Dr. Mary Jane Koren, vice president for the Picker-Commonwealth Fund Long-Term Quality Improvement Program

Mark Masselli: This is Conversations on Health Care. I am Mark Masselli.

Margaret Flinter: And I am Margaret Flinter.

Mark Masselli: Margaret, Congress averted that government shut down with a
last-minute basket when the President and the Speaker of the House got a deal
to cut $38 billion in spending to fund the government through September.
Congress is finalizing the details. What’s certain is that this is no way the end of
the budget battle.

Margaret Flinter: And what did think about those giant countdown clocks at the
news stations around showing us how many seconds it was until the government
would be shut down.

Mark Masselli: Edge of my chair.

Margaret Flinter: But it is true. Congress is gearing up for more budget battles
this week. And as you said, Mark, the budget deal that was struck late Friday
night concerns the current year’s budget, and that still needs full congressional
approval this week. Then we have to move on to next year’s budget.

Mark Masselli: Right, the short-term budget concerns are behind us, but the
nation’s long-term economic future is front in centre. We talked last week about
Republican Budget Committee Chair Paul Ryan’s proposal for 2012. It is very
controversial proposal to change Medicare. Essentially, it would privatize the
entitlement program for the elderly. This is expected to be voted on the House at
the end of this week, and we will see if there are any Democrats who are in
support of that.

Margaret Flinter: Well, Mark, I am going to be really interested to see whether
there is any of the hands-off Medicare holds by seniors that we heard a couple of
summers ago when privatizing Medicare or just discussing Medicare in the
context of Health Reform was on the table. And it's interesting to watch
President Obama. Certainly, he is not mum on the topic of the deficit and the
long-term debt. Like everyone else, he knows this long-term debt ceiling is
incredibly important, and I think he also wants to tackle some changes to
entitlement programs like Medicare and Medicaid, certainly not in the same way
as Representative Ryan but clearly very important strategic and policy issues for
him.

Mark Masselli: Well, I think the tensions hopefully will come down. It sounds like
the President and the Speaker who have gotten a better relationship and
hopefully even the President talks to the country, he can start a conversation,
and hopefully, we can have the public debate that President Obama provided in
the Health Reform Act with any proposal that’s coming out.

Margaret Flinter: And one thing that’s clear is you can't talk about a growing
federal budget or federal deficit without talking about health, and you can't talk
about health-related expenses without acknowledging the really important issue
of the aging baby-boomer population and issues of health care surrounding long-
term care and long-term care expenses. And these are going to be front in
centre I think in the discussion about Health Reform in the coming year.

Mark Masselli: And on today’s show, we are going to bring long-term care into
the limelight. We are happy that Dr. Mary Jane Koren, Vice President for the
Picker and Commonwealth Fund Long-Term Quality Improvement Program, can
join us today. She will give us some perspective on issues surrounding long-term
care that are driving this need for change as well as some of the innovations and
reform efforts that’s seen most promising.

Margaret Flinter: We are delighted that Dr. Koren is with us today on
Conversations. And remember, no matter what the story, you can hear all of our
shows on our website Chcradio.com . You can subscribe to iTunes to get the
show downloaded or read a transcript of our shows at Chcradio.com . If you are
social media ______ 3:09, become a fan of Conservations on Health Care on
Facebook. And don’t forget, you can follow us on Twitter too.

Mark Masselli: And as always, if you have feedback, email us at Chcradio.com .
We would love to hear from you. Before we speak with Dr. Mary Jane Koren,
let's check in with our producer Loren Bonner with Headline News.

Loren Bonner: I am Loren Bonner with this week’s Headline News. The
Department of Health and Human Services unveiled a new plan to reduce health
disparities. Some of the ideas outlined include working with states to increase
the number of poor children who receive preventative dental care using trained
promotoras, the Spanish word for a trusted local, as community health workers,
initiating new studies comparing which treatments work best for diabetes,
asthma, arthritis and heart disease in minority populations, and creating an online
national registry of certified interpreters that doctors or hospitals can use for
patients who don’t speak English. HHS has yet to put a dollar figure on these
pending projects but said it plans to pay for them with money already in hand and
not subject to congresses ongoing budget battle. A grant program in the Health
Reform Law will give states who are under pressure to cut Medicaid costs
incentives for Medicaid recipients who demonstrate a commitment to improving
their health. The Federal Grant Program is offering states $100 million to
experiment with wellness incentives like quitting smoking. States have until May
nd
2 to submit final proposals, and a number have already indicated interest.

This week on Conversations, we are discussing long-term care, a word that can
interpreted several different ways when we talk about caring for seniors and
those who need personal services on a continuing or reoccurring basis. Nursing
homes, assisted living facilities or homecare services may come to mind. But

what about a Naturally Occurring Retirement Community, or NORC as it's
referred to? In New York City, this phenomenon is not all that new. In the late
1980s, Penn South, a high-rise co-op in midtown Manhattan, became the first
official NORC program in the United States. Today, the NORC model, which
allows seniors to age in their homes and communities, is spreading throughout
New York and across the entire country. I visited one NORC in Northeastern
Queens, New York. Like most American suburbs, Clearview Gardens was built
after World War II to help fill the need for affordable housing. Low-rise brown
brick housing units are spread out over 88 acres of quiet tree-lined streets. After
the side of one unit, a sign points people around back to the NORC program
office and community rooms.

Gary Babad: What ended up happening is people got older. And especially
given the type pf community this is, some of the geographical spread of it and the
fact that there is no elevators, and between the spread of the community and the
steps that they had to take, we got more and more people that got older became
isolated. And without the kids around to kind of pull people together either, the
needs really grew.

Loren Bonner: That’s Gary Babad. He directs the Clearview Assistance
Program, a NORC that began in the late 1990s through the efforts of a group of
seniors in the community who recognized the need for more support systems.
By definition, a NORC is a demographic descriptor of a community or housing
development where a large concentration of elders live. It's a community that
wasn’t built for seniors but now houses them, and a NORC program is the
response to that. It's a model of care that offers a broad range of support for the
residents of a NORC. A group of senior women who welcomed me in one of the
two community spaces at Clearview rattled off a list of activities that could occupy
their days, ranging from transportation services, to local shopping, to daily
exercise classes and groups like needing for charity.

(Informal Talk)

Loren Bonner: Every NORC program is unique because it's based on the
individual community’s wants and needs. However, the objective remains the
same, to improve of quality of life for senior residents. Health, of course, factors
in heavily. Karen Schwab directs Older Adult Services at Samuel Field Y, one of
the larger programs that oversees Clearview’s NORC as well as two others in the
area. She says the support staff at Clearview like Patti Clementi, the onsite
nurse, make a huge difference in the health and well being of the residents.

Patti Clementi: Much easier engaging somebody who already knows about you.
So when people already know Patti because they have already met her, and you
have got to be ______ 8:22 as the NORC nurse. It's very easy to call somebody
and say, “Can Paddy come over” because now we know who Paddy is, and that

is really so much important what the NORC is. So we really work very hard in
engaging people when they are well .

Loren Bonner: Starting in about 2002, Congress directed the earmark spending
to fund NORC programs in 25 different states across the country. This ultimately
led to an increasing focus on prevention in NORC-funded programs. Fredda
Vladeck is the Director of the United Hospital Fund’s Aging in Place Initiative
which focuses on advancing the NORC model. She is also the Founding
Director of the first NORC program in New York City at Penn South.

Fredda Vladeck: Because we had such a critical mass in New York, we started
to look at that very issue. So how are the NORC programs maximizing the
health and well being of seniors? It took us a little while to really develop a
framework that permitted us to identify the health risks, develop some standards
of care practice and then measure the progress in reducing those health risks.

Loren Bonner: The Health Indicators project help different NORCs identify
themselves in terms of the population’s health. It permitted each NORC program
to pick an issue and decide as a community that they were going to focus on
reducing the risk of that problem. Clearview chose to address false risks
because they figured it was going to be important to prevent them as the
population grew older, again Gary Babad.

Gary Babad: What we do with the Health Indicators is we look at a set of factors
that have kind of determined to contribute to people’s likelihood of falling, and
Patti is probably biggest part of that because a lot of it is looking at things like
blood pressure. Patti will look at the trigger drugs, things that might lead to a fall
or drug interactions that might be dangerous for people.

Margaret Flinter: In terms of cost, this model strays away from how health care
is traditionally paid for, one hip fracture at a time, so to speak. Vladeck says the
NORC program model is in tie to Medicare or Medicaid reimbursement because
it's not the same as providing individualized medical care. Like most NORCs.
Clearview is funded by a public-private partnership, receiving some funding from
government grants and some from private donors. But staff like Schwab worry
about sustainability amidst so much budget tightening, especially she says when
thinking about future demand.

Female: In this community, you will have grandparents, parents and
grandchildren all living here. They have been children who have moved back
because of the supports. They are children that have moved back because they
like growing up in the community.

Margaret Flinter: To learn more about the NORC model visit, Norcblueprint.org .
Let’s turn now to our interview with Dr. Mary Jane Koren from the Commonwealth

Fund who can tell us more about some other reform efforts that are underway to
improve long-term care.

Mark Masselli: This is Conversations on Health Care. Today, we are speaking
with Dr. Mary Jane Koren who leads the Picker-Commonwealth Fund Long-Term
Care Quality Improvement Program. Welcome, Dr. Koren.

Dr. Mary Jane Koren: Thank you.

Mark Masselli: Advocates for long-term care have realized the need to reform
this type of care which, as you know, mainly serves senior citizens but also the
disabled and chronically-ill adults who cannot care for themselves. What are the
issues surrounding long-term care that are driving this demand for change?

Dr. Mary Jane Koren: Well, I think one of the things is that we have to realize
that long-term care does not equal nursing homes. And in fact, there are a wide
variety of supports and services that come under that ‘umbrella’ term. So for
example, we have assisted living, we have adult foster care, daycare. And I think
of the problems is that people have resisted the idea of long-term care because
they think it's just nursing homes. The other thing, and you pointed it out, was
that long-term care is not just for the elderly. I believe something like 35% or
40% of all long-term care services are given to people under the age of 65. So
this is an issue for everyone.

Margaret Flinter: So Dr. Koren, the Commonwealth Fund, through the Long-
Term Care Quality Improvement Program that you lead, is very committed to
reform and innovation of the delivery system for long-term care. And as you just
said, that’s a much broader area than many people realize. You have identified
several projects and practice models that have as their aim the improvement of
the delivery of the long-term care services. Maybe you could describe one or two
that you think are the most promising in terms of creating and sustaining change
and improvement.

Dr. Mary Jane Koren: Sure. One of our programs that we have supported now
for the last several years has been a quality campaign for nursing homes. It's
called Advancing Excellence, and people can go and look at the website, it’s
Nhqualitycampaign.org . And we have sections in there for consumers, for health
care workers, and also for the providers. And what we are doing is we are giving
nursing homes – because it’s nursing home directed – we are giving nursing
homes the opportunity to voluntarily get better. And we have been really excited
that we have been a partner with the Centers for Medicare & Medicaid on this,
and we have been able to show over the last four-five years that the nursing
homes that participate in the campaign actually get better, faster and improve
more than nursing homes who are not in the campaign. And right now, there are
over 7,000 nursing homes that have participated and joint Advancing Excellence.
So that’s one of I think our big wins. Another one, for example, is our pioneer

network that we have helped to support that. And I had talked a little bit about
trying to transform the care in nursing homes, and the pioneer network has really
supported all different kinds of providers with information to enable them to really
put the person in the center of care, rather than again trying to make the person
sit into the system in which they find themselves. So the pioneer network has
really worked with policy makers. There is even a section in the Health Care
Reform Law that calls for demonstrations to see how this kind of, what we call,
culture change works, how it affects individuals in nursing homes and also how it
affects workers at nursing homes.

Mark Masselli: And as you mentioned, the Affordable Care Law, there are
several provisions that support long-term care. Perhaps the most care talked
about is the CLASS Act, Community Living Assistance Services and Support.
And as you know, that program would provide cash benefits to recipients that
could be used for a variety of non-medical expenses such as paying for home
health aid or family member who provides care. ______ 15:54 taking aim at the
program over concerns that it won’t be able to sustain itself financially, what’s
your perspective on the CLASS Act? Does it change things for the better?

Dr. Mary Jane Koren: I think that the CLASS Act is probably one of the most
revolutionary pieces of legislation that we have seen. People should not have to
impoverish themselves in order to get long-term care. And just as you ensure
yourself against acute events when you are younger, you also should be
ensuring yourself against long-term care needs. We certainly know, as I said,
almost 40% of people who need long-term care are under 65. So this is not just
a problem of the elderly. And we also know that, for example, something like one
in five people over the age of 65 are probably are going to spend some time in
the nursing home. So long-term care is probably going to be in your future. And
what the CLASS Act does is it enables you to ensure against that by enrolling in
the program early on and sort of self-ensuring yourself through that time period.
We think this is incredibly important. It was very interesting, the SCAN
Foundation did a poll of Americans right before the Health Care Reform Law was
brought forward and found that 92% of Americans said they wanted improved
coverage for care that would keep them out of nursing homes, and that’s one of
the things the CLASS Act does. So we know that there is widespread public
support for this, and now what we need to do is to be sure people understand
they need to enroll in it early.

Margaret Flinter: I agree with you in support when people understand but we
haven’t heard people talk about it that much on the street, so we are really glad
to put some attention on that today. Let me ask you, Dr. Koren, in addition to the
financing of long-term care, there is other areas of great concern, as you said,
certainly quality improvement, probably some regulatory issues. But I want to
talk particularly about workforce development. In the Reform Bill and in the
literature, generally we talk a lot about shortages in primary care. But I would
suspect that workforce development, recruitment training, retention both on the

clinical levels such as geriatrician like yourself but also on the frontline worker
level with the elderly and with others in long-term care is an area of real concern.
Anything that you are working on there is you see is promising and hopeful?

Dr. Mary Jane Koren: There is a lot going on in that area. You are probably
familiar with the recent report that the Institute of Medicine did looking at the
elder care workforce, recognizing, as you said, that as the baby-boom generation
ages, we are going to need more workers and we are going to need better
trained workers in order to care for them. One of the things we know in long-term
care is that it's what we call high touch, not high tech. And so quality is going to
be predicated on the quality of the workers. And that goes whether or not you
are a geriatrician or you are a nurse’s aide in a nursing home. One of the things
that we have recognized with the culture change that I talked about is that it is as
much about helping workers do the job they want to do as it is about changing
the environment or helping the residents. And there are several alliances that
are working on this. There is the Eldercare Workforce Alliance that really is
looking at all the levels, both professional and non-professional, trying to do this.
And so we are really excited about what’s happening. And also, if you think
about it from an economic perspective, in some ways, this is good because we
are going to need an additional 3.5 million health care workers in the next 15
years. So it's a job opportunity.

Mark Masselli: This is Conversations on Health Care. Today, we are speaking
with Dr. Mary Jane Koren, a long-term care expert at the Commonwealth Fund.
Dr. Koren, we would like to follow what innovations were happening at the state
level here on Conversations on Health Care, and I am sure there are a lot in this
area. And we have been looking at the states as incubators for a change or
laboratories for change. So what do you see out in the states that we should be
keeping an eye on?

Dr. Mary Jane Koren: One of the things that we are trying to do is we are trying
to think about how we can use payment incentives to encourage nursing homes
and other long-term care providers to really provide more, as we were saying,
person-centered care. Colorado is testing some of these; a couple of other
states are thinking about it. I know Ohio is looking at this. So we are really
working closely with states to do just exactly what you said to sort of test things,
to incubate ideas, try anything. We have culture change correlations in probably
25 or 30 states. So we know that this is a kind of thing that’s happening. And
one of the very encouraging things is that these are not just the efforts that are
happening by people within the states but they are partnering with the agencies,
the health department and the state Medicaid agencies, the Ombudsman
program. All of these state programs are actually coming together and
participating with consumers to try to create a better system. So it's pretty
exciting.

Margaret Flinter: Well, I would like jump off the comments on culture change
and maybe talk about culture in a little bit different sense. It is just such a grey
area of fascination for all of us. It’s just way the diverse the United States is, how
many cultures, how many countries of origin. People here the in United States,
having that, of course, as people get older continues right into the long-term care
setting. At the Commonwealth Fund, you have done so much work looking at the
differences and culture and health status and disparities. Is your center focusing
on this sort of transformation that we will see in the long-term care area as well
as our increasingly diverse culture ages?

Dr. Mary Jane Koren: What we are trying to do is we are piloting a program right
now in four states called the Critical Access Nursing Home Project, and it is a
project that we saw the need for based on some of the research that Dr. Vince
Mor at Brown university was doing that really highlighted the disparities in care
for people utilizing usually inner-city nursing homes. And very often, these were
people who were poor, that were on Medicaid or were members of a minority
ethnic group. So we really saw this as something that needed to be addressed.
So what we have done is we have created networks within the states to come
together and really try to work closely with a couple of nursing homes in the inner
cities to see to see if we can improve their quality. And so far, we are having
some really good effects. We are not finished with the project yet. But I think
that it is addressing an issue that we know is there. And so far, there haven’t
been a lot of ideas out there about how to fix it.

Mark Masselli: Dr. Koren, speaking of ideas, we would like to ask all of our
guests this question. When you look around the country and the world, what do
you see in terms of innovation and who should our listeners at Conversations be
keeping an eye on?

Dr. Mary Jane Koren: I think one of the really innovative ideas that we are seeing
right now is a recognition that no single provider group can fix things, that in a
sense, it takes the community to fix it.

Margaret Flinter: Today, we have been speaking with Dr. Mary Jane Koren who
leads the Picker-Commonwealth Long-Term Care Quality Improvement program.
Dr. Koren, thank you so much for joining us today on Conversations.

Mark Masselli: Each week, Conversations highlights a bright idea about how to
make wellness a part of our communities into everyday lives. This week’s bright
idea focuses on mobile applications that are helping patients better manage their
pain symptoms and communicate their pain with caregivers and providers more
effectively. Roughly 9,000 health-related applications are currently available
across mobile platforms making it difficult for consumers to choose among the
most effective. Pain Care, developed by Ringful Health, has gained recognition
since winning a Project HealthDesign award. This award is part of a larger
national program from the Robert Wood Johnson Foundation and the California

HealthCare Foundation that designs next generation Personal Health Record
systems. The app provides patients with an electronic pain journal to record their
daily symptoms. With pain, triggers, medications, users indicate pain levels by
touching a frowning or smiling face as well as locations, durations,
characteristics, mood, and triggers. This data can then be shared instantly with
their provider so that they can treat the patient better as well as measure
progress. The designers of Pain Care based the app on similar personal health
application that was tested at the University of Massachusetts Medical School.
The research team received input from focus groups on content, function and
design and then tested a working prototype. User-friendly applications that are
helping patients better manage their symptoms, medications and communication
with caregivers and providers, now that’s a bright idea.

Margaret Flinter: This is Conversations on Health Care. I am Margaret Flinter.

Mark Messalli: I am Mark Messalli. Peace and health.

Conversations on Health Care, broadcast from the campus of Wesleyan
University at WESU, streaming live at Wesufm.org and brought to you by the
Community Health Center.