Turning LTC upside down: interview with Len Fishman, president and CEO, Hebrew SeniorLife, and past-president of the American Association of Homes and Services for the Aging

Nursing Homes, June, 2005

For any organization to change its name is a big deal--and for one as nationally recognized and successful as Boston's Hebrew Rehabilitation Center for Aged, perhaps especially so. But change their name they did late last year, to Hebrew SeniorLife. Usually an event like this signals a major change, and this one did: Under the auspices of President and CEO Len Fishman and the board of trustees, Hebrew SeniorLife was signaling not only growth, but a redefinition of long-term care. Instead of having a nursing facility, even a rehab-oriented one, as the base of the long-term care pyramid, Fishman and the trustees are defining it as the last stop at the end of a continuum of housing and services supporting the elderly as they age. Fishman, in a Boston Globe editorial, explained that they were creating not a pyramid, but a "funnel.... Services such as adult day health, in-home care, assisted living, transportation, geriatric subacute care, and rehabilitation must now represent the largest portion at the top of the funnel. Only when these resources have been expended should nursing home care be considered." Hebrew SeniorLife is creating just that sort of continuum and, in the process, reconsidering its long-term care environment, as well. The story resonates for an entire industry now contemplating profound redefinition toward a more home-based model. Recently, Fishman--no doubt recognizable to many readers as past-president of AAHSA in the late 1990s--addressed questions about the name change, the new continuum, and what it all means in an interview with Nursing Homes/Long Term Care Management Editor-in-Chief Richard L. Peck.

Peck: As your organization's recent name change indicates, long-term care is starting to move out of the nursing home to some extent and into more independent situations. What are your views on that?

[ILLUSTRATION OMITTED]

Fishman: Nursing homes will always be a critical part of the continuum, but we want to get to a place where no one is admitted to a nursing home unless they absolutely have to be, and we're being very public about it. Bottom line: If we plan our facilities and services in accordance with what seniors want, then we will thrive, even in difficult times. At Hebrew SeniorLife, we are trying to make our system look like the kind of system that seniors, including frail seniors, would design themselves. This means we are expanding at both ends of the spectrum. On the more acute end, we have opened the largest postacute geriatric unit in Massachusetts, and we have opened a medical acute care unit for geriatric patients. This unit provides extended medical and rehabilitative care for seniors with complex medical conditions and/or multiple acute or chronic illnesses. We think that there is an opportunity for an organization like ours to be the lowest-cost and highest-quality provider of long-term acute care and chronic care for geriatric patients in need.

On the other end of the spectrum, we have greatly increased the variety and amount of housing that we offer. For the first time in our history we have many more seniors in housing than in long-term care--an important milestone for us. Overall, then, I think the number of nursing home beds will probably diminish, even as the number of frail seniors increases, because people in this field are catching on to the fact that it is no longer a seller's market.

Peck: Your organization previously had "rehabilitation" in its name, and now your emphasis is moving toward home-based services. How did you begin to move your organization in that direction?

Fishman: First, the board undertook a planning process that looked at trends here in Boston and around the country. We wanted to design a system that we ourselves would find to be acceptable if we were in need of long-term care. At this point, this means moving in the direction of nursing home alternatives--specifically, in the direction of housing. It is my view that senior housing will be a platform for delivering care even to frail elders in the future.

One of our models is the system in northern Europe, where long-term care is considered, first and foremost, to be a housing issue. In the Netherlands, Denmark, and Finland, for example, it is common to find people whom we would consider to be in need of an assisted living or even a nursing home level of care receiving that care in their own apartment units.

So we start with the housing, which is an apartment unit with universal design, and figure out how we can efficiently bring healthcare and personal care services into that unit. A similar model in the United States would be a CCRC. The reason that it is so appealing to deliver this service in housing is, first of all, it isn't just "homelike," it is actually home. Second, because there is a lot of affordable senior housing available, you have a platform that is more economically feasible. One of the big complaints about assisted living is that people without considerable means cannot access it. It is easier to serve those people if you are bringing a rich array of supportive services into HUD housing, and we have done that with our HUD facilities.