it also should be home-like. people are going to be there and whether you're there for three weeks or for three years, the more home-like it is, the more functional you will become. i'd like a show of hands how many of you have an overhead public address system in your homes. [laughter] >> with the technology we have today you don't have to do that and so we've got to try to think about what's not home-like in these environments and what can we change that's pretty easy to change? when we talk to residents, west to them. -- we say to them, what do you value. it's the close relationship with the nurses aid and form these close relationships and these bonds. it also recognizes the fact that quality is based on the staff and so it is giving the resources and the staff to do the job and the authority and the autonomy and authority to do that.

it's incredibly hard work but quality is dependent upon the empowerment of those people. it is also collaborative decision-making. a nursing home that is a culture change nursing home spreads decisional authority and lets the people at the front line make decisions. it also is continuous quality improvement and we have a feeling sometimes, i think, that it's just about the environment or it's just about a parrot in the lobby. it is not. it really is about measuring and showing the changes that you're making and how it affects not just in a sense the physical care but also the well-being of people in that nursing home. there's a growing evidence base for culture change. it is not a single model. it really espouses as i said a set of principles and how people enact those quite different. but we have had evaluation of some models, the eden alternative you've probably heard of. certainly the greenhouse model.

which shows that there are very he good outcomes both for residents and for staff. there are a number of culture changes and the work that the greenhouse project is doing will give us some very good information on the costs of this particular type of program. we found 73 healthcare opinion leaders had never heard of this. we repeated the survey in 2008. and less than 34% the never heard of it. we also did a nursing home survey asking directors of nursing, are you doing culture change? and almost everyone heard about it. unfortunately, it's not an easy thing. it takes really committed

leadership over a long period of time to kind of get this to happen. but about a third of the nursing homes, in fact, said we're doing something about this. we're trying. another third said we know about it. we're committed to starting soon. so how do we get that third to start and the third that has done nothing? and i think that's going to be the challenge. we've been very fortunate. i say we, the culture change movement have been incredibly fortunate in the support it had from cms. several people have worked very hard to ensure that regulation is less and less a barrier to culture change. there's still other problems. obviously, robin mentioned work force and the need to train people not just -- excuse me, not just to work with the elderly but to work in this very different way, very team-based way. we also have the finance problems and other issues, sort of the dominance of clinical concerns that we have in nursing

homes, maybe we should be looking more atwell being and quality of life. what the policymakers do? you say it's down in the weeds. but there's an incredible amount they can do. robyn stone did an amazing job looking at what states are doing on culture change. many are being generous with their staff and letting them participate in culture change coalitions. helping to use civil monetary penalty funds to move these movements. four states are starting to use payment incentives. ge phenomenon.rs for the pay foh colorado springs to mind particularly. also looking at support for innovation and design. so many of our nursing homes are really obsolete. and we don't want to start building 1950s nursing homes again.

we now know that there are other models that we can be using such as the green houses or small houses that bring people together spoke households.. kansas is in the forefront with their peak program. they go around and find out who's doing culture change, who's doing this and, in fact, they found that what they do is they give them $300, you know, to have a party and their picture with the commissioner of health or something. people love it. it doesn't have to be a high cost thing. certainly work force enhancements and participation in research efforts. somebody mentioned the word "fun" and you don't usually say fun and nursing homes in the same sentence. but mississippi methodist senior services operates a number of campuses around mississippi. they were the ones that started the prototype for the green houses in tupelo and when

hurricane katrina was threatening they moved people up into tupelo where they had four brand-new greenhouses set to open. at the end of that, at the end of sort of the aftermath of the hurricane, most of the houses and assisted living down on the gulf had not been damage aed and the people moved up to the greenhouses didn't want to leave. thank you. [applause] >> and that story brings to brian -- i did a story in a lincoln, nebraska, where one of the older residents who had eventually died but was able to celebrate her 100th birthday at the green house before she did and the staff asked her what she most wanted for her 100th birthday a margarita and a cigarette and she got them both. [laughter] >> so fun can be had.

we have fallen a bit behind schedule so we're going to try to keep this section of q & a relatively short in the interest of moving on to our final panel and then we'll have a longer stretch of time for more generalized questions and answers. let me ask you first, haiden, to discuss one issue that i think arises out of the conversation earlier this morning as well as your paper, which is -- we heard a lot earlier this morning about the problem of having particular programs drive people into situations that they may not want and particular benefit structures lock people into situations that they don't want particularly obviously in the case of medicaid and driving to the institutional side. as we think of creating new benefits such as the one you described which really does sound like it would meet a tremendous need, how do we get out of the business of creating

new benefits that also will lock people into various structures or settings as opposed to creating the most flexibility for people really to have choices as to where it is that they live? i know you've given a lot of thought to this. how do we get out of this policymaking bind going forward? >> sure. and i should mention one of my co-authors is sitting next to me, david stevenson who he should feel free to chime in also. it's a big problem across the healthcare setting these sort of silos that have been created certainly with medicare and medicaid. and that end up resulting in poor quality of care in many ways for patients. that's one of the reasons why we wanted to, you know, advocate for a bundled pavement and there's lots of talk these days of bundling of payments and there's some real advantages to doing that in terms of, you know, creating more flexibility for meeting residents needs in this case so if you could -- you could bundle post-acute payments and payments for long-term supportive services and

end-of-life care payments we think that would go a long way in terms of giving more flexibility to facilities and meeting needs. >> david? >> no, i'd just second what haiden said in terms of rationalizing benefit needs whether it's post-acute and chronic care in the nursing home to, you know, end-of-life care separating them out in different benefits. what we propose intagrating them in bundled care. >> let's take a question right over here, please >> gary, now with attas research. it's really a comment on this last report. which i have to say i'm rather disappointed that it really does

not come down to the ultimate bottom line of the decision process in cultural change. in nursing homes which is the management. when you say that one-third of homes are doing one thing or another. no, it's not one-third of homes. it's one-third of managers and owners that are or aren't doing something. and that reflection repeats itself as you go through all the findings of who's doing what, it's not the physician that's deciding to change the culture. they are not even there half the time. it's not the nurse. it's the manager who decides whether there's going to be a nurse or not. and in terms of of a policy implication, we've got to figure out ways to strengthen the professionalism and investment management level in those institutions because they are the translation medium they are the ones reading the journals, feel. -- hopefully, and reading the study of this kind and the only person who's going to carry it

in the front door and do something about it really is the person that's running the place and that's more true of a nursing home than any other institution in the system. >> maryjane? >> i think that's why in one of my slides that i pointed out that what you have to have is of committed leadership. and that's what i was referring to. so it's not just organization redesign and environmental enhancement but the first sort of the foundational piece is the committed leadership. >> let's take a question from larry there. >> i'd like to ask dr. koren, you know, everyone is complaining about nursing home care. it's the one sector that we all seem to love to hate. and we know it needs to get better. can you comment on the culture of quality improvement and the effects of advancing excellence on creating a management culture of quality improvement.

and does that really hold promise or is it sort of short term flash in the pan that we can all feel better about? >> what larry is referring to is the advancing excellence quality campaign for nursing homes. that was started with paul mcgann at cms and a whole group of stakeholders who came together to try to help the industry pull its socks up. and it has been remarkably effective. i think that it is going to hopefully be a continuous process. what we've tried to do is we've tried to have eight goals in nursing homes work on and work on the organizational supports for good quality as well as just sort of the clinical areas that we're trying to do. we've set up local area networks for excellence in every state except for about two. and we're hoping that that would be the legacy of the campaign. but at this point it really seems from the data from everything else that we can show

a campaign effect in the clinical areas. but that it also helps nursing homes reduce turnover, stabilize their staff and their work force and also try to create this consistency of assignment between aides and their residents so that the relationships that are so valued are there. so i think that it will continue. maybe not in its current form. i don't know how it will metamorphosisize and the idea of culture change is permeated even though that terminology is not particularly used. >> let's take a question or comment from diane meyer who also has a piece in the journal as i mentioned earlier responding to haiden's piece. >> if you. -- thank you. haiden and david, obviously, i'm very familiar with your article. and maryjane just read yours when i got the journal this morning.

and what hasn't been mentioned is the link between culture change and improving access to palliative care because what's great about the culture change movement is it sets a new default and it says the standard of care of all people in nursing homes should include attention to resident-centeredness should include focus on making things home-like. because all people residing in nursing homes have similar needs. the vast majority of similar needs. so i argued in my prospectus piece in david and haiden's article that essentially all nursing home residents who are not receiving rehab are near the end of their life. and have universally palliative care needs. and palliative care is care focused on relief of symptoms, care focused on understanding patient and family goals and making sure that care is comportant with goals and reducing transitions and enhancing continuity of care.

it's not prognosis-driven. so my concern about your proposal is that it is -- it remains prognosis-driven. in other words, it depends on being able to identify a population within the nursing home who's more likely to die than another population. and my concern is that since virtually everyone in the nursing home is in the last few years of their life, how do you justify trying to subsegment that population and deliver different care to a subset than you deliver to the whole? >> who wants to respond to that? david will take that up? >> we and diane spoke earlier about this. you know, to some extent, you know, our basing the palliative service needs on a trigger, whether it's through the mds or through other clinical information it might have been

through a practical, you know, mechanism to limit, you know, the reach of the benefit but i think your point is the right one. that, you know, all residents with long-term care needs who aren't there for long-term needs going back tore a assisted-living facilities will have palliative care needs and drawing the line with an mds assessment or with something else can be quite difficult and may be counterproductive. i think, you know, that needs to be taken spoke consideration whether, you know, something such as what we proposed was implemented or something broader. >> i would echo what david said, too, in that it's very difficult to draw a line. we tried to base our line of need, some indicators of end of care life rather than a six month prognosis. but i think it's a difficult thing to do. and, you know, weighing the practical aspects of getting something like this through congress and, you know, a broad expansion of something as opposed to sort of a redesign

that could help. so, you know, these were things we were waiting when we did it. >> great. let's take another question or comment here, please. >> hi, i'm brenda spillman from the urban institute and i was interested in david's topic, it's a topic that i worked on in residential care settings. and i wondered if you could comment -- i know -- you won't know what an assisted-living care is and how can you count them. but your number suggest no growth since the late '90s. 800,000 to 2 million beds or units and so i just wondered if you could talk about that since i haven't had time to read your article yet. >> the way we define numbers in terms of our study is that we limited assisted-living facilities to those of 25 or more.

robert's work previously had identified around 38,000 facilities and around a little bit short of a million beds. our work identified the same number, 38,000 total facilities and a little bit more than a million beds. but those numbers are fairly comparable to, you know, the late '90s early 2000s. there haven't been a great deal of growth since then. but in the study and correlations that we looked at we looked at facilities that had 25 or more units that was 1135 units. and so in beds it's not a great deal different from the total number of beds if you include all the small facilities. and our rationale for excluding the small facilities in our analyses is that we really wanted to look more at the purpose built of the assisted-living facilities unless it's a small board and care homes that had been included in previous analyses. it was a judgment call and we actually did the analyses both ways and found very similar things but some states such as michigan have a very high number

of these facilities with a small number of these beds, fewer than 10 beds, for instance, and we didn't include those in our study. >> david, just to conclude the rap on assisted-living facilities for years is that there's a lot of living going on in them but not assistance. what is the likely -- one imagine the likelihood is large that this could change under implementation of the classic act. suddenly there would be resources available for people to import their own assistance into assisted-living. is that a good thing or is that a bad thing? >> i think it's largely a good thing. i think, you know, like most good things, though, there can be negative aspects as well. and if individuals have an extra few thousand dollars a month because of the benefit like the class act benefit it certainly can be advantageous to people hoping, you know, to seek services in assisted living facilities which are average, you know, can be 34, $35,000 a year. but then the prices can go up quite a bit if people need more substantial levels of services.

and so, yes, it's a very good thing to give this option to more people. but there are -- you know, again, there's an oversight responsibility that, you know, will rise if more disabled people are being served in assisted living facilities as they have been and if more individuals continue to be served in these facilities that will come up in terms of potential government oversight that would be needed. >> so a recommendation to policymakers as they watch this unfold is what? >> you know, it's hard to say. i mean, assisted living facility regulation has largely fallen to the states and i think that would largely continue unless there were a substantial infusion of federal dollars and when the cash benefits such as the class act -- i don't know that will change and so i think the states are really the ones who will be on the front lines of assisted living facility oversight now and in the future. >> i'm sure they'll be grateful for the opportunity. well, terrific. a great discussion. i just wanted to mention for those of you who might have been

furiously looking through the journal for maryjane koren's article. actually we are publishing it this week on the web as one of our web first papers. so you will actually be able to access that on the website. i believe we do have hard copies of it available as well. but it's -- as we emerge into a great digital age we increasingly have the ability at health affairs to not only publish obviously on paper but publish very timely pieces on the web and we took advantage of that in this case so that we could prix out that article as quickly as possible. anyway, thank you very much all three of you for a terrific discussion. and we'll now -- thank you. [applause] >> we'll now move right spoke our final panel. on who pays and how and may i ask the three panelists on that panel to join me up here on the stage. we're going to be hearing here from authors of three papers.

one of which deals with the complement of private financing of long-term services. david stevenson was also a co-author on that. but we're going to have one of his co-authors on the piece, mark cohen, who is president of long-term care insurance provider life plans speak about that. we'll then hear from rachel warner, assistant professor of medicine at the university of pennsylvania on how to use the markets to incentivize for quality improvements and finally we'll hear from marian who as i mentioned earlier was our thematic issue advisor on this issue. but who also is on her other life the marian professor of gerontology at the pennsylvania school of nursing who will be speaking about the very important announcement today which is about the formation of

the new long-term quality alliance. and in our journal there is a people and places column that provides some more information about the formation of this alliance and the exciting opportunities it will afford to continue to improvement long-term quality care. in the interest of time, i'm not going to go spoke your terrific bio s and they are in your packets. mark? >> i want thank the scan foundation for the opportunity to present the paper and my co-authors david stevenson who has probably written half this issue. eileen and brian. in this paper among other things we hope to put to rest the false dichotomy that long-term care should be either a public or private responsibility and that public policy should prioritize either development of the

private market or expanded public coverage for long-term care. proponents and critics alike point to the current modest role of private insurance and financing care respectfully arguing that public policies impede development of a more robust private market or that private policies are unaffordable to most americans and are, therefore, unlikely to play a substantial risk in risk protection. we begin from the premise that public and private coverage for long-term services and supports can serve complementy roles making the key public policy question which not approach to make central but rather how to align incentives across public and private financing sources to create a rational, more sustainable system where both public and private coverage play sizeable roles. on one point both proponents and critics of private long-term care agree that the distribution of financial risk where many people will spend nothing on

care and a few people will incur catastrophic expenses implies a private role for insurance as an effective mechanism to spread risk. most people do not have private insurance. in a review of the current state of the market shows that there are around 8 million policies in force. clearly, the market size and complexion have not lived up to projections. ironically, if we look historically the quality of policies has greatly improved over time with expanded coverage for home and community-based care, assisted living care, parity and daily benefits and inflation protection features. today's buyers have also changed and tend to be younger, wealthier and less likely to be drawn from middle class. why is it that more middle class americans don't buy long-term care insurance? some argue that the product is simply not affordable to a broad

cross-section of americans. or put another way, it is not viewed pi a majority of consumers as providing sufficient value in light of its premium cost. in fact, there are both supply side and demand side reasons why there is a value gap in the market. on the supply side, there's information asymmetries between peers and sellers which lead to adverse section and moral hazard thus affecting premium pricing as well as the comprehensiveness on the marketplace. on the demand side research has shown that individuals who do not buy policies tend to generally underestimate their risk and overestimate premium costs. many people mistakenly believe that if they need care, the government or their current health insurance policies will cover this care. moreover, some say the presence of medicaid crowd out a very large portion of the market. an important area where both

demand and supply factors intersect is consumer confidence about whether benefits will actually be paid when they're needed. and whether premiums will remain relatively stable over time. data from claims denial reporting and independent research show very low claims denial rates and high claim rate in satisfaction. even though there have been serious allegations that the claims practices of certain -- of certain companies are suspect and may be designed to make it difficult for people to access benefits. there have been also been consumer concerns about rate increases that have resulted primarily from optimistic interest rate assumptions, lower than anticipated voluntary lapse rates and inadequate risk management strategies. clearly the focus should be around better integrating the public market with public

programs3

in other words, in the context of partial public coverage, individuals really need to understand the limits of that coverage and in turn the value of any supplemental private coverage.gúc third, to the extent that any public coverage relies on an insurance model, policymakers should take note of lessons learned in the private market. a, any voluntary public program will have to balance concerns about adverse selection, against broad goals pertaining to covered populations. b, the program must be structured so that premiums are no more costly than for similar plans that can be purchased privately yet sufficient to ensure that the program is acuarially sound. the program must employ adequate risk management controls relating to program participation, validation of benefits access criteria and more. fourth, policymakers should focus efforts on more innovative

strategies that encourage individuals to plan -- to purchase plans at younger ages by making them less costly through flexible spending accounts and by supporting models that explicitly connect public programming and private insurance coverage such as what is found in the long-term care partnership programs. for wrap-around products to take hold there must be a very consistent definition of eligibility for private and public coverage. while these are some of the important prerequisites for the markets to work together i do want to point out as connie did that there is no consensus that in the context of the class act, the private insurance market will thrive. some believe that the program will lead to the demise of the private sector because it will be priced inappropriately. consumers will believe that they are already covered and need not take any additional planning steps. agents may find it simply too difficult to sell the project. and the very structure of the program, a long, skinny benefit

makes the development of wrap-around products different. on the other hand, other see it as a great opportunity and argue that the program will enhance consumer awareness, encourage the development of innovative, more affordable wrap projects to increase the overall pool of insureds and assist agents as they either sell with or against the public program. clearly to maximize the chance of this more optimistic view, the issues that i raised and the co-authors need to address in the book. given the fiscal restraints on the public programs and the market programs, neither a public more private financing approach on its own can meet the long-term needs of all americans. in all likelihood, public and private coverage will continue to work in tandem to mitigate the catastrophic costs associated with long-term care. public policy that supports a

coordinated public/private financing approach holds the greatest promise for achieving efficient and equitable outcomes for consumers and taxpayers alike. thank you. [applause] >> well, thank you very much. i'd like to join on the previous presenters and thanking health affairs and the scan foundation and also thank and acknowledge to mark who's my collaborator and lead author on this paper. market based reforms such as public reporting and pay for performance has taken on a tremendous momentum as a way to improve quality of care. however, these reforms may not compatible and how do you use market based reforms to advance those depose. so long-term care policy and practice have pointed to several broad goals that are generally

agreed upon goals of the long-term care quality. the first is to improve quality of care is daily life. improving quality of life is an important goal for long-term care. second -- the second goal is to reduce the frag mentation of the delivery and the financing system. our current system is quite fragmented leaving also to discontinuities of care, unmet needs and for providers leading to conflicting incentives for quality and cost. the third goals is where feasible to increase the use of homes and community-based care. although there is general agreement upon the importance of these goals, it's unclear how to achieve them. at the same time that people have agreed upon these goals, there has been increased momentum to adopt market based reforms. we define market based reforms

as policies that are designed to change the underlying incentives for quality of care in healthcare. so in the typical healthcare market, little information is available about the quality of providers leaving consumers who wish to choose high quality providers with relatively little information or tools with which to do so. as a result of the lack of transparency about quality, providers have less incentive to deliver high quality care or compete for consumers based on their quality. so market based reforms are really designed to address these two problems. to improve consumer decision-making about selecting providers and to improve competition for quality or have providers improve the quality of care that they deliver. there are a number of examples of adoption of market based reform in long-term care, most notably for -- in public reporting and pay for performance. back in 2002, under the nursing home quality initiative, the centers for medicare and medicaid services began publicly

reporting quality information on all nursing homes nationally on their website nursing home compare. this was followed a year later by a similar effort in the home health arena. simultaneously there have been a number of demonstration projects led by medicare and paid for performance in home health and in skilled nursing facilities. state medicaidations have also begun experimenting with the use of pay for performance in the nursing home setting. so the question for us is how do these current market based reforms address these broad goals of long-term care?t!ç in theory these reforms are perfect compatible with these depose improving quality of life and reducing fragmentation and increasing the use of home and community-based services. however, there's several key attributes. a first limitation that current market based reforms tend to rely on narrowly defined quality

control measures. this tends to re-enforce a medical model of care which pays more attention to clinical quality than it does to issues related to quality of life and may tend to crowd attention to quality of life out. second, all of these current market based reforms are setting-specific. therefore when a consumer goes to choose a setting for their long-term care, they must first choose a setting and then compare quality only within that setting. and then a third limitation is that the incentives are all payor specific and they include in nontraditional care providers. and these policies have not reached there yet. so the limitations of current policies are really problems of form and the implementation of market-based reforms so in theory it should be relatively straightforward to address them. one of the easiest ways to address them may be to add

different or new measures. so quality of life is one measure that is used in some settings but is not uniformly used across existing market-based reforms. and by including it in market-based reforms may refocus attention on quality of life over the discreet clinical problems that are currently tied to the exclusions but to the clinical problems that we currently look at. another option may be used broader clinical measures such as option and the use of palliative care because we know that these are associated with quality of life and long-term care. a third option to improve measurtn away from clinical quality measures and instead focus on organization characters of that. and the principles of culture change in nursing homes.

being able to reduce fragmentation is a more complicated matter. it requires coordinating and -- both management and incentives across different payors and it would be the first step for implementation and then finally expanding the use of home and community-based services is logistically a challenge that currently exists and requires a great deal of work. it would include developing and collecting a core set of measures both existing formal avenues of home and community-based services and less informal ones also and this is also -- not something that is epps solved logistically and a long-term commit to measuring these activities but would also enable again the comparison quality across these settings. these are big changes to the current format of market-based

reforms but they also provide an important opportunity to use these policy levels of market based reforms to fundamentally address the quality and improve the quality of long-term care. thanks. [applause] >> good morning, i'm it between now and lunch. i want to join all of my colleagues and thanking susan and the health affairs team and bruce and the scan foundation not only for a terrific health affairs issue but for this very special opportunity to announce the launch of the long-term quality alliance. this alliance is the result of many months of work by a dedicated steering committee chaired by mark mcclellan. the membership organization that results will be guided by a richly diverse board, founding board, most of whom are here in this audience today.

these are leaders in the delivery of long-term services and supports, representative payors and evaluators of these services, consumer and family care-giver advocates, funders, researchers, policymakers and others who have joined together with a common mission and a common vision to significantly accelerate quality improvement for the growing population of individuals who wake up every day requiring support for the things that all of us take for granted. bathing, eating, walking, et cetera. this organization will also focus on that invisible group that carol referred to. those individuals, the family caregivers that these individuals rely on primarily for help. the alliance will achieve this mission by fostering the development and use of measures that offered the most promise to improved quality in all context in which individuals receive services and supports. and by positioning organizations to implement innovative, evidence-based practices

designed to achieve meaningful growth and improvement in performance. now, as susan mentioned i had the great fortune to serve as an advisor, the theme advisor for this issue of health affairs, an issue that has generated not just an outstanding set of papers but an excellent foundation for action. the alliance hopes to be an important vehicle to achieve many of the recommendations outlined in this issue. so first why focus? why focus on the quality of long-term services and support? it has been outlined by steven and many others, there is a demand for these services. approximately 11 million americans currently receive long-term services and support. and this number is expected to double by 2050. not so much because we are not doing a better job in prevention of disability but because we have a silver tsunami along the way. currently the measures that we have available to assess the

quality of long-term services and support do not adequately capture information that's important to the vast population or consumers of these services for whom progressive loss of function rather than cure is a trajectory. specifically, we lack measures that help us to understand the experience of the consumers and family caregivers and their perception of quality of life. perceptions about quality of life can be tremendously influenced by the quality of long-term services and support in people's homes, in community settings and in institutional settings. services that do not communicate respect for the individual dignity may negatively affect an individual's person quality of life. additionally, despite a major growth in the home and community-based sector, we have very few measures focused on this context. most available measures as you've heard focus on the quality of services in institutional settings such as nursing homes. we also have with this alliance a great opportunity to impact national health priorities.

among the major opportunities identified by the national priorities partnership, a diverse group of organizations convened by the national quality forum, are the need to substantially enhance engagement of the recipients of care and their family caregivers decision-making, to improve care transitions and coordination, to promote earlier access to palliative and end-of-life care and to minimize overuse of services. this was the action agenda agreed upon by these partners in order to assure high quality, affordable healthcare. the recipients of long-term services and support are disproportionately high consumers of costly health services. by targeting these priorities for this important subgroup, we expect to make a great contribution to enhancing quality and increasing -- and decreasing cost for all americans. how can we make a difference? we hope to facilitate dialog and partnerships among all providers

of serces and support as well as between providers in a long-term and acute services and we want to break down the silos. we plan to help consumers, family caregivers, partners with government provider agencies and others to set goals for quality. a unique feature of this alliance relative to other alliances will be the efforts that we will make not just to improve the measurement of care but to better link practices available to improve performance in these measures and we hope to collaborate with other quality groups on common priorities. we want to complement and leverage and advance a number of the initiatives that you've heard about today, both public and private targeting this population. and in a long run we realize that organizations that provide long-term services and support must have adequate quality and financial incentives to improve quality so we will use what we learn from pilot efforts and demos to assist policymakers in designing effective incentives.

what are our short-term priorities? clearly, advancing quality indicators that are important to consumers and family caregivers is a top priority. we need measures that are respectful of and response to these individuals needs preferences and values. you've heard from carol and others that measuring care transitions is important. among the population of people with serious disabilities, transitions in health, and, therefore, healthcare are the norm. notably episodes of acute care resulting in frequent hospitalizations are very common. and we have much of our data on this from the nursing home population. but at any six-month period 1 in 6 nursing home residents are in the hospital. 40% of them are accessing care within the broader population of those receiving long-term services and support living in the community 40% will be hospitalized each year. these hospitalizations are disruptive. they're fraught with complications.

and they frequently are associated with poor outcomes, accelerating functionals cognitive decline, medical errors and avoidable hospitalizations. individuals who are receiving long-term services and supports are especially vulnerable to the failures in our current system, lack of transfer of our system, poor communication between family members, providers and others, inadequate preparation of staff in both the acute and long-term sectors to address the comprehensive needs of these people, et cetera. so we have lots of opportunities here. high rates of avoidable hospitalizations, though, are major outcomes as a result of these gaps in care. available data suggests between 25 and 40% of hospitalizations of just elderly long-term care recipients are so i believe. -- invoiceable. so decreasing costs is a major goal of alliance. in addition to the tremendous human burden associated with frequent use of acute care hospitalizations, these hospitalizations have been associated with rapidly escalating cost.

the estimated savings just hospital costs alone for medicare for nursing home residents range from 1.1 to $1.4 billion. our strategies, therefore, are as follows in the short term. to set very meaningful goals of achievement and family-centered care to improve care transitions, to work toward preventing avoidable hospitalizations and we expect to focus to these goals over the next few years to help create the incentives to reward performance in summary improving care transitions, reducing avoidable hospitalizations and decreasing when he can costs for this group are essential if we're to substantially contribute to addressing national health priorities. these short-term priorities had the additional benefit of placing a spotlight on a growing population of people who need much more attention locally, nationally -- excuse me, local, national reform efforts.

these individuals also deserve long-term services and support that are aligned to meet their definition of quality. we have a huge opportunity to make a major difference in the lives of millions of americans and we plan to capitalize on the ideas generated in these great papers today by many of the thought leaders presenting here and others sitting in the audience as well as others to make the most of this moment. thank you. i should mention, there is a press release on the alliance out at the table so we welcome your taking a copy of that on your way out. thank you very much. [applause] >> and in addition the alliance is also holding a press briefing, correct? right after the session just across the hall at the press club here. so conveniently situated for all of you who would like to go right over and find out more. mary, just a quick question to start with, to tie this back, for example, to robyn's discussion earlier about the

work force, where is the quality of the people in the work force on the alliance's agenda and the investments that she and others have said are going to be needed to improve the quality of that work force? >> there is absolutely no question that we will not achieve the quality -- the standards of care that we need without investing in the work force. but setting the benchmarks, setting the expectations is the first step to recognizing where the gaps in quality are and then what investments need to be made to address them. so there's an intimate linkage between work force and the work of the alliance. >> okay. once again we will open this up to questions or comments from all of you. so let's take one right here. >> thanks. gayle hunt, national alliance for care giving. i have a question for marc. with regard to the middle class uptake of private long-term care

insurance, can you comment on the success or failure of both the federal long-term care insurance policies that were offered, you know, the big, massive campaign to reach federal employees. and then the public awareness campaign that's been, i think, that those have been doing, own your future or something like that and how that -- both of those have certainly gone out to middle class people so can you comment on the uptake? >> sure. i have an advantage of having some of my co-authors here so i'm going to let eileen speak a little bit about the own your -- own your future campaigns since she's been intimately involved with that. i guess it depends on really what the definition of success is. i mean, i think by all measures, the growth of the market has been less than what optimists as well as pessimists thought it would be at this point.

it's clear that with suitability rules that have been put in place where unless you have a certain level of income in assets you are not considered to be a suitable purchaser by definition that means that you're going to be going after higher incomed people. the take-up rate for the federal long-term care insurance plan, i think we have john cutler here as well and maybe he could comment on that. i know there was -- it's still considered to be the largest group long-term plan out there. i don't know exactly what the benchmark was -- benchmark was for whether it's successful or not in terms of penetration. i'll let john actually answer that question. john, is opm and was intimately involved when that program was set up. >> thanks for that. the federal program is a group program. and we have the same 5% that most employer groups have.

so as an insurance success story i would say it is, as a public policy matter, i think mark's right. -- marc's right. private insurance sales is not where people would want and i also have eileen on your own future -- >> whoops, story about that. okay. an educational campaign orientally broadly to long-term care planning and it was designed specifically to address all demographic segments on long-term care planning, including those with different financial needs, those currently receiving services looking at housing, finance, service delivery and selection so it just wasn't about insurance and we did achieve the goal of reaching a very broad and diverse group of people so there was no income cutoff for the mailings.

they went in about 30 states, i think, to individuals aged 45 to 65. and there was no income cutoff or exclusion. and we saw the response rates coming back among those people who ordered the planning kit, the how to plan for long-term care and those that did not being pretty similar demographically particularly with respect to income. we did find that people who got this planning guide were twice as likely to take some kind of planning action and action was defined very broadly not just buying insurance but consulting, talking with your family about what your needs and wishes would be. talking with an agent or financial planner about long-term care, looking at your existing healthcare coverage looking to see if that was long-term care because that was a wakeup moment for many people. thinking about your housing needs as you get older. so when the initiative is more broadly defined and obviously

more affordable planning is not something that