Sometimes leadership isn’t easy. Sometimes you get arrows shot at you. That’s what happened to our colleagues at the Ecumen community of Lakeshore in Duluth, Minnesota (and all of us who are working on creating new and better aging services) in an ugly article on the front page of Sunday’s Duluth News-Tribune by a reporter who doesn’t hold the same crystal ball that we do …What We See in Our Crystal Ball– A U.S. health care system that is completely integrated (a real system, not a bunch of fragmented ‘stuff’) and provides the right care at the right time in the right place.- A care system that doesn’t unnecessarily institutionalize people. This happens too often, draining a person’s will and public dollars.- Nursing homes that are specialized medical respite centers for rehablilitation and chronic care management, not under-funded, antiquated institutions where someone recovering from a hip replacement shares a wing with an Alzheimer’s patient (which also happens all too often today).What We Did Because of What We See– In Duluth, we tore down a 1950s-style nursing home. Instead of selling the valuable Lake Superior shorline to a developer, we built a new neighborhood (but also a new way to deliver services) that has a short-term care and rehabilitation center, independent living, assisted living and memory care apartment homes. – We serve many different people there (and all incomes) but our short-term care center is exactly that, it’s for short-term stays. It fills a service need in the community that wasn’t served previously. We want that short-term care center to be known as the place where people come to to get better and go home. And we’re succeeding.- If a person needs long-term intensive care, we coordinate that at an Ecumen-managed nursing home in Duluth: Bayshore. Of the 700 people we served in short-term care last year, only 30 went to a nursing home. The rest went home or to assisted living. This is moving toward an integrated system that we envision.- Because there is no federal classification for this new short-term care and rehab product, we have to license it as a ‘skilled nursing facility’ or a nursing home. We don’t want to create another nursing home. Duluth has plenty. Consequently, we’re decertifying from Medicaid, which pays for most Americans’ long-term care nursing stays. We will continue serving all income levels at Lakeshore’s short-term care center, but we’ll do it under Medicare. People who want to stay beyond their Medicare benefit will have the option to pay just as they would do if they wanted to stay in a hospital beyond their regular stay. Fact is most people don’t want to stay in a hospital or at our short-term care center long-term because they want to go home.This is the right approach to get to the vision we see in our crystal ball. You can read the reporter’s interpretation below. This isn’t the case where the truth lies somewhere in the middle. He missed the story.What the Reporter Saw

“They felt they could make it work,” Peer said. “I thought, €˜That’s not what I’m seeing, but I’m not the expert.’ ”About 10 days later, Wick had another stroke. He’s now in a nursing home where he can’t swallow, eat or breathe on his own. He’s only 68.“I’m hoping that the stress of the placement didn’t contribute to the stroke,” Peer said. “It’s a time when there are massive changes in a person’s life. But you trust the personnel at the home.”While Peer wanted her brother to stay longer at Lakeshore, she said that was never presented as an option €” a violation of federal law, according to Bob Daly, a manager of long-term care enforcement for the Centers for Medicare and Medicaid Services.Though Lakeshore says it’s a short-term rehab center, it’s still licensed and registered as a skilled nursing facility. That means that Lakeshore has to provide the same type of long-term care that one would expect from a nursing home, Daly said €” it has to allow people to stay there as long as they want and can afford to pay.“They should have nursing services able to focus on people who don’t really need short-term rehab,” Daly said. “People who are older and slowly declining in their functions should be able to stay there.”After getting a tip those services were not available, the Minnesota Department of Health investigated and found that nearly a dozen patients were discharged and sent to other nursing homes to receive care that Lakeshore should have provided. One resident was discharged from Lakeshore for being too confused, after being there for only one night. Another resident was discharged for having dementia. Another was discharged for frequently falling.Though no actual harm came to the patients, the report noted, all those discharges violated federal law.Officials who manage Lakeshore contend that, in the case of the violations, they did nothing wrong. In fact, they say, Lakeshore was doing what it is supposed to do: send patients who need that type of care to places better-suited to provide it.But Daly said that as a licensed skilled nursing facility, Lakeshore has to provide services one would expect from a nursing home.“There was no reason for this facility to discharge these residents to other facilities,” he said.CHANGES TO BUSINESS MODELThis was the first time Daly had heard of a case like this.“I know that the nursing home industry in many instances is focusing on the short-term rehab patient,” he said. “But we’ve never had a case that I know of where a facility was actually discharging people because they didn’t meet that business model.”Lakeshore is managed by the nonprofit Ecumen, one of the country’s largest nonprofit senior housing companies. Ecumen leadership stresses that Lakeshore is not set up to provide long-term care anymore. Instead, they describe their facility as a new model of care designed to get recovering patients back to their homes as soon as possible.The services they provide are unique in the Duluth area and were developed in response to local demand, they say.“The nursing home that used to be called Lakeshore is gone,” said Eric Schubert, Ecumen’s vice president of communications. “We don’t have a nursing home there anymore. We built a new product. It’s a short-term-care rehab center. It’s not a long-term-care center.”Patients who aren’t making progress in rehab belong in traditional nursing home facilities, said Mick Finn, Ecumen’s vice president and chief of operations. Finn said Ecumen essentially has been forced to be licensed as a nursing home because there’s no licensure for a short-term-care center or any facility that fits their business model. In essence, they say, federal policies haven’t caught up to their product.“We were hoping we could be accommodated in the current licensure system and it turns out that we cannot be,” Finn said. “So, you know, our bad.”But Darcy Miner, who manages compliance monitoring for the Minnesota Department of Health, said that though Lakeshore may say it’s a short-term care facility, “it’s still certified as a skilled nursing facility.”“As such, they need to accommodate residents who develop long-term-care needs,” Miner said. “This raises a lot of very interesting questions, to say the least.”Lakeshore, or any other adult care center, must be certified as a skilled nursing facility if it wants to get Medicare reimbursement. Medicare will cover the cost of rehabilitation, room and board for up to 100 days. After that, patients must pay for services through private insurance, private dollars or Medicaid, which covers long-term care for those not able to afford it but doesn’t reimburse providers at as high a rate as Medicare does.That Lakeshore is still licensed as a nursing home and has to provide long-term care is a surprise to some in the medical community who refer patients there.“They made a public showing that they were getting rid of their long-term beds,” said Dr. Paul Sanford, an internist and chief of medicine at St. Luke’s.Sanford said he believes Lakeshore has provided exemplary care, but he doesn’t understand why patients who need long-term care are being admitted. For them, he said, he worries they might be discharged too soon.“It’s a real ethical issue,” he said.Peer wonders if that’s what happened to her brother.“If they were anxious to get rid of him €” if they weren’t 100 percent sure or at least weren’t very certain that he could succeed somewhere else €” and they encouraged it because they wanted wealthier people,” she said, “then I’m very distressed by that.”CHANGING TO ADAPTIt is no secret that most traditional nursing homes across the state and the country are struggling financially. Since 2000, 50 homes have closed in the state, according to the Minnesota Health and Housing Alliance. About a third of all the state’s nursing homes are in danger of closing, according to the Long-Term Care Imperative, an advocacy group for nursing homes.Daly, of the Centers for Medicare and Medicaid Services, said that’s why more homes have turned to short-term care models to improve revenues.But some health-care experts speculate there might be financial incentive for Lakeshore to continue to be registered as a nursing home.Jennifer Schultz, a health-care economist at the University of Minnesota Duluth’s Labovitz School of Business and Economics, reviewed Lakeshore’s deficiency report from the state as well as the tip letter sent to the state, which the News Tribune obtained, and felt that Lakeshore could be targeting patients in need of care that is reimbursed at higher rates.“What I think they’re doing is they’re keeping patients as long as they need expensive rehab services that can be reimbursed at a higher rate, and then it looks like they’re transferring them to other nursing homes when they don’t need that level of skilled services and don’t get that level of reimbursement,” Schultz said. “I would say this looks suspicious and needs to be investigated.”Still, she said, Lakeshore is doing what would be expected of a business trying to stay profitable.“It’s an incentive setup to conduct that type of behavior,” she said. “And if it’s operating like a business, it’s maximizing revenues. You would expect them to game the system that way.”Jill Klingner, an assistant professor of health care and operations management at the Labovitz School of Business, also reviewed the report and tipster letter and concurred with Schultz.“They just want to keep the people that don’t need help with daily living,” she said. “They want to keep the people they can provide rehab to that they can bill additional charges for.”A business model of this type isn’t illegal, Daly said, but patients can’t be discharged if they want to stay and can pay for it.Lakeshore administrator Paul Libbon flatly denied that the facility is only seeking higher-reimbursing patients. The only patients they’re seeking, he said, are those seeking short-term care.NO LONGER WILL TAKE MEDICAIDBoth the state health department and Ecumen leaders said steps have been taken to ensure that similar violations don’t happen again. Ecumen now provides information to new patients that they can stay and receive extended care at the home.But administrators still insist that Lakeshore will only provide short-term treatment. To avoid getting patients seeking long-term care, Finn said, Lakeshore will no longer accept patients on Medicaid, or patients with low incomes.For those patients, under general reimbursement rules, that means they likely can only stay at Lakeshore for 100 days €” or the amount of time Medicare will cover 100 percent of costs before Medicaid payments kick in.To some, that poses another line of questions. Ecumen is affiliated with the Evangelical Lutheran Church in America and raised money for the center’s renovation by saying it would help provide charity care.“Given that the community made contributions to this charitable organization, what was the community’s idea about the facility?” Klinger asked. “Did the community know this would be a high-end facility that, if you couldn’t make improvements, you’d have to go somewhere else, and they wouldn’t allow just anybody in?“It looks ugly. It sounds ugly. It is ugly.”The ELCA referred questions to Lutheran Services in America, which declined comment.But Schubert said Lakeshore provides thousands of dollars in charity care.“We’ve served a ton of low-income people that come through here for short-term rehab,” he said. “When short-term rehab is done, they can move on to places that provide people with long-term care.”Libbon agreed, noting that Lakeshore provides home-delivered meals to 100 seniors in Duluth, provides computer training to seniors and accepts Medicaid clients at the campus’s Assisted Living facility.“It’s about what do people want,” he said. “We are fortunate to have this in the city of Duluth.”