Assessing-Experts-Views-of-the-Future-of-Long-Term

://roa.sagepub.com/cgi/content/abstract/30/4/450Theonlineversionofthisarticlecanbefoundat:Publishedby:://roa.sagepub.com/cgi/alertsEmailAlerts::::):(thisarticlecites9articleshostedontheCitationsatUniversityofVermontonSeptember17,2008’ViewsoftheFutureofLong-TermCareEdwardAlanMillerBrownUniversityMarkBoothNewZealandMinistryofHealthVincentMorBrownUniversityConsensusisgrowingthatlong-termcaredelivery,regulation,andfinancingarenolongerviable,aconcernthatwillgrowmoresalientasthepopulationages.Tobetterunderstandtheseprevailingchallenges,theauthorsinterviewedexpertsregardingthecurrentstateoflong-termcareintheUnitedStates,theattributesofanideallong-termcaresystem,andpotentialareasforreform.Thefindingshighlighttheproblemofmaintaininganadequateworkforcedespitechangingdemographics.Theyalsoidentifycommonlyagreeduponattributesofanidealsystem—personcentered,professionallyrewarding,integrated,affordable,accountable,communitybased,andconsumerdirected—inadditiontolesscommonlyidentifiedattributes—supportive,comprehensive,dignified,culturallyappropriate,innovative,responsible,andsafeandsecure.Areasforreformincludeworkforcerecruitmentandretention,financingandinsurance,qualityimprovementandregulation,healthinformationtechnology,andorganizationalchangeandinnovation.Thechallengesfacinglong-termcaremustbeaddressedbybothgovernmentandprivatecitizensalikeiflong-termcarerecipients’livesaretoimproveandtheincreaseddemandforservicesistobemet.Keywords:long-termcare;financing;regulation;quality;values;qualitative;interviewsToday,anestimated10millionAmericansrequireassistancewithbasicpersonalactivitiesofdailylivingfromotherpeoplebecauseofeitherphysicalinfirmityorcognitiveimpairment(RogersandKomisar2003).Furthermore,closeto2millioncommunity-dwellingelderssufferfromfunctionaldependencies,cognitiveimpairments,andmedicalconditionsthatareonparwiththoseofthenation’s1.6millionnursinghomeresidents(Cigolleetal.2005).Butdespitethisneed,thereisagrowingconsensusResearchonAgingVolume30Number4July2008450-473©2008SagePublications10.1177/0164027508316607://roa.sagepub.comDownloadedfromMilleretal./Experts’ViewsofLong-TermCare451thatthewaylong-termcareisnowdelivered,regulated,andfinancedisnotacceptable.Indeed,thegrowingsalienceofreformishighlightedbyhigh-profilereportsreleasedbytheNationalAcademyofSocialInsurance(Burke,Feder,andVanDeWater2005),theWhiteHouseConferenceonAging(2005),thePresident’sCouncilonBioethics(2005),andtheNationalCommissionforQualityLong-TermCare(2006).Itisalsoreflectedincon-siderablegrowthinthenumberofarticlesaboutlong-termcareappearinginmajorU.S.newspapers.Fromjust1,533articlesreportedbyLexisNexisfrom1989to1994to7,681from2001to2006,therelevanceoflong-termcaretothegeneralpopulationhasclearlyintensified.Butalthoughrecenteffortshaveidentifiedthescopeandseriousnessoftheissuesinstatisticalterms,therehasbeenlittleefforttodeterminewhatanideallong-termcaresystemshouldlooklike.Indeed,mostextantinitiativeshavefocusedonpromulgatingsolutionstodiscreteaspectsoftheproblemratherthanidentifyingattributesthatshouldguidebroadersystemreform.Thepotentialbenefitsofdoingso,however,arereflectedinninegeneralprin-ciplesthatguidedtheInstituteofMedicine’s(2001)recommendationsonhowtoimprovethequalityoflong-termcare.Theseincludeestablishingsys-temsofconsumer-centeredcarethatservepeoplewithdiversecharacteristicsandpreferences.Theyalsoincludedevelopingmeasuresthatcanbeusedtoholdprovidersaccountableandthatrecognizethatlong-termcareisbothaquality-of-careandaquality-of-lifeissue.Otherprinciplesrelatetotheuseofreliableinformationtoaidconsumerdecisionmaking;themaintenanceofamotivated,capable,andsufficientworkforce;andtheimportanceofsustainedgovernmentcommitmentandongoingeffortsinthisarea.Inadditiontoqualityimprovement,guidingprinciplesmaybeusedtodirecteffortstoreformlong-termcarefinancing.ThisisreflectedinthreegeneralprinciplesunderlyingNationalAcademyofSocialInsurancerecom-mendationstoexpandthefederalfinancingoflong-termcare(Burkeetal.2005).Specifictenetsincludebasinglong-termcaresupportsandservicesonAuthors’Note:EdwardAlanMillerandVincentMorweresupportedbytheNationalCommissionforQualityLong-TermCare.MarkBoothwasaHarknessFellowattheCenterforGerontologyandHealthCareResearchatBrownUniversity.TheHarknessFellowshipissup-portedbytheCommonwealthFund,aprivateindependentfoundat