1 1 2 3 4 5 6 ***************************************************** 7 UNITED STATES SENATE COMMITTEE OF VETERANS AFFAIRS 8 9 Field Hearing: Caring for America's Aging Veterans 10 ***************************************************** 11 12 13 14 TAKEN AT THE FIRST UNITED METHODIST CHURCH, TUPELO, MISSISSIPPI, 15 ON JULY 3, 2008, BEGINNING AT 10:35 P.M. 16 17 18 19 (APPEARANCES NOTED HEREIN) 20 21 22 Reported by: MEAH M. BENNETT, CSR 1708 _____________________________________________________ 23 ADVANCED COURT REPORTING 24 P.O. BOX 761 TUPELO, MS 38802-0761 25 (662) 690-1500 2 1 APPEARANCES: 2 3 4 SENATOR ROGER WICKER 5 6 WITNESSES 7 8 CHRISTA HOJLO, DNSc, Director, Nursing Home Care, Department of Veterans Affairs 9 BILL THOMAS, MD, Founder, The Eden Alternative 10 STEVE McALILLY, Chief Executive Officer, Methodist Senior Services, Inc. 11 ROBERT JENKENS, Director, The Green House Project 12 LOIS CUTLER, PhD, Research Fellow, School of Public Health, Division of Health Policy and 13 Administration, University of Minnesota 14 15 16 17 18 19 20 21 22 23 24 25 3 1 TABLE OF CONTENTS 2 3 WITNESS PAGE 4 DR. BILL THOMAS . . . . . . . . . . . . . . . . . . 8 5 STEVE McALILLY . . . . . . . . . . . . . . . . . . 15 6 DR. LOIS CUTLER . . . . . . . . . . . . . . . . . .27 7 ROBERT JENKENS . . . . . . . . . . . . . . . . . . 32 8 CHRISTA HOJLO . . . . . . . . . . . . . . . . . . .40 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 4 1 SENATOR WICKER: Well, thank you very 2 much. I want to tell you, as a member of the Senate 3 and as a veteran myself, I very much believe in 4 punctuality. But the press grabbed me, and Kyle 5 Stewart tells me, when the press wants to quote you 6 or give you a little publicity, it is a good thing to 7 cooperate, even if it makes us a minute or two late. 8 But, welcome. We will have a few introductory words 9 and then begin. But, at this point, I would ask that 10 all of us stand for the flag presentation which will 11 be made by Troop 12, a troop where my son, Daniel, 12 achieved the rank of eagle scout. Troop 12 is a part 13 of the Yocona Area Council. 14 (Whereupon, Troop 12 presented the flag 15 of the United States of America.) 16 SENATOR WICKER: Thank you. And our 17 pledge will be led today by Mr. Rex Mooney, president 18 of the Vietnam Veterans of America, Chapter 842. 19 Brother Pastor, after the pledge, I am going to ask 20 you to come up and lead us in an invocation. 21 MR. MOONEY: Please join me in the Pledge 22 of Allegiance to our flag. 23 (Whereupon, the Pledge of Allegiance was 24 recited by all present.) 25 PASTOR: Let's pray. Lord, on this day 5 1 of a new beginning of a new day, we honor You with 2 our lives. We remember how we are to respect our 3 elders and those who have given of their service. 4 And so we come today to deliberate, to understand 5 what it is that makes our nation great, to honor 6 those who have come before us who have given 7 sacrificially of their lives. We remember this 8 because of Your sacrificial giving of Your Son and 9 our Savior. So be present in this hearing. May we 10 honor You with our lives. Be in our speech and be in 11 our hearts and be in our action, be in all that we do 12 for the sake of Your kingdom, amen. 13 SENATOR WICKER: Thank you, Brother Andy. 14 And you may be seated. I very much appreciate your 15 attendance today, and welcome to this field hearing 16 of the United States Senate Committee on Veterans 17 Affairs dealing with the subject of caring for 18 America's aging veterans. At this point, I want to 19 introduce to you two members of the committee staff 20 who have traveled from Washington, D.C., to be with 21 us today. And stand as I call your name: Aaron 22 Sheldon. Aaron is a staff member for the chairman of 23 the Senate committee, Senator Danny Acaca of Hawaii. 24 And then John Towers -- please stand, John -- is a 25 staff member for Senator Richard Burr of North 6 1 Carolina, the ranking minority member of the 2 committee. So we appreciate these staff members 3 taking their July 3rd to come here and be with us 4 today. 5 Now, we have a distinguished panel of 6 witnesses that I will speak more about later, but 7 let's just have them, at this point, stand and turn 8 around, if you don't mind, so that we can make sure 9 that we get a face with a name. Dr. Christa Hojlo -- 10 now, did I pronounce that correctly? 11 DR. HOJLO: Yes, sir. 12 SENATOR WICKER: I think I butchered it 13 pretty bad on public radio this morning. But just 14 think of high and low. Dr. Hojlo is director of VA 15 Community Living Centers and State Veterans Home 16 Clinical and Survey Oversight. Then, next to her -- 17 and we'll just go down the line -- Dr. Bill Thomas, 18 founder of The Eden Alternative; then, in the center, 19 our own Tupelo representative, Steve McAlilly, chief 20 executive officer of Methodist Senior Services, 21 Incorporated; then Robert Jenkens, director of The 22 Greenhouse Project; and Dr. Lois Cutler, research 23 fellow, School of Public Health, Division of Health 24 Policy and Administration, University of Minnesota -- 25 came all the way from Minnesota. So, thank you, and 7 1 let's give a warm Mississippi welcome. 2 And what I am going to do, I am going to 3 make just a few remarks, and then we will take 4 testimony individually from each of these witnesses. 5 And I'll give Dr. Thomas warning that I will ask 6 Dr. Thomas to go first on that. But welcome to this 7 hearing. I did not realize, until we got into this, 8 that I am the first Mississippi senator ever to serve 9 on this particular committee, Senate Veterans Affairs 10 Committee. We have had many distinguished 11 Mississippians precede me in the halls of the U.S. 12 Senate, but they have served on other very important 13 committees. I am glad to be holding this committee 14 hearing in Tupelo, Mississippi. 15 Now, Tupelo is famous for many things. 16 We had a big tornado one time. We have a native son 17 named Elvis Presley, who hasn't been around here very 18 often, recently. And we're proud of the many 19 accomplishments that we have made, in terms of job 20 creation and manufacturing and economic development, 21 but increasingly, this city has become known as the 22 birthplace of a revolution in long-term health care. 23 In Mississippi, actually, we are proud to be on the 24 cutting edge of long-term health care reform. We're 25 here today to discuss ways to keep that momentum 8 1 going and consider how we might expand the successful 2 formula that we have put into place here known as The 3 Greenhouse Project, to work within the Department of 4 Veterans Affairs and the VA system. 5 These distinguished witnesses have, I 6 think, set some sort of record for long distance 7 traveled to a Senate Veterans Affairs field hearing, 8 and I do appreciate their attendance today, as well, 9 of course, as the staff members. And thank you all 10 for coming and participating. We have many veterans 11 here, and we have representatives of the a number of 12 the veterans service organizations. So welcome, and 13 let's begin our testimony with Dr. Bill Thomas. He 14 is the one who started this excitement. Do we call 15 you Bill or William? 16 DR. THOMAS: Bill is fine. 17 SENATOR WICKER: Bill is okay. Bill is a 18 geriatrician and a trailblazer in the realm of elder 19 care. He developed the greenhouse model and created 20 The Eden Alternative to help facilitate long-term 21 care transformation in the United States of America. 22 Dr. Thomas, welcome, and proceed in your own fashion. 23 We're glad to have you. 24 DR. THOMAS: Thank you very much, 25 Senator. And thank you for hosting this hearing, and 9 1 thank you for holding it in Tupelo, Mississippi. I 2 think it is very important that we draw attention to 3 the fact that the first greenhouses were created 4 right here in this community by pioneers from this 5 community. I have given thought, of course, to what 6 I wanted to say to you and to the committee, and I 7 will leave it to others to talk about some of the 8 details about the greenhouse. I think that is 9 important, but I thought I might spend some time 10 talking about the nature of the field of long-term 11 care, in general, and the nature of change in that 12 field, and what is going on and how I believe that 13 our veterans should be benefitting from the 14 improvements in the field of long-term care that are 15 underway right now. 16 Let me say, first off, that historically, 17 it is our nation's commitment to veterans that 18 started us down the path of providing care to older 19 and frail and disabled people. It was actually after 20 that -- what I'll refer to as the War Between the 21 States, otherwise known as the War of Northern 22 Aggression, it was after that conflict that our 23 governments respectively started making a provision 24 for commitment to veterans. And, indeed, that 25 commitment was expanded upon enlarged after World 10 1 War I, and again after World War II. So, in fact, 2 it's been an important part of the fabric of our 3 national promise to our veterans that we would 4 provide for them in their later years as they 5 provided for us in their earlier years. 6 Now, early on, that promise was delivered 7 in the form of institutional long-term care. We, as 8 Americans, I think, as we're prone to do, we followed 9 the logic of economics, economies of scale. We 10 followed the logic of the Division of Labor and 11 created large institutions that focussed primarily on 12 the tasks that needed to be accomplished and put 13 those tasks, unfortunately, ahead of the people being 14 served. And the result was really what we have come 15 to know in America as the 16,000 long-term care 16 institutions created and are currently being managed 17 today -- 16,000. And I would like to point out 18 something that people often don't realize; there are 19 more nursing homes in America than there are 20 McDonald's restaurants. And it is a fundamental part 21 of our health care system, and it is increasingly 22 clear that it is based on flawed assumptions from 23 decades and decades ago. 24 So, what is changing. What is changing 25 is an industry-wide acknowledgment that you have to 11 1 put the person first. You have to put relationships 2 first, that economies of scale cannot and do not 3 apply to human relationships. Fundamentally, 4 long-term care is, more than anything else, about the 5 care. And care is a habit of the heart. It is a 6 human activity, and it does not scale up the way a 7 furniture factory does, where, clearly, it is better 8 to build a bigger factory and a bigger assembly line, 9 because it is more cost effective. 10 What we're increasingly learning -- and I 11 think Dr. Cutler will address this, in part -- is 12 that it is not cost efficient to attempt to scale up 13 human relationships and caring. Because what happens 14 is people begin to feel lost. They begin to feel 15 that they are just a number. And I think it is wrong 16 in all circumstances, and I think it's particularly 17 wrong when that kind of existence is what we offer to 18 our veterans. 19 So what is changing? We're learning to 20 put the person first. We're learning to create small 21 scale environments where relationships matter most. 22 And I think our veterans deserve the benefit of this 23 research. I know that some of the other speakers are 24 going to talk about some of the research funding and 25 the grants that are being made to support this. I 12 1 think it is really essential that our veterans get 2 the full benefits. And I'll close, actually, my 3 comments with a simple analogy that I use that is 4 really effective for me in my work. I grew up in a 5 rural area, a good close-knit small town family. And 6 one of the things -- 7 SENATOR WICKER: Where did you grow up? 8 DR. THOMAS: Upstate New York, a fine, 9 fine place. 10 SENATOR WICKER: Absolutely. 11 DR. THOMAS: I am actually the grandson 12 of World War II veterans. And my boy, I'm proud to 13 say, is enlisted in the United States Coast Guard, so 14 it is personal to me, as well. So my feeling about 15 this is my family taught me that sometimes half a 16 loaf is better than no loaf at all. And I grew up 17 understanding that you don't always get what you 18 want, and sometimes you have to have something for 19 less than you might have preferred. But my work on 20 the reform movement of the greenhouses has taught me 21 another lesson, and that's that sometimes it's not 22 about half a loaf. It is about getting it right. 23 And I sort of imagine, kind of, what it 24 would be like to tell our service people, you know, 25 half an aircraft carrier is better than no aircraft 13 1 carrier. Half a fighter jet is better than no 2 fighter jet. Half a tank is better than no tank. 3 Well, it doesn't make sense. People need the tools 4 that are properly created and properly designed to do 5 the job you're asking them to do. And one thing I 6 want to make clear to the committee and committee 7 staff, and to you, Senator, is that I think it is 8 very important that, as the Veterans Affairs 9 Committee looks at this, and the agency looks at 10 this, that you understand that the greenhouse is a 11 complete model created to do a specific thing, and 12 that is create a life worth living for the people it 13 houses and shelters, and that taking one piece ,or 14 half of it, or one little part and calling that 15 enough is a mistake, just as providing our service 16 people with a one-winged aircraft would be a mistake. 17 This is a case where we have to get the 18 whole thing, because in order for it to work 19 effectively -- and I'll leave it, for example, to 20 Steve McAlilly to talk about the experience right 21 here in Tupelo -- this is a case where half-measures 22 are not necessarily the desired outcome. So, you 23 have given me the honor of your attention and the 24 honor of testifying before you, and I want to say 25 thank you very much. 14 1 SENATOR WICKER: Okay. I think I am 2 going to change the order here. First of all, can 3 everybody hear in the back? I think, Mr. McAlilly, I 4 am going to go to you next, if you don't mind. But I 5 want everyone to understand exactly what we're 6 describing here. This -- I think what we have said 7 is that this is an innovation that began here in 8 Tupelo. It has moved to other sections of the state 9 of Mississippi now. United Methodist Senior Services 10 has been very active in this, and without which, we 11 probably wouldn't be here today. 12 We want the best care possible for 13 everyone, but certainly for someone who has served 14 our nation in the armed services and kept us free and 15 risked life and limb during the time of conflict. We 16 deserve and they deserve the very best that we can 17 provide. And we have heard from Dr. Thomas that this 18 involves relationships, and we're trying to research 19 this. But, Mr. McAlilly, you have got your testimony 20 in front of you, and I don't want to throw you off, 21 but I would hope that you could describe, for those 22 who have not been out to the greenhouses here in 23 Tupelo, exactly how it looks, how it differs from 24 traditional long-term health care, and why you think 25 it is better. Now, having thrown you that curve, we 15 1 welcome Steve McAlilly. And let me tell you a little 2 more about him -- CEO of Methodist Senior Services 3 here in Tupelo. His leadership and vision were 4 important in advancing a new, and at that time, 5 unproven concept in long-term health care. Perhaps 6 you can discuss, Mr. McAlilly, whether that has now 7 been proven. But we look forward to hearing your 8 insights, and we appreciate your work here locally 9 and your willingness to be part of this hearing. 10 Steve, take it away. 11 MR. McALILLY: Thank you, Senator Wicker. 12 We welcome you back home. 13 SENATOR WICKER: Well, thank you. It is 14 good to be home. 15 MR. McALILLY: And we're honored to be 16 here with you and the staff members from the United 17 States Senate and this panel of witnesses. We are 18 honored to be able to have this chance to talk about 19 the very thing you mentioned. I feel a little bit 20 like Dustin Hoffman in the movie Tootsie with the 21 curve you just threw me, except I'm not the one 22 throwing the curve. You were. I hate to be stuck to 23 a script, so I was already thinking of varying from 24 that, anyway. So that will fit just well. 25 SENATOR WICKER: By the way, your 16 1 prepared statements will be made part of the 2 permanent record for the committee. We appreciate 3 that. 4 MR. McALILLY: Essentially, a greenhouse 5 is a small group home for 10 or fewer elders who need 6 skilled nursing care or assisted living services. 7 The design is crucial to it, just as the keystone of 8 an arch is crucial to the arch. If you pull the 9 design, you pull the space away, and the whole thing 10 falls, we believe. In that small group home, we 11 provide private rooms and private baths for the 12 elders. And there is a hearth there in the center of 13 the house with recliners from Sam's, and everybody 14 has their favorite chair and their favorite spot. 15 The kitchen is like a great room. The kitchen is 16 right there. There is food always available, like 17 there is at home. They can go into the refrigerator 18 or eat cookies off of the kitchen counter, their 19 kitchen counter. 20 There is a big table next to the kitchen 21 where all of the elders and the staff members sit 22 down together and eat. And the way we -- I don't 23 think operate is the right word, but the way it 24 functions is just like at your house. The kitchen 25 table, I would bet, is the most sacred space in your 17 1 house, and if your best friend comes over at 2 mealtime, you're going to put a plate out for them, 3 and they will join in fellowship and activity at the 4 kitchen table, rather than go into the dining room 5 with the fancy china and sit down. That's the way we 6 function in a greenhouse. And we've had family 7 members have weight problems because they come over 8 and eat because the food is so good. 9 SENATOR WICKER: That is another 10 Mississippi problem. 11 MR. McALILLY: Dr. Thomas describes it -- 12 and I steal his words all of the time, and he knows 13 it. I think I have permission, and usually I give 14 him credit, but he describes it as the world's most 15 inefficient nursing home or the world's most 16 efficient home health delivery system. The nurses 17 come over and ring the door bell, just like they 18 would if you were having home health brought into 19 your home. And they come in, and they do their 20 nursing. They do their medical treatment, and then 21 they locally have 10 clients there within 6500 square 22 feet, rather than 10 clients scattered all over 23 Tupelo, Mississippi. And they do their thing, and 24 then they leave and go to the next house. 25 The house revolves around the elders, the 18 1 people who live there. And we make decisions and we 2 put the resources as close to the elders as possible, 3 because that's where they make the biggest 4 difference. So what that means to us, they are 5 dollars that go into buildings. And so the building 6 is better. It is home. It costs a little more than 7 a traditional semiprivate nursing home. It does. 8 But we move those dollars that are in the system to 9 the front line, where they make the biggest 10 difference. The other part of that is the staffing 11 levels among the front line staff, and pay. I will 12 go ahead and put this word out there. It used to be 13 hard to say this in Mississippi. The front line 14 staff member is a shahbaz. And that means -- 15 SENATOR WICKER: How do you spell that? 16 MR. McALILLY: S-H-A-H-B-A-Z, and it 17 comes from a great story that Bill Thomas tells about 18 the first shahbaz. It's a Persian word that means 19 royal falcon. And it's given the CNA, the certified 20 nursing assistants -- they are the shahbazi. That is 21 the plural of shahbaz, or so Bill tells us. We 22 believe it, anyway. But it has given them a new 23 purpose and function. Their job is to protect, 24 sustain and nurture the elders who live in their 25 house. And they cook. They do light housekeeping. 19 1 They do the personal laundry. They oversee and 2 participate in the activities in the house. They are 3 a self-managed work team. They self-schedule 4 themselves. And just in terms of growth of people 5 who work there, we have seen astounding results and 6 decrease in turnover and just self-worth. They have 7 become people -- they were people stuck in jobs that, 8 I think, the system caused them to be smaller than 9 they were. But in this vessel, in this system, in 10 this house, in this space, they have been enabled to 11 become who they were created to be. Now, that is the 12 first part, I think, of what is a greenhouse -- a 13 small group home where we do skilled nursing care. 14 But the other piece is the culture. 15 SENATOR WICKER: The same people who 16 would be admitted, traditionally, to a nursing 17 home -- 18 MR. McALILLY: Absolutely. 19 SENATOR WICKER: -- as we have known to 20 expect it, are housed in the greenhouse. 21 MR. McALILLY: Cared for in the 22 greenhouse. There has not been a person yet in 23 Tupelo, Mississippi, in our greenhouse homes that, 24 because of their frailty or medical needs, that we 25 haven't been able to serve in a greenhouse. And they 20 1 are designed to provide everything, in terms of 2 treatment and care, that the traditional nursing home 3 was designed to provide. And we do it. 4 And people are doing that in Tupelo every 5 day. The people who have the finances to provide 6 'round the clock care, they are doing it. And that 7 is why, to us, it is not that novel. It is just, 8 duh, that kind of reaction. Why did we ever do it 9 the other way? Because people still do it, and 10 people are cared for there in their homes, if they 11 have the money to do it. But in this system, there 12 is the money there to do it right now, today. And we 13 have proven that over the last five years. 14 SENATOR WICKER: Okay. Let's do this, 15 Steve, let's take another four to five minutes on 16 your testimony, and then I'll have a couple of 17 questions. And I think we'll probably have an 18 opportunity for some back and forth. Can everyone 19 hear? 20 UNIDENTIFIED SPEAKER: We're having a 21 little of trouble hearing the -- 22 SENATOR WICKER: Okay. We'll ask the 23 witnesses to speak right into the microphone. I 24 think it is on. Just speak -- just put your mouth 25 right up to it like you are Mick Jagger. 21 1 MR. McALILLY: Can you hear me now? 2 Basically, as we started this journey -- you met Bill 3 Thomas, and when he talked about relationships, 4 that's what it is about. And it started with the 5 relationship that he and I developed that goes on now 6 about 10 years. And as you heard, when Bill talks, 7 he talks about truths with a capital T. And his 8 truths that he talked about in Eden Alternative made 9 perfect sense to us. 10 We started this journey in 1994. We 11 wanted to build a nursing home. We believed the 12 essence of dignity was a private room with a private 13 bath. We didn't understand why, when people got old 14 and frail, they had to move in with a stranger with a 15 sheet pulled between their beds. That just didn't 16 sound right to us. The other thing is we wanted to 17 create a place, as we built this new nursing home, in 18 which the children of frail elders would feel pride, 19 rather than guilt, that their parents were living 20 there. 21 So we started this journey looking for 22 the best design. And Bill started talking about the 23 Eden Alternative, and we got to know him. And we 24 realized we were asking the wrong questions, and the 25 system is asking the wrong questions. The 22 1 stakeholders asked, what quality insurance and total 2 quality system can we put into a nursing home to 3 improve quality? What the question really ought to 4 be is, why has proven quality systems in other 5 industries not made much of a difference in a nursing 6 home? The stakeholders asked, what type of 7 regulations or penalties can we put on people who are 8 operating nursing homes so that they will improve 9 compliance, when the question ought to be, what is 10 wrong with the system that, no matter how many 11 regulations and how tough penalties are, that quality 12 and satisfaction is not consistently changed? 13 The stakeholders asked what oversight and 14 control can we put on this industry to improve 15 outcomes? Here's what you have got, you've got a 16 CMS, State Departments of Health, State Medicaid 17 division, ombudsmen, State Attorneys General, looking 18 over this industry's shoulder. The question is, what 19 is wrong with that picture? Why does this industry 20 need that much control and oversight? And the bottom 21 line is people still say a short prayer when they 22 walk in the door of a nursing home: God, save me 23 from this. 24 And so we started asking those questions 25 and moving along, and we came up with a wonderfully- 23 1 designed nursing home. And Bill, pick my brain -- it 2 was going to be a 140-bed replacement for Cedars 3 Health Center on the Traceway Campus, a 4 state-of-the-art design with 20-unit neighborhoods, 5 or pods, and a town hall in the middle that would 6 remind them of home. And we were proud of what we 7 had come up with. And one day Bill was in 8 Mississippi, and we were talking, and I was 9 enthusiastically describing that nursing home, and he 10 goes, you know, I don't think that's what we ought to 11 be building anymore. And that question haunted me 12 for a long time. And then he came up with the 13 greenhouse concept. 14 To the credit of the good people in 15 Tupelo, our board of directors here had the courage 16 to stop that project that we had invested thousands 17 of dollars in, and evaluate Bill's ideas. And when 18 we did, we realized they made sense. We realized 19 that the question was home, not home-like. The 20 question was, why do we do it this way? Why was this 21 ever a good idea? The question is, why don't we cook 22 the food in the presence of the elders, instead of 23 having it carted down the hall? The ideas just made 24 plain sense to us, and as a matter of intuition and a 25 matter of heart, our board of directors had the 24 1 courage to go off on this idea without scientific 2 data. 3 Now, I think Dr. Cutler will talk about 4 the research data that verifies that we were right, 5 but our anecdotal data is that people who were in 6 wheelchairs are walking again. People who wouldn't 7 eat in the nursing homes started eating and gaining 8 weight again. People who hadn't had a visit from a 9 friend or a family member in years started having 10 company again. Family members, as I mentioned, 11 started gaining weight. Every way you look at it, 12 it's been good. 13 Now, it is hard, because we're not 14 transforming something. It is not just the design, 15 it is the culture. We're replacing the whole 16 culture. And when you get to deal with changing 17 people's paradigms, it is hard. And sometimes the 18 paradigms filter the data so that we don't see the 19 need to change. And I think that's really where we 20 are in the system. 21 SENATOR WICKER: Okay. Now, we're going 22 to put your whole statement in the record, and then 23 you can get back to us and make some other points 24 that you would like to, after the others have had a 25 chance to talk. How long have we now had greenhouse 25 1 nursing home care in Tupelo, Mississippi? 2 MR. McALILLY: Since May of 2003, just 3 over five years. 4 SENATOR WICKER: Okay. I think I was 5 there for the opening of that one. It's hard to 6 believe it's been five years. How many people are 7 currently housed in that type of care here at the 8 Tupelo campus? 9 MR. McALILLY: There are 112. We started 10 out with four homes of 10 persons each, and then we 11 opened six more the fall after Katrina hit. And 12 those houses have 12 persons each, so we have 112 13 people who live in greenhouse homes here in Tupelo. 14 We have another two greenhouse homes on one of our 15 other campuses that provide assisted living, and 16 we're building six more 10-person homes in Yazoo 17 City, as a part of the Martha Coker home system 18 there. 19 SENATOR WICKER: Does United Methodist 20 Senior Services have what we would call traditional 21 nursing home kind of beds? 22 MR. McALILLY: We do. 23 SENATOR WICKER: And that is all over the 24 state? 25 MR. McALILLY: We have three -- including 26 1 the Traceway campus, we have two other campuses with 2 traditional nursing homes; Trinity Health Care in 3 Columbus and Doogan Home in West Point. 4 SENATOR WICKER: Okay. How do you decide 5 who goes to the greenhouse and who goes to the more 6 traditional nursing home? 7 MR. McALILLY: Well, the first level is 8 the people in the Columbus area want to stay in 9 Columbus, so they apply to move to Trinity Health 10 Care. Here in Tupelo, Traceway Campus, as you know, 11 is large and has about 420 total people that live on 12 that campus. Those people have -- they are people 13 who are living independently in cottages and 14 apartments, people who need assisted living at the 15 Mitchell Center, those people have first priority to 16 move into a greenhouse when their care needs get that 17 high. And then, if we have space or openings, the 18 greater Tupelo community is able to move in. And 19 it's on a -- we need to put your name on a waiting 20 list. And we've had, in essence, 99 percent 21 occupancy and a long waiting list since we opened. 22 Now, the first 40, they were pioneers, 23 too. Our medical director at the time thought we 24 were crazy for moving those people out there in the 25 woods. Now, if you talk to him, he thinks he 27 1 invented the thing, and we let him think that. We're 2 proud for him to say it was his idea. 3 SENATOR WICKER: Well, thank you for your 4 testimony. Our next witness, as I said, is from the 5 University of Minnesota, Dr. Lois Cutler. And 6 Dr. Cutler was part of the team that studied the 7 greenhouses in Tupelo. I'm told they found multi 8 outcomes that we'll hear about today, and these 9 outcomes have given credence to Dr. Bill Thomas' 10 vision and proved his hypothesis that there is a 11 better way to handle long-term care. 12 Dr. Cutler, is that true? Is this the 13 wave of the future, or is this just a nifty thing 14 that we're spending a little extra money on here in 15 Tupelo that we can't replicate? 16 DR. CUTLER: Our hope is it is the wave 17 of the future. 18 SENATOR WICKER: Okay. Let me just ask 19 you to get right up next to that, just scoot right up 20 next to that microphone. My dad is on the next to 21 last row. He is 80-hmmhmm years old, and he wants to 22 hear you. 23 DR. CUTLER: Okay. My hope is, our dream 24 is, our expectation is that it is the wave of the 25 future. We can change, and our data has shown that 28 1 this is a good model of change. And now, Senator 2 Wicker and ladies and gentlemen, my name is Lois 3 Cutler, and I am one of the researchers that studied 4 the effects of the first four greenhouses in Tupelo, 5 Mississippi and outcomes for the residents, 6 residents' family members and front line staff. My 7 background is in housing and design, as well as 8 gerontology. This testimony also reflects the views 9 of Dr. Rosalie Kane, the director of the study. For 10 the record, we would like to include the article on a 11 greenhouse study that was published in the 12 prestigious Journal of the American Geriatrics 13 Society. 14 SENATOR WICKER: That will be made part 15 of the record. 16 DR. CUTLER: Thank you. We conducted 17 research over the first two-and-a-half years of the 18 greenhouse experience, and we compared the results to 19 the traditional nursing home on the same campus and a 20 second traditional nursing home, Trinity, located 21 about an hour and a half away. At four points in 22 time, each six months apart, we interviewed 23 residents, family members, and all nurses-aid level 24 staff at the greenhouse and the two comparison 25 studies. We also compared results of the minimum 29 1 data set, the MDS, a national assessment protocol 2 conducted in all nursing homes, for the residents in 3 the three settings. 4 I personally spent many, many, many hours 5 observing how the space was used in the greenhouses. 6 Were residents with dementia using the space 7 differently? And I also wanted to see how the staff 8 and the visitors used the physical space. And what 9 we found is the greenhouse residents experience a 10 better -- and this means they are significant 11 findings. The greenhouse residents experienced a 12 better quality of life on many dimensions of quality 13 of life that we measured, and are even more satisfied 14 with the services in the nursing home and the place 15 where they live. Now, this is just a generic version 16 of all of the findings that you'll find in the 17 article. 18 Family members -- our greenhouse 19 residents spent more time visiting, and we calculated 20 the time, were more satisfied with the residents' 21 care, and were more satisfied with how their own 22 needs, as family members, were met. For example, 23 they were better satisfied with their own 24 communication with the nursing home. Compared to the 25 nurses-aid level staff in the comparison nursing 30 1 home, residents' assistants in the greenhouses had 2 more intrinsic success and were more likely to 3 believe that they had the ability to bring about 4 better outcomes for residents in psychological and 5 social dimensions, that they knew the residents in 6 their care better and were more likely to remain in 7 the job. 8 And for me, personally, the staff change 9 is one of the key models or key parts of this 10 concept. The staff, they were partners in everything 11 they did. Using the quality indicator measured 12 nationally for all nursing homes, the results for 13 greenhouse residents were as good as in a comparison 14 setting -- in a few cases, better. This is important 15 because we want to make sure that no harm was done to 16 quality of care with the greater freedom and quality 17 of life experienced by greenhouse residents. 18 Elders in the two greenhouses that were 19 dementia-specific functioned better in the 20 greenhouses than in their previous space in the large 21 dementia care units. We speculate that the 22 greenhouses are successful because of the small scale 23 and the emphasis on normal quality of life and 24 because of the model of care-giving that allows front 25 line staff and other staff to really know the 31 1 residents. The greenhouses are also successful 2 because of the physical setting with -- and we feel 3 the private rooms are incredibly important. And 4 inviting shared spaces evoke a particular kind of 5 behavior for residents and staff alike. 6 We are pleased that the Veterans 7 Administration is considering developing similar 8 small house model nursing homes at the Trence 9 Administration Medical Center long-term care 10 programs, including the nursing home care units and 11 long-stay units. The model should be adaptable to 12 many veterans in the medical center campuses, 13 particularly those where the nursing homes are older 14 and are slated for rebuilding, and where land is 15 available to build a small-house style nursing home. 16 Although, perhaps, not in the scope of this 17 committee, we also believe that this model is very 18 suited to nursing homes in the State veteran homes 19 that and are operated by many State governments in 20 partnership with the VA and the local veterans 21 medical center. 22 The Veterans Administration programs are 23 characterized by a high degree of professionalism 24 among the staff members, in nursing, social work and 25 other fields, and has shown historic leadership in 32 1 clinical geriatrics and geriatric team building. 2 Some of the building blocks for a successful 3 greenhouse project are, therefore, already in place. 4 A small-house nursing home program such as the 5 greenhouse requires a high degree of skill, 6 flexibility and commitment from those who will serve 7 as leaders, educators and middle managers. Please 8 read the article, and you will find more results, but 9 this is an overview, and we did find the concept to 10 be very, very successful. Thank you. 11 SENATOR WICKER: Thank you very much, 12 Dr. Cutler. We're now going to move to Robert 13 Jenkens, who is with us today from the Robert Wood 14 Johnson Foundation, a group that I came to know as a 15 state senator, when I was working on the public 16 health and welfare committee in Jackson, and later as 17 chairman of that committee. We appreciate the work 18 of the Robert Wood Johnson Foundation. 19 The Greenhouse Project's goal is to put a 20 greenhouse in every state within five years. So 21 we'll have an opportunity to hear about the lessons 22 learned from Mr. Jenkens today. If you could, 23 Mr. Jenkens, start off by telling us a little about 24 the Robert Wood Johnson Foundation, and speak right 25 into the microphone, if you don't mind. And then go 33 1 from there to your prepared testimony. 2 MR. JENKENS: Sure. Thank you, Senator. 3 The Robert Wood Johnson Foundation is the funder for 4 The National Greenhouse Replication Initiative. The 5 Robert Wood Johnson Foundation has provided funding 6 to the nonprofit that I work for, NCB Capital Impact, 7 to implement the program. And they have done that 8 because they are the largest grant funder in health 9 care in the United States. They are a foundation 10 that was established initially by the man who started 11 the Johnson & Johnson Pharmaceutical Company, and he 12 had an enormous commitment to the health and health 13 care of all Americans. 14 So the foundation has worked for years in 15 many areas of improving health care and health 16 delivery systems. They have not worked in long-term 17 care with skilled nursing care. They had worked to 18 provide alternatives to skilled nursing care in the 19 community, but they really felt that the system of 20 nursing home care in the United States was, as Bill 21 said, so deeply flawed and broken from its years of 22 focussing on the medical model and the institution 23 that they didn't believe that they would have an 24 impact. And last week, in a really very good Wall 25 Street Journal article, the foundation was on record 34 1 for saying it was the greenhouse model, it was coming 2 down to Tupelo and meeting Steve and seeing the 3 enormous successes that Lois documents in her 4 research, that convinced them that they could 5 actually have an impact on long-term care, and 6 changing it to be something that you or I would want 7 to either have someone we loved or cared for in a 8 greenhouse, or would ourselves be happy living in a 9 greenhouse. And I think, as Steve said, the prayer 10 that we all say to ourselves when walk into a typical 11 nursing home doesn't happen in a greenhouse. And 12 that's been a success. And The Wall Street Journal 13 article documents the foundation's, really, I think, 14 amazement that they have been able to partner with 15 Steve and Bill and the others to create greenhouses 16 around the United States to make a change that they 17 didn't believe was possible up to five years ago. So 18 that is the reason for their involvement in this 19 field. 20 We have been working with the Robert Wood 21 Johnson Foundation at NTB Capital Impact for the last 22 about 13 years on a variety of programs to improve 23 long-term care for aging Americans, and particularly 24 aging Americans with relatively low income and lack 25 of access to the private health care that Steve 35 1 mentioned that you can receive. 2 I am the director of The Greenhouse 3 Replication Initiative, which is the latest Robert 4 Wood Johnson Foundation grant in this area. As you 5 mentioned, the grant is a five-year partnership. It 6 is a partnership between Bill's Center for Growing 7 and Becoming, the Robert Wood Johnson Foundation, and 8 then, very importantly, the really pioneering 9 providers like Steve and Mississippi Methodist Senior 10 Services who have taken an enormous risk. As Steve 11 said, they didn't have Lois' research, but they 12 believed in the concept, and they have made this 13 happen. 14 The grant totals 15 million dollars, and 15 that provides a variety of technical assistance and 16 tools development, and that is a small revolving loan 17 fund to help organizations create greenhouse 18 programs. I'll focus my comments today on the 19 successful implementation of the greenhouse model and 20 how best to provide incentives and support to the 21 Department of Veterans Affairs to include the 22 greenhouse model among the many excellent culture 23 change initiatives that they are working so hard on 24 today to improve the care for our veterans. 25 Let me say first how proud I am of the 36 1 greatly-enhanced quality of life and care outcomes 2 that are being achieved in the greenhouse homes 3 across the country, and to say how important it is 4 that these are based on Dr. Bill Thomas' concept and 5 the pioneering work of Steve McAlilly and his team at 6 Mississippi Methodist Senior Services in Tupelo, 7 Mississippi. We know from Dr. Cutler that these 8 results show a very significant improvement in areas 9 that we have worked for years and years in long-term 10 care to improve, without success. And it is 11 important that we take these successes forward, not 12 as the only option, not as the predominant option, 13 but as a choice among the others for all Americans, 14 including our veterans. 15 The success of the greenhouse homes in 16 Tupelo has inspired many others, and I am pleased to 17 report today that there are 41 greenhouse homes open 18 and operating across the United States. They are on 19 15 partners' campuses in 10 states. We have another 20 139 greenhouse homes in development on 19 campuses in 21 an additional 12 states. So, in total, we're in 22 almost half the states. You mentioned our goal is to 23 be in all 50 states, and we think we are well on our 24 way to doing that. 25 The dramatic improvements shown by 37 1 Drs. Kane and Cutler's research indicate that, 2 fully-implemented, the greenhouse homes can provide 3 the improvements in the areas that Lois mentioned, 4 including for our veterans. What I am particularly 5 pleased about is that these improvements are in the 6 areas that have been so hard to crack before, areas 7 including privacy, dignity, autonomy, individuality, 8 emotional well-being, meaningful relationships and 9 activities, reductions in depression, reductions in 10 induced dependence and incontinence. 11 Each of our operating greenhouses report 12 similar improvements to the Tupelo greenhouse 13 results. And next year we will start a broader 14 research project to look and to document that these 15 same improvements that Lois and Rosalie Kane found in 16 Tupelo are able to be replicated, that there wasn't 17 something in Tupelo, maybe in the water or the 18 creeks, that made this a distinct place where it 19 won't happen again. 20 The outcomes, however, I think, are 21 important to note. We need to have the full 22 implementation. Bill talked about half of an 23 aircraft carrier or a one-winged aircraft. And I do 24 think it is important that it is understood that 25 while, for instance, the self-managed work teams 38 1 stand alone as a good idea, they support all of the 2 outcomes and accomplishments of The Greenhouse 3 Project. And they are integrated in ways that are 4 really very complex, and they can't be pulled out and 5 segmented. So we do have people who come to us and 6 say, we don't know about the self-managed work teams, 7 or we don't know about the fully-detached houses. 8 And I think it's important, as you all consider 9 helping support and spread the greenhouse concept, 10 that it is supported in a way that at least the core 11 principle, which can be implemented very flexibly, 12 but that those core principles are present in every 13 greenhouse, or we will have lost the magic that has 14 started in Tupelo. And I can say that because I have 15 worked on assisted living for many years as an 16 advocate, especially for people with low incomes, to 17 have access to high-quality assisted living. And 18 that is a movement that started very pure and has 19 been diluted over the last 15 years by people who 20 used the name and applied half or a third of the 21 concept. And the results in assisted living today 22 are no better than what they would have been in a 23 traditional board and care home or another model of 24 care that has been since really discredited. 25 So I would like to emphasize that The 39 1 Greenhouse Project, and helping veterans' homes adopt 2 The Greenhouse Project, really needs access to people 3 like Steve and Bill and the technical assistance that 4 the Robert Wood Johnson Foundation has sponsored. 5 Because we have learned from each success of 6 implementation and the importance of the different 7 pieces coming together in a flexible way to support 8 the individual needs of campuses across the country. 9 Let me stop there, and thank you very much for this 10 opportunity to be part of the hearing. 11 SENATOR WICKER: Well, thank you very 12 much. And our final witness is Dr. Christa Hojlo. 13 And as we said before, she is director of the VA 14 Community Living Centers and State Veterans Home 15 Clinical and Survey Oversight. Who pays your salary, 16 Dr. Hojlo? 17 DR. HOJLO: The Department of Veterans 18 Affairs. 19 SENATOR WICKER: The Department of 20 Veterans Affairs, okay. Well, we look forward to 21 hearing your testimony today. We have already heard 22 that -- we have already heard some excellent 23 compliments from Dr. Cutler about the VA and the 24 professionalism of the staff working for our 25 veterans. "The Veterans Administration programs are 40 1 characterized by a high degree of professionalism 2 among the staff members." So we're glad to have that 3 testimony as part of the record. But what can you 4 add, and what can you tell the viewers, the audience 5 today, as well as the committee? 6 DR. HOJLO: In order to do that, I would 7 like to stay with my written testimony -- 8 SENATOR WICKER: Yes, ma'am. 9 DR. HOJLO: -- because I think it is 10 important for the audience to understand the context 11 of the services that we provide in our VA Community 12 Living Centers. So, if I can do that, sir. 13 SENATOR WICKER: Absolutely. 14 DR. HOJLO: And then I certainly would be 15 willing to answer some questions as we move forward. 16 First of all, I would like to thank you for hosting 17 this hearing. And I am truly honored, and your staff 18 knows that. I am truly honored to be able to appear 19 before you as a representative of the 13,000 20 community living center employees serving our 21 nation's greatest and finest. I am proud to report 22 that the Veterans Health Administration is following 23 the lead of the innovators at this table by providing 24 a dynamic array of services to veterans of all ages 25 who require care in VA Community Living Centers. 41 1 The VA owns and operates 133 community 2 living centers from Puerto Rico to Hawaii, with an 3 average daily census of more than 11,000 veterans in 4 fiscal year 2007. These facilities range from 20 5 beds to 240 beds, and we serve approximately 49,000 6 veterans annually with a budget of approximately 2.7 7 million dollars, and we do offer a dynamic array of 8 services. This is an important concept, dynamic 9 array of services. We have identified in the VA that 10 some of our services are short-stay, similar to those 11 covered under Medicare in the private sector, and 12 then we also cover long-stay services. And the 13 short-stay services, for example, are for veterans in 14 need of rehabilitation or short-stay, post-hospital 15 care, or short-stay for veterans awaiting placement 16 someplace else in the community. And short stay is 17 generally less than 90 days. 18 We also offer long-stay services for 19 veterans with a disability rating of 70 percent or 20 greater or who are in need of nursing home care for a 21 service-connected condition requiring lifelong care. 22 VA Community Living Centers also offer respite care 23 to any family members who care for veterans at home, 24 and we offer hospice care in a kind and supportive 25 environment so veterans may be with their loved ones 42 1 and have the opportunity to live fully until they die 2 with dignity. 3 Through its community living centers, the 4 VA provides care to veterans of all eras. And this 5 is very important, because in the nursing home arena 6 today, we often hear reference to elders. However, 7 our members are not all considered elders. It is a 8 very important concept for us. So, for example, we 9 do offer care to veterans from World War II, from 10 Korea, Vietnam, the Gulf War, and then the new cohort 11 of veterans of Operation Enduring Freedom and 12 Operation Iraqi Freedom. 13 Some veterans have short-stay needs, and 14 others require longer stays, as I said earlier. 15 Whatever their specific situation, we are there to 16 help. We are sensitive to the fact that these 17 different groups will have different expectations and 18 different clinical needs. However, we are confident 19 that the VA has the resources and the right strategy 20 to address the interests of all veterans requiring 21 care in these settings. 22 The term nursing home conveys certain 23 impressions and ideas that do not reflect the VA's 24 approach to care. Informing a young, severely- 25 injured veteran, for example, that he or she 43 1 will need to live in a nursing home can be extremely 2 distressing because the term often invokes 3 stereotypical images of being cared for in a large 4 institutionalized and geriatric setting. 5 Consequently, we no longer use the term nursing home 6 to refer to our facilities, rather, we refer to them 7 as community living centers. This terminology more 8 accurately conveys the VA's philosophy of care and 9 our commitment, and represents more than a name 10 change. 11 This change in nomenclature is important 12 because it emphasizes that the veterans residing in 13 our facilities are unique individuals who have basic 14 rights to privacy and autonomy that must be 15 respected. The VA's policies have evolved to clearly 16 reflect and encourage the transformation in the 17 culture of care. We are significantly improving work 18 and care practices at existing VA facilities, and we 19 are adjusting our designs for new centers as well as 20 when renovations are in place. 21 Traditional nursing home designs have 22 been centered on the needs of staff. The nurses' 23 station, for example, served as the central gathering 24 place, and events are planned according to the 25 staff's calendar. In contrast, the VA's approach is 44 1 similar to the greenhouse or small house model first 2 developed here in Tupelo. We believe that our 3 residents should be able to live as independently as 4 possible. They decide when to have guests, when to 5 eat, when to bathe and when to sleep. 6 Nursing care takes place in the veteran's 7 bedroom, not the patient's room -- a very important 8 concept because the bedroom connotes an entirely 9 different approach to personalized care than does the 10 acute care model of a patient room, implying that the 11 person is acutely ill and very sick. 12 SENATOR WICKER: Dr. Hojlo, are those all 13 private bedrooms, or are some of them -- 14 DR. HOJLO: Sir, because our facilities 15 currently are very old, we still have a fair number 16 of semiprivate rooms, and in some cases, three beds, 17 which we are very consciously attempting to change. 18 In our new construction, our new construction 19 guidelines are very clear that we're committed to 20 private rooms. 21 SENATOR WICKER: Thank you. 22 DR. HOJLO: Our residents also choose 23 what they want to eat, and the food is served as if 24 at home or in a restaurant. Now, again, I just want 25 to deviate here for a minute and say that this is a 45 1 huge culture change for a system as large and as 2 complex as ours, and we're actually beginning to 3 serve, in some of our centers -- we're moving away 4 from a mess hall approach to dining, and 5 personalizing. And we have some photographs of what 6 folks are doing. 7 We respect the dignity of each of our 8 veterans, and we try to simulate life as it might be 9 in a private home. So we also are committed to home, 10 not just home-like. The VA is committed to a 11 veteran-centered model of care, and we are developing 12 formal guidance for our community living centers, 13 with input both from residents and field staff. And 14 again, I want to deviate from the formal testimony 15 for a minute to say that we are in the process of 16 finalizing some official guidance national policies. 17 And for the first time in our history, this set of 18 national policies, which hopes to be signed on fairly 19 soon, is written from the veteran's perspective. In 20 other words, the policies are typically written by 21 me, in my office, and we have engaged field staff in 22 writing this policy and we have engaged field staff 23 to incorporate veterans' thinking. And we have used 24 the Resident Bill of Rights as the foundation for the 25 document. And again, this emphasizes the person - 46 1 centered approach to care. 2 SENATOR WICKER: Can I go online and find 3 that Bill of Rights? 4 MS. HOJLO: The Patient's Bill of Rights, 5 I believe so -- the associated Medicaid services. It 6 is a standard bill of rights, yes. The VA is the 7 largest integrated health care delivery system in the 8 United States. To adopt these principles -- and we 9 think that there is even more that we can do to 10 provide a more personalized environment for our 11 residents. Last month, the VA held a conference for 12 nurse and physician leaders in New Orleans to discuss 13 this culture transformation and to emphasize care for 14 a new generation of veterans. 15 A chairperson has been selected to 16 oversee a national training program, and a planning 17 committee will meet later this month to discuss the 18 next steps, particularly so that as we design our 19 culture transformation and the approach to care, that 20 we recognize the fact that we are receiving a new 21 cohort of veterans. And we're expanding our 22 age-appropriate care models in several ways in 23 response to the needs of all of our residents. 24 In some locations, we pair young veterans 25 with each other, in our current models. At other 47 1 facilities, the populations reflect several 2 generations. Both models have their advantages. In 3 an age-specific cohort, we can meet specific needs of 4 younger veterans who are more likely to have young 5 children and similar interests, such as computer 6 technology and electronics, that differ from the 7 interests of older veterans. 8 In mixed generational settings, however, 9 our older residents can serve as parental surrogates 10 for our young veterans. For example, what we're 11 seeing in the cohorts of veterans that we have, we 12 see the young son of the Vietnam era vets are very 13 often, for example, equivalent to what the young vets 14 would see in their dad's age, and then we have the 15 grandparents. 16 And in reflecting on that model, we find 17 that, although the generational differences may be 18 significant, they all have one thing in common; they 19 have served our country. And that has created a 20 buddy system and opportunity for these veterans of 21 different cohorts to actually -- for example, when 22 you have a young man or woman with TBI, a brain 23 injury, who is cohorted with some older veterans, the 24 older veterans actually tend to look out for that 25 young person. And it is quite awe-inspiring to see 48 1 the bonding that occurs. So this is to dispel the 2 fact that young people may not do well in an old 3 folks home. When there is a mixing of generations 4 with a consciousness toward what that 5 intergenerational activity could really accomplish, 6 the outcomes are quite touching and quite profound. 7 SENATOR WICKER: How large of a group are 8 you talking about? 9 MS. HOJLO: For the Iraqi -- 10 SENATOR WICKER: In this context, you 11 mentioned the settings. How many people are in a 12 setting? 13 MS. HOJLO: It varies across the country. 14 In the new models, as we're trying to reflect on 15 small house and greenhouse models, we're speaking of 16 about eight to 10. And we have not had the 17 opportunity yet to build those structures. 18 Currently, our individual nursing home neighborhoods 19 or communities range anywhere from 22 to 30 units. 20 And within those units, we can cohort veterans as 21 well. So it really differs across the country, based 22 on what the population needs are, what the individual 23 veteran's needs are. And our structures also 24 limit -- 25 SENATOR WICKER: So those are the 49 1 smallest settings -- those are the smallest groups 2 now in a setting? 3 DR. HOJLO: Right. 4 SENATOR WICKER: Is the VA actually 5 looking at trying this 10 or 12 and below setting and 6 actually experimenting with that? 7 DR. HOJLO: Absolutely, sir. 8 SENATOR WICKER: When do you think we 9 might be able to break ground on the first one of 10 those? 11 DR. HOJLO: We have, actually -- we're 12 working with the National Defense Authorization Act, 13 and we have submitted a budget for several 14 greenhouses within the context of that act. So we're 15 actually having some conversations with Mr. Jenkens. 16 Some of our facilities have engaged in conversations 17 with Mr. Jenkens. We have established a design guide 18 that is actually affirming this direction. I am 19 sorry, I cannot give you an exact date, but I can 20 tell you that there is a strong commitment to moving 21 in this direction, especially in new facilities. 22 We have an example that I brought here of 23 our facility in Biloxi. It isn't quite greenhouse, 24 but it is very close to cohorting veterans in a 25 smaller setting. So this is actually a first. 50 1 SENATOR WICKER: Are those the pictures 2 that -- 3 DR. HOJLO: Yes. I will go through them. 4 All of the pictures don't reflect Biloxi, but 5 Biloxi's model is in the drawings that we have. 6 SENATOR WICKER: Okay. I am going to go 7 ahead and pass these through the audience. We have 8 only one copy -- two copies. We will start one in 9 the back and one in the front. Okay, go ahead. Are 10 you almost finished? 11 DR. HOJLO: Yes, sir, I am. Some of our 12 facilities are geared specifically to younger 13 veterans with cognitive deficits produced by the 14 trauma of war, usually a traumatic brain injury or 15 post-traumatic stress disorder. And I would like to 16 highlight our Tuscaloosa community living center has 17 established a center with a TBI and PTSD program team 18 for young veterans returning from Iraq and 19 Afghanistan. The VA's community living center in 20 Washington, D.C., has separate living areas for these 21 veterans. As I have said, the National Defense 22 Authorization Act requires the VA to provide age- 23 appropriate nursing home care to veterans in need of 24 these services. And we, to fulfill this mandate, the 25 VA is developing proposals for future modifications 51 1 to the environment of care-giving in our facilities 2 to further the goal of the institutionalized nursing 3 home. 4 So even though we don't have a greenhouse 5 at the moment, we have developed some policies, 6 again, that were recently signed off that gives 7 specific guidance of how veterans coming into the VA 8 nursing homes, particularly the younger veterans, 9 would require definitely a home-like, personalized 10 environment for actually the home setting, even in 11 the context of some of our old facilities. And it is 12 amazing. You'll see by the photographs what we have 13 been able to accomplish, even in some of the current 14 facilities. 15 We realize we can never completely match 16 the experience of living in one's own home. The VA 17 is taking significant strides toward a more 18 responsive and responsible model of care in a 19 de-institutionalized setting. I thank you for the 20 opportunity to appear before you today, and ask if 21 you would like me to go through the slides? 22 SENATOR WICKER: Well, let me ask you, I 23 think we'll try to -- it's 11:44. We're going to try 24 to wind up in 30 minutes. That will get us out of 25 here by 12:15, if that's okay. So let me proceed on 52 1 without that. But I do very much appreciate it. Let 2 me just ask you in follow-up, there are VA settings, 3 and you have changed the name, and you say that it is 4 not only a name change, it is actually a change in 5 mindset. What interaction at all do you have -- and 6 you can answer briefly -- with the DOD retirement 7 homes? 8 DR. HOJLO: Directly, in my position, I 9 don't have any direct working relationship with the 10 DOD. However, through the National Defense 11 Authorization Act, as we design these principles, 12 that act does require some type of interaction 13 between the DOD and the VA. However, the clarity of 14 that interaction and relationship to the nursing 15 homes or community living centers isn't there. So I 16 certainly would be happy to interface with them. 17 However -- 18 SENATOR WICKER: Here's why I ask -- go 19 ahead. I don't want to cut you off. 20 DR. HOJLO: The concept of culture 21 transformation is really very new. And in some ways 22 we feel that we need to establish what it means for 23 us, the VA. And in a way, it is take care of your 24 own house and then move it to someplace else. 25 SENATOR WICKER: Sure. I am just 53 1 wondering if you shared data or concepts or research. 2 And here's what I'm getting to: We had a very 3 interesting meeting with DOD representatives of the 4 armed forces retirement homes, and basically they 5 said the veteran is different, has a different desire 6 for long-term health care. They loved the mess hall 7 setting. They are used to it on the ship or in the 8 mess hall. And so breaking it down into a 12- or 10- 9 person home-like setting is not the way to go. I 10 just wondered if you had found that to be the case in 11 dealing with veterans yet in another agency? And 12 then I'll let others respond to that question. 13 DR. HOJLO: Thank you for that question. 14 I believe that we don't really have enough 15 information in the Department of Veterans Affairs to 16 be able to make a judgment either way, again, because 17 all of this is so brand new. And as we develop the 18 greenhouse model, and as we move the culture 19 transformation forward, we are intending to obtain 20 data and do some research in that area. So I 21 personally am convinced that that's a great 22 opportunity. And what we are doing in our current 23 settings is we are moving away from the mess hall 24 model. You see photographs where we have white 25 tablecloths with a smaller number of veterans. And 54 1 anecdotally, veterans seem pleased with that. We're 2 making the atmosphere in the dining rooms quieter. 3 We are not providing medications or treatments during 4 that time, as we did in the past. People would come 5 in and do blood pressure checks and maybe provide 6 insulin or medications during mealtime. We don't do 7 those things anymore. So we're trying to humanize 8 and de-institutionalize the way food is served, but 9 we don't have enough data yet. 10 SENATOR WICKER: All right. Well, I am 11 going to let other members of the panel address that 12 question. Let me mention this Wall Street Journal 13 article which is already a part of our testimony, and 14 that also will be made a part of the permanent 15 record. It is dated July 24, 2008, by Lucette 16 Lagnado of The Wall Street Journal. And, basically, 17 let's start with you, Dr. Thomas. Susan Feeney, of 18 the American Health Care Association, visits 19 thousands of for-profit and not-for-profit nursing 20 homes and says that you're being overly harsh, that 21 many of the traditional nursing homes aren't able to 22 scrap a large building, but they are changing and 23 making reforms and changing the culture to a more 24 home-like feel. Are you being a little unfair to the 25 thousands and thousands of traditional nursing homes? 55 1 Would you respond to that? 2 DR. THOMAS: I would love to, thank you. 3 First off, I'll tell you a distinction that I use in 4 my work that is very helpful to me. There are the 5 tens of thousands, hundreds of thousands of dedicated 6 nurses, doctors, care-givers, speech therapists who, 7 every day in America, do the hard work of providing 8 long-term care. These are flesh and blood human 9 beings, and I honor them entirely. 10 SENATOR WICKER: In a variety of 11 settings. 12 DR. THOMAS: Oh, yes. Then there is the 13 institutional pattern of long-term care. The 14 institutional mindset that puts tasks ahead of 15 people, the institutional architecture, the 16 nonprivate room, with a sheet hanging between two 17 beds. I do not honor that. I reject that. I say 18 that it is time to move forward. And I would like to 19 make it really clear that the harshness of my 20 criticism -- and, yeah, I'll use harsh language -- is 21 directed at the system we have created. 22 What I have found, and I know Dr. Hojlo 23 shares this with me over a long period of time, is 24 that efforts to change the system are very difficult, 25 that I have found in my work and research that making 56 1 small changes to an institutional long-term care 2 setting is not only hard to do; it is hard to make 3 the changes stick. And that is why -- and Steve and 4 I share this view -- that I have moved toward a more 5 transformational approach that says it is time to put 6 an end to the warehousing and institutionalization of 7 our elders. And that requires us to develop and 8 test, research and improve new models. And that's 9 really where I am coming from, and that is where 10 greenhouse is coming from. And honestly, if the 11 chief lobbyist for the nursing home industry says I 12 am being too harsh, then I am probably doing my job. 13 SENATOR WICKER: Is Mr. McAlilly 14 warehousing elderly people in this traditional 15 nursing home facility? 16 DR. THOMAS: Yes. And it is not Steve's 17 fault, and it is not the fault of the people who go 18 to work there every day and give their hearts to that 19 work. It is not their fault. It is a pattern, a 20 system that does not provide the kind of dignity and 21 autonomy that our elders deserve. 22 SENATOR WICKER: Is there data on the 23 other side of this question? 24 DR. THOMAS: Dr. Cutler would be the one 25 to really talk about this, but I'll tell you this: 57 1 The funny thing is there is really no -- I am going 2 to say, Dr. Cutler, you disagree with me, if you 3 can -- there is no research that shows that 4 institutional long-term care is the best model. 5 SENATOR WICKER: Okay. He has tossed to 6 you, Dr. Cutler. 7 DR. CUTLER: He is correct. Fortunately, 8 in the last several years we have been even breaking 9 down studying the institutional model to private 10 rooms, the benefits of private rooms -- and one thing 11 I think -- one thing I do like about the greenhouse 12 model, and what we try to do in any nursing home, 13 traditional or not, that we go into is to subdivide 14 the institution, the greenhouse, into three 15 categories. You have your physical environment, of 16 course, which is very easy to model or to measure. 17 You have got your organizational patterns, and that 18 is where the greenhouses went totally topsy-turvy. 19 And then you have your philosophy of care, which is 20 much more difficult to measure. 21 I think it kind of makes me -- number 22 one, I am not fond of the word culture change, but it 23 kind of makes me a crazy lady that now we're, all of 24 a sudden, concerned with person-centered care. And I 25 keep thinking, okay, over the last 40 or 50 years, 58 1 who were you centering the care on? And I do digress 2 from your question. And Dr. Thomas is correct; there 3 is not a lot of research, probably -- well, I won't 4 even add that. But there is not a lot of research on 5 contentment in the traditional nursing home. 6 SENATOR WICKER: I see. Mr. McAlilly, 7 are these facilities in Tupelo coed? 8 MR. McALILLY: Yes. 9 SENATOR WICKER: And how are they 10 selected? Are they intentionally coed, or does it 11 just work out that way? 12 MR. McALILLY: It just works out that 13 way. We try to make the population in each 14 greenhouse as diverse as we can make it. 15 SENATOR WICKER: Okay. 16 MR. McALILLY: We think diversity is 17 healthy. 18 SENATOR WICKER: Now, what if you want to 19 visit some friends two houses down? 20 MR. McALILLY: You go visit them. 21 SENATOR WICKER: Does that happen? 22 MR. McALILLY: It happens. 23 SENATOR WICKER: So it's not that you're 24 just locked into these 12 people forever? 25 MR. McALILLY: No. And that becomes -- 59 1 you know, there is not a traditional activities 2 program in a greenhouse. What the activity is, is 3 living. So, if you used to visit neighbors in your 4 neighborhood, you have friends two houses down, you 5 go visit them. We know, either -- if a person needs 6 assistance to get down there, we provide that. But 7 it is not like a self-contained prison that you can't 8 get out of. It is a neighborhood. 9 SENATOR WICKER: I bet this question is 10 in the minds of those in the audience: Is this 11 something that we can afford? Now, I know, 12 Mr. McAlilly, you say that you offer the care at the 13 Medicaid rate, and yet Methodist Senior Services is a 14 well-endowed charitable organization that is 15 supported by many people of good will all over the 16 state and all over the nation. If it weren't for 17 that, would you be able to offer care at the Medicaid 18 rate? And are we talking about something that would 19 be desirable for everyone, but simply at a time of 20 deficits and the skyrocketing cost of health care, we 21 really can't afford at the federal level? I'll let 22 each member of the panel answer that question. What 23 about the cost, and can we afford this concept that 24 sounds very, very desirable? 25 MR. McALILLY: I believe, absolutely, you 60 1 can afford it. And the reason for that is our 2 operations are strictly based on the income that we 3 receive through Medicaid, Medicare or private pay 4 residents. The operations are not subsidized by 5 charitable giving in the greenhouses, except for on 6 the front end in the upfront capital of building the 7 building. We did have charitable donations there so 8 we could afford the debt service of payment on the 9 greenhouses. We made a commitment early on. We knew 10 that we were going to spend more money, because we 11 were going from semiprivate rooms to private rooms. 12 But the outright operations on a day-in and day-out 13 basis can be done at the current funding levels that, 14 I think, pretty much everyone receives across the 15 country. 16 SENATOR WICKER: Mr. Jenkens, you're 17 scribbling notes. 18 MR. JENKENS: I am. Thank you, Senator. 19 SENATOR WICKER: I think this really gets 20 to the heart of what the committee will need to know, 21 and that is, is this something that actually can be 22 afforded on a large scale by the federal government? 23 MR. JENKENS: Yes. There are, I think, 24 three areas that are important to consider with that 25 question. The first is that there is a significant 61 1 body of research which shows that improvements -- 2 significant and meaningful improvements in quality in 3 nursing homes does result in lower operating costs, 4 to the extent that we, as a government and a society, 5 reimburse based on operating costs, which we do in 6 many states through the Medicaid program. That would 7 offer some potential for cost reductions. The Wall 8 Street Journal article that you mentioned quotes one 9 of our greenhouse providers in Billings, Montana, 10 that when you compare their operations in a 11 greenhouse to their operations in the remaining 12 skilled nursing home, that they are about $42 a day 13 less in operating costs in the greenhouse. 14 Now, in the beginning, they were a little 15 bit more. And there is a typical transition that 16 people go through as their operations settle in, but 17 we're beginning to hear anecdotally that same comment 18 from others. We shift costs from administrative 19 functions and middle management into direct care 20 staff. So we significantly increase the direct care 21 staff, but we believe there are savings from the 22 operational redesign as well as the improvement in 23 quality. 24 Research has also shown that having about 25 four hours of direct care time per day, which is what 62 1 the greenhouse mandates, at a minimum, is one of the 2 surest ways to improve your quality outcome. So the 3 model in building design, as Steve has implemented in 4 Tupelo, is really designed very carefully to look at 5 how do you get the best of our research, the best of 6 our understanding in there. It is a nice 7 combination, but it actually turns out to help reduce 8 cost because of higher quality. 9 Important from the federal level is 10 that -- and research that we will start next year 11 should show what we have heard anecdotally -- is that 12 the greenhouse also -- because people know each other 13 better and nurses and physicians can treat people 14 better with better information from the shabhazi, 15 that you are seeing fewer hospitalizations. Our 16 project in Lincoln, Nebraska reports their greenhouse 17 elders, compared to their elders remaining in the 18 traditional setting, had fewer acute illnesses, fewer 19 hospitalizations. That doesn't translate into 20 savings to Medicaid, but it does translate into 21 savings to Medicare. So, at the federal level, it is 22 very meaningful to have a foundation of homes, like 23 the greenhouse, to offer a combined savings to the 24 Medicaid/Medicare program. 25 Steve mentioned the capital costs, and 63 1 the capital costs -- if you were to build any new 2 nursing home, you would face capital costs. We don't 3 fund capital costs through the Medicaid system. We 4 have caps for development costs, which are generally 5 at about half of what it truly costs someone like 6 Steve to build a greenhouse home. So the one area 7 where the federal government may want to look at 8 expenditures that would be different from what you 9 would have in a typical nursing home setting is 10 around the capital, in order to capture some of these 11 long-term operating savings, which will quickly 12 outpace any capital costs. 13 SENATOR WICKER: Anyone else want to jump 14 into that? 15 DR. THOMAS: I would like to say one 16 thing. 17 SENATOR WICKER: Dr. Thomas? 18 DR. THOMAS: I think that Dr. Hojlo and 19 the Veterans Affairs group is really very ideally 20 positioned to actually use these kinds of new models 21 to increase quality and create savings. Because what 22 they have, which a lot of us, for example, Steve, 23 doesn't have, is a really integrated system of health 24 care at work. And in Steve's case, he can save 25 Medicare a lot of money, but it doesn't save Steve 64 1 any money, you know, his organization. And the 2 Veterans Affairs group has the opportunity to drive 3 quality to higher levels, generate savings, which go 4 to the system and allow them to provide even better 5 service for the veterans. 6 DR. HOJLO: Would you like me to comment, 7 sir? 8 SENATOR WICKER: Yes, please, ma'am. 9 DR. HOJLO: Thank you. There are several 10 pieces in this that I think are important to be 11 looked at. I would like to just comment about what 12 we talked about earlier about the warehouse model. 13 Prior to the culture transformation movement -- and I 14 will speak about this in terms of VA -- we simply -- 15 somebody in acute care wrote an order and said, 16 "nursing home care." So what my office did was we 17 said, what does nursing home care mean? Well, we 18 recognize that, first of all, nursing home care truly 19 does offer -- it is a set of services. So you have 20 to be clear on why is the person going to a nursing 21 home and not going home? So we actually articulate 22 it, what those services might look like. 23 Now, Medicare has a defined set of 24 services, and Medicaid has the longer term. However, 25 even within those categories, there are specific 65 1 reasons why people have to go to nursing homes. And 2 we recognize that. So that, in itself, first of all, 3 has cost implications. Because we no longer say, 4 well, just go to the nursing home and figure out what 5 he or she needs -- a very, very important piece of 6 this. 7 Secondly, there is ample research on the 8 fact that, you know, when folks don't have attention 9 to incontinence, falls, those kinds of things, and 10 they don't have meaningful use of time, then we 11 increase psychotropic medication use. Costs of care 12 significantly increase because of falls and those 13 kinds of things. So settings and mindsets that 14 provide care delivery in a manner in which you do pay 15 attention to the individualized needs for care -- 16 consistent staffing, for example, very, very 17 important, that the same nursing personnel take care 18 of that same veteran so they protect that person. 19 They know what this person's likes and dislikes and 20 what their needs are, so you can anticipate them, 21 therefore preventing falls and -- 22 SENATOR WICKER: And the veteran has a 23 comfort level. 24 DR. HOJLO: Exactly, the veteran has -- 25 so the quality of life improves. And we know, as the 66 1 quality of life improves, the veterans' outcomes 2 improve. And finally, the notion of meaningful use 3 of time, having something to do all day, not just 4 Bible, Bingo and birthdays, but actually planning the 5 day around who is this person? We're even changing 6 our approach to care planning. We use the new 7 methodology called I Care Plans, meaning that I, as a 8 care provider, put myself in the shoes of that 9 veteran and not talk about their diagnosis, but plan 10 the care around who is this person who happens to 11 have Alzheimer's, or who is this person who has had a 12 stroke? 13 So all of those things, I believe, 14 contribute to improved outcomes and hopefully, cost 15 reduction. However, we really don't have enough 16 data. We don't have research yet to document that. 17 This is all very new. And our intent in the VA is 18 that, as we develop and evolve these models, that we 19 will, in fact, contribute to the very important 20 evidence base to make this movement go forward. 21 SENATOR WICKER: In terms of the progress 22 that we're making in the VA toward advancing the 23 greenhouse concept, Dr. Thomas and Mr. Jenkens, I 24 think the testimony from Dr. Hojlo is that there is 25 language in the current DOD authorization bill that 67 1 will authorize an experiment in the greenhouse 2 concept. And I know that you, Dr. Thomas, are 3 completely sold on the concept for every single 4 elderly American. But is the language in that 5 bill -- you have looked at the language, and is it 6 sufficient to get us to where we need to be in terms 7 of an honest-to-goodness experiment on the ground to 8 see if this will work? 9 DR. THOMAS: Actually, I would like 10 Mr. Jenkens to start, and then I will pick up on 11 that. Because we actually were meeting and talking 12 about that this morning. 13 MR. JENKENS: Thanks, Bill. First, I 14 would like to recognize Dr. Hojlo for what I think 15 has really been exceptional leadership within the 16 Department of Veterans Affairs around this issue, not 17 just with the greenhouse, but with culture change and 18 the people that she works with who support her. It 19 takes a courageous person to do this. Steve 20 spearheaded this in the nursing home industry. And I 21 think Dr. Hojlo is doing that with the VA. 22 SENATOR WICKER: Particularly courageous 23 to scrap thousands of dollars worth of design and 24 plans when you have a board looking at you. 25 MR. JENKENS: It is. I think that is very 68 1 true. I think that there are a couple of things, in 2 looking at how to move forward and understand whether 3 it works for the VA, particularly. I think pilot 4 sites are very worthwhile. I would recommend a few 5 more pilot sites than two, because I think there is 6 such variety and diversity within the VA system that 7 you might want to start with a slightly larger number 8 around this. 9 I think you would also want to add to 10 that an initiative a work group between people like 11 Steve, who have done this, Bill, people who are 12 providing technical assistance at a national level. 13 Because I think one of the challenges that Dr. Hojlo 14 and her team face are, how can a model be translated 15 effectively into the VA system without losing its 16 core benefits, but with not being able to understand 17 exactly how those pieces all play into the results? 18 Bill mentioned we don't know exactly what it is with 19 this whole model that delivers any piece of the 20 results. I think Dr. Cutler would agree that we 21 haven't disaggregated the research enough to know 22 that. So I think the only way we can do that 23 effectively is to talk to each other and make our 24 best educated guesses, based on what we have seen. 25 So I think a work group, as part of that initiative, 69 1 would be a very healthy addition. 2 Then, of course, providing incentives is 3 very important so that Dr. Hojlo and her team don't 4 have to carry all of the weight and make all of the 5 errors or changes. That can be very difficult, and 6 many people can be very opposed to education 7 performance indicators or other measures that would 8 help people be inspired to do this. 9 SENATOR WICKER: Okay. Thank you. We're 10 nearing the end of our allotted time, and I 11 appreciate everyone participating. Let me say I will 12 call on each one of you, if you want to sum it up or 13 make a final statement, say, one minute each. 14 Before that, I had asked Susan Sweat, on 15 my staff, to give me a list of the staff members 16 here, and in all humility, she did not provide me a 17 name of my own staff. So let me particularly single 18 out Susan Sweat for her hard work. She is part of my 19 Washington, D.C., staff and did a great deal of work, 20 and has been a very effective staffer for you, the 21 taxpayers, in this area of health care, and is now my 22 legislative director. 23 So, Susan, stand up. This is Susan 24 Sweat. Kyle Stewart, my long-time administrative 25 assistant, is in the back of the room. And Jamie 70 1 Ellis, where are you? Jamie Ellis, stand up. Jamie 2 Ellis is my new Veterans Affairs staff member, and he 3 will be working now in the Tupelo office. Thank you, 4 Jamie. And as many of you know, Bubba Lawler, for 5 some 13-and-a-half years, was my veteran staffer. 6 And he and his family surrendered to a call to the 7 mission field, and they are now in Birmingham, 8 England, and I would be remiss if I did not 9 recognize, in a public way, his great service for 13- 10 plus years for the taxpayers in that regard. And 11 Jamie, we welcome you. 12 So I will -- and again, we appreciate 13 John Towers of Senator Burr's staff, and Aaron 14 Sheldon of Senator Acaca's staff, for coming all this 15 way and being part of this and for supplying me with 16 information and suggestive questions. Let's start 17 with Dr. Hojlo. Would you like to summarize for one 18 minute? And then we'll pass the microphone right on 19 down. 20 DR. HOJLO: Yes, sir. Once again, thank 21 you for the opportunity to be present at this 22 hearing. And I would like to, just for the record, 23 to make it very clear that the Department of Veterans 24 Affairs is extremely committed to moving forward with 25 the agenda in transforming the culture of nursing 71 1 home care, not only in the VA, but also contributing 2 to that influence in the nursing home industry in the 3 country. And I think it is very courageous of you 4 and your committee to bring this to the front, 5 because I think it is time that, as a country, we 6 started to address the plight of folks who have been 7 assigned to needing nursing home care. And the 8 circumstances in this country have not been ideal. 9 So I appreciate the fact that we are able to move 10 this agenda forward through forums like this. 11 SENATOR WICKER: Thank you. Dr. Thomas? 12 DR. THOMAS: I would like to say, first 13 and foremost, thank you to Dr. Hojlo for the work she 14 is doing, because she is there; she is responsible; 15 she is the person with the obligation to move a giant 16 bureaucracy forward, and I honor that. 17 SENATOR WICKER: As do I. 18 DR. THOMAS: Yes. I want to say thank 19 you for that. Secondly, I just want to say, if I 20 may, I think that the Veterans Affairs Committee and 21 your leadership on that committee can help Dr. Hojlo 22 by providing the tools and support that is in the 23 legislative language that can help her go farther 24 faster. Honestly, in the field of long-term care, we 25 definitely have a debate about specific techniques, 72 1 but it is very clear that long-term health care in 2 America is moving in this direction, and our veterans 3 need to benefit from that movement. And I would like 4 to strongly endorse the concept of giving Dr. Hojlo 5 improved access to tools and resources to help her 6 move her administration forward in this circle. 7 Thank you. 8 SENATOR WICKER: Thank you very much. 9 Mr. McAlilly? 10 MR. McALILLY: First, I want to say to 11 you, thank you, again. We are honored that you and 12 the Committee are here for this hearing, and the 13 staff members. It is an important time to you, and 14 we're honored that you thought this idea was worthy 15 enough to come to Tupelo. I think, to sum it up for 16 me, the statement is you can't put new wine in old 17 wineskins. And the research is there. 18 SENATOR WICKER: Where did you get that? 19 MR. McALILLY: Thirty years ago, we 20 didn't know better, and we were doing the best that 21 we could with what we knew. Twenty years ago and 10 22 years ago, we didn't know better. We were doing the 23 best that we could with what we knew. Today we know 24 better. There is a difference between food cooked in 25 your home, where you can smell the bacon frying and 73 1 hear the dishes rattling and the pots rattling, and 2 sitting down at a 120-room dining hall, or even in a 3 small pod and eating food that was delivered from the 4 central kitchen on a cart to your area. 5 There is a difference between six friends 6 sitting around their kitchen table playing rook and 7 45 people in the activity room at a bingo game. And 8 there is a difference between being able to walk out 9 of your bedroom and go out into your den or even out 10 onto your patio and tend the flowers that you planted 11 and 30 people lined up in the hall in their 12 wheelchairs waiting. We know better today. We know 13 better today, and the veterans of our country, those 14 people who have given more than most of us, on this 15 eve of our country's birthday, these people who have 16 risked their lives and given it all deserve the best 17 that we can give them. And we believe that this 18 model of care is the best that we can give them. 19 Thank you. 20 SENATOR WICKER: Thank you. Mr. Jenkens? 21 MR. JENKENS: I think I would like to go 22 back to the quote from The Wall Street Journal 23 article that you mentioned from Susan Feeney. And I 24 think what is interesting to me about that quote, as 25 a representative of the nursing home industry, is 74 1 that she criticizes Bill's comments for being overly 2 harsh. She did not criticize them for being unfair. 3 And I think that is an important distinction. I 4 think nursing home providers want to change. As 5 Steve says, they now know better, and they want to 6 change. With courageous leadership, leadership like 7 Steve's and Dr. Hojlo's, I think they will change. 8 They will change by example. They will change by 9 inspiration. But they need appropriate support, and 10 they need appropriate resources to be effective in 11 that change. And I think that's where the committee 12 can have a significant impact to help and assist in 13 moving forward. I would like to add my thanks for 14 your work to both have the hearing and the work that 15 you are pursuing to bring this as an option to the 16 veterans. Thanks very much. 17 SENATOR WICKER: Thank you very much. 18 And Dr. Cutler, I am tempted to say you have the last 19 word, but actually, that lies with me. 20 DR. CUTLER: Nor should I. I am speaking 21 from our researchers' perspective with my remarks, 22 and what we found with our research was that, 23 compared to a traditional nursing home model, the 24 greenhouses work. And what I would ask, that as we 25 go forward and do research, and we desperately need 75 1 more research, that we not study setting, philosophy, 2 organizational patterns, anything in isolation. It 3 is the interrelationship of these three components of 4 the greenhouses that make them work. And therefore, 5 going forward, I applaud Robert Wood Jenkens for the 6 organization to uphold these three principles. 7 Because think of it as the three-legged stool. You 8 take one leg out, and it is going to topple. So not 9 only research, that we research all of the three 10 components' interrelationship, which we did in this 11 study, but that -- don't try to study the model in 12 isolation. It needs -- you need to look at the staff 13 and how they interrelate with the elders, and how 14 they interrelate with the family, and then, 15 importantly, which has been somewhat ignored, how 16 they interrelate with the professional staff, the 17 home health component. And I thank you as well. 18 SENATOR WICKER: And I thank you all. 19 Let me take this opportunity not only to thank the 20 panel and staff members, let me take this opportunity 21 to, one day early, wish each of you a happy 22 Independence Day and to point out to our guests in 23 Tupelo that, until 1:00 p.m. today -- and I am 24 reading from the Northeast Mississippi Daily 25 Journal -- until 1:00 p.m. today, at One Mississippi 76 1 Plaza at South Spring Street and Troy, there is a 2 downtown Independence Day kickoff celebration 3 featuring Kay Bain and the Morning Show Band with 4 free hotdogs and lunch. So you're all welcome to 5 that until 1:00 p.m. today. 6 And we thank our veterans groups that 7 came today and all of the interested citizens. Thank 8 you to the media for helping us to get the word out. 9 Mr. McAlilly, I am going to end with a quote that I 10 used five years ago at the opening of the greenhouses 11 in Tupelo. The veterans who are actually -- and the 12 elderly people who are actually living in nursing 13 care and living in the greenhouses, of course, can't 14 be here today. But if I could be there and speak to 15 them, I would say that the words of Tennyson are very 16 appropriate to our regard for their service, and 17 particularly the service of those who are veterans. 18 Where Tennyson says, "Though we are not now that 19 strength which in old days moved earth and heaven, 20 that which we are, we are. One equal temper of 21 heroic hearts made weak by time and fate, but strong 22 in will." And with those words of Tennyson, I salute 23 our veterans, those in nursing care, and veterans 24 everywhere on this, the eve of our nation's birthday. 25 Thank you very much, and God bless America. 77 1 HEARING CONCLUDED AT 12:27 P.M. 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 78 1 C E R T I F I C A T E 2 3 STATE OF MISSISSIPPI ) COUNTY OF TIPPAH ) 4 5 RE: UNITED STATES SENATE COMMITTEE ON VETERANS AFFAIRS 6 I, Meah M. Bennett, CSR 1708, a Notary Public 7 within and for the aforesaid county and state, duly 8 commissioned and acting, hereby certify that the 9 foregoing proceedings were taken before me at the 10 time and place set forth above; that the statements 11 were written by me in machine shorthand; that the 12 statements were thereafter transcribed by me, or 13 under my direct supervision, by means of 14 computer-aided transcription, constituting a true and 15 correct transcription of the proceedings. 16 I further certify that I am not a 17 relative or employee of any of the parties, or of 18 counsel, nor am I financially or otherwise interested 19 in the outcome of this action. 20 Witness my hand and seal on this 11th day of 21 July, 2008. 22 ________________________ 23 My Commission Expires: CSR 1708 September 10, 2011 Notary Public 24 25