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We Are the Ones: Keynoter Promotes Collaboration in Times of Change

2017; Elsevier BV; Volume: 19; Issue: 1 Linguagem: Inglês

10.1016/j.carage.2017.12.001

2377-066X

Joanne Kaldy,

Healthcare Policy and Management

Cheryl Phillips, MD, CMDR, took the title of her keynote address for AMDA — the Society for Post-Acute and Long-Term Care Medicine’s 2018 Annual Conference from a Hopi prayer that speaks to the importance of having the knowledge, strength, and wisdom to face the challenges we encounter rather than relying on someone else to rescue us. Her presentation, “We Are the Ones: The Future of PA/LTC and Our Role in Leading the Change,” is designed to empower post-acute/long-term care practitioners to be strong leaders moving into a world of value-based, high-tech medicine. “We are the ones we’ve been waiting for,” she said. “We who are the experts in this setting; we know the residents, family, care teams, and regulatory environment better than anyone. If we don’t guide decisions and policy moving forward, outside forces will devise solutions for us that work for them but not necessarily for our patients or us.” As a Society past president and a longtime leader in PA/LTC medicine, Dr. Phillips has worn many hats and navigated numerous changes and challenges over the years. Caring sat down with her to reflect on the past, present, and future of the profession and the Society that represents it. She started by noting, “In some ways, I’m no longer of the Society. I’m not a medical director anymore; I’m on the outside looking in, and I have an outsider’s appreciation of the complexity of systems of care and the changes faced, not just by PA/LTC facilities but also hospitals, payers, insurance companies, and others. Everyone is trying to a do a piece of the work, but there is little coherence or coordination. Being an outsider, I understand these components better now; and I understand that the cohesion is much more difficult than I realized.” Dr. Phillips acknowledged that “we are still working on how to fit all of the pieces together.” She noted that PA/LTC practitioners have always felt outside of the mainstream, and they are struggling for a sense of purpose and to find their place in this strange new world. Nonetheless, Society members have a head start on succeeding in a world where they must interact effectively with many partners. “We have long embraced teamwork, and the Society has invited team members beyond physicians — nurse practitioners, physician assistants, pharmacists, dietitians, and others — into its membership,” Dr. Phillips told Caring. By embracing all team members, she said, the Society puts them on the same page with consistent data, news, and information, as well as a common understanding of everyone’s roles and the possibilities for collaboration and partnerships. “The success of PA/LTC is driven by team-based care delivery,” she said. Although the Society is appropriately no longer just about medical directors, said Dr. Phillips, the organization’s origin was appropriate and necessary. “We needed to start with medical directors because it was a competency that wasn’t recognized or valued, and it needed to be defined,” she said. “We don’t want to lose our legacy, and we don’t want to abandon it. The medical director still plays a vital role. But as an organization we need to be bigger than that. “When each discipline is creating its own curriculum and training programs, everyone comes in seeing themselves as experts, but without understanding what others do or how they can work together. This just serves to fragment care delivery further,” she told Caring. By bringing various disciplines and practitioners to the table, giving everyone a seat and a voice, “we create a stronger community of care. I’m excited about that.” The Society and its members have made much progress over the years. Through the efforts of the organization and its members, the Centers for Medicare & Medicaid Services, the Medicare Payment Advisory Commission (MedPAC), and many legislators have gained a greater understanding of long-term care medicine. However, Dr. Phillips noted, there still is a lack of awareness about the competencies necessary in this care setting. “We have to differentiate our expertise. Payers are beginning to understand the value of specially trained practitioners on quality care in this setting, but the public and health care system at large are still struggling to understand this role.” There are challenges ahead, of course. “Personally, I’m worried about what is happening with Medicaid,” said Dr. Phillips. Clearly, these concerns are not unfounded. In their efforts to repeal and replace the Affordable Care Act earlier this year, House Republicans proposed a fundamental change in the way the government has financed Medicaid for more than 50 years — calling for caps on how much states get per Medicaid enrollee, based on how much the state spent on the program in 2016. Later, the Senate’s health care reform efforts, called the Better Care Reconciliation Act of 2017, also included proposals for significant reductions in Medicaid. The Senate’s plan would have phased out the enhanced federal funding for Medicaid expansion and limited federal Medicaid funding through a per capita cap or block grant. The Society has formally opposed all such attempts to place caps on Medicaid or create a block-grant system. Although these repeal and replace efforts ultimately failed, both House and Senate Republicans have signaled that Medicaid cuts are on the table. At press time, a tax bill being supported and promoted by congressional Republicans and President Donald Trump could end up cutting spending for programs including Medicaid. As this program covers more than 70 million Americans, many of them elders, such deep cuts would have widespread implications. “As Medicaid is negatively impacted, it will in turn affect the quality of and access to long-term care for those who need it most,” said Dr. Phillips. Another key concern, said Dr. Phillips, is how providers are measured and assessed. This brings up a plethora of questions. What are the measures of quality? What do we need to be reporting? Who do we need to be collaborating with? How will all this impact how we practice? “Quality measurement is messy and complicated, and it’s not going away. The measurement discussion of late is huge,” she said. “The Society’s role is critical in interpreting this for post-acute and long-term care practitioners and ensuring we have a voice in these discussions moving forward.” She further noted, “I worry that those without a voice will get lost in all of the quality measurement discussions, so our voice is essential. We need to be able to measure what matters and not just what impacts costs — such as resource utilization and lengths of stay.” Technology has improved the ability to document and, to some degree, share data, but Dr. Phillips stressed the need to ensure that care remains high-touch even as it becomes increasingly high-tech. “EHRs [electronic health records] are significant and have provided a wealth of information, triggers, and compliance reminders. They have become an important platform for extracting information for quality measures. But they also have created a cut-and-paste phenomenon, where everything is carried over from prior input.” In reality, she pointed out, “people are dynamic, and lives are dynamic; but often when I look at EHRs, everything looks static.” Strategies to use technology to encourage engagement with patients and population health strategies are needed, “so we can spend more time one-on-one with the people we care for,” she said. The changes in the PA/LTC world have been significant over the years. Dr. Phillips said the Society’s founders would hardly recognize their profession and practice today. “Billy Dodd [the Society’s founder and first president] was an old-style physician who worked hard, saw lots of patients, and did fee-for-service billing. He worked in a world where regulations were just starting to address quality. He never worked in population-based health, and I don’t think he would recognize the PA/LTC environment today.” However, she added, “he would appreciate the value of recognizing the physician’s role and would embrace the team approach to care and involvement of nurse practitioners and others as vital.” James Pattee, MD, CMD, an early Society leader and father of the certified medical director and core curriculum programs, “picked up where Dr. Dodd left off,” she said. “He believed that we needed competencies and the curricula to support them. He would value the quality measurement work being done today, but he would be frustrated that it doesn’t measure what good quality in a nursing home looks like.” She noted that both Society pioneers would be “distrustful of payment strategies that only look to reduce costs but don’t have quality embedded in them.” So even though the founders might not recognize the industry they once had supported, “They would be proud of how the Society and its members have built on what they started and our commitment to continuing and expanding on their early visions,” Dr. Phillips said. And she believes they would be pleased that commitment to patients and providing the best possible care pervade and guide “everything we do.” She said it is important to reflect on and learn from history, but “wanting the world to go back to the way it was is not the strategy for success. The biggest value of our Society is helping people navigate tumultuous practice in a rapidly changing world,” Dr. Phillips said. “We need to get back to the idea that you can’t do this alone. More than ever, we need each other.” Dr. Phillip’s keynote address is scheduled for 8 a.m. on Friday, March 23. Joanne Kaldy is a senior contributing freelance writer in Harrisburg, PA. Let me walk in beauty, and make my eyes ever behold the red and purple sunset. Make my hands respect the things you have made and my ears sharp to hear your voice. Make me wise so that I may understand the things you have taught our people. Let me learn the lessons you have hidden in every leaf and rock. I seek the strength, not to be greater than my brother/sister, but to fight my greatest enemy — myself. Make me always ready to come to you with clean hands and straight eyes. So that all that we do now must be done in a sacred manner and in celebration. We are the ones we’ve been waiting for.