Beyond Bedrails and Bingo: Dave Devereaux on the Realities of Nursing Home Care

In this episode of Taking Healthcare by Storm, Quality Insights Medical Director Dr. Jean Storm speaks with Dave Devereaux, a nationally recognized expert and thought leader in long-term care.

Dave shares lessons from a 45-year long-term care career and his book Beyond Bedrails and Bingo: Myths, Truths, and the Future of America's Nursing Homes, explaining why nursing homes evoke fear, how COVID eroded trust and changed operations, and how “patient-centered care” can miss what patients actually want. He also weighs AI and blockchain’s potential benefits and risks, offers practical advice for families choosing a facility, questions whether litigation improves care, and outlines policy ideas focused on rewarding wellness and strengthening healthcare financing.

If you have any topics or guests you'd like to see on future episodes, reach out to us on our website.

The views and opinions expressed by the host and guests are their own and do not necessarily reflect the views, positions, or policies of Quality Insights. Publication number QI-080726-GK

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Welcome to "Taking Healthcare by Storm: Industry Insights," the podcast that delves into the captivating intersection of innovation, science, compassion, and care. 

In each episode, Quality Insights’ Medical Director Dr. Jean Storm will have the privilege of engaging with leading experts across diverse fields, including dieticians, pharmacists, and brave patients navigating their own healthcare journeys. 

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Hi, everyone. Welcome to another episode of Taking Healthcare by Storm. I am Dr. Jean Storm, the medical director here at Quality Insights. Today's guest is Dave Devereaux, a nationally recognized leader in long-term care, whose career has spanned more than 45 years in healthcare leadership, innovation, and advocacy. From his early days working as a teenage housekeeper at a nursing home, to overseeing organizations with hundreds of facilities across dozens of states, Dave has spent a lifetime immersed in the realities of aging, caregiving, and the business of long-term care. He is the author of a new book, Beyond Bed Rails and Bingo: A Candid and Deeply Personal Look Inside the Nursing Home Industry, an industry often misunderstood, definitely emotionally charged, and increasingly important as America ages. Drawing from decades of frontline and executive experience, Dave explores everything from fear surrounding nursing homes, and we know there is so much of that, to COVID's lasting impact on long-term care, we'd like to think that the pandemic is over, but the impacts are still going on, to the future of technology and AI in caregiving. Beyond his executive leadership, Dave has also been passionate, advocating for education, nursing, and healthcare innovation, supporting initiatives in nursing education, public health research, and music therapy, something that I am very interested in. In today's conversation, we'll be talking about why nursing homes evoke such strong emotions, what families should know when choosing care for a loved one, whether litigation improves patient care, I know how I feel about that, how AI might reshape the industry, and where long-term care and healthcare itself may be headed in the years ahead. Dave Devereaux, thank you so much for coming on the podcast. I am very excited for this conversation. Thank you, Jean. It's very good to be here with you and your listeners. So I'm just gonna dive in. You spent four decades in long-term care. That's a very long period of time. As I said in the introduction, you started as a teenager working as a housekeeper in a nursing home, and I know many individuals who've kind of started in similar ways in long-term care. So how did those early experiences shape your decision to dedicate your life to this field? Well, it- When I started in 1978 as a 16-year-old, my mom was a, a registered nurse and a director of nursing in a nursing home, and it was a place I was familiar with since really 1966 as a very little boy. And I found that it was the most interesting place to spend time. Everybody in a nursing home had a story. Patients at that time, they were young during the Roaring '20s, and that period, like now, is a fascinating time in American history, and they were able to tell those stories. They'd had, they had relatives that they'd known that fought in the Civil War, which brought a- another dimension. And because it, it was located in northeastern Pennsylvania, many had worked in coal mines as children, like my grandfather. And it was unavoidable that everybody had a Depression-era experience. And beyond that, families and coworkers, they had their own stories, and they were very willing to share them. So it was a great place to get an education, and it was my first introduction, honestly, to business, beyond that of a customer in a retail store, a grocery store, or McDonald's. And because I was working for a wage, it was also my orientation of personal finance. At that time, Jean, I was making $2.35 an hour, and what I was being paid as a high schooler was on par with adults that They were paying rent, they had children, car payments, and they were trying to find ways to work it out. And those conversations y- you couldn't get in a classroom or in a textbook. But the real, you know, the, the real selling point to me that, that drew me to the industry as a lifelong experience was it was fun. It was fun working in a nursing home, and even the most miserable days included some fun, which was unique, remarkable, and something that I really wanted more of when choosing what to do with my life. You were making big bucks. I'll tell you, the f- the first paycheck I got, I can remember sitting in my mother's Volkswagen Beetle, and, you know, 235 times 40-plus hours, I was expecting a paycheck approaching $100, and when I opened it it was my first in-person experience with taxation. Yes. And I w- and we all go through it. I went through it with my own kids, and they said, "Dad, you know, taxes are a rip-off." "Hey I'm long ahead of you." That was rolling. And I think gas back then was probably 39 cents a gallon, Jean. Mm-hmm. So it, you did get some mileage out of the money you made, and it was money that I could save and use when I finally went to college three years later. So yeah, it was a ... it's a pretty low number, but it did go a long way back then. Yeah. You have a new book, Beyond Bed Rails and Bingo. You write in this book that nursing homes are often viewed as America's nightmare and- That is something that breaks my heart. I've heard it a lot from families and nursing home residents. But why do you think that people are so afraid of nursing homes, and how much of that fear is deserved versus just misunderstood? I believe that people generally, myself included, are afraid of things they don't understand or aren't prepared for, and nursing homes are no exception. Many times, a patient or a family's first experience with a nursing home is at the time of admission, and these fears are further compounded by the trauma that created the need for admission in the first place. So they're in a very fragile situation, and when those fears are accompanied by incomplete care or mismanaged customer service, that's when it devolves into the, quote, "nightmare." Now I, I've got a little bit different point of view, obviously. I spent my life doing it, but almost from birth, I took my kids into nursing homes, and patients and coworkers spoiled them terribly. And then in later years, after they entered school, bring your child to work days were the same thing. Either you're going to the building with me or you're going to the office, if I was supervising multiple nursing homes across several states. So it was an introduction to them at a very early age that continued, and I really, I wasn't alone. In many communities back then and even today, nursing homes welcome young people and their parents to visit, to be part of the community, and that also helps develop what a nursing home does and for whom they do it. So I think it really is all about what you know and don't know and what your preparation has been prior to seeing a nursing home as a patient or a family member that determines whether or not you view that experience positively or negatively Yeah I would agree. I mentioned COVID in the introduction, and I know a lot of people don't wanna talk about it, but I was a medical director attending physician in nursing homes during the pandemic, so I know it definitively impacted me and impacted everyone in those nursing homes. You've witnessed some of the biggest moments in modern healthcare history, including the COVID pandemic. So how do you feel that the pandemic permanently changed the long-term care industry, both operationally and emotionally? In the book, I wrote that, quote, "COVID broke the world." And that may be a pretty strong term, but it's something just now six years later I think is still fairly true, and the long-term care industry did not get a pass. On the operating side it's really easy to point at the number of workers that exited and didn't return, but what's harder and rarely discussed is what role the industry opinion makers and providers played in this exodus, and what's different today. It's also easy to highlight the billions in taxpayer money that providers received, but what's harder and rarely discussed is exactly where the money went, who did it benefit, and did it result in any meaningful and enduring changes? So these are the questions that I ask, and if you add to it everything, and I was in... I went through this experience because I had my mom in a memory care home at the time during COVID. The questions around restricting visitors, and then states failing to survey nursing homes for years in some cases, as you bring together all of these- Features, trust in the industry became eroded. Trust that was in short supply before because of the misunderstanding we talked to just a little bit ago, and it might not ever be recovered because people have really been tested as a result of their COVID experience. Whether they'll acknowledge it or n- or not is always gonna be a very personal item, but I know my orientation moving forward as a result of COVID has been shaped, and that's probably gonna be enduring. But I think the big thing that-- the biggest thing that I found as it relates to COVID in nursing homes is what might have been considered infrastructure prior to COVID, like public schools, like higher ed, like nursing homes, for example, they became very ripe for public reexamination. And the effect still lives on today in that people who might have once considered working or living in a nursing home don't today and might not ever. So I think that the impact has been significant and it-- and long-lasting, both operationally and emotionally Yeah. And I have a lot to say about this, but yeah it's a very, it's a very charged answer and, and I just keep thinking or hoping that we've learned, and if anything like that happens ever again, we will do it differently. But- I share that same thought. And in a deeper, longer conversation, that would be pretty interesting territory to go over. Yes I lecture a good amount about patient-centered care. It is one of the more popular provocative ideas in healthcare today. You suggest that there may be problems with how that concept is applied. What do you think people misunderstand about patient-centered care, and what should the focus actually be? when you wanna select terms out of the healthcare encyclopedia, I don't think there are many terms as loaded as the term patient-centered care. And I- I'll first, I'll start by explaining the way I've interpreted it, and that is you assemble thought leaders and stakeholders to design a, a comprehensive course of action to achieve the best possible outcome for a person receiving care. That may seem or sound somewhat simplistic, but when I was working every day inside or around a nursing home and they talked about patient-centered care, it was putting patients in the center of the conversation, and that didn't seem very complicated. And I really wish that it were only this easy, but as we both know it, it isn't. It gets hard because the word outcome becomes a moving target, and sometimes that creates a turf war between provider and family member, or across disciplines, or even across provider settings. And sometimes the breakdown occurs in determining exactly where the patient fits within the center of patient-centered care. As I wrote in the book in the section about financial dialysis, the patient is at the center of the revenue and profit cycle for the nursing home and the related party businesses serving the nursing home's patients. And when legislators and budget analysts try to address patient-centered care, I know that it's difficult for me to determine many times if the patient is in the center of the conversation or is polling in public sentiment. And the overarching let's call it disappointment. When I look at how others view patient-centered care, contrary to my view, is that many times it never includes asking the patient what it is they want And I, think that's That's a misalignment of incentives, and it certainly is an unintended consequence where the person that's supposed to be by definition at the center of the conversation is oftentimes excluded completely Yeah I've seen that and it, I think it's very challenging. Everybody has their own bias and then you have finances come into this, so it's not about what the patient wants or about what's best for the patient if the patient can't tell you what they want. So it becomes very... It's a, it becomes a very distorted Concept and emotional Yeah And terribly emotional Yes. So shifting away from emotional topics, I guess, we'll go, we'll talk about artificial intelligence. Everyone feels strongly about artificial intelligence these days. It's rapidly entering healthcare. Do you feel that AI will meaningfully change long-term care, and where do you think it could help, or could it potentially hurt residents and caregivers? Well, today, unless people are talking about SpaceX, they're talking about AI. And as you said, it's inescapable. And just as a matter of history, the internet Influenced how we look at electronic health records today, and the smartphone and texting replaced talking. And I think AI in the same context is going to meaningfully change long-term care. I'm gonna give you an example. Right now, I'm working with a company that uses AI to help nursing homes correctly stage pressure injuries that are present at admission. And their research across over a million images is that nursing homes are routinely misclassifying these injuries. So, for example, a stage two on admission really should be classified as a stage three. So as a result, a condition that, by definition, requires a daily skilled service isn't, and the treatment approach to these injuries is incorrect from the outset, and we know that influences the rate of healing, and many times the rate of healing is prolonged, the risk of infection is heightened, and the cost associated with the overall care is compounded. And for homes that embrace this idea, they're gonna become-- they're g- they're going to possess a tool that helps them be smarter and faster and more effective in taking care of a person that really needs taking care of. But that's just the beginning. When you look at the mismatch in terms of this example, you end up with compliance issues, you end up with litigation risks, and that's just, where the pain associated with this practice begins to snowball. And some nursing homes will benefit greatly just from this, this individual thing we're talking about. And others who decide to lean on already overworked clinicians or take a pass because of pricing or cash flow or creditworthiness, they're gonna suffer. I think that the beneficiaries of AI are gonna be nursing homes and their companies that are willing to make the investment and manage it, though manage it with guardrails. And I say that I point that out because there seems to be a belief, and I think it's somewhat societal, so I'm not gonna specify it to the nursing home business, but there's a belief that AI, AI is gonna be a solution, the universal solution, like WD-40 is the solution to mechanics and DIYers And I'm not yet sure that's the case, but it is early days. One of, you know, one of the AI's frequently touted benefits are its predictive and monitoring abilities, and I think those will be difference-makers, Jean, simply based on using speed as a differentiator. We know, though, that a nursing home is a dynamic environment, and the people being cared for, they can change in an instant, physically, emotionally, behaviorally, and that unpredictability isn't new and it isn't going away, and I'm not sure that AI can plan for that or predict that. So the-- to me, the real challenge for nursing homes, beyond the, the financing that we talked about a little bit ago, and other businesses with expectations for AI is when tension is created between what I'm gonna call velocity and capacity. Velocity meaning that things are known much more quickly than they might have been, if at all, in the past, and then capacity is how much can one process and execute? So if you know all these things, and you know with the help of AI, you know them immediately, what do you do? How do you manage the bottlenecks? Does that mean that additional people are gonna be needed to manage the velocity of all this information? I don't know. And if the actions that are now prescribed or suggested or required because of the speed of AI, if they're delayed due to workforce issues or fatigue, then who owns it? Is there a penalty for knowing earlier but not executing, quote, "timely"? And I think those are big questions. If I were, If I were a nursing home administrator today, those are the things that would keep me up at night, among certainly other things. And then to go further, you really have to wonder, is there a risk of the lines blurring? Will families and their surrogates use AI to practice their own versions of nursing or medicine? I know that goes on in households. I know that's gone on in my own household from time to time, and people are probably doing this already for their loved ones in the nursing homes, and that adds another dimension for nursing homes to de- to, to manage because- That level of information is now gonna be possessed universally and very quickly without, I would say, a complete understanding by all parties. I think one, one thing though that is not talked about enough is how the government intends to use AI within the industry. If you listen to Dr. Oz and the DOJ, and I pay a fair amount of attention to information that comes out of those branches, both CMS and the DOJ, I'd say it's virtually guaranteed that surveyors and auditors and law enforcement will end up using AI to examine nursing home performance and their behavior, billing, and compliance. And they will be quite formidable for the industry because their budgets are larger than any one provider can ever pull together. So when you look at just that hand- that handful of developments, I do think it's unavoidable that AI is going to materially change the nursing home business. I think it's going to help residents and caregivers because knowing earlier has a benefit, but I think there's still a lot of territory that remains unknown. You know, one thing that I think got lost in the entire conversation about AI and, you know, things come and go, but it's been a while since I've read anything about the advantages of block- blockchain technology, and I spend time on that. I wrote about it a little bit in the book, but the use cases for blockchain technology to me appear interesting, whether it's smart contracts or storing patient information with integrity or info- sharing information with Medicaid applications and redeterminations, payments and benefits, workforce credentialing, prior authorization, appeals management. I think all those topics are in bounds and it eliminates duplication of effort, it would reduce costs, and it would give providers More financial wherewithal to put it in the pockets of caregivers or hire more of them, which was the whole idea around nursing homes in the first place. So I think for, for all of the ener- energy that's been devoted to AI, and I think w- the majority of that's appropriately placed, I think there is a blind spot around the advantages of blockchain, blockchain technology, and there's still a chance to revisit that and make a lot out of it. I think that this is a, gonna, would, could be a whole nother podcast, but I am gonna save my comment And we can come back and revisit it again, because I really wanna get to these next two topics. Okay. So I know I have been asked this a lot about loved ones, you know, families placing their loved one in a nursing home and what they should look for. And also, I wanna talk about litigation, 'cause that is a huge nursing home topic. So the first question, for someone who is facing that decision of placing a loved one in a nursing home, what advice would you give them about what to look for, what questions should they ask, and what, what matters most? Okay. It, at the end of each chapter in the book, except the last one, there is a section that helps guide people in what to ask, what to look for, and what to listen to. So I'm gonna condense it into the top five. And I would say the first one is to get right with your loved ones, and that includes the patient. And that means s- spend some time working on checking family baggage and eliminating drama, and then have a candid conversation about whether this is likely to be a short nursing home stay or an extended nursing home stay. The second thing would be to acquire data from as many sources as possible. And people in communities, they know a tremendous amount about nursing homes. So ask everyone you know, and just don't stop asking. And even if it turns into what I would call a Ferris Bueller moment, where I heard from my cousin's next-door neighbor's girlfriend, that, that kind of intelligence can be helpful. The third thing would be to convert that data into information that can be used to make decisions. The fourth would be to visit places more than once. And I would, add two things to that, and the first is take a friend. Don't go alone, don't take a family member, take a friend. Take someone who's gonna look at it maybe a little bit differently than you, and really isn't afraid of being candid with you. And I know that family dynamics can get complicated, and the people I rely on most to give it to me straight are often, if it's not my wife, certainly is a friend. And a friend will tell you, so take a friend. And while you're visiting, be unrelentingly and unapologetically curious. There's no such thing as a stupid question, but it isn't advantageous to leave any questions unasked. And then the final thing, and I learned this with finding placement for my mom across the last six and a half years of her life, and that is make each place prove that they can care for your loved one based on what they need. Every nursing home is different, and not all nursing homes are good at everything. And if a loved one has a certain condition, but that nursing home is not very skilled at it or doesn't have a lot of experience with people who have what your loved one's had, they can do so many things well, and they could be very close to your home, and they could look really pretty, but un- unless they're very good at what your f- what your loved one or family member needs, they're probably not the best choice for you to consider. And tho- Jean, those are the top five. And like I said, there, there is an abundance of guidance that I provide across the first nine chapters for readers where it gets into significantly more detail than what I just went through. But those top five, if that's all you did, that, you're covering a tremendous amou- amount of landscape, and you can give yourself a lot of confidence that when it comes to making a decision, you're gonna make a g- one that you can feel good about. I would highly encourage individuals who are in that, that spot that have to make this decision to l- to get the book, 'cause it is, I mean, it is a huge decision. So that guidance is spot on. I agree You have been involved in patient care litigation from both the plaintiff and defense side. This is a very difficult subject, especially in long-term care. Do you think litigation ultimately improves patient care in nursing homes, or does it sometimes create unintended consequences? I know that sometimes the atmosphere an environment of defensive medicine can come about, which sounds good, but it... I personally do not feel that it is a good situation. Well I've been involved in patient care litigation actively since 1998, starting as an executive and a person most knowledgeable about the company I was working for, and then since 2006 as an e- expert witness both for plaintiffs and defense. And whether a case ultimately finds its way to trial or not, to me, each is a lers- learning opportunity, and the things I learn many times is that the more things change, the more they stay the same, which is really unfortunate. Errors of commission and omission that were occurring 30 years ago, they continue today, and some of the, some of this is simply a function of people taking care of people. And my point of view may be controversial, Jean, but I'm g- I'm gonna share it 'cause you asked it. I think it's important to separate litigation from patient care improvement, and to me, one doesn't beget the other. And my reasons are closing a patient care litigation case, it takes years because of the way the rules are and the way that people who are representing the patient and the provider behave. And in cases, remedies are being sought for something that's already happened, and during the span of these years, an individual nursing home's patient care quality can rise, fall, it rise and fall again, depending on its leadership, its commitment to people, and its approach to care. And From my vantage point, and I've been, as you said in the, introduction, I've been in the nursing home business for part of six decades, and patient care improvements to me depend on the owners and the operators, with or without litigation. And those that consider themselves victims of a litigious environment or consider litigation expenses as the cost of doing business, they usually don't and likely won't improve patient care in their nursing homes. And I, find that terribly unfortunate. But on the other hand, there are owners and operators who really do embrace what you and I talked about a moment ago, and that is patient-centered care, and good things happen in those nursing homes. And they may be sued, oftentimes they aren't, but when they do, they have a foundation to represent and defend themselves. But there are unintended consequences. As I said, I've been doing this a long time, and I've known very talented and committed people to exit the nursing home profession because of a litigation experience that simply wore them out. They said, "Hey I've, got skills. I can go do something different. I don't, I don't need this." And I've als- also watched families fractured when deciding to sue or not sue a nursing home, or if they have sued a nursing home, go through discovery, 'cause family members have different lenses through which they view their loved one and the provider. So people, beyond the patient, they can be hurt badly Yeah. Yeah. I've, yeah, I've seen a lot of people leave. A lot of good physicians not wanna be medical directors of nursing homes 'cause of the risk. It's a really it's problematic. I think we, we really, there's gotta be a better way, but- Yeah there sh- there should be a better way. And the way it's designed today, it's very high stakes and it's, it's hard to tolerate at scale, and it's hard to tolerate for the duration. I'll just speak for myself. I was in an operating role from, uninterrupted from 1986 to 2006, and in 2006 I took a detour and went down a couple entrepre- entrepreneurial paths that continued to take care of people, and started a business with a college friend of mine when we did medical transportation in three states and several thousand rides a year for people who needed to go certain places. So knowing the business and knowing how to take care of patients was greatly beneficial, and then returned to it. And I think you get smarter with different experiences, and returning was something I'm glad I did, but so was leaving for a short period of time to go develop another set of skills and have a- another set of new experiences because doing it uninterrupted can be very difficult yeah. I could talk a lot about that too, but I'll hold my comments. I wanna get to this last question. I ask a, an iteration of this question to all my guests and I think I probably should put together a list of all the answers, so I'm very curious to hear your response. If you were put in charge of healthcare in the United States tomorrow, what is the very first thing you would do? Well, what an incredible assignment would that be, right? The first thing I'd do would be to creative incent- create a set of incentives that recognize and reward wellness, with the goal of extending a person's need for chronic care for as long as possible. And whether the condition is obesity, diabetes, mental illness, for example, any set of incentives that extends the health span of a person's life would be beneficial at scale. So that would be the first thing I would be looking at to say how can we accomplish improving population health to the point where someone needing extended chronic care can be pushed deep, deeply into their life's experience. At the same time, because it's really impossible to separate money from the healthcare equation I'd be working on designing a financing mechanism that provides people with the information and the access and the ability to choose providers. And this is gonna get a little bit tougher soon, Jean, because Social Security and Medicare are virtually guaranteed some level, whether it's partial or complete, insolvency. And you can argue about why that, why it is what it is, whether it's because legislators didn't do their job or didn't do the math or seize available opportunities decades ago or make decisions that might have limited their terms in power. Those are great conversations, and they're debatable. But History would help These lessons as reference points and could be used as incentives for everyday people to start early in building the financial strength they need to determine their own healthcare destinies and when they need care, and that they be aware of price. So I'm, I'm all for independence and self-determination, and also giving people a reason to be as healthy as they can for as long as they, they can. And then you build the infrastructure n- you build the infrastructure to help people who, for a multitude of reasons, aren't able to do either of those things for themselves early I love that. I love that answer, and I hope you get your wish someday. That would be quite a fun job, Jean. I'd probably be giving you a call. So how can people find out about your book or more about you? Okay. Well, I have a website, and it's www.daveDevereaux.com, and you will find information about my book. There are a number of FAQs that, that I posted and answered on the home page for people to get a feeling for the things that are important to me. I also have blogs that I've written myself. There are review, book reviews that are already out there, and there's, there are a couple of buttons. There's one you can press for a sneak preview to the book to see if you like the, the foreword and the preface, and then you also have the ability to order right off the website directly from Amazon. And the, the book was a rated a number one new release for three, three weeks running in a number of categories, including nursing home care, Medicare and Medicaid, geriatrics, gerontology across that time, which was incredibly gratifying. And there's also reader reviews and other parts other information from professional reviews. So you can either go to my website or go straight to Amazon and look up Beyond Bed Rails and Bingo: Myths, Truths, and the Future of America's Nursing Homes, and give it a look. I encourage everyone to check it out if, you know, you or someone you know is going into a nursing home. Dave Devereaux, I really enjoyed this conversation. Thanks so much for joining me. Jean, thank you. I hope you invite me back. This was an awful lot of fun.

Thank you for tuning in to Taking Healthcare by Storm: Industry Insights with Quality Insights Medical Director Dr. Jean Storm. We hope that you enjoyed this episode. If you found value in what you heard, please consider subscribing to our podcast on your favorite platform.

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