administrators.
Each chapter opens with a thought-provoking quote (Einstein's "It has become appallingly obvious that our technology has exceeded our humanity," for example) usually followed by a vignette posing a hypothetical dilemma related to the respective topic. Each chapter closes with a summary, bulleted key points, a set of review questions, and a list of references. As a teaching tool, the text looks like it will work nicely.
For those experienced in management but new to long-term care, the book includes an excellent overview on the subject, detailing the broad spectrum of services and types of facilities involved. The authors provide a clear assessment of the problems inherent in managing a system characterized by fragmentation in its services, funding sources, and regulations. They illustrate the point clearly, outlining a variety of services along with their respective funding sources, typical costs, accreditation agencies, and staffing components. They also add a helpful sidebar listing major pieces of federal legislation pertaining to aging services going back to the Social Security Act of 1935.
The authors cover a lot of territory in the book, but they might have added a nice touch to their work with a section exploring the basic distinctions of profit versus nonprofit health-care operations and elaborating on how these differences may affect management styles and decisions.
An Overview of Long-Term Care Components
The Continuum of Long-Term Care, in its third edition (which includes new chapters on "Disability," "HIV/AIDS," and "Quality"), presents a comprehensive review of many of the components of long-term care discussed earlier. The book, composed of 23 chapters authored—or coauthored—by no fewer than 39 individuals, provides concrete information about the components of the long-term care continuum. But, as might be expected with such a number of authors, there is some variation in quality across the book. The goal of the book is to offer an in-depth introduction to long-term care services for undergraduate and graduate undergraduate students pursuing interests in health care administration. It is not so much management information offered by the book as information on the various aspects of health care necessary for management in the field. For those teaching about long-term care, this is a book worth using. The text offers a tremendous resource and reference manual to students and others looking to obtain a stronger, detailed grasp on the many aspects of long-term care.
A warehouse of information is sandwiched between the covers of this book, and it is presented with a unifying format wherein every chapter contains a conclusion, client example, facts review, and reference section. Additionally, the text offers appendices including a timeline of federal legislation pertinent to long-term care and a directory of health-care and social organizations useful to offering a continuum of care and any special services that may be needed along the way.
Both books do a nice job of describing long-term care. If there is one criticism that cuts across the two books, it would be that they are written from a "provider perspective." There is very limited focus on consumer involvement, consumer-directed services, culture change in long-term care, and other reform efforts that have emphasized the consumer's role in long-tem care.
Long-term care is indeed the interface between health and social services, and, as such, it includes many services about which consumers can and do have opinions. Institutional long-term care has its roots in the almshouses, county poor farms, and in health-care settings. Not one of these institutions has a strong history of consumerism. We will not have high quality long-term care in any setting until we learn how to make sure that the system is designed for—and gains from—continuous feedback from consumers.
Those looking to serve as managers and administrators in long-term care settings would, ideally, do well to have a basic understanding of the information and principles of both texts—one primarily for management and management techniques, and the other for a broad understanding of the complex components to be managed and how they at times may come together as a whole in the best interests of care for the individual.
References
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