Dr. Daniel Haimowitz, CMD,
an internist and geriatrician
in private practice in Levittown, Pa.,
where he serves as medical director
of two nursing homes and two
assisted-living facilities, as well as
a program of all-inclusive care for the elderly:

Many of the issues of 2012 will be as those of the past 2 years, of course. Some of those and other things I hope might happen this year:
► Progress delineating nursing home physician “specialists”: What makes physicians who take care of nursing home patients unique, qualified, and valuable and, by extension, what is the particular value to nursing homes of medical directors with CMD certifications?
► Continued focus on money, especially as affected by the 30-day rehospitalization rate among nursing home residents in postacute care ACOs and their inclusion of LTC, and PACE (Program of All-Inclusive Care for the Elderly) programs and their medical directors.
► More attention on improving medical care in assisted living (AL). AMDA is restarting its AL committee, and national AL organizations seem more willing than ever to look at preventive care and keeping residents out of the hospital.
► Transitions of care as a priority, and not just with a hospital focus. Groups will try to get together to gather available resources and then fashion what works for them.
► Increased use of technology.
► Continued increase of nurse practitioners in LTC.
► I agree that antipsychotic use will be a focus, at the very least because of the government’s concerns. What I’d like to see is help for nursing homes to do a better job at educating staff about non-pharmacologic treatment of behavioral issues; improving communication about this between staff and physicians; and improving documentation of what the behaviors are, what has been done in the past, and what the plan will be.



Pamela Chapman, DRS, LCSW,CTRS,
an adjunct faculty member at
MiraCosta College in
Oceanside, Calif.:




► The funding of LTC seems to me to be of the utmost importance with the rapid graying of America and the state of our budget. We need to identify viable options for LTC for the poor and middle class. The government recognizes its inability to pay for LTC with Obamacare, so an exploration of other alternatives seems crucial.
► The improving of technology and the advancement of supportive services to allow people to age in place seems to be increasing at a rapid pace. I have a special interest in the village movement. I think that in the next decade, it will have a huge impact on the way we age.
► A longstanding concern of mine has been the number of skilled nursing facility residents who are there because of funding issues vs. true need. An issue that I think we need to address is ways to have Medicaid pay for less-restrictive and less-costly levels of care for those who are truly in need.



Bill Kubat, MS, LNHA,
director of mission integration
for the Evangelical Lutheran
Good Samaritan Society,
Sioux Falls, S.D.:



Once again, my perspective on the top LTC issues for 2012 is that of a non- clinician, having had management roles in a provider organization that serves the full continuum of LTC services.
► Health care reform and regulatory implementation: The 2012 election will have an impact on implementation, as will the change of leadership at the CMS as Don Berwick resigns. But reform will continue even though there is much to be negotiated. The Supreme Court’s ruling on the constitutionality of the Patient Protection and Affordable Care Act will come right in the middle of the presidential campaign. How the leadership transition at the CMS will affect the development of new models of payment and delivery and what those will mean for LTC remains to be seen.
► Seemingly, the Department of Justice, the CMS, and its Office of Inspector General are gearing up with more legal tools to find and punish fraud, waste, and abuse, which will mean more scrutiny on providers across the health care continuum. There will be increased focus on preventable medical errors, substandard care, and inadequate patient monitoring and assessment (remember MDS 3.0?).
► Reimbursement: There are so many issues here with Medicare and Medicaid cuts. For physicians, plans to repeal the Sustainable Growth Rate (SGR) formula will have massive implications for primary care physicians – and thus a huge impact on LTC – and their relationships with specialist partners and efforts to streamline care via more integrated care delivery models. Staffing pressures on LTC will be exacerbated by reimbursement cuts demanding manpower reductions and/or reduction of staffing levels and/or limits on salaries and benefits. For some LTC providers, the reimbursement cuts will strain efforts to implement electronic health records.
► New models of care delivery: Three key words here are ACOs: Who becomes one, how will they ultimately be defined, what role will LTC providers play, and how will service integration be optimized, given many issues being named here? A related issue will be heightened focus on hospital readmissions. Hospital providers are waiting anxiously for clarity from the CMS on penalties for higher-than-expected 30-day readmissions. Obviously, this will greatly affect LTC providers.
► Continued expansion of home- and community-based services: Options for care and support in these settings will continue to be developed, consistent with current understanding of consumers’ wants and needs. Seniors are choosing to age in place, technology will be key in promoting independence, seniors are demanding customized services, and they want choice and value. An important piece to watch is the CMS’s development of a definition of home- and community-based services, which will have a huge impact in terms of access to Medicaid-waiver dollars and will specifically relate to assisted living. Is AL home- or community-based? If not, is it eligible for Medicaid-waiver dollars, and what would their ineligibility mean to seniors’ access to this service?
► Focus on quality: This will continue to be a major focus, and of importance to LTC is the future of the Advancing Excellence Campaign, which has evolved with a new structure and funding mechanisms. With Dr. David Gifford, CMD, and Dr. Cheryl Phillips, CMD, as cochairs, Advancing Excellence has a unique opportunity for an even greater synergy and collaboration between stakeholder organizations that are part of the campaign – the kind of synergy that is unprecedented in any arena of health care. There will also be heightened focus on MDS 3.0 and collaborations with culture-change advocates, such as the Pioneer Network, to rev up individualized, high-quality care.

We will continue to hear the mantra of “value-based purchasing.” Any provider’s effectiveness in this area will depend on an authentic and systemic focus on quality assurance, quality improvement, and innovation.



Barbara Resnick, PhD, CRNP,
the Sonya Ziporkin Gerschowitz
Chair in gerontology at the
University of Maryland School
of Nursing, Baltimore:



► In the coming year, we will be hearing more about wellness and optimizing function and physical activity in residents. With the coming of the baby boomers, this is what folks want to hear and see when they walk into long- term care facilities. Programs and environments may vary, but I expect to see more facilities with “wellness” centers, exercise rooms, walking paths, and pools.
► I anticipate we will hear more about innovative “homelike” environments with wood floors, plants, and comfortable seating. Let’s hope that at the same time we focus on the psychosocial environment and making sure that our long- term care homes are filled with the love and caring that true homes should have.
► It is all about the money. In the coming year we will hear and focus more on the ways we can provide cost-effective care through interdisciplinary teams. I hope we will continue to explore who best meets the needs of the residents at any given time and can provide that level and type of care or service in the most cost-effective manner.