Health Progress - Winter 2021

JOURNAL OF THE CATHOLIC HEALTH ASSOCIATION OF THE UNITED STATES

HEALTH PROGRESS www.chausa.org

WINTER 2021

Aging and

LONG-TERM CARE

To celebrate the 5th Anniversary of CHA’s Guiding Principles for Conducting Global Health Activities, CHA HAS TWO NEW RESOURCES! A 5th Anniversary Edition of the Guiding Principles INCLUDES A MODERN DAY PARABLE ON PANDEMIC

An Essay Collection to help us rethink, reset and re-engage in Global Health activities!

Among the many influential voices in global health, authors include Cardinal Peter Kodwo Appiah Turkson, Prefect of the Dicastery for Integral Human Development, and Andrew S. Natsios, former Administrator of the U.S. Agency for International Development.

ACCESS THEM AT CHAUSA.ORG/GLOBALHEALTH

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WINTER 2021

FEATURES

AGING AND LONG-TERM CARE

50 NEXT GENERATION OF MISSION INTEGRATION: CHA’S NEW COMPETENCY MODEL FOR MISSION LEADERS BRIAN P. SMITH, MS, MA, MDiv 57 IN-DEMAND CHAPLAINS ADJUST THEIR APPROACH DAVID LEWELLEN

DEPARTMENTS 2 EDITOR’S NOTE MARY ANN STEINER 61 HEALTH EQUITY Building Trust for Vaccine Rollout KATHY CURRAN, JD 64 ETHICS A Closer Look at the Authority of Church Teachings NATHANIEL BLANTON HIBNER, PhD 66 COMMUNITY BENEFIT Community Health Improvements — Don’t Forget Seniors JULIE TROCCHIO, BSN, MS 69 THINKING GLOBALLY The Guiding Principles BRUCE COMPTON Excellence SR. MARY JO McGINLEY, RSM, MS Ed, MPH 73 AGE FRIENDLY New Standards for Age-Friendly Surgical Care LINDSEY ZHANG, MD, MARCUS ESCOBEDO, MPA and MARCIA M. RUSSELL, MD

Illustrations by Jon Lezinsky

4 SPONSORS AND THE CRISIS IN LONG-TERM CARE: IS THIS A ‘MAN FROM MACEDONIA’ MOMENT?’ Charles E. Bouchard, OP, STD, and Alec Arnold, PhD(c)

11 POPE FRANCIS 76 PRAYER SERVICE

12 HAPPILY EVER AFTER Sr. Julia Upton, RSM, PhD, MPH 18 PANDEMIC IS A TRAGEDY AND A CHANCE TO RETHINK LONG-TERM CARE Howard Gleckman 24 NURSING HOME CARE AND ITS FINANCIAL HEALTH John Morrissey 31 MARY IMMACULATE’S TEAM EXHIBITS CATHOLIC CARE IN PANDEMIC RESPONSE Suzanne Dumaresq 36 THE AGING OF AMERICA REQUIRES PERSONAL, CULTURAL AND POLICY CHANGES Ruth E. Katz 42 PACE EXPANSION CAN MEET GROWING NEEDS OF FRAIL OLDER ADULTS Shawn M. Bloom 46 REFLECTION: GROWING OLD Msgr. Charles J. Fahey

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IN YOUR NEXT ISSUE

CARING FOR THE CAREGIVERS

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EDITOR’S NOTE

M

aybe I’m listening and pondering things more, or maybe the readings of the season just past raised glad tidings in different ways for me this year. Because the stories that struck me were the ones about the old people who appear in the stories that precede and follow the miracle birth, the characters whom only the evangelist Luke describes.

First there was Elizabeth, Mary’s much older cousin, living with the shame of her age and barrenness. And there was Zechariah, her even older husband, made mute from the moment he doubted the prophecy of Elizabeth’s pregnancy until MARY ANN he affirmed the baby’s name as STEINER John, all at the sport of family and neighbors who wondered if he’d slipped into senility.

Then there were ancient Simeon and the prophetess Anna. Simeon had been promised by God that he wouldn’t die until he beheld the Messiah, so when his parents placed Jesus in Simeon’s arms, the old man recognized the baby as the one he’d been waiting for. Anna, an aged widow who took up residence in the Temple to await the Messiah, saw him and prophesied the greatness he would bring to God’s people. The respect Jerusalem’s Jews had for Simeon and Anna’s announcement that the Savior had arrived was a way for Luke to acknowledge the truth of the promise being fulfilled.

The humiliation of Zechariah and Elizabeth compared to the regard for Simeon and Anna is not so different from how older people in the United States are perceived and cared for today.

The divide is wide between those who are held up as wisdom characters and beloved mentors and others who are alone, living in situations of compromise and confinement, who never thought the hard work and planning of their middle years would yield the end stage they find themselves in.

There is a crisis in the care of elderly people in the way they are insured (or not), in the limited options for housing, in transitions of support and care, and especially in the financial arrangements that force many older people to fall into poverty and limited options in their old age. Like other disparities in our society, the pandemic has shone a harsh light on the inequities of aging in America.

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Medicare, the federal program for senior health care, and Medicaid, the federal program of health care for low-income citizens, were signed into law in 1965. That year the average life expectancy was 70 years, generally just a few years after expected retirement age. With the life expectancy in the U.S. approaching 80 years and expected to go up, the safety nets created to support seniors and people with certain illnesses or disabilities are being stretched to accommodate health care costs for many more years per person than originally expected.

Health care for the elderly has become what is known as a “wicked problem.” Wicked problems don’t exist in math, logic or the hard sciences, only in the social sciences, policy and planning. The solutions to wicked problems are never simply true or false, just good or bad, better or worse.

What has Catholic health care to do with all of this? Very much. The Catholic health ministry begins with the dignity of every person, and especially vulnerable persons who may be ill, troubled, aged or poor. Older people are often all of those things, which means they need a special kind of care and protection that our ministries have been rendering since the founding of the first Catholic homes for the elderly in the U.S. in the 1840s.

Now many of the Catholic nursing homes and long-term care facilities are closing, being sold, or being reconfigured for a payer mix that will keep them viable. How those developments can be kept true to our ministry, how to explore the opportunities for aging well, how to finance the facilities our elders need, how to pursue policy changes that improve care and what role Catholic health care may need to relinquish or remake are topics you can explore in this Winter 2021 magazine.

Before you delve into the articles though, turn to page 11 and consider Pope Francis’ exhortation to the young and hearty about the honor and love they should give to parents and grandparents.

Then go and do likewise.

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Association Media & Publications EXCEL: Best Special Issue, Bronze Produced in USA. Health Progress ISSN 0882-1577. Winter 2021 (Vol. 102, No. 1).

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EDITORIAL ADVISORY COMMITTEE Kathleen Benton, DrPH, president and CEO, Hospice Savannah, Inc., Savannah, Georgia Sr. Rosemary Donley, SC, PhD, professor of nursing, Duquesne University, Pittsburgh Fr. Joseph J. Driscoll, DMin, director of ministry formation and organizational spirituality, Holy Redeemer Health System, Meadowbrook, Pennsylvania Marian Jennings, MBA, president, M. Jennings Consulting, Inc., Malvern, Pennsylvania Tracy Neary, regional vice president, mission integration, St. Vincent Healthcare, Billings, Montana Sr. Kathleen M. Popko, SP, PhD, president, Sisters of Providence, Holyoke, Massachusetts Laura Richter, MDiv, system senior director, mission integration, SSM Health, St. Louis Gabriela Robles, MBA, MAHCM, vice president, community partnerships, Providence St. Joseph Health, Irvine, California Michael Romano, national director, media relations, CommonSpirit Health, Englewood, Colorado Linda Root, RN, MAHCM, chief mission integration officer, Ascension Michigan, Warren, Michigan Fred Rottnek, MD, MAHCM, director of community medicine, Saint Louis University School of Medicine, St. Louis Becky Urbanski, EdD, senior vice president, mission integration and marketing, Benedictine Health System, Duluth, Minnesota

CHA EDITORIAL CONTRIBUTORS ADVOCACY AND PUBLIC POLICY: Lisa Smith, MPA COMMUNITY BENEFIT: Julie Trocchio, BSN, MS CONTINUUM OF CARE AND AGING SERVICES: Julie Trocchio, BSN, MS ETHICS: Nathaniel Blanton Hibner, PhD; Brian Kane, PhD FINANCE: Loren Chandler, CPA, MBA, FACHE INTERNATIONAL OUTREACH: Bruce Compton LEADERSHIP AND MINISTRY DEVELOPMENT: Brian P. Smith, MS, MA, MDiv LEGAL: Catherine A. Hurley, JD MINISTRY FORMATION: Diarmuid Rooney, MSPsych, MTS, DSocAdmin MISSION INTEGRATION: Dennis Gonzales, PhD THEOLOGY AND SPONSORSHIP: Fr. Charles Bouchard, OP, STD

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AGING AND L O N G -T E R M C A R E

Sponsors and the Crisis in Long-Term Care

Is This a ‘Man from Macedonia’ Moment?

CHARLES E. BOUCHARD, OP, STD, and ALEC ARNOLD, PhD(c)

W

e are in the midst of an unprecedented public health crisis that is changing our personal lives, our economy and our health care system. This is particularly true of elder care, which has been described as “ground zero” for the COVID-19 virus.1 The COVID-19 pandemic did not cause the crisis in long-term care, but it did exacerbate it and expose many of its latent flaws. Society as a whole must face this problem, but we believe that sponsors in Catholic health care should ask themselves whether a crisis of this magnitude is a call to rethink their role and their responsibility.

DECLINING CATHOLIC INVOLVEMENT IN ELDER CARE

Changes in the delivery and funding of elder care have long been in order, but the spotlight recently shone on the vulnerability of so many of our elders underscores the need for radical transformations. Bill Thomas, a famous innovator in longterm care, said in a podcast that “this pandemic will change long-term care forever — inside and outside.” He said the consequences are like “flipping the game board,” and starting all over.2 If the board is flipped, we want to ask: as the pieces are reassembled, where will the Catholic role in elder care fit?

There are some outstanding Catholic longterm care ministries, including Benedictine Health Service, Carmelite Sisters of the Aged and Infirm, Franciscan Ministries and Trinity Health’s extensive PACE program. Their stories show what quality care looks like and also that quality care is achievable, even with our current payer mix. But our presence is much less than it used to be.

Catholic systems and sponsors have steadily divested themselves of long-term care and continue to do so. According to research conducted

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by the investment firm Ziegler, over the past decade there have been 90 Catholic-sponsored facilities that have converted, at least 70 of which either sold to a for-profit entity or closed entirely.

Of the remaining transitions, only about half (or 11% of the whole) affiliated with another Catholic organization.3 Given the difficulty in tracking every shift of ownership or management across various systems, such data has its limits; and yet public announcements about ministries in transition continue apace. The Little Sisters of the Poor recently initiated plans to phase out of their long-term commitments in Richmond, Virginia, (where they have served since 1874) as well as in San Pedro, California.4 In short, while a number of things contributed to our current situation, the diminishing presence of Catholic elder care is cause for concern (see Figure 1 on page 6).

FINANCIAL ISSUES AND CARE QUALITY

Long-term care as we know it today started with the establishment of Medicaid and Medicare in the 1960s. For many of the nation’s elderly, such programs were an improvement over board and

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Figure 1

STATUS OF SPONSORSHIP TRANSITION AMONG CATHOLIC PROVIDERS Sale to For-Profit, 60%

Closure, 18% Acquisition of a For-Profit, 1%

Nonprofit Affiliation with Another Nonprofit, 21%

Across the past 10 years, nearly 90 Catholicsponsored facilities have changed owner/sponsor Of those that have gone to another nonprofit sponsor since 2010 (21%): 53% with another Catholic organization 24% have affiliated with a faith-based non-Catholic sponsor 23% with a not-for-profit that was not faithbased Source: Ziegler investment banking, 12/31/2019

care facilities (residential group homes that often don’t have nursing and medical care on site), but they were never intended to support a comprehensive array of elder services nor to provide for impoverished middle-income seniors.

Changes related to Medicaid and Medicare concretized a “nursing home model” of care, defined by institutional provision of skilled nursing alongside long-term residential services in licensed facilities, such that alternative arrangements (such as family-supported, home-based care) fell outside the scope of coverage.5 Nursing home chains soon emerged as the monolithic provider of elder care, with private equity and forprofit investors steadily absorbing most of the market.6 The investor model became predominant because of a strategy that focused more on real estate than health care. This was possible because often the property on which a care facility was

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located was more valuable than the services taking place therein. One report describes how this worked.

“Investors created new companies to hold the real estate assets because the buildings were more valuable than the businesses themselves, especially with fewer nursing homes being built.

Sometimes investors would buy a nursing home from an operator only to lease back the building and charge the operator hefty management and consulting fees. … [They] also pushed nursing homes to buy ambulance transports, drugs, ventilators or other products from other companies they owned.”7 This enabled the facility itself to show a respectably thin profit while the parent corporation made money through the management company.

This arrangement is eerily reminiscent of the business model that Ray Kroc developed for McDonald’s in the 1950s, portrayed in the movie “The Founder,” starring Michael Keaton. There is a scene in which Kroc realized, with the help of a savvy finance guy named Harry Sonneborn, that he could make far more money by leasing than franchising. Sonneborn tells him, “You’re not in the burger business, you’re in the real estate business. You don’t build an empire off a 1.4% cut of a 15-cent hamburger.” And the rest is history. Today there are just about as many McDonald’s as there are nursing facilities.8 It is not hard to see how some of the same strategies led to the acquisition of so many long-term care facilities and that these acquisitions did not always serve the best interests of residents. Along this line, Charlene Harrington of the University of California San Francisco led a 2011 study examining the quality of care provided by 10 companies responsible for an aging population that amounted to about 14% of all American nursing home residents.9 The study found that for-profit nursing homes were more poorly staffed and had greater deficiencies than other providers.

More recently, researchers examined the question, “Does Private Equity Investment in Healthcare Benefit Patients?”10 Using evidence derived specifically from nursing homes, the short answer was no. When private equity gets involved, care suffers.

The problem is obvious if you observe that most nursing homes operate according to a notoriously problematic business model, which hangs on getting the right mix of private pay, Medicaid and Medicare funders. Medicaid pays facilities much

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AGING AND L O N G -T E R M C A R E

less to attend to their long-term residents than Medicare will pay for short-term rehab patients.

Short-term patients with higher billable care are needed to compensate for the less lucrative longterm residents. On average, the mix of long-term residents to short-term patients is in the ballpark of 87% to 13%.11 This means the majority of beds are draining the provider of money, while 13% of the beds — used for those short-term, post-acute patients in rehab or recovering from illness — are responsible for financial viability.

In the past, private payers helped the dynamics of the spreadsheet, but in recent years, many people with the capacity to pay have opted for other arrangements. The longer and healthier lifespan of the boomer generation is inspiring major changes in the way elder care is conceived, arranged and accessed.

For the poor and vulnerable, however, too few options are available. As COVID-19 has made clear, the aging poor are dangerously dependent on a system structured to prioritize its own financial interests over the care of patients.12

CONCEPTUAL PROBLEMS

a wide range of problems in the quality and accessibility of care.

Nevertheless, a conceptual distinction persists between the acute care setting and the elder care context—even though, paradoxically, nursing homes are still viewed and often managed as “little hospitals.” The president of the Society for Post-Acute and Long-Term Care Medicine recently pointed out that “hospital systems really do not know that much about the nursing environment,” and that hospital-based providers “keep on forgetting” that nursing homes are “not mini-hospitals.”13 The prevalence of this hospital paradigm has limited the creativity that would lead to truly effective and comprehensive senior care.14 Long-term care also suffers from an image problem, which no doubt contributes to its funding problems. It is easy to celebrate a high-specialty children’s hospital where smiling children are discharged after surgery or chemotherapy to treat a brain tumor. Long-term care has less media appeal. Recent deaths arising from the COVID19 crisis have made things even worse. And yet, would anyone argue that the child is less vulnerable or more valuable than an aging senior?

A number of efforts have already been underway, aiming to reconceive what long-term care can look like in the future. The goal will extend beyond housing and medical care, but will manage what Msgr. Charles Fahey, a pioneer in longterm care, describes as “progressive intermittent frailty,” in a variety of settings.

Notable bright spots here include CHA’s partnership with The John A. Hartford Foundation, the American Hospital Association and

In addition to these financial issues, there are also conceptual problems. For example, we don’t even know what to call whatever is not acute care.

In the past the nursing home (or just “the home”) was the place you went when acute care could do no more for you. Many people still see it as the place they never want to be. Yet elder care today encompasses a wide variety of services ranging from true long-term, skilled nursing care, to assisted living, to PACE programs, to “high acuity assisted living” (“aggressive symptom management in patient’s preferred setting”) to short-term rehab care, which As COVID-19 has made clear, often takes place in the same facility as long-term care. the aging poor are dangerously Nursing homes now exist alongside dependent on a system structured life plan communities, adult day care, affordable housing options, freestandto prioritize its own financial ing memory care centers, and assisted living and home health programs that interests over the care of patients. enable “aging-in-place.” Rather than focusing strictly on skilled care at the end of life, the Institute for Healthcare Improvement in the many advocates have been working to realize a Age-Friendly Health System initiative, geared to vision of aging that is sufficiently comprehensive improving patient care policies,15 and The Pioneer while being driven by deeper values than those of Network, organized in 1997 to change the culture the market alone. As a case in point, LeadingAge of aging from a medical, institutional model to a has an illustrious history of organizing collabora- person-centered model. Bill Thomas’s work on tive relationships among nonprofit elder care pro- the Green House Project and the Eden Alternaviders, for the sake of finding creative solutions to tive do the same thing by different building design

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and a range of educational and training programs to put residents first.

Thomas says that “good health care is necessary, but it is not enough. Long-term care needs to be integrated into the health care system” rather than seen as an auxiliary enterprise.16 Home health care will also play a bigger role. Thomas says that in the future we are going to see “home and health care blended in surprising ways.”17 Indeed, we have not yet integrated many elements that are already at hand. Newer specialties, like hospice and palliative care, are still often stand-alone programs that have not been integrated into acute care or long-term care. Spiritual care, which could help bridge the gaps between acute care, palliative care and hospice, is often neglected in favor of medical solutions. As one commentator notes wryly, in addition to providing “real medicine and real nursing, that deal with real problems,” we also have to deal with “that other ‘squishy stuff’ like loneliness, helplessness and boredom.”18

POLICY REFORM

steps necessarily involve reconfiguring the ways in which Medicare and Medicaid programs invest in elder care across various settings. Some states attempted to allow Medicaid-funded care to be provided at home, for example, but funding has declined overall while a piecemeal approach to coverage has persisted, stymying opportunities for providing comprehensive coverage.

THE ROLE OF SPONSORS

The role of Catholic health care in long-term care is a sponsor question. Sponsors do not set policy or strategy, but they do hold the mission in trust.

It is their role to see that it is realized, and maybe even changed.

In CHA’s sponsorship formation video, “Go and Do Likewise,” Bishop Timothy Doherty refers to sponsors as “sentinels” who must assess their environment and community needs, and determine how the ministry of health care should respond.21 This is part of the prophetic role of the sponsor: to see what others do not see, to discern the spirit in the real situation in which we find ourselves.

Sponsorship implies a prophetic function—a capacity to exercise a forward-looking vision for where the health care ministry is being called.

COVID-19 poses several immediate challenges.

Legislators and policy makers at the federal level must focus on the various problems related to COVID — inadequate testing, lack of personal THE MAN FROM MACEDONIA protective equipment (PPE), medicine and space. The book of the Acts of the Apostles describes These things require funding as well as effective how the early Christians took up their leader’s management. Our failure in both areas is painfully mission, spreading the good news that God’s obvious right now as seniors and their families rule and reign had come in the person of Jesus. suffer anxiety and loss. Those of limited means All throughout the book of Acts, the narrative are at even greater risk. shows us how very human God’s missional work Reorganizing health care in a way that improves can be in the concrete: Plans are made; plans are elder care, integrates it with acute care, pallia- thwarted. Something is tried; it doesn’t work. New tive care and hospice and lowers cost is an enor- calls to ministry are made and accepted. mous long-term policy challenge.

In a recent interview with Senior Sponsorship implies a prophetic Housing News, Ascension Living function—a capacity to exercise a CEO Danny Stricker talks about all of these problems and makes some forward-looking vision for where the policy recommendations as well.

He describes how his organization health care ministry is being called. works with Ascension’s acute care and says these partnerships are invaluable. “As In Acts 16:6-10, a strange event takes place as long as we keep open the collaboration and com- the apostle Paul is sleeping. He and his team were munication with those organizations and govern- frustrated because they had been stalled from ing bodies that are supporting us now,” he says, “I making any headway into a certain region of Asia think we’re going to weather the storm just fine.”19 Minor. Paul has a vision, in which “a man from A number of constructive proposals have Macedonia” stands before him and says: “Come already been made and need to be explored, as over to Macedonia,” the man begs, “and help us.” to what “solving the nursing home crisis” ought Paul responds to this call and goes to Macedonia to look like in the aftermath of COVID-19.20 First where he preaches the Gospel.

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IS COVID-19 OUR MACEDONIA MOMENT?

The ministry of health care is a Gospel ministry, a tangible way of preaching the Gospel. Is COVID-19 a call to us to re-assess and re-imagine the future of Catholic involvement in elder care?

Can sponsors initiate a conversation about how we should respond and take action?

If a fresh sense of urgency is leading more of us in this direction, we should know by now that we can’t do it alone. This is a social issue, and so we will need to widen our conversation to include policy makers, politicians and voters so that our elders have everything they need to age gracefully. Closer to home, we will need to find new ways to collaborate with other ministries—Catholic Charities, education and local parishes—to help ensure that our elders lead not only longer lives, but better lives sustained by community and in a spirit of solidarity, leading ultimately to what we used to call a “happy death,” a death relatively free from anxiety and suffering, in the company of family and friends, and above all, enjoying the consolation of faith. All of us should have reason to hope for such an end, and so we all have a share in this mission of care and concern.

FR. CHARLES E. BOUCHARD, OP, is senior director, theology and sponsorship, the Catholic Health Association, St. Louis. ALEC ARNOLD is a doctoral candidate in health care ethics and theology at Saint Louis University and was recently the graduate intern in ethics at the Catholic Health Association, St. Louis.

NOTES 1. Michael L. Barnett and David C. Grabowski, “Nursing Homes Are Ground Zero for COVID-19 Pandemic,” JAMA, March 24, 2020, https://jamanetwork.com/channels/ health-forum/fullarticle/2763666.

2. Valerie Arko, “Transform Podcast #23: Dr. Bill Thomas, Founder of Minka,” Senior Housing News, April 8, 2020, https://seniorhousingnews.com/2020/04/08/transform-podcast-23-dr-bill-thomas-founder-of-minka/.

3. Figures cited here are drawn from private correspondence between the authors and Susan McDonough, a Catholic eldercare and post-acute specialist, and Lisa McCracken, director of senior living research and development with Ziegler investment banking, through year-end 2019. While the numbers aren’t as current, those seeking more information can see “Hot Topics in Catholic Senior Care,” a presentation for the Catholic Leaders’ Symposium 2019, October 26, 2019, and Susan McDonough, “The 2019 State of Catholic Aging Ser-

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vices,” presentation for Catholic Health Assembly 2019, June 9, 2019, https://www.chausa.org/docs/defaultsource/2019-assembly/2019-Assembly/state-of-catholic-aging-service.pdf?sfvrsn=0.

4. R.W. Dellinger, “Little Sisters of the Poor Ponder the Future of Home for the Elderly,” Angelus News, March 18, 2020, https://angelusnews.com/local/lacatholics/79811-copy/; and Bridget Balch, “Little Sisters of the Poor to Leave Richmond Region–They’d Been Here Since 1874,” Richmond Times-Dispatch, October 31, 2019, https://richmond.com/news/local/littlesisters-of-the-poor-to-leave-richmond-region—-theydbeen-here-since/article_a09faffe-be79-512b-bc744a8d9c74f4a3.html.

5. Rachel M. Werner, Allison K. Hoffman and Norma B. Coe, “Long-Term Care Policy after Covid-19–Solving the Nursing Home Crisis,” New England Journal of Medicine, May 27, 2020, https://www.nejm.org/doi/pdf/10.1056/ NEJMp2014811?articleTools=true.

6. A 1986 study traces the evolution of for-profit elder care and notes that, during the late 1960s, the “Fevered Fifty,” corporations owning or planning to own nursing homes, emerged as the “hottest” stocks on the market. In a 1969 article in Barron’s, J. Richard Elliott, Jr., explained the phenomenon: “Of late . . . [a] kind of frenzy seems to grip the stock market at the merest mention of those magic words: ‘convalescent care,’ ‘extended care,’ ‘continued care.’

All euphemisms for the services provided by nursing homes, they stand for the hottest investment around today. Companies never before near a hospital zone— from builders like ITI’s Sheraton Corporation, National Environment, and Ramada Inns, to Sayre and Fisher... have been hanging on the industry’s door. ‘Nobody,’ a new-issue underwriter said the other day, ’can lose money in this business. There’s just no way.’”

Cited by Catherine Hawes and Charles D. Phillips, “The Changing Structure of the Nursing Home Industry and the Impact of Ownership on Quality, Cost, and Access,” in B. H. Gray, ed., For-Profit Enterprise in Health Care (Washington, D.C.: National Academies Press, 1986), https://www.ncbi.nlm.nih.gov/books/ NBK217907/.

7. Matthew Goldstein, Jessica Silver-Greenberg and Robert Gebeloff, “Profit Push Takes a Toll in Eldercare,” The New York Times, May 8, 2020, https://www.nytimes. com/2020/05/07/business/coronavirus-nursinghomes.html.

8. Howard Gleckman, “Why Are So Many Nursing Homes Shutting Down?” Forbes, March 2, 2020, https://www. forbes.com/sites/howardgleckman/2020/03/02/ why-are-so-many-nursing-homes-shuttingdown/#eaf8e6a1712b.

9. Charlene Harrington et al., “Nurse Staffing and

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Deficiencies in the Largest For-Profit Nursing Home Chains and Chains Owned by Private Equity Companies,” Health Services Research 47 (2012): 106-28.

10. Atul Gupta et al., “Does Private Equity Investment in Healthcare Benefit Patients?

Evidence from Nursing Homes,” (unpublished paper in progress), SSRN, February, 2020, https://papers.ssrn.com/sol3/ papers.cfm?abstract_id=3537612. A helpful summary of this article can be found here: https://revcycleintelligence.com/news/benefit-of-private-equity-in-healthcare-lessonsfrom-nursing-homes.

11. See Michael L. Barnett and David C. Grabowski, “Covid-19 Is Ravaging Nursing Homes. We’re Getting What We Paid For,” The Washington Post, April 16, 2020, https://www.washingtonpost.com/opinions/2020/04/16/covid-19-is-ravagingnursing-homes-were-getting-what-wepaid/. See also Maria Castellucci, “Nursing Homes Brace for New Medicare Payment System,” Modern Healthcare, May 25, 2019, https://www.modernhealthcare.com/ post-acute-care/nursing-homes-brace-newmedicare-payment-system.

12. Matthew Goldstein, Jessica Silver-Greenberg and Robert Gebeloff, “Push for Profits Left Nursing Homes Struggling to Provide Care,” The New York Times, May 7, 2020,

https://www.nytimes.com/2020/05/07/ business/nursing-homes-profits-privatecoronavirus.html.

13. Maggie Flynn, “Multi-State Nursing Home Operators Navigate Conflicting COVID-19 Rules,” Skilled Nursing News, April 22, 2020, https://skillednursingnews. com/2020/04/multi-state-nursing-homeoperators-navigate-conflicting-covid19-rules/.

14. Concerning the overall need to shift out of a hospital-based paradigm, a commentary in the New England Journal of Medicine

by Italian physicians surmised that hospitalized COVID-19 victims there might be facilitating transmission to uninfected patients, and that home care and mobile clinics could help patients with mild symptoms. They drew the following lesson: “Western health care systems have been built around the concept of patient-centered care, but an epidemic requires a change of perspective toward a concept of community-centered care;” Mirco Nacoti et al., “At the Epicenter of the Covid-19 Pandemic and Humanitarian Crises in Italy,” NEJM, March 21, 2020, https://catalyst.nejm.org/doi/full/10.1056/ CAT.20.0080.

15. CHA, “Creating Age-Friendly Health Systems,” https://www.chausa.org/eldercare/ creating-age-friendly-health-systems.

16. Arko, “Transform Podcast #23.”

17. Arko, “Transform Podcast #23.”

18. Joyce Famakinwa, “Senior Care Innovator Bill Thomas: COVID-19 Rewriting Health Care Rules, Pushing Home Care into the Spotlight,” Home Health Care News, April 20, 2020, https://homehealthcarenews. com/2020/04/senior-care-innovator-billthomas-covid-19-rewriting-health-carerules-pushing-home-care-into-the-spotlight/.

19. Tim Regan, “Ascension Living President: Pandemic Proves Value of Health System, Senior Living Integration,” Senior Housing News, October 19, 2020, https://seniorhousingnews.com/2020/10/19/ascension-living-president-pandemic-proves-value-ofhealth-system-senior-living-integration/.

The podcast upon which this print piece was based is available at https://seniorhousingnews.com/2020/10/22/transform-podcast34-danny-stricker-of-ascension-living/.

20. Werner, Hoffman and Coe, “Long-Term Care Policy after Covid-19.”

21. CHA, “Sponsorship Part 7 Formation,” at 4:45, part seven of the series, “Go and Do Likewise,” YouTube video, uploaded March 4, 2014, https://www.youtube.com/ watch?v=bgTP7Y2viUk.

QUESTIONS FOR DISCUSSION Fr. Charles Bouchard, OP, and Alec Arnold, PhD (c), are concerned with the role of Catholic health care in long-term care facilities. They explore the mission commitments and financial viability of traditional forms of eldercare and raise important questions about where the ministry should go from here in the care of vulnerable people who are old.

1. What do you think about the mission vs. margin equation that Catholic ministries have to deal with in evaluating longterm care services and facilities? As difficult decisions have to be made about doing the most good with limited resources who needs to be at the table when discernment takes place?

2. In explaining the importance of real estate to the viability of long-term care, Bouchard and Arnold make a surprising comparison to the McDonald’s business model. What do you think of the validity of that comparison? Talk about the value of the ministry’s holdings vs. the commitment to mission.

3. The article leads to the challenging question of what role sponsors may have in shaping the future of long-term care in the Catholic health ministry. Does your ministry use your sponsors as prophets with a forward-looking vision for where the health care ministry is being called? Do you think they have the right relationship with executive leadership? How would you change it if you could?

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presidenciamx/Alamy Stock Photo

Finding God in Daily Life “I would like to invite young people to make a gesture of tenderness toward the elderly, especially those who are alone, at home and in residences, those who for many months have not seen loved ones. Send them a hug.

They are your roots.’’

— Pope Francis at Vatican City on July 26, 2020, the feast day of Sts. Anne and Joachim, Jesus’ grandparents

AGING AND L O N G -T E R M C A R E

Happily Ever After SR. JULIA UPTON, RSM, PhD, MPH

Y

ears ago, a friend and I went to see the Broadway production of Stephen Sondheim’s musical Into the Woods. The first act ends with all the fairy-tale characters’ complicated situations resolved in a “happily ever after” style.

“It’s over?” my friend asked, surprised that the show was ending so soon.

“No,” I replied. “This is intermission.”

“But what could come next?” he further probed.

“Not so happily ever after!” I answered, to which he just groaned.

No one’s life journey is as smooth or simple as those fairy tales led us to believe. Throughout life’s ups and downs, twists and turns, we need support and encouragement to maintain health— physical, emotional and spiritual—particularly in our later years. Rather than “happily ever after,” we seek a more realistic and achievable goal: to live the best life possible all our days.

What does the “best life possible” look like?

Most people, when asked, value health above all else. The World Health Organization Constitution (1946) defines health as “a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity.” As a theologian, I would add spiritual well-being to that list. As people are living longer, often needing to move to long-term care residences, maintaining well-being can be challenging. Too often residences are designed to serve staff needs rather than residents’ needs. Resident-centered or, even better, resident-directed residences are more lifegiving for all. Residents report being happier and healthier with fewer hospitalizations and staff report a stronger sense of purpose.1 Public health has begun to focus more on well-being rather than the absence of disease or chronic conditions. There are several iterations

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of the “domains of well-being,” but the one developed in 2005 by The Eden Alternative, a nonprofit organization dedicated to improving the lives of elders and their care partners in all living environments, is comprehensive.2 Rather than relying just on the more traditional measure of “quality of life” or “quality of care,” which come from the biomedical model, the “domains of well-being” address the individual person as a whole. They include: Identity — being me, well-known, having personhood, individuality.

Connectedness — being with, belonging, engaged, involved.

Security — finding balance, freedom from doubt, anxiety or fear.

Autonomy — seeking freedom, liberty, selfdetermination, self-governance.

Meaning — making a difference, significance, hope, purpose.

Growth — growing and developing, enriching, unfolding.

Joy — having fun, expressing happiness, pleasure, delight.

It is not difficult to envision how these pandemic times are having an impact on the wellbeing of us all, but it is possible to address each of the domains in spite of one’s physical health or living situation.

Much of society’s understanding of human psychosocial development is based on the work of Erik Erikson (1902-1994). In a series of essays published in the 1940s he began to work out what

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we now know as the stages of psychosocial devel- ological and therefore they might misunderstand. opment.3 Erikson’s theory described the impact of Such implicit bias might result in discouraging the social experience across the whole lifespan, build- very aspects that indicate well-being among the ing one upon the other. Each stage was marked very old. by successfully resolving a conflict in a way that Whenever I have presented the concept of struck a balance between two poles. The last gerotranscendence to older adults, I see lots of stage in Erikson’s original construct, occurring head-nodding, and later conversations reveal that during “old age” (age 65 to death) is resolving the participants were actually relieved to have their conflict between Integrity and Despair. Erikson experiences validated. If staff and family memheld that when death is approaching, everyone, bers were aware that the characteristics of gerowhether consciously or unconsciously, enters a transcendence were not only normal, but actually life review process, balancing life’s successes and desired, they might alter their expectations and disappointments to arrive at a resolution, seeing life ultimately as meanMake room in the conversation for ingful or meaningless or somewhere thoughts about death. If an older in between.4 Since 1950 when Erikson began person leads the conversation in that publishing, life expectancy in the United States has increased 17.7 direction, it is likely an important years. 5 That would give a person issue for them. almost an extra 20 years to resolve the identity crisis. The Swedish social gerontologist Lars Tornstam pioneered another personalize their care. This could increase everyapproach to the last stage of life with his doctoral one’s sense of well-being.

One way to provide support for older adults thesis on aging at Uppsala University in 1973. He theorized a more open-ended approach to the last would be to ask questions regarding their expestage of life which he named gerotranscendence. rience. For example, one could say to an elder, It was not Tornstam’s intention to nullify the work “Some people say that they their concept of time of other theorists, but he believed that some ele- has changed. The past is so strongly present that ments of their theories were not applicable to the they almost live in it at the same time as they live in the present. Have you experienced something very old.6 Gerotranscendence provides a paradigm for similar?” While that might elicit a simple “No!” understanding the developmental process of it might also open up an important conversation aging, which is evident on three levels: the cosmic about the past, maybe how childhood memories level, the level of self, and the level of social and are more vivid than ever before. When I would personal relations.7 Tornstam’s construct notes visit my elderly aunt in her residence, I would take along the family genealogy. Although my aunt was the following characteristics about the very old.

There is an increased affinity with past gen- blind by that point, she helped me fill in the blanks erations and a decreased interest in superfluous on our family tree while relating wonderful family stories I had never heard before. Well-tailored social interaction.

There is also often a feeling of cosmic aware- questions can open up the cosmic dimension ness of being in both the past and present simul- while acknowledging and appreciating increased taneously, and a redefinition of time, space, life interest in the past.

Too often we rely on “How are you feeling?” and death.

The individual becomes less self-occupied as the opening question with someone. Intended and at the same time more selective in the choice or not, that question immediately focuses on the elder’s physical self, which leads too easily to disof social and other activities.

The individual might also experience a cussion of decline and limitations. Choose some other topic instead. Consider a conversation decreased interest in material things.

Solitude becomes more attractive. beginning like this, “Some people say that as they To younger people or even to medical person- age they discover sides of themselves they hadn’t nel these characteristics might be viewed as path- known before. Have you made any discoveries

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like that?” Although that also might lead nowhere, revise their work, adding to their understandit could also open up an unexpected conversa- ing of the life cycle. The Life Cycle Completed – tion on self-discovery. Where there is life there is Extended Version (1998) includes final chapters growth and change on many levels. written by Joan Erikson, revising their schema to Make room in the conversation for thoughts include a ninth stage whose focus is on transcenabout death. If an older person leads the conver- dence. She finds fault when gerontologists use the sation in that direction, it is likely an important term “gerotranscendence” without fully explorissue for them. Too often such conversations are ing the new and positive spiritual gifts it brings. aborted because the family or caregiver is uncom- “Perhaps they are just too young,” she suggests. fortable with the topic. As family and staff, it is “With great satisfaction I have found that `tranessential to listen to the elders and acknowledge scendence’ becomes very much alive if it is actitheir feelings. Fear of death generally decreases vated into ‘transcendance,’ which speaks to soul with age and questions about life after death and body and challenges it to rise above the dysemerge. Once I was invited to give a sermon at tonic, clinging aspects of our worldly existence evening prayer in an upscale continuous care resi- that burden and distract us from true growth and dence. In it I suggested residents might approach aspiration.”8 life’s next great adventure the way they had prepared for other travel Designing new types of activities adventures in their lives. While there is no Michelin guide to the afterlife, such as reminiscence therapy or a there is Scripture, the work of spiritual writers, the stories of others and meditation course could foster the even the daily news that can lead older person’s personal growth. one to anticipate crossing to the next world as an adventure.

Encouraging and facilitating quiet The third level of gerotranscendence, in which an elder’s attitude and peaceful times and places would toward social and personal relationalso go a long way to improving ships begins to shift, is too often viewed negatively as “social disenresidents’ well-being. gagement.” The need for positive solitude is not automatically a manifestation of loneliness. Out of choice some elders opt The concluding lines of Mary Oliver’s poem out of activities that lack content, preferring the “When Death Comes” reflect the thoughts of company of a few like-minded people to a large most of the elders with whom I have worked in crowd playing bingo. They might even prefer recent years: their own company or that of a good book. Designing new types of activities such as reminiscence When it’s over, I don’t want to wonder therapy or a meditation course could foster the if I have made of my life something particular, and real. older person’s personal growth. Encouraging and I don’t want to find myself sighing and frightened facilitating quiet and peaceful times and places or full of argument. would also go a long way to improving residents’ I don’t want to end up simply having visited this world. well-being.

In 1982 Erikson and his wife Joan Erikson (1903This is the fullest life possible that everyone in 1997) published The Life Cycle Completed, but as the healing professions should be helping to prohe grew deeper into the eighth stage of his own vide to everyone in their care. Eternal life is ours life, Erikson began to rethink the completeness of now, today. Living fully in that reality is the chaltheir work. Shortly before he died, Joan Erikson lenge of using the gifts that have been given. Some found her husband’s copy of The Life Cycle Com- day we will slip across the road and know eternal pleted and saw that no page was free from under- life in its fullness, but for now we listen to the Holy lining, highlighting or annotation. She began to Spirit who is ours in Baptism, knowing that we are wonder what they all meant. Soon she began to beloved and sharing that love with the world.

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SR. JULIA UPTON, RSM, is provost emerita of St. John’s University in New York and Distinguished Professor of Theology and Religious Studies (retired).

NOTES 1. Michael Lepore et al., “Person-Directed Care Planning in Nursing Homes: A Scoping Review,” International Journal of Older People Nursing 13 (2018), https://doi. org/10.111/opn.12212.

2. G. Allen Power, Dementia Beyond Disease: Enhancing Well-Being (Baltimore: Health Professions Press, 2017) 23-37. This model was developed by 12 experts in transformational care called together by The Eden Alternative.

3. These essays formed the basis for Erik Erikson’s first

book, Childhood and Society (New York: W. W. Norton, 1950).

4. Simon Hearn et al., “Between Integrity and Despair: Toward Construct Validation of Erikson’s Eighth Stage,” Journal of Adult Development 19 (2012) 1-20.

5. Jochen Klenk et al., “Changes in Life Expectancy 19502010: Contributions from Age- and Disease-specific Mortality in Selected Countries,” Population Health Metrics 14 (2016) 20.

6. Lars Tornstam, Gerotranscendence: A Developing Theory of Positive Aging (New York: Springer, 2005).

7. Lars Tornstam, “Gerotranscendence—A Theory about Maturing into Old Age,” Journal of Aging and Identity 1 (1996) 37-50.

8. Erik H. Erikson and Joan M. Erikson, The Life Cycle Completed - Extended Version (New York: W. W. Norton, 1998) 127.

QUESTIONS FOR DISCUSSION Sr. Julia Upton, RSM, is a theologian and public health specialist. She takes a particular interest in older people in terms of a person’s spiritual depth and their right to move into their final years with the best opportunities for fulfillment. Her article “Happily Ever After” discusses what elements of happiness are unique to the elderly and what interactions, memories, honest questions and preferences for silence might lead to a more realistic and peaceful transition to the Ever After.

1. Upton argues that “quality of life” is too vague a term and puts forth seven domains of well-being identified by the Eden Alternative that can explore the well-being of elders in a more holistic way. Of the seven, security, autonomy and meaning seem the most obvious. How important do you think identity, connectedness, growth and joy are in older people? How does your organization attend to these domains in the elders you serve?

2. Conversation about death is difficult for most of us. Yet Upton explains it is sometimes the conversation that older people often want to have. How does your organization train caregivers and family members to become comfortable when patients/residents want to talk about death? During the pandemic, how can such conversations take place without adding to the anxiety the patient might have?

3. Upton uses the term “gerotranscendence” to describe how an older person might begin to separate from some of the things, people and interests of their life in order to give greater attention to things that really matter. Have you experienced this in people you love or patients you’ve felt close to? Is your ministry able to offer activities like reminiscence therapy or meditation courses to support people in this personal pursuit?

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Pandemic Is a Tragedy, And a Chance to Rethink Long-Term Care HOWARD GLECKMAN

T

he COVID-19 pandemic has been a tragedy for hundreds of thousands of older adults in the U.S. and their families. It has amplified and exposed the nation’s already deeply flawed system of long-term supports and services (LTSS). Yet it also has created a historic opportunity to rethink our model for caring for frail older adults and younger people with disabilities.

The COVID-19 crisis did not spring from nowhere. Indeed, while many close observers of the nation’s long-term care system have been shocked at the amount of illness and death among older adults, they were not entirely surprised.

The pandemic focused attention on questions that often have been ignored by policy makers and even by providers. Does the nation’s longterm care system provide care in the setting that is most appropriate for each frail elder? Does it provide the right person-centered care? Does it effectively integrate supports and services with medical treatment? Are there enough direct care workers and are they properly trained? Has the nation dedicated sufficient resources to finance the care older adults deserve?

The answer to each of those questions is “no.”

And COVID-19 has exposed the consequences.

The way we care for older adults in the U.S. is, self-evidently, not working. The Kaiser Family Foundation estimates that as of Oct. 8, 2020, there were least 537,000 COVID-19 cases and 84,000 deaths in long-term care facilities.1 At least another 83,000 older adults living in the community have died from the disease, according to the Centers for Disease Control and Prevention.2 The indirect effects of COVID-19 are severe as

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well. Millions of older adults have been isolated from family and friends for months. While data are limited, families and operators of care facilities report that residents are prematurely dying from the effects of social isolation.3 How can we prevent this from happening again?

Start with where frail older adults live.

Today, 85% to 90% of those with long-term care needs — or about 12 million people — receive care at home. Many get this assistance with the support of family members and some have the help of paid aides.

But that care often is built on a flimsy foundation. Spouses and adult children often provide care with great love — and little skill. Few communities have programs to teach family caregivers the skills they need, for example, to safely transfer a frail spouse from a bed to a chair. Many family caregivers have no idea where to ask for help with transportation. Meal delivery services such as Meals on Wheels are underfunded and suffer from long waiting lists.4 Without that solid infrastructure, those aging at home are likely to suffer from social isolation or require emergency department visits or hospitalizations. For example, many older adults who visit

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emergency departments are found to be suffering where (pre-COVID-19) frail older adults who are highly vulnerable to infection often shared buildfrom malnutrition.5 Another 700,000 older adults with physical ings, dining rooms, day rooms, and even bedor cognitive limitations live in assisted living or rooms with people just discharged from hospitals, other residential care, and nearly all pay out-of- where infection is common.

The pandemic also further exposed the gaps pocket. Under limited circumstances, Medicaid will pay for services, but not room and board, in in the direct care workforce. About 1,000 longthese settings. Thus, assisted living is available term care facility staff have died from COVID-19.11 for those with the financial resources — at a cost It appears that coronavirus often was brought in averaging $4,000 per month.6 And they often are by staff, who either were asymptomatic or who not set up to provide the high level of personal assistance that Today, the nursing home business model many older frail adults require. is in jeopardy. Many facilities were Finally, about 700,000 people live out their days in nursoperating on narrow margins before ing homes. 7 Roughly 80% of those long-stay residents COVID-19.13 Now they are under even receive Medicaid.8 While they more intense financial pressure from may need a high level of personal assistance, few need both declining revenues and rising costs. skilled nursing care. Thus, the vast majority have no clinical reason to live in such a facility.9 They are there came to work despite symptoms. Many were largely because Medicaid creates powerful incen- poorly trained in infection control. Many may tives for them to do so, even if other settings are have spread the disease by working in multiple more appropriate. This arises from four interre- settings. Direct care workers often work two or more jobs to make up for low wages. lated circumstances.

Medicaid pays for room and board in nursing Yet, the risks of viral infections in long-term homes, but nowhere else — a strong incentive for care facilities were well-known before the panrecipients to choose a nursing home over settings demic. Every year, nursing homes suffer outwhere they would have to pay their own rent. This breaks of seasonal flu or the intestinal norovirus.12 model also means operators overvalue real estate Today, the nursing home business model is in relative to the services they provide. jeopardy. Many facilities were operating on nar Medicaid eligibility varies by state, but row margins before COVID-19.13 Now they are financial requirements often are less rigorous for under even more intense financial pressure from a nursing home resident than for someone receiv- both declining revenues and rising costs.

On the revenue side, the pandemic accelerated ing care in the community.

Nearly all states finance their share of Med- the shift of lucrative post-acute care to home or icaid in part by imposing provider taxes on nurs- other less costly congregant settings. This change ing homes. Those taxes generally are based on has been driven in part by changing consumer patient revenue. Thus, states have an incentive to preferences. But it also comes from the managed steer Medicaid beneficiaries to nursing facilities care plans that now insure one-third of Medicare beneficiaries and are looking to place members because they generate significant revenues.

Medicaid home and community-based ser- in less costly post-acute care settings. And those vices (HCBS) are available in each state, but often that still send members to nursing facilities pay are severely underfunded. That means long wait- an average of about 20% less than traditional ing lists or benefits that are insufficient to provide Medicare.

At the same time, state Medicaid budgets are quality care for those living at home.10 But because Medicaid payments are so low, under severe pressure because of COVID-19, and nursing homes have built up a second business — nursing home reimbursement rates are likely to post-acute care — that is funded much more gen- remain frozen or even decline. Facilities may also erously by Medicare. The result: A model of care lose revenue if, for post-COVID-19 regulatory or

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market reasons, they will have to eliminate semi- tance. They currently must navigate two enormously complex and disconnected systems. private and even quad rooms.

For example, physician offices rarely inform At the same time, facilities are seeing significant cost increases, including for personal pro- patients about sources of personal care. Hospitective equipment and coronavirus testing. Even tal discharge planners have neither the time nor before the pandemic, labor rates were rising due the knowledge to prepare a patient or her family to a growing shortage of aides, nurses and other for her care needs when she returns home. This is staff. COVID-19 has driven compensation even another reason why many families default to postacute care in a nursing home. higher, at least temporarily.

In this enormously challenging environment, Facilities face significant capital costs as well.

Many are more than 40 years old and need to be what could a new model look like?

Frail older adults and younger people with disremodeled. And the effects of the pandemic may require significant redesign to reduce the spread abilities, with support from family and a case manager, would choose the care setting and supports of infectious disease among residents and staff.

Not everyone with cognitive and physical limi- that would help them live the best life possible. It tations can stay in their own home, especially if could be a group home, traditional assisted living, they have no family members to care for and advo- a nursing home or their own home. But the decicate for them. But they could live in less costly, sion would be based on what is most clinically and socially appropriate, not on the constraints of an less medical settings than a nursing home.

For many older adults, small group homes and outmoded payment system.

The vast majority of those receiving longsimilar alternatives could be more appropriate.

But they are inaccessible for many families who term care at home are getting their support from cannot afford to pay out-of-pocket. And state laws unskilled relatives. Health systems, insurance that limit the services aides can provide make companies or government could make caregiver creative staffing difficult. For example, in many training a benefit. Perhaps family caregivers jurisdictions, nursing assistants cannot adminis- could even be paid.

Direct care workers need to be paid more ter routine over-the-counter medications unless and should receive benefits such as sick leave. they are directly supervised by a nurse.

The flaws of the current payment system affect more than care Direct care workers need to be settings. They also create perverse paid more and should receive incentives for care delivery by building a financial and regulatory wall benefits such as sick leave. Whether between medical treatment and personal assistance for those with they are working in facilities or in chronic illness. Medicare pays for people’s homes, they are paid less health care but generally not longterm care. For those eligible, Medicthan a living wage for what, even aid pays for long-term care but not health care. before COVID-19, was an extremely This creates two problems. dangerous job.

First, this model discourages states from enhancing their Medicaid long-term supports and services. To the Whether they are working in facilities or in peodegree that better LTSS could reduce emergency ple’s homes, they are paid less than a living wage department visits and hospital stays, it could save for what, even before COVID-19, was an extremely significant money. But today those cost savings dangerous job.14 Long-term care providers will flow to the federal Medicare program, not to the create a quality workforce only by paying comstates that expand their LTSS programs. petitive wages and benefits.

Most important, this bifurcated payment Those with chronic disease and physical or model acts as an impediment to families who need cognitive limitations should have services wellfully integrated health care and personal assis- coordinated and tailored to their individual needs,

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not driven by an outdated and dysfunctional pay- of housing with services, where low-income residents of subsidized housing could receive some ment system.

Long-term supports and services would be basic supports as well as routine nursing care.

Medicaid also needs to be flexible enough to well integrated with medical treatment, with no regulatory or payment barriers, and through a provide non-traditional services. For example, the financial model that creates incentives for strong CAPABLE program, designed at Johns Hopkins chronic care management. This could be deliv- University School of Nursing, combines social ered through managed care plans, such as Medi- supports, physical therapy and modest home care Advantage (MA) or fully integrated models repairs, all aimed at helping older adults remain such as the Program for All-Inclusive Care for at home. The program lowers costs and improves the Elderly (PACE). They also could be provided participants’ quality of life.15 through expanded special needs plans (SNPs), State and local governments provide many of which are MA plans targeted to members with these services today, but in a disconnected way. specific needs. For example, Institutional SNPs Like specialist physicians, each program cares serve those who live in the community but who would need instiBut in some way, the U.S. needs to tutional care without the additional put more money into long-term services offered by the plan, such as care coordination, or nutrition or supports and services. Our system transportation.

Delivering fully integrated care never will provide adequate care for through traditional fee-for-service frail older adults and younger people Medicare would be more challenging but still possible. The many with disabilities so long as it remains value-based models now being tested could create incentives for severely underfunded. primary care practices to partner with, for example, community-based organiza- for just part of a person, not her whole life. The tions to deliver fully integrated medical and social agencies that deliver these programs need to care. It might also be possible in traditional Medi- work with one another to provide flexible, holiscare through Medicare Supplement (Medigap) tic care. California is one state working to design insurance. such a model.

A public program such as Medicaid would While Medicaid would continue to assist those continue to support long-term care for those with with low incomes, everyone else would pay for very low incomes. But Medicaid would be far their long-term services and supports through a more flexible than today, and the default setting mix of private savings (including home equity) for care would be people’s own homes, not nurs- and self-funded, universal public insurance. It ing facilities. Medicaid HCBS programs would be could be operated through Medicare or as a sepamore generously funded, and long waiting lists rate government program. could be eliminated.

But in some way, the U.S. needs to put more States should better align Medicaid LTSS with money into long-term supports and services. Our other public services, such as low-income hous- system never will provide adequate care for frail ing, transportation, home delivered meals, adult older adults and younger people with disabilities day services and primary medical care. For exam- so long as it remains severely underfunded. ple, the asymmetry of using Medicaid funds to Where will the additional funding for all this pay for room and board in a nursing home and come from? The reality is that few Americans have nowhere else could be addressed by shifting all saved sufficiently for the cost of long-term care government housing support to a separate pro- in old age, few have private long-term care insurgram. This could free up Medicaid dollars to pay ance, and Medicaid does not have the resources to for services and supports. support this care for the fast-growing Baby Boom Similarly, Medicaid and state housing pro- generation. grams could work together to build out a model A public long-term care insurance pro-

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gram could supplement out-of-pocket spending, especially for those with true catastrophic costs that few private long-term care insurance policies cover. A cash benefit (with care management) would let older adults decide where to live and give them the flexibility to purchase the services they need. Such a program could supplement managed LTSS benefits delivered through a health plan.

Washington state already has adopted a modest public long-term care insurance plan. A halfdozen other states, including California, Minnesota and Illinois, are exploring similar ideas. And there is some interest in Congress.

Such a program would not only benefit older adults, but it also could save substantial Medicaid dollars. Over the long run, the Urban Institute estimated a mandatory public catastrophic LTC benefit could reduce Medicaid LTSS spending by as much as one-third.16 Long-term care in the U.S. was failing long before COVID-19. But now that this terrible disease has exposed its flaws, we have an opportunity to fix them. We may not get to an ideal model, but many intermediate solutions already are on the table. With the political will, we can vastly improve a failed system that is needlessly killing our seniors before their time.

HOWARD GLECKMAN is a senior fellow at The Urban Institute in Washington, D.C., and author of the book Caring For Our Parents.

NOTES 1. Kaiser Family Foundation, “State Data and Policy Actions to Address Coronavirus,” Issue Brief, https// www.kff.org/health-costs/issue-brief/state-data-andpolicy-actions-to-address-coronavirus/. The statistics on this site change because they are updated frequently.

2. Centers for Disease Control and Prevention, “Weekly Updates by Select Demographic and Geographic Characteristics,” https://www.cdc.gov/nchs/nvss/vsrr/covid_ weekly/index.htm.

3. Suzy Kim, “The Hidden Covid-19 Health Crisis: Elderly People are Dying from Isolation,” NBC News, Oct. 27, 2020, https://www.nbcnews.com/news/us-news/ hidden-covid-19-health-crisis-elderly-people-are-dyingisolation-n1244853.

4. Marie C. Gualtieri et al., “Home Delivered Meals to Older Adults: A Critical Review of the Literature,”

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https://pubmed.ncbi.nlm/nih.gov/29722706/.

5. Collin E. Burks et al., “Risk Factors for Malnutrition among Older Adults in the Emergency Department: A Multicenter Study.” Journal of the American Geriatrics Society 65, no. 8 (August 2017): 1741–47. https://doi. org/10.1111/jgs.14862.

6. Genworth Financial, Annual Cost of Care Study: https://www.genworth.com/aging-and-you/finances/ cost-of-care.html.

7. U.S. Department of Health and Human Services, National Center for Health Statistics, Long-term Care Providers and Services Users in the United States, 2015–2016, published 2019.

8. ATI Advisory, Senior Housing Data Book, https:// atiadvisory.com/2020-seniors-housing-data-book/.

9. Charlene Harrington et al., “Nursing Facilities, Staffing, Residents and Facility Deficiencies, 2009 Through 2016,” Kaiser Family Foundation, 2018.

10. From the AARP’s “Long-Term Services and Supports State Scorecard 2020 Edition,” http://www. longtermscorecard.org/~/media/Microsite/Files/2020/ LTSS%202020%20Short%20Report%20PDF%20923. pdf.

11. Kaiser Family Foundation, “State Data and Policy Actions.”

12. Louise E. Lansbury, Caroline S. Brown, Jonathan S. Nguyen-Van-Tam, “Influenza in Long-Term Care Facilities,” Influenza and Other Respiratory Viruses 11, no.5 (Sept. 2017), 356-66, https://www.ncbi.nlm.nih.gov/ pmc/articles/PMC5596516.

13. Medicare Payment Advisory Commission, A Data Book: Health Care Spending and the Medicare Program.

Washington, DC., Medicare Payment Advisory Commission, 2020. http://www.medpac.gov/docs/defaultsource/reports/mar17_medpac_ch8.pdf2017 14. PHI International website, “Direct Care Workers in the United States: Key Facts,” https://phinational.org/ esource/direct-care-workers-in-the-united-states- key-facts/.

15. Sarah Szanton et al., “Home-Based Care Program Reduces Disability and Promotes Aging In Place,” Health Affairs 35, no. 9 (September 2016): 1558–63, https: //doi.org/10.1377/hlthaff.2016.0140.

16. Melissa M. Favreault, Howard Gleckman and Richard W. Johnson, “How Much Could Financing Reforms for Long-Term Services and Supports Reduce Medicaid Costs?” Urban Institute, February 2016, https://www.urban.org/sites/default/files/ publication/77476/2000603-How-Much-Could- Financing-Reforms-for-Long-Term-Services-and- Supports-Reduce-Medicaid-Costs.pdf.

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Nursing Home Care And Its Financial Health JOHN MORRISSEY

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ay a prayer for the venerable Catholic nursing home, often many decades old, challenged to stay up to date, and at the mercy of a financial model that doesn’t cover the cost of doing business. Its biggest source of revenue, the Medicaid program, pays as little as 73% of the cost of care, a recent analysis shows.1 Its best bet for profitable business — post-hospital therapy and rehabilitation paid by Medicare — increasingly skips past the nursing home stop and directly to home health care. The patients that nursing homes do receive often have more complex needs than in previous times, eating into Medicare margins.

Specialized managers and direct-care workers alike are hard to find and afford.

There are ways out of this daunting predicament, often involving expanding into related senior living arrangements that subsidize the skilled nursing and long-term care operations.

“It’s well documented that Medicaid rates do not cover the cost of care,” said Katie Smith Sloan, president and CEO of LeadingAge, an association representing aging-focused organizations. “It’s absolutely necessary that the [financial] models diversify revenue sources, whether it’s by adding assisted living, which largely is private-pay, or it’s adding more short-term rehab.”

Large senior-care systems can help formerly freestanding nursing homes build that diverse residential care community, supply expertise that single-site facilities can’t afford, update aging structures, and help find and train the workforces.

Those needs are often beyond the capabilities of nursing homes going it alone, “so it really puts a freestanding nursing facility operator in a very difficult circumstance — and at some point, they’re going to either have to partner with a larger organization that has the capital to keep their facilities competitive, or outright sell or close,” said Timothy Dressman, vice president of business development for CHI Living Communities. The senior

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care division of CommonSpirit Health, CHI Living includes 12 nursing homes, 11 of them part of a continuing care retirement community.

Nursing home care runs deep in the missions of Catholic orders and other nonprofits serving the elderly. The LeadingAge annual ranking of the top 200 senior-care organizations lists nearly

“It’s absolutely necessary that the [financial] models diversify revenue sources, whether it’s by adding assisted living, which largely is private-pay, or it’s adding more short-term rehab.”

— KATIE SMITH SLOAN

50 that were founded more than 100 years ago.2 “Where nonprofits really stand out is the deep and abiding focus on mission, on service, to the exclusion of profit,” said Sloan. “Faith-based, mis-

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sion-driven organizations were caring for older apartment buildings or assisted living adjuncts, adults long before government payments were with the comfort of knowing that they can move available, and they’ve been the mainstay of aging on to nursing care if and when the time comes for that more intensive level of residential care. services for many years.”

“The communities that are withstanding the But the Medicare Act of 1965 changed the rules and sparked competition, said Dan Hermann, best right now … are those that have the larger president and CEO of Ziegler, an investment continuum of care,” said Lisa McCracken, direcbanking firm for the senior living industry, which tor of senior living research and development for co-sponsors the LeadingAge senior-care analy- Ziegler. “Independent living, you’re just paying sis. Medicare and Medicaid greatly increased the to live there. Generally, the staffing levels are not market volume, he said: “It blasted out the new the same, they don’t need the same level of care giving.” construction of freestanding nursing homes.”

The capacity to create a more diverse senior The explosion of funding ushered in a new level of financial sophistication necessary to bill living community has been a significant factor for government reimbursement and to follow affecting the likelihood of survival during a period the dictates of Medicare and Medicaid certifi- of consolidation among health care systems in cation and the requisite regulations issued by the Centers for Medicaid represents between 63% and Medicare and Medicaid Services.

Aging facilities housing two or 68% of a nursing home’s payer mix, three residents per room faced according to multiple studies. Another off against new buildings offering single-occupancy suites.

13% on average comes from Medicare Catholic nursing homes devoted to serving the poor found them skilled nursing care, but that small pie uniformly covered by Medicaid, a slice of the overall mix potentially can money-loser that worsened as its percentage of census got higher. offset much of Medicaid’s shortfall.

Medicaid represents between 63% and 68% of a nursing home’s payer mix, according to multiple studies. Another general, and senior care in particular, said Her13% on average comes from Medicare skilled nurs- mann. Whether nursing homes came together in ing care, but that small pie slice of the overall mix health system mergers or were freestanding, “the potentially can offset much of Medicaid’s short- general theme on who’s doing well is that they fall. Recent findings from the National Invest- committed to grow and rotate into independent ment Center for Seniors Housing & Care illus- living, and had attractive land in a nice suburban trate the contrast: nursing facilities in 2019 were setting to work with.” paid an average of $216 per day by Medicaid and Landlocked nursing homes, on the other hand, about $544 per day by Medicare.3 At those rates, were not positioned for survival, especially in Medicaid at 68% of daily census would actually poorer urban or isolated rural areas. These are represent 55% of daily revenue, while Medicare facilities lacking in restorative capital, exposed at 13% of census would constitute 26% of revenue. to a high-Medicaid population, highly likely not Medicare as the gap-filler in the nursing home to be savvy about Medicare-reimbursed rehabilibudget is “fragile,” Sloan cautioned. The impact tation or convalescence. “Therefore, in this enviis very market-specific, in terms of the types of ronment, they are having losses that are starting cases referred to each facility and the margins to become unsustainable,” Hermann concluded.

Dressman of CHI Living was even less optimisgenerated, “but I still think it is part of the equation of the business model for the nursing home.” tic: “Any freestanding nursing facilities, regardA more financially sound solution with a reli- less of where they are located, are struggling able future is to create housing options within a financially.” If they are eking out a positive marsenior campus to attract seniors healthy enough gin and can’t divert money into improvements or to want congregate living, either in independent maintenance, “buildings are starting to be really

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out of date, their equipment is starting to get old,” [stand-alone facilities], and it’s difficult to make he said. It can be the start of a slide that ultimately them financially sustainable long term.”

Catholic and other nonprofit nursing homes can lead to a decision to sell or close.

That often was the case for the 90 clos- that hope to survive as freestanding businesses ings or divestitures of Catholic-sponsored have to carefully reconsider how to transform facilities across the past 10 years that the their mission-driven service to people who are LeadingAge analysis recorded. Sixty percent of elderly and otherwise vulnerable, as well as how those were sold to a for-profit operator, and only about 1 in 4 caught on with The nursing home was instituted another nonprofit sponsor. The rest were shut down. and long managed as a charitable Though joining with another nonundertaking on behalf of financially profit is usually the preferred goal, often it’s easier to find a for-profit and physically vulnerable people, buyer, Dressman said. “Even with our organization, we will certainly have which in this day and age means conversations with nonprofit freethose depending on Medicaid. standing providers, but to take over one of those and think you’re going to make it viable financially is a tall task,” he related. One they set up and diversify the use of their buildings of the key factors is whether they are “sitting on and campuses to their full potential.

The nursing home was instituted and long a plot of land where there’s an option to grow out managed as a charitable undertaking on behalf assisted living or independent [living].”

To grasp the significance of the senior liv- of financially and physically vulnerable people, ing movement, consider the housing-forward which in this day and age means those depending approach of the Benedictine system, operating on Medicaid. The addition of facilities that attract more than 40 senior care and living communities seniors paying their own way runs counter to that in five Midwest states. Of a total 4,000 “doors” in charitable undertaking. If the mission is to take in the system, a way of listing living units of all types, and care for the vulnerable, paying customers are, the current ratio is 47% housing to 53% nursing, by definition, not the target demographic.

“You’ve made a decision to be compassionsaid Jerry Carley, president and CEO. “Our strategy over the next two years is to get to 60 percent ate, but the model doesn’t afford you to offer that independent living and assisted living, and 40 per- unless you are part of a larger-scale entity or if cent skilled nursing. It gets us to a nice cash-flow, in a good neighborhood you’re offsetting it with independent living, assisted living and memfinancially sustainable position.”

One way to get there is by building new facili- ory care,” Hermann asserted. “If you’ve chosen ties. In December 2019, Benedictine opened a to serve Medicaid … you make a decision: Can I 98-unit campus in Northfield, Minnesota, with [also] be private-pay? Well, those aren’t the poor independent/assisted living and memory care, people, private-pay is going to be wealthy. But to but no skilled nursing home on the premises. A serve [only] Medicaid, by definition you have to similar project opened in December 2020 in Sha- be sophisticated in order to survive on reimbursekopee, Minnesota, paired with an existing 109-bed ment rates that most providers say is below cost.”

Sophistication extends to reimagining every nursing home about two miles away. The new 198unit campus will help supplement the finances of square foot of a building. Competition from forthe nursing home even though not physically on profit facilities, which now make up 70% of the the same property, Carley explained. Residents market for skilled nursing and residential care who eventually need skilled nursing can be trans- facilities, should spark efforts to modernize and update to meet demand for attractive surroundferred down the road.

Benedictine doesn’t consider acquiring stand- ings and private rooms that for-profits have alone nursing homes without the option of asso- turned into consumer expectations, said Susan ciated congregate care, he emphasized. “We kind McDonough, Catholic eldercare and skilled nursof know what the future is going to hold for them ing specialist for Ziegler.

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The Catholic reputation for compassion, a bedrock of Catholic care, also can offer a market advantage, but it can’t often overcome obsolete operations.

Day-to-day operation of nursing homes is scarcely possible without the personnel to go with it, and personnel costs are often more than nursing homes can manage on the revenue their Medicaid-heavy population can generate. The consequences include shortages of the basic floor workers to cover residents’ needs as well as not enough of the expert managers required to oversee regulatory compliance, risk management, correct reimbursement and other essential aspects of an ever more complex nursing and financial environment.

Expertise is especially vital for skilled nursing.

“Medicare is complicated — you have to make sure that you have somebody that really understands the Medicare reimbursement program,” Carley noted. That means the capacity “to make sure that people are getting the services that they need, and that you’re getting paid to provide those services.”

The process of assessing needs and costs of incoming skilled nursing patients, using a coding manual called the Minimum Data Set, is so critically important under Medicare, because “if you’re not taking credit for the services that you are providing, you could have a $100-a-day difference,” Carley said. Benedictine has a full-time Minimum Data Set expert to consult with and look in on its member facilities, which on any given day combine for 350 to 400 Medicare recipients.

Another costly but necessary call for expertise is in the area of technology, such as for recordkeeping and information exchange, which is “not an amenity, not a nice-to-have, you have to have it,” McCracken said. “The ability to have the expertise

The Catholic reputation for compassion, a bedrock of Catholic care, also can offer a market advantage, but it can’t often overcome obsolete operations. Studies by the Catholic Health Association and other sources show that “people still think very highly of religiously based organizations,” McDonough said. “But if you walked into some Catholic facilities … it reminds you of the Holiday Inns of the 1970s.” And if a resident is going to share a room with two or three others there, when competitors offer a private room with a private bath, “you can see why people make decisions to go elsewhere.”

A single-site Catholic skilled nursing facility tends to be bigger than local demand and work force can support. “That 300-bed nursing facility is a lot harder to manage than a 120-bed facility,” McDonough explained. “So, one of the things folks have been doing is looking at what their scale should be … to fit into what the market they now work in needs.” Then converting the freedup space to private rooms makes more sense than adding new rooms onto the building.

Just like senior housing adds profitability, freed-up space can be devoted to specialty services that turn a profit. Some examples are bariatric, behavioral health Just like senior housing adds or memory care, said Sloan. Another use could be the leasing of space to profitability, freed-up space can be other health-based services, such as devoted to specialty services that turn dialysis or adult day care.

Services also could extend outa profit. Some examples are bariatric, side the facility to geriatric-care behavioral health or memory care. management, providing care coordination for the surrounding community, or to managing other properties for a fee, and the financial wherewithal to implement some Sloan suggested. “It takes the skill sets that you of those technologies, if you are a small organizahave, which is providing excellent care services tion” is “definitely a point of vulnerability.”

The growing need for these specialized and and support for older adults, and figuring out how else to apply that to serve a broader and differ- well-paid positions is one argument raised ent population that can offset some of the losses for multiple-site systems. The proliferation of COVID-19 infections has accelerated that need, you’re experiencing from Medicaid.”

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from the technology to track and report cases to move in. It also becomes a staffing issue, because the pressure to field and execute CMS changes there aren’t as many younger people to draw from.

Occasionally a town in danger of losing its nursin policy, which Dressman said has been almost a daily occurrence. To that end, CHI Living has ing home beats the odds through sheer grit. The an administrator dedicated to communicating townspeople of Shelby, South Dakota, population changes to each facility along with the training 650, and the surrounding two-county catchment involved. “The freestanding facilities can barely area rallied to raise $500,000 to keep its nursing keep up with the changes as they come,” he said, home open after its long-time operator, the Good citing as examples infection control policies and Samaritan Society, a Lutheran-sponsored system, visitation schedules. However, there are free- informed them it was shutting the facility down at standing facilities that fill an important function the end of 2018. in the communities they serve, with one example detailed later in this “The reason for the turnover is, article.

Finding and keeping sufficient these are hard jobs. It’s tough work numbers of workers for the longbut it’s also low-paid work that we as term residential care side of the facility — certified nurse’s assistants, a society do not value.” nurse aides, medical technicians — — KATIE SMITH SLOAN is a challenge for all nursing homes but especially for small, freestanding The system cited Medicaid reimbursement facilities. High turnover and low pay lead to serishortfalls, numerous agency nurses on the payroll ous staffing shortages.

“It’s not considered an attractive career path and not enough local help as reasons the location for many, and we underpay the workers who are was not sustainable, said Dan Biel, a local busiproviding essential services,” said Sloan of Lead- nessman who helped spearhead the fund drive ingAge. “The reason for the turnover is, these are and became a board member of the Walworth hard jobs. It’s tough work but it’s also low-paid County Care Center, incorporated and launched work that we as a society do not value.” Leadin- on Dec. 1, 2018.

He said the center’s first goal was to eliminate gAge is pushing for higher pay on the argument that it increases productivity and decreases turn- agency nursing, which it accomplished as of February 2020. Nurse staffing agencies, which build over enough to offset pay increases.4 But “how dependent on Medicaid you are often in a profit margin on top of their compensation sets the tone for how much you pay,” McDonough of agency nurses, charge more per worker than said. “To do difficult work, you are looking at a it costs a facility to hire its own, but they become pool of people who … can easily find (similar-pay- necessary if that facility cannot fill the required ing) jobs in a whole bunch of settings that would number of positions.

The center successfully built a base of locally be frankly a lot easier work.”

In rural areas, with mostly Medicaid on top of trained workers, attained a steady 50-50 ratio a limited job pool, nursing homes have problems of Medicaid to private-pay, and has managed to with both low reimbursement and short staffing, operate in the black for two years, Biel said. Meansaid Dan Revie, a specialist in senior housing and while the fundraising has continued — it passed care practice for Ziegler. “We’ve had providers the $1 million mark in February 2020 — and that have limited admissions to their facilities in enough “rainy day” funding is on hand to keep the rural areas because they can’t find enough work- 60-year-old facility operating for about two years if it suffered a financial hit, he said. ers to care for the residents.”

Such happy endings are rare, though, and orgaDemographic shifts in rural towns gradually eat away at survivability, Carley added. As com- nizations that start thinking about the future from munities age, young people who move away aren’t a position of strength end up with more possibilireplaced, and population dwindles. That creates a ties, McDonough said. “You can’t start too early to census problem as elderly nursing home residents think about the future of your single site. This is die and there are fewer people left who might an issue that goes from sponsor to board to senior

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management. If you’re struggling, or start to think you are struggling, plan now and think about options before it’s too late.”

Before considering a for-profit buyer, she advised, look to other Catholic organizations or other faith-based options “that might help preserve Catholic identity, or at least preserve some of the important things that Catholic organizations hold dear: social justice issues, care for the poor, taking good care of employees, serving populations that are considered vulnerable.”

PAU S E . B R E AT H E . H E A L .

JOHN MORRISSEY is a freelance writer specializing in health care delivery, policy and performance measurement. He lives in Mount Prospect, Illinois.

NOTES 1. Hansen Hunter & Company for the American Healthcare Association, “A Report on Shortfalls in Medicaid Funding for Nursing Center Care,” http://publish. ahcatech.org/facility_operations/medicaid/ Documents/2017%20Shortfall%20Methodology %20Summary.pdf.

2. LeadingAge, “Nursing Homes Closures and Trends 2015-2019,” https://leadingage.org/sites/default/ files/Nursing%20Home%20Closures%20and%20 Trends%202020.pdf.

3. National Investment Center for Seniors Housing & Care (NIC), “Skilled Nursing Data Report, Key Occupancy and Revenue Trends, https://info.nic.org/hubfs/4Q19_ SNF%20Report_Final.pdf .

4. LeadingAge website, “Making Care Work Pay,” https://www.leadingage.org/making-care-work-pay.

Peace in Anxiety For just this moment, bring your attention to your breath.

INHALE deeply and settle yourself into your body.

EXHALE the stress and tension you feel.

In these days of anxiety, a moment to pause is both a gift and a necessity.

GENTLE YOUR BREATHING, your gaze and your heart as you consider:

Where have I found peace in the past days?

THINK FOR A MOMENT.

In these days of anxiety where have I found peace?

[Pause to consider] DWELL in the peace you have found and bring it with you into the rest of your day.

Even now, God is with you, as near to you as your breath. Continue giving yourself the gift to pause, breathe and heal, knowing you are not alone.

Peace I leave with you; my peace I give you. I do not give to you as the world gives. Do not let your hearts be troubled and do not be afraid. JOHN 14:27 © Catholic Health Association of the United States

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This “must-have” program provides a solid foundation in core theological and moral principles of Catholic health care and how they apply to our work.

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Mary Immaculate’s Team Exhibits Catholic Care In Pandemic Response SUZANNE DUMARESQ

O

ne of the most heartbreaking effects of the coronavirus pandemic is the toll it’s taking on skilled nursing communities. In response to such challenge, the team at Mary Immaculate Health/Care Services, a member of Covenant Health, rose to the call to care for three important populations — residents, staff and the local community — in countless small, important, beautiful and spiritual ways.

HARD HIT BY COVID-19

Mary Immaculate includes a 231-bed nursing center in Lawrence, Massachusetts, a city incredibly hard hit by the virus in Spring 2020. As COVID-19 infiltrated the state, visitors to residents in Mary Immaculate were restricted, and all pertinent Centers for Medicare and Medicaid Services and Centers for Disease Control and Prevention infection control guidelines were stringently enforced.

Care was coordinated with the Massachusetts Department of Public Health; the National Guard assisted with testing of all residents and staff. Yet, these efforts were sometimes not enough. By the end of April, 145 residents tested positive, some with mild or moderate symptoms, and 47 of our residents died. We had increased support from hospital nurses when over 60 staff members were not able to come into work because they were quarantined, isolated or recovering at home.

“Each member of our team shared in the anxiety, uncertainty and dread of this virus. We often found ourselves weeping and praying with residents, consoling each other and trying to process the enormity of how COVID-19 had ravaged our community,” said Jeanne Leydon, president of Mary Immaculate Health/Care Services. “However, we were driven by the healing ministry of

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Jesus, which inspired our founders to action — and inspired us to forge on. We called on Catholic social teachings and served with all the dignity, grace and faith we could muster. It was our duty and privilege to care for the vulnerable and those who truly value what differentiates us from other care providers.”

COMPASSION FOR RESIDENTS

This scenario is not unique ­­— many other skilled nursing facilities across the nation have had to cope with similar circumstances. What’s notable, however, is that the compassionate response from the Mary Immaculate community included more than supporting residents with Facetime/Zoom calls, window visits and car parades so readily shared via social and local media. They embraced the community with:

Daily Prayer

“Our community is our residents’ home. Typically, the intercom system wouldn’t be used for daily announcements. We always felt strongly that interrupting our residents’ sense of peace, in their home, wasn’t a good idea. However, during the pandemic we sensed our residents needed the interruption, needed to hear a prayer, a poem

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or even a song to provide a bit of inspiration or maybe a moment to reflect,” said Adrienne Cullen, director of mission integration and spiritual care advisor. “Ironically, we quickly learned this daily outreach resonated with residents and staff alike — many have requested we continue the practice.”

Rosary in the Hall

It’s exactly what it sounds like. Given that residents were restricted from gathering, they took to the halls. Residents came out of their rooms in their wheelchairs, or sat in chairs, which were at least six feet from one another, and joined in the rosary. They were longing to feel connected to their faith and fellow residents. Rosary in the hall lifted their spirits and fulfilled a spiritual need.

Resident Andrew Begoss shared, “Saying the rosary felt joyful and praying with other residents made it even more special.” Staffers found this effort to be especially touching for their memory care patients who seemed to feel consoled by the familiar tradition connecting them to their faith and past.

Spiritual Communion

Residents were encouraged to make an Act of Spiritual Communion, which is the recitation of a specific prayer — especially those who watched daily televised Mass. It was an invitation to residents to open their minds and hearts to accepting the Body of Christ in a new way — and it was

An Act of Spiritual Communion My Jesus, I believe that You are present in the Most Holy Sacrament.

I love You above all things, and I desire to receive You into my soul.

Since I cannot at this moment receive You sacramentally, come at least spiritually into my heart.

I embrace You as if You were already there and unite myself wholly to You. Never permit me to be separated from You. Amen.

This is the prayer used when residents temporarily were not able to receive Communion.

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a very significant ask for many devout residents who longed for the Eucharist. Cullen said, “Our community now offers in-person Communion while observing very strict protocols to do so.

Resident reaction has ranged from being deeply grateful to shedding tears of joy.” Communion resumed in October. A chaplain remains in the hall with a “Communion cart” while Cullen wears a mask, goggles and gloves to offer it to residents.

Respect for Faith Traditions

Approximately 70% of Mary Immaculate’s residents are Catholic. A new chaplain, who is Protestant, was recently hired. He will offer Bible study groups for residents who do not pray the rosary or who have a different faith. Separate opportunities for socializing also are offered, such as bingo and trivia.

Self-Guided Spiritual Booklets

To help keep residents intellectually and spiritually engaged, Mary Immaculate offered selfguided spiritual booklets, which included a morning gratitude affirmation, a verse from daily Scripture and corresponding reflection, a daily meditation practice such as a “choose one moment of your day that made you happy” exercise and more. Residents said they genuinely appreciated the booklets’ meaningful content and daily activity prompts. The booklets, which are created by staff, include New Testament passages as well as poems and aids to meditation that are non-denominational.

Good Day “MI”

At Mary Immaculate — commonly called “MI” — there’s now Good Day MI. This in-house version of Good Morning America began airing on Monday mornings a couple of months into the pandemic. Good Day MI is hosted by Cullen and one of MI’s chaplains. Each week they host a show filled with segments on daily prayers, the week’s Sunday Gospel, discussions on saints and feast days, a joke of the day and more. Hosts have even included personal shout outs to residents in need of some cheer, or who are celebrating a birthday that week. Cullen chuckled as she shared, “Many residents were watching quite a bit of television.

We thought–let’s give them some quality programming to watch that is personalized just for them! It’s been so much fun for everyone.”

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End-of-Life Care

letin board’s theme morphed into “The Road to Betty Desjardins and her husband, Roger, made Resilience,” which shared messages of strength the decision to move Betty’s father, Leo Bernard, and moving forward. to Mary Immaculate in 2018. He had been diagnosed with dementia and required full-time care. Recognizing Loss The adjustment to MI went well. Betty Desjardins When Mary Immaculate’s staff struggled with shared, “The nursing team referred to my Dad as processing the loss of so many of their residents the mayor.” When the who over the years pandemic hit, Betty had become extended and Roger were not family, the spiritual concerned with the care team responded. no-visitors policy. DesMary Immaculate held jardins said, “I wasn’t memorial services on particularly anxious each of the commubecause I knew how nity’s floors, so staff well they took care of could take a moment him. They cared for to honor those who him as if he were famhad died. The names ily.” In early April the of the departed were news came that Leo read, a bell was rung, a had tested positive moment of silence was for COVID-19. Des- To provide an encouraging message to staffers observed, Scripture jardins recalled, “My arriving around the clock at Mary Immaculate was read, hymns were Dad was 89 years old Health/Care Services in Massachusetts, a walkway sung, and everyone and his dementia was was marked with chalk art featuring a butterfly and prayed. Cullen said, progressing … we con- the word HOPE. “The loss of life was nected with the nursgreat, and our staff ’s ing team and agreed to focus on his comfort.” suffering was significant. It was important for us Given the end-of-life situation, Desjardins was to acknowledge the sadness in a meaningful way.” invited to Mary Immaculate. “I went through all the appropriate screenings. When I arrived at my Sustenance Dad’s room, I saw Chaplain Neven Pesa, in full Under normal circumstances, Mary Immaculate’s personal protective equipment (PPE), sitting vigil employees would bring their lunch to work or just outside his door. I was deeply touched.” Leo order out, but these times were anything but norBernard passed away peacefully on April 6. Des- mal. Richard Gibbons, MI’s director of dining serjardins reflected, “Before he passed I was able to vices, recalled, “Prior to the pandemic, our dining reassure him he was loved, safe and cared for. He system was decentralized. Our team of 10 served passed with dignity. It was an experience every meals in seven different dining rooms. Under the family should have.” circumstances, we couldn’t do that. We literally turned on a dime and implemented a tray line model and delivered meals to residents’ rooms to THE WALL OF HOPE AND ROAD TO RESILIENCE During the pandemic, Mary Immaculate’s staff ensure their safety.” The dining services team also worked multiple shifts, seven days a week under responded to the needs of their colleagues. Gibdifficult circumstances. They needed to feel bons added, “Given infection control guidelines, a sense of hope and they got it — right at the staff couldn’t have food in the care units, so we building’s staff entrance. The paved walkway made it for them and designated our break room was adorned with chalk street art that featured a as a hub for much-needed breaks and sustenance.” vibrant butterfly and one word — HOPE. When The break room was stocked for every shift with employees first saw the art, many paused for a hot, cold and individually-wrapped meals, along moment to take it in. Open the door and employ- with drinks, every day. Gibbons shared, “The ees were met by “The Wall of Hope,” a welcoming response was overwhelming. That break room wall space offering encouraging quotes, Scripture and food was a message to our team that we verses and thank you notes from family members. understood they were stressed and fatigued — At some point following the initial crisis, the bul- and we wanted to care for them too. Our entire

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community was experiencing a traumatic situation. Managing it together created a genuine team bond we were all very grateful for.”

Transportation

Many of Mary Immaculate’s certified nursing assistants used a taxi or Uber to commute to work.

When the pandemic hit, those services were suspended, and employees were left without a way to get to work. Noemi Quinones, our transportation coordinator for the last 25 years, stepped up and offered to drive CNAs to work for their weekend shifts. Quinones said, “The staff was scared — afraid of losing their jobs, of contracting COVID19, of watching residents suffer and pass away. I jumped in my bus, which could only accommodate four riders due to social distancing guidelines, picked up employees, dropped them off at work with blessings and got them home safely after what was often an emotional and exhausting shift.” Rosita Colon, a CNA at Mary Immaculate who got to work on the bus, explained, “I had a lot on my plate, there was so much happening. I just wanted to help care for residents. In this role, you have to have a big heart – and I knew my residents needed me to be there for them.”

CONNECTION TO COMMUNITY

Part of Mary Immaculate’s mission is maintaining community connections; many of these were abruptly suspended due to the pandemic. We

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decided we could build community — with a celebration of National Mac and Cheese Day. MI’s Dining Services team whipped up a macaroni and cheese lunch for residents as well as staff, who were also asked to donate a box of macaroni and cheese. Nearly 100 boxes were donated to Lazarus House, a local services program that includes a soup kitchen and food pantry that had been unable to serve meals due to pandemic safety guidelines. This effort drew the community together to help others while they also enjoyed a break from daily challenges with some wonderful comfort food.

PRIDE IN BEING DIFFERENT

“Our entire team, from administrators and clinicians to activity staff and kitchen crew take pride in our unwavering focus on compassionate care and our sincere dedication to mission,” said Leydon, president of Mary Immaculate Health/Care Services. “I’m genuinely proud of how our entire team leaned into our Catholic faith and values to make a real difference when faced with extraordinary challenge. As always, the approach served us well. It is why Catholic health care is different.”

SUZANNE DUMARESQ is a communications manager at Covenant Health, based in Tewksbury, Massachusetts, which is one of New England’s largest nonprofit post-acute care providers.

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The Aging of America Requires Personal, Cultural And Policy Changes RUTH E. KATZ

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t has become abundantly clear that the long-term care “system” in one of the richest countries on the planet is not a system at all, but rather a patchwork quilt of solutions that have evolved to accommodate changing demographics. Even if the system had been fully functional and available to all who need help before the coronavirus pandemic, it is facing some tough challenges now. Why, and what can be done to get the country on track with an aging services system consistent with increasing numbers of older people?

Nursing homes, assisted living and other residential communities see heartbreaking losses of life, declines in the well-being of residents and staff, and gaping holes in federal and state support.

Community providers shut down or significantly adapted their services. A false narrative emerged in some media coverage and amongst the public that blamed aging services providers, assuming COVID deaths in nursing homes were the result of malfeasance on the part of the nursing home or its staff. The Centers for Medicare and Medicaid Services and state policies restricted visitation in long-term care settings, yet providers were blamed for isolating residents and restricting family visits.

Policy makers have largely neglected longterm care services for decades, treating them as an optional add-on to health care. (A long-term care proposal known as the CLASS Act or Community Living Assistance, Services and Supports was originally enacted as Title VIII of the Affordable Care Act, the component that helped make the financing of the ACA work. The CLASS Act was repealed before it could be implemented.) So now it’s hard when a global pandemic strikes the people living and working in aging services to see

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several media reports and the attitude of some Americans blame or even demonize the provider community.

Few people want to think about aging — their own or that of the population as a whole — and even fewer want to contemplate needing help with basic daily activities like eating, getting out bed or using the bathroom. Meanwhile, right under our noses, whether we pay attention or not, like most of the developed world, as a nation we are growing older. It’s not all bad; there are some distinct opportunities awaiting each of us, our loved ones, and American society — if we can only get it right.

The pandemic provides a wake-up call. Our financing systems, policies, and social and community attitudes need to catch up. It is time to confront the reality that if we are going to live well into our 80s and 90s we are going to have to build and finance the capacity to provide older people with the help they need to live their best lives, even if they experience functional impairments.

WHY HAS LIFE EXPECTANCY GONE UP?

Getting old is a relatively new concept. Americans have nearly doubled their life expectancy over the past 120 years. At the turn of the last cen-

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tury, the average American lived to the age of 47. 1999; and everyone faces the triple threats of obeWe’ve come a long way. Mid-century, life expec- sity, heart disease and diabetes — the leading tancy was 68 years and now, it’s close to 80. By causes of preventable and premature death.

Pervasive attitudes of ageism, in addition to 2060, the U.S. Census Bureau estimates it will be closer to 86. 1 To what do we owe this widespread the physical declines, social isolation and loneliness that often accompany aging, also shorten longevity?

The most significant benefits come from lives. A recent review of research in 45 countries public health — efficient waste disposal, widely found that structural biases such as denied access available clean water, vaccinations against deadly to health care and negative stereotypes induce diseases, antibiotics, and the effectiveness of prevention programs COVID-19 has sharpened the nation’s for smoking and alcohol consumpfocus on aging and the services and tion and the promotion of physical activity. systems that are in place — or not — Technology and science have played a big part. We all gain from to support aging lives. the widespread use of electricity and refrigeration to keep food safe and improve- stress, increase depression and shorten life expecments in transportation and communication. tancy. 4 Medical research has given all of us more time; better cardiovascular treatments and widespread COVID-19 THE MASTER TEACHER access to them may be responsible for decreasing And then along came COVID. Coronavirus is a prevalence or incidence of Alzheimer’s disease danger to all generations, but it has been particuand related dementias.2 larly deadly to older people. COVID-19 has sharpened the nation’s focus on aging and the services and systems that are in place, or not, to support REDEFINING “OLD” When most Americans died in their 40s and 50s, a aging lives.

The pandemic offers all of us — individuals few short generations ago, they lived compressed lives. They were born, lived short childhoods and and providers and policy makers a great opporlaunched into adulthood by age 18. The concept of tunity to see what must be done and do it. As a the “teenager” emerged in the middle 1950s, with nation, like the rest of the world, we have paid the post-war economic boom, the emergence of dearly for these lessons; we must not squander better education and leisure time, and the longer them. We need to evolve personally, culturally and in our policy zeitgeist. lives people were starting to expect. 3 Just as the concept of the “teenager” was created because we found ourselves enjoying longer BEGINNING WITH THE INDIVIDUAL lives, the idea of a demographic group of people In the landmark Harvard Study of Adult Developbeyond retirement is emerging. As Americans and ment, begun in 1939 and now in its second genthe world craft this new generation, some advan- eration, researchers identified the psychological tages that support aging well accrue more easily factors and biological processes in earlier life that to those with more resources, including abundant predict health and well-being in late life (80s and food supply and reduced food insecurity, better 90s). 5 access to health care and secure housing.

They found that genetics was less important As a whole, the United States is not doing as than physical activity, absence of alcohol abuse well as it should be worldwide. In 1960 we had and smoking, having mature mechanisms to deal the 20th highest life expectancy. By 2060 we’re with life’s stressors, and being at a healthy weight. expected to drop to 43. There are likely many But by far, they found that the key to healthy, reasons for this, starting with unequal access to happy aging is satisfaction with relationships in health care, housing and education across racial midlife. and economic groups. But across all groups drug The importance of relationships, in addition overdoses were six times higher in 2017 than in to clean living, is confirmed in other major stud-

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ies. Researchers at the Stanford Center on Lon- behaviors, we have a cultural obligation to make gevity in their 2016 Sightlines Study summarized change. scientific evidence that “living long and living well is most realistic for those who adopt healthy HOW WE LIVE, WHERE WE LIVE, ATTITUDES, behaviors, are financially secure, and are socially AND AGEISM engaged.”6 Looking at older adults, the Stanford team found Consider the reasons older people offer for that there are “signs of progress and reasons to why they move into life plan communities (also be concerned about the ways Americans are preknown as continuing care retirement communi- paring for longer lives.” By 2030, people over 65 ties). Beyond just safety, many are seeking social will outnumber those under 18. It is essential that connections. Ironically, one of the deepest cuts our practices and cultural values keep up with the from COVID has been social isolation, both for demographic shift.

In particular, looking at 26 factors associated those in residential settings and senior communities and for those living alone in the outside with longer lives, there are big disparities. Nonwhites are more likely to live in or near poverty, community.

In his search for the secrets of longevity, in have less access to insurance and health care, 2004 Dan Buettner set out on a National Geo- are less likely to have retirement savings plans, graphic expedition that turned into a discovery of and have lower educational achievement. Finanfive places in the world where people consistently cial insecurity, they conclude, is associated with live to be older than 100; he called these places the “Blue Zones.”7 Non-whites are more likely to live in The common denominators in the Blue Zones that are believed to slow the or near poverty, have less access to aging process are: insurance and health care, are less Move naturally, live in environments that constantly require movement likely to have retirement savings Have a sense of purpose Have routines to shed stress, like plans, and have lower educational prayer, naps, or happy hours achievement. Financial insecurity, The Okinawan Hara hachi bu rule, stop eating when 80% full they conclude, is associated with Eat more plants Drink one or two glasses of wine increased susceptibility to illness per day, with friends and food and shorter lives.

Belong to a faith-based community, any denomination Put families first, take care of aging parents, increased susceptibility to illness and shorter lives. It’s no coincidence that COVID has hit these invest time and love in children Live in communities with social circles that groups the hardest. Other studies have found that those with lower incomes and non-white people support healthy behaviors.

We also know a lot more about living better have higher rates of obesity and are more likely with chronic illness and functional impairments. to smoke.8 In part, health care and pharmaceuticals have a The other big cultural disparity issue is agehuge impact. Equally important, the Americans ism. Ageism across our culture fosters loneliness with Disabilities Act, a disability civil rights law and isolation. Outdated attitudes of what older signed by President George H.W. Bush in 1990, people can and cannot do — or should and should has systematically reduced the impact of func- not do ­— are cemented deeply into media/social tional impairments and turned disability to abil- media and part of our everyday assumptions and ity through advances in technology and the built language. We have to build communities that welenvironment (e.g., more curb cuts, ramps). come older people into the very fabric of everyday In addition to taking charge of our personal life.

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lic relations effort to promote what the press had Our cultural evolution will have to include: Communities with built environments that started calling Medicare, saying “We are behind every country, pretty nearly, in Europe, in this support intergenerational living.

Education approaches based on assump- matter of medical care for our citizens.”

Among others, people of color and older peotions and with intentional focus on awareness of aging. As the population gets older, any jobs or ple emerged as growing segments of an enriched careers young people pursue will involve interact- American population. The Civil Rights Act and ing with older people. For example, all doctors will care for older Now that we are routinely living people, not just geriatricians. All Starbucks managers will serve longer, it is time to follow the forward older customers. thinking leaders who saw a future Working together, with three or more generations potenwhere older people would need tially on work teams, sharing work projects and spaces. health supports and took bold policy Playing and exercising steps by building Medicare. together.

Celebrating and marking life events together, including grieving together the Older Americans Act were two sweeping legislative responses. The idea that policymakers and being ready to accept death as part of life.

Having meaningful conversations about could do something about economic disparities diversity, equity and inclusion – in communities produced the War on Poverty. Congress established rent supplements and low-income housthat include people of different races and ages.

Alongside changing attitudes and behaviors, ing. Of course, health care was an essential part of policy must respond and keep evolving. COVID the equity equation; Medicare and Medicaid gave has taught us that for their entire lifetimes, people older people and those with low incomes access need income, health care, housing and the guar- to health care.

Preserving the progress policymakers have antee of safe long-term care supports if needed. made in forging a competent context for aging in America means continuing forward motion IT’S TIME TO MODERNIZE GOVERNMENT’S in health care, housing, economics and ensuring ROLE TO SUPPORT HEALTHY AGING Only once before in American life was aging equal access for an increasingly diverse popusuch a universal focus. The early 1960s were lation. We must keep the hard-earned growth such a heady time, when the country had recov- we’ve worked together to earn and address newly ered enough from the big mid-century wars to emerging challenges with the same forward think beyond preserving the status quo. Leaders focused spirit. were taking a closer look at the diversity of our population.

LONG-TERM CARE AND A PLACE TO LIVE: In 1965, when Medicare was enacted after THE NEXT FRONTIERS more than two decades of discussion, the average Now that we are routinely living longer, it is time American lifespan was around 70 years. One of to follow the forward thinking leaders who saw the rationales for Medicare was that older Ameri- a future where older people would need health cans’ hospital spending was more than twice that supports and took bold policy steps by building of those under age 65. Today, when we can expect Medicare. to live well into an older age, there is little arguIt is unacceptable in a country as rich as the ment that health coverage through Medicare is United States that two out of three people eligione of the reasons. ble for low-income senior housing do not receive In the 1940s President Truman tried to estab- it because the supply is so limited.9 The housing lish a program to cover health care but failed. His options that do exist provide only limited serplan was branded un-American and “socialized vices to help older residents maintain their indemedicine.” President Kennedy undertook a pub- pendence in the community, even if they develop

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impairments. Regardless of their income, older people should be able feel secure in having a safe place to live.

ACCEPTING THE COVID CHALLENGE

No one can stop time; we are all aging every day.

But we can ensure that every life — and every year of every life — lived in the United States can be a good life. The researchers in the Harvard longitudinal study recommend that the most important thing is to connect — and do it with joy.

Let’s reach across generations, across race and economic class, into homes, schools and communities. Let’s make sure Congress and state legislatures are on board with policy and financing to support the richness this country has to offer an aging population.

COVID has done a great deal of damage, stolen too many lives and so much of the way we live. We can’t be done with it soon enough, but we can appreciate the spotlight it has shone on aging, racial diversity and aging services. Let’s take our hard earned COVID lessons and turn the pandemic on its head. We have the opportunity to emerge stronger.

RUTH E. KATZ is senior vice president, public policy/advocacy for LeadingAge, the Washington, D.C.-based nonprofit focused on education, advocacy and applied research for older adults.

NOTES 1. Jennifer M. Ortman, Victoria A. Velkoff and Howard Hogan, “An Aging Nation: The Older Population in the

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United States, U.S. Census Bureau, May 2014, https:// www.census.gov/prod/2014pubs/p25-1140.pdf.

2. “Dementia Trends: Implications for an Aging America,” Population Reference Bureau, Today’s Research on Aging, no. 36, July 2017, https://assets.prb.org/pdf17/ TRA%20Alzheimers%20and%20Dementia.pdf.

3. Derek Thompson, “A Brief History of Teenagers,” Saturday Evening Post, Feb. 13, 2018, https://www.saturdayeveningpost.com/2018/02/brief-history-teenagers/.

4. World Health Organization, Aging and Life-Course, https://www.who.int/ageing/ageism/campaign/en/.

5. Harvard Second Generation Study, Study of Adult Development, https://www.adultdevelopmentstudy. org/grantandglueckstudy.

6. The Sightlines Project, https://longevity.stanford. edu/the-sightlines-project/.

7. Dan Buettner and Sam Skemp, “Blue Zones: Lessons from the World’s Longest Lived,” American Journal of Lifestyle Medicine 10, no. 5 (September 2016): 318–21, https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC4948154/.

8. Raees A. Shaikh et al., “Socioeconomic Status, Smoking, Alcohol Use, Physical Activity, and Dietary Behavior as Determinants of Obesity and Body Mass Index in the United States: Findings from the National Health Interview Survey,” International Journal of MCH and AIDS 4, no. 1 (2015): 22-34, https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC6125071/.

9. Worst Case Housing Needs Report to Congress, U.S. Department of Housing and Urban Development, Office of Policy Development and Research, https://www. huduser.gov/portal/sites/default/files/pdf/worst-casehousing-needs-2020.pdf.

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PACE Expansion Can Meet Growing Needs Of Frail Older Adults SHAWN M. BLOOM

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he COVID-19 pandemic has been devastating for older adults, especially those with significant and complex medical conditions. Individuals over the age of 65 account for 16% of the U.S. population, yet so far, they have accounted for over 80% of all U.S. deaths due to COVID-19.1 Especially hard hit have been residents of long-term care facilities: they have made up 45% of these deaths in the U.S. as of Sept. 1, 2020.2 Growing numbers of adults need long-term services and supports (LTSS), which include assistance with medical and personal care. It’s also believed policy makers will increasingly seek community-based service options to minimize the impact of COVID-19 on older adults. Such service options have long been preferred by consumers and could significantly expand in the near future as the number of older Americans continues to increase.

Due to these circumstances, and the growing numbers of consumers needing long-term services and supports, state and federal policy makers likely will begin seeking community-based service options proven to be effective at minimizing the impact of COVID-19 on those they care for. Community-based service options have long been preferred by consumers and could significantly expand in the near future as the number of older Americans continues to increase.

Dating back to February when COVID-19 first emerged in the United States, Programs of AllInclusive Care for the Elderly (PACE) have innovated and flexibly adapted to meet the significant medical, LTSS, nutritional and social needs of those they serve. As of October 2020, the COVID-

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19 fatality rate among PACE participants is 1.5%.

Among the PACE participants that have died from COVID-19, 40% resided in long-term care facilities.3 Most PACE participants live in the commu-

As of October 2020, the COVID-19 fatality rate among PACE participants is 1.5%. nity and less than 1% of community-based PACE participants have died from COVID-19.

Moving forward, our country needs to engage in a serious and long overdue discussion about reorganizing our long-term care delivery system, especially for older adults who rely on Medicaid to cover their LTSS costs. PACE has proven to be a cost-effective,4 comprehensive, consumer-centric model of care that should be part of future discussions.

BACKGROUND

On Jan. 11, 2020, China’s Centers for Disease Control reported its first COVID-19 fatality: a 61-yearold man who regularly shopped at a market in

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Wuhan. Data released in February by the same inpatient settings.

Today there are 135 PACE organizations in 31 agency clearly revealed that the COVID-19 fatality rates were directly correlated with advanced age.5 states, with their enrollments ranging from about On Feb. 28, 2020, when the first reported U.S. 50 to over 3,000 participants. Ninety percent of case of COVID-19 was identified in a female resi- PACE participants are dually eligible for Medicare dent of a long-term care skilled nursing facility and Medicaid, 9% are eligible only for Medicaid, in King County, Washington, we had more insight and less than 1% are eligible only for Medicare.

Although all PACE participants are certified into the vulnerability of frail older adults. Epidemiologic investigation of the facility identified 129 as clinically eligible to receive nursing home care cases of COVID-19, including 81 residents, 34 staff by their state, few are placed in a facility: only members and 14 visitors; 23 persons died, the first being a female Today there are 135 PACE organizations resident whose death occurred in 31 states, with their enrollments on March 6.6 The outbreak in the Seattle ranging from about 50 to over 3,000 nursing home was truly a “wakeup call” that the PACE commuparticipants. nity faced head on and with a goal of minimizing the impact of COVID-19 on the vul- about 5% of PACE participants actually reside in a nursing home.7 This low percentage is achieved nerable older adults in their care. despite the fact that, on average, PACE participants have six chronic conditions (including 46% THE PACE MODEL OF CARE PACE is a well-established care delivery and who have dementia and over 40% who have serifinancing model for adults. PACE organizations ous mental illness).8 serve those people who are among the most vulIn 2020, the mean Medicaid capitation rate nerable of Medicare and Medicaid recipients— paid by states to PACE organizations for each adults over age 55 who are assessed and certified PACE participant was $3,981 and the mean Mediby their state as needing a nursing home level of care capitated payment was $2,797,9 with no sercare. Participants have both multiple, complex vice limitations, co-pays or deductibles. Capitated medical conditions and functional and/or cogni- payments for all Medicare and Medicaid services tive impairments. align PACE organizations’ financial incentives Fully integrated PACE organizations provide with the quality of care their participants seek. program participants with all needed medical Under this capitated arrangement, PACE orgaand supportive services, including the entire con- nizations are incentivized to keep participants as tinuum of Medicare- and Medicaid-covered items healthy as possible in order to reduce inpatient and services, with the objective of maintaining hospital and skilled nursing facility costs. Evithe independence of participants in their homes dence shows PACE organizations generally have and communities for as long as possible. lower inpatient hospital use and shorter hospital The hallmark of the PACE model is an interdis- lengths of stay.10 ciplinary team, made up of directly employed priTo achieve these outcomes, PACE interdismary care providers, nurses, social workers, phys- ciplinary teams work together to assess particiical, occupational and recreational therapists, and pants’ individualized needs, develop care plans numerous other health care professionals. As a and provide and coordinate all primary, acute, team, they comprehensively assess participants’ behavioral health and LTSS services. The teams care needs, and develop and implement partici- meet daily to discuss the emerging and ongoing pant-centered care plans. Services are provided care needs of the individuals for whom they are by staff in the PACE center, a unique setting that responsible. While people can see the PACE cencombines the attributes of a primary care clinic, ter and the PACE vans, the interdisciplinary care adult day health care center, physical therapy and team serves as focal point of the PACE model occupational therapy clinic. Services are also pro- of care and plays a vital role in the outcomes vided in participants’ homes and, when necessary, achieved.

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Once enrolled, nearly all participants remain in the PACE program through the rest of their lives, unless they move out of the geographic service area. In a 2018 National PACE Association survey of 973 family members and other primary care providers for PACE participants, 96% reported overall satisfaction with the services and 97% said they would recommend PACE to a family member in a similar situation.11

PACE ORGANIZATIONS RESPOND QUICKLY TO COVID

Most recently, and with the support of the John A. Hartford Foundation, the Gary and Mary West Foundation and the Weinberg Foundation, the National PACE Association has launched the PACE 2.0 growth initiative that aspires to double the number of people served by PACE organizations from 100,000 in 2021 to 200,000 by 2028.

The PACE 2.0 initiative targets three streams of growth to meet its goal: 1. Scale — Provide current PACE organizations with the tools to achieve scale by growing exponentially. The tools will be based on best practices from high-performing, high-growth PACE programs.

2. Spread — Support new program development by identifying models for expedited start-up

In early March, prompted by the outbreak of COVID-19 in Seattle, the National PACE Association organized a call with its PACE organization members to discuss the outbreak, learn how a PACE organization in Seattle had responded to the outbreak and begin outlining strategies to reorganize their operational delivery PACE customizes a range of primary, model to both meet the ongoing needs of their participants and protect them therapy, acute and home-based from COVID-19. Individual PACE orgaservices and supports that control nizations turned to telehealth to monitor participants; reassigned vans to costs and have been found to deliver home-based care and services, nutrition services, medical equipment achieve positive outcomes and high and medications rather than bring levels of satisfaction among frail participants to a PACE center; turned some PACE centers into COVID-19 elderly and their families. infirmaries; used PACE Centers to offer respite care (including overnight care) for families who need a safe place for their and growth for organizations that are well posielderly loved ones to be while they are working tioned to reach unserved or underserved commuor need a break; and developed new programs to nities by establishing new PACE programs. address participants’ social isolation.

3. Scope — Expand service eligibility beyond the current population to Medicare-only participants and make it available to high-need popuTIME FOR CHANGE AND GROWTH Since the passage of the Social Security Act of lations not currently eligible for the program 1965, nursing homes have been and remain the because they are under age 55 or do not meet a only mandatory state LTSS option for Medicaid nursing home level of care. beneficiaries. Over the last 10 years in particular, state and federal initiatives have been effec- AN IMPROVED SYSTEM OF CARE tive at expanding home and community-based Redesigning our current systems of care for frail waiver options that offer a limited range of home older adults will require a significant and broadcare, adult day care and other services to mitigate based effort, with the support of consumers, pronursing home use. However, we can do better by viders interested in developing new communityoffering other models of care. PACE customizes a based options and policy makers motivated to range of primary, therapy, acute and home-based support proven, comprehensive and consumerservices and supports that control costs and have centric options. We can and must redesign our been found to achieve positive outcomes and high LTSS delivery system. As we do so, we should levels of satisfaction among frail elderly and their focus on advocating for services that achieve the families. mutual triple aim goals of lowering costs, improv-

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ing outcomes and enhancing the consumer experience with care.

The population of Americans age 65 and older is growing at an unprecedented rate. In 2014, there were 46.2 million adults age 65 and older, and this number is expected to more than double to about 98 million older adults by the year 2060.12 The majority of these older adults will require at least some support with activities of daily living as they age—activities like cooking, bathing, or remembering to take medicine.13 The time to act is now. Given the social, economic and ethical implications associated with caring for the fastest growing segment of our population, we can no long assume that the primary pillars of our LTSS system established in 1965 can accommodate the future needs of our aging population.

SHAWN M. BLOOM is chief executive officer of the National PACE Association, based in Alexandria, Virginia.

NOTES 1. Meredith Freed et al., “What Share of People Who Have Died of COVID-19 Are 65 and Older — and How Does It Vary By State?,” Kaiser Family Foundation, July 24, 2020.

2. “COVID-19 Outbreaks in Long-Term Care Facilities Were Most Severe in the Early Months of the Pandemic, but Data Show Cases and Deaths in Such Facilities May Be On the Rise Again,” Kaiser Family Foundation, Sept. 1, 2020.

3. NPA COVID-19 positive case and fatality data reported weekly by PACE organizations, April-November 2020.

4. Under federal statute 42 U.S. Code § 1396u–4 (d) (2) Medicaid rates paid to capitated programs must be less than the amount that would otherwise have been made under the state plan if the individuals were not so enrolled.

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5. Yanping Zhang, “The Epidemiological Characteristics of an Outbreak of 2019 Novel Coronavirus Diseases (COVID-19) — China, 2020,” Feb. 17, 2020, doi: 10.46234/ccdcw2020.032.

6. Temet M. McMichael et al., “COVID-19 in a Long-Term Care Facility — King County, Washington, February 27– March 9, 2020,” Centers for Disease Control and Prevention, Morbidity and Mortality Weekly report 69, no. 12 (March 27, 2020): 339-42.

7. DATAPACE3 data (demographic, service utilization, functional, diagnostic and other health care related data derived from electronic health records and other sources) submitted quarterly by PACE organizations.

8. Logan Kelly, Nancy Archibald and Amy Herr, “Serving Adults with Serious Mental Illness in the Program of All-Inclusive Care for the Elderly: Promising Practices, Center for Health Care Strategies brief (Sept. 2018), https://s8637.pcdn.co/wp-content/.

9. NPA Annual PACE Capitation Rate Survey, June 2020.

10. Robert L. Kane et al., “Variations on a Theme Called PACE,” The Journals of Gerontology Series A 61, no. 7 (July 2006): 689-93.

11. NPA Survey of 973 Family Caregivers of PACE enrollees, 2018.

12. NPA Survey of 3617 Participants and family care– givers, Aug.-Oct. 2020.

12. Administration on Aging, U.S. Department of Health and Human Services, “A Profile of Older Americans: 2015,” https://www.acl.gov/sites/default/files/ Aging%20and%20Disability%20in%20America/ 2015-Profile.pdf.

13. U.S. Department of Health and Human Services, National Clearinghouse for Long-Term Care Information, “The Basics,” http://longtermcare.gov/the-basics/.

Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, “Long-Term Services and Supports for Older Americans: Risks and Financing Research Brief, Revised 2016, https://aspe.hhs.gov/basic-report/long-term-servicesand-supports-older-americans-risks-and-financingresearch-brief.

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AGING AND L O N G -T E R M C A R E

Reflection

Growing Old MSGR. CHARLES J. FAHEY

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ll living things have a life span. And underlying the human journey is our physiological makeup. Cells are in a constant state of flux; some are wearing out and others replacing them. In the latter part of human life, replication does not keep up with decline. Those of us who dare try to fathom Divine Providence, who have an appreciation for all of creation, might consider we are co-creators in an ongoing evolutionary process. Even from early catechism, we learn God made us to know, love and serve Him in this world as well as to be happy with Him forever in Heaven.

With this perspective, we can divide the human journey into three stages. The first stage is from conception onward with growing physical, emotional, intellectual and, hopefully, spiritual maturity until the individual is able to develop capacity for a productive and fruitful life.

The second stage is usually the time of greatest physical capacity to sustain the individual, the family and make a contribution to the common good. It may bring the blessings of marriage, children, vocation or other ways to serve and flourish in the fullness of life.

The third stage is part of a continuum. The prior times and places, relationships and events are integral to the personhood of the older person. Most people will continue to be parts of families in the third stage, including the important role of grandparenting. Even for those living through it, this stage can seem like an exploration of unknown or unfamiliar territory.

The third stage may involve a decline in vitality. However, many older adults use experience to their advantage and to the advantage of those around them. They may use more of their knowledge and dexterity, and rely less on physical strength and stamina than they might have in the earlier stages.

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The third stage may include progressive intermittent frailty, with increasing difficulty to deal with activities of daily living. This phenomenon differs from person to person and can be mitigated with voluntary support or paid assistance. Some challenges can be modified while others cannot.

A distinguished German psychologist Paul Baltes developed the expression “select, optimize and compensate,” which includes selecting those things in one’s life of which are most valuable and which one is still capable of and to concentrate on them. We are fortunate to live at a time in which many discoveries have been made concerning the preservation of health, as well as medical and rehabilitation activities that can assist an individual to function despite disease or injury. Assistive devices and pharmacological treatments allow individuals to deal with losses that would have been devastating in prior years.

The ability of an individual to deal with changes, especially losses, has a great deal to do with how one has dealt with loss, disability or frailty throughout one’s life previously. One’s abilities in old age — physical, emotional and spiritual — are predicated to a large extent upon the choices for better or for worse that have already been made throughout the life journey.

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This personal reflection on old age has been opment of St. Camillus, the founding of the Proa grace-filled, though at times painful, exercise. gram of All Inclusive Care of the Elderly (PACE), It has occurred over a several month “lockdown” Christopher Community and the growth of day at my home in the Jesuit residence at Le Moyne care and family life programs. All of this meant College in Syracuse, New York, due to the coro- the scope and breadth of services for older people navirus pandemic. It has been as though I am on a were changing in good and innovative ways.

Having served 20 years, I recognized that the lengthy retreat. It has been both an exercise in my spirituality and an evaluation of what I have done, agency might benefit from new leadership. After and will do, with the challenges and opportuni- my “retirement” I was kidnapped to teach in Fordham University’s School of Social Work and was ties I have.

At age 87, I have lived 10 years beyond the life the Marie Ward Doty Chair of Aging Studies. This expectancy for males born in 1933. My current marked the beginning of my now 40 years of hapcohort has a life expectancy of five years. Even pily living in a Jesuit community.

Over the years, I became deeply involved in an elementary understanding of statistics cautions one to be aware of the “norm” since some the relatively new aging movement. I was active will die younger and some older. My old age is on the boards of a number of organizations, ultiidiosyncratic from several vantage points. I have mately serving as chairperson for four (Amerilived, directly or indirectly, through a number of can Society on Aging, LeadingAge, the National major social events such as the Great Depression, Council on Aging and Catholic Charities USA) World War II, the Civil Rights movement of the ’60s, Vatican Moving from active work into more of an Council II and Vietnam.

A decision of special signifemeritus role, I have found this time to icance in my life was to enter be a time to focus on faith — an escape the seminary, which meant I would never marry. Though I from the distractions that can come have many friendships I cherish, I am single, with no close from being an administrator, organizer, relatives. After ordination, public policy person and professor to I expected to be involved in pastoral ministry. As fate and concentrate on my spiritual life as a the bishop would have it, that Christian and priest. lasted only two years during which I was a happy assistant having been elected by the membership in each. I pastor at St. Vincent DePaul parish in Syracuse.

I soon began down a path that led to decades of was chair of a fifth, the federal Council on Aging, involvement in improving policy and care for the by President Jimmy Carter’s appointment. I also elderly. I was sent to the School of Social Work was a member of the board of the Catholic Health at Catholic University to see what I could learn Association and a founding member of the Amerabout services to the aging. The Catholic nurs- ican Foundation for Aging Research. I served ing home in the region needed updating to better as the Vatican spokesperson at the 1982 Vienna serve people and to pass muster in the new reim- United Nations’ World Assembly on Aging and as a United States delegate to the 2002 Madrid bursement and regulatory environment.

Post Vatican II, Catholic vowed religious and United Nations’ World Assembly. I hope this lay people of several faith traditions developed work brought people together, in association and many new services and programs for older adults through agencies, to address the problems of the in the Syracuse area, some of which served as elderly and to envision long-term care beyond an guidance for other regions as well. During the institutional approach.

Despite many changes in my roles over the period from 1961 through 1979 we experienced the renewal and significant expansion of Loretto years, I have moved into old age without havGeriatric Center, the establishment and devel- ing to make dramatic psychological adjustments

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I am blessed and grateful for the opportunities that have been afforded to me and the people with whom I have crossed paths. because I continue to center my identity on being a priest. Moving from active work into more of an emeritus role, I have found this to be a time to focus on faith — an escape from the distractions that can come from being an administrator, organizer, public policy person and professor to concentrate on my spiritual life as a Christian and priest.

I cannot escape both the decline and losses associated with old age without some feeling of regret. The most obvious decline has been in energy, though changes to my skin, eyes and teeth have an impact. Fortunately, I have an artistic dentist, skillful dermatologist and an able ophthalmologist, so I am able to deal with these declines with little loss of functional capacity. I miss skiing and golf. Then too it is strange to reflect that I have done a number of things for the last time.

A few years ago Delta Airlines informed me that I had flown more than an actual one million miles since having been with them. I suspect my flying days are over. I sometimes have a little short-term memory loss. When I need it, my iPhone sometimes serves as my supplemental memory.

At this stage in my life, I have outlived many of my closest friends. I still cherish the friendships that remain, including those I have known since my youth and those who may not live nearby but remain dear to me. I also find I have developed some new friendships in recent years.

As I age, I also acknowledge loss. A particularly poignant loss is being unable to physically preside

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at daily liturgy, though I feel I am fully concelebrating any liturgy I attend. There’s a degree of anxiety about the loss of autonomy from no longer driving a car. I am avoiding long drives. Good-bye, New York City. I do not drive at night. I do drive early in the morning for Mass at St. Joseph’s in Liverpool. I have been taking this same route for almost 20 years, so I know the way and go when it is well-lighted. I have enough humility that I will stop driving when I need to, as painful as it may be.

Other concerns arise, of physical capacity, even to just walk. And particularly having the intellectual capacity to learn, to remember, to discern, to make good judgments and to pray. Of course, we all face the reality of death which could occur at any moment in life, but it’s much more dramatic when you know you are close to it. As a person of faith, I have hope, but that does not remove all uncertainties about death or my worthiness of whatever is in store.

I am blessed and grateful for the opportunities that have been afforded to me and the people with whom I have crossed paths. While most of these opportunities and personal interactions have been grace-filled, not all have been. At this time in my life, I wish I could set “all relationships right.” How grateful I am to have been exposed to and absorbed the Good News, to have found in Christ a brother who modeled redemptive activity, to have the Holy Spirit’s continuing inspiration and to have knowledge of our Creator, who wants to be known as our loving parent.

MSGR. CHARLES J. FAHEY, known for his many contributions to improve understanding of aging and services to the elderly, was the Marie Ward Doty Professor of Aging Studies at Fordham University, New York City. He received a Lifetime Achievement Award from the Catholic Health Association in 2012.

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Next Generation Of Mission Integration CHA’s NEW COMPENTENCY MODEL FOR MISSION LEADERS

BRIAN P. SMITH, MS, MA, MDiv

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he role of the mission leader in Catholic health care in the United States was created in the mid-1970s. The responsibilities and skills of those early mission leaders varied greatly, and it was soon recognized that in order for the mission leader position to be relevant and successful, a set of standard competencies was necessary.

The Catholic Health Association published its first mission leader competency model in 1999.

The competencies were primarily designed for academic institutions to develop courses and programs that would help educate and form mission leaders in the desired knowledge base and necessary personal qualities. That first model focused on theological, spiritual, ethical and organizational development as well as practical understanding of the operations and dynamics of health care organizations, recognizing that life-long learning is necessary to respond to the changing needs in the ministry.1 In 2009, working with the Reid Group of Seattle, CHA engaged the ministry through a series of online surveys, focus groups and personal interviews to understand the challenges, needs and hopes of sponsors, CEOs and other stakeholders and what competencies they found necessary in a mission leader. The 2009 CHA Mission Leader Competency Model included personal qualifica-

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tions required and five competencies: Leadership, Theology, Spirituality, Ethics and Organizational Management.

The 2009 model served the ministry well for a decade. Since then, Catholic health care has expanded into wellness and prevention, population health and care delivery in non-acute settings. New partnerships between Catholic health entities and other-than Catholic providers became more common, and new models of governance and sponsorship emerged. In addition, lay mission leaders began to outnumber those who were religious sisters, brothers and priests.

These new lay mission leaders come from a variety of backgrounds: theological, operational and clinical.2 While many mission leaders continue to have oversight for “traditional” areas of mission integration — church relations, ethics, pastoral care, formation and community benefit — we also see mission leaders specializing in areas such as mea-

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suring and improving Catholic identity, ministry formation, population health and advocacy.

Today, more mission leaders serve in system and regional roles, which means they are responsible for mission integration in several facilities and across shared services. Because of all these changes and factors, the ministry realized it was time for the mission leader competency model to mature again.

DEVELOPING THE 2020 CHA COMPETENCY MODEL FOR MISSION LEADERS

Beginning in June 2019, CHA again partnered with the Reid Group of Seattle to update the mission leader competency model.

The process included interviews of over 30 key stakeholders (sponsors, CEOs and other senior executives), a survey of more than 600 mission leaders, and the convening of focus groups comprised of system executive mission leaders.

A steering committee comprised of mission, human resources and organizational development leaders offered advice and recommendations to the mission department staff of CHA and the Reid Group as the competencies were being discussed and developed.

In February 2020, as drafts were being shared for feedback with system executive mission leaders, the coronavirus pandemic was beginning to impact the ministry and the country. While the goal had been to complete and share the new competency model at the CHA Assembly in June 2020, system mission executives agreed it was best to “hit pause” on the model. They asked, “What might we learn from the pandemic and what might the resulting changes in health care mean for mission leaders?

How could this change the competency model?”

Months into the pandemic, CHA and its members were beginning to learn how health care was transforming and how the role of mission leaders was evolving once again. In addition, the killing of George Floyd on May 26, 2020, and the resulting protests calling once again for an end to systemic racism in the U.S., strengthened within the minis-

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try our commitment to act on behalf of justice and to end racial disparities in health care. Recognizing that these watershed moments in our nation had implications for health care, CHA used this opportunity to add some behavioral expectations to the model to include leading transformational change as well as addressing racial injustice.

In summer 2020, CHA resumed the development of the competency model by adding several mid- and entry-level mission leader listening sessions. In September, the final draft was approved by system mission executives.

Affirming the variation among systems’ structures, the model allows for adaptation. What one system expects of an executive mission leader may be required of a mid-level mission leader in another system. A ministry primarily focused on senior care in non-acute settings will have different expectations of a mission leader than one who is primarily serving in acute care and clinical settings.

Another example is that in one system a mission leader may be responsible for overseeing ethics, community benefit or spiritual care functions for a facility or region; and in another system, the mission leader may have oversight for these areas and collaborate with others who have specific expertise and who take responsibility for these areas that report up to the mission leader. The flexibility of the competency model is seen by many systems as one of its strengths.

Personal Qualifications and General Leadership Skills

A major change between the 2009 and 2020 mission leader competency model came from the input given by CEOs and other senior leaders interviewed. They strongly suggested there be a presumption that mission leaders already possess the necessary personal qualifications and general leadership competencies. These key stakeholders asked that the new competency model focus on the unique contribution mission leaders bring to the senior leadership team and the ministry

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they serve. Therefore, the new model assumes a mission leader will have the necessary personal and leadership qualifications, and that like other senior leaders, those competencies will need to grow as their responsibilities increase.

The personal qualifications a mission leader is presumed to possess include: Is well formed in the Catholic theological tradition Applies theological and ethical principles in a health care setting Models servant leadership Establishes mutually beneficial relationships with diverse groups Inspires others to live the mission and values of the organization Exhibits ongoing personal and professional development The general leadership qualities a mission leader are presumed to possess include: Strategic thinking Business acumen Adaptability and agility Communication skills Managerial skills Succession planning

TIER I

Tier I refers to entry-level positions such as manager or coordinator. This level focuses on basic skills associated with the mission role. Such roles are important to succession structures and the maturity of the discipline.

COMPETENCY MODEL FOR MISSION LEADERS3

The 2020 Competency Model for Mission Leaders includes seven competencies: Catholic Identity, Strategy, Operations, Formation, Spirituality, Ethics, Advocacy. The new model offers three tiers (entry, mid, and executive) for each of the seven competencies. The competencies are the same for all three levels; however, the behavioral expectations vary depending on the tier. The thought behind this approach is that a tiered model shows the increasing responsibility and expertise required as a mission leader develops. This creates a clear career path for the mission leader and a better understanding for those who work with them as to what to expect from their mission colleagues.

DEFINING THE TIERS

The presumption of certain personal qualifications and general leadership qualities for mission leaders means that even entry-level mission candidates will begin with a good amount of skills and responsibilities. Mission structures and titles vary widely across our ministries. While it is up to each system to determine which positions fall into each of these levels, the following outlines the positions that are likely to fall into each of the tiers below:

TIER II

Tier II refers to mid-level positions, which vary widely by system and structure.

Mission directors and senior directors likely fall into this tier as well as certain parts of a regional leader role.

TIER III

Tier III refers to the executive mission leader. Positions over large regions and certain system-level roles will also need many of the competencies at this level.

While many mission leaders continue to have oversight for “traditional” areas of mission integration — church relations, ethics, pastoral care, formation and community benefit — we also see mission leaders specializing in areas such as measuring and improving Catholic identity, ministry formation, population health and advocacy.

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CATHOLIC IDENTITY

Stewards Catholic Identity and Strengthens Church Relations

Mission leaders foster the creation of a missioncentered culture that permeates everything throughout the organization and enhances relationships with the institutional church. They promote a strong Catholic identity and implement key mission activities within the organization to ensure the ministry flourishes well into the future. Mission leaders serve as a bridge between sponsors and local bishop(s) regarding discussion of ethical and

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moral decisions, advocacy issues affecting the poor and marginalized, and accountability for Catholic identity.

General behavioral expectations include: A. Distinguishes the unique roles of sponsors, bishops, boards and senior leaders for overseeing the ministry B. Promotes and assesses the Catholic identity of the organization and appropriately reports to sponsors and bishops C. Builds trust and maintains excellent relationships with sponsors, bishops, pastors, local religious leaders and other Catholic ministries D. Inspires others to participate in and advance the healing ministry of Jesus and models the charism of the founding community(ies)

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STRATEGY

Ensures the centrality of mission in strategy

Mission leaders serve an essential role in integrating the heritage, tradition and values of Catholic identity amidst the changing context of health care.

As the landscape and concerns change, mission leaders must read the signs of the times to ensure evolving strategies, partnerships and care models are suited to bring ministries into the future with integrity to the vision and charism of the founding communities. As vital culture bearers, mission leaders drive mission-focused strategy at all levels of the organization through personal integrity, wisdom and vision. Working with their partners, they bring the Catholic imagination to bear on the future of the organization.

General behavioral expectations include: A. Models the mission and legacy of Catholic health care B. Applies the Catholic theological and ethical tradition to strategic discussions C. Influences strategic direction to meet the needs of the times D. Innovates practices and procedures to ensure the vitality of the ministry

OPERATIONS

Incorporates the mission and values into all operations of the organization Mission leaders are critical partners in ensuring that the Catholic worldview and commitments are expressed in an organization’s policies, practices and procedures.

While day-to-day operations may look the same in Catholic health care and other-than-Catholic health care organizations, it is the how and why things are done that differentiate the experience of patients, residents, families, co-workers and communities served by Catholic health. Every mission leader must be able to promote, shape and create practices consistent with the values and vision of Catholic health care and Catholic social teaching, which acknowledges the inherent dignity of each person, calls for the furthering of the common good and seeks justice through solidarity.

General behavioral expectations include:

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A. Collaborates with leaders to ensure recruitment, selection and retention are inclusive and consistent with the organization’s mission B. Analyzes the culture to ensure mission and values are embedded in policies and procedures of the organization C. Applies the Catholic theological and ethical tradition to operations and clinical practices D. Ensures that organizational and clinical practices reflect the radical inclusivity, caring and compassion of Jesus

FORMATION

Champions formation at all levels of the organization

Mission leaders are uniquely responsible for the creation, delivery, measurement and integration of formative experiences for associates at all levels of the organization. Understanding that formation is critical to a thriving Catholic health ministry now and into the future, mission leaders are attentive to designing a variety of formation experiences—in person, digital and virtual—that build on one another and meet individuals where they are. They invite others into conversations to consider the depths of their jobs and careers as vocations and as facilitators, and they hold space for the work of the Holy Spirit in each person.

General behavioral expectations include: A. Invites others to discover meaning and purpose in their work B. Facilitates or ensures excellent formative experiences are provided in a variety of modalities C. Presents or ensures presentations are of high quality D. Supports leaders in creating meaning and purpose across the organization

SPIRITUALITY

Nurtures spiritual health

Mission leaders articulate their lived faith experience and the meaning it brings to their lives as well as encourage and empower individuals and organizations to do the same. Cultivating an integrated spiritual life, they establish mutually beneficial relationships with diverse individuals and groups that are honest, caring and joyful. They help others find the

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sacred in the ordinary events of life and connect their own work and spirituality to the mission and values of the organization. Mission leaders help build a sense of community in the organization and, in collaboration with others, develop and foster well-being initiatives and holistic care models responding to the physical, spiritual and emotional needs of patients, residents and caregivers.

General behavioral expectations include: A. Demonstrates personal commitment to one’s ongoing spiritual and vocational development B. Promotes workplace spirituality resonant with the desired organizational culture while inviting the expression of diverse spiritualities and their practices C. Ensures the vibrancy and professionalism of spiritual care services to meet the unique needs of patients, residents, families and associates

ETHICS

Promotes organizational and clinical ethics

Mission leaders understand, apply and serve as a resource regarding the principles of Catholic social teaching and moral theology, including the Ethical and Religious Directives for Catholic Health Care Services (ERDs). They are responsible for ensuring that the appropriate level of ethics training is provided to various levels and disciplines in the ministry.

Mission leaders can identify clinical and organizational ethical issues and facilitate an ethical discernment process in collaboration with key stakeholders, subject matter experts and trained ethicists. They create and cultivate an organizational culture where difficult conversations can occur in a safe and transparent environment. Mission leaders consistently inspire fidelity to Catholic identity in all aspects of business operations and ensure that a respect for human dignity and the common good are at the core of the ethical discernment process.

General behavioral expectations include: A. Ensures effective on-going staff education on human dignity, the common good and other relevant ethical principles B. Promotes the implementation of ethical standards throughout the organization C. Serves as a resource regarding the Catholic moral tradition, including the ERDs

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D. Ensures Catholic social and moral traditions are respected as partnerships are explored E. Creates safe space for managing tensions and assists in resolving conflicts F. Promotes use of ethical discernment models

ADVOCACY

Advocates for persons who are affected by poverty and are marginalized

Mission leaders are uniquely positioned to hear the voices of those in vulnerable populations and then passionately advocate on their behalf. They engage community and system leaders in dialogue to ensure strategy, decisions, policies and budgets demonstrate a tangible commitment to justice, solidarity and right relationship. They also are intricately involved in setting advocacy priorities and collaborating with stakeholders to meet the demonstrated needs of the community. This advocacy encompasses the needs of patients, residents, families and associates, as well as the wider community. Mission leaders encourage all associates and community leaders to follow the Gospel values demonstrated in the example of Jesus Christ, with a preferential option for those who are marginalized and affected by poverty and a special focus on ending systemic racism and injustice that lead to health disparities and inequities.

General behavioral expectations include: A. Relates with and respects vulnerable populations, including employees and contract workers B. Establishes relationships with social service agencies serving individuals on the margins C. Influences and encourages the organization to respond to the needs of people who have limited resources D. Advocates for public policies that enhance the common good E. Advocates for the community health needs assessment, community improvement plan and reporting

FINAL THOUGHTS

As the new competency model neared completion, one mission executive joked that, “Only Jesus can meet all of the competencies required of a mission leader!� Still, the majority appreciate that the model is both inspirational and aspira-

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tional, calling mission leaders to ongoing development and formation. A new mission leader is not expected to have developed all of the competencies to the same extent as a mid- or executivelevel colleague. In some cases, a mission leader may possess a mix of entry and mid-level competencies. Others may have both mid- and executive-level competencies.

This model offers mission leaders a career path that with self-awareness, feedback from peers, as well as mentoring, they should be able to mature in their role and take on increasing responsibility.

It is recommended that all mission leaders use the self-assessment tool that accompanies this competency model along with the new virtual coaching tool — both located on the CHA website. Mission leaders are encouraged to share these results with their supervisor and mentor to ensure accountability and ongoing development and formation. Knowing where one is in one’s competency development and what is expected to move toward the next level will enable a mission leader to determine what further studies, leadership opportunities and formation is needed to move forward. In order to support mission leaders in their ongoing personal and professional development, CHA will continue to develop resources with our members to help the profession of mis-

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sion integration grow.

While this is the third Mission Leader Competency Model published by CHA in the last 30 years, it will not be the last. However, CHA is confident this 2020 model will well serve its members for several years, until that time when the health care landscape has shifted in unforeseeable ways and the competencies of mission leaders must again be discerned and reimagined.

BRIAN P. SMITH, MS, MA, MDiv, is vice president of sponsorship and mission services, the Catholic Health Association, St. Louis.

NOTES 1. Brian Smith, “Form Follows Function: The Evolution of Mission Integration in U.S. Catholic Health Care,” Health Progress 101, no. 2 (March-April 2020): 55.

2. Smith, “Form Follows Function,” 59.

3. Please see the seven competencies and behavioral expectations for each of the tiers: https://www.chausa. org/mission/mission-leader-competencies.

4. Please see the Framework for Ministry Formation for competencies specific to a formation leader: https://www.chausa.org/ministry-formation/ ministry-formation-leadership-competencies.

5. Mission Leader Competencies Self-Assessment Tool: https://www.chausa.org/mission-leader-competencies.

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In-Demand Chaplains Adjust Their Approach DAVID LEWELLEN

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he impact of the COVID-19 pandemic reaches far beyond sick people. Everyone is disrupted; everyone is struggling with loss and uncertainty and grief for the way things used to be. In the health care universe, the job that is best suited to treat those feelings is the chaplain, but the pandemic has forced changes in how they do their work.

“We learned that we can pivot really fast,” said Mary Heintzkill, senior director of spiritual care and mission integration for Ascension Health in St. Louis. Just as physicians have learned to use tablets and Zoom to practice telehealth, telechaplaincy has gained more acceptance in the past year than it did in the previous decade. “If we hadn’t had COVID, chaplains wouldn’t be believers in this, but we’ve become believers,” Heintzkill said.

“We can do really good spiritual care with an iPad or a phone.”

Chaplains and their skills have been a vital aspect of the pandemic response, and their services have been in high demand. “You don’t know you need a chaplain until you need a chaplain,” said Rev. Marilyn Barnes, vice president of mission and spiritual care at Advocate Aurora in Chicago.

“And right now, everyone needs a chaplain, the CEO of our company and everyone else.”

While chaplains in her system are rounding to visit with patients, they consistently check in with employees, too. Barnes explained that the experienced chaplain knows to avoid general questions that may get a perfunctory response, and instead ask much more targeted questions to gauge someone’s physical or emotional state. “We don’t ask, how they are doing? It’s more how are you sleeping, what have you done for yourself, what are you grateful for, what’s keeping you up at night? We’re listening for whether something else is going on and do we need to make a referral.”

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That kind of concern extends to everyone in the building. Rev. Ruth Goldthwaite, a Boise, Idahobased director of spiritual care for Trinity Health, said that amid the celebration of acute care health workers as heroes, her chaplains also cultivate relationships with housekeeping and food service employees. “We’ve made an effort to say we know this is having an impact on you and we want to be mindful of that, so that you recognize how your work is essential,” she said. “Everyone needs a sense of their importance and the integrity they bring to the work.”

All eight health systems contacted for this article classified their chaplains as essential workers, who received their share of personal protective equipment and got no more than their share of furloughs, if any. Some workers have been furloughed in Advocate Aurora, which represents a merger of a secular and a Protestant-affiliated system, but chaplains have been exempt. “We need every chaplain,” Barnes said.

At Trinity, part of being essential means being on-site, but some chaplains also have an opportunity to minister via phone calls and video. “We’re rethinking how to be present when we were not physically present,” Goldthwaite said. And spiritual care provided through a tablet is also proving effective in other situations, such as for patients in rural areas or in home care.

Establishing connections by distance ministry is essential for another reason. Relatives are most-

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ly barred from visiting many health care facilities, and chaplains have been called on to assist with contacting and supporting patients’ loved ones.

At Methodist Health System, the spiritual care department keeps a daily log of nonresponsive patients across the system, and those families are prioritized, so that if the situation worsens, “usually a chaplain has called the family many times,” said Rev. Caesar Rentie, vice president of pastoral services at that system in Texas. “I didn’t want the first time the hospital called a family to be about disconnecting their loved one from life support.”

Like many other systems, Ascension has created internal wellness resources for staff. Heintzkill said that includes encouraging self-care and taking paid time off as well as setting up virtual support groups and a 24-hour hotline (somewhere in the system, at least one chaplain is always on duty).

In part because access to patients and families is now more difficult and also because staff need support more than ever, many spiritual care departments in recent months have spent much more time working with employees than they did before the pandemic. In normal times, a chaplain’s time is divided about equally among

When a staffer is prevented from doing what they believe to be the right thing, moral distress is the result; an easy example is the necessity of keeping patients and loved ones apart. patients, family and staff, according to Rev. Tom Harshman, system vice president of pastoral care at CommonSpirit Health in northern California.

But recently, staff has taken about 60% of the time.

Hospital employees “are bearing a phenomenal burden,” Harshman said, “and if we help them, that helps the patients.”

When a staffer is prevented from doing what they believe to be the right thing, moral distress is the result; an easy example is the necessity of keeping patients and loved ones apart. Seeing a

MINISTERING IN NEW WAYS

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he challenges of pastoral care in a pandemic world also extend to long-term care communities, with all of the acute-care problems plus some new ones.

At Trinity Health Continuing Care, which runs 60 retirement communities across the country, chaplains have continued their ministry via technological connections. Creative solutions include meeting residents outside in “front porch ministry” and holding outdoor Mass with a public address system and open windows so those inside also can hear, according to Alan Bowman, vice president of mission integration.

Ministry to families has also become more important, as chaplains listen to their grief at enforced separation from their loved ones. And video connections have allowed chaplains at one location to provide ministry at another, Bowman said. Trinity has started covering spiritual care needs system-wide because there’s current

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demand for those services around-the-clock, including the need to minister to those who experience a loss.

Although chaplains always had families on their radar, “this has moved us into proactively reaching out to family members and engaging with them as they deal with distress of not being able to physically visit their loved ones,” said Bob Smoot, chief mission integration officer for Ascension Living, which has 50 communities in 12 states.

Staffers, too, feel “deep concern when they see residents missing their loved ones, still having restrictions,” Smoot said. “So much of what we do to keep people safe and healthy goes against what we would normally do.” But as an organization, “we’ve all learned the importance of caring emotionally and spiritually, so we’re making efforts to provide more care for associates and chaplains as well.”

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To address that gap, at the PeaceHealth system patient suffer without family allowed to be nearby, staff “feel the loss of a role, the loss of an image, in the Pacific Northwest, Theresa Edmonson has the sense of who I am,” Harshman said. And a new created a system to document chaplains’ interacthing to most staff is the realization that “what I do tions with staff, whether it’s a phone call, a hallway conversation or a supportive email. “It’s not during the day is a threat to my family.”

In those situations, chaplains have a role to just COVID,” said Edmonson, the system director play. “It’s more listening than telling,” Harshman for mission integration and spiritual care. “It’s all said. “You listen to how the person voices their the 2020 events we’re responding to,” including feelings and receive it non-judgmentally. It helps racial unrest and nearby wildfires.

The form, which went live in April, has helped validate both their moral compass and their decisions. You confirm that this is a dilemma. Some- Edmonson document more than 1,000 interactimes that’s the most critical thing, confirming tions between chaplains and caregivers, which she estimated at an average length of 15 minutes. that this is a tension.”

If staffers are distressed about times when the Staffers’ names and specific details are not refamily can’t be present, “there’s a twofold oppor- ported, but “I knew it was important to capture tunity in that space,” Goldthwaite said. Chaplains this,” she said. She also is encouraging chaplains, will “say this isn’t what anyone would hope for, who are in turn encouraging staff, to step away but you (the staffers) are in that space represent- from work periodically and take the paid time off ing the family, and that has significance and mean- that they are entitled to. “When leaders are saying ‘We want you to and we need you to take PTO,’ ing.”

“We’ve always been sensitive to the fact that that’s really empowering,” she said. “It’s kind of a hospital is a stressful environment,” said Rent- like guilt-free PTO.” The spiritual resources are part of the overall ie, the Methodist Health System officer. “People come here at the worst time of their life, and they program of emotional and financial support that experience enormous stress, even if they’re hav- PeaceHealth is offering, including mental health ing a baby.” Even in normal times, that stress tends to spill over to staffers, but in a pandemic, “you cannot operate under these conditions and not have workers affected. PTSD, moral injury, all those things produce burnout.”

Much as free movement at airports became restricted following the Sept.

— THERESA EDMONSON 11 terrorist attacks, the need to limit the spread of coronavirus has changed access for counselors. Because of increased salience of rahospital visitors. At the airport, “you used to go cial issues, the system is also offering that “if you all the way to the gate and watch your family take want a professional counselor who is a person of off. Not anymore. You go to the checkpoint and color, we have that resource available.”

“We aren’t always appreciated, because what that’s it,” Rentie said. Something similar is happening in hospitals now, and no one is used to it. we do is hard to measure,” Rentie said. There“That produces moral injury and moral distress fore, about six years ago Methodist Health Sysfor our staff, because they’re caught in the middle. tem chaplains began logging the time they spend They’re trying to protect the patient and public with staff, and Rentie has found that the average interaction takes 20 minutes. “If we’re not doing health and themselves.”

In addition to listening to staffers’ fears and it, who is, and is that the right person to do it?” he concerns, spiritual care managers are also con- asked.

Even before the pandemic, Rentie said, “If sidering how to document those interactions.

In recent years, it has become standard practice we’re not doing (pastoral care), the nurse is probfor chaplains to write notes about their interac- ably doing it, and it’s not a good use of the nurse’s tions with patients and patients’ families in the time.” Encouraging staff to make referrals to chapelectronic medical record. But staffers don’t have lains when patients need spiritual care, and also logging time chaplains spend ministering to staff charts.

“It’s not just COVID, it’s all the 2020 events we’re responding to,” including racial unrest and nearby wildfires.

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has “really been helpful. We’ve been able to show not only senior leadership but also our board of directors exactly what it is we do, and that it’s a good use of dollars.”

Ministry to staff, which totaled 1,500 hours in Methodist Health System in 2019, also improves employee morale and retention, Rentie believes.

“We can’t one-hundred percent say that we saved this many jobs, but we can say that someone was there to respond to an incident and get (the employee) the help they need.”

Any great challenge also produces opportunities, and the pandemic may offer spiritual care leaders a chance to look at the big picture. “It’s a great opportunity to think about spiritual health and not just spiritual care,” Edmonson said. For people to draw on their own resources of resilience, “we need to help make sure that well is well-stocked and to highlight moments of hope and delight. We’re good at sitting with people in their pain. But what does spiritual health look like? What do we hold and share in common? It’s a rich topic.”

In the future, Harshman expects, “we’ll have a

different relationship with hope, a story about our future that’s nourishing.” When so many people have had their lives and beliefs upended, a pandemic is “a chance to invite people to reflect on the foundational building blocks for your sustenance.

How do you lay them again, or notice what is still standing?” Grief and loss must be acknowledged, of course, but “there are all kinds of creative ways of being nurtured by one another. We can open new ways to extend ourselves differently.”

And one way can even involve the muchmaligned Zoom call. Harshman told of a recent virtual session in which one participant turned off her video for a moment, then rejoined the group and explained she had broken down weeping before composing herself. “That format creates a boundary for just as long as necessary,” Harshman said. “That wouldn’t happen in a conference room.

But now we have a way to be more intimate.”

DAVID LEWELLEN is a freelance writer in Glendale, Wisconsin, and editor of Vision, the newsletter of the National Association of Catholic Chaplains.

PAU S E . B R E AT H E . H E A L .

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I Find Rest For just this moment, bring your attention to your breath.

INHALE deeply and settle yourself into your body.

EXHALE the stress and tension you feel.

On your next inhale, pray, I Find Rest.

And as you exhale, In Your Shelter I Find Rest, In Your Shelter KEEP BREATHING this prayer for a few moments.

(Repeat the prayer several times) CONCLUDE, REMEMBERING:

Even now, God is with you, as near to you as your breath. Continue giving yourself the gift to pause, breathe, and heal knowing you are not alone.

Whoever dwells in the shelter of the Most High will rest in the shadow of the Almighty. PSALM 91:1 © Catholic Health Association of the United States

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H E A LT H E Q U I T Y

BUILDING TRUST FOR VACCINE ROLLOUT KATHY CURRAN, JD

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n early November there was, at last, a piece of good news about the coronavirus pandemic.

Preliminary data from the first Phase III trial data for one of the four vaccines in the final stages of testing in the U.S. showed it to be more than 90% effective at protecting against COVID-19 infection. If these data hold up and no safety issues arise, it could be that some of you reading this column in January may have already been vaccinated. Can we begin to hope for a level of immunity soon that will help us get back to normal?

The news also reminds us we have a lot of work build trust so that members of these communities to do to get ready for COVID-19 vaccines. The are willing to be vaccinated when proven, effecprospect of having an effective COVID-19 vaccine tive vaccines are available.

Ensuring equity in access to COVID-19 testing, highlights important equity issues for our nation and for the Catholic health care ministry. We all treatment and vaccination is a key focus area of are familiar by now with the reality that racial and an initiative that the Catholic Health Association ethnic communities have suffered most severely is developing with our members to address racfrom the coronavirus. Blacks, Hispanics and Na- ism and health equity. We must recommit to entive Americans are hospitalized with COVID-19 at gaging with and listening to community groups four times the rate of whites.1 People of color have and leaders trusted by communities of color to higher mortality rates, with Black Americans dy- identify and address unmet health needs to ening at twice the rate of white Americans.2 The ex- sure that COVID-19 testing, treatment and safe, istence of racial health disparities is nothing new, effective vaccines actually reach those most at but the coronavirus has brought them into much risk. State and local governments are mobilizsharper focus. Making sure that vaccines are ing for COVID-19 vaccination program planning available and accessible to people in these communities must be a priority.

We must recommit to engaging with A significant challenge is the lack and listening to community groups of trust in vaccines. Black, Hispanic and Native American people are and leaders trusted by communities more likely to be skeptical of vaccines, more likely to think the risks of color to identify and address outweigh the benefits, and less likely unmet health needs to ensure that to get vaccines.3 Distrust of the medical establishment is especially deep COVID-19 testing, treatment and among African-Americans. When the presidents of two Historically safe, effective vaccines actually Black Colleges and Universities enreach those most at risk. couraged students, faculty, staff and alumni to enroll in COVID-19 vaccine clinical trials, they were surprised at the strong and implementation. Catholic health ministry negative feedback they received.4 The reaction il- members should seek to be part of the planning lustrates the legacy of abuses such as the Tuske- — many already are — and to make sure that those gee Syphilis Study, as well as the ongoing injus- most affected by the coronavirus are included in tices of racial disparities and inequities in the U.S. decision-making.

We should not have been surprised that the health care system.5 We have a lot of work to do to

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pandemic has highlighted and exacerbated the such as grocery store clerks, nursing aides, cleanexisting disparities in our health care system, be- ers, day care workers, warehouse workers, and cause we have been aware of them for years. We bus drivers – lower income jobs that also expose know, for example, that racial and ethnic minor- them to a greater risk of coronavirus infection.9 ity populations have less access to needed health We face two pandemics — one new and one care than whites. Hispanics, Blacks, and Ameri- very old — that have converged in time. The can Indians and Alaska Natives are more likely than whites to delay or We should not have been surprised go without needed care, and they are still more likely to be uninsured than that the pandemic has highlighted whites, despite coverage expansions and exacerbated the existing under the Affordable Care Act. They also suffer from poorer health and disparities in our health care worse health outcomes. Hispanics, system, because we have been Blacks, and American Indians and Alaska Natives are more likely than aware of them for years. whites to report a range of health conditions, including asthma and diabetes; American Indians and Alaska Natives police killings of George Floyd, Breonna Taylor, also have higher rates of heart disease compared Ahmaud Arbery as the coronavirus spread, the to whites.6 The existence of these disparities is calls for racial justice and the disparate impact of one reason minorities have been more vulnerable COVID-19 on people of color make it very clear: to the coronavirus, which takes a greater toll on we are living in a time when racism and health disparities can no longer be ignored, or given merely people who already have poor health conditions.

In addition to disparate health impacts, eco- perfunctory attention. Racism is more than a synnomic hardship due to the coronavirus has hit onym for prejudice. We are coming to understand minorities harder, as illustrated by a September the implications of the deep roots of systemic racsurvey of households by NPR, the Robert Wood ism in our society.

The Catholic health ministry has a long history Johnson Foundation and the Harvard T.H. Chan School of Public Health, “The Impact of Corona- of caring for everyone regardless of race or sociovirus on Households, By Race/Ethnicity.”7 Mil- economic status and a deep commitment to the lions of Americans across all demographics faced social teachings and moral principles of the Cathunemployment due to the shutdown of the econ- olic faith based upon the inherent dignity of each omy. But as jobs have been restored, not every- person. We are uniquely positioned to be leaders one is recovering at the same pace. Significantly in a movement for systemic change in health care greater proportions of Hispanics, Blacks and Na- and our society. As Catholic health care, we are tive Americans than whites have reported facing committed to achieving equity in health care: in serious financial problems, including struggling the care we provide, in the communities we serve to pay for food and housing costs, and depleting and in the nation as a whole. We recognize the profound effect racism has on the health and welltheir savings.

This is not surprising, either. The racial wealth being of individuals and communities. We refuse gap has been as persistent as racial disparities in to accept the existence of racial and ethnic health health. In September 2020 the Federal Reserve’s disparities because they stand in direction oppoBoard of Governors decried the “long-standing sition to the mission of Catholic health care.

Thanks to the extraordinary investment of fiand substantial wealth disparities” between white families and Black or Hispanic families. In 2019, nancial and human resources to produce vaccines white families had a median wealth of $188,200 in record time, we will soon have vaccines that compared to $24,100 for Black families and $36,100 will begin to get the coronavirus pandemic unfor Hispanic families.8 And racial minorities are der control. No vaccine will help us end systemic more likely than whites to be essential workers racism. But it will take a similar commitment by

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everyone — government, business, nonprofits, health care, communities — to make the personal, social and economic investments needed for change to happen. We can no longer afford to be immune to the suffering and injustice of systemic racism.

KATHY CURRAN is senior director of public policy, Catholic Health Association of the United States, Washington, D.C. NOTES 1. “COVIDview,” Centers for Disease Control and Prevention website, Oct. 31, 2020, https://www.cdc. gov/coronavirus/2019-ncov/covid-data/pdf/covidview-11-06-2020.pdf.

2. “The COVID Racial Data Tracker,” The COVID Tracking Project at The Atlantic, https://covidtracking.com/race.

3. Vicki S. Freimuth et al., “Determinants of Trust in the Flu Vaccine for African Americans and Whites,” Social Science & Medicine 193 (2017): 70-79. See also https://www.ncbi.nlm.nih.gov/pmc/articles/ PMC5706780/; https://www.pewresearch.org/facttank/2020/01/07/more-americans-now-see-very-highpreventive-health-benefits-from-measles-vaccine/; https://www.cdc.gov/flu/highrisk/disparities-racialethnic-minority-groups.html.

4. Nicholas St. Fleur, “Two Black University Leaders Urged Their Campuses to Join a COVID-19 Vaccine Trial.

The Backlash Was Swift,” Stat, Oct. 12, 2020, https:// www.statnews.com/2020/10/12/two-black-university-

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leaders-urged-their-campuses-to-join-a-covid-19- vaccine-trial-the-backlash-was-swift/.

5. Liz Hamel at al., “Race, Health and COVID-19: The Views and Experiences of Black Americans,” Kaiser Family Foundation, October 2020, http://files.kff.org/ attachment/Report-Race-Health-and-COVID-19-TheViews-and-Experiences-of-Black-Americans.pdf.

6. Samantha Artiga and Kendal Orgera, “Key Facts on Health and Health Care by Race and Ethnicity,” Kaiser Family Foundation, (November 2019), https://www.kff. org/disparities-policy/report/key-facts-on-health-andhealth-care-by-race-and-ethnicity/; Yiling J. Cheng et al., “Prevalence of Diabetes by Race and Ethnicity in the United States, 2011-2016,” JAMA 322, no. 24 (December 24, 2019): 2389, doi:10.1001/jama.2019.19365.

7. “The Impact of Coronavirus on Households Across America,” Robert Wood Johnson Foundation website, https://www.rwjf.org/en/library/research/2020/09/ the-impact-of-coronavirus-on-households-acrossamerica.html.

8. Neil Bhutta et al., “Disparities in Wealth by Race and Ethnicity in the 2019 Survey of Consumer Finances,” FEDS Notes, https://www.federalreserve.gov/econres/ notes/feds-notes/disparities-in-wealth-by-raceand-ethnicity-in-the-2019-survey-of-consumerfinances-20200928.htm.

9. Hye Jin Rho, Hayley Brown and Shawn Fremstad, “A Basic Demographic Profile of Workers in Frontline Industries,” Center for Economic and Policy Research, April 2020, https://cepr.net/a-basic-demographic-profile-ofworkers-in-frontline-industries/.

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ETHICS

A CLOSER LOOK AT THE AUTHORITY OF CHURCH TEACHINGS

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recently released documentary included a clip of Pope Francis where he spoke approvingly of same sex civil unions. The provenance and context of the clip raised some questions, as it was recorded years ago, but only recently aired. A similar amount of fanfare arose in 2016 when Pope Francis spoke on the potential use of condoms during a Zika virus outbreak while he was being interviewed on an airplane. Both instances highlight a confusion about the authoritative nature of a Pope’s words, or of a bishop’s, and the impact those words have on official church teaching.

Two recent texts, Fratelli Tutti by Pope Francis and Samaritanus Bonus issued by the Congregation for the Doctrine of the Faith, are more formal statements of church teaching. Beyond the different subject matters of these two texts, there NATHANIEL is also a distinction in authorBLANTON ity. As a hierarchical church that believes in the teaching power HIBNER of its religious leaders, it is useful for the faithful to know when a statement is to be respected and when a statement is simply a remark. We can explore different levels of church teaching and what they mean to the broader faith community.

PROFESSIONS OF FAITH

Magisterium refers to the teaching authority of the church. The term comes from “magister,” the Latin word for teacher.

The first level are those doctrines “contained in the Word of God, written or handed down, and defined with a solemn judgment as divinely revealed truths either by the Roman Pontiff when he speaks ‘ex cathedra,’ or by the College of Bishops gathered in council, or infallibly proposed for belief by the ordinary and universal Magisterium.”2 A pope who speaks ex cathedra is doing so in his role as the successor of St. Peter, exercising the official teaching authority inherent in the shepherd of the church.

These doctrines require the assent of the faithful. Anyone who places them in doubt or who denies them can be censured with heresy. Examples of this level of authority include the Scriptures, the Nicene Creed, Mary’s Assumption into Heaven, and the real and substantial presence of Christ in the Eucharist.

Definitions and levels of authority come to us from many sources of church teaching. Under the papacy of Pope St. John Paul II, the Congregation for the Doctrine of the A pope who speaks ex cathedra is Faith wrote “Doctrinal Commentary doing so in his role as the successor on concluding formula of ‘Professio fidei’.” The document explains disof St. Peter, exercising the official tinctions between the “order of truths to which the believer adheres.” The teaching authority inherent in the document reiterates that the pope and shepherd of the church. the College of Bishops in communion with him, are the only people “qualiThe second level of authority, according to fied to fulfill the office of teaching with binding authority…”1 As a single bishop oversees his own the Professio fidei “includes all those teachings diocese, the College of Bishops is the collection belonging to the dogmatic or moral area, which of all bishops who oversee the entire church. The are necessary for faithfully keeping and expound-

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ing the deposit of faith, even if they have not been proposed by the Magisterium of the Church as formally revealed.”3 These include truths that are historically connected with formal revelation or have a logical connection that “expresses a stage in the maturation of the understanding of revelation…”4 Examples of this category include papal infallibility, the canonization of saints and the illicitness of euthanasia.

One must believe in the teachings found within these two levels. However, our assent comes from two different sources. In the first level of teaching, assent stems from one’s faith in the authority of the Word of God. In the second, it is based on faith in the Holy Spirit’s role of assisting the Magisterium.

The third level of teaching authority is defined for the believer in this way: “Moreover, I adhere with religious submission of will and intellect to the teachings which either the Roman Pontiff or the College of Bishops enunciate when they exercise their authentic Magisterium, even if they do not intend to proclaim these teachings by a definitive act.”5 These texts often are used to explain a teaching, to dispel opposing ideas to accepted teachings, or to connect the teachings amongst one another. These teachings demand our belief from a “religious submission of will and intellect” rather than the virtue of faith. We use these teachings as tools to help form our consciences and function more as a roadmap than a final destination. While some will be difficult to understand or believe, it is through grace and continued formation that we move along the path of faith and understanding. Examples could include homilies, texts from national bishop conferences and individual bishop’s letters.

RECENT EXAMPLES

From these definitions we can begin to categorize the two recent texts. Fratelli Tutti is an encyclical promulgated by Pope Francis. Within the document are various teachings, some from Scripture, some from a logical connection to revelation, and some that explain more fully teachings that have already been put forth. Therefore, one cannot label the entire document under one category but would need to differentiate among the various lessons within the text. However, because of the nature of the document — a papal encyclical — we would certainly rank this high among formal

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church teachings.

The Congregation for the Doctrine of the Faith document Samaritanus Bonus comes to us by way of a congregation within the Holy See. The text

One of the primary functions of the Catholic Church is to help the faithful understand revelation and the way it should guide our lives. primarily reiterates established teaching, gives clarity on ethical applications, and dispels contrary thinking. Like the encyclical, this is a text related to the first two categories mentioned above, however, I would see it as falling primarily in the third category of teaching.

CONCLUSION

One of the primary functions of the Catholic Church is to help the faithful understand revelation and the way it should guide our lives. The Magisterium has been given that role. It is important to recognize which teachings are fundamental to our faith. The comments by Pope Francis mentioned in the beginning of this article have been misinterpreted as having more authority than they actually possess. To properly differentiate between official teaching and passing remarks is crucial to maintaining the continuity and authority of the tenets of our faith. While this article only scratches the surface of this topic, I hope that it gives a bit of clarity about the role of the teachers and the faithful. We are called to follow Christ, let us pray for those who help lead the way.

NATHANIEL BLANTON HIBNER, PhD, is director, ethics, for the Catholic Health Association, St. Louis.

NOTES 1. The Congregation for the Doctrine of the Faith, “Doctrinal Commentary on concluding formula of ‘Professio fidei,’” (Vatican City, 1998) #4.

2. “Commentary,” #5.

3. “Commentary,” #6.

4. “Commentary,” #7.

5. “Commentary,” #10.

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COMMUNITY BENEFIT

COMMUNITY HEALTH IMPROVEMENTS — DON’T FORGET SENIORS

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hen planning community health improvement activities for coming years, leaders of these initiatives face multiple community needs that compete for attention. As decisions about priorities are being made, it is important to remember an oftenoverlooked group — seniors.

WHY SENIORS?

Demographics tell the story.

Seniors are the fastest growing population in the country. In 2030 the population of people 65 and older is projected to be twice as large as it was in 2000. It is increasingly diverse, reflecting the JULIE U.S. population as a whole, and increased age is associated with TROCCHIO higher rates of poverty, especially among minorities.1 According to the National Council on Aging, over 25 million Americans aged 60 and over are economically insecure, living at or below 250% of the federal poverty level. The National Council on Aging reports that rising housing costs and health care bills contribute to financial distress in this population.

Chronic illnesses among seniors include asthma, arthritis, heart disease, hypertension, cancer and diabetes. Many older persons experience dementia and depression. Falls that result in hip and other fractures are a major risk. Rates of obesity in persons over age 65 have steadily increased over the years as has food insecurity. We also know that increased age is often associated with social isolation and loneliness.2

WHAT TO DO?

While community health improvement plans must reflect local needs, the national health objectives from Healthy People 2030 can be a starting point. (See sidebar.) The Healthy People 2030 objectives suggest activities for community health improvement plans, such as: Exercise programs for seniors: Older adults who don’t get enough physical activity are more

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likely to develop disabilities, and evidence shows that physical activity is linked to better health, can reduce the incidence of falls and may delay cognitive impairment.

Educational programs on managing diabetes and other chronic illness: Teaching older adults how to manage their diabetes and other chronic conditions can reduce hospitalizations.

Screening programs for osteoporosis can reduce hip fractures.

Immunization programs for flu and pneumo–

HEALTHY PEOPLE 2030 OBJECTIVES FOR OLDER AMERICANS Increase the proportion of older adults with physical or cognitive health problems who get physical activity

Reduce the rate of hospital admissions for diabetes among older adults

Reduce the proportion of preventable hospitalizations in older adults with dementia

Reduce the rate of hospital admissions for urinary tract infections among older adults

Reduce fall-related deaths among older adults and the rate of Emergency Department visits due to falls

Reduce hip fractures among older adults Increase the proportion of older adults who get screened and get treated for osteoporosis

Reduce the rate of hospital admissions for pneumonia among older adults

Reduce hospitalizations for asthma in adults

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aged 65 years and over

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coccal vaccines can reduce hospitalizations and illness.

MORE TO-DOS: SOCIAL DETERMINANTS OF HEALTH

As health care turns more of its attention to the social determinants of health, the needs of seniors become particularly important, especially in the areas of food and housing insecurity and the reality of social isolation. The National Council on Aging reports that millions of older Americans, especially low-income and minority populations are at risk for hunger and food insecurity.3 Addressing seniors’ food insecurity starts with screening in clinics and other health care settings and continues with referrals to emergency food banks and other community services. Other strategies include support of congregate meal and Meals on Wheels programs and enrollment in Supplemental Nutritional Assistance Programs (SNAP).

Accessible and affordable housing is a concern for many older adults. The Joint Center for Housing Studies of Harvard University reports that an increasing number of seniors face high housing costs and housing instability. Their reports have documented an increase in homelessness among older adults with the number of people over 62 living in emergency or transitional housing rising by about 69% in the last decade. They also report a growing demand for subsidized housing and a shortage of accessible housing.4 As with food insecurity, housing strategies start with screening in clinical settings and referrals to community services for emergency and permanent housing solutions. Joining community coalitions for homelessness and housing is another logical step. CHA’s new Toolbox on Community Investing offers suggestions for working with community partners to invest in needed housing and other community services. It’s at www.chausa.org/communitybenefit.

Another social determinant of health is social and community connectedness. A recent AARP study found that nearly half of midlife and older adults with annual incomes of less than $25,000 report being lonely and that people who are lonely and socially isolated are more likely to have health problems, which can have serious financial implications. They say, “Social isolation among midlife and older adults is associated with an estimated $6.7 billion in additional Medicare

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spending annually.”5 Parish and other faith community health programs have been effective in addressing social isolation and keeping seniors in touch with their faith communities.6 Senior villages can help volunteers and neighbors support seniors who want to stay in their homes and communities and stay connected.7 Community benefit programs can support these efforts.

CAREGIVER NEEDS

When looking at the needs of seniors, family caregivers also need attention. It is estimated that over 65 million Americans or nearly 30 percent of the general population care for an older adult. AARP’s 2019 update to its ongoing study of caregivers reports that family caregivers perform complex medical and nursing tasks (such as wound care, giving injections, and handling medical equipment) in the home, usually with little instruction or support.8 They often feel highly strained and overwhelmed, and they, too, are at increased risk for loneliness.9

PARTNER, PARTNER, PARTNER

An important step to assess and address the needs of seniors in your community is connecting with organizations serving this population, including your local Area Agency on Aging (AAAs) and Catholic Charities agency.

Area agencies on aging (AAAs) can be a onestop shop for senior services because they work with federal and state aging agencies and administer most of the Older Americans Act funds. They collect data and provide numerous services. Depending on the agency, services could include: Aging and Disability Resource Centers (ADRCs) in area agencies on aging serve as single points of entry into the long-term services and supports (LTSS) system for older adults, people with disabilities, caregivers, veterans and families.

Some states refer to ADRCs as “access points” or “no wrong door” systems.

Caregiver support — AAAs provide direct support to caregivers, with such services as respite care, individual counseling and support groups; caregiver education classes/training; and emergency assistance.

Care transitions — AAAs can work with older adults’ families to plan for services and help arrange services such as transportation, in-home

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care and case management. Some provide or pay for home modification.

Elder justice — AAAs’ elder justice programs address issues associated with elder abuse and other legal challenges confronting older adults, including guardianship, health and longterm care, and public benefit programs.

Health insurance coverage — Each state operates a federally funded State Health Insurance Assistance Program (SHIP) with one-on-one telephone and face-to-face counseling and assistance sessions, public education presentations and programs on topics such as Medicare Part D coverage.

Evidence-based disease prevention and health promotion programs — AAAs may offer formally recognized programs, such as the Chronic Disease Self-Management Program, A Matter of Balance, Diabetes Self-Management Program, Powerful Tools for Caregivers and Tai Chi Moving for Better Balance.

Home and community-based services — Many agencies offer a range of services and supports to assist older adults to live independently in their homes and communities, including homedelivered meals, home health care, homemaker/ chore services, transportation and more.

Catholic Charities agencies help people of all faiths who are struggling with poverty and other complex needs. Not all agencies provide all services, but here are frequently available services for seniors: Direct Care: Some Catholic Charities agencies offer skilled nursing and personal care homes, respite care, hospice, home health services and visiting nursing services.

Housing: Many Catholic Charities agencies sponsor affordable housing for seniors and some offer shared senior housing.

Community centers: Many Catholic Charities agencies have senior centers and adult day centers.

Support services: Some of the support services available through Catholic Charities agencies include transportation, case management, home repair, chore services, financial counseling and debt management.

Food programs: This can include home delivered meals, congregate meal programs and emergency food.

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While the needs of seniors in our communities are many and complex, there are resources available to both assess and address these needs.

JULIE TROCCHIO, BSN, MS, is senior director, community benefit and continuing care, Catholic Health Association, Washington, D.C.

NOTES 1. Federal Interagency Forum on Aging-Related Statistics, “Older Americans 2020: Key Indicators of WellBeing, U.S. Government Printing Office, 2020, https://agingstats.gov/docs/LatestReport/ OA20_508_10142020.pdf.

2. Federal Interagency Forum, “Older Americans 2020.”

3. National Council on Aging, “SNAP and Hunger Facts”: https://www.ncoa.org/news/resources-for-reporters/ get-the-facts/senior-hunger-facts/.

4. Joint Center for Housing Studies of Harvard University: https://www.jchs.harvard.edu/research-areas/ aging.

5. Lynda Flowers et al., “Medicaid Spends More on Socially Isolated Older Adults,” AARP Public Policy Institute, November 27, 2017, https://www.aarp.org/ ppi/info-2017/medicare-spends-more-on-sociallyisolated-older-adults.html#:~:text=Now%20a%20 new%20study%E2%80%94the,in%20additional%20 Medicare%20spending%20annually.

6. CHA, “Improving the Lives of Older Adults through Faith Community Partnerships: Healing Body, Mind and Spirit,” 2016, https://hmassoc.org and https://www. chausa.org/docs/default-source/eldercare/improvingthe-lives-of-older-adults-through-faith-communitypartnerships_final-oct-192016.pdf?sfvrsn=0; see also https://hmassoc.org.

7. Stewart M. Butler and Carmen Diaz, “How Villages Help Seniors Age at Home,” Brookings, Oct. 19, 2005, https://www.brookings.edu/blog/uscbrookings-schaeffer-on-health-policy/2015/10/19/ how-villages-help-seniors-age-at-home/.

8. AARP Public Policy Institute, https://www.aarp.org/ content/dam/aarp/ppi/2019/11/valuing-the-invaluable2019-update-charting-a-path-forward.doi.10.264192Fppi.00082.001.pdf.

9. G. Oscar Anderson and Colette Thayer, “Loneliness and Social Connections: A National Survey of Those 45 and Older,” AARP Research, September 2018, https:// www.aarp.org/research/topics/life/info-2018/loneliness-social-connections.html.

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T H I N K I N G G L O B A L LY

THE GUIDING PRINCIPLES

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xcellence in global health activities is essential and something that we can be attending to even as our world continues to isolate against the coronavirus.

For the fifth anniversary of the creation of CHA’s Guiding Principles for Conducting Global Health Activities, we’ve been exploring how they’ve been put into practical use in a series of Health Progress columns. Here, Sr. Mary Jo McGinley, RSM, reflects on BRUCE the principle of Excellence in the COMPTON global health activities she has overseen first at Catholic Health East and now at Trinity Health. Her memories and commitment to Excellence dovetail many of the essays we’ve published in a new collection that is COVID-19 related, but her comments here are particularly apt for our celebration of the Guiding

Principle’s fifth anniversary. Like Sr. McGinley, many of our authors in Renewing Relationship: Essays as We Evolve and Emerge from Pandemic consider past and present, opportunities and challenges.

Have you participated in a medical mission trip or immersion experience, donated to an international disaster response, or are responsible for colleagues who participate in such activities?

If so, please take time to consider your involvement in relation to Sr. McGinley’s experience and CHA’s Guiding Principles. I hope that you will also take a few minutes to read the anniversary edition and the essay collection at www.chausa. org/guidingprinciples.

EXCELLENCE SR. MARY JO McGINLEY, RSM, MS Ed, MPH

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n October 22, 2010, less than a year after the horrific earthquake that claimed more than 200,000 Haitian lives, Haiti’s National Public Health Laboratory announced a cholera epidemic in the Artibonite Valley in northwest Haiti. Since we were scheduled to take a medical team to that region in less than three weeks, this news caused great concern for our organization, Global Health Ministry. With over 20 years of experience conducting medical missions, Global Health Ministry reached deep into those years of experience and its never-ending quest for doing the right thing the right way. Keeping tabs on the bulletins coming from Haiti and the Centers for Disease Control and Prevention, we first reached out to our in-country partner to ask if they still wanted us to come or would we add to their burden. Once they affirmed the need for us to come, we contacted each team member, directing them to confer with their loved ones and decide if they were in or wanted out. All 15 team members said

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yes, and so we moved to a rapid review with our in-country partner, CDC input and other sources to determine what we needed to add to our supplies and personal preparations. The Sunday before Thanksgiving we all came home, very tired but quite healthy, after our most difficult medical mission. That is still true more than 10 years and over 50 missions later.

Looking back at the 2010 mission and considering the Guiding Principles, it is obvious that all six principles were active then and must be active in every medical or surgical mission in the following ways: Prudence — Good planning precedes every mission, and if an emergency overtakes the norm, initiate rapid and prudent research and planning.

Authenticity — Your in-country partner must know the community and be able connect with needed external resources in an emergency. In the case of the 2010 cholera epidemic that occurred 10 months after the earthquake, in-country con-

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nections with the United Nations assured ample recognize this and serve with humility promote supplies of IV fluid, and Catholic Relief Services the principle of Excellence.

As an organization that conducts short-term responded rapidly with needed support.

Honesty — International service groups earn international medical missions as its primary opthe trust of their constituents by not distorting the erational goal, Global Health Ministry strives for Excellence with every mission and every particitruth. pant. This principle, along Patience — In an emerwith the mandate “Do No gency, you must focus on one Harm,” animate our staff patient at a time. In developto prepare, implement and ing long-term relationships evaluate each mission with and helping your in-country all the Guiding Principles in partners move toward selfmind. We often use the prinsustainability, “poca a poca” ciples for our team orienta(little by little) brings about tions and evening refleceffective and lasting change. tions during the mission.

Humility —taking the Global Health Ministry, time, even in an emergency, a member of Trinity Health, for the team to reflect on Best intentions do not equal began in 1989 in response to their feelings and learnings best practices an invitation from Sisters of the day enriches the exSomething is not always better of Mercy from Philadelphia perience and helps make tothan nothing. Low-resource who were ministering in the morrow or the next mission settings do not permit lower Piura region of northwest better. standards. The high standards we Peru. That initial request unExcellence — We are follow in the U.S. — in delivering derpins Global Health Minchallenged and required to health care and developing istry’s basic philosophy, that establish and execute high partnerships — should not be set we serve “at the invitation standards in all we do. aside when working abroad. The and direction of our in-counStriving for Excellence laws of the country must be try partners, assisting them must direct all persons who followed, the men and women in their goal to build sustainendeavor to conduct shortproviding services must be able, healthy communities.” term international medical competent in their roles, and People often ask, “How do missions. This goal inspires outcomes must be measured by you pick where your teams our Global Health Ministry quality, not simply quantity. go?,” and we respond, “they medical and surgical teams picked us.” We constantly that currently serve with in-country partners in Peru, Haiti, Jamaica and remind ourselves and our U.S. volunteers that it Guatemala. During a recent Global Health Minis- is our in-country partners’ program and that we try medical mission, a photographer and reporter are there to serve side-by-side with them. We have from Vanity Fair Italy approached our team to shared the Guiding Principles with our in-country inquire if they were doing “voluntourism.” Our partners, our board and individuals and organizateam leader viewed this as a personal insult and tions that ask for our advice as they endeavor to quickly and graciously ushered them from the initiate international health programs. The Princlinic site. Voluntourism refers to missions that ciples possess dynamic possibilities.

Successful missions start with careful screenfocus primarily on the volunteers themselves and what they get from their half service/half vaca- ing and selection of qualified team members and tion experience. Excellent short-term medical move forward with well-prepared and presented missions focus on and empower local leaders, as orientation experiences months before deparwell as the local recipients, to move toward self- ture. Screening applicants must include emphasustainability. Short-term mission volunteers who sis on organizational values that lay out volunteer

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expectations, and clearly define goals as well as learning about the culture as well as the daily chalquality parameters. All team members must be lenges encountered by those they volunteer with fully qualified for their assigned roles, and no one and those they serve. Capitalizing on the wealth of should be expected or allowed to practice beyond veteran volunteers as well as paying attention to their professional scope. These values are shared original questions from new volunteers enriches by many international Ministries of Health that the orientation for everyone.

Once on site, time is scheduled for an opening require pre-registering team members and submitting the academic credentials as well as cur- meeting that recalls the goals spelled out during rent licenses of all clinicians on the team. One orientation. Challenging team members to use the way we try to screen out persons looking to be mission experience to meet and learn from those “saviors” is to ask potential volunteers to identify with whom and whom we are serving helps fostheir motives both in writing their applications ter the transformation of each participant. Taking and in the personal interviews that take place dur- time for frequent team reflections nurtures this ing the application process. If they say, “... sounds even further.

In a recent Health Progress article, Bruce like a nice place to visit … or … I want to go and preach the Gospel …” we encourage them to pur- Compton, CHA’s senior director of global health, sue those goals on their own. The words written identified the “…unequal power dynamics of racand the tone heard in answers provide great insight when you read or Do we come in as the “experts,” or listen with your maximum intuitive are we willing to accept and promote skills. While far from perfect, this process helps us develop teams that leadership by our in-country come together as learners, not doers. partners?

Unfortunately, we have encountered “do-gooder” groups who ignore the quality standards of their host govern- ism and classism...” in the global health field. We ment and seem to believe they know how to do need to look in the mirror and see what our interit all. A clinician who cavalierly thinks it is OK to national partners and our international patients act beyond their scope of practice should not be see. Do we appear to question or even belittle the clinical skills of local providers and facilities, or do tolerated or supported.

With over 30 years of experience, Global Health we recognize the hard work that has helped them Ministry has witnessed significant improvements to get this far? Do we come in as the “experts,” or in the health status and health infrastructure at are we willing to accept and promote leadership each location where we serve. We know this prog- by our in-country partners? On a more mundane ress gives testimony to years of day-in and day-out level, do we separate ourselves from our hosts and hard work on the part of our in-country partners patients by wearing hats or T-shirts with our orand not solely our appearance for a short-term ganization’s logo? Are we gracious guests if our mission once or twice a year. The ministry com- vegan diet means we reject the food offered at the municates with its in-country partners through- table to which we have been invited? Inviting our out the year, often responding to various requests U.S. volunteers and as many of their supporters to that assist the partner in their community’s well- recognize and appreciate not just the culture, but being. The adage “teach a person to fish …” works also the inherent strength and goodness of those both ways. That means that sharing learnings with we serve helps to expand one’s global view.

What you bring in and what you leave serve our international partners, along with fostering health education, underpins a great deal of the as additional measures of Excellence for all international medical and surgical missions. Most progress we see.

In addition to providing practical information, countries have strict standards regarding expiraorientations should encourage participants to use tion dates of medicines and medical supplies, and the experience to broaden their worldview by these standards need to be respected and strictly

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Great care should be taken to identify qualified local professionals responsible for distributing surplus medications and supplies. followed. In addition, before bringing equipment and other supplies, good stewardship means we first ask our in-country partner if the item can be used. All items should be clean, in good working order, and not quickly become obsolete because replacement parts or needed supplies are not easily acquired.

Great care should be taken to identify qualified local professionals responsible for distributing surplus medications and supplies. In addition, the medical team is responsible to do everything possible to assure that each patient who needs additional treatment after the team leaves will receive that treatment. This often requires leaving the financial resources needed in the hands of your trusted in-country partner and establishing a manageable feedback mechanism for reporting follow-up care.

No longer being needed should be our ultimate goal. The Guiding Principles encourage us to be honest in our relationships. Staying vigilant and avoiding being too comfortable will alert you to know when it is time to amicably part ways with a partner, hopefully in a spirit of mutual gratitude. Honestly admitting that we are no longer needed gifts us with a reality to be celebrated. Global Health Ministry has faced and acted on this reality more than once.

SR. MARY JO McGINLEY, a member of the Sisters of Mercy of the Americas, is the executive director for Global Health Ministry with Trinity Health.

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A Shared Statement of Identity for the Catholic Health Ministry We are the people of Catholic health care,

a ministry of the church continuing Jesus’ mission of love and healing today. As provider, employer, advocate, citizen — bringing together people of diverse faiths and backgrounds — our ministry is an enduring sign of health care rooted in our belief that every person is a treasure, every life a sacred gift, every human being a unity of body, mind, and spirit.

We work to bring alive the Gospel vision of justice and peace. We answer God’s call to foster healing, act with compassion, and promote wellness for all persons and communities, with special attention to our neighbors who are poor, underserved, and most vulnerable. By our service, we strive to transform hurt into hope.

AS THE CHURCH’S MINISTRY OF HEALTH CARE, WE COMMIT TO:

romote and Defend Human Dignity P Attend to the Whole Person ! Care for Poor and Vulnerable Persons ! Promote the Common Good ! Act on Behalf of Justice ! Steward Resources ! Act in Communion with the Church ! !

© The Catholic Health Association of the United States

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A G E F R I E N D LY

The Geriatric Surgery Verification Program

NEW STANDARDS FOR AGE-FRIENDLY SURGICAL CARE LINDSEY ZHANG, MD, MARCUS ESCOBEDO, MPA, AND MARCIA M. RUSSELL, MD

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he United States is in the midst of an unprecedented growth of the older adult population. As life expectancy increases and baby boomers enter their seventh and eighth decades, it is expected that 18 million people will turn 65 in the next ten years.1 Although a greater proportion of older adults is a reflection of the many health care advances seen over the last half century, the medical community is now faced with the challenge of how to best care for older patients.

Providing safe and high-quality geriatric care preservation of physical and cognitive function is a mission that has been embraced by surgeons, and maintenance of independence are among as adults 65 and older now account for more than the most important outcomes for older surgical 40% of the surgical volume in the U.S. and are an- patients.8, 9, 10 However, consideration of these ticipated to have growing operative needs.2, 3, 4 The outcomes is rarely prioritized in the preoperaAmerican College of Surgeons, a professional or- tive decision-making process and sometimes ganization dedicated to improving care of the sur- overlooked entirely during the surgical encoungical patient, has responded to this need by devel- ter. The Geriatric Surgery Verification Program oping the Geriatric Surgery Verification Quality Improvement Program.

The Geriatric Surgery Verification This program was created through the collaborative efforts of the AmerProgram is centered on four main ican College of Surgeons, The John aspects of geriatric surgical care: A. Hartford Foundation, and nearly 60 stakeholder organizations repregoals and decision making; cognition senting patients, caregivers, providand preventing postoperative ers and payers. These groups worked together over four years to compile a delirium; maintaining function and set of expert-vetted and evidencedbased standards of care, focused on mobility; and optimizing nutrition what matters most to older adults.5, 6 and hydration.

The Geriatric Surgery Verification Program is centered on four main aspects of geriatric surgical care: goals and decision strives to change this status quo and challenges all making; cognition and preventing postoperative hospitals to transform the way that they provide delirium; maintaining function and mobility; and surgical care to older adults. optimizing nutrition and hydration. These four The impact of the program can first be seen areas pre-date but overlap extensively with the in the preoperative phase of care. Traditionally, framework of the Age-Friendly Health Systems when an older adult presents to the surgical clinic initiative, which the Catholic Health Association for evaluation, the surgeon asks about the pais currently promoting.7 The areas were chosen tient’s physical symptoms, their medical history, through in-depth discussions with stakeholder allergies and medications. A physical exam is perorganizations and extensive literature review, formed, and a decision is made regarding the pawhich highlighted that respect for goals of care, tient’s appropriateness for an operation. In a Ge-

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When the older surgical patient is ready for riatric Surgery Verification hospital, this model is revised to prioritize the patient’s perspective. The discharge, Geriatric Surgery Verification hospiprogram requires that surgeons ask the patient tals understand that the recovery journey is far about treatment and overall health goals, and to from over. They focus on educating patients and discuss the anticipated impact of the operation, caregivers on expectations after they leave the not only on survival, but on symptoms, function, hospital. Additionally, for patients who are unindependence and quality of life. Thus, consider- able to return home after surgery, the transition ing whether surgery is the right choice for the pa- to post-acute care facilities can be challenging tient becomes less of a paternalistic verdict from with a lack of transparency and understanding the surgeon and more of a patient-centered de- of what happens to patients once they leave the cision focused on the outcomes that older adults hospital. The Geriatric Surgery Verification Provalue. In addition to considering goals of care, gram asks hospitals to address these issues with older patients presenting to Geriatric Surgery Verification hospitals must The development of the Geriatric be screened for high-risk geriatricspecific vulnerabilities (for example, Surgery Verification program impaired cognition or mobility), and a plan must be made to address these emphasizes that with an aging issues when they are detected. population comes an opportunity After surgery, the program continues to ensure that older patients to revolutionize the way we care receive care that is patient-centered and designed to address their unique for older adults and to make vulnerabilities. This includes mana meaningful impact on this dating early and efficient return of glasses, hearing aids and other sensovulnerable population. ry devices immediately after surgery, providing protocols to avoid potentially inappropriate medications and encourage protocols for two-way communication and trackmulti-modal pain management, and standardiz- ing the quality of care provided at these facilities. ing postoperative care to focus on preventing de- The goal of improving transitions of care is to both lirium, encouraging early mobility, and avoiding expedite recovery and decrease unnecessary hosmalnutrition and dehydration. Furthermore, the pital readmissions. Finally, as a quality initiative, Geriatric Surgery Verification Program recog- the program requires the measurement and colnizes that patients who are identified as high-risk lection of data on important geriatric outcomes, on preoperative screening assessments are more such as postoperative delirium and declines in likely to suffer adverse outcomes after surgery. physical and cognitive function, to help hospitals Thus, the program requires that such patients re- engage in continuous quality improvement on ceive postoperative care from an interdisciplin- outcomes that matter most to older adults.

The development of the Geriatric Surgery Verary team, including a provider with geriatrics expertise. Importantly, this aspect of the Geriat- ification program emphasizes that with an aging ric Surgery Verification Program highlights that population comes an opportunity to revolutionimproving geriatric surgical care is not about ize the way we care for older adults and to make a avoiding operations on high-risk older adults meaningful impact on this vulnerable population. all together, but rather to recognize high-risk By joining the Geriatric Surgery Verification propatients earlier, to make sure the patient’s goals gram and implementing these evidence-based, are aligned with the potential outcomes after sur- patient-centered standards, more hospitals can gery, and to design interdisciplinary postopera- join this transformation to improve the surgical tive care that works to prevent negative outcomes experience for older adults and focus on outsuch as cognitive or functional decline and loss of comes that matter to them.

To learn more about the Geriatric Surgery Verindependence.

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ification Program, visit www.facs.org/geriatrics or send us an email at geriatricsurgery@facs.org.

The authors would like to acknowledge GSV Core Development Team members JOANN COLEMAN, DNP ACNP; EMILY FINLAYSON, MD; MARK KATLIC, MD; SANDHYA LAGOO-DEENADAYALAN, MD, PHD; MEIXI MA, MD; THOMAS ROBINSON, MD; VICTORIA TANG, MD; and RONNIE ROSENTHAL, MD, as well as ACS staff members KATARYNA CHRISTENSEN; GENEVIEVE RANIERI, MSN, RN; SAMEERA ALI, MPH; and CLIFFORD KO, MD, for their contributions to this article.

NOTES 1. Mark Mather, Linda A. Jacobsen and Kelvin M. Pollard, “Aging in the United States,” Population Bulletin 70, no.

2 (2015): 1-18.

2. David A. Etzioni et al., “The Aging Population and Its Impact on the Surgery Workforce,” Annals of Surgery 238, no. 2 (August 2003): 170–77, https://doi. org/10.1097/01.SLA.0000081085.98792.3d.

3. David A. Etzioni et al., “Impact of the Aging Population on the Demand for Colorectal Procedures,” Diseases of the Colon & Rectum 52, no. 4 (April 2009): 583–90, https://doi.org/10.1007/DCR.0b013e3181a1d183.

4. Centers for Disease Control and Prevention, “Number of Discharges from Short-Stay Hospitals, by First-Listed Diagnosis and Age: United States, 2010,” www.cdc.gov/

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nchs/data/nhds/3firstlisted/2010first3_numberage.pdf.

5. Julia R. Berian et al., “Hospital Standards to Promote Optimal Surgical Care of the Older Adult: A Report from the Coalition for Quality in Geriatric Surgery,” Annals of Surgery 267, no. 2 (February 2018): 280–90, https://doi. org/10.1097/SLA.0000000000002185.

6. Melissa A. Hornor et al., “Optimizing the Feasibility and Scalability of a Geriatric Surgery Quality Improvement Initiative,” Journal of the American Geriatrics Society 67, no. 5 (May 2019): 1074–78. https://doi. org/10.1111/jgs.15815.

7. Creating Age-Friendly Health Systems. Catholic Health Association of the United States. https://www.chausa. org/eldercare/creating-age-friendly-health-systems.

Accessed March 3, 2020.

8. Cynthia Hofman et al., “The Influence of Age on Health Valuations: The Older Olds Prefer Functional Independence While the Younger Olds Prefer Less Morbidity,” Clinical Interventions in Aging (July 2015): 1131-39, https://doi.org/10.2147/CIA.S78698.

9. Terri R. Fried et al., “Understanding the Treatment Preferences of Seriously Ill Patients,” New England Journal of Medicine 346, no. 14 (April 4, 2002): 1061–66. https://doi.org/10.1056/NEJMsa012528.

10. Julia R. Berian et al., “Association of Loss of Independence with Readmission and Death after Discharge in Older Patients after Surgical Procedures,” JAMA Surgery 151, no. 9 (September 21, 2016): e161689. https://doi.org/10.1001/jamasurg.2016.1689.

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P R AY E R

SERVICE

Sacrifice on Behalf of the World KARLA KEPPEL, MA, MA MISSION PROJECT COORDINATOR, THE CATHOLIC HEALTH ASSOCIATION, ST. LOUIS

CALL TO PRAYER Leader: In our day-to-day lives, we often make sacrifices unknown to others—instances wherein we are called to “offer it up” because we have no other choice. Abraham’s sacrifice in the Hebrew scriptures, however, is known: he makes a conscious choice to offer to God his eldest born, making the offering all the more meaningful. Let us quiet our hearts as we listen to the word of God, and reflect together on Saint Mother Teresa’s attitude toward the gift of sacrifice.

Reader 1: A reading from the book of Genesis (Gen. 22: 9-12) When they came to the place of which God had told him, Abraham built an altar there and arranged the wood on it. Next he bound his son Isaac, and put him on top of the wood on the altar. Then Abraham reached out and took the knife to slaughter his son.

But the angel of the Lord called to him from heaven, “Abraham, Abraham!” “Here I am,” he answered.

“Do not lay your hand on the boy,” said the angel. “Do not do the least thing to him. For now I know that you fear God, since you did not withhold from me your son, your only one.”

The Word of the Lord.

All: Thanks be to God REFLECTION Reader 2: “Sacrifice, surrender, and suffering are not popular topics nowadays. Our culture makes us believe that we can have it all, that we should demand our rights, that with the right technology all pain and problems can be overcome. This is not my attitude toward sacrifice. I know that it is impossible to relieve

the world’s suffering unless God’s people are willing to surrender to God, to make sacrifices, and to suffer along with the poor.

From the beginning of time the human heart has felt the need to offer God a sacrifice. What is an acceptable sacrifice? One that is good for the people of God. One that is made on behalf of the world.”1 How are you being called to offer sacrifice to God for the sake of God’s people?

What does it mean for you to make a sacrifice “on behalf of the world” in your current context?

In what ways can you make small changes in your day-to-day life — how you spend your time, money, energy — such that you can have a part in relieving the suffering of the poor and marginalized?

CLOSING PRAYER Leader: God of Abraham and of Isaac, you who sacrificed your own Son for our sake: walk with us as we work to sacrifice for the good of your people.

Even as Abraham was prepared to offer the ultimate sacrifice of his own flesh and blood, Isaac, you did not leave them alone to suffer.

Indeed, amid our most difficult moments, we know that you are there with us, supporting us in our surrender to you.

Grant, we pray, the courage and the humility to make difficult choices for the good of the world, that our sacrifice might alleviate some of the world’s suffering and thus be pleasing to you.

Through Christ our Lord, we pray: Amen.

NOTE 1. Excerpted from In the Heart of the World: Thoughts, Stories, and Prayers by Mother Teresa, edited by Becky Benenate, ed., (1997): 47-48.

“Prayer Service,” a regular department in Health Progress, may be copied without prior permission.

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WINTER 2021

www.chausa.org

HEALTH PROGRESS

Theological Depth and Spiritual Maturity For Health Care Ministry The Ashley-O’Rourke Center for Health Ministry Leadership at Aquinas Institute of Theology is proud to introduce two new programs designed specifically for Catholic health care leaders who wish to draw upon the rich Dominican tradition of study and its contribution to the Church’s healing ministry.

“Catholic health care leaders know health care, but they also need to know why they do what they do, why it matters, and what it means from a theological perspective.

This is what the AOR Center at Aquinas Institute does best.”

– fr. charles bouchard, op senior director, theology & sponsorship, catholic health association

application deadlines: Fall:

Priority: March 15 / Final: August 1

Spring:

Priority: October 15 / Final: January 1

Graduate Certificate in Health Care Mission This online, five-course Certificate prepares current and future professionals to foster strategic and collaborative thinking and spirit in their organizations in order to ensure faithfulness to their purpose, identity, and values. Designed for any health care leader seeking competency in the theological and ethical dimensions of health care mission.

Master of Arts in Practical Theology with Specialization in Health Care Mission This 36-credit Master of Arts

Visit:

in Practical Theology (MAPT)

ai.edu

with Specialization in Health

Email: admissions@ai.edu Call:

314.256.8801

Care Mission builds on the five-course Certificate program with seven additional courses providing a firm foundation for health care leaders seeking a more comprehensive theological

ASHLEY-O’ROURKE CENTER

for Health Ministry Leadership

grounding with others committed to a deeper understanding of the Catholic faith.

23 South Spring Avenue | St. Louis, Missouri 63108 | 314.256.8800 | ai.edu

NOW AVAILABLE

2020 Mission Leader Competency Model NEW online selfassessment tool with coaching prompts

NOW WITH TIERS for entry-, midand executive-level mission leaders

FIND OUT MORE AT CHAUSA.ORG/MISSIONLEADERCOMPETENCIES