The Commonwealth Fund and AcademyHealth launched a new multi-year strategic initiative, Building Bridges: Making a Difference in Long-Term Care, with the first annual colloquium on June 5, 2004, in San Diego. Held in conjunction with AcademyHealth's Annual Research Meeting, the colloquium provided an opportunity for long-term care (LTC) stakeholders to exchange information, debate the issues, seek solutions, and identify where additional research is needed. This venture brought together policy leaders, providers, consumer representatives, researchers, and funders around critical issues in long-term care. In order to involve a broader cross-section of LTC stakeholders in these discussions, we have prepared this summary of the colloquium presentations and discussion.

The 2004 colloquium featured an impressive line-up of speakers and focused on two important issues:

• The use of information to improve long-term care quality; and
• The challenges of providing long-term care to people dually eligible for Medicare and Medicaid.

The goal of the initiative is to foster development of a network of key players and to raise policymakers' awareness of the importance of LTC through a series of annual colloquia and ongoing workgroup discussions among conference participants and others.

To learn more about ongoing activities of this initiative, please contact us at ltc@academyhealth.org.

LONG-TERM CARE POLICY: TIME FOR ATTENTION

Karen Davis, Ph.D., of The Commonwealth Fund, delivered the keynote address. She created a framework for the colloquium by developing a vision for the future of long-term care and discussing the need for information and evidence. She presented evidence on the scope of the LTC problem and shared her perspectives on why LTC is important. She then presented her vision of the role for The Commonwealth Fund's multi-year strategic effort in meeting those needs. Davis also presented examples of some successful LTC innovations, including the Wellspring Model, and options for policy intervention to improve LTC delivery options and financing.

In the discussion that followed, Davis reiterated that the public ranks nursing home quality as a primary policy concern. There is no lack of consumer interest in LTC reform, according to Davis. Rather, there is a lack of mobilization around the issue, she said.

IMPROVING QUALITY WITH BETTER INFORMATION

Vincent Mor, Ph.D., of the Brown University School of Medicine, prepared a commissioned paper on how information might be used to improve LTC quality. His paper and presentation examined the quality of quality data and the impact of quality information on providers' efforts to improve care, as well as on consumers' choices and experiences. Mor identified conceptual, technical, and operational gaps in research and knowledge about LTC quality measures. In addition, he identified where research is needed to fill gaps in quality measures, ultimately leading to quality improvement. He cautioned that policymakers and regulators must be careful that technical deficiencies do not lead to biased comparisons or inappropriate system redesign. However, he argued, existing quality measures must continue to be used for public reporting and other uses while efforts at improvement continue.

During the colloquium discussion, participants noted that additional quality indicators are needed in order to inform placement decisions made by family members or hospital discharge planners. One of the insights from the discussion however, was that encouraging consumers to use public information to assess a provider's service quality may have unintended consequences. Provider backlash directed at empowered consumers may discourage the use of available information. Federal policy can address these issues once the role of government in quality reporting is clearly defined.

MEDICARE, MEDICAID, AND THE DUAL-ELIGIBLE WITH LONG-TERM CARE NEEDS

Judith Feder, Ph.D., of Georgetown University, presented highlights from a paper she authored with Harriet Komisar and Judith Kasper. She summarized survey data from six states on the unmet LTC needs of the dual-eligible population. Her presentation specified the health care challenges inherent in providing LTC, both financially and clinically, to this population. She also identified areas where additional research and/or policy intervention is needed. Feder presented evidence that public support of paid home care reduces unmet need. Survey data showed that as the proportion of people receiving paid care increased, the proportion with unmet LTC needs decreased. However, among those with unmet needs, there was still a large number requiring assistance with activities of daily living. Feder added that shared federal-state responsibility inevitably produces variation from place to place.

In the colloquium discussion, participants debated coverage options for dual-eligibles. This vulnerable population receives insurance coverage through both Medicaid and Medicare, resulting in complexities in reimbursement and system design.

IMPLICATIONS FOR POLICY AND PRACTICE

Following the Mor and Feder presentations discussants placed the presentations in a real-world context, attempting to answer questions relating to long-term care policy and practice. These discussants offered the perspectives of a practitioner and a policymaker. The discussants identified issues that might be addressed by future research or through collaborations among researchers, practitioners, and policymakers. The discussions following their presentations highlighted potential unintended consequences of policy and system design in the long-term care arena.

Trudy Lieberman, health policy editor of Consumer Reports, and Len Fishman, president and chief executive officer of the Hebrew Rehabilitation Center for Aged in Boston and formerly New Jersey's Commissioner of Health and Senior Services, commented on the value and impact of quality information from the consumer, provider, and regulatory angles. Both discussants highlighted real-world unintended consequences of quality reporting. Consumers can be punished for demanding information and quality reporting often reinforces a culture of mediocrity. Fishman noted that there are few efforts to highlight top performers; quality reporting in the nursing home often translates into being free of deficiencies, rather than adopting innovations. Lieberman concluded that though consumers cannot change the health care marketplace, they can change their expectations and force policy change.

• Lieberman Presentation Slides
• Fishman Presentation Slides

Views on the challenges of providing care for the dual-eligible population from the federal and state perspectives were provided by Diane Braunstein, program director for health policy studies at the National Governors Association, and William Scanlon, Ph.D. formerly the managing director of health care issues at GAO and now of Georgetown University. Using trends from Georgia and Iowa, Braunstein predicted that states will continue to focus on cost-containment mechanisms, while attempting to address the needs of low-income seniors who do not quality for Medicaid but live near poverty. Scanlon urged researchers and policymakers to redefine unmet need and include measures of inadequate assistance, quality of life, and family burdens rather than simply objective measures of disability and service use.

• Braunstein Presentation Slides
• Scanlon Presentation Slides

WHAT'S ON THE HORIZON?

In his closing remarks, Peter Kemper, Ph.D., outlined next steps in the initiative. He described the role of the Advisory Committee and urged participants to become involved in future networking opportunities and collaborative activities, as well as to pursue projects filling some of the information gaps identified throughout the day.