Dr. Bill Thomas, Independence Officer, Lifespark

Dr. Bill Thomas is known for driving innovations such as the Green House model of long-term care and tiny Minka homes to empower aging adults. He has also served as chief wellness officer of Holiday Retirement, the nation’s largest provider of independent living communities, and today holds a role as Independence Officer for Lifespark.

Through the Vision Series, Dr. Thomas shares his vision for the health system of tomorrow with an emphasis on improved quality of care for older adults. He discusses the “twilight” of the hospital-centric health system of today, and explains the forces driving a major shift toward community and home-based care.

If you could change one thing about the current experience aging Americans face, what would that be, and why?

The issue of ageism is so big that we don’t even see it. To grow old in an ageist society is to place a social burden on top of the ordinary human process. As such, ageism is a larger problem than aging. Aging is a normal human process of growth and development. It’s not a problem. Ageism is the problem.

If I could live in a world or in a country where people experienced aging without ageism, I think the industry as a whole would be having very different conversations about the future.

Describe your vision for a health care system or an aging services system.

I’m actually following Florence Nightingale’s strategic advice, which is that hospitals are only an intermediate stage in the development of our society’s approach to health and wellness. We’ve confused an intermediate stage with a final stage, and there is some history to that concept.

Around 1910, Abraham Flexner published a report on the state of medicine in America, and it became very influential in driving the centralization and consolidation of health care. At that time, health care was a sprawling, uncontrolled cottage industry, and the Flexner Report led us toward the hospital-centric model we have today.

I’m not being critical of that report. I’m not saying it was a bad thing. I’m saying it was an intermediate step. Florence Nightingale had a vision that health care belonged at home; that home is where you would get the best health care. And maybe 170 years after her time, we are starting to see this change take place.

I think we’re approaching the twilight era of large, hospital-centered health care systems because those systems are expensive. They have continuing problems of quality, and they weren’t built for helping large populations of older people live good lives with multiple comorbidities.

Why would they be good at that? There isn’t a single thing about a hospital system that was designed from the ground up to help large populations of older people thrive. So it’s not the hospital’s fault. They were built to do a certain kind of job in a certain kind of reimbursement environment — primarily fee-for-service provided to a younger, healthier population. That doesn’t describe our situation today. Emerging from the mist is a home-based approach to health and wellness, designed from the ground up to help populations of older people thrive, at a lower cost, with better outcomes.

For a long time, skilled nursing, senior living and home-based care have all been treated as additions to the hospital-centric health system. We’re going to see a shift toward home- and community-based systems, where hospitals are the addition.

The next 10 years will be pivotal for both demographic and economic reasons. In art photography, there’s something called the decisive moment, and this decade is the decisive decade in health care. I expect an accelerating pace of change throughout the ’20s, especially coming out of COVID. It’s going to be very upsetting to some people, and very rewarding for others.

As that shift occurs, what do you see as the big opportunities for senior housing and care providers and operators?

This is a chance to raise your game. An approach that’s based almost exclusively on rate, occupancy and amenities is only enough to keep you in business. To play in this new world, your organization needs to become more sophisticated in how it handles data, information, systems, partnerships and collaboration with providers of more sophisticated services., You have to integrate all of that into your daily operations, which was not necessary when health care was outsourced to the hospital system.

We’re going to insource health care, and that means health care is going to come through our doors. We have to be ready to accommodate it in our daily operations, and to tell you the truth, I don’t see a lot of that happening yet.

What is the biggest hurdle to achieving better care?

People know what they know, and they do what they do, and there’s nothing wrong with that. People in our field need to learn more, faster than they ever have before. In the old days, if you kept up with surveys and regulations, you would be just fine. Now, that’s just table stakes.

Today, you have to get up to speed with new types of insurance products that come with risk, new systems for handling information, communication, interacting with larger entities on an equal basis, rather than being the subordinates of a larger health care system. You have to learn how to do that. Nobody just wakes up one morning knowing how to do that.

What role do you think technology is going to play in allowing people to age well and address some of the challenges you’ve brought up?

We’re all products of an era based on the centralization of expertise. Of course, we see that in hospital systems, but we also see it in senior living, where a management company or an entity tries to put together 30 or 50 or 100 communities, attempting to centralize expertise in a way that will make their operations more efficient and higher quality. That’s always been the play.

What’s happening with technology is that we’re beginning to learn how to decentralize expertise. A classic example is hospital at home.

Hospital at home decentralizes some of the expertise that was historically exclusive to hospitals — it decentralizes it into the context of people’s homes and their communities. Hospital at home is useful, because it’s really clear. It happened because we decentralized expertise, and we have the tools and technology to deliver that expertise in a different setting.

There’s going to be a lot more decentralization of expertise, and that’s the great promise yet to be realized. That’s a great promise of technology and information in our sector that will flow toward homes and communities, and we have to be ready for that. If you don’t get ready for that, you’re going to get left behind.

How do we handle facilitating care transitions, and continuity of care, and who is in charge of that?

We’re emerging from an era that followed a fee-for-service mentality, where services were exclusively defined in terms of clinical expertise. It rewarded ever-greater specialization, which has some advantages, but it also created a system with a growing number of gaps between episodes of care. The fee-for-service system never paid to help people navigate the gaps between services.

I don’t know if your family has any experience with this, but if and when you do, you won’t like interacting with a health care system where, “Hey, the cardiologist was great, but now we’re in this gap in between another episode of care, and we’re really on our own.” In that old economic model, nobody was responsible or compensated for contending with the gaps between episodes of care.

The first attempt to deal with this was looking at the horrendous data on re-hospitalization of older people. That’s blatant evidence of lack of coordination, and that’s what we’re leaving behind.

The new financial architecture is increasingly being built around risk, so you have risk-oriented, value-based reimbursement, which the federal government also desires.

The federal government is trying to use policy levers to make sure somebody is incentivized to help people manage these gaps in care. We’re talking about a health care system-centric language where the emphasis is on reimbursable episodes of care, and what happens “in the gaps” is none of their concern.

We want a system where whoever’s holding the risk is incentivized to attend to the whole experience, because … there shouldn’t be gaps in care, there should be an experience that a person has with health and wellness, and it is managed as one experience.

In our field, when we talk about gaps in care, we’re actually embracing the broken language of the hospital-centered era by saying the … gaps are just empty spaces. But the gaps aren’t empty spaces, the gaps are real people.

This is why we need to move past that language, and I think we’re equipped to do this. Think about the whole-person experience instead of trying to navigate gaps in care. That’s a failed strategy, in my opinion.

Give our older readers and their families some advice for successfully navigating this twilight era of the current system.

On the most general level, if you talk to older people, they want to be supported in their homes and communities—it’s nearly universal. Older people should advocate for what they want, which is support and services in the home and community.

Second, I recommend doing a little research on what kinds of insurance products incentivize people to take care of you as a whole person, and what products incentivize systems to divide you up into a bunch of little discrete diagnoses and parcel you out to the specialists. They’re different, and you need to understand which products are aligned with giving you what you really want, and which products are aligned with giving the hospital system what it really wants. You have to learn to tell the difference between the two.

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