A dozen or so years ago, Ted Goins Jr. had his road-to-Damascus moment.
A veteran administrator at Lutheran Services Carolinas who had started his career as a nurse assistant, Goins, 55, had gone to a conference to hear Bill Thomas, MD, whom many regard as the chief evangelist of person-centered care. And Thomas talked about dogs.
“I grew up, unfortunately, in the era where you wouldn’t let a dog through the door of a nursing home,” Goins recalls. “They might shed. You were a health facility. We mopped the floors all the time because there might be a hair somewhere on it. And then here was a guy standing up there on stage saying, ‘You should have a dog in the facility.’”

Resident-centered Care

Goins had always considered himself receptive to the idea of treating residents as he would want to be treated. He had trained more than three decades earlier under a man who “was doing person-centered care before we called it that.” But, hearing Thomas, Goins realized that, for all of his self-supposed open-mindedness, he, too, was bound up in the Old Way of doing things.
“All of a sudden, the light bulb switched on,” Goins says. “I remember thinking, ‘Maybe there’s a different way of looking at this.’”
Goins grabbed Thomas after the speech. “I ended up sitting in the hall, on the floor, with him—just discussing some of the issues,” Goins says.
He went a step further and invited Thomas down to North Carolina. “And he came and spent a day with our board of trustees and senior management staff and just helped ignite the passion,” Goins says.
But it wasn’t until after Thomas had moved on that Goins realized that, while he had been honoring person-centered care with his lips, his heart was still far away from the ideal.
Goins wants you to read his story. Because he thinks that the changes brought on by Thomas’ intervention have helped Lutheran Services not only survive but thrive, even as state and federal funds are drying up and so many providers find themselves staring at the prospect of extinction.

Like An Obstacle Course

Goins had promised himself that he would incorporate the theory and practice of person-centered care, but he hadn’t realized that he had been harboring his own, stubborn doubts until he heard that one of his company’s maintenance men had solved a seemingly intractable problem.
Employees at one of Lutheran’s homes found themselves flummoxed by how often residents were falling down. True to the principles of person-centered care, all the building’s workers were invited to a brainstorming session. The answer came from a seemingly unlikely source, Goins says.
“And the maintenance man, who normally wouldn’t even be in a meeting like this—this was a nursing issue, not a maintenance issue—said, ‘Well, look at all the stuff in their way,’” Goins says. “‘There’s a call bell here, there’s an oxygen tube here, there’s a phone cord there—it looks like an obstacle course. Do you realize how many people are tripping over those cords?’”
Having heard the story, Goins couldn’t un-hear it.
“Those are the kinds of things that were starting to come out of those meetings,” Goins says of the unexpected wealth of wisdom Lutheran discovered in its front-line workers. “All of a sudden, things made sense. And now it feels like, ‘Why weren’t we doing this all along?’”
He realized that, for all of his talk about patients first, he had been throwing away a pearl richer than his tribe by not seeking out his front-line workers.

“The housekeepers spend the most time in the room. So we should be listening to those people,” Goins says. “I started as a nursing assistant, and it was almost like we weren’t allowed to have ideas.”
The road to quality did not end there. But for Goins and Lutheran Services, those first, tentative steps have led to a road of riches. This year, Lutheran Services finds itself in a the midst of a five-year plan that will see two buildings remodeled and two brand new buildings opened. (In fact, ribbons have already been cut on three of the buildings.)
Most of the rooms in the redone and new buildings already (or soon will) have private rooms, living rooms, dining rooms, spas, bistros, playgrounds for child visitors, computers (and computer classes), and libraries. There are lavender-scented bathrooms with towel-warming cabinets; residents routinely take twice-yearly trips to Carolina’s beaches (see Beachin' It). Even as many providers find themselves collapsing (or barely holding firm), Lutheran Services is expanding.
“It seems to me to all come back to that mission, vision, and values,” Goins says. “Because we’ve stayed true to that, we’ve got the reputation with the state, with the Medical Care Commission; they know we do good work. A lot of the not-for-profit groups have gotten out of the nursing home business, if you will. We’ve doubled down.”
It is notorious that correlation doesn’t mean causality. But Goins is convinced that his company’s successes aren’t an accident. And his message is being heard.

“We are encouraged and inspired by Ted’s growth,” American Health Care Association (AHCA) President and Chief Executive Officer (CEO) Gov. Mark Parkinson says. “It confirms what our most progressive members have proved: Even in tough times, person-centered care—whether it’s Eden, green houses, or some other alternative, works. It works for the patient, it works for the employees, and it works as a business model.”

Postcards From The Apocalypse

In principle, no one disputes those findings, of course.
The question is how to deliver on the promises? So many dispatches from long term care these days read like postcards from the Apocalypse.
“As far as I’m concerned, quality of life is equally important,” Rhode Island Health Care Association President and CEO Virginia Burke says. “But given the regulatory scheme we operate under, it’s really difficult to operate.”
The paradox, Burke says, is that the regulators themselves don’t seem to have learned the difference between lip service and real service.
“The least expensive way to provide care is also the worst way to provide care: the assembly line. If you treat every patient as a widget waiting to be manufactured, then of course the quality isn’t going to be there,” she says.
“Every blow to that funding just jeopardizes that further,” Burke says. “You just can’t go on. I don’t know if anyone’s giving much thought on how to innovate at the moment.”
In late May, the Kaiser Family Foundation crunched the numbers and found that nearly half of America’s seniors may actually be poorer—because of rising health care costs—than official statistics show. In Rhode Island and 11 other states, the “supplemental” poverty numbers were at least twice as high as official numbers, Kaiser found.
“The supplemental poverty measure indicates that elderly poverty rates overall and at the state level are much higher than indicated by the official poverty measure,” Kaiser researchers said.
“At the national level, this result is largely due to the fact that the supplemental measure deducts health expenses from income, while the official measure does not.”

In one of those 12 poor states, California, public retirees were recently told that their long term care insurance rates were going to explode by nearly 85 percent. Making matters worse, in 2011, California Gov. Jerry Brown signed legislation that cut Medicaid reimbursement to providers by another 10 percent.
“Our providers are getting reimbursed $86 for every $100 in costs,” California Association of Health Facilities spokeswoman Deborah Pacyna says. “Because the costs are capped, there is no way to recoup that revenue.”

Managed Care Crisis

To make matters worse, more than half of the states are, or will be, moving to managed care to handle the influx of new Medicaid enrollees after President Obama’s Affordable Care Act.
Rhode Island is one of those states heading toward managed care. Burke is not pleased.
“It’s just an extra hand in the process,” she says. “It’s an extra party that needs to be paid for services. Instead of the department just paying the providers, the department is now paying a health plan, which is going to pay the providers. It’s more money away from patient care.”
 Harvest Moon Ball
In June, AHCA issued a set of guiding principles that it hopes will blunt the worst effects of managed care (see box, page 30). Among the top concerns for providers was to make sure that managed care contracts had adequate long-term services and support programs.
The supports “may be expensive in the short term,” AHCA’s Vice President of Medicaid and Long Term Care Policy Mike Cheek said in his report, “but they will provide long-term savings.”
Burke says that culture change—and the investment that comes with it—has to seep beyond providers to regulators.
“Ideally, under culture change, you’d have private rooms,” she says. “But I could never see our state Department of Human Services paying for private rooms. The quality people are never talking to the money people.”
Goins says he understands how tough it is out there and that sometimes talk about quality can seem glib. But for him and Lutheran Services, it’s not a poster slogan: It’s a long-term investment that has paid off. “We have to prove to the public and our regulators that we’re worthy of adequate reimbursement and that it’s important to get what we’re owed.
“And I know that’s a tough one in today’s world. If you’re sitting in a 50-year-old facility in Illinois—and they’ve got a notorious reimbursement rate—then it is hard to look beyond that. You’re just barely surviving, day to day.
“But, then again,” he says, “you have to start somewhere. And you have to be willing to invest in quality. The days of that 120-bed facility that was all semi-private rooms with shared bathrooms is over. That means they’re going to have to invest, or they’ll be out of business.”

Leap Of Faith

Lutheran Services’ employees will be the first to tell you that committing to quality is risky. And, perhaps worse, you can’t kinda do it.
“Sometimes that’s easier said than done,” Lutheran’s Operations Director Jill Nothstine says. “We all talk about giving resident-centered care, but it’s really a battle every day to make that happen.”
 Jill Nothstine
Nothstine knows of what she speaks. She signed on with Lutheran six years ago, when Goins’ massive cultural overhaul was just underway.
“I thought they were really interested in providing resident-directed care, in culture change, and in empowering their staff. I know those are buzz words, but I find that they’re genuine here,” she says. “I was so impressed that I kind of casually asked if they needed a nurse consultant.”
Her hunch about the place wasn’t wrong, Nothstine says.
“I felt like, that from the minute I came here, it was a different place,” she says. “Those new buildings they’re building—that’s a leap of faith, when you think about it. But I think that’s shown our staff that we believe in what we’re doing.”
But, like her boss, Nothstine was quick to discover that awkward, geographical relationship between one’s money and one’s mouth.
“The whole electronic records, I didn’t think you could do it,” she says. “I have to admit, I had trouble at first really buying into that. I remember saying to our IT trainer … ‘I am a nurse. I’m not a technology person.’”
Nothstine understands the fear of change. After all, the consequences of getting things wrong can be disastrous—not just for patients, but for companies.
“I think a lot of it is fear of the state,” Nothstine says. “When you have a regulation that says there are so many hours between dinner and breakfast and you have to give medications before … and we’re saying, ‘No, we’re going to let Mrs. Smith sleep in until 10 a.m., so, yeah, we’re going to go over that 16-hour rule.’
“But we’re thinking differently,” Nothstine says.

Not An Option

Scary, perhaps, but if you really think about it, Nothstine adds, you really don’t have a choice: “I can learn it now, or I can learn later, but not learning is not an option.”
And it’s the focus on learning that has made all the difference, Lutheran Services folks say. About eight years ago, the company developed curricula that were a hybrid of the Eden Alternative/Wellspring models. The company calls its curricula “New Pathways.”
Once per quarter (at least), Lutheran Services employees, from housekeepers to executives, are taken out of their homes or offices and sent off-site for continuing education.
It runs the gamut of topics and people: Housekeepers, most recently, were given an in-service training on hygiene for the residents, Nothstine says.
Once per year, select employees are sent out of town for lengthy seminars. There were some concerns the first year because the site didn’t have television sets in every room, “but it was all we could afford,” Goins says (see Paying For It).
“It sends a message to the staff, who love to get out of the building, that education is important and we’ll find a way to get it into the budget,” Nothstine says. “Because it matters.”

Staff Respond To Training With Enthusiam

Lutheran Services Certified Nurse Assistant Gail House has been with the company for 26 years and has been to at least four of the training seminars. She recalls vividly a discussion on making bath-time more pleasant for residents. She was initially surprised to hear about towel-warming cabinets, lavender scents, and soothing music.
“I hadn’t thought about it myself,” she says, “but I wish I had. It’s creating a spa-like atmosphere. Who doesn’t like to go to a spa?”

Meanwhile, House is a regular attendee at staff meetings, where employees aren’t just asked, but encouraged, to speak up about problems they’re seeing.

“It really has worked,” House says. “I can’t see working anywhere else.”
 Ted Goins, Trinity resident
Apparently, others agree. According to Lutheran Service’s numbers, the company’s turnover rate is barely above 29 percent, significantly below the national average for long term care.
In a recent survey, 91 percent of the company’s employees said they were satisfied in their jobs. Lutheran Services’ resident satisfaction surveys are even better: 96 percent of residents and families agreed, or strongly agreed, that they were satisfied with their community, and 93 percent would recommend, or strongly recommend, the experience to others.

‘University’ To Launch

Not satisfied with the quarterly seminars, Lutheran Services is now going digital. By September, the company hopes to launch what it is calling its “University,” Nothstine says.
“It’s going to be an online, kind of one-stop shop for our staff members. It’ll be a place where they can log in and go,” she says. “They’ll have links to our online learning programs. We’ll also have an education calendar, things companywide like medication training or CPR training. What I think is interesting and fun about this setting is we can put links to outside training materials, for our lifts, for our incontinence supplies—any kind of training.”
Goins himself was skeptical about the off-site training. “You know, penny-wise and pound-foolish,” he says.
Because the plain fact is, Goins says, the more staff believed that they were key to effective care, the more they invested themselves personally in resident care; that, in turn, made it easier for Lutheran Services to invest in technology and training more efficiently, to make the employees’ jobs easier. That made it easier for the company to rack up rewards and recognition and get flexibility from regulators. Wash, rinse, repeat.

A Case In Point

Take a small example. Goins, like Nothstine, was a reluctant technocrat and wasn’t thrilled to hear about electronic records. “Because I remember the days when I said, ‘We don’t do technology. We take care of people,’” Goins says. Remembering the sapient maintenance man, Goins swallowed his misgivings and gave the gadgets a go.
As has happened so often in the past decade, Goins says, he was thrilled to be wrong.
“The [certified nurse assistants] can actually make that thing sing on the walls,” he says of the electronic records system. “If they document it in real time, they’re more likely to get it right. And it’s in a useable format. We are completely paperless in our medical records. The quality of care is better because we know what’s happening with that resident in real time, but also we’re making sure we’re getting paid right.”
And, in melancholy retrospect, Goins says he wishes he’d jumped on electronic records sooner.
“I remember the last 30 minutes of every shift that I worked as a nursing assistant, and it was just going over those huge notebooks about the residents,” he recalls. “It took so much time away from patient care. Plus, I’m not sure that everybody—including me—was as diligent about making sure they were putting information in the book. So you weren’t getting good information, and you were wasting a lot of time to get it.”

Lutheran ITSo, even as the scenery seems to be collapsing around long term care, how does a provider recommit to quality?
“For once, I feel like I have an answer to that,” he says. “And the answer is, get a mentor or a coach right away.”
A great mentor can be found keynoting a convention or cleaning the rooms in your building, Goins says.
“We can all change,” Goins says. “It’s all learnable. You have to start with that mission and then bring people aboard who can support that.”