The Commonwealth Fund Long-Term Care Opinion Leader Survey: A First Look Edward Alan Miller, Ph.D., M.P.A. Vincent Mor, Ph.D. Melissa Clark, Ph.D. Brown

The Commonwealth Fund Long-Term Care Opinion Leader Survey: A First Look

Edward Alan Miller, Ph.D., M.P.A.

Vincent Mor, Ph.D.

Melissa Clark, Ph.D.

Brown University

Fifth Annual Building Bridges Long-Term Care Colloquium, Washington, D.C., June 7, 2008

Purpose•Assess the views of LTC opinion leaders with regard to

the current state of LTC in the U.S. and potential areas and strategies for reform

•Identify areas of agreement and disagreement among the views of different types of opinion leaders, including consumer advocates, provider representatives, public officials, policy experts, and others

•Learn about the networks of LTC opinion leaders and how knowledge and views regarding important LTC issues diffuse

•Compare the views of LTC care opinion leaders to those of other health care leaders and the general public

Outline•Major Activities•Respondent Characteristics•Challenges, Policy, and Reform•Discussion

Major Activities•Instrument Construction•Sample Frame Development•Survey Administration

Instrument Construction

•Draft Survey Instrument•Own knowledge, literature review, analyses,

39 in-depth interviews with leading LTC experts

•Advisory Panel Feedback •Two teleconferences, 15 panel members

•Cognitive Interviews•Think aloud, focused-probing interviews, 11

subjects

•Final Review by Commonwealth Fund

Sample Frame Development

•Wave 1 (Purposive Sample): September-November ‘07

• Web-searches, published sources, and databases• Surveyed 1,954 potential respondents

•Wave 2 (Purposive Sample): January-March ‘08• Surveyed 117 potential respondents in initial sample but without

good email

•Wave 3 (Snowball Sample): January-March ‘08• 1,996 wave 1 recommendations; 1,104 unique persons• Surveyed 506 potential respondents not already in the database

but for whom sufficient identifying information was provided

Survey Administration•Survey Logistics

•Entire sample: 2,577 eligible individuals•Via Web-based Format•Pilot Tested•Conducted September 2007-March 2008•First three follow-ups 7 days apart; last follow-up 14

days

•Survey Protocol •Challenges, Policy/Reform•Background & Demographics

Survey Administration•Overall Response Rate

•44.5% (completed all survey questions)

•Response Rate by National v. State•National: 48.7%•State: 40.6%

•Response Rate by General Role •Consumer: 45.9%•Provider: 42.2%•Public Official: 38.5%•Policy Expert: 56.3%•Other: 51.5%

Respondent Characteristics

Level & General Role

•Level•National: 47.3%•State: 52.7%

•General Role•Consumers: 10.6% •Providers: 25.9%•Public Officials: 31.8%•Policy Experts: 24.3%•Others: 7.3%

Years Working in Long-Term Care

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

5 Years orLess

6-10 Years 11-15 Years 16-20 Years 21 Years orMore

Perc

en

t Y

ears

Wo

rkin

g i

n L

TC

10.8%13.7% 16.1%

17.4%

41.9%

Family Members/Friends Served by Long-

Term Care System

11.4%

88.6%

No

Yes

Types of Providers Serving Family Members/Friends in

LTC System1

1Excludes those with no family members or friends served by long-term care system

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

NursingHome

PaidHomeCare

UnpaidHomeCare

AssistedLiving

Adult DayCare

Other

Perc

en

t w

ith

Fam

ily M

em

ber/

Fri

en

d i

n L

TC

84.2%

64.9%

41.9% 39.0%

10.9%

18.5%

Gender

39.4%

60.6%

Male

Female

Race/Ethnicity

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

100.0%

Hispanic AfricanAmerican

Asian Other Non-HispanicWhite

Perc

en

t in

Racia

l/E

thn

ic G

rou

p

92.6%

1.8% 2.3% 2.0% 2.3%

Age

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

18-34 Years 35-44 Years 45-54 Years 55-64 Years 65 Years orOlder

Per

cen

t in

Ag

e G

rou

p

2.8%

15.3%

34.1%

40.3%

7.5%

Education

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

35.0%

40.0%

45.0%

High SchoolGraduate

SomeCollege

CollegeGraduate

MastersLevel Post-Graduate

Work

DoctoralLevel Post-Graduate

Work

Pe

rce

nt

Hig

he

st

Ed

uc

ati

on

0.3%2.4%

16.4%

42.1%38.9%

Income

28.7%

44.1%

1.8%6.3%

12.3%6.8%

0.0%5.0%

10.0%15.0%20.0%25.0%30.0%35.0%40.0%45.0%50.0%

Per

cen

t H

ou

seh

old

Inco

me

Political Party Affiliation

54.2%

13.4%

25.1%

3.5% 3.8%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

Republican Democrat Independent SomethingElse

Don't Know

Per

cen

t P

oli

tica

l P

arty

Census Division

0.0%

5.0%

10.0%

15.0%

20.0%

25.0%

30.0%

Perc

en

t C

en

su

s D

ivis

ion

13.8%

9.9%10.6%

28.4%

8.6%

4.5%5.1%

6.5%

9.0%

3.8%

Challenges

What are the top three challenges facing LTC? TOTAL

Percent Ranking in Top Three

Workforce 85.1%

Financing 66.4%

Achieving Quality 60.0%

Supply of Home/Community Services

29.3%

Regulation/Enforcement 27.6%

Accelerating Demand 15.8%

Information for Consumers/Families

12.5%

How would you rank the quality provided by the average… TOTAL

Percent Ranking ‘Fair’/‘Poor’1

Nursing Home 53.3%

Assisted Living Facility 29.2%

Hospital 29.0%

Home Care Agency 24.3%

Adult Day Care Provider 14.2%

Hospice 5.8%

1Response Options: Poor, Fair, Good, Very Good, Excellent, Don’t Know

How would you rank the quality provided by the average… GENERAL ROLE

Percent Ranking ‘Fair’/‘Poor’1

Consumer

Provider

Public

Official

Policy

Expert

Other

Nursing Home 73.8% 34.0%

48.2%

71.0%

54.8%

Assisted Living Facility

51.6% 20.9%

25.2%

33.7%

28.6%

Hospital 39.3% 26.3%

27.1%

29.0%

32.1%

Home Care Agency

33.6% 14.1%

23.0%

31.5%

28.6%

Adult Day Care 17.2% 7.7% 15.3%

17.2%

17.9%

Hospice 5.7% 4.4% 8.0% 4.3% 6.0%

1Response Options: Poor, Fair, Good, Very Good, Excellent, Don’t Know

Policy & Reform

Potential Areas of Reform

• Financing• Linking Individuals and Families to Services• Physical and Organizational Change• Workforce Recruitment and Retention• Quality Improvement and Regulation

Financing

How much do you oppose or favor the following approaches to paying

for LTC needs? TOTAL

Percent ‘Favor’/‘Strongly Favor’1

Should be a shared responsibility

83.6%

Government programs should cover most LTC costs

51.4%

Employers should contribute in part to their employees/retirees LTC costs

50.7%

Individuals should pay most of their LTC costs

30.6%

Adult children should contribute in part to their parents LTC costs

24.5%

1Response Options: Strongly Oppose, Oppose, Neutral, Favor, Strongly Favor

How much do you oppose or favor specific strategies for paying for

LTC? TOTAL


Add a long-term care benefit to Medicare, financed by a premium

79.8%

Adopt government incentives to promote greater savings

79.3%

Provide tax incentives for individuals to purchase LTC insurance

76.6%

Institute Medicaid ‘buy-in’ for non-Medicaid eligible LTC population

59.9%

Provide government incentives to expand use of reverse mortgages

42.7%1Response Options: Strongly Oppose, Oppose, Neutral, Favor, Strongly Favor

How much do you oppose or favor specific strategies for paying for

LTC? GENERAL ROLE


Consumer

Provider

Public

Official

Policy

Expert

Other

Add a long-term care benefit to Medicare, financed by a premium

87.7% 80.8%

76.7%

80.3%

76.2%

Adopt government incentives to promote greater savings

71.3% 86.2%

82.2%

71.3%

79.8%

Provide tax incentives for individuals to purchase LTC insurance

60.7% 87.5%

79.5%

66.7%

81.0%

Institute Medicaid ‘buy-in’ for non-Medicaid eligible LTC population

63.9% 57.2%

57.0%

64.9%

59.5%

Provide government incentives to expand use of reverse mortgages

26.2% 50.2%

42.7%

42.7%

40.5%

1Response Options: Strongly Oppose, Oppose, Neutral, Favor, Strongly Favor

Linking Individuals/Families to Services

How effective would the following strategies be for helping people make informed choices? TOTAL

Percent ‘Effective’/‘Very Effective’1

Formal care coordination services that explicitly link people to available options

74.1%

Counseling services that help people navigate the maze of available options

67.0%

Primary care physician assistance in finding services and making choices

34.0%

Public information campaigns to stimulate people to plan for future LTC needs

24.3%

Consumer report cards such as CMS’s NH/HH compare to help people choose

21.8%

1Response Options: Not at all Effective, Slightly Effective, Moderately Effective, Effective, Very Effective

How effective would the following strategies be for supporting informal

caregivers? TOTAL

Percent ‘Effective’/‘Very Effective’ 1

Expand care coordination and counseling services to link people to available support

69.8%

Expand availability of respite services

68.0%

Expand availability of adult day care

64.2%

Allow public payment for family members providing personal assistance

53.1%


How effective would the following strategies be for supporting informal

caregivers? GENERAL ROLE


Consumer

Provider

Public

Official

Policy Exper

t

Other

Expand care coordination and counseling services to link people to available support

79.5% 71.4%

70.4%

64.9%

64.3%

Expand availability of respite services

77.9% 64.0%

71.5%

63.1%

69.1%

Expand availability of adult day care

65.6% 61.6%

67.7%

62.4%

61.9%

Allow public payment for family members providing personal assistance

68.9% 40.7%

53.2%

58.4%

56.0%


Do you feel the LTC system should be rebalanced away from institutions

toward HCBS? TOTAL

No

Yes

83.8%

16.2%

How effective would the following strategies be for rebalancing LTC toward HCBS? TOTAL

Percent ‘Effective’/ ‘Very

Effective’ 1,2

Expand eligibility of HCBS under Medicaid

76.5%

Establish programs that offer a comprehensive package of HCBS (e.g., PACE)

76.8%

Provide single point of entry through which individuals may access needed services

71.5%

Increase rate of reimbursement for HCBS providers

67.1%

Limit supply of nursing home beds 20.9%1Response Options: Not at all Effective, Slightly Effective, Moderately Effective, Effective, Very Effective

2Excludes those who thought system need not be rebalanced away from institutions toward HCBS

How strongly do you oppose/favor expansion of consumer-directed

programs (“Cash & Counseling”)? TOTAL

Strongly Oppose/Oppose

Neutral

Strongly Favor/Favor

27.3%

11.8%

60.9%

How strongly do you oppose/favor expansion of consumer-directed

programs (“Cash & Counseling”)? GENERAL ROLE

79.5%

58.9%

69.5%

5.7%

20.9%

10.1% 6.8%11.9%

14.8%

31.7% 31.0%

23.7%

26.2%

47.5%

61.9%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

Consumer Provider PublicOfficial

PolicyExpert

Other

Pe

rce

nt

Fa

vo

r/O

pp

os

e C

on

su

me

r D

ire

cti

on

Strongly Oppose/Oppose

Neutral

Strongly Favor/Favor

Physical & Organizational Change

How familiar are you with the resident-centered care or culture change movement in NHs? TOTAL

17.5%

16.9%

65.6%

Not at All/Slighlty Familiar

Moderately Familiar

Familiar/Extremely Familiar

How familiar are you with the resident-centered care or culture

change movement in NHs? GENERAL ROLE

8.2%

17.9%23.3%

13.1%

19.7%15.5%

25.5%

17.3%11.5%

10.7%

81.2%

75.4%

63.0%

51.3%

66.7%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

Consumer Provider PublicOfficial

PolicyExpert

Other

Perc

en

t F

am

ilia

r w

ith

Cu

ltu

re C

han

ge

Not at All/Slighlty Familiar

Moderately Familiar

Familiar/Extremely Familiar

What proportion of NHs have fully adopted culture change or resident-

centered care? TOTAL

65.2%

22.9%

6.9%

5.0%

<10%

10% to 25%

26% to 75%

Don't Know

What proportion of NHs have fully adopted culture change or resident-

centered care? GENERAL ROLE

82.0%

49.8%

75.6%

64.3%64.4%

27.4%

17.6%

23.8%

29.0%

14.8%

7.1%2.2%5.5%15.5%

0.8%

1.2%4.7%6.3%5.7%2.5%

0.0%

10.0%

20.0%

30.0%

40.0%

50.0%

60.0%

70.0%

80.0%

90.0%

Consumer Provider Public Official Policy Expert Other

Perc

en

t F

ull

y A

do

pte

d C

ult

ure

Ch

an

ge

<10%

10% to 25%

26% to 75%

Don't Know

What are the top three barriers to resident-centered care or culture

change in NHs? TOTAL


Cost 69.7%

Senior Leadership Resistance

67.8%

Regulation 63.1%

Care Staff Resistance 52.6%

Size of the Facility 41.2%

Family Resistance 5.6%

Workforce Recruitment & Retention

What are the top three most effective options for improving recruitment/retention

paraprofessionals? TOTAL


Promote work environments that value and respect their contributions

90.7%

Increase compensation (wages, benefits)

85.4%

Expand opportunities for career advancement

69.1%

Redesign work processes to give greater autonomy to paraprofessionals

37.3%

Provide with more structured orientation to job responsibilities

17.4%

What are the top three most effective options for increasing the proportion of

professional trainees? TOTAL


Educational assistance programs targeted at individuals considering geriatrics

79.8%

Increase emphasis on geriatrics in professional schools’ curricula

78.6%

Higher salaries for geriatric specialists

67.5%

Redirect portion of Medicare GME funding toward geriatric settings

63.1%

Expansion of online resources and training in geriatrics

11.0%

Quality Improvement & Regulation

How well do you think the Federal government is doing in the regulation

of NURSING HOMES? TOTAL

Percent ‘Well’/‘Very Well’1

Establish quality standards 33.8%

Enforce quality standards 15.0%

Apply sanctions to facilities with poor inspection records

12.5%

Survey residents/families about the care received

8.0%

Advise on how to improve care quality through other mechanisms

7.0%

Consistently apply regulation across states

6.1%

1Response Options: Not at all Well, Slightly Well, Moderately Well, Well, Very Well, Don’t Know

How well do you think the Federal government regulates HOME HEALTH

CARE AGENCIES? TOTAL

Percent ‘Well’/‘Very Well’1

Establish quality standards 14.9%

Enforce quality standards 7.6%

Apply sanctions to agencies with poor inspection records

4.5%

Survey patients/families about the care received

3.6%

Advise on how to improve care quality through other mechanisms

5.1%

Consistently apply regulation across states

4.5%

1Response Options: Not at all Well, Slightly Well, Moderately Well, Well, Very Well, Don’t Know

Do you think the regulation of ASSISTED LIVING FACILITIES in your area should be more stringent? TOTAL

No

Yes

67.7%

32.3%

How effective do you think the following would be for assuring quality in

ASSISTED LIVING? TOTAL

Percent ‘Effective’/ ‘Very

Effective’1,2

Implement quality improvement efforts 56.1%

Mandate collection of resident assessment data

43.8%

Survey assisted living residents and families

41.6%

Regulate through a comprehensive survey and inspection process

37.8%

Regulate through licensure standards 26.6%


2Excludes those who thought the regulation of assisted living facilities need not be more stringent

How effective would the following be for ensuring and improving the quality

of care provided in LTC? TOTALPercent ‘Effective’/

‘Very Effective’1

Payment incentives (e.g., pay-for-performance)

53.3%

Establishment of higher staffing requirements

47.7%

Increased payment rates to providers 46.9%

More aggressive use of state enforcement remedies and sanctions against low quality providers

43.5%

Provision of technical assistance to improve quality through the Medicare QIOs

43.4%

Increased availability of consumer report cards

32.7%1Response Options: Not at all Effective, Slightly Effective, Moderately Effective, Effective, Very Effective

How effective would the following be for ensuring and improving the quality

of care provided in LTC? GENERAL ROLE


Cons-umer

Provider

Public

Official

Policy Exper

t

Other

Payment incentives (e.g., pay-for-performance)

53.3%

52.5%

60.0%

43.7%

58.3%

Establishment of higher staffing requirements

76.2%

32.3%

51.0%

47.3%

47.6%

Increased payment rates to providers

32.0%

64.7%

37.5%

41.9%

63.1%

More aggressive use of state enforcement against low quality providers

70.5%

29.6%

52.3%

35.8%

40.5%

Provision of technical assistance to improve quality through the QIOs

32.0%

49.5%

45.8%

34.4%

58.3%

Increased availability of report cards

41.0%

24.2%

44.4%

21.5%

36.9%


Summary Observations

•Nursing homes have considerably poorer reputations than any other provider type but especially hospices

•Few believed individuals and families should pay most (or even share in the cost) of LTC; Half thought employers should contribute

•Adding a long-term care benefit to Medicare financed by premiums was favored over more particularistic options such as buying into Medicaid, LTC insurance, or reverse mortgages, particularly by policy experts and consumers

•Few respondents have any faith in using report cards or other publicly available information to help consumers select providers; rather, respondents were far more favorable toward formal care coordination and counseling services.


•Care coordination, respite, and adult day services were more popular for supporting informal caregivers than paying family members to provide personal assistance, except by consumer advocates

•While nearly all felt that LTC should be rebalanced in favor of HCBS, virtually no one wanted to do so by limiting the supply of nursing home beds

•The majority of LTC experts, regardless of type, are familiar with “culture change” and most think that less than 10% of nursing homes have adopted it; resistance to culture change is generally though to be associated with cost and senior leadership resistance

•Most respondents viewed improved work environments and increased compensation as the keys to recruiting and retaining paraprofessional workers


•Most respondents felt that the federal government performs poorly in regulating nursing homes. In most areas, however, its performance vis-à-vis home health care was ranked even lower

•A large percentage of respondents felt that assisted living should be regulated according to the nursing home model (e.g., resident assessments, inspection surveys, etc.)

•Consumer advocates felt strongly that staffing requirements and more aggressive regulatory enforcement was the road to improving quality in LTC; There was little consensus among other respondent types, though most providers felt increasing payment rates was the key

The Future?

Documents

The Commonwealth Fund Long-Term Care Opinion Leader Survey: A First Look Edward Alan Miller, Ph.D., M.P.A. Vincent Mor, Ph.D. Melissa Clark, Ph.D. Brown