[Senate Hearing 110-808]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 110-808
 
                         PERSON-CENTERED CARE: 
  REFORMING SERVICES AND BRINGING OLDER CITIZENS BACK TO THE HEART OF 
                                SOCIETY 

=======================================================================

                                HEARING

                               before the

                       SPECIAL COMMITTEE ON AGING
                          UNITED STATES SENATE

                       ONE HUNDRED TENTH CONGRESS

                             SECOND SESSION

                               __________

                             WASHINGTON, DC

                               __________

                             JULY 23, 2008

                               __________

                           Serial No. 110-33

         Printed for the use of the Special Committee on Aging



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                               index.html

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                       SPECIAL COMMITTEE ON AGING

                     HERB KOHL, Wisconsin, Chairman
RON WYDEN, Oregon                    GORDON H. SMITH, Oregon
BLANCHE L. LINCOLN, Arkansas         RICHARD SHELBY, Alabama
EVAN BAYH, Indiana                   SUSAN COLLINS, Maine
THOMAS R. CARPER, Delaware           MEL MARTINEZ, Florida
BILL NELSON, Florida                 LARRY E. CRAIG, Idaho
HILLARY RODHAM CLINTON, New York     ELIZABETH DOLE, North Carolina
KEN SALAZAR, Colorado                NORM COLEMAN, Minnesota
ROBERT P. CASEY, Jr., Pennsylvania   DAVID VITTER, Louisiana
CLAIRE McCASKILL, Missouri           BOB CORKER, Tennessee
SHELDON WHITEHOUSE, Rhode Island     ARLEN SPECTER, Pennsylvania
                 Debra Whitman, Majority Staff Director
            Catherine Finley, Ranking Member Staff Director

                                  (ii)

  






















                            C O N T E N T S

                              ----------                              
                                                                   Page
Opening Statement of Senator Herb Kohl...........................     1
Statement of Senator Gordon H. Smith.............................     2
Statement of Senator Robert P. Casey.............................     3
Statement of Senator Ron Wyden...................................     6

                                Panel I

Statement of William Thomas, M.D., Professor, Erickson School of 
  Aging Studies, University of Maryland, Ithaca, NY..............     8
Statement of Robert Jenkens, Director, Green House Project, NCB 
  Capital Impact, Arlington, VA..................................    16
Statement of Melinda Abrams, M.S., Assistant Vice President, 
  Patient-Centered Primary Care, The Commonwealth Fund, New York, 
  NY.............................................................    29
Statement of Eric Coleman, M.D., MPH, Director, Care Transitions 
  Program, University of Colorado, Aurora, CO....................    66

                                Panel II

Statement of Zoe Holland, Daughter of a Former Green House 
  Resident, Lincoln, NE..........................................    85
Statement of Edna Hess, Shahbaz, Lebanon Valley Brethren Home, 
  Palmyra, PA....................................................    94
Statement of Diana White, Ph.D., Senior Research Associate, 
  Institute on Aging, Portland State University, Portland, OR....   103

                                APPENDIX

Testimony submitted by Assisted Living Federation of America 
  (ALFA).........................................................   120
Statement submitted by AARP......................................   123

                                 (iii)

  


 PERSON-CENTERED CARE: REFORMING SERVICES AND BRINGING OLDER CITIZENS 
                      BACK TO THE HEART OF SOCIETY

                              ----------                              


                        WEDNESDAY, JULY 23, 2008

                                        U.S. Senate
                                 Special Committee on Aging
                                                   Washington, D.C.
    The committee met, pursuant to notice, at 11 a.m. in Room 
SD-562, Dirksen Senate Office Building, Hon. Herb Kohl 
(Chairman of the committee) presiding.
    Present: Senators Kohl [presiding], Wyden, Lincoln, Casey, 
Whitehouse, and Smith.

             OPENING STATEMENT OF SENATOR HERB KOHL

    The Chairman. Good morning, and we thank you all for being 
here this morning.
    This morning, I will be very pleased, along with Senator 
Smith, to turn the gavel over to our colleague Senator Casey. 
While serving as Pennsylvania's auditor general for 8 years, 
Senator Bob Casey worked to improve the nursing homes in his 
State, making them safer and exposing holes in State oversight. 
We are very grateful to have him on the Aging Committee, and we 
are pleased that he is holding today's hearing.
    The issue we will consider today is one that should seem 
obvious. When providing someone with healthcare or long-term 
care, our first consideration should always be that particular 
individual's needs and desires. This is known as person-
centered care. What a very simple idea.
    Unfortunately, our health and long-term care industries 
have grown so complex that such a straightforward concept has 
gotten lost and, to some, providing personalized care with the 
individual senior in mind has become inconvenient.
    Twenty-one years ago, Congress passed a landmark nursing 
home reform known as OBRA 87. OBRA laid the foundation for 
person-centered care. Today, Senator Casey will examine 
facilities called ``Green Houses'' that are successfully 
implementing person-centered care. Green Houses that are 
successfully implementing person-centered care are all too 
rare.
    We will also hear about the medical home model that CMS is 
exploring, which reorganizes the way that physicians, nurses, 
and others work together to tailor services to each individual. 
Finally, the Committee will explore ways to make it easier for 
other nursing homes to move forward toward these model 
programs.
    It is clear that within the realm of long-term care there 
are many more choices available today than there were just 20 
years ago. We are very pleased to see this expansion of 
options, and we are very hopeful that this trend will continue.
    The Aging Committee has a long and a proud history of 
moving Congress forward on issues of long-term care. So we 
thank you once again, Senator Casey, for taking us a step 
further with today's hearings.
    We turn now to the Senator's Ranking Member, Senator Smith.

              STATEMENT OF SENATOR GORDON H. SMITH

    Senator Smith. Thank you, Chairman Kohl.
    Senator Casey, we thank you for bringing this important 
issue to the attention of this Committee. As debate continues 
on healthcare reform, we often find ourselves embroiled in 
discussions of cost control and payment reform, and too often 
forget the people our reforms are intended to serve.
    The recent debate over this year's Medicare legislation was 
an excellent example of how we can make necessary policy 
adjustments while improving the Medicare program for our 
seniors. I look forward to today's discussion as it is in 
keeping with this positive trend of placing the care of the 
person at the center of healthcare policy discussions.
    We have an impressive list of witnesses today, all of whom 
will share with us their perspective on person-centered care. I 
want to extend a personal welcome to Dr. Diana White, who flew 
all the way from Oregon to be with us today. Dr. White will 
share with us some of the initiatives going on in Oregon and 
provide recommendations garnered from the lessons learned.
    As an Oregon Senator, I am very proud of our State's 
healthcare system. We have a large number of community-based 
care choices, including home care, hospice, and other services. 
The diversity in care options and our State's continued 
emphasis on providing a variety of services has supplied 
Oregonians with one of the Nation's best healthcare systems.
    The Oregon model has a strong collaborative philosophy and 
is designed to get individuals the appropriate care in the 
settings that best meet their needs. Oregon's system lends 
itself in many ways to the philosophy of person-centered care. 
Similarly, person-centered care focuses on the inherent value 
of each individual and emphasizes the importance in 
relationships between caretakers and receivers.
    As we look for new ways to provide quality care for our 
seniors, examining concepts and philosophies like the ones 
discussed today, will help us all make informed decisions. Our 
seniors deserve the very best. If we can design public policies 
that maximize choice, autonomy, and relationships between 
caregivers and receivers, I believe this can go a long way in 
helping to improve the quality and dignity of care our seniors 
receive.
    I am committed to looking at all of the alternatives that 
will help our dedicated health professionals in providing the 
highest quality of care to their patients. To that extent, I 
welcome the opportunity this morning to learn more about 
person-centered care and the potential contributions it could 
hold in providing improved quality and increased satisfaction 
of seniors in outpatient and long-term care settings.
    So, with that, I turn back to you, Mr. Chairman and Senator 
Casey.
    The Chairman. Thank you very much, Senator Smith.
    Senator Casey.

              STATEMENT OF SENATOR ROBERT P. CASEY

    Senator Casey [presiding]. Mr. Chairman, thank you very 
much.
    I appreciate your willingness to bring us together today 
for this hearing and for your leadership on this Committee 
that, frankly, we don't hear enough about these issues in the 
public press, and we are grateful for the opportunity you are 
giving us today. The families of America, older citizens across 
this country, as well as the witnesses who are here, we will 
all benefit from the wisdom and the insight and the experience 
that these witnesses bring to bear on this important issue.
    I want to thank Chairman Kohl and thank him again for his 
leadership, and Ranking Member Smith as well for being with us 
today.
    I know we are joined by Senator Wyden, long a leader and an 
active voice on this issue of how we care for and honor older 
citizens.
    I wanted to thank the witnesses for your presence, your 
scholarship, your experience, but also for your willingness to 
travel. We have witnesses as far away as Oregon, Colorado, 
Nebraska. We have some Pennsylvanians here, as well as some 
from the State of New York as well. We thank you for that.
    We want to highlight today the issue that both Senator Kohl 
and Senator Smith mentioned, which is person-centered care, 
reforming services and bringing older citizens back to the 
heart of society. I guess we should talk about the philosophy 
that brings us together today. It is very simple. Older 
citizens deserve to live lives of dignity and respect at all 
stages of their lives.
    I was recalling this morning what was written in the 
Philadelphia Inquirer 10 years ago in a series about long-term 
care. A writer by the name of Michael Vitez, V-I-T-E-Z, a good 
man and a good writer. In the middle of one of his stories in a 
series, he said, and I quote--and he was referring to experts 
in the field. ``Life can have quality and meaning even until 
the very last breath.'' He was using as his foundation for that 
statement those who were experts.
    I think that is critically important to remember today. No 
matter how old someone is, no matter what stage of life they 
are in, their life has quality and meaning until the very last 
breath. Elders have a profound right to be decisionmakers in 
their own care, to be at the center of their own care with a 
partnership of family and providers.
    Older citizens are critically important to the overall 
health and well being of our society. I quote one of our 
witnesses today, Dr. Bill Thomas, and in fact, our hearing 
title today borrows from a phrase of his. ``People of all ages 
will live better lives when we succeed in bringing elders back 
to the heart of our society.'' A well-crafted summation of what 
we are doing today, that we have to bring them back to the 
heart of our society.
    I will ask that my full statement be made part of the 
record, but I did want to review a couple of areas of my 
statement before I turn to our other colleagues.
    [The prepared statement of Senator Casey follows:]

           Prepared Statement of Senator Robert P. Casey, Jr.

    Good morning everyone and thank you all for being here. I 
want to thank Chairman Kohl for the opportunity to call this 
hearing today and I'd like to give a warm welcome and 
tremendous thanks to the witnesses we have with us today-- some 
of whom have traveled from as far away as Oregon, Colorado and 
Nebraska, others from PA and NY. Thank you all for taking the 
time to be here and for your tremendous expertise and 
commitment to the work we'll be discussing.
    Our hearing is called ``Person-Centered Care: Reforming 
Services and Bringing Older Citizens Back to the Heart of 
Society.'' What do we mean by person-centered care? It is both 
a philosophy of care as well as the defining principle of 
several exciting and specific initiatives within health care 
and long term care for older citizens. The philosophy is 
simple: Our older citizens deserve to live lives of dignity and 
respect through all stages of life. About 10 years ago, the 
Philadelphia Inquirer reported, ``Life can have quality and 
meaning even until the very last breath.'' Elders have a 
profound right to be decision-makers in their own care--to be 
at the center of their own care, with a partnership of family 
and providers. Our older citizens are critically important to 
the overall health and well being of our society. I quote one 
of our witnesses today, Dr. Bill Thomas, and in fact our 
hearing title borrows a phrase from the following quote of his, 
``People of all ages will live better lives when we succeed in 
bringing elders back to the heart of our society.''
    In recent years, this philosophy of person-centered care 
has been translated into very specific action. This morning we 
will hear testimony about person-centered care within two types 
of settings: (1) outpatient care for older citizens living on 
their own or in assisted living, and (2) long term residential 
care in nursing facilities. I think you will find this 
testimony fascinating, enlightening and inspiring. We have with 
us experts in policy and academia and medicine. We also have 
the ultimate experts--family members and direct care workers. 
All these individuals will testify about how person-centered 
care has transformed their professional and personal lives.
    In hearings before the Aging Committee, we frequently hear 
the statistics, and they are alarming, about the increase in 
Americans over the age of 65. We currently have an estimated 38 
million Americans in this age group, and that number is 
expected to double within the next twenty years. In the midst 
of this, health care costs are rising exponentially, the 
quality of outcomes is not consistent, older citizens are often 
abandoned to navigate a confusing and complex health care 
system. Also, older citizens report extremely low levels of 
satisfaction with life in nursing homes. This $122 billion 
industry includes 16,000 nursing homes and significant concerns 
persist about maltreatment and neglect of our older citizens in 
20% of these homes. As I know from my work in state government, 
most nursing homes provide quality care but that 20% is what we 
hear most about. However, a recent survey by the AARP found 
that fewer than 1% of individuals over 50 with a disability 
want to move to a nursing home. There has to be a better way, 
and in fact there is.
    Person-centered care provides that better way. It is a 
straightforward concept and yet it has taken years of hard work 
to get concrete initiatives underway. We have a long way to go 
and much to learn. But in order to succeed, we must also 
examine why this kind of culture change is difficult.
    Part of the answer is that our current systems for health 
care and long term care are neither structured nor rewarded for 
person-centered care. Medicare offers financial incentives for 
scheduling multiple patients and single services, not 
coordinating complex care and providing counseling and genuine 
partnership in care. This is unsatisfying for both patients and 
practitioners--and can even be dangerous or deadly. The NY 
Times contained a report Monday about a Philadelphia man, 
Robert Williamson, who received a cursory primary care exam 
which missed the danger signs of an oncoming stroke that Mr. 
Williamson suffered a short time later. Not only did Mr. 
Williamson suffer a severe health crisis, he incurred $30,000 
in hospital costs and had to go on disability at a cost of 
$1,900 per month.
    The number of primary care or ``family'' physicians, those 
who traditionally have an ongoing relationship with patients 
and their family members and the greatest understanding of 
comprehensive needs, is decreasing. The American Academy of 
Family Physicians reports a 50% decline in medical students 
choosing family medicine. Primary care physicians get lower 
reimbursements from Medicare and need to see increasing numbers 
of patients, in already over-crowded schedules, just to stay 
afloat financially.
    In residential care, nursing facilities require residents 
to revolve around institutional schedules for such personal 
preferences as waking, bathing and dressing, far too often 
identifying residents by their health conditions, 
vulnerabilities and room numbers rather than their unique 
strengths and gifts. Staff members attracted to the field of 
direct care service because they want to help older citizens 
are just as ill-served by this institutionalized culture as are 
the residents. Workers are minimally trained, over-worked and 
carry patient loads that make it impossible to engage in any 
personal time with residents--in fact, such relationships are 
often discouraged. They have little or no say in decision-
making, relegated--like the residents--to the fringes of a 
system that places the needs of the institution over those of 
the human beings in it.
    The majority of our health care and long term care systems 
are missing a critical element in caring for our older 
citizens--and that is the importance of relationships. Elder 
care has become entrenched in habits and methodology and 
reimbursement policies that are more suited to ``one size fits 
all'' than to personalized, individualized care. We reimburse 
physicians on the number of patients they can see in a day 
rather than engaging older citizens and their family members in 
a partnership of care. We evaluate direct care workers on the 
number of pills they can dispense in an hour, rather than the 
joy they can engender in the life of an older individual.
    Of course the culture change of person-centered care 
involves more than just an emphasis upon relationships, and we 
will hear much about its specific requirements here this 
morning. But changing the way we care for older citizens does 
not need to be difficult. We have to stop engaging in 
``business as usual'' and look at what is working. That is why 
I chose to hold this hearing and will devote a great deal of 
attention to this issue here in the Senate. That is why I will 
be introducing a bill that will provide loan funding for long 
term nursing facilities that commit to the principles of 
person-centered care.
    The movement toward person-centered care has been called a 
revolution. But although it is revolutionary and ``new'' in 
what we are doing, it is also a profound return to the bedrock 
values of respecting our older citizens and living the golden 
rule. It's also about peace of mind for family members. The 
pioneers of this revolution--and we are fortunate to have many 
of them with us here today--show us how we can enrich the lives 
of both our older citizens and everyone around them. I am so 
grateful to them for their willingness to believe in something 
better, for their courage and persistence in engaging very 
entrenched systems in innovative change. They are here today to 
tell us how to create change in very specific and successful--
terms, focusing in particular on the outpatient ``Medical 
Homes'' model and the ``Green House'' model for in patient 
residential care. Since serious conditions often lead to 
hospitalizations and periodic rehabilitative care for older 
citizens, we will also hear testimony about how to best 
navigate such transitions within a culture of person-centered 
care.
    The solutions we will hear this morning are win-win for 
everyone. They provide older citizens and their families with 
better care, better outcomes, and more enjoyable lives; they 
provide direct care workers long-overdue respect and job 
satisfaction; they allow health care practitioners to meet the 
comprehensive needs of their patients; and they save money in 
the long run.

    Senator Casey. The majority of our healthcare and long-term 
care systems are missing a critical element in caring for older 
citizens, and that is the importance of relationships. Just one 
word, but so powerful and so profound for today.
    Elder care has become entrenched in habits and methodology 
and reimbursement policies that are more suited to one-size-
fits-all than to personalized, individualized care. We 
reimburse physicians on the number of patients they see in a 
day rather than engaging older citizens and their families in a 
partnership of care. We evaluate direct care workers on the 
number of pills they can dispense in an hour rather than the 
joy they can engender in the lives of an older individual.
    The movement toward person-centered care has been called a 
revolution. But although it is revolutionary and new in what we 
are doing, it is also a profound return to the bedrock values 
of respecting our older citizens and living the golden rule. It 
is about peace of mind for families and family members.
    The pioneers of this revolution, and we are fortunate to 
have many of them with us today, show us how we can enrich the 
lives of both older citizens and everyone around them. I am so 
grateful to them for their willingness to believe in something 
better, the people who are here providing testimony and 
supporting the testimony, for their courage and persistence in 
engaging very entrenched systems in innovative change.
    Finally, the solutions we will hear today are a win-win for 
everyone. They are a win for older citizens, a win for those 
who provide the care, and for family members. These changes and 
these solutions provide older citizens and their families with 
better care, better outcomes, and more enjoyable lives. They 
provide direct care workers with long-overdue respect and job 
satisfaction. They allow healthcare practitioners to meet the 
comprehensive needs of their patients, and they save money in 
the long run.
    In the end, and I will conclude with this, what we are 
doing today is, in a larger sense, paying tribute to and 
affirming the contribution of those who have gone before us, 
older citizens in our societies, those who fought our wars, who 
worked in our factories, who taught our children, who gave us 
life and love. The least that we can do is to stay focused on 
better ways to make sure their care is the best that it can be 
and especially to affirm the good work that is done by 
healthcare practitioners and, of course, the direct care 
workers who provide most of the daily and hourly care to older 
citizens.
    So, Mr. Chairman, we thank you for your leadership and for 
this opportunity today. Thank you very much.
    Now I have the honor and the privilege, as of chairing this 
hearing in my about 18th or 19th month in the Senate, to be 
able to call on a witness, and I appreciate the Chairman 
allowing me to do that.
    I want to call on now another Senator from the State of 
Oregon, someone I have known for several years now and someone 
who has been a leading voice on these issues, Senator Ron 
Wyden.

                 STATEMENT OF SENATOR RON WYDEN

    Senator Wyden. Thank you. Thank you very much, Mr. 
Chairman.
    I want to commend you, Senator Casey. Thank you for your 
very fine statements, Chairman Kohl and Senator Smith.
    I will be very brief. I think what is striking about this--
and Ms. Abrams touches on it in her opening statement--is that 
when you look at the debates that we are now having in this 
country about healthcare, it seems that so often the patient is 
almost an afterthought.
    You hear constant references to the providers, to the 
insurances companies, to various payers and budget experts, and 
at the end of the discussion, you wonder where does the patient 
really fit in?
    I know in the Senate Finance Committee--Senator Smith and I 
are part of the Finance Committee--we had a long discussion 
last week about health information technology, a very exciting 
development. We also discussed something known as comparative 
effectiveness analysis so that you could see, for example, 
which provider gave the best-quality services and at what 
price. These are all very useful tools.
    But after something like 2 hours' worth of discussion, I 
asked how does the patient fit into all of this? We have heard 
about why it makes sense for the budgets and for payers and 
insurance companies. How would you actually get the fruits of 
these wonderful technologies to patients and their families in 
a usable fashion?
    So that is why I think it is very, very helpful that 
Senator Casey, with the bipartisan leadership of our Committee, 
is looking at care that is patient-centered. This topic and 
this hearing give us a chance to elevate the concerns of 
patients so that at least they get up to the same plateau as 
concerns of providers, budget experts, insurance companies, and 
others.
    The Healthy Americans Act is the first bipartisan universal 
coverage health bill in the history of the Senate--we have now 
got 16 Senators, 8 Democrats and 8 Republicans. Senator Smith, 
I am pleased to say, is one of our group. What we do is 
establish what is called a ``healthcare home.'' We don't call 
it a medical home because we want to convey to the world that 
nurses and physician assistants and others should also be in a 
position to do the good work that Senator Casey has described 
this morning.
    As this debate goes forward about a medical home--what I 
call a health home and I am going to ask several of you 
witnesses to talk particularly about how we can make sure that 
this concept really gets embedded in the health reform efforts. 
I think it really is one of the best ways to follow up on this 
idea of a patient-centered universe in healthcare.
    Thank you Senator Casey for this hearing, your leadership 
and especially for making sure that the patient isn't an 
afterthought in this debate.
    Senator Casey. Thank you, Senator Wyden. We are grateful 
for your leadership as well.
    I think we will go to our witnesses now, and I think it 
will start on my left. I think what I will do is just introduce 
the witnesses as they testify.
    First of all, Dr. William Thomas is a Professor at the 
Erickson School of Aging Studies, University of Maryland. He is 
the Founder of the Green House model. He is a resident of the 
State of New York. To say he has been an innovator and a 
pioneer is a dramatic understatement.
    He is a Harvard-trained medical doctor and also known in 
some circles as a ``gentleman farmer.'' I will have him explain 
that if he wants to at some point. But, Doctor, we are grateful 
for your presence here today and your testimony, and we will 
start off with you.
    We are going to try to keep, as best we can, our witnesses 
to 5 minutes. Of course, each of your statements will be made 
part of the record. We will start with you, Dr. Thomas.

 STATEMENT OF WILLIAM THOMAS, M.D., PROFESSOR, ERICKSON SCHOOL 
      OF AGING STUDIES, UNIVERSITY OF MARYLAND, ITHACA, NY

    Dr. Thomas. Thank you, Senator Casey. Thank you to the 
Committee for having me.
    I actually always like to take a question of public policy 
and dig into the history. It is fascinating to me. As I was 
preparing my remarks, I went back across the history of 
medicine and healthcare in America, and it is fascinating to 
look at healthcare in America in the 19th century.
    In the 1800's, it was a wild and woolly environment out 
there, with just about anybody who wanted to could call 
themselves any kind of doctor or practitioner they wanted to. 
Families, consumers, patients really had no way of knowing if 
this snake oil salesman was really going to offer them some 
kind of cure or not. I will give you one little anecdote from 
that era, which I found fascinating.
    The early--when oil was discovered in western Pennsylvania, 
the first use it was put to was as a patent medicine. Some 
enterprising souls in western Pennsylvania began collecting the 
oil that was running in the streams out there and selling it as 
a medicine. That didn't work out so well. So this whole 
petroleum thing took over instead.
    But in 1910, a man named Abraham Flexner, with the support 
of the Rockefeller family, actually conducted a detailed 
analysis of medicine in America, and his findings were, as I 
have described to you, crazy. He recommended that we 
standardize American medicine and much in the same kind of way 
that the petroleum or oil industry was being standardized.
    As a result, for the very first time, there were specific 
requirements for physicians to go to medical school. That was 
new. To actually have faculty who were doctors, that was new. 
To actually see patients, that was new. All of this was new. 
The modern medical school was born in the early 1900's.
    The result of that, I am really happy to say, was a 
dramatic improvement in the healthcare made available to 
American citizens because now you had people who were actually 
trained in what they were trying to do. There was real research 
going on, and we began to see real improvements in our health 
and healthcare.
    The other thing that happened as a result of this improved 
attention to kind of training and prestige, the reputation of 
the doctor changed from possibly snake oil salesman, ``I don't 
know about this person,'' to a respected member of the 
community. In fact, there are some really wonderful pieces of 
art that are created in the early 20th century kind of showing 
physicians in very kind and caring and compassionate roles.
    We began to match that new social role with some tremendous 
technology--the development of antibiotics, effective 
immunizations, effective surgical techniques. Medicine went 
through a stunning transformation. With each new development, 
the stature of the doctor rose higher and higher and higher.
    In fact, I was a medical student in the 20th century, and 
when I began my training, it was customary for nurses to rise 
from sitting when a doctor entered into the room. That was a 
courtesy that was extended to physicians in part because of 
this high prestige.
    In fact, there was a joke that went around medical schools 
at that time, which I will repeat here because you guys didn't 
go to medical school so--what is the difference between God and 
a surgeon? God doesn't think he is a surgeon.
    So what happened is we developed a ``doctor knows best'' 
kind of culture, where patients were expected to defer to the 
expert judgment of the physician. I think that worked well at 
the time. You know, it had its advantages, but we live in a 
very, very different world now. I want to lay out for the 
Committee just the basic elements that are changing so you know 
where the policy--where this policy impulse is coming from.
    First off, medical information is now available to 
everybody all the time, everywhere. Some of it is very good on 
the Internet, and some of it is very bad. But people have 
access to information in ways that were unimaginable in the 
1960's, 1970's, and 1980's, you know, before the information 
boom.
    Physicians are now regularly dealing with patients who have 
sometimes as much information as they do about new drugs and 
new treatments and new therapies, and it is changing the 
relationship between doctor and patient.
    Also--and I think this is very, very important--we are the 
inheritors of a system that was built on acute medical care. 
The system was created and optimized to provide immediate 
urgent treatment to illness and injury, and it is good.
    The problem is we are living in a society where more and 
more people spend more and more of their lives managing chronic 
illness. The ongoing management of chronic illness requires a 
different relationship between doctor and patient than the 
immediate urgent treatment of an illness or injury.
    So we are changing away from an acute care oriented system 
toward a chronic care oriented system, and social roles are 
going to have to change to accommodate that.
    Next, what used to be--the doctor in Sayre, PA, the Dr. 
Robert Packer hospitals started by Dr. Robert Packer, OK? There 
you go. It used to be clear exactly where you went for the 
answer. Now it is confusing.
    In fact, Dr. Robert Kane, who is a well-known expert in the 
field of aging and public policy in aging, wrote a book about 
how difficult it was for him, an expert in the American 
healthcare system, to navigate when his mother became ill, and 
he was not the expert, he was the son of a woman who needed 
help. So what we find is that both doctors and patients are 
increasingly struggling with the complexities of the system we 
have created.
    Finally, there is a need to put patients, as has been 
mentioned in the opening comments, at the center of what we do. 
There is a pretty exciting thing that happens when people like 
me and the other people in the hearing room here get to develop 
new models based on patient centeredness. That is what is 
different. That is what is new. That is what has changed.
    I am not here today to talk to you about making a nursing 
home a better nursing home. I am here today to talk to you 
about transcending that older model with a new patient-centered 
model and reaping the benefits of that change.
    So--and you will hear more about this in detail as we go 
along, but the medical home concept, I really want to say, I 
trained in family medicine. My sympathies are entirely with 
providing people with a healthcare home where they--home-based, 
where they can go and get reliable information from people with 
whom they have a relationship.
    Senator Casey. Doctor?
    Dr. Thomas. Yes?
    Senator Casey. I just want to cut you short because we are 
over by more than 3 minutes.
    Dr. Thomas. On time? No worries.
    Senator Casey. I want to--we won't penalize you today. 
But--[Laughter.]
    Dr. Thomas. I thank you for giving me time, and I am sorry 
I went on so long.
    [The prepared statement of Dr. Thomas follows:]

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    Senator Casey. That is OK. Maybe we will give others a 
little warning.
    Senator Whitehouse is here from the State of Rhode Island. 
I don't know if he wants to offer a statement now or whether 
you want to do a statement later?
    Senator Whitehouse. I am more than happy to hear from the 
witnesses and not deliver a statement.
    Senator Casey. That doesn't always happen in this place. 
[Laughter.]
    Thank you, Senator Whitehouse.
    Senator Whitehouse. Maybe it will catch on.
    Senator Casey. Let me move to our second witness.
    Robert Jenkens is here, and he is the Director of the Green 
House Project.
    Just by way of background, Mr. Jenkens serves as Vice 
President of the subsidiary of NCB Capital, the Community 
Solutions Group. He directs the Green House Project and the 
Coming Home Program, and I know we are going to be hearing--
have a chance to ask some questions about all of these and 
about the elements of the Green House, what characterizes the 
Green House.
    But, Mr. Jenkens, if you have a chance, we will try to give 
you 5 to 6 maybe. Thank you very much.

STATEMENT OF ROBERT JENKENS, DIRECTOR, GREEN HOUSE PROJECT, NCB 
                 CAPITAL IMPACT, ARLINGTON, VA

    Mr. Jenkens. Thank you, Senator Casey, Chairman Kohl, 
Ranking Member Smith, and other members of the Committee for 
this opportunity to share with you information about one 
successful model of person-centered care, The Green House 
Project.
    I am Robert Jenkens, Director of the Green House Project. 
The replication of The Green House model is a partnership 
between NCB Capital Impact, the Robert Wood Johnson Foundation, 
Bill Thomas, and the early pioneering providers who have joined 
with us in this effort.
    Person-directed care is about creating a place where people 
live lives on their own terms while receiving the care they 
need with dignity and control. Today, I want to share a brief 
overview of The Green House model, our research, challenges, 
and what Congress can do to help.
    Edna Hess and Zoe Holland will speak on the next panel 
about their personal experiences with The Green House homes and 
how they transform the lives of elders and staff. Additional 
detailed information is available in my written statement.
    The Green House model reinvents nursing homes to make them 
real homes. Not home-like, but real homes with the control, 
choice, and flexibility that you or I expect when we get home. 
To do this, the model changes three areas--the environment, the 
organization, and the philosophy of care typically found in 
skilled nursing homes. This comprehensive and integrated 
approach is key to the model's success.
    The environment in The Green House homes is a small, warm, 
and fully independent home with an open common area with a 
kitchen, dining room, and living room at its core, surrounded 
by 10 to 12 private bedrooms, each with a private bath and all 
the support areas necessary, each organized to meet skilled 
nursing home requirements and building standards.
    At the core of the philosophy is creating an environment 
where people living and working in the home are in control of 
their lives and have the chance to get to know each other. When 
you have control and know someone well, you can better 
understand and meet their individual needs and preferences.
    The organizational design restructures staff and flattens 
the management of traditional nursing homes. It is an 
empowerment workforce model where direct care staff called 
Shahbazim work in self-managed teams. The Shahbazim are 
certified nursing assistants with 120 hours of additional 
training. They provide and manage all the critical tasks of 
running the household--providing care, cooking, cleaning, and 
doing the laundry.
    Self-management and the universal worker approach leverage 
the Shahbazim's great capacity, creativity, and compassion to 
create a flexible environment and schedule that meets 
individual preferences. Just as at home when we care for a 
small number of people we truly know and care about, we find 
ways to accommodate and celebrate their individuality. The 
organization's clinical staff continues to provide skilled 
services using the best practices we have developed in 
traditional settings.
    Dr. Rosalie Kane of the University of Minnesota, a leading 
researcher in long-term care, conducted an independent 
evaluation of the first Green House homes. Her research found 
significant improvements for the elders in both quality of life 
and quality of care, areas we have tried to have an impact on 
for many years. She also found great improvements for staff in 
their job satisfaction.
    We believe these improvements translate into significant 
Medicaid and Medicare cost savings through greater functional 
and mental health as well as avoided and shortened 
hospitalizations and acute episodes. CMS has been supportive of 
The Green House model, finding that it meets all Federal rules 
and more fully implements the intent of the Nursing Home Reform 
Act.
    There are three major challenges to spreading The Green 
House model of person-centered care. The first challenge is 
capital cost. Green House homes require new construction. State 
Medicaid rates are generally inadequate to cover the costs 
associated with new construction for any nursing home, a 
traditional nursing home or a Green House home.
    The second challenge is low Medicaid rates. Nationally, the 
average Medicaid rate has been found to be less than the cost 
of good quality care. The Green House model is a high-quality 
model requiring staffing levels higher than the national 
average, but at the rate research has shown is necessary to 
provide good quality care. Low Medicaid rates mean that even 
the most mission-driven providers are often forced to limit 
their Medicaid participation.
    The third challenge is getting the Green House homes off of 
campuses and into the communities where people live and homes 
belong. Community integration requires a scattered site 
approach. To make a scattered site approach financially viable, 
multiple homes need to be licensed together so they can share 
overhead costs. Federal nursing home rules may not support such 
an umbrella licensing approach.
    To assist with these three challenges, we recommend that 
Congress consider the following. To help with the capital 
costs, create Federal programs to offset development costs for 
projects with a low-income focus. Program models could include 
a dedicated tax credit equity program, targeted grants, and 
interest rate subsidies.
    Senator Casey, the proposal you plan to introduce, the 
Promoting Alternative Nursing Homes Act, will be a significant 
resource in this area if passed.
    To improve access for Medicaid-funded individuals, develop 
long-term Federal Medicaid incentives to encourage States to 
provide adequate rates designed to support the operations of 
Green House homes and similar innovations. Long-term incentives 
are necessary to align with the 20- to 30-year commitment 
providers assume when they develop these models.
    Finally, to get Green House homes into the community, form 
a workgroup to identify an acceptable community-based Green 
House strategy and license and identify and resolve any 
conflicts with Federal rules.
    Thank you again for this opportunity to testify today.
    I look forward to your questions.
    [The prepared statement of Mr. Jenkens follows:]

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    Senator Casey. You are under your time. That counts for a 
lot around here.
    Next we have Melinda Abrams, who is the Assistant Vice 
President, Director of Patient-Centered Primary Care, that 
project, I should say, of the Commonwealth Fund. She does 
direct that particular patient-centered project. Ms. Abrams has 
a distinguished career in health policy. Since coming to the 
Commonwealth Fund in 1997, she coordinated the Fund's Task 
Force on Academic Health Centers, Commission on Women's Health, 
and the Commonwealth Fund Harvard University Fellowship in 
Minority Health Policy.
    She has played a lead role in reviewing and modifying State 
policies regarding preventive healthcare that addresses early 
childhood development. It is an honor to have you here, Ms. 
Abrams, and you have the floor.
    Thank you very much.

 STATEMENT OF MELINDA ABRAMS, M.S., ASSISTANT VICE PRESIDENT, 
PATIENT-CENTERED PRIMARY CARE, THE COMMONWEALTH FUND, NEW YORK, 
                               NY

    Ms. Abrams. Thank you. Thank you, Mr. Chairman, Senator 
Smith, and Senator Casey, to testify on person-centered care 
for older adults in ambulatory care settings.
    I am Melinda Abrams, Assistant Vice President of the 
Commonwealth Fund, where I direct our program on patient-
centered primary care.
    An approach to providing person-centered care in primary 
care settings is the patient-centered medical home. We can call 
it a healthcare home, I don't mind. But the point is that it 
organizes care around the relationship between the patient and 
the personal clinician.
    In February of 2007, four primary care specialty societies, 
representing more than 300,000 physicians, released joint 
principles outlining and defining key characteristics of a 
medical home. In practical terms, a medical home promises a 
personal clinician whose practice provides better access and 
effective care coordination within the context of an ongoing 
relationship.
    In a medical home, for example, a patient can expect to 
obtain care from the practice on holidays, evenings, and 
weekends without going to an emergency room or have medical 
questions answered by telephone or email on the same day that 
she contacts the office. In a medical home, the primary care 
clinician helps a patient select a specialist and, with support 
from designated staff, proactively follows up with both the 
providers and the patient about tests or examination results, 
reviews treatment options, and helps to resolve conflicting 
advice possibly received from multiple providers.
    To carry out these enhanced functions, the medical home 
requires improved infrastructure, such as an electronic health 
record, patient registries to organize clinical information, 
ability to review results remotely, and the capacity to collect 
and analyze information about the quality of care provided. 
That information about quality should also include information 
from patients about their experience.
    I want to emphasize the importance of the medical home for 
older Americans. Since 86 percent of Medicare beneficiaries 
have one or more chronic conditions, investing in improving 
coordination of care in primary care is critical to reduce 
unnecessary and redundant services, gaps in service, problems 
with care transitions, and medical errors.
    The patient-centered medical home also requires fundamental 
payment reform. Many medical home services are reimbursed 
either inadequately or not at all by the current fee-for-
service system. Primary care practices would submit to a 
voluntary and objective qualification process to be recognized 
as a medical home, and in exchange, the practice would be 
supported with an enhanced or additional payment to cover the 
improved care management infrastructure and care coordination.
    There is substantial evidence showing that a strong 
foundation of primary care can reduce costs and improve 
quality. The Commonwealth Fund's 2007 International Health 
Policy Survey found that only half of all adults in the United 
States have a medical home. Patients with a medical home were 
more likely than those without to report better access to care, 
more time with their doctor, fewer duplicative tests, and 
greater involvement in healthcare decisions.
    Among adults with chronic illness, patients with a medical 
home were less likely to report medical errors and more likely 
to have a written care plan to manage illness at home.
    The Commonwealth Fund is supporting evaluations of several 
medical home demonstrations, including one in Rhode Island, to 
determine if they slow the growth of healthcare expenditures. 
There is data to suggest--however, there is data to suggest 
that this approach can reduce health system costs.
    For example, a medical home pilot project at the Geisinger 
Health System, an integrated delivery system in northeast and 
central Pennsylvania, showed a 20 percent reduction in hospital 
admissions and a 12 percent decrease in hospital readmissions 
at their Lewistown hospital.
    Although not serving a large proportion of elderly 
patients, a few State Medicaid programs, such as North 
Carolina, have demonstrated cost savings of about $225 million 
in 2004 when beneficiaries were enrolled in networks of medical 
homes. In both of these examples, primary care clinicians were 
paid an additional per member per month fee to manage and 
coordinate patient care above and beyond the standard covered 
by traditional fee-for-service payments.
    Congress has recognized the potential value of stronger 
patient-centered primary care. The Tax Relief and Healthcare 
Act of 2006 instructs the Centers for Medicare and Medicaid 
Services to develop an eight State demonstration of the medical 
home under Medicare. The recently passed Medicare Improvements 
for Patients and Providers Act of 2008 provides an additional 
$100 million to augment the demonstration. I commend the 
Congress for its willingness to test this promising approach in 
Medicare.
    As the Committee considers legislative and regulatory 
strategies to encourage person-centered care for older adults 
in ambulatory care settings, there are a number of steps 
Congress could take.
    First, you can ensure greater transparency of the Medicare 
medical home demonstration. In light of the keen interest from 
numerous stakeholders to reform and improve primary care, 
regular reporting to Congress and the public about the progress 
and early lessons from the Medicare demonstration can inform 
policy and practice around the country as well as ensure timely 
evaluation results.
    Second, direct the Centers for Medicare and Medicaid 
Services to join commercial and State payers in the Medicare 
medical home demonstration. With explicit encouragement from 
Congress, Medicare could collaborate with several of the 
commercial payers in State Medicaid programs around the country 
that are already willing to change payment rates to primary 
care practices to test this concept.
    Another strategy is to pursue an intermediate and 
incremental financing changes to promote components of the 
medical home. One option is to authorize a separate payment for 
discrete services associated with key care coordination 
functions, such as hospital discharge planning which could help 
reduce unnecessary hospital readmissions. Another is to 
implement the recent recommendation of the Medicare Payment 
Advisory Commission to increase payment levels for evaluation 
and management services provided by primary care clinicians to 
help support care management, care coordination, and patient-
centered care.
    Finally, consider implementation of scholarships or 
educational loan forgiveness programs to encourage medical 
students to choose careers in primary care. This strategy would 
address the current shortage of primary care physicians to 
staff medical homes.
    Thank you for the opportunity to participate, and I look 
forward to your questions.
    [The prepared statement of Ms. Abrams follows:]

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    Senator Casey. Ms. Abrams, thank you very much.
    Finally, we have Dr. Eric Coleman. Dr. Coleman is a 
Professor of Medicine and Director of the Care Transitions 
Program at the University of Colorado. He is also executive 
director of the Practice Change Fellows Program, designed to 
build leadership capacity among healthcare professionals who 
are responsible for geriatric programs and service lines. He is 
a board-certified geriatrician.
    Dr. Coleman, we appreciate your willingness to be here and 
look forward to your testimony.

     STATEMENT OF ERIC COLEMAN, M.D., MPH, DIRECTOR, CARE 
    TRANSITIONS PROGRAM, UNIVERSITY OF COLORADO, AURORA, CO

    Dr. Coleman. I thank the leaders of the Committee for 
inviting me to participate in this important hearing on person-
centered care.
    This morning, we have heard how the Green House model and 
the medical home can offer great promise for assuring person-
centered care in long-term care settings and outpatient 
settings, respectively. I would like to submit before this 
Committee that these models are particularly suited for persons 
whose medical conditions are in a steady state.
    Inevitably, many of these people will experience an 
exacerbation of their medical condition or a sudden traumatic 
event, and this will require a transfer to a place such as an 
emergency department or a hospital. These transfers are often 
referred to as ``transitional care'' or the handoff of care 
across settings.
    Transitional care poses challenges that distinguish it from 
other types of care. Many transitions are unplanned, and they 
result from exacerbations of medical problems that can occur at 
all hours of the day, the night, and on weekends. They often 
involve clinicians who have never met this person before.
    To better illustrate the challenges of transitional care, I 
offer the case of Mrs. Sanchez. She is 84 years old. She has 
high blood pressure, diabetes, and is in the early stages of 
Alzheimer's disease.
    One morning, she awakened with a stomach virus that caused 
her to lose her appetite. Because she had taken her morning 
diabetes medication but had not eaten all day, later that 
afternoon, she became light-headed. After this, she lost her 
balance. She fell, and she fractured her right arm.
    She was admitted to the hospital, where she underwent 
surgery to stabilize the fracture. Late on a Friday evening, 
she was discharged home to the care of her daughter. Three 
o'clock in the morning on Saturday, however, she woke up in 
excruciating pain, and it was then that her and her daughter 
realized they didn't have an adequate supply of pain medication 
to last through the weekend.
    The daughter could not reach the on-call orthopedist. She 
spent hours making phone calls and looking to find a 24-hour 
pharmacy to finally obtain the pain medication. Mrs. Sanchez 
further was not prepared for her self-care. She did not receive 
advice for how to keep from becoming constipated from her pain 
medication. Five days later, she was readmitted to the hospital 
with severe abdominal pain.
    Poorly executed care transitions can confound our best 
attempts to provide person-centered care. As illustrated by 
this case, they also contribute to our rising healthcare costs. 
The excellent care provided by a Green House or by a medical 
home can quickly unravel as the person is transferred to a new, 
unfamiliar care setting.
    Yet the challenges to providing person-centered care during 
these care transitions can be overcome. The Care Transitions 
Program that I direct recognizes that often by default patients 
and their family caregivers perform a significant amount of 
their own care coordination without the preparation, the tools, 
or the support.
    With generous funding from the John A. Hartford Foundation 
and the Robert Wood Johnson Foundation, we developed the Care 
Transitions Intervention to provide true person-centered care 
during these care transitions.
    What is the Care Transitions Intervention? Well, during a 
1-month program, recently hospitalized older patients and their 
families work with a transitions coach to learn transition-
specific self-management skills that will ensure that their 
needs are met during this vulnerable time of the handoff from 
hospital to home.
    What is the evidence that the model is effective and 
reduces cost? Patients who received this program were 
significantly less likely to be readmitted to the hospital. 
What is more, the benefits were sustained for 5 months after 
the end of the 1-month intervention. Thus, rather than simply 
providing post hospital care in a reactive manner in the 
moment, investment in imparting self-management skills pays 
dividends long after the program ends.
    Annually, a single transitions coach can manage 350 
patients coming out of the hospital. During this time, the 
model produces a net cost savings of $300,000 per coach. The 
Care Transitions Intervention is in the public domain 
(www.caretransitions.org). There are no licensing fees, and to 
date, 128 of the Nation's leading healthcare organizations have 
adopted this model.
    How can this Committee further support person-centered care 
models such as the care transitions intervention? Well, the 
primary barrier to making the model available to all older 
Americans concerns the lack of financing mechanisms within the 
Medicare program that supports self-management. We now have 
some experience with self-management programs in the area of 
diabetes.
    It is time for us to re-examine our approach to Medicare 
reimbursement and explore modifications for how to support 
self-care models like the Care Transitions Intervention that 
have been proven to improve outcomes, reduce cost, and promote 
greater person-centered care.I thank you for your attention.
    [The prepared statement of Dr. Coleman follows:]

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    Senator Casey. Dr. Coleman, thank you very much.
    We will move to questions now, and I want to welcome 
Senator Blanche Lincoln from the State of Arkansas for her 
presence here. We will move to questions.
    I will start, and I will be brief and try to come back 
maybe. But I wanted to thank Chairman Kohl for his leadership 
and for allowing us to gather here today and for allowing me to 
chair this hearing. It doesn't happen very often when you can 
become the chair of any hearing this early in a Senate term.
    Dr. Thomas, I wanted to start broadly, I guess, on two 
areas. One, let us not talk about how difficult it will be to 
get where we want to get to. We will do that second. We will 
have the challenge second.
    The first thing I wanted to ask you, though, is just--if 
you could just outline, you did some of this in your opening, 
but some of it you could reiterate, but also amplify, which is 
to talk about the vision you have for this concept of patient-
centered care. Where do we need to get to? Not some ideal that 
is not achievable, but where do we need to get to?
    Then the second part of the question, if you could answer, 
is what are the challenges and what advice can you give us, as 
Members of Congress, but also give others who are struggling 
with this issue?
    Dr. Thomas. Thank you, Senator.
    I would say, first off, where are we going and how does 
patient centeredness get us there? Patient centeredness is 
really a bridging concept that helps us take the healthcare 
system we have today, which we all can describe and we know, 
and helps us cross over to the healthcare system we ought to 
have.
    In other words, to think of it in sort of pendulum-type 
terms, that pendulum swing toward a technology provider-focused 
approach to healthcare is starting to swing back--with the aid 
of concepts like the medical home and patient-centered care, 
starting to swing back into a system that creates partnerships 
between people with expert knowledge and people who need access 
to that knowledge.
    I thought Dr. Coleman's remarks were really spot-on in 
terms of commenting on the terrible wastefulness of a provider-
centered system because, you know, our healthcare system is not 
and should not be set up to run at the convenience of the 
providers. It should be run and set up to establish good 
outcomes for patients. So that is the first thing.
    I guess I would argue to the Committee that patient 
centeredness is a way of aligning our healthcare system with 
our ideals, and that is important work that is going to take 
years to accomplish. But that is where it needs to go.
    In terms of how can we--what can be done to help swing this 
pendulum back to a better place, I think, No. 1, we need more 
elbow room for innovators to be able to put together new 
approaches that challenge the orthodoxy.
    We were chatting earlier about the Commonwealth of 
Pennsylvania's desire to kind of put together a new strategy 
for long-term care. Well, you know there are a lot of providers 
out there who are hesitant to take those kinds of risks, and we 
need to help put together a system that protects patients and 
allows providers to develop new approaches and programs.
    The last point I would make in terms of what can help is 
there is a difference between the money you need to operate an 
established ongoing service and the money you need to jump 
across the creek to the other side and get it going in a new 
model. It is especially difficult in healthcare.
    We can talk about this in manufacturing and services, but 
in healthcare, you have to operate the existing model at a high 
degree of efficiency while you are creating this new model at 
the same time. We need people like the people here in this room 
and the adopters of Green House and other models, they need 
help getting to the other side.
    Senator Casey. I am going to reserve some of my time for 
later, but I wanted to turn to Senator Wyden and our colleagues 
so they can get their questions in.
    Senator Wyden. Mr. Chairman, thank you, and you have 
arranged a terrific panel.
    I only want to take a minute to kind of ring the alarm bell 
on what I think is a coming calamity in terms of the workforce 
to try to meet the needs of older people. You mentioned that, 
Ms. Abrams. But what is striking is you look, for example, at 
what has happened in Massachusetts. They are going forward with 
their efforts at providing universal coverage but they have 
bumped up against a huge calamity. Already they don't have 
enough primary care physicians just to meet the needs of the 
working age population, not to say anything about seniors and 
long-term care.
    My sense is that given what we all want to do, and you all 
are the pioneers in this area, is have health care providers 
spend more time with patients and more time with families. To 
achieve this we are going to need a huge increase in the number 
of people who are trained in geriatrics. I was in fact, 
appreciative of your comment, Ms. Abrams, that it is fine to 
call it a health home rather than a medical home. The primary 
reason we call it a health home in the Healthy Americans Act is 
to try to get more professionals into the act, that we would 
get more nurses and physician assistants and others providing 
this care for patients.
    My question to all of you is what are your ideas for 
increasing the number of people going into the field, 
particularly without breaking the bank? One of the areas we are 
looking at in the Healthy Americans Act is the idea of redoing 
job training programs in this country, many of which now seem 
to be training people for jobs that are going to go overseas in 
a few years.
    We would like some of those dollars go, for example, to 
train people as nurses, physician assistants, and others to do 
exactly the kind of work you are talking about. That would give 
us a chance to stretch existing funds that are now spent on 
training in an area that could pick up on some of your good 
ideas.
    With your indulgence, Mr. Chairman, one question before I 
do an introduction of a witness on behalf of Senator Smith. I'd 
like to get your thoughts on what we could do to expand the 
workforce in the geriatric area particularly, without breaking 
the bank.
    Dr. Coleman, you have been nodding your head. So I guess I 
am making you a glutton for punishment and starting with you. 
Your thoughts, workforce?
    Dr. Coleman. Critical question. As you know, the Institute 
of Medicine just released a report on the need to retool our 
country's workforce for the aging population. I had an 
opportunity to testify before that committee. One of the points 
that I made had to do with not only how do we attract people to 
the field, but also looking at their workflow, their daily 
professional lives, et cetera.
    One of the phrases that jumps to mind is ``all assessed up 
and nowhere to go.'' We spend a disproportionate amount of time 
assessing our patients, which leaves very little time for 
actually taking care of them. This is true in home care and in 
nursing home care among others.
    Senator Casey used the term earlier ``relationships.'' 
Those of us who chose to go into primary care, as opposed to 
specialty care, did so because we wanted to have meaningful 
relationships with our patients. We knew where the salaries 
were going to be lower. We knew the time expended per week was 
going to be greater. We chose this to have the meaningful 
relationships.
    The advanced medical home offers an opportunity for 
building these relationships. But as I look through each of the 
different initiatives, I see a lot of discussion, focused on 
how the practice is going to change, what the requirements are 
going to be in order to be certified as a needed home. We don't 
hear as much about how this type of approach or any approach is 
going to improve the time for face-to-face, meaningful 
relationships with our patients. I think that is the hook that 
makes people want to come to primary care and what keeps them 
in primary care.
    Senator Wyden. Any other witnesses? Perhaps even for the 
record because this may be something you want to talk about. 
This is an area that we are making a special focus with our 
group of 16 Senators, 8 Democrats and 8 Republicans. Because I 
think this is a showstopper.
    We don't have enough providers to meet the needs of our 
country today. However, we are going to add 47 million 
uninsured people as part of a universal coverage effort and we 
want to be sensitive to the thoughtful points that you are 
making. We are going to have to find some creative new ways to 
get folks trained and on the front lines.
    Do any of you want to add anything for now? Yes, sir?
    Mr. Jenkens. Yes, thank you, Senator Wyden.
    One of the critical aspects of the Green House model is to 
create a job that nurses and direct care workers want to have 
and make them want to come to work in the morning. I think one 
of our biggest problems in long-term care is that we haven't 
valued those jobs, and we haven't made those jobs very pleasant 
jobs to be in. That is more than just the hourly wage that we 
pay. As a matter of fact, I think you will find that the hourly 
wage is a very small piece of the dissatisfaction with long-
term care jobs.
    So the Green House project focuses on giving direct care 
workers power and authority and then valuing them. The reason 
we call direct care workers in The Green House homes 
``Shahbazim'' is that we didn't want them to be called care 
attendants or nurse aides because there is such a negative 
connotation associated with those terms.
    What we found in the Green House is that when you give 
nurses and you give direct care workers an environment and an 
organizational structure that really values them and lets them 
do the job and create the relationships they came to long-term 
care to have, they stay in those jobs. People who said they 
would never be in those jobs come to those jobs. So you expand 
the pool of people who are willing to do that work.
    You will hear from a Shahbaz, Edna Hess from Pennsylvania, 
and a family member from Lincoln, NE, about this very thing. We 
have two Shahbazim in Lincoln, NE that also demonstrate this 
expansion. One was a bartender who had left long-term care. She 
had been an LPN and she came back to be a Shahbazim, she left 
long-term care because she said she couldn't take it anymore in 
the old system, but she wanted to be part of it in the new 
green house homes.
    Senator Wyden. Ms. Abrams?
    Ms. Abrams. I mentioned--I just want to affirm everything 
you said in terms of the calamity and the concern over the 
workforce. I originally had a lot longer comment about 
workforce and cut it, so I appreciate that opportunity to 
mention it.
    I did mention--the piece that I was focusing on was the 
number of physicians choosing primary care, which is what has 
come up a little bit in Massachusetts. So I did mention the 
idea of loan forgiveness programs for physicians that go into 
primary care or scholarships for medical students who go into 
primary care.
    But another real issue is, and Dr. Coleman mentioned this, 
making it attractive. The way physicians are trained, there is 
the curriculum and then there is the hidden curriculum, and it 
is what is modeled in the academic health center. In that 
academic health center, most of their time is spent in a 
hospital. So they don't have enough time in primary care 
settings, community settings. They have very little exposure to 
how to actually work effectively in a team, in a 
multidisciplinary team.
    I think that because of our reimbursement system, we are 
biased toward surgical procedures, and we don't value and we 
underinvest so that physicians or clinicians have time to take 
a medical history and to really help do medication 
reconciliation and spend time to kind of come up with a care 
plan. The reason I mention that as well is because I think if 
we can come up with ways to make primary care more attractive, 
both in terms of reimbursement--I mean, primary care physicians 
make about half of what specialty care physicians make.
    There is this huge income gap, and none of us should feel 
sorry for how much primary care physicians make. It is just 
that in your medical work, if you are worried about primary 
care workforce, it is not that they are poor, it is just more 
that we want them to also be going into primary care to take 
care of and do the care coordination for older Americans.
    So part of it is about the training, and the training is in 
the place and the training is also with teams. I am not an 
expert on IME and DME, you know, payments from Medicare, but my 
understanding is the way that those are funneled is it is very 
much in the interest of the hospital to hold onto those 
resources. So another possibility is to think about kind of 
maybe it would be a grant program.
    I don't know if it is a grant program that would allow to 
some of these academic health centers or residency training 
programs that actually do come up with models that are patient-
centered and multidisciplinary and team-based care. Because 
that is also how we are going to be more efficient and not use 
the physician's high-scale time for some other things that 
could be used with other kinds of professionals and help to 
expand the workforce.
    Senator Wyden. Your ideas are very helpful, and you can see 
all the heads nodding on this side of the dais. I will look 
forward to following up with the four of you.
    Chairman Casey has given me a lot of time. I just want to 
note on behalf of Senator Smith and myself that on the next 
panel, we will have Dr. Diana White, the Senior Research 
Associate of the Institute on Aging at Portland State. She has 
been one of the pioneers, as you know, in this area. Senator 
Smith and I are very pleased that she is going to be here. We 
want to thank Chairman Casey for inviting her.
    Senator Casey. Thank you, Senator Wyden. We appreciate your 
work in so many of these areas and especially the work on 
healthcare broadly and in particular on our long-term care 
workforce.
    Senator Whitehouse has spent--and I will be introducing 
Senator Lincoln in a moment as well. But Senator Whitehouse has 
spent a lot of time on the issue of healthcare in the 18 months 
that we have been in the U.S. Senate, especially in the area of 
having the infrastructure in place for information technology 
and other ways to deliver quality healthcare to as many people 
as possible in a better way.
    We are grateful for his leadership on those issues and his 
willingness to participate in today's hearing.
    Senator Whitehouse?
    Senator Whitehouse. Thank you, Chairman Casey.
    You have predicted my question, which is that whether we 
follow the various models that have been mentioned here today, 
a system specializing in chronic care that is patient centered, 
a Green House model, the medical home model, or the care 
transitions model, it strikes me that we are lacking an 
underlying infrastructure support that would enable and empower 
all of those models, and particularly in the area of health 
information technology--electronic health records, personal 
health records, electronic prescribing, interoperable health 
records, and so forth.
    I would just like to ask each of you, first of all, do you 
agree with that? Second of all, if you agree with that and you 
think there is a goal we should achieve, a baseline of 
infrastructure to support these various modalities, are we 
close to it? If not, how far off are we, and what steps should 
we be taking to enable that kind of infrastructure to develop?
    Why don't we start with Mr. Thomas, go the other way this 
time so Dr. Coleman is not always being picked on first.
    Dr. Thomas. I know, from his work, he is going to have a 
lot to say, Dr. Coleman is. Well, here is the thing. The 
information technology revolution that has changed virtually 
every part of our society except healthcare, I used to--I think 
it remains--pretty much remains true. I used to say--
    Senator Whitehouse. I am told by the--just to interrupt for 
a second, I am told by The Economist magazine that there is 
actually one other industry that is even behind the healthcare 
industry in terms of information technology, and that is the 
mining industry.
    Dr. Thomas. Oh, mining. Yes, OK, so we are there with the 
mining industry.
    Senator Whitehouse. Then it is healthcare, and then it is 
everything else in the world.
    Dr. Thomas. Yes. OK, yes. Well, you know, a typical nursing 
home, as it stands today, has less technology available to the 
people than is available to the guy who drives a FedEx truck. I 
mean, that is awful.
    I like the proper application of information technology, 
especially in long-term care, because chronic care generates a 
huge amount of information. I still have a bump on my hand from 
my years in practice of handwriting notes hours and hours a 
day. Somewhere around America, there are rooms stuffed full of 
the handwritten notes that I took over the years, entirely 
useless, and my handwriting wasn't quite that bad even.
    But we need to move into this system so we can gain 
efficiencies in how we handle data so that we can enable the 
development of the relationships. That is the win here. It is 
not just, ``Well, now we have a computer system.'' Well, great. 
So what?
    It is now we have a computer system that moves this 
information efficiently, and now we can concentrate more time, 
energy, and training on relationship-based healthcare.
    Mr. Jenkens. We push very hard for The Green House adopters 
to implement a whole variety of technology, including 
electronic medical records, and monitoring technology. The 
Green House in Lincoln has a marvelous technology even beyond 
the doors of the house, allowing people with dementia to go 
outside safely.
    The challenge that we see is really twofold. One is the 
cost of implementing the technology. I think people are 
willing, but the training and the technology itself is outside 
of what they can (eek spelling) out of usually thin or 
nonexistent margins associated with a heavy Medicaid 
population.
    The second is trust. I think trust is an area that we are 
addressing with the workforce in many areas. We have Shahbazim 
who we trust with the most intimate and complicated tasks of 
someone's daily life, someone we love, but many organizations 
that we talk to will not trust them with an email account or 
web access. They can't communicate with each other. One of the 
greatest benefits of technology is to allow people to share 
what they have learned.
    We run 11 forums through the Green House Project for people 
to share information, every position within the Green House, 
and our biggest challenge is that the Shahbazim don't have 
access to email and the Internet to participate in those 
discussions.
    Senator Lincoln. They do not?
    Mr. Jenkens. They do not.
    Senator Whitehouse. Is that HIPAA at work?
    Senator Lincoln. Why?
    Mr. Jenkens. Typically, they can't afford to have a 
personal account, and the organizations either don't feel that 
they need it, don't feel they can afford it, or, very often, 
don't trust them to have it.
    Senator Casey. I am just going to jump in for one second. 
Just for purposes of definitions, my staff did a good job here 
about the definition of Shahbaz and Shahbazim.
    Mr. Jenkens. Yes.
    Senator Casey. I am told it is a Persian word meaning 
``royal falcon'' or ``king's falcon,'' the mightiest, the 
bravest, the fastest, the most courageous of all falcons, 
right? OK. Which is we are talking about the direct care 
workers.
    Mr. Jenkens. Yes,
    Senator Casey. I wanted to read that for the record. I am 
sorry for cutting into Senator Whitehouse's time.
    Ms. Abrams. I want to start by saying that I completely 
agree that we are lacking the infrastructure that we need to 
and that with health information technology. We need to 
consider it. There was a paper not that long ago that said we 
would never consider a cardiologist appropriately trained and 
prepared unless they knew how to do catheterizations.
    To think that in primary care and long-term care that we 
should be sending providers out into the field without the 
skills and the tools to provide that care well, I think that we 
have to kind of rethink the competencies of our providers and 
the competencies that they need both to work in teams, but also 
to provide better quality care.
    Senator Whitehouse. You are referring to a coordination of 
care competency?
    Ms. Abrams. Right.
    Senator Whitehouse. OK.
    Ms. Abrams. A care coordination competency. Yes, I mean, I 
guess it doesn't make sense to have a health information 
technology competency for the reasons that Dr. Thomas mentioned 
because it is really just a bunch of wires. So, it is about how 
you use that hardware and that software that are so important. 
So I think that we are lacking that infrastructure.
    You asked about, well, is there a baseline, and are we 
close to it? I think that there are pockets of innovation 
around the country such as either in health systems or in 
communities where they have really begun to use health 
information technology in a way that is incredibly productive 
and in a way that has helped to improve quality of care, such 
as Group Health Cooperative out in Seattle, Washington. Or 
there is the Mid Hudson Valley Region in New York, where they 
are implementing a lot of EHRs, and it is also creating a 
health information exchange where all the data is being 
aggregated.
    I think that so when we also think about the health 
information technology, it is what do we need at the practice 
level? What do we need at the community level so that we can do 
better management of population health? Then also thinking and 
part of the question is, well, what is the role of Government, 
to some extent, in this both in terms of trying to promote the 
adoption, but also the standards?
    Because at some point because our system is public and 
private and a lot of the vendors are private, there are 
different templates, and it is inoperable. It seems daunting. 
But I believe that the Agency for Healthcare Quality and 
Research has been doing an enormous amount of work in trying to 
set some of those standards and trying to have standards for 
both interoperability and for some of those templates.
    But I think that is some of the goals. That is really the 
goal. So that if you are sick in Nebraska and you live in New 
York, that someone can pull up your record.
    Senator Casey. Dr. Coleman, I am sorry to pinch you off, 
but we are over time. So if you have anything to say--
    Ms. Abrams. Oh, sorry.
    Dr. Coleman. I will be brief.
    Senator Casey [continuing]. If you could kind of shorten it 
so that I am not treading too badly on Senator Lincoln's time.
    Dr. Coleman. Sure. I am a strong believer in the potential 
for information technology to improve person-centered care. In 
fact, one of the four pillars of our Care Transitions 
Intervention is a personal health record, encouraging folks to 
take ownership over their own health information.
    Last year, we completed a detailed study for the Assistant 
Secretary for Planning and Evaluation in HHS on health 
information exchange. We spoke with experts. We did site visits 
to the examplar programs, some of which were already mentioned.
    The main take-home points were, first, there are places 
that are doing this well. However, it is often just the 
hospital and the clinic that share information. Nursing homes, 
home care agencies are not even invited to the table.
    Second, it is really all about workflow. The technology 
solutions are here. It is about having healthcare professionals 
understand how not to do, as Dr. Thomas described, endlessly 
writing down information and transferring it somewhere else.
    Third, it also comes down to relationships again. This has 
become a common theme for this hearing. We saw healthcare 
professionals actually going around the technology because they 
wanted to connect with their professional colleagues. So a 
hospital discharge planner has an electronic system in place to 
make transfers to a nursing home but sidesteps the electronic 
system to telephone her friend because that relationship was 
more important in some respects than ensuring the patient's 
transfer went well.
    There is reason for hope, and I will just finish by shining 
a positive light on the State of Indiana, where they have a 
program called ``Docs for Docs,'' Documents for Doctors. If I 
am practicing in Indiana and I have the patient's unique 
patient identifier, I can look up all of their lab results, all 
of their radiology results, all of their hospital discharge 
summaries, procedures, et cetera, no matter where in the State 
this took place.
    So we do have examples that I believe we can learn from. 
Thank you.
    Senator Whitehouse. Thank you all very much.
    Thank you, Chairman.
    Senator Casey. Senator Whitehouse, thank you very much.
    We have Senator Blanche Lincoln, who has long been a great 
advocate for people at both ends of the age scale, the children 
in the dawn of life, as Hubert Humphrey said, and older 
citizens and not to mention all of rural America.
    We are grateful for her presence here and, Senator Lincoln, 
thank you very much.
    Senator Lincoln. Thank you, Mr. Chairman.
    Thank you so much for encouraging this hearing, which I 
think really does focus on so much of what we need to do. 
Obviously, some of the things we have gotten right. But without 
a doubt, the enormous list of tasks that we have before us.
    Dr. Coleman, just to your last point, the Documents for 
Docs, is that just very similar to a physician's ability to 
write prescriptions? I mean, do you have an access where you 
can then access those documents through a physician code or a 
physician licensing?
    Dr. Coleman. That is right. There is a portal that any 
physician in the State can use provided you have that 
individual's personal identifier. This becomes the rub and not 
all American citizens are comfortable with this approach of 
having a unique patient identifier. The State of Indiana was 
willing to accept the risks and the benefits.
    Senator Lincoln. Right. We have that problem with privacy 
here. I mean that has been one of our bigger challenges and 
hurdles. But it is interesting to look at that opportunity of 
access to information.
    Two points that I would just like to bring up and certainly 
get any of your comments on. I have been working on 
coordination of care for quite some time, and it really came 
from my own personal experience with my dad. My dad was 
diagnosed with Alzheimer's at an early age, and we made a very 
long journey as a family with his multiple chronic diseases 
plus dementia and the real need for having a coordination of 
care in order to see the kind of loving care we wanted him to 
receive.
    I grew up in a very small community within walking distance 
of all my relatives, my grandparents. I didn't know I was a 
caregiver at the age of 16 just because I took dinner up to my 
grandparents every other night. But it was. It was a huge part 
of their needs in terms of caregiving, but it was a wonderful 
part of my growing up and learning from them, learning about 
what it means to care for individuals, learning how hard that 
work can be and how important it is.
    So the bill that I have got, S. 1340, mainly focuses not 
necessarily on a medical home for the whole spectrum of care, 
but when you look at acute and chronic and long-term and all of 
that, but specifically on chronic conditions, one of those 
including dementia, and making sure that we are working to 
create that coordination of care that is going to provide both 
efficiencies that lowers our costs, but more importantly, the 
quality of care that we want our seniors to have.
    I think that is so important. It is difficult because we 
are in an environment where we have created over the last 50 
years healthcare delivery that is focused on acute care. It is 
not focused. I mean, our whole system is designed for acute 
care. So we are going to have to create some real social 
changes here in the culture and the mindset of individuals 
about their own prospective healthcare as aging adults, but 
also what they are predicting for their aging parents and 
grandparents and what have you.
    In our coordination of care, Ms. Abrams, we have the 
doctor, and the doctor does get an increased reimbursement as 
the overall guidance for that team. But the patient can choose 
who their care manager will be. So if they are more comfortable 
with the nurse practitioner or somebody else, then that can be 
their care manager.
    But it makes sure that that entire team is communicating 
and coordinating that care based on the multiple chronic 
diseases that that patient is dealing with. There is no doubt 
that training is a huge part of that.
    My husband is a physician. I asked him what he went through 
in terms of medical school and residency and the things that he 
learned, as we cared for both my father and then his mother, 
and he said, you know, it is just not there in terms of what 
physicians are learning particularly in medical school about 
how to organize, work with that team.
    His father was a surgeon, and it was unbelievable, when his 
mother was hospitalized before she passed away, the lack of 
coordination in that care. I had two physicians right beside 
me. So, it is--there is just so much we need to do, I think, to 
get to the ultimate goal of the kind of quality of care that we 
want for seniors.
    So I guess my question to you, Ms. Abrams, or to anybody, 
the way that the medical home is currently defined with the 
word ``physician'' being used rather than ``primary care 
provider,'' and the fact that what you mentioned, which we have 
a lack of primary care physicians. There is certainly a 
shortage there, and the medical home seems consistent with the 
kind of care that advanced practice nurses currently provide. 
Do you think the definition could use some--do we look at that 
in terms of both the shortage that exists and certainly the 
care that folks are wanting to have in their coordinated care 
effort and in their team, the actual team perspective of how we 
go through that?
    Ms. Abrams. Thank you, Senator Lincoln.
    I do. I think that the patient at a medical home, the joint 
principles that I referenced in the beginning of my statement, 
they were endorsed and released by the primary care specialty 
societies, by physicians. So it is their belief and their 
opinion that the model is physician directed.
    Senator Lincoln. Right. Ours is physician directed.
    Ms. Abrams. But I have to tell you that it is my position, 
I think that advanced practice nurses and independent nurse 
practitioners could also lead a healthcare home and a medical 
home.
    Senator Lincoln. Right.
    Ms. Abrams. Again, we can call it a healthcare home, and it 
is really more about the functions and keeping the patient at 
the center and having the other pieces in place. So I--and many 
nurse practitioners, they provide care under the supervision, 
even though loosely defined, or under the supervision many of 
them with a physician. But I think there is--and I think it 
could work under that model. I think that it could also work 
with advanced practice nurses, as you mentioned.
    Senator Lincoln. Well, we just have to realize that that 
the shortages not only exist now, but we are training less 
academic physicians, which means we not only have less 
practicing physicians. We have less physicians that are there 
in the medical schools to train particularly geriatrics and 
geriatric training. So I think--
    Ms. Abrams. Right. The other thing we also have to 
remember, too, is that a lot of nurse practitioners, they begin 
to specialize as well. So it becomes an issue--
    Senator Lincoln. We have got another bill--
    Ms. Abrams [continuing]. About encouraging people to go 
into geriatrics.
    Senator Lincoln. Right. We have got another bill to 
encourage particularly nursing students to take a subspecialty 
or some type of a specialty part in their training in 
geriatrics.
    Dr. Thomas, absolutely if you want to answer that, but I 
have got another accolade for you.
    Dr. Thomas. I just want to say--oh, well, thank you so 
much. I do want to add to what Ms. Abrams was saying is that 
you are really seeing the contours of a problem with prestige. 
Our system is set up to throw the greatest prestige toward the 
most subspecialized technocratic providers, and our society 
needs a system that gives prestige to people who do that work 
that your father-in-law and your family needed.
    Senator Lincoln. Right.
    Dr. Thomas. So that is not--I don't think the Senate can 
solve that issue. But when you are thinking about what is the 
problem, it is a--we have a misallocation of prestige in our 
system.
    Senator Lincoln. But what we can do and what Government's 
responsibility is is to create an environment where those 
social changes can happen, so that those who need that prestige 
are being reimbursed for the kind of hard work that they are 
doing, so that there is an appreciation level and a prestige 
that comes with that.
    There is no doubt that we can help create that environment 
in a better way than what we are doing. I just want to thank 
you, Dr. Thomas, for your vision and collaboration with so many 
dedicated individuals. In Arkansas, we are proud that Arkansas 
Green House Project called the Northwest Senior Services--
    Dr. Thomas. Yes.
    Senator Lincoln [continuing]. Is both the first Green House 
in Arkansas, but it is also the first Green House in the 
country that is partially funded with low-income housing tax 
credits, which we try in every which way we know how in 
Arkansas to be innovative because we do have a disproportionate 
share of our population that are elderly.
    Disproportionately, they live in rural areas, where all of 
that technology is important if we are going to get them the 
kind of medical care they need.
    But they are also disproportionately low income on very 
restrictive fixed incomes. So, we have got a large portion of 
our older adults and so many low income that reside in these 
rural areas. But you might even comment a little bit on that if 
you get a chance, focusing on affordability of these types of 
facilities and whether tax credits and other incentives and 
other creative accounting that we can put together with 
different programs to help produce more.
    Senator Casey. Doctor, can you be really, really--
    Dr. Thomas. I will be so brief. I would say Mr. Jenkens was 
responsible for, I think, a lot of that creative thinking, and 
it is part of what we need to do through the whole system is 
take all the pieces apart and put them together in new and 
creative ways.
    Senator Lincoln. Robert Wood Johnson has been fabulous in 
Arkansas. So we appreciate it.
    Thank you, Mr. Chairman.
    Senator Casey. Senator Lincoln, thank you very much.
    We want to thank this panel. We have to move to our second 
panel. I know I am over time now to get to our second panel. 
But we are grateful for your presence here, for your testimony.
    We will be--I know I will, but I am sure other members of 
the Committee will be submitting questions in writing that you 
could make your answers then would be part of the record. Thank 
you very much.
    We are going to move now to our second panel. Zoe Valentine 
Holland, Edna Hess, and Dr. Diana White, who will be coming up 
next. Thank you very much.
    Well, thank you very much. We are going to move right to 
our witnesses. I will start with Zoe Valentine Holland, who is 
the daughter of a former Green House resident in Lincoln, NE. 
It is an honor to have you here and to speak of your own 
personal experience.
    Then I will introduce each of our witnesses as we go 
forward, and I know we are moving kind of quickly, but we had 
to make a quick transition. This room is being--we are going to 
get a little extra time, but this room is being used for 
another purpose. So we are almost out of room time, and I don't 
make those decisions. So I will move rather quickly.
    Thank you very much.

  STATEMENT OF ZOE HOLLAND, DAUGHTER OF A FORMER GREEN HOUSE 
                     RESIDENT, LINCOLN, NE

    Ms. Holland. Senator Casey and fellow Committee members, 
thank you for inviting me to testify this morning.
    My name is Zoe Holland. My assignment this morning is to 
tell you a story, to speak to your imaginations and your 
hearts. On March 26 in 1906, a red-haired baby girl was born on 
a small farm in Minden, NE, to Andrew Boicourt and Elizabeth 
Boicourt, and they named their sixth child Mary Josephine. She 
was my mother, and this is her story.
    Mary left her home as a young woman for Omaha, the big 
city, to fulfill her dream of becoming a nurse, which she did. 
She later married a physician and surgeon, and they raised two 
children.
    Fiercely independent, Mary returned to Nebraska in her 90th 
year to set up home in a high-rise apartment. She was on the 
top floor with an amazing view of clouds and sky and trees. She 
was so grateful and so happy to be there, and she made many new 
friends.
    Suddenly, in 2002, Mary suffered an illness that required 
treatment and care only available in a nursing home. I think 
Dr. Coleman's reference to the difficulty in transitioning and 
getting that 24/7 care really illustrated our family's 
situation and experience. Her illness coincided with my knee 
replacement surgery and the reality that her daughter was 
aging. I no longer had the strength to care for my mother, and 
we were both very sad.
    After exploring several possibilities, she and we chose 
Tabitha Healthcare Services in Lincoln. She moved into a little 
room. There was no room for her treasures. Good-bye to the art, 
the music, the pretty shoes, the clothes, and the mementos of a 
rich and fulfilling life.
    She had worked in nursing homes as a nurse, and she knew 
what was to come. She was angry at me and what was happening to 
her. Who could blame her? She had always disciplined herself to 
exercise daily, move around. There was no room, and it was so 
dark and so small in there.
    Visits of family and friends gradually tapered off. There 
was only space for one person at a time in her room, while 
others waited in the hall. We took turns. As the days went by, 
we watched the light that had burned so brightly for so many 
years grow very dim. Mother spent much of her time in bed, 
sleeping as much as she could because she had nothing to do and 
nowhere to go.
    She always reminded me of how much she appreciated the care 
of the staff and told me that they were doing the very best 
they could in the environment they were working in and with the 
resources they had.
    We began planning her 100th birthday party nearly a year in 
advance to lift her spirits, knowing that family and friends 
were coming from Washington, Oregon, Colorado, New York State, 
and Glasgow. This was a grand and glorious event, and she 
received many gifts. But the greatest gift of all was her 
selection to be one of the first elders to be in the Green 
House in Lincoln, NE.
    Suddenly, to Mary Valentine, my beautiful mother, life 
mattered again. With light flooding through her bedroom window, 
she sent us scurrying after her lost treasures.
    She could sleep as late as she pleased in the morning and 
still have breakfast. A Shahbaz would attend to her hair and 
nails and clothing for the day. Monica took a dress home and 
ironed it so her dress would not be wrinkled on one occasion. 
Every night, a Shahbaz would tuck her in bed lovingly and tell 
her good night.
    She also received at the Green House the coordinated care 
that I think you were discussing. There was, all of a sudden, a 
smaller staff and a closer connection to the doctors and 
nurses. It was a really tight relationship, very good.
    During the day, she could sit in her tiny recliner that fit 
her tiny body and hold a tiny Chihuahua, Tupac, who belonged to 
a staff member. They were a good fit. She was convinced that 
Tupac wanted to be wrapped in a silk scarf every day as he 
snuggled in her lap.
    The year 2006 belonged to Mary. The Green House itself was 
the scene of many celebrations, dinners, and parties, and many 
of them were ours. For the first time in many years, my husband 
Mike and I felt free to travel, knowing Mother was secure and 
comfortable and, oh, so happy. We could contact her caregivers 
daily and expect an accurate and thorough report.
    Her 101st birthday has been recorded and documented. Mary 
sitting on the Green House porch with Tupac and her margarita 
and her celebratory cigarette, and they used their technology 
to send that all over the country. All of the people involved 
in the Green House project, ``Oh, you are Mary's daughter. We 
saw her picture.'' It made that relationship very real.
    April 17, 2007, was a soft and gentle spring day, almost 
perfect and was to be the last day of Mary's life on Earth. 
Attended by a beautiful red-haired young nurse, with Shahbaz 
Monica present, she died with the gentle grace and the quiet 
beauty that had exemplified her life on Earth in the arms of 
her beloved granddaughter Ann.
    In my announcement of her death, I wrote, ``The staff at 
Tabitha and the Green House loved her fiercely and are grieving 
mightily. Please pray for these angels on Earth.'' In May, her 
remains were buried beside her son on a hillside in Eugene, OR.
    Later, a memorial was dedicated in her honor at Tabitha. On 
the porch, you will see a fountain with a big dog and a little 
toy, which welcomes all the visitors in the spirit of Mary.
    In her last room at the Green House, there now lives a 
sweet, small redhead named Gwen. Once in a while, like Monday, 
I stopped in with a flower. She understands that sometimes I 
just need to be in that room.
    On the anniversary of Mother's birthday, my husband Mike 
and I took some friends and had a little margarita party in the 
Green House. We had dips and chips, and all the elders came 
out, and we told Mary stories. We wanted these elders to know 
that when they were no longer here, someone would remember 
them, too.
    That is one person's story, but that is not the end of our 
story. We have constructed in America a beautiful democratic 
system, which through its agencies works to provide sustenance 
and direction for all of its citizens almost, but not quite, 
across their life spans. We have fallen just a wee bit short.
    It is time for us to cover that gap. How do we do it? ``In 
small places close to home, so small they cannot be seen on any 
map,'' as Eleanor Roosevelt suggested, or just maybe build more 
places like a Green House.
    Thank you again for the opportunity to testify and tell the 
story of my mother, Mary Valentine.
    [The prepared statement of Ms. Holland follows:]

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    Senator Casey. Ms. Holland, thank you very much for your 
testimony. It was poignant and moving and an important personal 
reflection.
    We often have testimony here in these hearings that is data 
driven. It is important. But very rarely do we get the chance 
to listen to someone who has had the kind of experience and, as 
you say, speaks from that experience. But it especially speaks 
from the heart.
    You said in your testimony that you weren't sure you had 
the strength to care for your mom, and it is readily apparent 
that you did and your strength is enduring.
    Ms. Holland. We, our family is so grateful because we had 
the Green House there and the Tabitha there and the transition. 
We didn't have the strength, but it was there. We are a team 
with the Shahbazim. They are family to us.
    Senator Casey. Well, you are giving important testimony to 
the importance of this patient-centered approach, and we are 
grateful that you took the time to testify and to tell that 
story about your own mother and your own life experience, but 
also to travel the distance you did.
    So thank you very much. If I have time, I will ask you a 
question. But we are going to move to our next witness.
    Edna Hess, I had the chance to meet earlier today, this 
morning. She is a Shahbaz. Am I saying that right?
    Ms. Hess. Yes, you are. You are saying that correctly.
    Senator Casey. I want to commend her for her work. I have 
spent a good deal of time on the issue of what happens to and 
what are the programs and strategies that support direct care 
workers. So, Edna, we are grateful for your work, and we are 
especially grateful for you taking the time to be with us 
today.
    I also wanted to take this opportunity to announce that, as 
Mrs. Hess knows, there will be a congressional staff visit to 
the Lebanon Valley home in early October of this year. For 
those of you who don't know, that happens to be in the State of 
Pennsylvania, where we are proud of that.
    But I wanted to have Edna testify now, and then we will go 
to our last witness.

STATEMENT OF EDNA HESS, SHAHBAZ, LEBANON VALLEY BRETHREN HOME, 
                          PALMYRA, PA

    Ms. Hess. Thank you, Senator Casey.
    Senator Casey. Oh, the microphone?
    Ms. Hess. Thank you, Senator Casey, Ranking Member Smith, 
and other members of the Committee for their kind invitation to 
appear before you this morning and to tell you my experiences 
as a Green House Shahbaz. It is a privilege and an honor to 
share that story with you.
    This year marks my 30th year as a nursing assistant. Like 
many of my colleagues, I became a nursing assistant just 
because I needed a job, and it turned into a lifelong calling. 
I have always felt that the care provided by myself and the 
rest of the staff at Lebanon Valley Brethren Home was of the 
highest quality. Our residents were clean, well tended, well 
fed. Still, there was something missing that I could not put my 
finger on.
    Looking back on it now, I realized that while we offered 
our residents excellent care, that did not always translate 
into highest quality of life. When the Green House concept was 
first introduced by my employer, I was skeptical. After nearly 
30 years as a nursing assistant, it was difficult to think 
about providing care in a new way.
    Still, the description of the Green House lifestyle was 
very appealing. I decided to apply for a Shahbaz position and 
was fortunate to be selected as one of the first Shahbazim to 
be trained.
    It has now been 9 months since my house, the Hostetter 
House, first opened its doors. The 10 elders who live in my 
house were transferred from the existing nursing units at the 
Brethren home. So I already knew many of them.
    I cannot believe how much better they are all doing in the 
Green House setting. The most noticeable improvement I have 
witnessed is the amount of socialization that occurs in our 
house. Several of my elders were hardly ever out of their rooms 
in the traditional nursing units. Now they are frequently seen 
chatting in the living room, out on the patio, or lingering at 
the dining room table. Very seldom do they want to go to their 
room.
    The second biggest improvement is in the dining experience. 
Every meal is home cooked in our open kitchen, and the elders 
experience all the smells and sights of the meal preparation. 
They really chow down at mealtime. When we first moved into the 
house, four of my ladies were receiving daily nutritional 
supplements like Ensure, and now, none of them.
    The living conditions in our Green House homes are much 
better than in the traditional nursing home units. It is much 
calmer because you don't have the background noises of intercom 
announcements, alarms to deal with. There are no medication 
carts, laundry carts, housekeeping carts, or food carts to 
obstruct the walkway paths for our elders.
    There is no gathering of wheelchairs around a crowded 
nurses station. Our elders now congregate in front of the 
fireplace or out on the patio.
    One of the things that I now realize was missing in the 
traditional nursing home was the ability to make choices. Our 
residents were given very few opportunities to make choices 
that were important to them, like what time to wake up in the 
morning or what activity to attend.
    All that is different in our Green House. We no longer 
awaken our elders. We wait for them to wake up when they want 
to. We make them breakfast when they get up, whether that is 6 
o'clock in the morning or 10 o'clock. As far as activities, 
they are now individualized. Sophie, she likes to do puzzles by 
the fireplace. George, he watches TV in his room at times. Bill 
putters on the patio with gardening, and Gertrude loves to go 
bowling with our newest toy, Nintendo Wii game system, which I 
want to add I like, too.
    I can honestly say that I love being a Shahbaz and so do my 
fellow Shahbazims. We have not had a single Shahbaz resign in 
the 9 months that our house has been open. This compares 
favorably with the national average for turnovers for nursing 
assistants, which is over 70 percent.
    The working life we now enjoy is very demanding because we 
do cooking, cleaning, and activities, in addition to nursing 
care, but it is so much more fulfilling. I no longer feel like 
I am working on an assembly line. There are two Shahbazims on 
my shift for just 10 elders, so we feel like there is plenty of 
time to provide the person-centered care that is truly needed.
    One of the greatest things about the Green House homes is 
the consistency of staffing. I always work in the Hostetter 
House, and so the elders feel very secure and comfortable 
because they know me and I know them. This helps to provide 
better care. A few of my elders were chronically incontinent in 
the nursing home, but now we know them so well that we can 
anticipate their toileting needs.
    I often think of one of our elders that has since passed 
on. This gentleman and his wife were both elders in the 
Hostetter House, and they shared adjoining rooms. Though he was 
terminally ill with cancer, the gentleman was always more 
concerned with his wife's welfare than with his own. Over many 
decades of marriage, he had always taken great care to make 
sure that his sleeping wife had a covering blanket on top of 
her to keep her warm.
    When the couple was in our traditional nursing unit, the 
husband always worried that the staff would forget the covering 
blanket. Sometimes they did because the staff changed regularly 
and not everyone knew the ritual. After a short time in our 
Green House, we realized how important it was for the covering 
of the blanket to Mr. P, and we never forgot it. I believe it 
gave him great peace that he knew his wife would be cared for 
in the same attentive way that he had done.
    In conclusion, I feel very lucky to be a Shahbaz and to 
work in a Green House home. In talking with many of my fellow 
Shahbazim, we all agree that we feel spoiled by our Green House 
experience in the sense that none of us would want to ever go 
back to the traditional nursing home setting again.
    Senator Casey, other members of the Committee and your 
staff, I encourage all of you to personally visit a Green 
House, our Green House, and see firsthand what a difference it 
is making in the lives of the resident elders. With Green 
Houses, seeing is believing.
    Thank you once again for this opportunity to present this 
testimony.
    [The prepared statement of Ms. Hess follows:]

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    Senator Casey. Well, Edna, thank you very much.
    Ms. Hess. Thank you.
    Senator Casey. When you referred to your own lifelong 
calling, now I think those of us in the room who didn't know 
your story before understand why it has been such a calling for 
you. We appreciate that. We will visit not only because you 
said it and asked us to do it in public, but that helps. 
[Laughter.]
    We will be submitting questions to you.
    Finally, and I know because we have to give up our room 
shortly, I wanted to make sure that Dr. Diana White, who is the 
Senior Research Associate at the Institute on Aging at Portland 
State University in Portland, OR, I wanted to make sure that 
Dr. White had an opportunity to testify.
    She has done extensive research into person-centered care 
and has tremendous expertise on the most recent developments 
around the country and in her home State of Oregon. Dr. White, 
thank you very much for being here.

  STATEMENT OF DIANA WHITE, PH.D., SENIOR RESEARCH ASSOCIATE, 
  INSTITUTE ON AGING, PORTLAND STATE UNIVERSITY, PORTLAND, OR

    Dr. White. Thank you, Senator Casey.
    It is an honor for me to be here and an honor to be 
representing all of my colleagues in Oregon. I have been 
working in this area since 2001, and for most of that time, I 
worked for the Oregon Health and Science University's Hartford 
Center of Geriatric Nursing Excellence, and I am continuing 
that at Portland State.
    The Hartford Center partnered with the State's unit on 
aging and 10 long-term care facilities to develop person-
centered care practices, many of which we have heard talked 
about today. In 2003, the partnership expanded when Oregon 
received a Better Jobs Better Care demonstration grant. We were 
one of five, and Pennsylvania was one of our fellow 
demonstration grantees.
    Our partners included eight provider organizations, the 
long-term care trade associations, the Oregon State Board of 
Nursing, and many, many others. Through Better Jobs Better 
Care, we worked to improve living and working environments for 
direct care workers and residents, both, through person-
centered care practices. I was the local evaluator of that 
project.
    One of our first challenges was to clarify and define what 
we meant by person-centered care. Everybody has their own 
vision of what that is. We went through a rigorous and 
systematic process to create a definition and then a 
measurement tool we could use in our evaluation. As our own 
thinking and experience evolved, we began to use the term 
``person-directed'' rather than ``person-centered'' because we 
wanted to emphasize that residents, even those with severe 
cognitive and physical disabilities, needed and were able to 
guide their care.
    Person-directed care is a way of thinking about care that 
honors and values the person receiving support. The elements 
comprising person-directed care we identified are personhood, 
knowing the person, choice and autonomy, comfort and 
relationships. I have attached definitions of each of these 
elements.
    To implement these practices, we found organizational 
systems must be in place. For all levels of staff, this means 
adequate education and training, the ability to be an advocate 
for residents, the ability to make care decisions with 
residents, having the time to work with residents, teamwork, 
skilled supervisors, and adequate staffing.
    I would like to give one example of some of the work that 
emerged and that was done. At Rogue Valley Manor, which is a 
nursing home in Medford, OR, a nursing assistant meets with 
each new resident to learn how and when they like to get clean. 
If the person is used to showers at night, they continue to get 
showers at night. If they prefer a bath in the morning, they 
can get that, too.
    If bathing or showering is painful or frightening, a towel 
bath might be a comforting solution. The CNA also learns what 
kinds of soaps and shampoos and lotions and ritual routines are 
preferred, whether their hair should be washed during their 
bath or shower or at a different time.
    Sometimes residents with dementia can't describe their 
preferences or routines. The CNAs get what information they can 
from the resident. They ask family members. They talk to each 
other. Most importantly, they pay a lot of attention to the 
behaviors of the resident to figure out the rest.
    During this process, workers also identify what kind of 
music or conversation, if any, would be pleasurable to the 
person to help put them at ease. The shower or bathing schedule 
is then built around resident preferences, and then staff have 
the flexibility to go with the flow. If a resident does not 
feel like following their routine on a particular day or they 
request a different one, that can happen, too.
    At many other facilities throughout Oregon, person-centered 
practices have not stopped with bathing programs or the many 
dining programs that have been developed. Each led to new 
activities, as staff and residents experienced successes and 
saw different areas that needed a person-directed approach. For 
example, with flexible dining and bathing schedules, residents 
now get up and go to bed when they want. Some residents go to 
breakfast in their pajamas if that was their routine in the 
past.
    Some facilities have started therapeutic gardening 
programs, and almost all are really working to build teams and 
leadership skills among the direct care staff. Many have 
experimented successfully with worker-directed teams who make 
their own assignment to residents, mentor new staff, and do 
their own scheduling.
    Although exciting and rewarding, the process is not easy, 
even when organizations are committed to these changes. We 
would like to see more investment in organizations that are 
working toward person-directed care practices.
    An example is a partnership between Oregon's seniors and 
people with disabilities and 12 nursing homes using civil 
penalties money. We are also experimenting with educational 
programs directed at nursing students, direct care workers, 
people who are in the field, to make sure that the training 
starts at the very beginning of this process.
    Person-directed care practices continue to evolve in 
Oregon, and I will leave here the philosophy statement that has 
been developed by key stakeholders, including Government and 
provider organizations, and information about several ongoing 
person-directed care activities.
    Again, I thank you for this opportunity to share our 
experiences and our hopes to transform long-term care.
    [The prepared statement of Dr. White follows:]

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    Senator Casey. Thank you, Dr. White.
    I want to thank our witnesses. We are out of time for the 
room. We are about 15 minutes over time. But we are grateful 
that each of you made the trip to be here, that your 
testimony--if you didn't get to all of it, the full testimony 
will be made part of the record.
    But we are grateful for your leadership. We all have to 
run, but we are certainly grateful that you are here today.
    Thank you very much.
    [Whereupon, at 12:50 p.m., the hearing was adjourned.]

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