The Changing World of Long-term Care in RI.

The nursing home is a unique institution in American society that commonly elicits public and professional responses of dread and resignation, as well as brave efforts at reform. Nursing homes within the US long-term health care system have undergone major changes since I first began to study them in the early 1980s. As guest editor for two themed issues on long-term care in RI for the Rhode Island Medical Journal (RIMJ), I am honored to dedicate them in loving memory of Dr. Stanley M. Aronson, my long-time mentor, collaborator and friend. As evident in his professional career and as editor emeritus of this Journal, the nursing home was of special interest to him for many decades; he was deeply committed to its improvement. I first met Stan in 1981 as a PhD student in cultural anthropology at Brown specializing in the study of aging. He had recently retired from his position as founding dean of the Medical School, and I asked if he would consent to be on my dissertation committee. In agreeing, he suggested I focus on the nursing home as a fascinating topic of rich history, complex individuals and high promise. I immersed myself in the culture of one nursing home for 14 months, going day and night for long hours at a time, trying to understand what it was like to live and work in this place. Each week I brought Stan my field notes, impressions and drafts about which we fervently argued and discussed. His red edits on my drafts were unsparing and clear-headed; his praise, when it came, was all the more precious. I later turned the dissertation into a book, Uneasy Endings: Daily Life in an American Nursing Home (Cornell, 1988). Years later, we co-authored Aging in Today’s World: Conversations between an Anthropologist and a Physician (Berghahn, 2003), and we continued a deep and joyful friendship until his recent death. I owe profound thanks to Stan. What a huge loss for me, my family and for our community. The authors in this and the next themed issue of RIMJ discuss important facets of long-term care in RI and the changes these institutions have undergone. This issue begins with Pelland, Mota and Baier’s overview of long-term care services and costs situated within the demographic context of the aging population of our state. Nanda next provides a summary of the roles and responsibilities of the nursing home medical director, a role increasingly important given the complex medical needs of the varied populations in our nursing homes. Kevin McKay, administrator of Tockwotton Home, describes his view of the culture change movement in nursing homes and chronicles on-the-ground details of how Tockwotton has worked to implement innovative, person-centered reforms. Sue Vinhateiro rounds out this issue by describing her personal trajectory as a long-term care nurse in one RI facility. Her perspective mirrors changes that nursing homes have undergone over the last decades as she has experienced them. Dr. Bill Thomas, creator of the reform effort called the Eden Alternative (www.edenalt.org), in attempting to explain the origins of this institution, said a hospital and a poorhouse got together to produce the nursing home.1 This characterization embodies the contradiction that the nursing home is modeled after the hospital, is poorly reimbursed and is often a long-time last “home” for its residents. The predicament caused by its funding status and its split identity of hospital versus home creates challenges for reformers who want to ensure that competent and person-centered care is maintained in as home-like a setting as possible. Stan Aronson was cautiously optimistic about the strides RI nursing homes were making to provide such care for our most frail and vulnerable Rhode Islanders. He wanted their care to be respectful and exceptional. In honor of his insistence on compassion and excellence, we offer these two issues. This issue provides an overview of the evolving nature of long-term care in RI, and the April issue will focus on transitions and end-of-life care. We hope they help inspire us to continue to improve and achieve the superb care that older Rhode Islanders deserve. Given the pressing demographic reality of our aging state, this goal must be our imperative.