Nearly 1,500 of Britain’s care homes will close by 2020 because of the financial crisis facing the sector, a new report predicts. The National Health Service (NHS) will be left with an annual bill of £3 billion (US$4.55 billion) after 37,000 care home beds disappear over the next five years, according to think tank ResPublica.

“Yes, I think inevitably we will have to sell homes, some of which will stay as nursing homes, but some of which will end up closed and changing their use. It’s not something we want to do,” the founder of private equity firm Terra Firma, Guy Hands, told the Guardian.

One such study, by the Harvard University economists David Cutler and Nikhil Sahni, estimates that “structural changes” in our health-care system account for more than half of the slowdown.

In a sense, Brad Stuart is one of those changes. He is a leader in a growing movement advocating home-based primary care, which represents a fundamental change in the way we care for people who are chronically very ill. The idea is simple: rather than wait until people get sick and need hospitalization, you build a multidisciplinary team that visits them at home, coordinates health-related services, and tries to nip problems in the bud. For the past 15 years, at Sutter Health, a giant network of hospitals and doctors in Northern California, Stuart has devoted himself to developing home-based care for frail, elderly patients.

(i.e. the Uk version of this plan is really simple – you build a multidisciplinary team that visits the elderly at home, coordinates health-related services, then robs from their estate to pay for their care at death).

For years, many people in medicine have understood that late-life care for the chronically sick is not only expensive but also, much too often, ineffective and inhumane. For years, the system seemed impervious to change. Recently, however, health-care providers have begun to realize that the status quo is what Stuart calls a “burning platform”: a system that is too expensive and inefficient to hold. As a result, new home-based programs are finally reaching the market, such as one launched about five years ago at Sutter, called Advanced Illness Management. “It’s much more feasible now to make a program like this work than it was a few years ago,” Stuart told me. “There are a lot of new payment schemes in the pipeline that are going to make this kind of program much easier to support.”

This is good news. Generalizing from a small sample is always perilous, but if what is happening at Sutter is any indication, a more humane, effective, and affordable health-care system is closer than we think.

The problem that home-based primary care addresses has been well understood for years. Thanks to modern treatment, people commonly live into their 70s and 80s and even 90s, many of them with multiple chronic ailments. A single person might be diagnosed with, say, heart failure, arthritis, edema, obesity, diabetes, hearing or vision loss, dementia, and more. These people aren’t on death’s doorstep, but neither will they recover. Physically (and sometimes cognitively), they are frail. Joanne Lynn, the director of the Altarum Institute’s Center for Elder Care and Advanced Illness, says that this “frailty course,” a gradual and medically complicated downslide, was once exceptional but is now the likely path for half of today’s elders.

Seniors with five or more chronic conditions account for less than a fourth of Medicare’s beneficiaries but more than two-thirds of its spending—and they are the fastest-growing segment of the Medicare population. What to do with this burgeoning population of the frail elderly? Right now, when something goes wrong, the standard response is to call 911 or go to the emergency room. That leads to a revolving door of hospitalizations, each of them alarmingly expensive. More than a quarter of Medicare’s budget is spent on people in their last year of life, and much of that spending is attributable to hospitalization. “The dramatic increase in costs in the last month of life is largely driven by inpatient hospital stays,” Helen Adamopoulos recently reported on MedicareNewsGroup.com. “On average, Medicare spends $20,870 per beneficiary who dies while in the hospital.”

Hospitals are fine for people who need acute treatments like heart surgery. But they are very often a terrible place for the frail elderly. “Hospitals are hugely dangerous and inappropriately used,” says George Taler, a professor of geriatric medicine at Georgetown University and the director of long-term care at MedStar Washington Hospital Center. “They are a great place to be if you have no choice but to risk your life to get better.” For many, the worst place of all is the intensive-care unit, that alien planet where, according to a recent study in the Journal of the American Medical Association, 29 percent of Medicare beneficiaries wind up in their last month of life. “The focus appears to be on providing curative care in the acute hospital,” an accompanying editorial said, “regardless of the likelihood of benefit or preferences of patients.”

Taler can attest to one of the more peculiar elements of this situation, which is that a better model—namely, providing care and support at home—has been known and used for decades. Taler himself pioneered an interdisciplinary house-call model in Baltimore in 1980, and in 1999 he co-founded a home-based primary-care program at Washington Hospital Center that has served almost 3,000 people. In the 1970s, the Veterans Administration (now the Department of Veterans Affairs) began  building a home-based primary-care program, which now operates out of nearly every VA medical center and serves more than 31,000 patients a day. This is not newfangled, untested stuff

The “frailty course,” a gradual and medically complicated downslide, was once exceptional but is now the likely path for half of today’s elders. Home-based primary care comes in many varieties, but they share a treatment model and a business model. The treatment model begins from the counterintuitive premise that health care should not always be medical care. “It’s not medical treatment, it’s helping meet personal goals,” Brad Stuart said. “It’s about ‘Who is this person, and what do they want in their life?

In Sutter’s Advanced Illness Management program, known as AIM, each patient is assigned to a team of nurses, social workers, physical and occupational therapists, and others. The group works under the direction of a primary-care physician, and meets weekly to discuss patient and family problems—anything from a stroke or depression to an unexplained turn for the worse or an unsafe home.

(This is not a freebie, and it is coming to the UK in a carbon copy form).

I sat in on some of these team meetings. A social worker and a nurse talked over a case and decided they needed to make a home visit together; a doctor suggested a medication change; the various members of the group compared notes on one patient’s hospitalization while discussing whether another’s 911 call might have been averted. Strikingly, patients were presented not as bundles of syndromes—as medical charts—but as having personal goals, such as making a trip or getting back on their feet. The team tries to think about meeting patients’ goals rather than performing procedures. An advantage of the multidisciplinary approach is that over time, as clients’ conditions change, the group can recalibrate the mix of services and providers, to avoid jarring transitions. “Once in AIM, always in AIM,” one coordinator told a patient’s family. Over several years, a person might move from independence and occasional social-worker visits to hospice care and finally death, all within AIM, and mostly at home.

One recent morning, while I was waiting at Sutter to accompany a nurse and a social worker on a home visit, the phone rang. It was a panicked caregiver whose charge had rectal bleeding. A case manager alerted the patient’s regular nurse so that she could make a visit right away, almost certainly averting a 911 call, and possibly an ambulance/ER/hospitalization ordeal. Later, in Washington, D.C., accompanying George Taler on house calls, I met a 92-year-old man afflicted with hypertension, blindness, gout, and diabetes, who had been in and out of the hospital before entering Washington Hospital Center’s home-care program in 2007, and who has not been back since.

Sutter figures that the program, by keeping patients out of the hospital whenever possible, saves Medicare upwards of $2,000 a month on each patient, maybe more. The VA, for its part, says its program reduces hospital days for its patients by more than a third and reduces combined costs to the VA and Medicare by about 13 percent.

But now we come to the business model, which has been problematic. For doctors, nurses, health systems, and insurers, providing in-home service costs money. Medicare pays for hospitalization, but it does not pay for much by way of in-home care, or for social workers, or for time spent coordinating complex cases and traveling to homes and talking with caregivers. Where in-home primary care has existed, it has tended to be a foundation-funded experiment, or a charitable project, or part of a vertically integrated system like the VA, which can capture any savings. The home-care program at Washington Hospital Center runs at a 30 percent loss. Meanwhile, hospitals lose “heads in beds,” and therefore revenue. Medicare—which is to say, taxpayers—may save money, but it has no mechanism either to track savings or to pay providers and insurers for hospitalizations that do not happen.

This is why Brad Stuart was frustrated for so many years. He could see the path forward, and others could see it, but it was blocked. Today, though, he’s feeling optimistic. The path is clearing.

(The path in the UK is extremely clear – sign over your house to us!).

lenin nightingale 2016



Could replacing nurses with nursing assistants pose risks to patients? Elizabeth Whitman, November 15, 2016: http://www.modernhealthcare.com

While swapping professional nurses for nursing assistants might seem less expensive for hospitals in the short term, new research suggests it’s associated with lower quality of care, increased patient risk and thus higher costs in the long run. The study, published in BMJ Quality and Safety, examined data from hospitals, patients and nurses in Europe. The richer the skill mix of nursing staff, the lower the mortality rates and odds of poor patient ratings or quality reports, it found, although it did not establish a causal relationship or identify specific mechanisms by which outcomes worsened.“Trying to substitute lower level people in an increasingly complex area is bound to have adverse clinical outcomes,” said lead author Dr. Linda Aiken, director of the Center for Health Outcomes and Policy Research at the University of Pennsylvania in Philadelphia. “Our study shows that it does.”

(Yet, the NMC welcomes “lower level people” into the “skills mix” of nursing, like the poodle of government it is).

(Suppose you were an idiot,  and suppose you were a member of the NMC, but I repeat myself).

(Their marketing is so good, they think they can get nurses to eat their own shit!).


  The NMC and Government – spot any difference?

The study drew on survey data from more than 13,000 nurses across 243 adult acute-care hospitals and more than 18,800 patients in 182 of those hospitals, and discharge data for more than 275,000 surgical patients in 188 of them. The hospitals were located in Belgium, England, Finland, Ireland, Spain and Switzerland.

“Nurses in hospitals with richer skill mixes have lower odds on reporting poorer quality care, lower patient safety, high burnout and job dissatisfaction,” the researchers found. Nurses were also more likely to recommend their hospitals and less likely to report problems involving patients including frequent pressure ulcers and falls with injuries. The researchers also found that substituting a nurse assistant for a professional nurse for 25 patients was associated with a 21% rise in the risk of dying.

(Please comment my dear NMC, you put on courses for  ‘nurse assistant  pretend nurses’ in nursing homes, to aleviate the debt problems of the private equity firms running them).

The study is salient at a time when hospitals are looking for ways to cut costs, including by changing the skill mix of nursing staff by hiring assistants with less training whom professional nurses would then supervise.

Those efforts have met with attempts at the state and federal level to mandate minimum levels of nurse staffing and skill mix levels. The Registered Nurse Safe Staffing Act has been repeatedly introduced in Congress, although it was never passed. More than a dozen states have enacted legislation or regulations governing the appropriate blend of nursing staff.

Changing nursing skill mixes is not the same as expanding scope of practice, which has also inspired proposals for changes in regulations. In May, for instance, the Veteran Affairs Department proposed authorizing advanced practice registered nurses to give care at the top of their licenses by providing services without clinical oversight from a physician.

The lowest-level credential in nursing is that of a certified nursing assistant — technically not a nurse — which typically requires a high school diploma and the completion of a state-approved program. CNAs provide basic care, such as bathing and transporting patients. In 2015, the median annual salary of a nursing assistant in the U.S. was $25,710.

Providers in the next tier, licensed practical nurses and licensed vocational nurses, must also complete a program, typically a year long. Their duties include registering patient vital signs and administering medications, earning a median salary of $43,170 per year in 2015 in the U.S.

Registered nurses must have an associate or bachelor’s degree, and they can assess patients, educate them and provide recommendations for care. In the U.S., their average salary was $67,490 in 2015.

Dump the bullshit. It’s all about cash!

“This is such an enticing idea, that we can solve our problems if we add lower-cost workers,” Aiken said. But, she added, it is “nurses that are driving not only the quality outcomes that hospitals are seeking, but these quality outcomes are associated with bottom-line performance.” She described nurses as “the surveillance capacity for hospitals,” the first to detect when something is not right with a patient and intervene before catastrophe ensues.

Joanne Spetz, a professor at the Institute for Health Policy Studies at the University of California at San Francisco, who was not involved in the research and had not read the study, pointed out that a variety of factors affect quality — financial problems at a hospital, for instance, or poor management — in addition to the skill mix of nurses.

“Maybe the registered nurses haven’t been trained well in supervising,” Spetz suggested, as one possibility. She suggested a deeper dive into data to see if any hospitals performed exceptionally well with a low skill mix — or exceptionally badly. That data could be more actionable, especially for hospitals whose budgets may leave them with little choice but to hire nurses with less training.


lenin nightingale 2016

So they are going to take your house from you ? – A proposal for an alternative.


Comments and development please!

Caring Community Care (CCC)


Community groups of carers  set up – suggest groups of 7, self-managing- all decisions made amongst selves, cover sickness amongst selves etc, no management layer.Trial periods- of individual and carer do not get on, change  carer.

Care provides eg shopping and company, take to toilet, meals or outings.

Could offer meals delivered for extra cost.

Everybody who signs to this- must have a camera recording care/ be inspected/ keep files in central location.

Team of carers have liaison numbers for services and relatives.


Training eg informal lifting and handling, hoist.

Recruit who they know and vetted by family. All carers within 10min walking distance of that persons home.


Team up with voluntary organisations for trips etc.

Could apply for voluntary status for help to take people out.


If eg one resident each, approach family- 60% of state pension will pay one week carer- each person has 2 people allotted to them, half week each.

Set it at £8 a hour- carer gets 7.5hrs each so recipient gets 35hrs a week.

One carer covers for sickness and holidays.

Rotational shift eg sat/sun/mon/tues one week- 4on, 3on, 3off,4off

No overheads/no agency fees/no sign house off.


Is a scam to say take house from you, in exchange for care.

Lenin Nightingale

Caring Community Care

Start the treble ‘C’ movement. If you need to know what to do- please ask Lenin.

In order to cut out the middlemen, who make profits on the back of home care, Lenin Nightingale proposes forming groups of carers within the community. Each person lives within walkking distance of where they live, about £8.50 a hour, cut administation costs, far less than agencies; under competition-rules LA have to accept lowest bid. Recruit people from families who support the use of cameras i care – ie use cameras in every room .

Have 7 people available- no one should work more than 4 days a week. Either 2/ 4 hours a day. Easy to set-up an off duty on that basis. If one is unwell- people agree to cover; or use  aback-upworker.

These people would deliver home-care in their own community eg voisists/shopping/washing. Key factors would need traiing eg moving and hadling- first aid.