As CEO of Atlanta-based nonprofit A.G. Rhodes and LeadingAge board member, Deke Cateau knows that well-intentioned policies sometimes simply don’t work in the real world – and can even wreak havoc for nursing homes.
“If we have individuals … making critical changes to an industry that they do not understand, it’s dangerous. It would be like me making changes to the aeronautical industry, [advising] the plane needs to fly in this direction. Please, don’t get on that plane,” Cateau told Skilled Nursing News during an interview at the LeadingAge conference this week in Chicago.
Cateau also spoke about how the poor image of nursing homes interferes with sound policy making, including in how the federal government and lawmakers have proceeded with the proposed staffing mandate, ignored the very promising stream of immigrant nurses, and failed to pursue legal reform to diminish damages from sometimes unnecessary litigation.
He also spoke about the trend toward person-centered care – and how the current regulatory environment impedes its progress.
Mandate could harm quality, dementia care especially vulnerable
The staffing proposal put out by Centers for Medicare & Medicaid Services (CMS) is a clear example of this disconnect between well-meaning policy and real world problems, Cateau said.
“The mandate has taken on a political spin, which I’m fearful about … I don’t want nursing homes to become a political volleyball,” said Cateau.
The bad image of nursing homes has led to unnecessarily punitive policies, in Cateau’s view, as politicians gain an advantage if they are seen as going after a rogue sector.
“Nursing homes are seen as the wild, wild west – that tone, I think, is very unfortunate. And it’s wrong. The wild, wild west is in DC … in some senses, we are an over-regulated industry,” Cateau argued. “The big issue I have with [the staffing proposal] is that there’s an assumption – that I believe generally is held publicly – that nursing homes want to staff at low standards … I’ve never met an owner that does not want more staffing.”
The unrealistic expectations of the staffing proposal – if it goes through in its current form – will likely lead to nursing homes being issued waivers, Cateau said. At that point, when it becomes obvious how impossible the mandate is to meet, more reasonable solutions might become reality.
Two particular flaws in the staffing proposal relate to the lack of supply of nurses generally, and more specifically registered nurses (RNs).
“The supply is not there. Any rational person looking at the mandate would tell you it’s not there,” said Cateau. “There are counties in this country that have zero registered nurses.”
And moreover, Cateau said, policy makers perhaps also ignored a key facet of care at skilled nursing facilities – dementia care. Nursing homes routinely care for a large population of dementia patients. These individuals are best served by direct care delivered by certified nurse aides (CNAs) and licensed practical nurses (LPNs), while RNs typically facilitate the pharmacological treatment of dementia.
“Every piece of evidence, empirical and otherwise, has shown that proper dementia care does not point us in the pharmacological direction. Medications are not helping [dementia patients]. What we need is more care and care closest to the resident,” Cateau said. “The mandate’s focus on registered nursing care, from that perspective, does not make much sense to me … Most of our population will need care closer to them, which means CNA and LPN care – yet the mandate strongly focuses on the registered nurse component.”
Strains on person-centered care
In fact, if the staffing proposal goes through, nursing homes will have to pivot away from more direct care provided by CNAs and LPNs in order to fulfill the RN requirement – a travesty with large ramifications in Cateau’s opinion, especially for person-centered care.
“[Resident family members] will tell you about those meaningful relationships with the individual who’s taking care of their loved one. And oftentimes, it’s the CNA. They see the residents at their most vulnerable points. They take care of them through their activities of daily living, socializing with them, bathing them, taking care of their personal needs. That’s a relationship that we cannot – through a mandate – reduce,” said Cateau.
The trend toward person-centered care, which focuses on improving dignity for residents in long-term care, is rising, but can be compromised by misdirected regulation that encourages litigation. Government policies often interfere with the delicate balance nursing homes are trying to strike with providing a home-like environment amid increasing levels of acuity.
“We are the home that the individual lives in, and we require and provide home-like care. And I understand that nursing homes over the years have changed. We have nursing homes that take care of critical individuals clinically, but I do not think that was ever the intention when nursing homes were developed. So if I look at it from a traditional perspective, the mandate does not make sense,” Cateau said.
Besides clinical care, the staffing mandate will also compromise other areas of care that indirectly impact health outcomes, Cateau said.
For example, the music and horticulture programs at A.G. Rhodes have been “revolutionary” and have been funded through private philanthropic efforts, and these might have to fold, said Cateau.
“I could easily see these programs going away and being pivoted in order to pay for that 24-hour RN expense,” he said. “That would be a very dangerous thing. Because those programs I’ve seen have kept individuals alive, made people flourish, made people thrive.”
Smarter immigration policies
For Cateau, to fulfill the workforce gaps, immigrant nurses are a very viable pool of untapped labor.
“We could try everything we want to, but the reality is that we don’t have the supply, and the only way to get that supply is from outside,” he said.
But as with nursing home policies, the proposition to get immigrant nurses is a casualty of politics, in this case, the public’s perception of illegal immigration.
“We have a very broken system where immigration has become associated with border crossing,” said Cateau. “We’re not talking about illegality here. We’re talking about sound immigration policy, which this nation was built upon.”
With rising acuity, Cateau said that something will have to give in order for nursing homes to play the role of being both a home and a place to accommodate a sicker population.
And that change might require reducing government oversight in the United States along the lines of Europe, which accords its nursing home sector greater autonomy.
“We’ll move further down that post-acute scale [and] we need to understand that we don’t work on the same financial mechanisms of a typical industry. But that would mean retooling the very regulations, the very expectations, if that is going to be the role of nursing homes,” Cateau said.
And the move towards person-centered care – which Cateau deems is the right way to care for an aging population – requires a shift in mindset from both the public and lawmakers. That’s because regulations currently are far too restrictive and directly or indirectly govern nursing home residents’ lifestyles and medical decision making, including the timing and manner of their death. He believes “huge philosophical conversations” are needed.
“[Real] homes don’t have regulations, let’s be real, let’s be honest. And that’s the whole basis of the person-centered care movement,” said Cateau. “It’s allowing individuals to live their life the way they would want to live, given choice … And regulations by description, they affect autonomy.”
Companies featured in this article:
A.G. Rhodes, Centers for Medicare & Medicaid Services, LeadingAge
