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Harvard expert discusses innovations in long-term care

November 20, 2022
by Amelia Lower

The Yale School of Public Health’s annual Dean’s Lecture and Program on Aging seminar was delivered this year by Harvard Professor David Grabowski, a leading national expert in health care policy and long-term care.

Titled “Innovations in Long-Term Care for Older Adults,” the event featured a conversation about new approaches to nursing home and long-term care. Grabowski is a professor of health care policy at Harvard Medical School, where he teaches health care policy and, in his research, studies the economics of aging, with a focus on long-term and post-acute care.

“I think everyone would agree that as we all become older and need more assistance from others in daily functioning that there needs to be high quality and accessible long-term care options,” said YSPH Associate Professor of Public Health (Social and Behavioral Sciences) Joan Monin, director of the YSPH Social Gerontology and Health Lab. “Unfortunately this is not how things currently work in our country. It was helpful to hear from Dr. Grabowski about the roadblocks in policy and payment structures that stop this from occurring.”

A recording of the Dean's Lecture can be viewed here.

YSPH Interim Dean Melinda Pettigrew, PhD ’99, began the event by introducing the Dean’s Lecture series. This year’s event was the 11th jointly-held lecture, sponsored by both the School of Public Health and the Yale School of Medicine’s Program on Aging.

The Program on Aging’s research looks into how we will collectively move forward in the space of long-term care to ensure that people are guaranteed a minimum standard of care throughout their lifetimes.

The program’s research has recently focused on studies exploring how to obtain data from clinical trials to improve care in a community-based setting, a point of interest deeply shared by Grabowski.

“Dr. Grabowski has been a thought leader on improving long-term care, which is an issue that will affect all of us at some point,” Yale School of Medicine Assistant Professor Dr. Brienne Miner said. “His lecture clearly identified the hurdles we need to overcome, and his vision for how long-term care might look with more investment of resources and through initiatives like the Green House Project, is inspiring.”

Yale Program on Aging Director Dr. Thomas Gill then introduced Grabowski. Grabowski originally worked at the University of Alabama Birmingham after receiving his BA from Duke University and PhD in public policy from the Irving B. Harris School of Public Policy at the University of Chicago before making his way to Harvard.

Grabowski has published over 200 peer-reviewed articles, appearing in the Journal of Health Economics, the New England Journal of Medicine and the Review of Economics & Statistics. He is an authority on nursing home and long-term care, and much of his recent work has focused on the effects of the COVID-19 pandemic.

“David Grabowski offered profound insights into tackling America’s long-term care crisis and its worsening after the pandemic,” Associate Professor of Public Health (Health Policy) Xi Chen said. “He called for substantial innovations in integrated payment and delivery models, financial accountability, [and a] sustainable workforce, [which is] at the core of fixing the broken long-term care system.”

During the lecture, Grabowski said there is a lack of innovation in nursing homes and long-term care. He attributed the lagging of investment in long-term care to four main issues: low Medicaid payments, a lack of policy prioritization, a lack of demand responsiveness, and a fragmented financing system.

Grabowski noted that there are negative non-Medicare margins and thin margins for all payers of insurance. He also mentioned that most nursing homes are not part of our health care system, which creates a problem when it comes to guaranteeing quality care to Medicare recipients.

“There are some real barriers to both innovation occurring and then being widely implemented,” Grabowski said. “I wanted to use two examples from my research to further this point. The first was an intervention we studied on off-hour telemedicine coverage in nursing homes, and the second is a model called the Green House Project.”

Because nursing homes often have a limited clinical presence on weekends and evenings, the rate of avoidable hospitalizations increases during that time. Off-hour clinical coverage could help avoid such issues; face-to-face contact over video [telemedicine] often prevents the need for a visit to the hospital.

Despite the benefits of the program, if nursing homes pay for the telemedicine intervention while only Medicare reaps the benefits and savings, the investment in the intervention would be limited and unsustainable, Grabowski said.

Another issue Grabowski mentioned was concern about the quality of care provided by some nursing homes such as unrelieved pain, poor end of life care, missed changes in condition, preventable functional decline, and poor quality of life for patients. His proposed solution is the Green House Model.

“The Green House Model … takes this traditional nursing home model and flips it on its head,” Grabowski said. “What Green House does is it totally re-designs the structures, roles, and processes of a nursing home.”

The program empowers the residents in nursing homes, while also eliminating the hierarchical nurse staffing structure, which then also empowers the core staff to manage daily life in each home using a universal worker model.

Each home consists of eight to 12 older adults, who live together in “what is really their home,” he said. These homes can appear in any neighborhood and replace larger nursing homes with spaces featuring kitchens, gardens, and individual rooms for residents.

In his research, Grabowski found Green House Project homes lowered total and avoidable hospitalizations by 18% and lowered readmissions by 59%. There was also a decrease in Medicare spending of 30% per resident per year. Yet, there are still not many Green Houses nationally.

“Dr. Grabowski’s visit stimulated a lot of discussion about potential collaborations among investigators in the School of Public Health and School of Medicine, which is one of the objectives of this co-sponsored visiting professorship,” said Gill, the Humana Foundation Professor of Medicine (Geriatrics) at the Yale School of Medicine..

Shifting to the pandemic, Grabowski mentioned many issues in nursing homes, such as frail older adults living in close proximity to one another with limited personal protection equipment (PPE) and a shortage of staff members and clinicians. The pandemic affected facilities with and without outbreaks. There are now 340,000 fewer nursing home workers in the United States than there were at the start of the pandemic, Grabowski said.

Two approaches during the pandemic that were efficient and effective were the implementation of telehealth visits and Green Houses, Grabowski said, as countries with bigger nursing homes had more nursing home deaths.

Grabowski concluded by saying that sustained long-term care innovation will not occur without major system-level change. He looks forward to seeing changes that will reform and transform the current nursing home and long-term care system.

“Ensuring long term care for older adults is so important,” Monin said. “We need to be working together from different disciplines to figure this out, and we need to do it now.”

Submitted by Colin Poitras on November 21, 2022