Regulate–deregulate. Can we really solve the crises in the economy and health care by doing one or the other? Is it really so simple?

I’m not an economist, but I am a nurse and journalist who can tell you that regulations in health care serve to protect the public. They can also get in the way of better care.

Consider the story of Dr. Meridean Maas, RN, and Dr. Janet Specht, RN, two advanced practice geriatric nurse specialists who had extensive expertise in long-term care of people with dementia. Based in Iowa, they realized that the facilities where they had worked were not places in which they would put their own parents. They believed they could provide a better model of care and decided to prove it. They took out a loan for $350,000 and a received a grant from the Iowa Development Corporation to purchase a ranch-style home with acreage that they called Liberty Country Living. They created a home-like atmosphere for people with dementia who dressed in their own clothes and could walk the fenced-in property without fear of becoming lost. Staff ate with the residents and got to know their interests and backgrounds, often encouraging the residents to engage in activities that held meaning for them. Family were told to come any time and supported in being with their loved ones as much as possible.

Maas and Specht also instituted best clinical practices in caring for people with dementia. As a result, the Liberty Country Living had one of the lowest rates of falls and incontinence among facilities in the state, as well as a low usage of psychotropic medications. Instead of a rapid decline with weight loss and frailty once institutionalized, the residents maintained a fairly stable and steady course.

And the care was not more costly than in other facilities. Although the Liberty Country Living was not eligible for Medicaid reimbursement, the facility made a profit after three years. Maas and Specht knew that the turnover of certified nursing assistants, licensed practical nurses, and registered nurses in long-term care facilities is high (more than 100% a year in some facilities), so they also used best employment practices. For example, the profits that second year were shared with the Liberty Country Living employees. They had one of the state’s lowest rates of employee turnover for long-term care.

A great success story, right? Wrong. The state told Maas and Specht that the facility was not meeting the state regulations for assisted-living facilities that cared for people with dementia. In order to do so, they would have to make changes in the facility, such as enclosing stairways and kitchens, that would have put them out of business. When they pointed to their outcomes and asked to be an exception, they were told they would have to get a law passed permitting such exceptions. Maas and Specht went to work doing just that. It got through the legislature, only to be vetoed by Governor Thomas Vilsack, supposedly because “it would place an Executive Branch regulatory agency in an advocacy role”. Maas and Specht had to close Liberty Country Living much to their own dismay and to that of the residents and their families.

The regulations that have arisen around long-term care are there because of bad care. Long-term care is an overregulated area of health care, but one in which enforcement is sorely lacking. Bad care continues to be uncovered, facilities are fined when it’s public or egregious, and many other facilities continue to understaff and provide bad care.

Maas and Specht have been identified by the American Academy of Nursing as “Edge Runners”—nurses who have developed innovative solutions to our ailing health care system. They have the clinical and financial outcomes to back up their work, but many have difficulty sustaining and spreading their innovations, as did Maas and Specht.

If we’re going to transform health care, it will take every innovative bone in our collective body politic. We must find a way to permit such innovative models of care to be tested, sustained and spread. We need a way out of the regulatory boxes that have arisen to protect the public from bad care. But we can’t throw the box out altogether. Doing so would only worsen most health care. When I was practicing in a hospital, I was amazed at how often the urge for an institution to do the wrong thing was resisted and finally stymied by a nurse pointing out that “the Joint Commission” or “the state” wouldn’t permit it. I cringed at times thinking about what health care would look like if many of the regulations institutions must live by were no longer there.

I suggest that every state and the nation support “out of the box” exceptions or demonstration projects on innovative models of care and interventions with the expectation that the projects demonstrate outcomes that are better than the state or national norm and more cost-effective than the status quo.

To read more about the American Academy of Nursing’s Edge Runners, go to www.aannet.org and click on Raise the Voice.

This entry was posted on Tuesday, October 14th, 2008 at 9:04 am and is filed under Caregiving, Consumer Health Care, Innovation, Patients, Policy, Quality. You can follow any responses to this entry through the RSS 2.0 feed. You can leave a response, or trackback from your own site.