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![Page 1: 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.](https://reader035.fdocuments.in/reader035/viewer/2022062409/5697c00c1a28abf838cc8f8c/html5/thumbnails/1.jpg)
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
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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
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Outline•Major Activities•Respondent Characteristics•Challenges, Policy, and Reform•Discussion
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Major Activities•Instrument Construction•Sample Frame Development•Survey Administration
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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
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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
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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
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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%
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Respondent Characteristics
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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%
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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%
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Family Members/Friends Served by Long-
Term Care System
11.4%
88.6%
No
Yes
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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%
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Gender
39.4%
60.6%
Male
Female
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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%
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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%
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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%
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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
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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
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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%
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Challenges
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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%
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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
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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
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Policy & Reform
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Potential Areas of Reform
• Financing• Linking Individuals and Families to Services• Physical and Organizational Change• Workforce Recruitment and Retention• Quality Improvement and Regulation
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Financing
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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
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How much do you oppose or favor specific strategies for paying for
LTC? TOTAL
Percent ‘Favor’/‘Strongly Favor’1
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
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How much do you oppose or favor specific strategies for paying for
LTC? GENERAL ROLE
Percent ‘Favor’/‘Strongly Favor’1
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
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Linking Individuals/Families to Services
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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
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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%
1Response Options: Not at all Effective, Slightly Effective, Moderately Effective, Effective, Very Effective
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How effective would the following strategies be for supporting informal
caregivers? GENERAL ROLE
Percent ‘Effective’/‘Very Effective’1
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%
1Response Options: Not at all Effective, Slightly Effective, Moderately Effective, Effective, Very Effective
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Do you feel the LTC system should be rebalanced away from institutions
toward HCBS? TOTAL
No
Yes
83.8%
16.2%
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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
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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%
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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
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Physical & Organizational Change
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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
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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
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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
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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
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What are the top three barriers to resident-centered care or culture
change in NHs? TOTAL
Percent Ranking in Top Three
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%
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Workforce Recruitment & Retention
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What are the top three most effective options for improving recruitment/retention
paraprofessionals? TOTAL
Percent Ranking in Top Three
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%
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What are the top three most effective options for increasing the proportion of
professional trainees? TOTAL
Percent Ranking in Top Three
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%
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Quality Improvement & Regulation
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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
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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
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Do you think the regulation of ASSISTED LIVING FACILITIES in your area should be more stringent? TOTAL
No
Yes
67.7%
32.3%
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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%
1Response Options: Not at all Effective, Slightly Effective, Moderately Effective, Effective, Very Effective
2Excludes those who thought the regulation of assisted living facilities need not be more stringent
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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
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How effective would the following be for ensuring and improving the quality
of care provided in LTC? GENERAL ROLE
Percent ‘Effective’/‘Very Effective’1
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%
1Response Options: Not at all Effective, Slightly Effective, Moderately Effective, Effective, Very Effective
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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.
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Summary Observations
•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
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Summary Observations
•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
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The Future?