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48–150 PDF 2009

S. HRG. 110–808 

PERSON-CENTERED CARE: 

REFORMING SERVICES AND BRINGING OLDER 

CITIZENS BACK TO THE HEART OF SOCIETY 

HEARING 

BEFORE THE

SPECIAL COMMITTEE ON AGING 

UNITED STATES SENATE 

ONE HUNDRED TENTH CONGRESS 

SECOND SESSION 

WASHINGTON, DC 

JULY 23, 2008 

Serial No. 110–33 

Printed for the use of the Special Committee on Aging 

( 

Available via the World Wide Web: http://www.gpoaccess.gov/congress/index.html 

SPECIAL COMMITTEE ON AGING 

HERB KOHL, Wisconsin, Chairman 

RON WYDEN, Oregon 

BLANCHE L. LINCOLN, Arkansas 

EVAN BAYH, Indiana 

THOMAS R. CARPER, Delaware 

BILL NELSON, Florida 

HILLARY RODHAM CLINTON, New York 

KEN SALAZAR, Colorado 

ROBERT P. CASEY, Jr., Pennsylvania 

CLAIRE McCASKILL, Missouri 

SHELDON WHITEHOUSE, Rhode Island 

GORDON H. SMITH, Oregon 

RICHARD SHELBY, Alabama 

SUSAN COLLINS, Maine 

MEL MARTINEZ, Florida 

LARRY E. CRAIG, Idaho 

ELIZABETH DOLE, North Carolina 

NORM COLEMAN, Minnesota 

DAVID VITTER, Louisiana 

BOB CORKER, Tennessee 

ARLEN SPECTER, Pennsylvania 

DEBRA WHITMAN, Majority Staff Director 

CATHERINE FINLEY, Ranking Member Staff Director 

(II) 

C O N T E N T S 

Page 

Opening Statement of Senator Herb Kohl ............................................................. 1 

Statement of Senator Gordon H. Smith ................................................................. 2 

Statement of Senator Robert P. Casey .................................................................. 3 

Statement of Senator Ron Wyden .......................................................................... 6 

PANEL I 

Statement of William Thomas, M.D., Professor, Erickson School of Aging 

Studies, University of Maryland, Ithaca, NY .................................................... 8 

Statement of Robert Jenkens, Director, Green House Project, NCB Capital 

Impact, Arlington, VA .......................................................................................... 16 

Statement of Melinda Abrams, M.S., Assistant Vice President, Patient-Centered Primary Care, The Commonwealth Fund, New York, NY ...................... 29 

Statement of Eric Coleman, M.D., MPH, Director, Care Transitions Program, 

University of Colorado, Aurora, CO ................................................................... 66 

PANEL II 

Statement of Zoe Holland, Daughter of a Former Green House Resident, 

Lincoln, NE ........................................................................................................... 85 

Statement of Edna Hess, Shahbaz, Lebanon Valley Brethren Home, Palmyra, 

PA .......................................................................................................................... 94

Statement of Diana White, Ph.D., Senior Research Associate, Institute on 

Aging, Portland State University, Portland, OR ............................................... 103 

APPENDIX 

Testimony submitted by Assisted Living Federation of America (ALFA) ........... 120 

Statement submitted by AARP ............................................................................... 123 

(III) 

(1) 

PERSON-CENTERED CARE: REFORMING SERVICES AND BRINGING OLDER CITIZENS BACK 

TO THE HEART OF SOCIETY 

WEDNESDAY, JULY 23, 2008 

U.S. SENATE

SPECIAL COMMITTEE ON AGING

Washington, D.C. 

The committee met, pursuant to notice, at 11 a.m. in Room SD– 

562, Dirksen Senate Office Building, Hon. Herb Kohl (Chairman of 

the committee) presiding. 

Present: Senators Kohl [presiding], Wyden, Lincoln, Casey, 

Whitehouse, and Smith. 

OPENING STATEMENT OF SENATOR HERB KOHL 

The CHAIRMAN. Good morning, and we thank you all for being 

here this morning. 

This morning, I will be very pleased, along with Senator Smith, 

to turn the gavel over to our colleague Senator Casey. While serving as Pennsylvania’s auditor general for 8 years, Senator Bob 

Casey worked to improve the nursing homes in his State, making 

them safer and exposing holes in State oversight. We are very 

grateful to have him on the Aging Committee, and we are pleased 

that he is holding today’s hearing. 

The issue we will consider today is one that should seem obvious. 

When providing someone with healthcare or long-term care, our 

first consideration should always be that particular individual’s 

needs and desires. This is known as person-centered care. What a 

very simple idea. 

Unfortunately, our health and long-term care industries have 

grown so complex that such a straightforward concept has gotten 

lost and, to some, providing personalized care with the individual 

senior in mind has become inconvenient. 

Twenty-one years ago, Congress passed a landmark nursing 

home reform known as OBRA 87. OBRA laid the foundation for 

person-centered care. Today, Senator Casey will examine facilities 

called ‘‘Green Houses’’ that are successfully implementing personcentered care. Green Houses that are successfully implementing 

person-centered care are all too rare. 

We will also hear about the medical home model that CMS is exploring, which reorganizes the way that physicians, nurses, and 

others work together to tailor services to each individual. Finally, 

the Committee will explore ways to make it easier for other nursing homes to move forward toward these model programs. 

2 

It is clear that within the realm of long-term care there are many 

more choices available today than there were just 20 years ago. We 

are very pleased to see this expansion of options, and we are very 

hopeful that this trend will continue. 

The Aging Committee has a long and a proud history of moving 

Congress forward on issues of long-term care. So we thank you 

once again, Senator Casey, for taking us a step further with today’s 

hearings. 

We turn now to the Senator’s Ranking Member, Senator Smith. 

STATEMENT OF SENATOR GORDON H. SMITH 

Senator SMITH. Thank you, Chairman Kohl. 

Senator Casey, we thank you for bringing this important issue 

to the attention of this Committee. As debate continues on 

healthcare reform, we often find ourselves embroiled in discussions 

of cost control and payment reform, and too often forget the people 

our reforms are intended to serve. 

The recent debate over this year’s Medicare legislation was an 

excellent example of how we can make necessary policy adjustments while improving the Medicare program for our seniors. I 

look forward to today’s discussion as it is in keeping with this positive trend of placing the care of the person at the center of 

healthcare policy discussions. 

We have an impressive list of witnesses today, all of whom will 

share with us their perspective on person-centered care. I want to 

extend a personal welcome to Dr. Diana White, who flew all the 

way from Oregon to be with us today. Dr. White will share with 

us some of the initiatives going on in Oregon and provide recommendations garnered from the lessons learned. 

As an Oregon Senator, I am very proud of our State’s healthcare 

system. We have a large number of community-based care choices, 

including home care, hospice, and other services. The diversity in 

care options and our State’s continued emphasis on providing a variety of services has supplied Oregonians with one of the Nation’s 

best healthcare systems. 

The Oregon model has a strong collaborative philosophy and is 

designed to get individuals the appropriate care in the settings that 

best meet their needs. Oregon’s system lends itself in many ways 

to the philosophy of person-centered care. Similarly, person-centered care focuses on the inherent value of each individual and emphasizes the importance in relationships between caretakers and 

receivers. 

As we look for new ways to provide quality care for our seniors, 

examining concepts and philosophies like the ones discussed today, 

will help us all make informed decisions. Our seniors deserve the 

very best. If we can design public policies that maximize choice, autonomy, and relationships between caregivers and receivers, I believe this can go a long way in helping to improve the quality and 

dignity of care our seniors receive. 

I am committed to looking at all of the alternatives that will help 

our dedicated health professionals in providing the highest quality 

of care to their patients. To that extent, I welcome the opportunity 

this morning to learn more about person-centered care and the potential contributions it could hold in providing improved quality 

3 

and increased satisfaction of seniors in outpatient and long-term 

care settings. 

So, with that, I turn back to you, Mr. Chairman and Senator 

Casey. 

The CHAIRMAN. Thank you very much, Senator Smith. 

Senator Casey. 

STATEMENT OF SENATOR ROBERT P. CASEY 

Senator CASEY [presiding]. Mr. Chairman, thank you very much. 

I appreciate your willingness to bring us together today for this 

hearing and for your leadership on this Committee that, frankly, 

we don’t hear enough about these issues in the public press, and 

we are grateful for the opportunity you are giving us today. The 

families of America, older citizens across this country, as well as 

the witnesses who are here, we will all benefit from the wisdom 

and the insight and the experience that these witnesses bring to 

bear on this important issue. 

I want to thank Chairman Kohl and thank him again for his 

leadership, and Ranking Member Smith as well for being with us 

today. 

I know we are joined by Senator Wyden, long a leader and an 

active voice on this issue of how we care for and honor older citizens. 

I wanted to thank the witnesses for your presence, your scholarship, your experience, but also for your willingness to travel. We 

have witnesses as far away as Oregon, Colorado, Nebraska. We 

have some Pennsylvanians here, as well as some from the State of 

New York as well. We thank you for that. 

We want to highlight today the issue that both Senator Kohl and 

Senator Smith mentioned, which is person-centered care, reforming 

services and bringing older citizens back to the heart of society. I 

guess we should talk about the philosophy that brings us together 

today. It is very simple. Older citizens deserve to live lives of dignity and respect at all stages of their lives. 

I was recalling this morning what was written in the Philadelphia Inquirer 10 years ago in a series about long-term care. A writer by the name of Michael Vitez, V-I-T-E-Z, a good man and a good 

writer. In the middle of one of his stories in a series, he said, and 

I quote—and he was referring to experts in the field. ‘‘Life can have 

quality and meaning even until the very last breath.’’ He was using 

as his foundation for that statement those who were experts. 

I think that is critically important to remember today. No matter 

how old someone is, no matter what stage of life they are in, their 

life has quality and meaning until the very last breath. Elders have 

a profound right to be decisionmakers in their own care, to be at 

the center of their own care with a partnership of family and providers. 

Older citizens are critically important to the overall health and 

well being of our society. I quote one of our witnesses today, Dr. 

Bill Thomas, and in fact, our hearing title today borrows from a 

phrase of his. ‘‘People of all ages will live better lives when we succeed in bringing elders back to the heart of our society.’’ A wellcrafted summation of what we are doing today, that we have to 

bring them back to the heart of our society. 

4 

I will ask that my full statement be made part of the record, but 

I did want to review a couple of areas of my statement before I 

turn to our other colleagues. 

[The prepared statement of Senator Casey follows:] 

PREPARED STATEMENT OF SENATOR ROBERT P. CASEY, JR. 

Good morning everyone and thank you all for being here. I want to thank Chairman Kohl for the opportunity to call this hearing today and I’d like to give a warm 

welcome and tremendous thanks to the witnesses we have with us today— some of 

whom have traveled from as far away as Oregon, Colorado and Nebraska, others 

from PA and NY. Thank you all for taking the time to be here and for your tremendous expertise and commitment to the work we’ll be discussing. 

Our hearing is called ‘‘Person-Centered Care: Reforming Services and Bringing 

Older Citizens Back to the Heart of Society.’’ What do we mean by person-centered 

care? It is both a philosophy of care as well as the defining principle of several exciting and specific initiatives within health care and long term care for older citizens. 

The philosophy is simple: Our older citizens deserve to live lives of dignity and respect through all stages of life. About 10 years ago, the Philadelphia Inquirer reported, ‘‘Life can have quality and meaning even until the very last breath.’’ Elders 

have a profound right to be decision-makers in their own care—to be at the center 

of their own care, with a partnership of family and providers. Our older citizens are 

critically important to the overall health and well being of our society. I quote one 

of our witnesses today, Dr. Bill Thomas, and in fact our hearing title borrows a 

phrase from the following quote of his, ‘‘People of all ages will live better lives when 

we succeed in bringing elders back to the heart of our society.’’ 

In recent years, this philosophy of person-centered care has been translated into 

very specific action. This morning we will hear testimony about person-centered care 

within two types of settings: (1) outpatient care for older citizens living on their own 

or in assisted living, and (2) long term residential care in nursing facilities. I think 

you will find this testimony fascinating, enlightening and inspiring. We have with 

us experts in policy and academia and medicine. We also have the ultimate experts—family members and direct care workers. All these individuals will testify 

about how person-centered care has transformed their professional and personal 

lives. 

In hearings before the Aging Committee, we frequently hear the statistics, and 

they are alarming, about the increase in Americans over the age of 65. We currently 

have an estimated 38 million Americans in this age group, and that number is expected to double within the next twenty years. In the midst of this, health care costs 

are rising exponentially, the quality of outcomes is not consistent, older citizens are 

often abandoned to navigate a confusing and complex health care system. Also, older 

citizens report extremely low levels of satisfaction with life in nursing homes. This 

$122 billion industry includes 16,000 nursing homes and significant concerns persist 

about maltreatment and neglect of our older citizens in 20% of these homes. As I 

know from my work in state government, most nursing homes provide quality care 

but that 20% is what we hear most about. However, a recent survey by the AARP 

found that fewer than 1% of individuals over 50 with a disability want to move to 

a nursing home. There has to be a better way, and in fact there is. 

Person-centered care provides that better way. It is a straightforward concept and 

yet it has taken years of hard work to get concrete initiatives underway. We have 

a long way to go and much to learn. But in order to succeed, we must also examine 

why this kind of culture change is difficult. 

Part of the answer is that our current systems for health care and long term care 

are neither structured nor rewarded for person-centered care. Medicare offers financial incentives for scheduling multiple patients and single services, not coordinating 

complex care and providing counseling and genuine partnership in care. This is 

unsatisfying for both patients and practitioners—and can even be dangerous or 

deadly. The NY Times contained a report Monday about a Philadelphia man, Robert 

Williamson, who received a cursory primary care exam which missed the danger 

signs of an oncoming stroke that Mr. Williamson suffered a short time later. Not 

only did Mr. Williamson suffer a severe health crisis, he incurred $30,000 in hospital costs and had to go on disability at a cost of $1,900 per month. 

The number of primary care or ‘‘family’’ physicians, those who traditionally have 

an ongoing relationship with patients and their family members and the greatest 

understanding of comprehensive needs, is decreasing. The American Academy of 

Family Physicians reports a 50% decline in medical students choosing family medicine. Primary care physicians get lower reimbursements from Medicare and need to 

5 

see increasing numbers of patients, in already over-crowded schedules, just to stay 

afloat financially. 

In residential care, nursing facilities require residents to revolve around institutional schedules for such personal preferences as waking, bathing and dressing, far 

too often identifying residents by their health conditions, vulnerabilities and room 

numbers rather than their unique strengths and gifts. Staff members attracted to 

the field of direct care service because they want to help older citizens are just as 

ill-served by this institutionalized culture as are the residents. Workers are minimally trained, over-worked and carry patient loads that make it impossible to engage in any personal time with residents—in fact, such relationships are often discouraged. They have little or no say in decision-making, relegated—like the residents—to the fringes of a system that places the needs of the institution over those 

of the human beings in it. 

The majority of our health care and long term care systems are missing a critical 

element in caring for our older citizens—and that is the importance of relationships. 

Elder care has become entrenched in habits and methodology and reimbursement 

policies that are more suited to ‘‘one size fits all’’ than to personalized, individualized care. We reimburse physicians on the number of patients they can see in a day 

rather than engaging older citizens and their family members in a partnership of 

care. We evaluate direct care workers on the number of pills they can dispense in 

an hour, rather than the joy they can engender in the life of an older individual. 

Of course the culture change of person-centered care involves more than just an 

emphasis upon relationships, and we will hear much about its specific requirements 

here this morning. But changing the way we care for older citizens does not need 

to be difficult. We have to stop engaging in ‘‘business as usual’’ and look at what 

is working. That is why I chose to hold this hearing and will devote a great deal 

of attention to this issue here in the Senate. That is why I will be introducing a 

bill that will provide loan funding for long term nursing facilities that commit to 

the principles of person-centered care. 

The movement toward person-centered care has been called a revolution. But although it is revolutionary and ‘‘new’’ in what we are doing, it is also a profound return to the bedrock values of respecting our older citizens and living the golden rule. 

It’s also about peace of mind for family members. The pioneers of this revolution— 

and we are fortunate to have many of them with us here today—show us how we 

can enrich the lives of both our older citizens and everyone around them. I am so 

grateful to them for their willingness to believe in something better, for their courage and persistence in engaging very entrenched systems in innovative change. 

They are here today to tell us how to create change in very specific and successful— 

terms, focusing in particular on the outpatient ‘‘Medical Homes’’ model and the 

‘‘Green House’’ model for in patient residential care. Since serious conditions often 

lead to hospitalizations and periodic rehabilitative care for older citizens, we will 

also hear testimony about how to best navigate such transitions within a culture 

of person-centered care. 

The solutions we will hear this morning are win-win for everyone. They provide 

older citizens and their families with better care, better outcomes, and more enjoyable lives; they provide direct care workers long-overdue respect and job satisfaction; 

they allow health care practitioners to meet the comprehensive needs of their patients; and they save money in the long run. 

Senator CASEY. The majority of our healthcare and long-term 

care systems are missing a critical element in caring for older citizens, and that is the importance of relationships. Just one word, 

but so powerful and so profound for today. 

Elder care has become entrenched in habits and methodology 

and reimbursement policies that are more suited to one-size-fits-all 

than to personalized, individualized care. We reimburse physicians 

on the number of patients they see in a day rather than engaging 

older citizens and their families in a partnership of care. We evaluate direct care workers on the number of pills they can dispense 

in an hour rather than the joy they can engender in the lives of 

an older individual. 

The movement toward person-centered care has been called a 

revolution. But although it is revolutionary and new in what we 

are doing, it is also a profound return to the bedrock values of reVerDate Aug 31 2005 14:42 Apr 27, 2009 Jkt 000000 PO 00000 Frm 00009 Fmt 6633 Sfmt 6633 H:\DOCS\48150.TXT SAG PsN: JOYCE
6 

specting our older citizens and living the golden rule. It is about 

peace of mind for families and family members. 

The pioneers of this revolution, and we are fortunate to have 

many of them with us today, show us how we can enrich the lives 

of both older citizens and everyone around them. I am so grateful 

to them for their willingness to believe in something better, the 

people who are here providing testimony and supporting the testimony, for their courage and persistence in engaging very entrenched systems in innovative change. 

Finally, the solutions we will hear today are a win-win for everyone. They are a win for older citizens, a win for those who provide 

the care, and for family members. These changes and these solutions provide older citizens and their families with better care, better outcomes, and more enjoyable lives. They provide direct care 

workers with long-overdue respect and job satisfaction. They allow 

healthcare practitioners to meet the comprehensive needs of their 

patients, and they save money in the long run. 

In the end, and I will conclude with this, what we are doing 

today is, in a larger sense, paying tribute to and affirming the contribution of those who have gone before us, older citizens in our societies, those who fought our wars, who worked in our factories, 

who taught our children, who gave us life and love. The least that 

we can do is to stay focused on better ways to make sure their care 

is the best that it can be and especially to affirm the good work 

that is done by healthcare practitioners and, of course, the direct 

care workers who provide most of the daily and hourly care to older 

citizens. 

So, Mr. Chairman, we thank you for your leadership and for this 

opportunity today. Thank you very much. 

Now I have the honor and the privilege, as of chairing this hearing in my about 18th or 19th month in the Senate, to be able to 

call on a witness, and I appreciate the Chairman allowing me to 

do that. 

I want to call on now another Senator from the State of Oregon, 

someone I have known for several years now and someone who has 

been a leading voice on these issues, Senator Ron Wyden. 

STATEMENT OF SENATOR RON WYDEN 

Senator WYDEN. Thank you. Thank you very much, Mr. Chairman. 

I want to commend you, Senator Casey. Thank you for your very 

fine statements, Chairman Kohl and Senator Smith. 

I will be very brief. I think what is striking about this—and Ms. 

Abrams touches on it in her opening statement—is that when you 

look at the debates that we are now having in this country about 

healthcare, it seems that so often the patient is almost an afterthought. 

You hear constant references to the providers, to the insurances 

companies, to various payers and budget experts, and at the end 

of the discussion, you wonder where does the patient really fit in? 

I know in the Senate Finance Committee—Senator Smith and I 

are part of the Finance Committee—we had a long discussion last 

week about health information technology, a very exciting development. We also discussed something known as comparative effecVerDate Aug 31 2005 14:42 Apr 27, 2009 Jkt 000000 PO 00000 Frm 00010 Fmt 6633 Sfmt 6633 H:\DOCS\48150.TXT SAG PsN: JOYCE
7 

tiveness analysis so that you could see, for example, which provider 

gave the best-quality services and at what price. These are all very 

useful tools. 

But after something like 2 hours’ worth of discussion, I asked 

how does the patient fit into all of this? We have heard about why 

it makes sense for the budgets and for payers and insurance companies. How would you actually get the fruits of these wonderful 

technologies to patients and their families in a usable fashion? 

So that is why I think it is very, very helpful that Senator Casey, 

with the bipartisan leadership of our Committee, is looking at care 

that is patient-centered. This topic and this hearing give us a 

chance to elevate the concerns of patients so that at least they get 

up to the same plateau as concerns of providers, budget experts, insurance companies, and others. 

The Healthy Americans Act is the first bipartisan universal coverage health bill in the history of the Senate—we have now got 16 

Senators, 8 Democrats and 8 Republicans. Senator Smith, I am 

pleased to say, is one of our group. What we do is establish what 

is called a ‘‘healthcare home.’’ We don’t call it a medical home because we want to convey to the world that nurses and physician 

assistants and others should also be in a position to do the good 

work that Senator Casey has described this morning. 

As this debate goes forward about a medical home—what I call 

a health home and I am going to ask several of you witnesses to 

talk particularly about how we can make sure that this concept 

really gets embedded in the health reform efforts. I think it really 

is one of the best ways to follow up on this idea of a patient-centered universe in healthcare. 

Thank you Senator Casey for this hearing, your leadership and 

especially for making sure that the patient isn’t an afterthought in 

this debate. 

Senator CASEY. Thank you, Senator Wyden. We are grateful for 

your leadership as well. 

I think we will go to our witnesses now, and I think it will start 

on my left. I think what I will do is just introduce the witnesses 

as they testify. 

First of all, Dr. William Thomas is a Professor at the Erickson 

School of Aging Studies, University of Maryland. He is the Founder 

of the Green House model. He is a resident of the State of New 

York. To say he has been an innovator and a pioneer is a dramatic 

understatement. 

He is a Harvard-trained medical doctor and also known in some 

circles as a ‘‘gentleman farmer.’’ I will have him explain that if he 

wants to at some point. But, Doctor, we are grateful for your presence here today and your testimony, and we will start off with you. 

We are going to try to keep, as best we can, our witnesses to 5 

minutes. Of course, each of your statements will be made part of 

the record. We will start with you, Dr. Thomas. 

8 

STATEMENT OF WILLIAM THOMAS, M.D., PROFESSOR, 

ERICKSON SCHOOL OF AGING STUDIES, UNIVERSITY OF 

MARYLAND, ITHACA, NY 

Dr. THOMAS. Thank you, Senator Casey. Thank you to the Committee for having me. 

I actually always like to take a question of public policy and dig 

into the history. It is fascinating to me. As I was preparing my remarks, I went back across the history of medicine and healthcare 

in America, and it is fascinating to look at healthcare in America 

in the 19th century. 

In the 1800’s, it was a wild and woolly environment out there, 

with just about anybody who wanted to could call themselves any 

kind of doctor or practitioner they wanted to. Families, consumers, 

patients really had no way of knowing if this snake oil salesman 

was really going to offer them some kind of cure or not. I will give 

you one little anecdote from that era, which I found fascinating. 

The early—when oil was discovered in western Pennsylvania, the 

first use it was put to was as a patent medicine. Some enterprising 

souls in western Pennsylvania began collecting the oil that was 

running in the streams out there and selling it as a medicine. That 

didn’t work out so well. So this whole petroleum thing took over 

instead. 

But in 1910, a man named Abraham Flexner, with the support 

of the Rockefeller family, actually conducted a detailed analysis of 

medicine in America, and his findings were, as I have described to 

you, crazy. He recommended that we standardize American medicine and much in the same kind of way that the petroleum or oil 

industry was being standardized. 

As a result, for the very first time, there were specific requirements for physicians to go to medical school. That was new. To actually have faculty who were doctors, that was new. To actually see 

patients, that was new. All of this was new. The modern medical 

school was born in the early 1900’s. 

The result of that, I am really happy to say, was a dramatic improvement in the healthcare made available to American citizens 

because now you had people who were actually trained in what 

they were trying to do. There was real research going on, and we 

began to see real improvements in our health and healthcare. 

The other thing that happened as a result of this improved attention to kind of training and prestige, the reputation of the doctor 

changed from possibly snake oil salesman, ‘‘I don’t know about this 

person,’’ to a respected member of the community. In fact, there are 

some really wonderful pieces of art that are created in the early 

20th century kind of showing physicians in very kind and caring 

and compassionate roles. 

We began to match that new social role with some tremendous 

technology—the development of antibiotics, effective immunizations, effective surgical techniques. Medicine went through a stunning transformation. With each new development, the stature of 

the doctor rose higher and higher and higher. 

In fact, I was a medical student in the 20th century, and when 

I began my training, it was customary for nurses to rise from sitting when a doctor entered into the room. That was a courtesy that 

was extended to physicians in part because of this high prestige. 

9 

In fact, there was a joke that went around medical schools at 

that time, which I will repeat here because you guys didn’t go to 

medical school so—what is the difference between God and a surgeon? God doesn’t think he is a surgeon. 

So what happened is we developed a ‘‘doctor knows best’’ kind of 

culture, where patients were expected to defer to the expert judgment of the physician. I think that worked well at the time. You 

know, it had its advantages, but we live in a very, very different 

world now. I want to lay out for the Committee just the basic elements that are changing so you know where the policy—where this 

policy impulse is coming from. 

First off, medical information is now available to everybody all 

the time, everywhere. Some of it is very good on the Internet, and 

some of it is very bad. But people have access to information in 

ways that were unimaginable in the 1960’s, 1970’s, and 1980’s, you 

know, before the information boom. 

Physicians are now regularly dealing with patients who have 

sometimes as much information as they do about new drugs and 

new treatments and new therapies, and it is changing the relationship between doctor and patient. 

Also—and I think this is very, very important—we are the inheritors of a system that was built on acute medical care. The system was created and optimized to provide immediate urgent treatment to illness and injury, and it is good. 

The problem is we are living in a society where more and more 

people spend more and more of their lives managing chronic illness. The ongoing management of chronic illness requires a different relationship between doctor and patient than the immediate 

urgent treatment of an illness or injury. 

So we are changing away from an acute care oriented system toward a chronic care oriented system, and social roles are going to 

have to change to accommodate that. 

Next, what used to be—the doctor in Sayre, PA, the Dr. Robert 

Packer hospitals started by Dr. Robert Packer, OK? There you go. 

It used to be clear exactly where you went for the answer. Now it 

is confusing. 

In fact, Dr. Robert Kane, who is a well-known expert in the field 

of aging and public policy in aging, wrote a book about how difficult 

it was for him, an expert in the American healthcare system, to 

navigate when his mother became ill, and he was not the expert, 

he was the son of a woman who needed help. So what we find is 

that both doctors and patients are increasingly struggling with the 

complexities of the system we have created. 

Finally, there is a need to put patients, as has been mentioned 

in the opening comments, at the center of what we do. There is a 

pretty exciting thing that happens when people like me and the 

other people in the hearing room here get to develop new models 

based on patient centeredness. That is what is different. That is 

what is new. That is what has changed. 

I am not here today to talk to you about making a nursing home 

a better nursing home. I am here today to talk to you about transcending that older model with a new patient-centered model and 

reaping the benefits of that change. 

10 

So—and you will hear more about this in detail as we go along, 

but the medical home concept, I really want to say, I trained in 

family medicine. My sympathies are entirely with providing people 

with a healthcare home where they—home-based, where they can 

go and get reliable information from people with whom they have 

a relationship. 

Senator CASEY. Doctor? 

Dr. THOMAS. Yes? 

Senator CASEY. I just want to cut you short because we are over 

by more than 3 minutes. 

Dr. THOMAS. On time? No worries. 

Senator CASEY. I want to—we won’t penalize you today. But— 

[Laughter.] 

Dr. THOMAS. I thank you for giving me time, and I am sorry I 

went on so long. 

[The prepared statement of Dr. Thomas follows:] 

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Senator CASEY. That is OK. Maybe we will give others a little 

warning. 

Senator Whitehouse is here from the State of Rhode Island. I 

don’t know if he wants to offer a statement now or whether you 

want to do a statement later? 

Senator WHITEHOUSE. I am more than happy to hear from the 

witnesses and not deliver a statement. 

Senator CASEY. That doesn’t always happen in this place. 

[Laughter.] 

Thank you, Senator Whitehouse. 

Senator WHITEHOUSE. Maybe it will catch on. 

Senator CASEY. Let me move to our second witness. 

Robert Jenkens is here, and he is the Director of the Green 

House Project. 

Just by way of background, Mr. Jenkens serves as Vice President 

of the subsidiary of NCB Capital, the Community Solutions Group. 

He directs the Green House Project and the Coming Home Program, and I know we are going to be hearing—have a chance to 

ask some questions about all of these and about the elements of the 

Green House, what characterizes the Green House. 

But, Mr. Jenkens, if you have a chance, we will try to give you 

5 to 6 maybe. Thank you very much. 

STATEMENT OF ROBERT JENKENS, DIRECTOR, GREEN HOUSE 

PROJECT, NCB CAPITAL IMPACT, ARLINGTON, VA 

Mr. JENKENS. Thank you, Senator Casey, Chairman Kohl, Ranking Member Smith, and other members of the Committee for this 

opportunity to share with you information about one successful 

model of person-centered care, The Green House Project. 

I am Robert Jenkens, Director of the Green House Project. The 

replication of The Green House model is a partnership between 

NCB Capital Impact, the Robert Wood Johnson Foundation, Bill 

Thomas, and the early pioneering providers who have joined with 

us in this effort. 

Person-directed care is about creating a place where people live 

lives on their own terms while receiving the care they need with 

dignity and control. Today, I want to share a brief overview of The 

Green House model, our research, challenges, and what Congress 

can do to help. 

Edna Hess and Zoe Holland will speak on the next panel about 

their personal experiences with The Green House homes and how 

they transform the lives of elders and staff. Additional detailed information is available in my written statement. 

The Green House model reinvents nursing homes to make them 

real homes. Not home-like, but real homes with the control, choice, 

and flexibility that you or I expect when we get home. To do this, 

the model changes three areas—the environment, the organization, 

and the philosophy of care typically found in skilled nursing homes. 

This comprehensive and integrated approach is key to the model’s 

success. 

The environment in The Green House homes is a small, warm, 

and fully independent home with an open common area with a 

kitchen, dining room, and living room at its core, surrounded by 10 

to 12 private bedrooms, each with a private bath and all the supVerDate Aug 31 2005 14:42 Apr 27, 2009 Jkt 000000 PO 00000 Frm 00020 Fmt 6633 Sfmt 6633 H:\DOCS\48150.TXT SAG PsN: JOYCE
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port areas necessary, each organized to meet skilled nursing home 

requirements and building standards. 

At the core of the philosophy is creating an environment where 

people living and working in the home are in control of their lives 

and have the chance to get to know each other. When you have 

control and know someone well, you can better understand and 

meet their individual needs and preferences. 

The organizational design restructures staff and flattens the 

management of traditional nursing homes. It is an empowerment 

workforce model where direct care staff called Shahbazim work in 

self-managed teams. The Shahbazim are certified nursing assistants with 120 hours of additional training. They provide and manage all the critical tasks of running the household—providing care, 

cooking, cleaning, and doing the laundry. 

Self-management and the universal worker approach leverage 

the Shahbazim’s great capacity, creativity, and compassion to create a flexible environment and schedule that meets individual preferences. Just as at home when we care for a small number of people we truly know and care about, we find ways to accommodate 

and celebrate their individuality. The organization’s clinical staff 

continues to provide skilled services using the best practices we 

have developed in traditional settings. 

Dr. Rosalie Kane of the University of Minnesota, a leading researcher in long-term care, conducted an independent evaluation of 

the first Green House homes. Her research found significant improvements for the elders in both quality of life and quality of care, 

areas we have tried to have an impact on for many years. She also 

found great improvements for staff in their job satisfaction. 

We believe these improvements translate into significant Medicaid and Medicare cost savings through greater functional and 

mental health as well as avoided and shortened hospitalizations 

and acute episodes. CMS has been supportive of The Green House 

model, finding that it meets all Federal rules and more fully implements the intent of the Nursing Home Reform Act. 

There are three major challenges to spreading The Green House 

model of person-centered care. The first challenge is capital cost. 

Green House homes require new construction. State Medicaid rates 

are generally inadequate to cover the costs associated with new 

construction for any nursing home, a traditional nursing home or 

a Green House home. 

The second challenge is low Medicaid rates. Nationally, the average Medicaid rate has been found to be less than the cost of good 

quality care. The Green House model is a high-quality model requiring staffing levels higher than the national average, but at the 

rate research has shown is necessary to provide good quality care. 

Low Medicaid rates mean that even the most mission-driven providers are often forced to limit their Medicaid participation. 

The third challenge is getting the Green House homes off of campuses and into the communities where people live and homes belong. Community integration requires a scattered site approach. To 

make a scattered site approach financially viable, multiple homes 

need to be licensed together so they can share overhead costs. Federal nursing home rules may not support such an umbrella licensing approach. 

18 

To assist with these three challenges, we recommend that Congress consider the following. To help with the capital costs, create 

Federal programs to offset development costs for projects with a 

low-income focus. Program models could include a dedicated tax 

credit equity program, targeted grants, and interest rate subsidies. 

Senator Casey, the proposal you plan to introduce, the Promoting 

Alternative Nursing Homes Act, will be a significant resource in 

this area if passed. 

To improve access for Medicaid-funded individuals, develop longterm Federal Medicaid incentives to encourage States to provide 

adequate rates designed to support the operations of Green House 

homes and similar innovations. Long-term incentives are necessary 

to align with the 20- to 30-year commitment providers assume 

when they develop these models. 

Finally, to get Green House homes into the community, form a 

workgroup to identify an acceptable community-based Green House 

strategy and license and identify and resolve any conflicts with 

Federal rules. 

Thank you again for this opportunity to testify today. 

I look forward to your questions. 

[The prepared statement of Mr. Jenkens follows:] 

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Senator CASEY. You are under your time. That counts for a lot 

around here. 

Next we have Melinda Abrams, who is the Assistant Vice President, Director of Patient-Centered Primary Care, that project, I 

should say, of the Commonwealth Fund. She does direct that particular patient-centered project. Ms. Abrams has a distinguished 

career in health policy. Since coming to the Commonwealth Fund 

in 1997, she coordinated the Fund’s Task Force on Academic 

Health Centers, Commission on Women’s Health, and the Commonwealth Fund Harvard University Fellowship in Minority 

Health Policy. 

She has played a lead role in reviewing and modifying State policies regarding preventive healthcare that addresses early childhood 

development. It is an honor to have you here, Ms. Abrams, and you 

have the floor. 

Thank you very much. 

STATEMENT OF MELINDA ABRAMS, M.S., ASSISTANT VICE 

PRESIDENT, PATIENT-CENTERED PRIMARY CARE, THE COMMONWEALTH FUND, NEW YORK, NY 

Ms. ABRAMS. Thank you. Thank you, Mr. Chairman, Senator 

Smith, and Senator Casey, to testify on person-centered care for 

older adults in ambulatory care settings. 

I am Melinda Abrams, Assistant Vice President of the Commonwealth Fund, where I direct our program on patient-centered primary care. 

An approach to providing person-centered care in primary care 

settings is the patient-centered medical home. We can call it a 

healthcare home, I don’t mind. But the point is that it organizes 

care around the relationship between the patient and the personal 

clinician. 

In February of 2007, four primary care specialty societies, representing more than 300,000 physicians, released joint principles 

outlining and defining key characteristics of a medical home. In 

practical terms, a medical home promises a personal clinician 

whose practice provides better access and effective care coordination within the context of an ongoing relationship. 

In a medical home, for example, a patient can expect to obtain 

care from the practice on holidays, evenings, and weekends without 

going to an emergency room or have medical questions answered 

by telephone or email on the same day that she contacts the office. 

In a medical home, the primary care clinician helps a patient select 

a specialist and, with support from designated staff, proactively follows up with both the providers and the patient about tests or examination results, reviews treatment options, and helps to resolve 

conflicting advice possibly received from multiple providers. 

To carry out these enhanced functions, the medical home requires improved infrastructure, such as an electronic health record, 

patient registries to organize clinical information, ability to review 

results remotely, and the capacity to collect and analyze information about the quality of care provided. That information about 

quality should also include information from patients about their 

experience. 

30 

I want to emphasize the importance of the medical home for 

older Americans. Since 86 percent of Medicare beneficiaries have 

one or more chronic conditions, investing in improving coordination 

of care in primary care is critical to reduce unnecessary and redundant services, gaps in service, problems with care transitions, and 

medical errors. 

The patient-centered medical home also requires fundamental 

payment reform. Many medical home services are reimbursed either inadequately or not at all by the current fee-for-service system. Primary care practices would submit to a voluntary and objective qualification process to be recognized as a medical home, and 

in exchange, the practice would be supported with an enhanced or 

additional payment to cover the improved care management infrastructure and care coordination. 

There is substantial evidence showing that a strong foundation 

of primary care can reduce costs and improve quality. The Commonwealth Fund’s 2007 International Health Policy Survey found 

that only half of all adults in the United States have a medical 

home. Patients with a medical home were more likely than those 

without to report better access to care, more time with their doctor, 

fewer duplicative tests, and greater involvement in healthcare decisions. 

Among adults with chronic illness, patients with a medical home 

were less likely to report medical errors and more likely to have 

a written care plan to manage illness at home. 

The Commonwealth Fund is supporting evaluations of several 

medical home demonstrations, including one in Rhode Island, to 

determine if they slow the growth of healthcare expenditures. 

There is data to suggest—however, there is data to suggest that 

this approach can reduce health system costs. 

For example, a medical home pilot project at the Geisinger 

Health System, an integrated delivery system in northeast and 

central Pennsylvania, showed a 20 percent reduction in hospital 

admissions and a 12 percent decrease in hospital readmissions at 

their Lewistown hospital. 

Although not serving a large proportion of elderly patients, a few 

State Medicaid programs, such as North Carolina, have demonstrated cost savings of about $225 million in 2004 when beneficiaries were enrolled in networks of medical homes. In both of 

these examples, primary care clinicians were paid an additional per 

member per month fee to manage and coordinate patient care 

above and beyond the standard covered by traditional fee-for-service payments. 

Congress has recognized the potential value of stronger patientcentered primary care. The Tax Relief and Healthcare Act of 2006 

instructs the Centers for Medicare and Medicaid Services to develop an eight State demonstration of the medical home under 

Medicare. The recently passed Medicare Improvements for Patients 

and Providers Act of 2008 provides an additional $100 million to 

augment the demonstration. I commend the Congress for its willingness to test this promising approach in Medicare. 

As the Committee considers legislative and regulatory strategies 

to encourage person-centered care for older adults in ambulatory 

care settings, there are a number of steps Congress could take. 

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First, you can ensure greater transparency of the Medicare medical home demonstration. In light of the keen interest from numerous stakeholders to reform and improve primary care, regular reporting to Congress and the public about the progress and early 

lessons from the Medicare demonstration can inform policy and 

practice around the country as well as ensure timely evaluation results. 

Second, direct the Centers for Medicare and Medicaid Services to 

join commercial and State payers in the Medicare medical home 

demonstration. With explicit encouragement from Congress, Medicare could collaborate with several of the commercial payers in 

State Medicaid programs around the country that are already willing to change payment rates to primary care practices to test this 

concept. 

Another strategy is to pursue an intermediate and incremental 

financing changes to promote components of the medical home. One 

option is to authorize a separate payment for discrete services associated with key care coordination functions, such as hospital discharge planning which could help reduce unnecessary hospital readmissions. Another is to implement the recent recommendation of 

the Medicare Payment Advisory Commission to increase payment 

levels for evaluation and management services provided by primary 

care clinicians to help support care management, care coordination, 

and patient-centered care. 

Finally, consider implementation of scholarships or educational 

loan forgiveness programs to encourage medical students to choose 

careers in primary care. This strategy would address the current 

shortage of primary care physicians to staff medical homes. 

Thank you for the opportunity to participate, and I look forward 

to your questions. 

[The prepared statement of Ms. Abrams follows:] 

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Senator CASEY. Ms. Abrams, thank you very much. 

Finally, we have Dr. Eric Coleman. Dr. Coleman is a Professor 

of Medicine and Director of the Care Transitions Program at the 

University of Colorado. He is also executive director of the Practice 

Change Fellows Program, designed to build leadership capacity 

among healthcare professionals who are responsible for geriatric 

programs and service lines. He is a board-certified geriatrician. 

Dr. Coleman, we appreciate your willingness to be here and look 

forward to your testimony. 

STATEMENT OF ERIC COLEMAN, M.D., MPH, DIRECTOR, CARE 

TRANSITIONS PROGRAM, UNIVERSITY OF COLORADO, AURORA, CO 

Dr. COLEMAN. I thank the leaders of the Committee for inviting 

me to participate in this important hearing on person-centered 

care. 

This morning, we have heard how the Green House model and 

the medical home can offer great promise for assuring person-centered care in long-term care settings and outpatient settings, respectively. I would like to submit before this Committee that these 

models are particularly suited for persons whose medical conditions 

are in a steady state. 

Inevitably, many of these people will experience an exacerbation 

of their medical condition or a sudden traumatic event, and this 

will require a transfer to a place such as an emergency department 

or a hospital. These transfers are often referred to as ‘‘transitional 

care’’ or the handoff of care across settings. 

Transitional care poses challenges that distinguish it from other 

types of care. Many transitions are unplanned, and they result 

from exacerbations of medical problems that can occur at all hours 

of the day, the night, and on weekends. They often involve clinicians who have never met this person before. 

To better illustrate the challenges of transitional care, I offer the 

case of Mrs. Sanchez. She is 84 years old. She has high blood pressure, diabetes, and is in the early stages of Alzheimer’s disease. 

One morning, she awakened with a stomach virus that caused 

her to lose her appetite. Because she had taken her morning diabetes medication but had not eaten all day, later that afternoon, she 

became light-headed. After this, she lost her balance. She fell, and 

she fractured her right arm. 

She was admitted to the hospital, where she underwent surgery 

to stabilize the fracture. Late on a Friday evening, she was discharged home to the care of her daughter. Three o’clock in the 

morning on Saturday, however, she woke up in excruciating pain, 

and it was then that her and her daughter realized they didn’t 

have an adequate supply of pain medication to last through the 

weekend. 

The daughter could not reach the on-call orthopedist. She spent 

hours making phone calls and looking to find a 24-hour pharmacy 

to finally obtain the pain medication. Mrs. Sanchez further was not 

prepared for her self-care. She did not receive advice for how to 

keep from becoming constipated from her pain medication. Five 

days later, she was readmitted to the hospital with severe abdominal pain. 

67 

Poorly executed care transitions can confound our best attempts 

to provide person-centered care. As illustrated by this case, they 

also contribute to our rising healthcare costs. The excellent care 

provided by a Green House or by a medical home can quickly unravel as the person is transferred to a new, unfamiliar care setting. 

Yet the challenges to providing person-centered care during these 

care transitions can be overcome. The Care Transitions Program 

that I direct recognizes that often by default patients and their 

family caregivers perform a significant amount of their own care 

coordination without the preparation, the tools, or the support. 

With generous funding from the John A. Hartford Foundation 

and the Robert Wood Johnson Foundation, we developed the Care 

Transitions Intervention to provide true person-centered care during these care transitions. 

What is the Care Transitions Intervention? Well, during a 1- 

month program, recently hospitalized older patients and their families work with a transitions coach to learn transition-specific selfmanagement skills that will ensure that their needs are met during this vulnerable time of the handoff from hospital to home. 

What is the evidence that the model is effective and reduces cost? 

Patients who received this program were significantly less likely to 

be readmitted to the hospital. What is more, the benefits were sustained for 5 months after the end of the 1-month intervention. 

Thus, rather than simply providing post hospital care in a reactive 

manner in the moment, investment in imparting self-management 

skills pays dividends long after the program ends. 

Annually, a single transitions coach can manage 350 patients 

coming out of the hospital. During this time, the model produces 

a net cost savings of $300,000 per coach. The Care Transitions 

Intervention is in the public domain (www.caretransitions.org). 

There are no licensing fees, and to date, 128 of the Nation’s leading 

healthcare organizations have adopted this model. 

How can this Committee further support person-centered care 

models such as the care transitions intervention? Well, the primary 

barrier to making the model available to all older Americans concerns the lack of financing mechanisms within the Medicare program that supports self-management. We now have some experience with self-management programs in the area of diabetes. 

It is time for us to re-examine our approach to Medicare reimbursement and explore modifications for how to support self-care 

models like the Care Transitions Intervention that have been proven to improve outcomes, reduce cost, and promote greater personcentered care.I thank you for your attention. 

[The prepared statement of Dr. Coleman follows:] 

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Senator CASEY. Dr. Coleman, thank you very much. 

We will move to questions now, and I want to welcome Senator 

Blanche Lincoln from the State of Arkansas for her presence here. 

We will move to questions. 

I will start, and I will be brief and try to come back maybe. But 

I wanted to thank Chairman Kohl for his leadership and for allowing us to gather here today and for allowing me to chair this hearing. It doesn’t happen very often when you can become the chair 

of any hearing this early in a Senate term. 

Dr. Thomas, I wanted to start broadly, I guess, on two areas. 

One, let us not talk about how difficult it will be to get where we 

want to get to. We will do that second. We will have the challenge 

second. 

The first thing I wanted to ask you, though, is just—if you could 

just outline, you did some of this in your opening, but some of it 

you could reiterate, but also amplify, which is to talk about the vision you have for this concept of patient-centered care. Where do 

we need to get to? Not some ideal that is not achievable, but where 

do we need to get to? 

Then the second part of the question, if you could answer, is 

what are the challenges and what advice can you give us, as Members of Congress, but also give others who are struggling with this 

issue? 

Dr. THOMAS. Thank you, Senator. 

I would say, first off, where are we going and how does patient 

centeredness get us there? Patient centeredness is really a bridging 

concept that helps us take the healthcare system we have today, 

which we all can describe and we know, and helps us cross over 

to the healthcare system we ought to have. 

In other words, to think of it in sort of pendulum-type terms, 

that pendulum swing toward a technology provider-focused approach to healthcare is starting to swing back—with the aid of concepts like the medical home and patient-centered care, starting to 

swing back into a system that creates partnerships between people 

with expert knowledge and people who need access to that knowledge. 

I thought Dr. Coleman’s remarks were really spot-on in terms of 

commenting on the terrible wastefulness of a provider-centered system because, you know, our healthcare system is not and should 

not be set up to run at the convenience of the providers. It should 

be run and set up to establish good outcomes for patients. So that 

is the first thing. 

I guess I would argue to the Committee that patient 

centeredness is a way of aligning our healthcare system with our 

ideals, and that is important work that is going to take years to 

accomplish. But that is where it needs to go. 

In terms of how can we—what can be done to help swing this 

pendulum back to a better place, I think, No. 1, we need more 

elbow room for innovators to be able to put together new approaches that challenge the orthodoxy. 

We were chatting earlier about the Commonwealth of Pennsylvania’s desire to kind of put together a new strategy for long-term 

care. Well, you know there are a lot of providers out there who are 

hesitant to take those kinds of risks, and we need to help put toVerDate Aug 31 2005 14:42 Apr 27, 2009 Jkt 000000 PO 00000 Frm 00078 Fmt 6633 Sfmt 6633 H:\DOCS\48150.TXT SAG PsN: JOYCE
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gether a system that protects patients and allows providers to develop new approaches and programs. 

The last point I would make in terms of what can help is there 

is a difference between the money you need to operate an established ongoing service and the money you need to jump across the 

creek to the other side and get it going in a new model. It is especially difficult in healthcare. 

We can talk about this in manufacturing and services, but in 

healthcare, you have to operate the existing model at a high degree 

of efficiency while you are creating this new model at the same 

time. We need people like the people here in this room and the 

adopters of Green House and other models, they need help getting 

to the other side. 

Senator CASEY. I am going to reserve some of my time for later, 

but I wanted to turn to Senator Wyden and our colleagues so they 

can get their questions in. 

Senator WYDEN. Mr. Chairman, thank you, and you have arranged a terrific panel. 

I only want to take a minute to kind of ring the alarm bell on 

what I think is a coming calamity in terms of the workforce to try 

to meet the needs of older people. You mentioned that, Ms. 

Abrams. But what is striking is you look, for example, at what has 

happened in Massachusetts. They are going forward with their efforts at providing universal coverage but they have bumped up 

against a huge calamity. Already they don’t have enough primary 

care physicians just to meet the needs of the working age population, not to say anything about seniors and long-term care. 

My sense is that given what we all want to do, and you all are 

the pioneers in this area, is have health care providers spend more 

time with patients and more time with families. To achieve this we 

are going to need a huge increase in the number of people who are 

trained in geriatrics. I was in fact, appreciative of your comment, 

Ms. Abrams, that it is fine to call it a health home rather than a 

medical home. The primary reason we call it a health home in the 

Healthy Americans Act is to try to get more professionals into the 

act, that we would get more nurses and physician assistants and 

others providing this care for patients. 

My question to all of you is what are your ideas for increasing 

the number of people going into the field, particularly without 

breaking the bank? One of the areas we are looking at in the 

Healthy Americans Act is the idea of redoing job training programs 

in this country, many of which now seem to be training people for 

jobs that are going to go overseas in a few years. 

We would like some of those dollars go, for example, to train people as nurses, physician assistants, and others to do exactly the 

kind of work you are talking about. That would give us a chance 

to stretch existing funds that are now spent on training in an area 

that could pick up on some of your good ideas. 

With your indulgence, Mr. Chairman, one question before I do an 

introduction of a witness on behalf of Senator Smith. I’d like to get 

your thoughts on what we could do to expand the workforce in the 

geriatric area particularly, without breaking the bank. 

76 

Dr. Coleman, you have been nodding your head. So I guess I am 

making you a glutton for punishment and starting with you. Your 

thoughts, workforce? 

Dr. COLEMAN. Critical question. As you know, the Institute of 

Medicine just released a report on the need to retool our country’s 

workforce for the aging population. I had an opportunity to testify 

before that committee. One of the points that I made had to do 

with not only how do we attract people to the field, but also looking 

at their workflow, their daily professional lives, et cetera. 

One of the phrases that jumps to mind is ‘‘all assessed up and 

nowhere to go.’’ We spend a disproportionate amount of time assessing our patients, which leaves very little time for actually taking care of them. This is true in home care and in nursing home 

care among others. 

Senator Casey used the term earlier ‘‘relationships.’’ Those of us 

who chose to go into primary care, as opposed to specialty care, did 

so because we wanted to have meaningful relationships with our 

patients. We knew where the salaries were going to be lower. We 

knew the time expended per week was going to be greater. We 

chose this to have the meaningful relationships. 

The advanced medical home offers an opportunity for building 

these relationships. But as I look through each of the different initiatives, I see a lot of discussion, focused on how the practice is 

going to change, what the requirements are going to be in order to 

be certified as a needed home. We don’t hear as much about how 

this type of approach or any approach is going to improve the time 

for face-to-face, meaningful relationships with our patients. I think 

that is the hook that makes people want to come to primary care 

and what keeps them in primary care. 

Senator WYDEN. Any other witnesses? Perhaps even for the 

record because this may be something you want to talk about. This 

is an area that we are making a special focus with our group of 

16 Senators, 8 Democrats and 8 Republicans. Because I think this 

is a showstopper. 

We don’t have enough providers to meet the needs of our country 

today. However, we are going to add 47 million uninsured people 

as part of a universal coverage effort and we want to be sensitive 

to the thoughtful points that you are making. We are going to have 

to find some creative new ways to get folks trained and on the front 

lines. 

Do any of you want to add anything for now? Yes, sir? 

Mr. JENKENS. Yes, thank you, Senator Wyden. 

One of the critical aspects of the Green House model is to create 

a job that nurses and direct care workers want to have and make 

them want to come to work in the morning. I think one of our biggest problems in long-term care is that we haven’t valued those 

jobs, and we haven’t made those jobs very pleasant jobs to be in. 

That is more than just the hourly wage that we pay. As a matter 

of fact, I think you will find that the hourly wage is a very small 

piece of the dissatisfaction with long-term care jobs. 

So the Green House project focuses on giving direct care workers 

power and authority and then valuing them. The reason we call direct care workers in The Green House homes ‘‘Shahbazim’’ is that 

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cause there is such a negative connotation associated with those 

terms. 

What we found in the Green House is that when you give nurses 

and you give direct care workers an environment and an organizational structure that really values them and lets them do the job 

and create the relationships they came to long-term care to have, 

they stay in those jobs. People who said they would never be in 

those jobs come to those jobs. So you expand the pool of people who 

are willing to do that work. 

You will hear from a Shahbaz, Edna Hess from Pennsylvania, 

and a family member from Lincoln, NE, about this very thing. We 

have two Shahbazim in Lincoln, NE that also demonstrate this expansion. One was a bartender who had left long-term care. She had 

been an LPN and she came back to be a Shahbazim, she left longterm care because she said she couldn’t take it anymore in the old 

system, but she wanted to be part of it in the new green house 

homes. 

Senator WYDEN. Ms. Abrams? 

Ms. ABRAMS. I mentioned—I just want to affirm everything you 

said in terms of the calamity and the concern over the workforce. 

I originally had a lot longer comment about workforce and cut it, 

so I appreciate that opportunity to mention it. 

I did mention—the piece that I was focusing on was the number 

of physicians choosing primary care, which is what has come up a 

little bit in Massachusetts. So I did mention the idea of loan forgiveness programs for physicians that go into primary care or 

scholarships for medical students who go into primary care. 

But another real issue is, and Dr. Coleman mentioned this, making it attractive. The way physicians are trained, there is the curriculum and then there is the hidden curriculum, and it is what is 

modeled in the academic health center. In that academic health 

center, most of their time is spent in a hospital. So they don’t have 

enough time in primary care settings, community settings. They 

have very little exposure to how to actually work effectively in a 

team, in a multidisciplinary team. 

I think that because of our reimbursement system, we are biased 

toward surgical procedures, and we don’t value and we underinvest 

so that physicians or clinicians have time to take a medical history 

and to really help do medication reconciliation and spend time to 

kind of come up with a care plan. The reason I mention that as 

well is because I think if we can come up with ways to make primary care more attractive, both in terms of reimbursement—I 

mean, primary care physicians make about half of what specialty 

care physicians make. 

There is this huge income gap, and none of us should feel sorry 

for how much primary care physicians make. It is just that in your 

medical work, if you are worried about primary care workforce, it 

is not that they are poor, it is just more that we want them to also 

be going into primary care to take care of and do the care coordination for older Americans. 

So part of it is about the training, and the training is in the 

place and the training is also with teams. I am not an expert on 

IME and DME, you know, payments from Medicare, but my understanding is the way that those are funneled is it is very much in 

78 

the interest of the hospital to hold onto those resources. So another 

possibility is to think about kind of maybe it would be a grant program. 

I don’t know if it is a grant program that would allow to some 

of these academic health centers or residency training programs 

that actually do come up with models that are patient-centered and 

multidisciplinary and team-based care. Because that is also how we 

are going to be more efficient and not use the physician’s high-scale 

time for some other things that could be used with other kinds of 

professionals and help to expand the workforce. 

Senator WYDEN. Your ideas are very helpful, and you can see all 

the heads nodding on this side of the dais. I will look forward to 

following up with the four of you. 

Chairman Casey has given me a lot of time. I just want to note 

on behalf of Senator Smith and myself that on the next panel, we 

will have Dr. Diana White, the Senior Research Associate of the Institute on Aging at Portland State. She has been one of the pioneers, as you know, in this area. Senator Smith and I are very 

pleased that she is going to be here. We want to thank Chairman 

Casey for inviting her. 

Senator CASEY. Thank you, Senator Wyden. We appreciate your 

work in so many of these areas and especially the work on 

healthcare broadly and in particular on our long-term care workforce. 

Senator Whitehouse has spent—and I will be introducing Senator Lincoln in a moment as well. But Senator Whitehouse has 

spent a lot of time on the issue of healthcare in the 18 months that 

we have been in the U.S. Senate, especially in the area of having 

the infrastructure in place for information technology and other 

ways to deliver quality healthcare to as many people as possible in 

a better way. 

We are grateful for his leadership on those issues and his willingness to participate in today’s hearing. 

Senator Whitehouse? 

Senator WHITEHOUSE. Thank you, Chairman Casey. 

You have predicted my question, which is that whether we follow 

the various models that have been mentioned here today, a system 

specializing in chronic care that is patient centered, a Green House 

model, the medical home model, or the care transitions model, it 

strikes me that we are lacking an underlying infrastructure support that would enable and empower all of those models, and particularly in the area of health information technology—electronic 

health records, personal health records, electronic prescribing, 

interoperable health records, and so forth. 

I would just like to ask each of you, first of all, do you agree with 

that? Second of all, if you agree with that and you think there is 

a goal we should achieve, a baseline of infrastructure to support 

these various modalities, are we close to it? If not, how far off are 

we, and what steps should we be taking to enable that kind of infrastructure to develop? 

Why don’t we start with Mr. Thomas, go the other way this time 

so Dr. Coleman is not always being picked on first. 

Dr. THOMAS. I know, from his work, he is going to have a lot to 

say, Dr. Coleman is. Well, here is the thing. The information techVerDate Aug 31 2005 14:42 Apr 27, 2009 Jkt 000000 PO 00000 Frm 00082 Fmt 6633 Sfmt 6633 H:\DOCS\48150.TXT SAG PsN: JOYCE
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nology revolution that has changed virtually every part of our society except healthcare, I used to—I think it remains—pretty much 

remains true. I used to say— 

Senator WHITEHOUSE. I am told by the—just to interrupt for a 

second, I am told by The Economist magazine that there is actually 

one other industry that is even behind the healthcare industry in 

terms of information technology, and that is the mining industry. 

Dr. THOMAS. Oh, mining. Yes, OK, so we are there with the mining industry. 

Senator WHITEHOUSE. Then it is healthcare, and then it is everything else in the world. 

Dr. THOMAS. Yes. OK, yes. Well, you know, a typical nursing 

home, as it stands today, has less technology available to the people than is available to the guy who drives a FedEx truck. I mean, 

that is awful. 

I like the proper application of information technology, especially 

in long-term care, because chronic care generates a huge amount 

of information. I still have a bump on my hand from my years in 

practice of handwriting notes hours and hours a day. Somewhere 

around America, there are rooms stuffed full of the handwritten 

notes that I took over the years, entirely useless, and my handwriting wasn’t quite that bad even. 

But we need to move into this system so we can gain efficiencies 

in how we handle data so that we can enable the development of 

the relationships. That is the win here. It is not just, ‘‘Well, now 

we have a computer system.’’ Well, great. So what? 

It is now we have a computer system that moves this information 

efficiently, and now we can concentrate more time, energy, and 

training on relationship-based healthcare. 

Mr. JENKENS. We push very hard for The Green House adopters 

to implement a whole variety of technology, including electronic 

medical records, and monitoring technology. The Green House in 

Lincoln has a marvelous technology even beyond the doors of the 

house, allowing people with dementia to go outside safely. 

The challenge that we see is really twofold. One is the cost of implementing the technology. I think people are willing, but the 

training and the technology itself is outside of what they can (eek 

spelling) out of usually thin or nonexistent margins associated with 

a heavy Medicaid population. 

The second is trust. I think trust is an area that we are addressing with the workforce in many areas. We have Shahbazim who we 

trust with the most intimate and complicated tasks of someone’s 

daily life, someone we love, but many organizations that we talk 

to will not trust them with an email account or web access. They 

can’t communicate with each other. One of the greatest benefits of 

technology is to allow people to share what they have learned. 

We run 11 forums through the Green House Project for people 

to share information, every position within the Green House, and 

our biggest challenge is that the Shahbazim don’t have access to 

email and the Internet to participate in those discussions. 

Senator LINCOLN. They do not? 

Mr. JENKENS. They do not. 

Senator WHITEHOUSE. Is that HIPAA at work? 

Senator LINCOLN. Why? 

80 

Mr. JENKENS. Typically, they can’t afford to have a personal account, and the organizations either don’t feel that they need it, 

don’t feel they can afford it, or, very often, don’t trust them to have 

it. 

Senator CASEY. I am just going to jump in for one second. Just 

for purposes of definitions, my staff did a good job here about the 

definition of Shahbaz and Shahbazim. 

Mr. JENKENS. Yes. 

Senator CASEY. I am told it is a Persian word meaning ‘‘royal falcon’’ or ‘‘king’s falcon,’’ the mightiest, the bravest, the fastest, the 

most courageous of all falcons, right? OK. Which is we are talking 

about the direct care workers. 

Mr. JENKENS. Yes, 

Senator CASEY. I wanted to read that for the record. I am sorry 

for cutting into Senator Whitehouse’s time. 

Ms. ABRAMS. I want to start by saying that I completely agree 

that we are lacking the infrastructure that we need to and that 

with health information technology. We need to consider it. There 

was a paper not that long ago that said we would never consider 

a cardiologist appropriately trained and prepared unless they knew 

how to do catheterizations. 

To think that in primary care and long-term care that we should 

be sending providers out into the field without the skills and the 

tools to provide that care well, I think that we have to kind of 

rethink the competencies of our providers and the competencies 

that they need both to work in teams, but also to provide better 

quality care. 

Senator WHITEHOUSE. You are referring to a coordination of care 

competency? 

Ms. ABRAMS. Right. 

Senator WHITEHOUSE. OK. 

Ms. ABRAMS. A care coordination competency. Yes, I mean, I 

guess it doesn’t make sense to have a health information technology competency for the reasons that Dr. Thomas mentioned because it is really just a bunch of wires. So, it is about how you use 

that hardware and that software that are so important. So I think 

that we are lacking that infrastructure. 

You asked about, well, is there a baseline, and are we close to 

it? I think that there are pockets of innovation around the country 

such as either in health systems or in communities where they 

have really begun to use health information technology in a way 

that is incredibly productive and in a way that has helped to improve quality of care, such as Group Health Cooperative out in Seattle, Washington. Or there is the Mid Hudson Valley Region in 

New York, where they are implementing a lot of EHRs, and it is 

also creating a health information exchange where all the data is 

being aggregated. 

I think that so when we also think about the health information 

technology, it is what do we need at the practice level? What do 

we need at the community level so that we can do better management of population health? Then also thinking and part of the 

question is, well, what is the role of Government, to some extent, 

in this both in terms of trying to promote the adoption, but also 

the standards? 

81 

Because at some point because our system is public and private 

and a lot of the vendors are private, there are different templates, 

and it is inoperable. It seems daunting. But I believe that the 

Agency for Healthcare Quality and Research has been doing an 

enormous amount of work in trying to set some of those standards 

and trying to have standards for both interoperability and for some 

of those templates. 

But I think that is some of the goals. That is really the goal. So 

that if you are sick in Nebraska and you live in New York, that 

someone can pull up your record. 

Senator CASEY. Dr. Coleman, I am sorry to pinch you off, but we 

are over time. So if you have anything to say— 

Ms. ABRAMS. Oh, sorry. 

Dr. COLEMAN. I will be brief. 

Senator CASEY [continuing]. If you could kind of shorten it so 

that I am not treading too badly on Senator Lincoln’s time. 

Dr. COLEMAN. Sure. I am a strong believer in the potential for 

information technology to improve person-centered care. In fact, 

one of the four pillars of our Care Transitions Intervention is a personal health record, encouraging folks to take ownership over their 

own health information. 

Last year, we completed a detailed study for the Assistant Secretary for Planning and Evaluation in HHS on health information 

exchange. We spoke with experts. We did site visits to the 

examplar programs, some of which were already mentioned. 

The main take-home points were, first, there are places that are 

doing this well. However, it is often just the hospital and the clinic 

that share information. Nursing homes, home care agencies are not 

even invited to the table. 

Second, it is really all about workflow. The technology solutions 

are here. It is about having healthcare professionals understand 

how not to do, as Dr. Thomas described, endlessly writing down information and transferring it somewhere else. 

Third, it also comes down to relationships again. This has become a common theme for this hearing. We saw healthcare professionals actually going around the technology because they wanted 

to connect with their professional colleagues. So a hospital discharge planner has an electronic system in place to make transfers 

to a nursing home but sidesteps the electronic system to telephone 

her friend because that relationship was more important in some 

respects than ensuring the patient’s transfer went well. 

There is reason for hope, and I will just finish by shining a positive light on the State of Indiana, where they have a program 

called ‘‘Docs for Docs,’’ Documents for Doctors. If I am practicing 

in Indiana and I have the patient’s unique patient identifier, I can 

look up all of their lab results, all of their radiology results, all of 

their hospital discharge summaries, procedures, et cetera, no matter where in the State this took place. 

So we do have examples that I believe we can learn from. Thank 

you. 

Senator WHITEHOUSE. Thank you all very much. 

Thank you, Chairman. 

Senator CASEY. Senator Whitehouse, thank you very much. 

82 

We have Senator Blanche Lincoln, who has long been a great advocate for people at both ends of the age scale, the children in the 

dawn of life, as Hubert Humphrey said, and older citizens and not 

to mention all of rural America. 

We are grateful for her presence here and, Senator Lincoln, 

thank you very much. 

Senator LINCOLN. Thank you, Mr. Chairman. 

Thank you so much for encouraging this hearing, which I think 

really does focus on so much of what we need to do. Obviously, 

some of the things we have gotten right. But without a doubt, the 

enormous list of tasks that we have before us. 

Dr. Coleman, just to your last point, the Documents for Docs, is 

that just very similar to a physician’s ability to write prescriptions? 

I mean, do you have an access where you can then access those 

documents through a physician code or a physician licensing? 

Dr. COLEMAN. That is right. There is a portal that any physician 

in the State can use provided you have that individual’s personal 

identifier. This becomes the rub and not all American citizens are 

comfortable with this approach of having a unique patient identifier. The State of Indiana was willing to accept the risks and the 

benefits. 

Senator LINCOLN. Right. We have that problem with privacy 

here. I mean that has been one of our bigger challenges and hurdles. But it is interesting to look at that opportunity of access to 

information. 

Two points that I would just like to bring up and certainly get 

any of your comments on. I have been working on coordination of 

care for quite some time, and it really came from my own personal 

experience with my dad. My dad was diagnosed with Alzheimer’s 

at an early age, and we made a very long journey as a family with 

his multiple chronic diseases plus dementia and the real need for 

having a coordination of care in order to see the kind of loving care 

we wanted him to receive. 

I grew up in a very small community within walking distance of 

all my relatives, my grandparents. I didn’t know I was a caregiver 

at the age of 16 just because I took dinner up to my grandparents 

every other night. But it was. It was a huge part of their needs in 

terms of caregiving, but it was a wonderful part of my growing up 

and learning from them, learning about what it means to care for 

individuals, learning how hard that work can be and how important it is. 

So the bill that I have got, S. 1340, mainly focuses not necessarily on a medical home for the whole spectrum of care, but 

when you look at acute and chronic and long-term and all of that, 

but specifically on chronic conditions, one of those including dementia, and making sure that we are working to create that coordination of care that is going to provide both efficiencies that lowers our 

costs, but more importantly, the quality of care that we want our 

seniors to have. 

I think that is so important. It is difficult because we are in an 

environment where we have created over the last 50 years 

healthcare delivery that is focused on acute care. It is not focused. 

I mean, our whole system is designed for acute care. So we are 

going to have to create some real social changes here in the culture 

83 

and the mindset of individuals about their own prospective 

healthcare as aging adults, but also what they are predicting for 

their aging parents and grandparents and what have you. 

In our coordination of care, Ms. Abrams, we have the doctor, and 

the doctor does get an increased reimbursement as the overall 

guidance for that team. But the patient can choose who their care 

manager will be. So if they are more comfortable with the nurse 

practitioner or somebody else, then that can be their care manager. 

But it makes sure that that entire team is communicating and 

coordinating that care based on the multiple chronic diseases that 

that patient is dealing with. There is no doubt that training is a 

huge part of that. 

My husband is a physician. I asked him what he went through 

in terms of medical school and residency and the things that he 

learned, as we cared for both my father and then his mother, and 

he said, you know, it is just not there in terms of what physicians 

are learning particularly in medical school about how to organize, 

work with that team. 

His father was a surgeon, and it was unbelievable, when his 

mother was hospitalized before she passed away, the lack of coordination in that care. I had two physicians right beside me. So, it 

is—there is just so much we need to do, I think, to get to the ultimate goal of the kind of quality of care that we want for seniors. 

So I guess my question to you, Ms. Abrams, or to anybody, the 

way that the medical home is currently defined with the word 

‘‘physician’’ being used rather than ‘‘primary care provider,’’ and 

the fact that what you mentioned, which we have a lack of primary 

care physicians. There is certainly a shortage there, and the medical home seems consistent with the kind of care that advanced 

practice nurses currently provide. Do you think the definition could 

use some—do we look at that in terms of both the shortage that 

exists and certainly the care that folks are wanting to have in their 

coordinated care effort and in their team, the actual team perspective of how we go through that? 

Ms. ABRAMS. Thank you, Senator Lincoln. 

I do. I think that the patient at a medical home, the joint principles that I referenced in the beginning of my statement, they 

were endorsed and released by the primary care specialty societies, 

by physicians. So it is their belief and their opinion that the model 

is physician directed. 

Senator LINCOLN. Right. Ours is physician directed. 

Ms. ABRAMS. But I have to tell you that it is my position, I think 

that advanced practice nurses and independent nurse practitioners 

could also lead a healthcare home and a medical home. 

Senator LINCOLN. Right. 

Ms. ABRAMS. Again, we can call it a healthcare home, and it is 

really more about the functions and keeping the patient at the center and having the other pieces in place. So I—and many nurse 

practitioners, they provide care under the supervision, even though 

loosely defined, or under the supervision many of them with a physician. But I think there is—and I think it could work under that 

model. I think that it could also work with advanced practice 

nurses, as you mentioned. 

84 

Senator LINCOLN. Well, we just have to realize that that the 

shortages not only exist now, but we are training less academic 

physicians, which means we not only have less practicing physicians. We have less physicians that are there in the medical 

schools to train particularly geriatrics and geriatric training. So I 

think— 

Ms. ABRAMS. Right. The other thing we also have to remember, 

too, is that a lot of nurse practitioners, they begin to specialize as 

well. So it becomes an issue— 

Senator LINCOLN. We have got another bill— 

Ms. ABRAMS [continuing]. About encouraging people to go into 

geriatrics. 

Senator LINCOLN. Right. We have got another bill to encourage 

particularly nursing students to take a subspecialty or some type 

of a specialty part in their training in geriatrics. 

Dr. Thomas, absolutely if you want to answer that, but I have 

got another accolade for you. 

Dr. THOMAS. I just want to say—oh, well, thank you so much. I 

do want to add to what Ms. Abrams was saying is that you are 

really seeing the contours of a problem with prestige. Our system 

is set up to throw the greatest prestige toward the most subspecialized technocratic providers, and our society needs a system that 

gives prestige to people who do that work that your father-in-law 

and your family needed. 

Senator LINCOLN. Right. 

Dr. THOMAS. So that is not—I don’t think the Senate can solve 

that issue. But when you are thinking about what is the problem, 

it is a—we have a misallocation of prestige in our system. 

Senator LINCOLN. But what we can do and what Government’s 

responsibility is is to create an environment where those social 

changes can happen, so that those who need that prestige are being 

reimbursed for the kind of hard work that they are doing, so that 

there is an appreciation level and a prestige that comes with that. 

There is no doubt that we can help create that environment in 

a better way than what we are doing. I just want to thank you, Dr. 

Thomas, for your vision and collaboration with so many dedicated 

individuals. In Arkansas, we are proud that Arkansas Green House 

Project called the Northwest Senior Services— 

Dr. THOMAS. Yes. 

Senator LINCOLN [continuing]. Is both the first Green House in 

Arkansas, but it is also the first Green House in the country that 

is partially funded with low-income housing tax credits, which we 

try in every which way we know how in Arkansas to be innovative 

because we do have a disproportionate share of our population that 

are elderly. 

Disproportionately, they live in rural areas, where all of that 

technology is important if we are going to get them the kind of 

medical care they need. 

But they are also disproportionately low income on very restrictive fixed incomes. So, we have got a large portion of our older 

adults and so many low income that reside in these rural areas. 

But you might even comment a little bit on that if you get a 

chance, focusing on affordability of these types of facilities and 

whether tax credits and other incentives and other creative acVerDate Aug 31 2005 14:42 Apr 27, 2009 Jkt 000000 PO 00000 Frm 00088 Fmt 6633 Sfmt 6633 H:\DOCS\48150.TXT SAG PsN: JOYCE
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counting that we can put together with different programs to help 

produce more. 

Senator CASEY. Doctor, can you be really, really— 

Dr. THOMAS. I will be so brief. I would say Mr. Jenkens was responsible for, I think, a lot of that creative thinking, and it is part 

of what we need to do through the whole system is take all the 

pieces apart and put them together in new and creative ways. 

Senator LINCOLN. Robert Wood Johnson has been fabulous in Arkansas. So we appreciate it. 

Thank you, Mr. Chairman. 

Senator CASEY. Senator Lincoln, thank you very much. 

We want to thank this panel. We have to move to our second 

panel. I know I am over time now to get to our second panel. But 

we are grateful for your presence here, for your testimony. 

We will be—I know I will, but I am sure other members of the 

Committee will be submitting questions in writing that you could 

make your answers then would be part of the record. Thank you 

very much. 

We are going to move now to our second panel. Zoe Valentine 

Holland, Edna Hess, and Dr. Diana White, who will be coming up 

next. Thank you very much. 

Well, thank you very much. We are going to move right to our 

witnesses. I will start with Zoe Valentine Holland, who is the 

daughter of a former Green House resident in Lincoln, NE. It is an 

honor to have you here and to speak of your own personal experience. 

Then I will introduce each of our witnesses as we go forward, 

and I know we are moving kind of quickly, but we had to make a 

quick transition. This room is being—we are going to get a little 

extra time, but this room is being used for another purpose. So we 

are almost out of room time, and I don’t make those decisions. So 

I will move rather quickly. 

Thank you very much. 

STATEMENT OF ZOE HOLLAND, DAUGHTER OF A FORMER 

GREEN HOUSE RESIDENT, LINCOLN, NE 

Ms. HOLLAND. Senator Casey and fellow Committee members, 

thank you for inviting me to testify this morning. 

My name is Zoe Holland. My assignment this morning is to tell 

you a story, to speak to your imaginations and your hearts. On 

March 26 in 1906, a red-haired baby girl was born on a small farm 

in Minden, NE, to Andrew Boicourt and Elizabeth Boicourt, and 

they named their sixth child Mary Josephine. She was my mother, 

and this is her story. 

Mary left her home as a young woman for Omaha, the big city, 

to fulfill her dream of becoming a nurse, which she did. She later 

married a physician and surgeon, and they raised two children. 

Fiercely independent, Mary returned to Nebraska in her 90th 

year to set up home in a high-rise apartment. She was on the top 

floor with an amazing view of clouds and sky and trees. She was 

so grateful and so happy to be there, and she made many new 

friends. 

Suddenly, in 2002, Mary suffered an illness that required treatment and care only available in a nursing home. I think Dr. ColeVerDate Aug 31 2005 14:42 Apr 27, 2009 Jkt 000000 PO 00000 Frm 00089 Fmt 6633 Sfmt 6633 H:\DOCS\48150.TXT SAG PsN: JOYCE
86 

man’s reference to the difficulty in transitioning and getting that 

24/7 care really illustrated our family’s situation and experience. 

Her illness coincided with my knee replacement surgery and the 

reality that her daughter was aging. I no longer had the strength 

to care for my mother, and we were both very sad. 

After exploring several possibilities, she and we chose Tabitha 

Healthcare Services in Lincoln. She moved into a little room. There 

was no room for her treasures. Good-bye to the art, the music, the 

pretty shoes, the clothes, and the mementos of a rich and fulfilling 

life. 

She had worked in nursing homes as a nurse, and she knew 

what was to come. She was angry at me and what was happening 

to her. Who could blame her? She had always disciplined herself 

to exercise daily, move around. There was no room, and it was so 

dark and so small in there. 

Visits of family and friends gradually tapered off. There was only 

space for one person at a time in her room, while others waited in 

the hall. We took turns. As the days went by, we watched the light 

that had burned so brightly for so many years grow very dim. 

Mother spent much of her time in bed, sleeping as much as she 

could because she had nothing to do and nowhere to go. 

She always reminded me of how much she appreciated the care 

of the staff and told me that they were doing the very best they 

could in the environment they were working in and with the resources they had. 

We began planning her 100th birthday party nearly a year in advance to lift her spirits, knowing that family and friends were coming from Washington, Oregon, Colorado, New York State, and Glasgow. This was a grand and glorious event, and she received many 

gifts. But the greatest gift of all was her selection to be one of the 

first elders to be in the Green House in Lincoln, NE. 

Suddenly, to Mary Valentine, my beautiful mother, life mattered 

again. With light flooding through her bedroom window, she sent 

us scurrying after her lost treasures. 

She could sleep as late as she pleased in the morning and still 

have breakfast. A Shahbaz would attend to her hair and nails and 

clothing for the day. Monica took a dress home and ironed it so her 

dress would not be wrinkled on one occasion. Every night, a 

Shahbaz would tuck her in bed lovingly and tell her good night. 

She also received at the Green House the coordinated care that 

I think you were discussing. There was, all of a sudden, a smaller 

staff and a closer connection to the doctors and nurses. It was a 

really tight relationship, very good. 

During the day, she could sit in her tiny recliner that fit her tiny 

body and hold a tiny Chihuahua, Tupac, who belonged to a staff 

member. They were a good fit. She was convinced that Tupac wanted to be wrapped in a silk scarf every day as he snuggled in her 

lap. 

The year 2006 belonged to Mary. The Green House itself was the 

scene of many celebrations, dinners, and parties, and many of them 

were ours. For the first time in many years, my husband Mike and 

I felt free to travel, knowing Mother was secure and comfortable 

and, oh, so happy. We could contact her caregivers daily and expect 

an accurate and thorough report. 

87 

Her 101st birthday has been recorded and documented. Mary sitting on the Green House porch with Tupac and her margarita and 

her celebratory cigarette, and they used their technology to send 

that all over the country. All of the people involved in the Green 

House project, ‘‘Oh, you are Mary’s daughter. We saw her picture.’’ 

It made that relationship very real. 

April 17, 2007, was a soft and gentle spring day, almost perfect 

and was to be the last day of Mary’s life on Earth. Attended by a 

beautiful red-haired young nurse, with Shahbaz Monica present, 

she died with the gentle grace and the quiet beauty that had exemplified her life on Earth in the arms of her beloved granddaughter 

Ann. 

In my announcement of her death, I wrote, ‘‘The staff at Tabitha 

and the Green House loved her fiercely and are grieving mightily. 

Please pray for these angels on Earth.’’ In May, her remains were 

buried beside her son on a hillside in Eugene, OR. 

Later, a memorial was dedicated in her honor at Tabitha. On the 

porch, you will see a fountain with a big dog and a little toy, which 

welcomes all the visitors in the spirit of Mary. 

In her last room at the Green House, there now lives a sweet, 

small redhead named Gwen. Once in a while, like Monday, I 

stopped in with a flower. She understands that sometimes I just 

need to be in that room. 

On the anniversary of Mother’s birthday, my husband Mike and 

I took some friends and had a little margarita party in the Green 

House. We had dips and chips, and all the elders came out, and 

we told Mary stories. We wanted these elders to know that when 

they were no longer here, someone would remember them, too. 

That is one person’s story, but that is not the end of our story. 

We have constructed in America a beautiful democratic system, 

which through its agencies works to provide sustenance and direction for all of its citizens almost, but not quite, across their life 

spans. We have fallen just a wee bit short. 

It is time for us to cover that gap. How do we do it? ‘‘In small 

places close to home, so small they cannot be seen on any map,’’ 

as Eleanor Roosevelt suggested, or just maybe build more places 

like a Green House. 

Thank you again for the opportunity to testify and tell the story 

of my mother, Mary Valentine. 

[The prepared statement of Ms. Holland follows:] 

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Senator CASEY. Ms. Holland, thank you very much for your testimony. It was poignant and moving and an important personal reflection. 

We often have testimony here in these hearings that is data driven. It is important. But very rarely do we get the chance to listen 

to someone who has had the kind of experience and, as you say, 

speaks from that experience. But it especially speaks from the 

heart. 

You said in your testimony that you weren’t sure you had the 

strength to care for your mom, and it is readily apparent that you 

did and your strength is enduring. 

Ms. HOLLAND. We, our family is so grateful because we had the 

Green House there and the Tabitha there and the transition. We 

didn’t have the strength, but it was there. We are a team with the 

Shahbazim. They are family to us. 

Senator CASEY. Well, you are giving important testimony to the 

importance of this patient-centered approach, and we are grateful 

that you took the time to testify and to tell that story about your 

own mother and your own life experience, but also to travel the distance you did. 

So thank you very much. If I have time, I will ask you a question. But we are going to move to our next witness. 

Edna Hess, I had the chance to meet earlier today, this morning. 

She is a Shahbaz. Am I saying that right? 

Ms. HESS. Yes, you are. You are saying that correctly. 

Senator CASEY. I want to commend her for her work. I have 

spent a good deal of time on the issue of what happens to and what 

are the programs and strategies that support direct care workers. 

So, Edna, we are grateful for your work, and we are especially 

grateful for you taking the time to be with us today. 

I also wanted to take this opportunity to announce that, as Mrs. 

Hess knows, there will be a congressional staff visit to the Lebanon 

Valley home in early October of this year. For those of you who 

don’t know, that happens to be in the State of Pennsylvania, where 

we are proud of that. 

But I wanted to have Edna testify now, and then we will go to 

our last witness. 

STATEMENT OF EDNA HESS, SHAHBAZ, LEBANON VALLEY 

BRETHREN HOME, PALMYRA, PA 

Ms. HESS. Thank you, Senator Casey. 

Senator CASEY. Oh, the microphone? 

Ms. HESS. Thank you, Senator Casey, Ranking Member Smith, 

and other members of the Committee for their kind invitation to 

appear before you this morning and to tell you my experiences as 

a Green House Shahbaz. It is a privilege and an honor to share 

that story with you. 

This year marks my 30th year as a nursing assistant. Like many 

of my colleagues, I became a nursing assistant just because I needed a job, and it turned into a lifelong calling. I have always felt 

that the care provided by myself and the rest of the staff at Lebanon Valley Brethren Home was of the highest quality. Our residents were clean, well tended, well fed. Still, there was something 

missing that I could not put my finger on. 

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Looking back on it now, I realized that while we offered our residents excellent care, that did not always translate into highest 

quality of life. When the Green House concept was first introduced 

by my employer, I was skeptical. After nearly 30 years as a nursing 

assistant, it was difficult to think about providing care in a new 

way. 

Still, the description of the Green House lifestyle was very appealing. I decided to apply for a Shahbaz position and was fortunate to be selected as one of the first Shahbazim to be trained. 

It has now been 9 months since my house, the Hostetter House, 

first opened its doors. The 10 elders who live in my house were 

transferred from the existing nursing units at the Brethren home. 

So I already knew many of them. 

I cannot believe how much better they are all doing in the Green 

House setting. The most noticeable improvement I have witnessed 

is the amount of socialization that occurs in our house. Several of 

my elders were hardly ever out of their rooms in the traditional 

nursing units. Now they are frequently seen chatting in the living 

room, out on the patio, or lingering at the dining room table. Very 

seldom do they want to go to their room. 

The second biggest improvement is in the dining experience. 

Every meal is home cooked in our open kitchen, and the elders experience all the smells and sights of the meal preparation. They 

really chow down at mealtime. When we first moved into the 

house, four of my ladies were receiving daily nutritional supplements like Ensure, and now, none of them. 

The living conditions in our Green House homes are much better 

than in the traditional nursing home units. It is much calmer because you don’t have the background noises of intercom announcements, alarms to deal with. There are no medication carts, laundry 

carts, housekeeping carts, or food carts to obstruct the walkway 

paths for our elders. 

There is no gathering of wheelchairs around a crowded nurses 

station. Our elders now congregate in front of the fireplace or out 

on the patio. 

One of the things that I now realize was missing in the traditional nursing home was the ability to make choices. Our residents 

were given very few opportunities to make choices that were important to them, like what time to wake up in the morning or what 

activity to attend. 

All that is different in our Green House. We no longer awaken 

our elders. We wait for them to wake up when they want to. We 

make them breakfast when they get up, whether that is 6 o’clock 

in the morning or 10 o’clock. As far as activities, they are now individualized. Sophie, she likes to do puzzles by the fireplace. George, 

he watches TV in his room at times. Bill putters on the patio with 

gardening, and Gertrude loves to go bowling with our newest toy, 

Nintendo Wii game system, which I want to add I like, too. 

I can honestly say that I love being a Shahbaz and so do my fellow Shahbazims. We have not had a single Shahbaz resign in the 

9 months that our house has been open. This compares favorably 

with the national average for turnovers for nursing assistants, 

which is over 70 percent. 

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The working life we now enjoy is very demanding because we do 

cooking, cleaning, and activities, in addition to nursing care, but it 

is so much more fulfilling. I no longer feel like I am working on 

an assembly line. There are two Shahbazims on my shift for just 

10 elders, so we feel like there is plenty of time to provide the person-centered care that is truly needed. 

One of the greatest things about the Green House homes is the 

consistency of staffing. I always work in the Hostetter House, and 

so the elders feel very secure and comfortable because they know 

me and I know them. This helps to provide better care. A few of 

my elders were chronically incontinent in the nursing home, but 

now we know them so well that we can anticipate their toileting 

needs. 

I often think of one of our elders that has since passed on. This 

gentleman and his wife were both elders in the Hostetter House, 

and they shared adjoining rooms. Though he was terminally ill 

with cancer, the gentleman was always more concerned with his 

wife’s welfare than with his own. Over many decades of marriage, 

he had always taken great care to make sure that his sleeping wife 

had a covering blanket on top of her to keep her warm. 

When the couple was in our traditional nursing unit, the husband always worried that the staff would forget the covering blanket. Sometimes they did because the staff changed regularly and 

not everyone knew the ritual. After a short time in our Green 

House, we realized how important it was for the covering of the 

blanket to Mr. P, and we never forgot it. I believe it gave him great 

peace that he knew his wife would be cared for in the same attentive way that he had done. 

In conclusion, I feel very lucky to be a Shahbaz and to work in 

a Green House home. In talking with many of my fellow 

Shahbazim, we all agree that we feel spoiled by our Green House 

experience in the sense that none of us would want to ever go back 

to the traditional nursing home setting again. 

Senator Casey, other members of the Committee and your staff, 

I encourage all of you to personally visit a Green House, our Green 

House, and see firsthand what a difference it is making in the lives 

of the resident elders. With Green Houses, seeing is believing. 

Thank you once again for this opportunity to present this testimony. 

[The prepared statement of Ms. Hess follows:] 

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Senator CASEY. Well, Edna, thank you very much. 

Ms. HESS. Thank you. 

Senator CASEY. When you referred to your own lifelong calling, 

now I think those of us in the room who didn’t know your story 

before understand why it has been such a calling for you. We appreciate that. We will visit not only because you said it and asked 

us to do it in public, but that helps. [Laughter.] 

We will be submitting questions to you. 

Finally, and I know because we have to give up our room shortly, 

I wanted to make sure that Dr. Diana White, who is the Senior Research Associate at the Institute on Aging at Portland State University in Portland, OR, I wanted to make sure that Dr. White had 

an opportunity to testify. 

She has done extensive research into person-centered care and 

has tremendous expertise on the most recent developments around 

the country and in her home State of Oregon. Dr. White, thank you 

very much for being here. 

STATEMENT OF DIANA WHITE, PH.D., SENIOR RESEARCH ASSOCIATE, INSTITUTE ON AGING, PORTLAND STATE UNIVERSITY, PORTLAND, OR 

Dr. WHITE. Thank you, Senator Casey. 

It is an honor for me to be here and an honor to be representing 

all of my colleagues in Oregon. I have been working in this area 

since 2001, and for most of that time, I worked for the Oregon 

Health and Science University’s Hartford Center of Geriatric Nursing Excellence, and I am continuing that at Portland State. 

The Hartford Center partnered with the State’s unit on aging 

and 10 long-term care facilities to develop person-centered care 

practices, many of which we have heard talked about today. In 

2003, the partnership expanded when Oregon received a Better 

Jobs Better Care demonstration grant. We were one of five, and 

Pennsylvania was one of our fellow demonstration grantees. 

Our partners included eight provider organizations, the longterm care trade associations, the Oregon State Board of Nursing, 

and many, many others. Through Better Jobs Better Care, we 

worked to improve living and working environments for direct care 

workers and residents, both, through person-centered care practices. I was the local evaluator of that project. 

One of our first challenges was to clarify and define what we 

meant by person-centered care. Everybody has their own vision of 

what that is. We went through a rigorous and systematic process 

to create a definition and then a measurement tool we could use 

in our evaluation. As our own thinking and experience evolved, we 

began to use the term ‘‘person-directed’’ rather than ‘‘person-centered’’ because we wanted to emphasize that residents, even those 

with severe cognitive and physical disabilities, needed and were 

able to guide their care. 

Person-directed care is a way of thinking about care that honors 

and values the person receiving support. The elements comprising 

person-directed care we identified are personhood, knowing the person, choice and autonomy, comfort and relationships. I have attached definitions of each of these elements. 

104 

To implement these practices, we found organizational systems 

must be in place. For all levels of staff, this means adequate education and training, the ability to be an advocate for residents, the 

ability to make care decisions with residents, having the time to 

work with residents, teamwork, skilled supervisors, and adequate 

staffing. 

I would like to give one example of some of the work that 

emerged and that was done. At Rogue Valley Manor, which is a 

nursing home in Medford, OR, a nursing assistant meets with each 

new resident to learn how and when they like to get clean. If the 

person is used to showers at night, they continue to get showers 

at night. If they prefer a bath in the morning, they can get that, 

too. 

If bathing or showering is painful or frightening, a towel bath 

might be a comforting solution. The CNA also learns what kinds 

of soaps and shampoos and lotions and ritual routines are preferred, whether their hair should be washed during their bath or 

shower or at a different time. 

Sometimes residents with dementia can’t describe their preferences or routines. The CNAs get what information they can from 

the resident. They ask family members. They talk to each other. 

Most importantly, they pay a lot of attention to the behaviors of 

the resident to figure out the rest. 

During this process, workers also identify what kind of music or 

conversation, if any, would be pleasurable to the person to help put 

them at ease. The shower or bathing schedule is then built around 

resident preferences, and then staff have the flexibility to go with 

the flow. If a resident does not feel like following their routine on 

a particular day or they request a different one, that can happen, 

too. 

At many other facilities throughout Oregon, person-centered 

practices have not stopped with bathing programs or the many dining programs that have been developed. Each led to new activities, 

as staff and residents experienced successes and saw different 

areas that needed a person-directed approach. For example, with 

flexible dining and bathing schedules, residents now get up and go 

to bed when they want. Some residents go to breakfast in their pajamas if that was their routine in the past. 

Some facilities have started therapeutic gardening programs, and 

almost all are really working to build teams and leadership skills 

among the direct care staff. Many have experimented successfully 

with worker-directed teams who make their own assignment to 

residents, mentor new staff, and do their own scheduling. 

Although exciting and rewarding, the process is not easy, even 

when organizations are committed to these changes. We would like 

to see more investment in organizations that are working toward 

person-directed care practices. 

An example is a partnership between Oregon’s seniors and people with disabilities and 12 nursing homes using civil penalties 

money. We are also experimenting with educational programs directed at nursing students, direct care workers, people who are in 

the field, to make sure that the training starts at the very beginning of this process. 

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Person-directed care practices continue to evolve in Oregon, and 

I will leave here the philosophy statement that has been developed 

by key stakeholders, including Government and provider organizations, and information about several ongoing person-directed care 

activities. 

Again, I thank you for this opportunity to share our experiences 

and our hopes to transform long-term care. 

[The prepared statement of Dr. White follows:] 

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Senator CASEY. Thank you, Dr. White. 

I want to thank our witnesses. We are out of time for the room. 

We are about 15 minutes over time. But we are grateful that each 

of you made the trip to be here, that your testimony—if you didn’t 

get to all of it, the full testimony will be made part of the record. 

But we are grateful for your leadership. We all have to run, but 

we are certainly grateful that you are here today. 

Thank you very much. 

[Whereupon, at 12:50 p.m., the hearing was adjourned.] 

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