A Call to Action
from Pioneer Network and Live Oak Institute
We are reimagining, redesigning and transforming Long-Term Care services and support systems so that each person can thrive.
Almost 50 percent of the people who died of COVID-19 in the United States were in long-term care settings.1 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.
The Live Oak Project Vision
Every great initiative begins with the vision of what we have set out to achieve. This is our vision for the prize upon which we will keep our eyes.
A transformed culture of Long-Term Care services and support systems rooted in basic human rights that cultivates well-being, relationships and community, by supporting the empowerment of each person and each group of stakeholders.
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.
A View from 30,000 Feet Up
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 well being 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 Resists Change
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.
Transformation Is Required
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 well being.
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.
At this point in the design phase for the unparalleled, integrated campaign to transform a whole sector of society, our initial focus is on five Action Domains which will be developed simultaneously.
The Action Domains
Create the Operational Infrastructure for the Project
Organize the Live Oak Project corps for Change
Engage Potential Allies in the Work
Build the Platform for an Interactive Network
Go Viral: Create Momentum and Engagement
Create the Operational Infrastructure for the Project
In an open process, Pioneer Network and Live Oak Institute teams will design an organizational structure, establish first-year objectives and a work plan; determine staffing and program needs; and develop a preliminary budget and a funding strategy.
Organize the Live Oak Project Corps for Change
Design the culture and structure for the values-driven Live Oak Project corps that will accomplish our strategic objectives. Each incubator will be a community that will stretch out
Design the culture and structure for the values-driven Live Oak Project Incubators that will create the initiatives that will enable us to accomplish our strategic objectives within the dimension.
Each corps will be a collaborative matrix for community development, continued learning, strategizing and action to accomplish our mission. The corps will be in continuous communication so that our efforts are integrated and coordinated.
The corps are organized around five hubs:
Long-Term Care Community
Workforce and Professional Pathways;
Diversity and Multiculturalism;
Public Policy and Legislation
Research and Education
Incubators for nursing home Prototypes;
Environment and Architecture
Capitalization and Investment
Engage Potential Allies in the Work
Disseminate the Call to Action. Identify and ally with potential individual and organizational partners to provide the cadre for the corps. Develop a questionnaire to match people’s expertise, wisdom, passion and experience with the appropriate corps.
Build the Platform for an Interactive Network
Design and build the platform for the social network and communications system that weaves the movement together by promoting strategic and interpersonal relationships, sharing our stories and updates from each corps, and support for our learning and personal growth.
Go Viral: Create Momentum and Engagement.
Develop a cascading media campaign that inspires hope.
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.
Join Us in Seizing the Moment
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.
Join us to provide America with the 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. Join us in seizing this moment!
Live Oak Project Principles
The world in which long term care services and supports are provided must be an integrated, holistic, interdependent and interconnected whole.
The system must be fully funded to support all of the Guiding Principles below. This is the system that everyone has a right to live and work in.
The perspectives, approaches, and practices that transform the system are person-centered, cultivate community, and empower each person and each group of stakeholders.
Each person who is eligible for long-term, services and supports, whether funded privately or publicly by Medicaid, Medicare, and Managed care, has a full range of options about their care setting, including their own home.
Each person is related to as a whole person, who is growing, learning, with potential, with physical, mental, emotional, spiritual and relationship
Each person is entitled to the full range of human rights, including self- determination, risk negotiation and simple pleasures.
Each person is entitled to have their needs and preferences met in a way that honors and respects one’s culture and beliefs.
Death is a sacred part of life’s journey and each person has a right to a compassionate, peaceful, spiritual end of life.
In congregate settings the physical environment must foster home by providing private rooms, spacious common areas, healthy air quality, natural light, easy access to outdoors and opportunities for self – directed living.
The system of reimbursement for long-term services and supports must be sufficiently structured and funded to reward high quality care that strengthens each person physically, emotionally, socially, spiritually and intellectually and promotes their well-being and quality of life.
Direct care workers, including Certified Nursing Assistants, are professionals . They must be well trained in all aspects of a person’s quality of life, equitably compensated, valued for what they know and can contribute, related to with dignity and respect, and have opportunities for professional growth and advancement within the field of long – term services and supports.
The management culture within each long – term services and supports setting must move from a hierarchical top-down medical model to one that is person and family centered, collaborative, transparent, learning based, and supports community
The regulatory system must approach organizations that deliver long-term services and supports as learning partners who work together to advance and reward the pursuit of excellence and innovation and chronically poor performance is not tolerated.
The process of transforming the culture is a journey and not a destination as it takes time, is challenging, and ultimately is rewarding for all the stakeholders involved, especially those people the system is designed to serve.
There must be people within each system who are responsible for growing the culture that supports these principles.
Pioneer Values and Principles
Know each person
Each person can and does make a difference
Relationship is the fundamental building block of a transformed culture
Respond to spirit, as well as mind and body
Risk taking is a normal part of life
Put person before task
All elders are entitled to self-determination wherever they live
Community is the antidote to institutionalization
Do unto others as you would have them do unto you
Promote the growth and development of all
Shape and use the potential of the environment in all its aspects: physical, organizational, psycho/social/spiritual
Practice self-examination, searching for new creativity and opportunities for doing better
Recognize that culture change and transformation are not destinations but a journey, always a work in progress