Bill Thomas on facility tours.
Bill Thomas’ revolution hasn’t been televised. But it will feature ticketed one-act plays. More than three decades ago, Thomas, a Harvard-trained gerontologist, took to the road. He had a simple request: Providers should change everything they do, in every way possible.

What a long, strange trip it has been. Three decades ago, hardly anyone used the words “person-centered care.”

Today, it’s the shibboleth of the profession. Just Google the phrase, and see what’s there. (There are more than 6,200 scholarly articles on the topic alone; the University of Buffalo in New York has endowed its own institute for person-centered care).

Thomas is not responsible for all of this, of course, but, surely, he is a founding father of a revolution. (How many other Birkenstock-wearing gerontologists are getting shout-outs from the Senate floor?)

On The Road Again

Yet, as George Orwell once observed about the French (“even the workmen in the bistros talk of la revolution—meaning the next revolution, not the last one…”), Thomas is not abandoning the barricades. La revolution is always the next one.

“I’m going on tour again, starting in April,” he tells Provider in an exclusive interview. “I feel a responsibility to have an impact on not just long term care, but how our country views aging and how our country thinks about older people. I think that many of the issues we deal with in long term care are driven by deep, cultural misunderstandings about aging.”

This month, Thomas and what he calls his “cool faculty” will mount up a recreational vehicle and tour 30 cities in April and May and then again in October through early November. He’s calling it, “The Age of Disruption 2015 Tour.”

“We’re bringing the show to town,” he says. “I’m going to get all disrupt-y.”

Aging Literacy

The tour will be part advanced biotech seminar, with morning clinics in local nursing homes on “disrupting infection.” (“They’re going to be providing evidence-based approaches to preventing infection in long term care,” Thomas says of his faculty. “You might ask, ‘Why are we doing that?’ The answer is, because we can make it better.”)

Part of the tour will be an old-fashioned rap session, with Thomas sitting down with leaders, that “explores new ideas, practices, and models to transform the experience of care and caregiving,” the tour’s ad copy says.

“The goal is to have a lot of conversation, not for me to talk for 90 minutes,” Thomas says. “It’s called ‘Tiger.’ Tiger is the strategy I’m using to leverage change in communities in terms of supports and services for older people.”

Part of the tour will be consciousness-raising, when Thomas will meet with long term and post-acute care executives. He’s calling the seminar, “Aging Reconfigured.”

“There is a very low level of aging literacy in the American health care system,” Thomas says. “We have in many ways a phenomenal system, but it’s limited in its understanding of aging.”

The final part of the tour will be Thomas taking the evening stage for a bit of “nonfiction theater” that he’s calling, “Life’s Most Dangerous Game.”

“Aging,” Thomas says, “is the most dangerous game you’ll ever play. It makes the NFL look like a powder puff league. The people who are taking the most risks, who are really living on the edge, are older people. The reason we can’t see that is because we see it all as a long decline.”

Thomas is no stranger to the open road. “That’s basically my day,” he says of the tour’s program. “Then I get on the bus, I wake up in the next city, and I do it all again—times 30.”

If that all seems a bit New Age, it won’t hurt Thomas’ feelings to say so: He’s proud of having been a flower child, and he spent a good bit of his last book trying to rescue the hippie ethic from what he sees as pernicious libel.

Yet the tour represents a revolution in Thomas’ thinking, as well. In the aforementioned book, released last year, Thomas called himself “a nursing home abolitionist,” and he’s published essays and speeches comparing what goes on in the nation’s long term and post-acute care centers to what went on in the old plantations of antebellum America.

If it now seems a contradiction to head into those same nursing homes, Thomas says it’s not because he’s mellowed out: He’s merely rethought his means (and ends).

“I’m continuing my commitment to go to people where they are and to sit down with them and listen to them in their communities,” he says. “Too often, people are content with saying, ‘I was on “Good Morning America,” so I’ve done it.’ That’s not how I think it’s done. It’s done by gently, respectfully engaging with people where they are.”

No one has ever disagreed with Thomas, exactly. About the worst that any of his critics have ever said about it him was that he was “too harsh,” or that he was talking to the wrong crowd—what else could providers do, the reasoning went, in such a hostile regulatory climate?

“When Bill was first out there, he got a lot of doors slammed in his face,” says Chris Perna, Thomas’ successor as chief executive officer of The Eden Alternative. “He’d get a couple of sentences out, and people wouldn’t understand what the [heck] he was talking about, and it would all shut down right there. Now, you can engage people on it. You do run into those numbers guys, occasionally, and if you can’t put it in dollars and cents, they’re not interested. They’ve got a business model. But they’re becoming fewer and fewer.”

Indeed, in the past half-decade, providers have made quality their mantra and their mission. By every metric that Thomas and his allies could have laid down, quality has improved in long term and post-acute care. And Thomas has had to admit that.

As if to underline the point, last year Eden Alternative signed on with Advancing Excellence. Whatever else that means, it means that the group is no longer outside the establishment.

Quality Becomes The Goal

If Thomas and his allies are converging with the profession, it’s also because the profession itself is revolutionizing. Twenty years ago, just as Thomas was beginning his then-quixotic crusade, leaders such as Ed McMahon of Sunrise Senior Living began to see that the best way to clean up the regulatory environment was to change the way providers themselves thought about care.

At McMahon’s urging, the American Health Care Association/National Center for Assisted Living (AHCA/NCAL) adopted quality measures from the congressionally funded Baldridge criteria and began awarding homes and centers for their commitment to rethink everything.

The awards themselves are beginning to lose their meaning for many providers, McMahon says, and he couldn’t be happier.

Bill Thomas“They suddenly realized that the criteria weren’t about getting an award,” he tells Provider. “They realized that this was a road map for consistently improving the quality of life for residents. That was eye-opening for me: It’s a long evolution. There’s this ‘aha’ moment where they realize, ‘This is making us better. We’re getting better.’ They didn’t even care if they got the award.”

A Self-Regulated Profession

Indeed, the profession embraced quality even when the metrics were someone else’s. As of February of this year, nearly half of all centers and homes had received either four or five stars from the federal government’s Five-Star Quality Rating System.

So rapid was the profession’s climb up the quality ladder that the Obama administration decided to redo its math, and late in February nearly one out of every three providers saw themselves losing a star in the course of an afternoon.

For McMahon, however, the important thing is the quest. With each new home that commits to a culture of quality, it becomes harder and harder to make the case that regulations should remain. In 20 years, he told Provider at the AHCA/NCAL convention (where he was feted as “A Champion of Quality”), the profession might even make the case it can be self-regulated.

The Humpty Dumpty Problem

For Thomas, regulation is someone else’s problem. What he worries about now is expanding the discussion. He and others like him say they’re worried that “person-centered” care might become a marketing slogan and not a real commitment to value older people.

“The problem with person-centered care,” Thomas says, “is that it’s possible for people to become satisfied with the name and to actually lose interest in the hard work that’s required to turn the name into a lived experience. The words are everywhere, but the meaning of the words is changing.

“I’ve had many conversations with good providers who will tell me about the person-centered care that they offer,” he says. “When I ask them, ‘Tell me what it means,’ they respond by recounting the artifacts, and they say nothing about the relationship. What we really mean by person-centered care is relationship-rich care.”

That may be a tough argument to make in this climate, and Perna says he sometimes feels himself having stepped through the looking glass. (“‘When I use a word,’ Humpty Dumpty said, in rather a scornful tone, ‘it means just what I choose it to mean—neither more nor less.’”)

Focus On Ends, Not Means

“The battle has not been won,” Perna says. “Because this is really hard work. This is not something that you just plug in and play.”

It’s great that homes routinely allow pets; or martini bars; or restaurant-style, quality dining; Perna says. “We do see some organizations describing some of the accouterments as person-centered care—‘Hey, we’ve organized a happy hour, we’ve got menu-based dining’—and those are terrific. But they’re only the tools, they’re not person-directed care. We want connectedness,” he says.

To do that—to do that really, means to disseminate power from homes’ administration and to put it into the hands of the residents, or the frontline, low-level workers, he says.

“And to a lot of companies, that’s scary,” Perna says. “Because they’re used to seeing results, right away. Here, you’re going to see results, but there will be failures, too. You’ll have small wins in small battles. But the small battles add up to victory in the war. And the war is won when you’re offering care that feels like home and people are excited to come to work.”

Changing Attitudes

Thomas may be going into homes, but he says his target is much bigger than that. If he has mellowed some of his harshness about the profession, it’s because he has rethought things, too.

“I really feel that it’s been the last three or four years that I’ve come to understand, much more fully, the degree to which long term care providers are actually prisoners of a larger cultural construct,” he says. “I’m sure there are lots of providers who ask themselves, ‘Why are things this way? Why can’t things be different?’ And a big part of the answer is the larger societal attitudes toward getting old.” Thomas has put a considerable effort into trying to change nursing homes from the inside, he says.
“Now, I’m trying to change them from the outside.”

And from the outside doesn’t mean writing new regulations or creating new rules, says Thomas, who says he’s not interested in that. His interest is in changing the cultural context in which long term care exists, he says.

“If by year six, people stop using the ageist slur, ‘elderly,’ and it passes out of our lexicon, and it’s not a part of polite conversation, then we’ll have made an impact,” he says.

“Think back in memory to the last time an older person referred to themselves as ‘elderly.’ People don’t introduce themselves by saying, ‘Hi, I’m Bob’s elderly mother.’ That’s put onto them. That’s the definition of a slur.”

Thomas is even willing to make a business case for his project.

Money Follows The Risk

“The perfectly clear answer is entrepreneurship,” Thomas says. “We’re sitting on a powder keg of entrepreneurship in long term care. A gigantic amount of human potential has been trapped into the system. Now, with the changes in the way that health care is financed, the door has swung wide open.”
In the past, he says, the money followed the certificate of need. But in the future, the money will follow the risk. “If you’re not taking any risk, you’re going to be at the bottom of the food chain,” he says.
“In the old days, if you had your certificate of need, and you had a reputable business, and your building was full, you made your money. Those people who were careful custodians of their certificates, of their money, and of their reputation—those things won’t save them anymore.”
Thomas says that what he believes is going to happen is that “this risk-based guide to population health is going to involve 21st century, noninstitutional models and that the big health systems will say, ‘We can’t afford the risk of working with a poor-performing center,’ and they’ll build around it. Now, your certificate of need and your license won’t protect you.”
Admittedly, it’s a huge project. But if Thomas has shown anything over his decades of service, it’s that one shouldn’t bet against him. Or, perhaps, that he can’t be bluffed out of the game.
“The tour is going to take a lot of time and energy this year, and I’m happy for it,” Thomas says. “If I have my wish come true, I’ll be on the road next year, and the year after that, and the year after that.”

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