Editor’s note: Dr. David Shulkin, Sanford Health’s chief innovation officer and one of the authors, spoke about senior care innovation at the inaugural American Hospital Association Center for Health Innovation Leadership Council meeting.
Today, 10,000 people in the United States turned 65. Tomorrow, another 10,000 will. And that daily toll of aging will continue for the next 20 years, at least.
The Baby Boomers are retiring. And they will continue to get older, turning 70 and 75 and 80.
The implications that will have for long-term care in the United States are enormous.
And the questions U.S. health care leaders are now asking are profound. How will we provide health care and long-term care for all of those 80-year-olds? Can we make it more efficient and cost effective than we’re doing it today? Which emerging technology can help?
What will senior care look like?
Sanford Health’s partnership with Good Samaritan Society — one of the nation’s largest not-for-profit organizations providing senior care, with more than 200 locations across the U.S. — became effective Jan. 1, 2019. The combination of two Sioux Falls, South Dakota-based organizations came about in large part because their leaders were asking questions about health care, and elderly health care, into the future. They wanted to form an organization that could create an integrated, community-based health system that could care for people throughout their entire span of life.
The affiliation “just bolsters and strengthens that integrated health system — by basically having every service you need from when you’re born until the end of your life,” says Clint Graybill, senior executive director for post-acute care for Sanford Health.
“We’re looking at a lot of opportunities here to really do it better. Do it better than anybody.”
Here are some of the likely challenges and opportunities in long-term care in the next 10 to 20 years. And how Sanford Health, with its new partner Good Samaritan Society, believes it can offer some innovative solutions.
Senior care, with the specialization of hospitals
While more and more older people will get long-term care outside of traditional skilled nursing homes in future years (more on that below), some people will still need that level of care. And those locations will likely have more highly trained nursing and other staff, providing some services that only hospitals and health care facilities provide today.
“I can see the emergence of new models of care inside skilled nursing (homes),” Arnold Whitman, founder and CEO of Formation Capital, which invests in senior housing and care, told Skilled Nursing News in November 2018. “We will deliver services to a more chronically ill population with more complex care needs. The industry will need a higher clinical quality of staffing and the ability to start to look at opportunities around alternative settings for people in the full health care delivery system.”
Sanford Health’s Graybill says organization leaders are already thinking about ways to integrate its health expertise into Good Samaritan Society locations. Some senior care sites may have specialized wings that care for people with congestive heart failure, for instance, or other chronic diseases — providing important care outside of a hospital. Meanwhile, Sanford Health can give special training to nurses in the residential locations. And its physicians and other health care providers might go to the nursing homes to check on the health of some residents.
“What can we do to bring those services to that patient, instead of the patient to the services?” Graybill asks. “That is one of the big pieces that gives us an advantage.”
And elderly patients set to be discharged from a hospital will transition more smoothly to nursing homes, he says.
The Sanford Health-Good Samaritan Society partnership “will be working in an integrated fashion between the attending physician and their team, along with the highly trained nurses at the locations,” Graybill says. “Now, we really finally have all of the tools in the health care continuum to help manage the patient.”
New payment models
Overall health reform, led by the Affordable Care Act, has begun to stress managed care and “value-based” care over the traditional fee-for-service payments that have existed for decades. That means Medicare, Medicaid and insurance payments will be based more on a patient’s overall health, rather than specific services provided. That model has begun moving into long-term care as well, and will only accelerate over the next five or 10 years.
“There’s been a real shift towards payments based on outcomes rather than on services — payments based on quality,” says Mark Parkinson, president and chief executive officer of the American Health Care Association and National Center for Assisted Living and a former governor of Kansas. “And I think there will continue to be an acceleration of that.
“I think that in the entire health care system, there were massive inefficiencies that existed because of a lack of accountability and, basically, a payment for services and not for outcomes,” says Parkinson, who owned a group of skilled nursing facilities before becoming governor. “Nobody was really responsible for making sure that the patient was doing really well and at the cheapest price possible.”
Better senior care
The new model will mean long-term care locations may lose residents to other types of care, Parkinson says. But they also will likely gain residents who no longer need long-term acute care hospitals or inpatient rehab, he says.
“Some of them have been in settings that were above the level of care that they needed. And we think that when it all shakes out, because of the aging of the population, that we’ll be fine,” Parkinson says. “There will be plenty of things for us to do that we’re in the right setting to do.”
Graybill says Sanford Health’s new partnership with Good Samaritan Society fits perfectly with the new model and will improve care for seniors.
Current Medicare rules on certain health conditions, for instance, pay for a stay in a skilled nursing facility only if a patient has been in a hospital for at least three nights — even if it would make more sense for the patient to be moved after one or two nights. Graybill says Sanford Health will be exploring managed care solutions that will provide resources for the overall health of the patient — and that will allow for a move from one of its hospitals to a skilled nursing facility when it makes the most sense for the patient’s health.
“We can move the patient fluidly through the system, based on their acuity and some of their psycho-social needs,” Graybill says, “instead of waiting for rules and red tape.”
Advanced technology will bring better care
Parkinson laments that technology hasn’t yet been able to create significant change in how we provide senior care.
Long-term care homes are often nicer than they were 50 years ago, he says. But staffing levels, and the duties staff perform, are not that different, he says.
“We desperately need some innovators, some disruptors to come along and figure out how we can take care of people as well or better than we are right now with less people,” Parkinson says.
“And we need it for a couple of reasons. First of all, we need it because it’s the only way we’re going to be able to afford to take care of all the folks that we’re going to need to take care of in the future. And secondly, we need it because of this horrendous labor shortage that we are experiencing right now and that, if you look at the long‑term demographics, looks like we could experience for many, many years. So my short answer is, I really hope that some technological innovations get developed. I don’t think it’s happened yet.”
But many are hopeful — even in technologies that exist today.
Sanford Health leaders are excited about how a new technology it developed — called the Sanford Chip — might improve elderly care.
The Sanford Chip is an inexpensive ($49) genetic screening blood test. It provides insights into a person’s predisposition to hereditary cancers and cardiac disorders. It also provides information on how a person’s body processes specific medications.
Many elderly people have been prescribed a wide range of medications, Graybill says. “If you take a look at the data … the percentage of (nursing home) residents on nine or more medications is absolutely staggering.”
Those prescriptions cause side effects, or can cause problems with other drugs a person is taking. “We’re treating a patient with this medication that they’re genetically predisposed to create a side effect,” Graybill says. “So now we’re treating the side effect, too. So now we’re already at two medications, possibly three medications, to do that.”
The Stanford Chip blood test shows how a person’s body reacts to certain types of medications, or combinations of medications. A person’s doctor uses that information before prescribing medications, Graybill says. The information could mean people would require many fewer medications and feel better, Graybill says.
Many also see hope for telemedicine. It could help improve senior care, especially in remote, rural areas that are home to many Good Samaritan Society locations.
Through computer screens, cameras and technology in Sanford Health hospitals and Good Samaritan Society locations, doctors are able to “see” patients from hundreds of miles away, and provide care and make many of the care decisions they make in one-on-one patient visits.
“We need to bring the clinic to them,” Graybill says of long-term care residents. Hospitals and physicians will be able to “do this visually, through technology that we have. The physician is at the other end of a video screen, managing the patient’s care at their bedside, in their lounge chair. It’s changing the care delivery model and bringing the care to the patient, instead of the other way around.”
More people at home
Those sorts of technologies will also be a major contributor to what will likely be another trend: a smaller portion of the aging population in skilled nursing homes. There will still be many people who need such advanced long-term care. But technology and other changes will allow others to remain healthier in less restrictive environments, including their own homes.
“I hope that’s the case,” Parkinson says. “Home is absolutely the best place for people to be if they can stay there safely. There’s still going to be plenty of things for … providers of long-term care facilities to do, including working with the people that are staying at home, having them in their community network of health and wellness.”
“I think that’s going to be a wonderful step,” Graybill says. “In the next 10 years, when (Baby Boomers) hit that 82-83 years old mark, we’re going to see increases in these type of senior services. And the old-style brick and mortar (facility) is probably not the answer.”
- New Sanford Health: A conversation with Kelby Krabbenhoft
- Sanford Health, Good Samaritan Society complete affiliation
- Sanford Chip FAQs: Q&A and videos
- Using technology to improve rural care