Deborah Buchanan

The Space Between Seeing and Saying

Well-Being: An Obligation Written into Law When did resident well-being become an aspiration for nursing homes? It didn't. 𝗧𝗵𝗲 𝗡𝘂𝗿𝘀𝗶𝗻𝗴 𝗛𝗼𝗺𝗲 𝗥𝗲𝗳𝗼𝗿𝗺 𝗔𝗰𝘁 𝗼𝗳 𝟭𝟵𝟴𝟳, 𝗽𝗮𝗿𝘁 𝗼𝗳 𝗢𝗕𝗥𝗔 '𝟴𝟳, 𝗲𝘀𝘁𝗮𝗯𝗹𝗶𝘀𝗵𝗲𝗱 𝗮 𝗳𝗲𝗱𝗲𝗿𝗮𝗹 𝗿𝗲𝗾𝘂𝗶𝗿𝗲𝗺𝗲𝗻𝘁 𝘁𝗵𝗮𝘁 𝗻𝘂𝗿𝘀𝗶𝗻𝗴 𝗵𝗼𝗺𝗲𝘀 𝗽𝗿𝗼𝘃𝗶𝗱𝗲 𝘀𝗲𝗿𝘃𝗶𝗰𝗲𝘀 𝗮𝗻𝗱 𝗮𝗰𝘁𝗶𝘃𝗶𝘁𝗶𝗲𝘀 𝘁𝗼 𝗮𝘁𝘁𝗮𝗶𝗻 𝗼𝗿 𝗺𝗮𝗶𝗻𝘁𝗮𝗶𝗻 𝘁𝗵𝗲 𝗵𝗶𝗴𝗵𝗲𝘀𝘁 𝗽𝗿𝗮𝗰𝘁𝗶𝗰𝗮𝗯𝗹𝗲 𝗽𝗵𝘆𝘀𝗶𝗰𝗮𝗹, 𝗺𝗲𝗻𝘁𝗮𝗹, 𝗮𝗻𝗱 𝗽𝘀𝘆𝗰𝗵𝗼𝘀𝗼𝗰𝗶𝗮𝗹 #𝘄𝗲𝗹𝗹-𝗯𝗲𝗶𝗻𝗴 𝗼𝗳 𝗲𝗮𝗰𝗵 𝗿𝗲𝘀𝗶𝗱𝗲𝗻𝘁. That obligation is found in two places in federal law: 42 U.S.C. § 1395i-3(b)(2) — Medicare-certified skilled nursing facilities. 42 U.S.C. § 1396r(b)(2) — Medicaid-certified nursing facilities. But there is another provision worth examining. 42 U.S.C. § 1395i-3(d)(1)(A) requires a Medicare-certified skilled nursing facility to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable well-being of each resident. This is tied directly to Medicare participation. Notice what the law connects: organizational administration, the effective use of resources, and resident well-being. This brings the conversation beyond the delivery of care. What does an organization have to make possible for residents to experience well-being? Consider an ordinary afternoon. A resident tells her visiting family member that she's meeting a friend on another hall. They're going to the courtyard for coffee. She also reminds her visitor that she has a hair appointment at 2 p.m. She has plans. She has relationships. She has somewhere to go and something to anticipate. She is exercising choice, maintaining friendships, participating in the life around her, and directing her own day. This is psychosocial well-being made visible. This is agency with boots on. The movement from institution to home gives us an opportunity to reconsider what these statutory requirements look like in everyday life. A house provides shelter. A home provides belonging. And well-being is not simply something a facility provides to a resident. It is something the organization must make possible through the conditions it creates. The question isn't simply whether we are providing care. It is whether we are making a life possible. @mtaylorstark @ConsumerVoices

📁MF #122 — A Place to Live A nursing home is a place where care is delivered, and it is also where people live. Home Sweet Home. The distinction matters. Residents bring their stories and biographies, preferences, relationships, habits, and expectations into the building. Their lives are to be matched by the delivery of services. When we reduce a nursing home strictly to a medical facility or clinical environment, we inadvertently invert the priorities of daily life. The schedule of the institution—medication passes, shift changes, meals delivered at scheduled hours—can begin to dictate the rhythm of human existence, rather than the needs and desires of the individual serving as the foundation around which support is organized. The distinction between a facility and a home lies in autonomy and personal narrative. A resident is not merely a patient occupying a bed; they are a parent, a reader, an artist, a spouse, an early bird, or a night owl. They carry a lifetime of agency. Needing help with activities of daily living does not forfeit one's right to decide how those days are lived: when to wake up, what to wear, how to spend leisure time, or whom to invite into one's private space. This requires a fundamental culture shift in long-term care—moving toward person-centered living. It asks staff and administrators to recognize the person and organize care around the life that person wants to live. The question is how the place accommodates the life of the person who lives there. Does the physical and social architecture of the building support connection, privacy, and dignity? Can a resident keep a favorite piece of furniture, share a meal in a familiar setting, or maintain a routine that feels authentically theirs? The quality of care is reflected in how well the delivery of care supports the quality of a person's life. 𝐇𝐨𝐰 𝐦𝐢𝐠𝐡𝐭 𝐰𝐞 𝐨𝐫𝐠𝐚𝐧𝐢𝐳𝐞 𝐝𝐚𝐢𝐥𝐲 𝐜𝐚𝐫𝐞 𝐬𝐨 𝐭𝐡𝐚𝐭 𝐭𝐡𝐞 𝐫𝐡𝐲𝐭𝐡𝐦𝐬 𝐨𝐟 𝐭𝐡𝐞 𝐡𝐨𝐦𝐞 𝐫𝐞𝐟𝐥𝐞𝐜𝐭 𝐭𝐡𝐞 𝐩𝐞𝐨𝐩𝐥𝐞 𝐰𝐡𝐨 𝐥𝐢𝐯𝐞 𝐭𝐡𝐞𝐫𝐞? Ask Better Questions.

Capacity for Self-Renewal Looking back to move forward. An organization is a living quiet. Long before the strategy or the draft, someone notices the small detail— the turn of a phrase, the shift in a room. That noticing is knowledge knocking gently at the door. Principles sit still on paper until someone picks them up, holds them against the daily work, and asks: Is this how we take care? The floor already knows. It carries years of morning routines, the insight of those who do the work,the quiet wisdom earned in real time. Nothing is lacking; it only asks to be brought together. Then a pattern shifts out of the background. We recognize what was always there, and a path opens where there was only habit. Observe. Recognize. Connect. Learn. Adjust. No single lesson settles the debt. A lesson matters only when it changes what comes next. The mirror behind us is small for a reason: to offer perspective, not a place to stay We look back to see clearly. We step forward to keep learning.

Great Memory Game!! @alzassociation @DementiaFriends @aarpmn

Yes. “I see it differently” opens the door; curiosity walks through it. The curious leader doesn’t stop at naming the difference. They ask, “How do you see it?” or “What am I missing?” That inquiry can surface a better frame, correct a blind spot, or simply make the relationship stronger while the issue gets clearer. Agreeing to disagree preserves the 'faux' peace; genuine curiosity improves the understanding. Builds relationships.

What Do We Discover When Someone Walks Through the Door? A recent conversation between @MarkCCrowley and Pam Manfredo Curtis about the backstory of leadership got me thinking about how much of a person’s composition may be visible long before a career begins. Think of the child who builds model airplanes and later becomes a pilot. Early interests can offer clues to the capacities and inclinations that eventually find expression in a calling. What if we brought that curiosity into hiring for long-term care? Ask a prospective CNA: What is your fondest memory with a grandparent? The answer might reveal an appreciation for companionship, a love of making things, patience, curiosity, or the pleasure of sharing everyday experiences. These questions invite us to discover the person behind the application. A well-being atmosphere in a home is shaped by the people who work and live there. What they notice, enjoy, value, and bring to their relationships matters. What might we discover if we interviewed for human capacities as well as job qualifications? Ask Better Questions.

CON battle update: AdventHealth vs. Mission/HCA in WNC NC Supreme Court declined to hear HCA’s final appeal of AdventHealth’s original 67-bed Weaverville CON. Construction is underway (groundbreaking March 2026); targeted opening Feb 2028—delayed ~3 years by appeals. +26 beds (awarded 2024) still under appeal by Mission. In a separate 129-bed allocation, state gave 95 to Mission (Asheville expansion) and 34 to Novant (Arden). AdventHealth & UNC have appealed. Mission argues the region is better served by adding complex/tertiary capacity at its existing Level I trauma center rather than dispersing beds. Hearings showed local opposition to more Mission beds (safety/staffing concerns) alongside support for competition, especially north/rural. Initial 67-bed Weaverville hospital (located in northern Buncombe county) is moving forward. Final size and broader bed distribution hinge on the remaining appeals. @DutchRojas @asheville @Weaverville hendersonvillelightning.com/…

The star ratings you see when you compare Medicare Advantage plans are meant to be simple: more stars = better quality care and better experience for people like you. But those same stars also decide how much extra money the insurance company gets from the government. Higher stars can mean hundreds of millions or even billions of dollars more in payments. Lower stars mean less money. So the company has two ways of talking about the exact same numbers. When the stars look good, they advertise them. “Look how strong our quality is. Most of our members are in 4-star or higher plans.” When the stars come out lower and that costs them a lot of money, they sue the government and say the rules used to calculate the stars were not legal and should not count. That is what happened with Aetna (part of CVS). In early October they put out a press release praising their new star ratings as proof of strong care. Less than three weeks later they went to court saying 28 of the measures used to create those ratings should be thrown out because they were done the wrong way, and that keeping them in would cost the company more than $2 billion. The stars on the Plan Finder website did not change. Only the company’s description of them changed, depending on whether the result helped them sell plans or cost them payments. For you as a retiree choosing a plan, this means the stars are still useful information, but they are not a pure, simple quality grade. They are also a payment system the companies fight over in court. When you see high stars, it is worth asking whether the company is currently challenging the way those stars were calculated. The number you see is real, but the story around it can shift quickly when money is on the line. @AARPNY @ARRPWV @CMAorg @GrayPanthersNY Ask Better Questions

📁WF #18 From Institutional Life to Home Living A nursing home is both a place where care is delivered and a place where people live. Understanding that distinction changes how we look at the environment, the organization of work, and the daily experiences of residents and caregivers. Home takes shape through ordinary experiences: familiar routines, recognizable faces, personal preferences, meaningful relationships, and opportunities to participate in daily life. These details provide continuity and a sense of belonging. They are especially important for people experiencing memory loss, for whom familiarity and predictable routines can help provide orientation and reassurance. The environment extends beyond the physical building. The way work is organized—how supplies are maintained, information is communicated, responsibilities are understood, and follow-through is sustained—also shapes the lives of residents. The conditions in which caregivers work influence the attention, judgment, and presence they can bring to the people they serve. This requires an organization capable of recognizing itself. Departments need to understand their own contributions and how those contributions connect with the whole. Frontline observations and the ordinary details of daily practice offer valuable insight into how the organization actually functions. When an organization understands how its work connects, it can improve the conditions for residents while expanding the knowledge, agency, and purpose of the people who provide care. This week, we will look at how the experience of home is created and sustained through the relationship between people, everyday practices, and organizational conditions. The experience of home is built through what happens every day—and through the organization that makes those experiences possible. @mtaylorstark @Honet334 @Justacarehomeg1 Ask Better Questions.

Healthcare is always a bipartisan issue —and AI in insurance is no different. Red states (DeSantis) and blue states alike are moving to require human review of AI-driven denials because patients and doctors are sick of opaque “computer says no” decisions. Trump’s push to preempt the states is about speed and national competitiveness, not a pure free-market purity test. The real fight isn’t left vs. right. It’s whether states can protect patients from bad AI denials or whether the feds will sue to keep the patchwork from slowing insurers and tech companies down.

The Gradual Sunrise A Week of Learning to See A place to live, a life unfolding— a thousand histories arriving at the door. Not simply where care is given, but where a person wakes. Where preferences have meaning, and memory finds its way through familiar days. Home is found in ordinary things: a face remembered, a place set at the table, a favorite sweater, the morning cup prepared just so. It lives in the rhythm of the day, in what is known without asking, in the comfort of being recognized, and in the freedom to belong. And home is how the work is organized, how supplies are made ready, how one shift meets another, and how time is made available for the people who live there. Sometimes knowing begins before understanding. A caregiver notices: a heavier step, a quieter voice, a meal left untouched. Something isn’t right. The observation travels— Someone listens. Someone considers. Someone has the means to respond. For knowledge lives in people long before it appears in reports. Can an organization recognize itself? Can its separate parts see what they contribute, what they depend upon, and how their work converges in the life of the whole? Look closely. The linen closet is stocked. The handoff is reliable. A name is remembered. A request is honored. A warm blanket arrives without being asked for twice. Small things, perhaps— but they tell us everything. The details gather. Patterns begin to emerge. What seemed separate begins to reveal its connections. Recognition is not a burst of light but a gradual sunrise— one that connects as it reveals. First we learn to notice. Then we begin to understand. And what we come to recognize becomes the ground from which improvement grows. For home is not something an organization can simply declare. It is something people create: in the way they live, in the way they work, and in the quiet attention they give to one another. Perhaps the first step toward a better way of living together is learning to see what is already happening.

MFR*V #121 — Capacity for Self-Renewal Weekly Review This week, The Moss Files examined a question at the heart of organizational development: What makes an organization capable of improving itself? MF #117 — Listening Is More Than Hearing Listening connects the observations and experiences of residents, families, and staff to the decisions that shape daily life. MF #118 — When Principles Meet Practice Principles gain practical force when people can use them to examine routines, make decisions, and improve the conditions of care. MF #119 — What the Work Already Knows Experience creates knowledge throughout an organization. Renewal becomes more possible when that knowledge can be recognized, shared, and used. MF #120 — Recognition Changes What Becomes Possible Recognizing a pattern or an overlooked source of knowledge can open a path to action. Improvement follows when insight is given a way into practice. Taken together, these posts return us to the relationship between knowledge and capacity. An organization may have considerable experience, commitment, and ingenuity. What matters is whether its structures and habits allow those resources to be brought together and put to work. Self-renewal is a continuing process: observe, recognize, connect, test, learn, and adjust. Looking back becomes valuable when it helps us understand what the experience has taught us and what we can do with that understanding now. The rear-view mirror gives us perspective on the road already traveled. We use that perspective to make better choices about the road ahead. The work of renewal is never finished simply because a lesson has been learned. Its value emerges when that lesson changes what becomes possible. Looking back to move forward. Building the capacity to keep learning. @LoriPorterNAHCA @MarkCCrowley Ask Better Questions.

Thank you. Elisabeth is seldom here on X so the contact is via her Facebook group. facebook.com/groups/payingti… Named for her "Paying Till It Hurts": Her acclaimed 2013–2014 New York Times reporting series exposed the hyper-inflation of medical costs in the U.S. and won multiple awards, laying the groundwork for her book. Her book is a worthy read. it made the 2017 New York Times bestselling booklist. An American Sickness: How Healthcare Became Big Business and How You Can Take It Back, which investigates how American medicine morphed into a profit-driven enterprise and provides practical strategies for patients to protect themselves from predatory billing practices. @EssentialCgC @LTCconsumer @mtaylorstark

According to The Wall Street Journal, social-media intelligence firm #SproutSocial found that in just three months there have been more than 426,000 mentions across X, BlueSky, YouTube and Reddit on medical bills, including advice on how not to pay them and how to negotiate them lower. That marks a 36,000% increase compared to the 1,163 mentions recorded in the same period last year. @jordanRau @geraldposner moneywise.com/news/top-stori…

Yes, even over $20,000 in AK. Most people do not realize that Medicare has NO long term care benefit. Medicare pays 100 days for skilled nursing. 100% for 20 days. Then 80% for the next 80 days. Usually residents go in for 20 days, and return 30 days later, for the next 80 days and apply for Medicaid for Long Term Care, forced to do the spend down so they qualify. Usually they are approved w/in 2 months and then Medicaid will back pay for the outstanding 20% for the skilled nursing. And then they will be admitted for Long Term Care. And Medicaid -remember is a state/federal fund. So that is a chunk of change out of the state budget. @joeygracia @jldobrinsky

📁MF #120 Recognition Changes What Becomes Possible Change often begins when people recognize something that has been present all along. A recurring difficulty becomes a pattern worth examining. An individual workaround reveals a weakness in the process. A resident’s repeated response offers information about the environment. A worker’s observation opens a question that the usual measures have not answered. Recognition changes the possibilities because it changes what people can see and consider. A problem that once appeared to be an individual failing may reveal a system condition. An isolated success may offer a practice worth testing elsewhere. A familiar frustration may become the starting point for a more useful question. Recognition alone does not renew an organization. The insight must be examined, connected to relevant knowledge, and translated into action. People need the opportunity and authority to test improvements, learn from results, and adjust their approach. This is how capacity becomes consequential. Knowledge is recognized; inertia begins to loosen; people gain room to act; and experience feeds the next round of learning. Recognition makes change thinkable. Releasing inertia makes change possible. What are we now able to see that could help us work differently? @LoriPorterNAHCA @mtaylorstark Ask Better Questions.