When thinking about the future of long-term care, we can start by drawing on the thoughts of Amazon’s CEO Jeff Bezos on the subject of strategy. “I very frequently get the question, ‘What’s going to change in the next 10 years?’ ... I almost never get the question, ‘What’s not going to change in the next 10 years?’ And I submit to you that that second question is actually the more important of the two” (Amazon Web Services, “2012 re:Invent Day 2: Fireside Chat with Jeff Bezos & Werner Vogels,” Nov. 29, 2012, https://www.youtube.com/watch?v=O4MtQGRIIuA
To address that more important question in the context of LTC — what’s not going to change? — I think Abraham Maslow’s Hierarchy of Needs (Psychol Rev 1943;50:370–396) provides a useful framework to identify our unchanging constants. For individuals, Maslow placed meeting physiological needs as the foundation, followed by safety, love and belonging, esteem, and finally self-actualization. To meet the needs of our LTC setting, we would place basic medical care and housing as the foundation of our hierarchy, followed by creating community and our own version of self-actualization — fulfilling our potential and accomplishing our goals.
The first nursing homes and assisted living facilities focused on hospitality only. When their narrow focus on room and board failed to sell well, they were forced to shift into including basic medical care as well — which has become the basis for all LTC facilities today. In the next 10 years, this foundation will not change, although our approaches to providing it may.
As LTC facilities have followed their own path up the Maslow hierarchy, community has been reflected in the name shift from assisted living facilities to assisted living communities (although skilled nursing facilities have been slowly embracing this change as well). Beyond community is the top of the hierarchy of needs: the realization of accomplishments through the achievement of goals and fulfillment of one’s full potential. Historically LTC has not done a terribly good job at meeting the higher needs, but we can — and should — argue for movement up the hierarchy to provide more.
Moving LTC Home and Abroad
Our hierarchy of needs is not changing, but LTC delivery of these needs is. During the COVID-19 pandemic, LTC facilities have seen not only significant spread of the disease but also an extremely high mortality rate. Separating COVID-19 from our population has prompted an increased emphasis on providing care at home, and more older adults and others are considering remaining home as their first care option to avoid or delay a move to a LTC facility. In the future, assisted living will move from residing within a facility to receiving assisted living services at one’s own home in the community.
Even as medical care has begun to be provided at home, the combination of American political instability and rising LTC costs has prompted increased interest in care outside the United States. Countries outside our borders are increasingly viewed as offering more stable LTC settings. In fact, data from the U.S. Social Security Administration on where social security checks are mailed reveal that Canada is now the leading foreign residence of recipients, followed by (in order) Japan, Mexico, Germany, and the United Kingdom (Social Security Administration, Old-Age, Survivors, and Disability Insurance, “Benefits in Current-Payment Status: Geographic Data,” Annual Statistical Supplement, 2018; https://bit.ly/344kDSy
One concern with older Americans establishing residency outside the country is their being cut off from Medicare benefits, which can only be used within the United States. Assisted living communities for Americans outside the United States must establish relationships, transportation, and care coordination so that Americans can be moved back to the United States when a situation requires them to access their Medicare benefits.
Maintaining Occupancy and Medical Care
Within the United States, in the face of outward delivery trends, the lifeblood of LTC remains occupancy. For this reason LTC facilities are focused on not only getting residents but keeping them. One new opportunity to increase the inward flow of residents is offering short-term stays. These short-term stays can occur through the use for respite, subacute, and hospice care.
Embedding a community geriatric clinic within a LTC facility has been another development. These clinics provide access in the LTC to a geriatric care provider for more hours per week in order to meet the increased volume coming from the community. They also allow older adults from the wider community to grow more familiar with the LTC facility, which may prompt them to move in sooner rather than later. These connected referral sources can also be built through the development of virtual continuing care retirement communities, where assisted living communities are linked to independent living communities and SNFs — thus providing the full range of services without incurring the cost of building a single community. In a similar manner, connecting the LTC to a health system for referrals — especially for short stays — often leads to long-term residents.
A community is not a one-and-done scenario but a living organism with the ability to change and grow over time.
Retaining residents in the LTC is the main driver of occupancy. This requires improving the basic medical services being offered. Seven foundational elements form the basic medical services needed within a LTC facility, as highlighted by the acronym Who CARES ... ME are W for wellness, especially around vaccinations, which are increasingly recognized as critical; C for both coordinated care and caregiver support, the additional aim in the quadruple aim; A for acute care; R for Rx/medication management; E for end-of-life care; S for social determinants of health; and ME for mental health services.
The extent of these basic services — and how they are delivered — is rapidly changing. Telemedicine and telemonitoring services provide for increased efficiency and effectiveness in care delivery, and COVID-19 has accelerated Medicare’s coverage expansion for them. Refinement of these offerings, based on recognized successes and failures, is already occurring. For example, telemedicine services have been found to be most useful when a provider already has an established relationship with the LTC resident; the provider’s greater understanding of the individual patients’ background promotes an increased level of trust. These services also are more effective when a nurse is at the bedside during the visit, which not only reduces some of the technical challenges but also provides enhanced assessment of the situation and implementation of the care plan.
The formation of community requires a cultural shift because communities are based on a shared common purpose that provides a sense of cohesion. LTC facilities can form communities among their residents based on a variety of interests, such as around religion, hobbies, or activities like gardening.
To function well, each part of a community has to effectively carry out its role in relation to the whole. By its members sharing responsibility for recognizing and resolving problems and enhancing the community’s well-being, a community can stay healthy and well-connected. Successfully addressing a community’s complex problems requires integration, collaboration, and coordination of resources from all parts — this means a community is not a one-and-done scenario but a living organism with the ability to change and grow over time.
Communities take a great deal of work to establish and maintain, but they make the difference between truly successful LTCs and those that ultimately fail. The health of an LTC’s community and its residents directly translates into occupancy rates and quality of life.
Maslow’s original hierarchy separates esteem and self-actualization as two distinct needs. Esteem encompasses confidence, strength, self-belief, personal and social acceptance, and respect from others, especially those within the community. Even though esteem is basically an internal quality, it is very much affected by external factors. In the LTC setting, these external factors come from validation and approval by the LTC staff, provided on an ongoing basis.
Self-actualization, in Maslow’s system, represents the highest need: the ability to become the best version of oneself. As he said, “This tendency might be phrased as the desire to become more and more what one is, to become everything that one is capable of becoming.” This varies by individuals and differs based on stage of life, for each individual has different values, desires, and capacities that change over time. As a result, self-actualization manifests itself differently.
Some may self-actualize through artistic expression; others, especially later in life, may find achievement in physical efforts, such as ambulating independently after a stroke. For LTCs, self-actualization means growing the current goals of care to encompass much more: the recognition of each individual’s life goals. For LTC leaders this requires identification, development, and realization of individual residents’ self-actualization goals.
Taking Responsibility for Health
Finally, the fee-for-service model is shifting into taking responsibility for the management of health care dollars. During the COVID period, the entities financially responsible for health care have realized significant positive savings by restricting elective procedures and reducing visits and diagnostic services. And beyond the financial gains, these risk-taking entities have seized on this opportunity to refocus their funding on preventive care and social determinants of health.
Medicare is opening up a range of vehicles for assisted living communities to take on financial risk. These include entities such as the Program for All-inclusive Care for the Elderly (PACE), Special Needs Plans (SNP), and most recently, Direct Contracting. Through these arrangements assisted living communities can assume more control of health care dollars, which provides the opportunity to concentrate on improving health rather than on just providing more services.
In the end, the future of assisted living communities is grounded in the elements that remain constant, as embodied in our own hierarchy of needs. The successful LTC leaders will be those who acknowledge these constants — while taking advantage of our new financial opportunities and their implementation.
Dr. Stefanacci maintains active clinical practice in PACE programs with Mercy LIFE. He also maintains a faculty appointment at the Thomas Jefferson College of Population Health as well as at the CMD program of AMDA – The Society for Post-Acute and Long-Term Care Medicine. While Dr. Stefanacci serves as medical director for Eversana, his proudest role is Board President of www.Go4theGoal.org
a foundation dedicated to helping children and their families battling pediatric cancer.