Articles by Robert L. Kane, MD
The View from Here
Reworking Workforce Thinking—Lessons to be Learned from Hospice Care
by Robert L. Kane, MD
The future of a workforce to serve older people looks bleak. The demographic pressures of an aging population of baby boomers and a stagnant generation just behind them conjures up all sorts of anxiety. Add the low esteem in which work serving older people is typically held, and we have a big problem, starting with fewer workers per older person.
The shortage of workers hurts at several levels, including that there will be fewer workers to support Social Security and fewer to provide services for older people. The former problem will require some adjustments in Social Security, such as removing the cap on the tax. Changing eligibility also makes sense, but may be too politically controversial. Social Security’s universality is its great strength but also its irrationality. People with good retirement programs or lots of savings see Social Security as a marginal gift, whereas the many Americans with little savings must view it as a major source of retirement income.
The workforce issue cannot be solved by simply trying harder. Of course, we need to pay direct care workers more, but we will never be able to afford wages that would make these jobs competitive. Ironically, the same is true of the professionals who serve older people. Geriatricians sit at the low end of the pay scale, but that is likely not what keeps doctors and nurses from entering the field. Rather, it is the fact that in addition to offering relatively low pay, serving older people is unglamorous hard work. It is not the basis for heroic television shows or celebrations. Technological medicine attracts clinicians away from primary care, which is the feeder stream upon which geriatrics relies. As that stream dries up, so does the number of people going into aging.
Achieving adequate staffing for both clinicians and line workers will require redesigning those jobs and raising their prestige. Eldercare is typically viewed as a necessary but unexciting task. Both those engaged in it and those viewing from outside see the effort to help frail older people as a daily struggle that inevitably ends in further decline. Without a comparator, the benefits of good care remain essentially invisible. However, success in this arena lies not in reversing the polarity of the clinical course but in slowing the rate of decline and making the end of life as positive an experience as possible. This philosophy is similar to that of hospice care, which in contrast to long-term care, is seen as valuable and satisfying work because it undertakes achievable goals. That is, hospice does not seek to reverse a clinical condition but rather emphasizes meeting patients’ goals and desires. This strategy makes sense for geriatrics as well, especially if married to improved chronic disease care.
The goal of chronic disease management is catastrophe prevention. This end is accomplished by proactive care, where status is monitored and interventions are launched when a patient’s clinical course falls outside of the expected trajectory. Establishing this model of care means developing ongoing personalized relationships with clients. It implies teaching line workers what to look for and respecting their judgements when they report that a client is just not herself today. It means doing away with most return appointments and using the time saved to be available for rapid response when a change in clinical course occurs. It implies creating an information system that shows the actual versus expected clinical trajectory of each patient and that shares that information with all caregivers and the patient, and that ultimately uses aggregations of this information to demonstrate to society that good care does indeed make a difference.
Research tells us that people who feel impotent to help others may actually develop negative feelings towards those they seek to help. That is the last thing we want. Indeed, we want to get workers feeling good about what they are doing and deriving job satisfaction from making a real difference in the lives of frail older people.
So workforce planning will require more than just finding new sources of payment or widening the recruitment net. It will entail systems thinking about how to make the work more satisfying and more efficient, both of which may require redefining what “success” looks like in eldercare. The role of information technology support is clear, but it can go much further. We need to rethink our approach to education. Currently, we rely on a technique similar to the one involved in making pâtés de foie gras; we shove a funnel down the learner’s throat and pour in all facts we can until their liver goes bad. We treat education as some sort of immunization that will ward off the vicissitudes of practice, when we know full well that environment shapes behavior. We need to create caring environments that encourage the behaviors we (and older clients) want. Surely the wanted behaviors are not institutionalization and 12-minute visits.
When we start defining our task this way, we may open ourselves to a host of new solutions. Who knows? Some of them might just work.
End of Life Care Needs an Overhaul
by Robert Kane, MD and Jennifer Brokaw, MD
September 29, 2016, Time magazine
What Do We Do with a Problem Like Demography?
by Robert L. Kane, MD
(This editorial originally appeared in the Summer 2016 edition of Old News)
By now everyone knows the country is aging. Fewer people realize that the cohort just behind this older one is barely growing. This has several serious implications. First, there will be fewer workers to pay for social programs like Social Security and Medicare. Second, there will be a care gap. Third, there will be fewer workers to assist frail older people.
Many conferences are attempting to address this impending crisis. Too often, such forums focus on numbers instead of creative solutions. But the solution will not be found through trying to squeeze more blood out of the caregiving turnip. Instead, we need to view this situation as an opportunity to reinvent caregiving.
It is no secret that long-term care (LTC) workers are not happy. They are overworked and underpaid. They deserve more money, but society will never afford what they are worth. We need to find a way to make their work more satisfying.
Part of the answer may lie in the example of hospice care. Hospice workers deal daily with death, but they report great satisfaction with their work. Why? Because they have defined an achievable, socially valued role. Their goal is not to prevent death (or even keep people safe), but to make the end of life as meaningful as possible. And they do!
We need to redefine LTC and the roles of LTC workers. Their prime directive should likewise be to make the lives of frail older people meaningful and comfortable. While we would never condone bedsores or abuse, their absence does not define successful LTC. Our care goals need to be more than the absence of bad events.
Likewise, living a fuller life may mean taking some risks. Many older people would happily risk falls if they could walk. Most would choose to eat foods they like even if doing so threatened glucose control or even aspiration. Once we redefine the goal as a better life, our priorities shift. Even more important, so do the priorities of the older people needing care.
Shifting the focus of care offers new opportunities for creativity. We recognize that LTC is really an extension of family care. We may not need as many professionals, each with their area of expertise. Dietetics gives way to culinary skill. Physical therapy becomes normal activity. Nursing assumes a supporting role, not a dominant one.
We need to rename LTC caregivers as life enhancers. We need to re-examine our approach to training. The traditional pâté de foie gras method of force feeding training (with little retention) should give way to new approaches that use information technology to help structure and guide care. Perhaps we should learn from the old Reader’s Digest approach to increasing your word power by learning new word each day. Rather than trying to cram a lot of information into a single session, we might provide an actionable fact each day to all workers on their IT tablets and ask them to implement it. The tablet could even record their experience.
Ultimately we will need to demonstrate that such care makes a difference. We need to create measures and metrics that reflect the new goals of care. Are recipients and their families happier? Do they feel the care responds to their needs and wants? Is the rate of decline in quality of life slowing compared to traditional care? Even the rate of physical decline may slow; ironically people on hospice care live longer than those not receiving such care.
Once we have evidence that good LTC makes a difference, we can garner public support to invest in it. Then workers may finally get the salaries they deserve and more will be attracted to this important work.
The Ticking Time Bomb of Long-term Care … and Two Bold Steps You Can Take Today
by Robert L. Kane, MD
(This editorial originally appeared in the Spring 2016 edition of Old News)
As I listen to the presidential debates and the news in general, I am overwhelmed by the number of crises our country seems to be facing internally and externally. We have widened the gap between rich and poor. We continue a set of inequalities. We fear terrorism. Our environment is literally going to hell. Education is underperforming.
As an advocate for improving long-term care for older adults, I find myself wondering where that agenda fits in this dismal context. We have an economic challenge to find decent work at decent pay for everyone, but we have a hidden problem as well. The changes in the pension system enacted two decades ago now mean that many people will approach retirement with limited savings. Traditional pensions were effectively forced savings. The 401k approach requires workers to take some initiative and many have not because of pressing immediate needs. We have a ticking time bomb. If upcoming generations cannot afford to retire, how will they ever afford long-term care?
And if they can’t pay for it, who will? The easy answer is Medicaid. We will become a nation of de facto old medical paupers. State governments fear this run on the treasury, and with good reason. States vary in their Medicaid generosity. Minnesota is at the upper end of this distribution. No wonder they have embraced a campaign euphemistically entitled, “Own Your Own Future,” which is basically urging everyone to save in whatever way possible to pay for long-term care. But given the reality of savings in general, it may be an unreasonable exhortation. Pressing for more individual responsibility does not seem to be the answer. We will need collective action.
The big question is, how do we even get anyone’s attention about this problem, especially in the context of all these other crises? How do we address tomorrow’s problems when we are swamped today? The challenge is all the greater because long-term care is not a sexy topic. People do not get worked up over it. Elections are not won by platforms based on it.
The first big step then is how do we change the public dialogue about long-term care to lend it more appeal? We need to start by making sure it is seen as something positive, not just a necessary social service.
In this issue of Old News, we describe a group that is trying to do just that. The Long-term Care Re-think Tank is a group of people from different backgrounds who are committed to getting people talking about long-term care and drastically improving its delivery. Essentially we want long-term care to do what people say they want: maximize frail older people’s dignity, autonomy, and choice, and allow them to live meaningful lives. The cost of care should not mean sacrificing these goals.
I urge you to take two steps today:
- Consider joining the Long-term Care Re-think Tank and becoming part of the solution.
- Send me five steps you would like to see society take to improve long-term care in the next five years. Ideally, they should be reasonably doable. Please make them as concrete as possible, but be bold.
by Robert L. Kane, MD
(This item first appeared on the University of Minnesota Facebook page in January of 2016)
Every person 65 or older should give a gift on his or her birthday. It is a notebook containing all the relevant information a caregiver might need to know. It can be in an old- fashioned three-ring binder or on an iPad.
Informal caregivers face a huge challenge in coordinating the affairs of their charges. One step toward facilitating that task is to gather all the relevant information in one place. The file should include any information that may prove pertinent. Here are some suggestions.
• Bank accounts (numbers and locations)
• Investment information (stocks, bonds, real estate) Name of broker/financial planner
• Retirement accounts (numbers) (pensions, 401Ks, IRAs)
• Social Security number
• Mortgage status and information (Who holds it? When are payments due? How much?)
• Other major debts (payments due)
• Names (addresses and phone numbers) or doctors and dentists
• Medicare information (HIC number)
• Supplemental health insurance policy numbers
• Long-term care insurance
• Drug insurance (Part D of Medicare)
• Durable powers of attorney for financial and medical decisions
• Advance directives
• Will location
• Lawyer (address)
• Life insurance
• Burial arrangements (including insurance)
Every birthday thereafter you should update the information and be sure someone knows where it is. It is not a bad idea to be sure that there is an authorized co-signer on bank accounts. Obviously, this step involves great trust, but if a catastrophe occurs, it will be important to get ready access to your funds.
None of us want to admit that bad things can happen, but a little preparation can go a long way.
LTC Consumers are from Venus …Where Do the Rest of Us Come from?
by Robert L. Kane, MD
(This editorial originally appeared in the Fall 2015 edition of Old News)
I have staunchly maintained that real progress toward improving long-term care (LTC) will require a new public dialog that starts by identifying what we truly want from such care. As Atul Gawande, author of Being Mortal, puts it, we need to ask the right questions. As a small step in that direction, I have been conducting a simple exercise with various groups wherein I ask them to write down 3 – 5 words that best describe the attributes they would like to see in a good LTC system.
When I do this with consumers, they tend to write words like choice, autonomy, respect, competence, dignity, control, informed risk-taking. And when I discussed such goals with the provider-dominated Minnesota Leadership Council on Aging, they too came up with a set of core values that resonated with these same constructs valued by consumers. I was thus quite surprised recently when I posed the same challenge to a gathering of geriatricians from different disciplines. Their lists were much more narrow and composed of words like less regulation, funded mandates, livable wages, better training, private rooms (with baths), care at home.
I am not sure how to explain the lack of big-picture thinking among the geriatricians. Maybe they feel beaten up and unappreciated. I feel their pain. But I despair at what it seems to have wrought. If our geriatric medical leaders are not at the front of the pack pressing for more innovative solutions that affect the whole of a person’s meaningful life, how can we hope to reframe the discussion? How can we get lay people to see that good care can make a big difference and is worth investing in?
Yes, we need more and better trained staff. But real change will require goals that transcend simply giving more care. We also need to make the lives of receiving that care more worth living. LTC is being increasingly linked with disability care (witness the newly merged Administration for Community Living). Persons with disabilities demand the right to a full measure of life’s social opportunities. Can some of that social expectation rub off on frail older people who need assistance? Assistance and support should not have to come at the cost of what is meaningful to its recipients.
I don’t want to sound like Pollyanna and deny that many of the aspects of LTC and end-of-life are harsh and difficult, because they are. But programs like hospice care have shown that they can still provide meaning and comfort despite difficult realities. Shouldn’t we seek the same for LTC?
The View from Here: Model Retirement
by Robert L. Kane, MD
(This editorial originally appeared in the Summer 2015 edition of Old News)
The past several issues of Old News have featured inspiring stories of people who have retired, for the most part successfully. We must bear in mind, however, that these people are outliers. They are accomplished professionals with adequate incomes. Normal retirements are typically much more stressful. Many people look forward to stopping their work, which is often simply a means of acquiring an income. Many reach retirement age with minimal savings. A recent estimate from the Kaiser Family Foundation suggests that as many as 45% of those aged 65+ are officially in poverty. They are hardly well positioned to enjoy retirement or withstand the first blow of a serious illness.
This finding makes the plans for the upcoming White House Conference on Aging (WHCOA) all the more disappointing. The conference, scheduled for July, will be barely a shadow of its former self, relegated to a single day rather than the week-long occasion it once was. Past conferences were meaningful opportunities for taking stock of important issues and proposing solutions to respond to upcoming challenges. Thanks to demographic and economic trends, we certainly have plenty of the latter.
Listening to presentations over a day is hardly the same as coming together in person with sleeves rolled up for a week of active problem solving. This year’s four topics of focus include healthy aging, improved health and social services, elder justice, and income security. These are good areas to focus on, but not to simply summarize what has been done. Each of these topics demands our attention, not only to recent accomplishments but also and more importantly to the gaps, challenges, and opportunities for doing better. Demographic and economic forces will not allow us to stay the course. Innovation and creativity are needed. We need to raise public consciousness about these issues and suggest reasonable ways to meet the challenge of the next decades.
Following the central mandate from Washington, DC, the Board on Aging has been gathering community input and feedback through listening sessions, but this year’s vastly truncated WHCOA format allows no opportunity to evaluate all that has been heard or to prepare thoughtful responses and proposals. At a time when we need creative thinking and innovative ideas, we are still at the stage of tabulating opinions. This is a tragic lost opportunity created in large measure by unwillingness to fund the conference as in past years. How can we afford to simply give lip service to what is one of the major social challenges of the next decades? We need active, impassioned, thoughtful public dialogue if we are going to generate the support we need to make the changes we want to get a system that is fair and effective. All four of the focus areas command attention. All four need creative ideas. We can afford neither to continue down the road we have taken, nor to deviate from our commitment to improving the lives of older people in need of care and resources.
Each of us should take every opportunity to tell people about the problems that older adults face and to suggest ways to solve them. It would be wonderful if someday soon most Americans could describe their retirement years in terms similar to those used on these pages. In the meantime, we need to work on ways to better address the challenges of long-term care. (See the story on the Long-term Care Re-think Tank in this issue.) If WHCOA won’t do it, each of us needs to become a spokesperson to raise public awareness about the needs and the opportunities to improve the lives of older people.
The View from Here: Dealing with Mortality
by Robert L. Kane, MD
The last several issues of Old News have featured wonderful stories about how people have approached retirement and all that it implies. In other words, how people navigate the last phase of their lives. Personally, I know I seem to spend more time of late at funerals and memorial services for friends and colleagues.
Different people approach the end of their lives differently. Some have a bucket list. Some just want to kick back and enjoy the time that remains, perhaps being nearer to family. Some just want to be warm.
Then there are those of us who still see a list of things undone, who want to leave an imprint. Such thinking is obviously a naive act of hubris. Most of us are quickly forgotten. One need only meet with a group of students to appreciate how fast the past is consigned to oblivion. I am tempted to revise George Santayana’s famous quote about those forgetting the past being condemned to repeat it to suggest instead that those ignorant of history are blessed with a constant sense of discovery.
Still, the urge to leave a legacy persists. This is at least part of the reason we have children. It is the reason we teach and mentor, this hope that we can help shape the next generation who will do things better.
As I think about what I can offer to the upcoming generations of researchers and thinkers about long-term care, I know it will not be methods. Like my grandchildren, young researchers can run circles around me in using technology to analyze questions. Hopefully I offer wisdom and insight. How do you dare to address that which is important rather than safe? How do you avoid choosing problems or questions simply because you have the perfect analytic technology or a handy data set?
Looking back over a half century of work in long-term care, we have come a long way; however, the basic issues have not changed. Our initial assumptions have shifted away from a belief in institutions, and we talk more about person-centeredness, but we continue to overprotect and infantilize older people. We are fixated on cost rather than what we hope to buy.
One of my favorite jokes is about the difference between an optimist and a pessimist. An optimist believes this is the best of all possible times, and a pessimist fears that that is true.
As a certified optimistic pessimist, I want to encourage people to think more about first principles. It is time to deconstruct our views of dominant institutions. Let’s take the fundamental elements of care and build new approaches that incorporate values of dignity, autonomy, respect, compassion, and concern, not to mention competency.
I want to use the remainder of my professional career pressing for constructive, meaningful change in a broken long-term care system. Heaven knows I will need lots of help. Fortunately, I keep finding like-minded people. I would love to attract more.