I thank you for inviting us here today to provide comments on current issues in long term care facing families and individuals in Pennsylvania. I am pleased to represent the Jewish Healthcare Foundation that has, since its inception sixteen years ago, had a commitment to funding, planning and advocacy on behalf of the seniors in this region. It is in that context that I offer my remarks today.

We applaud Representative Wagner’s initiative in holding this hearing to solicit input on this important and complicated issue – how do we ensure the care and safety for the seniors and their families in the Commonwealth.

In its short history, the Foundation has participated, funded and convened a number of planning efforts in aging. Much of that work, which involved providers, funders, seniors and researchers which showed a deep commitment to those who are aging, has languished on shelves for many years. We are gratified that at this moment in time, there is a convergence of thinking, planning and, most importantly, a bias towards action to ensure that the services and policies are in place to address the needs of this large and important segment of our Commonwealth – for the present and for the future.

Those of us who have watched the demographic trends for decades are frustrated that no one was concentrating on the perfect storm that is approaching – the aging of the baby boomers, the rising costs of care, the workforce shortages. We are pleased to read the Governor’s Prescription for Pennsylvania Health Plan, the Commonwealth’s newly released plan for End of Life Care for Pennsylvanians and the Allegheny County Senior Center report. We have been privileged to participate in each of these efforts and stand ready to partner with the Commonwealth to advance strategies that address our collective challenges and responsibilities.

It is clear that this Commonwealth, other states, and indeed the nation as a whole, must find innovative strategies to address the growing need for long term care services – and we must do so in ways that are financially prudent. But we must also be careful to make sure that any policies we put in place do not lose sight of why we are engaged in this work in the first place – to take care of seniors – and we must be sure that any proposals are respectful of the needs of seniors and their caregivers. Additionally we must try to think of the unintended consequences that might arise and plan for them in advance.

For example, the Commonwealth has declared its intention to shift from its traditional institutional bias in long term care to a more balanced institutional/home and community based balance. On its face – a terrific idea. It would seem to be a good way to save money for the state – limiting its burden to pay for nursing home care. However, it is more complicated than that:

No one grows up and announces that they wish to live out their final chapter in a nursing home. Sure most of us would like to have the privilege of living out our years in our community, surrounded by family and friends. We must stop to think what that means, what that will take and how we are going to get there. Have we adequately planned for the services that will be needed to support frail seniors in the community – transportation, home care, assistance with activities of daily living, meals, bathing? Have we looked at current waiting lists in various parts of the Commonwealth and considered what increased volume would do to those lists? Have we considered the ability or inability of families to afford even minimal co-pays for services? What if there are no capable willing family members to take care of a frail senior? One need only look at the impact of co-pays on the adult day care industry. Traditionally it provided respite care for frail seniors with dementia – a blessing to families whose loved ones were cursed with the feared and dreadful disease. Now, many who used that service have had to cut back or eliminate it entirely – the co-pays were overwhelming to those on fixed incomes.

The Foundation, through the Aging Environmental Scan, and support of advocacy work and demonstration models such as LIFE, has long advocated for the creation of home and community-based alternatives for frail seniors.

Shifting to home and community based services is a laudable goal – on its face. Many say it is cheaper. In some cases, it may be. But there is really little data that supports that conclusion for the all-in cost of care for seniors. Many of the costs for home and community based care do not disappear – the responsibility to pay for them shifts to others – often times, families without the resources and skills to assume the burdens that are thrust upon them.

Assisted Living and Personal Care were once touted as a wonderful bridge between home and institutional living. But without reimbursement mechanism in place, they are becoming a service reserved only for the wealthier seniors.

So yes, we must continue to address the needs of seniors to remain in their homes and to provide them with safe and cost effective care models. Assisted Living and Personal Care Homes should be included as partners in an aging network. Regulations governing staff training, safety, and protections from abuse, assessments and hopefully, payment streams should be moved forward so that real choices are available to seniors.

We must, however, not abandon the institutional network for long term care. For many, that is the right option. For that reason, we should continue to work with the Departments of Health and Public Welfare to assure safe, high quality, affordable services are available for seniors in need of nursing home services.

Nursing home care is now and will continue to be a vital service for some elders at some time in their lives. We must assure that that sector remains viable and delivers high quality services to the most frail and vulnerable who qualify for and seek out those services. That again underscores the need to ensure reimbursement rates for care are not slashed and in fact must keep up with the needs of the residents. As their frailty increases, adequately trained staff are vital. Current reimbursement rates already present a recruitment and retention challenge to nursing home operators, impacting their ability to meet regulatory requirements and provide continuity of care. Many of the Commonwealth’s workforce and employment strategies speak of living wages, jobs that provide for family wages, etc. Direct care workers in long term care deserve those wages and we need them to want to enter and stay in these jobs. Without adequate reimbursement which translates into wages and benefits, that is an impossibility and quality of care will suffer.

The challenge of workforce to meet these demands is huge. The Foundation through its supporting organization, Health Careers Futures, is committed to bridging the gap between supply and demand, working to assure that there is sufficient training available and career paths for those who are capable, compassionate and willing to serve our seniors. It will take creativity, collaboration and entrepreneurship to address the growing challenges. We have the capacity to meet that challenge. We welcome the opportunity to work with you.

I would like to shift my comments to talk about the "other" long term care – the primary care of geriatric patients. This is an issue that receives far too little attention.

Two thirds of all Medicare spending is for people with five or more chronic conditions. Pennsylvania in general and Pittsburgh specifically, is a high user of Medicare-funded health services – 33% above national averages. Managing multiple chronic conditions is central to the management of patients and the costs of their care:

Current Reimbursement Incentives are Misaligned: A few examples:

Policy and reimbursement systems often dictate patient care: Patients are transferred from setting to setting, at times based on maximizing reimbursements or avoiding significant losses from unsubsidized care. For example, patients from nursing homes are often transferred to hospitals for minor changes in condition as the care would only be reimbursed in a hospital setting. Given these flaws inherent in the system of geriatric primary care, it is not surprising that 18% of Medicare recipients are readmitted to hospital within 30 days of discharge.

One solution to the problems seen in primary care for seniors is the use of geriatric specialists. But geriatricians, who do bring together all the necessary resources to provide guidance to seniors and their families facing multiple chronic conditions and decisions in their later years, are among the lowest paid. The services they provide – geriatric assessment, case management, family consultations, etc. -- are not reimbursed by public or private payers. Studies conducted in Pittsburgh hospitals by experts from Harvard University document that care provided by geriatricians results in better outcomes and less costly care than that which is coordinated by non-geriatric specialists or internal medicine physicians. The absence of reimbursement for geriatrics is having unintended and costly consequences. Many geriatric providers are abandoning their practices and limiting the very services which could result in significant savings to the health care system. There are few medical students choosing to enter the field of geriatrics at the very time when the country’s demographics will require a larger pool of these providers. We must assure that polices put in place in the State help to reverse this dangerous trend.

The Jewish Healthcare Foundation and its other supporting organization, the Pittsburgh Regional Health Initiative, are working to identify and quantify the reimbursement "glitches" in our system that contribute to poorer outcomes and higher costs so that together we can work towards appropriate solutions.

Healthcare systems have failed to adapt to changing patterns of disease as well as the wishes of the dying. These failures have proven to be very costly for society, with providers focused on multiple interventions rather than assessing or balancing patient and family needs and wishes with likelihood of success of treatments. Driven by a combination of misaligned reimbursement incentives, the lack of available information for both consumers and providers about the costs and benefits of care options, and the absence of advanced care planning and supportive systems to care for the dying, the result is poor outcomes and high costs end of life. 

We must address the issues of end of life planning and service delivery. There are models in other states from which we can learn. There are seniors and family caregivers who should be listened to. There are forward thinking and caring providers who can help in our evolution to better care at end of life – care that reflects best practice, personal choice, desires for pain free living and peace of mind and body. The End of Life report must be implemented – not just applauded.

In closing, I reiterate that our Foundation stands prepared to work with the Commonwealth in whatever ways are deemed appropriate to help implement strategies that maximize the Commonwealth’s desire to claim that we are one of the oldest States in the Country and to do so with a sense of both pride and responsibility! The Foundation has long believed that old age does not equate with frailty or straight line deterioration. Seniors are living longer, have more opportunities to take advantage of medical discovery to live better, fuller lives as well. Our seniors are not homogenous – some are well, some are vulnerable, some are frail, some have physical limitations, others have developmental disabilities, and yes, mental illness past the age of 50!

We must recognize and plan for these distinctive needs. In all that is done for the Commonwealth’s seniors, we must assure the quality of care delivered by providers. Cost effectiveness is essential. Monitoring is a key. Standards are another. The public should be able to trust the quality of services and have choices about their lives and their care as they – and we -- age.

Thank you.