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  185 Chapter 12 Too Good to Be True? Overcoming Obstacles To change a culture is never easy. It not only involves a challenge to privilege and power, but also the dismantling of deep psychological resistance. —Tom Kitwood, Dementia Reconsidered Unless the culture changes, too many residents fall by the wayside. We may have the knowledge, but, apparently, the will is too often lacking. Change is never easy! Change toward a new orientation cannot be imposed but rather must come from within. —Sheldon S. Tobin, “The Historical Context of ‘Humanistic’ Culture Change in Long-Term Care” Bill Thomas is fond of saying that transforming nursing homes is akin to coaxing the draft horses on his farm to work in tandem. He told me this as I was bouncing along on a wooden wagon seat behind two 1800pound horses, Ned and Dan, plodding past the family’s wind turbine and woodpile. “Only by working in partnership can you effect change,” he said, patting the horses. “If you try to force change, the status quo is too massive and ingrained to budge.” I did not imagine myself in this pastoral pocket of New York when I set out to learn about new ways older people might live. But the leaders of the Pioneer Network turned out to be an eclectic bunch, scattered across the country. Bill Thomas is both the best known of these leaders and the most unusual, an unlikely mix of middle-aged hippie, Harvard-educated physician, and jet-setting international speaker. In June 2006, U.S. News and World Report named him one of “America’s Best Leaders.” More than one admin- 186 Old Age in a New Age istrator has told me they were so inspired by hearing just one talk by Bill Thomas that they immediately started their nursing home on the culturechange journey. What I have learned from him and others is that deep, transformative change is possible—but never easy. It requires making tough decisions, eliminating some jobs and reinventing others, throwing out schedules and rethinking rules, all while convincing skeptical staff that the old way of doing things—the way they’ve been taught through years of training and experience —is wrong. Some employees resign rather than change. Family members complain that too much freedom is dangerous for their loved ones. Regulators challenge the wisdom of giving residents more choice and thus perhaps less safety. Funds must be raised for renovations or training. “Corporate cultures don’t allow for a lot of flexibility, and this is not just in the for-profits, but big nonprofit chains as well,” long-term care researcher Robyn Stone told me. “It makes it harder because you need a lot of flexibility when you’re talking about organizational change, and that flies in the face of a lot of corporate culture—despite the fact that large corporations like Toyota and IBM were pioneers in culture change. There’s no reason why it couldn’t be done.” The reimbursement system is also skewed. Instead of being rewarded for wellness, nursing homes are rewarded for poor outcomes. Al Power of St. John’s explained, “We get paid more if someone has a bedsore than if they don’t. If we heal it, they pay less. If they are bedridden, and we get them to walk, we get paid less. That’s the basic problem.” But beyond that issue—and beyond the scope of this book—we have no rational plan for paying for long-term care, especially when the baby boomers will need it. The current system of using Medicaid as a last resort clearly satisfies no one: Middle-class elders must impoverish themselves in order to have their nursing home expenses covered (or hire lawyers to help them conceal their assets, an ethically problematic solution); low-income people, whom Medicaid was meant to benefit, are increasingly shortchanged as funds are used for long-term care insurance for everyone; and providers must go hat in hand every year to the government to plead for higher reimbursement. Meanwhile, state budgets are stretched thin. We need to create a rational, fair system that in its ideal form would encompass health care, affordable housing, transportation, and other needs of older people that today go unmet. As a first huge step, we need to figure out how to pay for the long-term care of the next generation. Perhaps we should mandate long-term care insurance, just as we require people to insure their homes and...

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