A Call to Action from Pioneer Network and Live Oak Institute

Originally Prepared for Pioneer Network and Live Oak Institute by:

Barry Barkin

Barry Barkan

Ashoka Fellow, Co-director,
Live Oak Institute, and Co-founder Pioneer Network
Evy Cugelman

Evy Cugelman

Eden Educator, Mentor and Guide

Cathy Lieblich

Director of Network Relations,
Pioneer Network

Elise Strom

Director of Development,
Aldersbridge Communities

Jeff Jerebker

Blogger, Author, Elder Care Influencer

Jennifer Carson, Ph.D.

Director, Dementia Engagement, Education and Research Program
School of Public Health
University of Nevada, Reno

Joanne Rader, RN MN

Pioneer Network

Lori Porter

Co-Founder & CEO,
National Association of Health Care Assistants

Rick Gamache

Aldersbridge Communities

Rose Marie Fagan

Co-Founder and Founding Executive Director,
Pioneer Network, Culture Change Network of Georgia Advisory Council

Steve Shields

President & CEO,
Action Pact Holdings, LLC

Mary Tellis-Nayak, RN MSN MPH

Post Acute Consultant

V. Tellis-Nayak, PhD

LTC Researcher

Jack Kupferman

Convener (Chairperson),
Gray Panthers, NYC Network

Beth Irtz, RN NHA

President and Chief Guide,
Focus Consultation, LLC

Tina Taylor, CTRS

Resident Services Director,
Bruceville Point Senior Living
Julie Murawski

Julie Murawski

Assistant Director,
National Adult Protective Services Association (NAPSA)

Joe Angelelli, PhD

Gerontologist and Family Care Partner

More than 200,000 staff and residents died of COVID-19 in the United States were in long-term care settings. The system failed. It's time for the long-term care system to be reimagined, redesigned, and transformed from bottom-to-top and inside-out.

Each person who meets the criteria for nursing homes will have the right to choose from a variety of different types of care settings, including their own homes.
Long-term care homes will be life-affirming communities where people can live out the narrative of their lives with joy and meaning, even as they encounter loss of capacity and the imminence of death; where people come for rehabilitation from a medical event and go home with not just their bodies but their spirits regenerated; where each person has a private room with good air circulation, and ample common space to socialize even when physical distancing is required.
All long-term care service delivery will focus on the physical, intellectual, emotional, spiritual, and social well-being of each person and strive to support them to achieve their highest possible potential.
Direct Care Partners, including Certified Nursing Assistants, will receive equitable compensation, and have a career ladder and opportunities for professional advancement; managers on all levels will become servant leaders, empowering everyone to work together to fulfill their potential for well-being and excellent service.
1 Although people over 65 account for 16 percent of the US population, they account for 80 percent of the COVID-19 deaths in the US. Nearly half of all Covid-19 deaths have been in long-term care facilities. (Kaiser Family Foundation www.kff.org)
Government will provide realistic funding for well-run, person-centered communities and service delivery that incentivizes providers for helping people achieve their highest potential; regulation is both part of a collaborative learning process and if necessary actually delicenses chronically underperforming operations; and business models will be accountable and transparent with a culture where profits are earned for the benefit of the people who are served, staff and community as well as investors.
The very culture of long-term care is transformed to render obsolete the ageism, racism, sexism, ableism and virtually every other -ism that permeates the system so young people can look forward to engaging their elders in welcoming environments and the fear of old age begins to be tempered by hope.
Every dimension of eldercare is part of one interconnected dynamic universe. The eldercare universe includes elders, caregivers, family and community members, for-profit and not-for-profit companies, managers, real estate investment trusts, professionals, federal, state government, and insurance companies, lawmakers, regulators, labor unions, trade associations, consumer, and disability rights advocates, and more.
All of these are part of one interdependent unit that are bound together by a common culture with the express purpose of keeping all people in the system functioning at their highest level. Right now that culture is fragmented and lacks cohesiveness and integration and thus the system breeds ill health and inefficiency. One need look no further than the huge number of deaths of people in nursing homes to see how unhealthy, failed, dysfunctional, and ineffective the system is. Piecemeal approaches have been failing for years as society’s return on investment in long-term care has been abysmal.
The Live Oak Project is about creating a wholistic vision for eldercare to drive a simultaneous revolutionary transformation of all the various elements of the system in a coordinated, integrated fashion. To do this we need a common, values based culture that supports the optimal wellbeing of everyone the system touches.
The lens through which Live Oak Project seeks to create the change is through all federally funded programs providing support and services for elders. The programs impact the life and well-being of each person who receives long-term care or is involved in the delivery of care or the assurance of quality, or any aspect of the eldercare universe. The system needs to be reimagined from the halls of congress to the bureaucracies that administer the programs, to the board rooms of corporations, to the habitats where people live and receive services. The system must become healthy and health promoting, bound together by an integrated common culture that supports optimal performance and cost effectiveness.
In our worst nightmare, we never dreamed of the devastation of the tens of thousands of the most vulnerable people in America who died in nursing homes during the pandemic. For the sake of their memories and the people who died risking their lives to serve them, we have a sense of urgency to seize the opportunity brought on by this moment.
Pioneer Network, its Council of Elders and Live Oak Institute have launched the Live Oak Project to structure, organize, and facilitate a campaign to fundamentally transform elder-care and the very culture that permeates it.
The whole milieu of long-term care is peppered with innovation from intentional communities for elders to government funded all-inclusive care models to naturally occurring retirement communities to home and community based programs to support systems for disabled people. We are focusing on federally-funded programs that provide care to the most vulnerable and frail people. We anticipate that there will be a huge rippling benefit to the rest of the long-term care milieu as our initiative gains momentum.
The common denominator among people in our network has been our commitment to imagine and provide an alternative to the institutional culture of long-term care homes by cultivating a dynamic culture that nourishes rather than diminishes the life force. For more than 50 years, we have been generating values-driven bright spots of transformation in all dimensions of long-term care. Research has demonstrated the positive impact of the culture we have been evoking, applying, and proliferating on resident and work life, professional practice, and cost benefit. Yet many providers in the United States remain wedded to an institutional culture that is dehumanizing. All we have accomplished up to now is not enough.
The system itself is a fragmented behemoth that resists widespread and deep systems change. This is due in part to the fact that federal and state governments have underfunded Medicaid, the primary payment source for the vast majority of nursing home residents and in many states’ other options for Medicaid nursing home eligible people. Regulations are unevenly enforced and have set up an adversarial paradigm that is often counterproductive to good management and good care. As a result, the intent and mandate of the visionary Nursing Home Reform Act of 1987 which assures quality of life and quality of care for each person, was never realized.
Moreover, the business culture that determines what happens in institutional long-term care settings is risk averse and often not grounded in the needs and preferences of the individual. Poor care that promotes dependency, boredom and isolation can be found among proprietary, nonprofit, and government-run homes. Workers-who have the greatest contact with residents-are underpaid and undervalued, often needing to work several jobs to make ends meet. At the very heart of the matter, the people for whom the whole long-term care enterprise exists-the actual consumers-are too often crowded together in mentally and physically unhealthy environments that breed epidemics, anxiety, and depression. Quality of life is perceived as a luxury that often falls through the cracks of a dysfunctional system and is usually the first thing cut in times of financial challenges.
We’re not talking about throwing out the baby with the bath water. Nor are we interested in fragmented fixes to a failed system. Despite the already pervasive antipathy to nursing homes exacerbated by the COVID-19 crisis, there will always be a need for congregate long-term care. However, every institutional setting in which people are crammed together, and the entire system through which they are operated, regulated, and paid for, needs to be transformed, including providing options for services at home.
From the collective imagination of all who will answer our clarion call, we will determine how to equitably finance the construction or major remodeling of institutional settings. We will create investment models that bring into alignment capital and equitable outcomes. Working collaboratively, all the stakeholder communities will reimagine how government agencies can function with flexibility and mutual accountability. Roles, responsibilities, and organizational practices within each home will be reoriented so that each person experiences optimal mind, body, and spiritual wellbeing.
To achieve our vision, the Live Oak Project will bring together dedicated people in all appropriate roles and disciplines to work together interactively in the following areas that comprise the system that has to be reimagined from top-to-bottom and inside-out.
Long-Term Care Community
  • Person Centered;
  • Workforce and Professional Pathways;
  • Diverse and Multicultural;
  • Remuneration;
  • Reenvision Management;
Public Policy and Legislation
  • Reimbursement;
  • Regulatory Process;
  • Tax code
Research and Education
  • Expand medical and clinical roles;
  • Reimagine leadership;
  • Support incubators for long-term care prototypes;
  • Evaluation and Learning.
Environment and Architecture
  • Redesign Buildings.
Capitalization and Investment
  • Values Driven
In the end, all of the components will synergize into a cost-effective, life-promoting, long-term care system. Together we will galvanize the national will to realize the Live Oak Project vision and mission.
Our strategy is simple. The end follows the means. We will strive for consistency between our shared values, our actions and our intended outcomes. Our approach cannot be too prescriptive. By constantly endeavoring to connect our actions to our vision and principles (Appendix 1), we will learn together to be fluid, organic and synergistic.
Now, we are seeking to free the genie of possibility from the bottle. People for whom this vision resonates will bring their hearts, wisdom, expertise and resources to the Live Oak Project. We will reach out into many quarters, both known and unanticipated, creating epicenters of change by engaging people that need to be brought together to realize our vision.
Road maps and detailed plans for achieving our mission will begin to emerge from the process. A multidimensional, vision-driven movement such as this can only grow organically. It is our intention to provide the framework and seed the culture that will enable us to accomplish our mission.
It is time to relegate to the trash bin of history the common refrain about long-term care homes, “I would rather die than go there”. The combination of the devastating impact of COVID-19 on people in long-term care homes coupled with the booming aging demographic must finally fuel profound systems changes that have eluded and frustrated previous efforts at piecemeal reform.
Connect with us to provide desperately needed proof that our system of human services, care, and support of elders can be made to work effectively, equitably and with loving care. The learning derived from the process of systemic transformation will impact all aspects of American life. Achieving our mission will not only be good for each person who lives and works in a home and their family members, it will nurture the resurgence of the can-do spirit of America.
Together we can do this. Connect with Us to seize this moment!