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GRAY MATTERS: Long Term Care

SaulFriedman75x75 Pulitzer Prize-winning journalist Saul Friedman (bio) writes the weekly Gray Matters column which appears here each Saturday. His Reflections column, in which he comments on news, politics and social issues from his perspective as one of the younger members of the greatest generation, appears here at Time Goes By twice each month.

If you have a friend or a loved one in a nursing home, with the holidays coming on, this would be a good time to check closely on conditions in the home and the quality of his or her care. For this economic downturn and Medicaid reductions in some states may be affecting the level of care, especially in for-profit homes that may cut corners to save money.

I say “may’ because some nursing homes are warning of staff layoffs and even closures, but there is little real evidence that residents are being affected. But the Centers for Medicare and Medicaid Services (CMS) recently updated its lists of so-called Special Focus Facilities (SFFs), which include scores of homes that have a history of serious problems such as the conditions and staffing of the institution and the level of care.

In August, the Government Accountability Office surveyed the ten-year-old SFF program and estimated that 580 of the 16,000 nursing homes in the country “could be considered the most poorly performing.” In addition, CMS lists dozens of other homes on the SFF lists – at least one in every state - have not shown substantial improvement in the past year or so.

CMS, which uses state agencies to monitor the homes, separates the SFFs into five categories:

  • homes recently added to the list that need improvement

  • those that have improved

  • those that have not improved

  • those that have improved enough to be removed from the list

  • those that are so poor they have lost Medicare and Medicaid participation

You may check out the list of homes considered SFFs for your state here [pdf].

Also, last December CMS began a five star rating system for the nation’s nursing homes. This compares the level and quality of care for facilities by area.

The concern about the recession’s effect on nursing home care was touched off, in part, by a widely circulated wire story last month in which an official of the American Health Care Association saw the possibility of layoffs in nursing homes. The story said the nursing home industry was in crisis, partly because “Congress is debating slashing billions more in Medicare funding a part of health care reform.”

But there are a number of pending proposals to strengthen long term care. And while Medicaid funds have been cut in many states and Medicare is cutting some direct payments to nursing homes over the next decade, the GAO and the official Medicare Payment Advisory Commission (MedPac) say the nursing homes have enjoyed billions in overpayments, especially for skilled nursing facilities, where patients who are supposed to get one-on-one therapy are among three or more getting treated at the same time.

With aides paid too little (less than $10 an hour) to attend to too many residents, MedPac found that nursing homes profits exceeded 10 percent for seven consecutive years. And the profit margin for nursing homes in 2007 was 14.5 percent.

The GAO noted, incidentally, that “the most poorly performing homes tended to be chain affiliated and for-profit and have more beds and residents.”

Richard Mollot, executive director of the New York-based Long Term Care Community Coalition, a watchdog group, told me that while it would be wise to keep a special eye out on the care given to loved ones:

“Providers are always crying that they don’t have enough money...basically there have been cutbacks to the raises facilities were expecting.”

And he noted that inflation has been minimal. He cautioned against buying into the predictions that cutbacks are necessary and cited the wire story‘s report on layoffs at three homes in Brooklyn in the Metropolitan Jewish Health System. In 2004, The New York Times, discussing the poorly paid aides, reported that the head of the system, Eli Feldman, earned over $1 million in salary.

Whatever the finances of the nursing home industry, the Obama administration, elected a year ago this week, has encouraged the Democratic Congress to propose a host of bills to fix problems large and small with long term care. One bill, for example, would make it easier for families to file complaints on behalf of patients and open the books on who actually owns, runs and profits from the homes. Another bill would strengthen programs to prevent patient abuse.

The most important proposal is part of the Senate Health Committee’s bill for health care reform. Introduced by the late Senator Edward M. Kennedy, it’s called the Community Living Assistance Service and Support Act, or CLASS.

Among other things, it would enroll workers over 18 to gradually build a long term care fund financed by a payroll tax. They could opt out, but the fund would in five years finance the long term care of enrolled workers who need help. The initial benefit, about $100 a day, for home or nursing home care, is small, but it would relieve some pressure on Medicaid, and supporters see this as a start to solve what AARP has called “the greatest unmet health need,” the lack of public long term nursing care.

The bill is also included in the House version of health care reform and is expected to survive after it is combined with the more conservative one from the Senate Finance Committee. But not surprisingly, it’s opposed by the American Association of Long Term Care Insurance which fears it will put private insurers out of business. That would not be a bad idea, but we can talk about the worth of long term care insurance at another time.

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My goodness Saul, sure wish we had you here in Canada. Excellent posting.

Thanks so much. Let me add my two cents, please, on the strength of Mom's six-year stay in a nursing home.

Consult the ratings, by all means, but bear in mind that when the top administrator changes, the entire facility may change. Also be aware that one tragic accident may leave an otherwise decent facility with a less-than-stellar rating the same way a single "0" can affect an otherwise decent average.

And finally, there is no substitute for your frequent presence. Be there at the quarterly care meetings for your loved one. Check the medications she's receiving (we had mistakes made with doses getting mixed up). Show up unexpectedly. Send an occasional pizza over by way of saying "Thanks" to a staff that's doing one of the literally sh******* jobs in the country.

Personally, I went around in a state of rage for a while over what was happening to my mother. Without embarrassing myself too much, let me add: it's not the NH's fault that the people we love end up there!

Kudos to you Saul and Ronni for bringing TGB readers information that most of us would rather put on a back burner. Even though I now live in a CCRC, I avoid thinking about this too.

We just laid to rest our friend Duck after a long struggle to get him the best care we could. Social workers with adult abuse organizations suggested one home near us as excellent. We discovered that the only way to get him passable care there was to be there every single day. He didn't even get two sheets on his bed unless we made a fuss. Only now that he is dead and gone do we hear of horror stories about that for profit home.

Thanks for being here.

Excellent!!!! And to be honest, none of this surprises me. My next door neighbor got laid off by what was allegedly one of the best nursing homes in our county after working there a very long time. I know she's a caring person because of the way she keeps an eye on me and sends her boys to help.

And one of my oldest friends who worked in such facilities for years has told her children that if they ever put her in a nursing home, she would haunt them for all eternity.

Ohio has an "Aging in Place" program that I'm exploring. It sounds like something that would work for me.

Glad to have you here.

I'm looking for

You can become a nursing home resident's best friend! If you have the time to volunteer, becoming a state-certified ombudsman for a nursing home may be an option for you.

President Nixon signed a bill mandating that an ombudsman system be in place in each state.

I served as an ombudsman in the nursing home that is only a couple of miles away from my home (Derby KS). Training was provided by the state, in a venue within 15 miles of my home. Time commitment varies, but I put in about 8 hours per week, including visiting the facility (at randomly-selected hours 24/7), record keeping, and attendance at monthly meetings with our Regional Ombudsman. Please consider this means of contributing to your community.

I've just started looking into LTC for my wife and possibly myself and I think I may look into becoming an ombudsman to help those in the homes and maybe pickup some on-site information for myself.
It's starting to look like LTC in a nursing home is really a "last resort" solution.

Please write more about care giving senior parents. So many of my friends are in this situation. We need support groups. Care giving can tear a family apart. Old roles come to the surface, everyone has his or her say, often the parent feels invisible while others plan around them.

Care centers are warehouses in which low paid aides are so busy they don't have time to interact with the clients in bed there.

Nurses are so overloaded that they are in the office going over paperwork and rarely interact with clients.

The atmosphere is one of a hospital rather than a home.
Where the care homes are profit making, the bottom line comes first. Heaven help anyone who does not have a personal advocate when a client is stuck there.

Caring should not be a business, it should be a priority of our government covered by our taxes.

I agree and it worry's me because I just read an article in Kay's blog and it provides info regarding the abuse of our SS funds why wouldn't they do the same for anyone paying for long term as well. How can we stop our lawmakers from robbing Peter to pay Paul..it's so frustrating.

Dorothy from grammology

You've written a really informative article and the links will be helpful to many of us, I'm sure.

I’m delighted an effort will be made to develop a long term care plan. I hope you’ll keep us apprised of developments in that area.

I'm intimately familiar with many of the Skilled Nursing Facilities (SNFs) in my area. I would agree with many of the CMS ratings I read from 1 star to 5 star, but there are some ratings, particularly in the area of quality, that I would seriously question (lower than deserved ratings in a comparison with other facilities listed I know) -- based on my personal view from the inside.

I would certainly agree that many of the chain for-profit facilities may be among the more "poorly performing" ones.

Fifteen or twenty years ago there was a national chain that was excellent, used some of the same personalized-patient-care features that in recent years have been presented, promoted and recommended by some writing about aging as new innovations to be adopted in such settings. Since the approach I saw has been absent for some years, guess the ideas seem new again.

Unfortunately, that chain experienced serious financial cutbacks, as all SNFS reported they had, due to funding changes. That chain was forced to sell their facilities to other companies who presumably had to immediately institute cutbacks in all areas, especially those directly affecting patients, including some of those more personal patient-benefiting features.

There is no substitute for personal visits to even the better facilities. Staff is always aware when someone is receiving attention from others and seem to respond in kind. In select SNF facilities those patients with no visitors may receive compensating attention from some staff with whom the patient may connect. In other facilities they may or may not garner much needed attention and may be influenced by the patient’s disposition and manner.

Once a loved one is in a SNF, family members frequent visits interacting closely with Nursing is important. For some of the other facilities a daily visit at different times of day/evening would be well-advised, and, again, interact with Nursing (Charge Nurse -- not just the CNAs and Aides) making sure they see you’re there.

My experience has shown that Skilled Nursing Units in retirement communities provide better care than many of those strictly SNFs that accept Medicare/Medicaid. In fact, many retirement communities didn't used to accept patients other than their own residents, but in recent years have begun to do so if they have beds available.
Non-retirement community residents admitted into their SNF are referred to as Community Patients. (There's a social pecking order and some "residents" may not regard them quite as highly.) Also, these retirement communities typically will accept only Community Patients with Medicare and supplemental private insurance, or cash out-of-pocket, but not Medicaid.

The reason given by most retirement community SNFs as to why they don't accept Community Patients with Medicaid as supplement to Medicare is that typically the cost of caring for these patients exceeds the reimbursement the facility receives. Also, the services Medicaid even covers is significantly meager. In some instances, I would even question with some therapy if it’s little more than “going through the motions” in terms of frequency, length of treatment, duration of service, not to mention the time and challenges the therapist encounters only to obtain little reimbursement for providing services and the frustration of knowing the patient needed and deserved more.

I would caution that if there is a possibility the loved one may need to remain for long term care rather than returning home or to prior living arrangements, be sure to learn in advance from the retirement community SNF what long term care costs will be, because skilled care there may well be much more expensive than in straight skilled nursing facilities. If relocating the patient to a more affordable SNF at that point is deemed acceptable, then requiring them to move is not an issue. Otherwise, in the beginning you might want to take them to the SNF where they would likely be able to remain if necessary.

Even regular SNFs look very closely before accepting for admission Medicare/Medicaid patients. They project their long term medical needs, life expectancy and may determine they're unable to accept some very medically involved patients who are anticipated to cost them more than expected reimbursements. Some patients can be hard to place so have limited choices.

I think a close examination of exactly what the financial status of SNFs is, exactly who owns them, and profits/salaries is very much in order.

There is uniform agreement everywhere I go that the Certified Nursing Aides (CNAs) provide the bulk of daily/nightly 1:1 care and are underpaid.

Work that RNs used to provide was long ago relegated to Licensed Vocational Nurses (LVNs) in Calif. The number of legally required RNs was significantly reduced but this reportedly was due to the shortage of nurses.

Just as a point of information, because I'm constantly encountering patients/families wondering when their Dr. is going to visit or why he/she hasn't been there. In Calif. the Dr. is legally required to see a SNF patient within a specified length of time after admission but thereafter only once a month. Typically the patient has come from an acute hospital where they've had doctors frequently in and out, nurses hovering around and, suddenly, without having been previously informed, they encounter this Dr./Patient/Family face-to-face change and reduction in medical attention relegated to a CNA and a LVN medicine nurse making the rounds 2 x’s daily or so, maybe an RN if the patient asks for them. The Doctors and Charge Nurses are generally in frequent contact by phone as warranted, especially in the better facilities. Therapists may contact Doctors directly and there are instances when we do find that necessary and welcomed.

The therapy situation where a patient is supposed to receive 1:1 service and it was found as many as 3 patients were being treated simultaneously, I would suggest likely occurred with one specific therapy discipline. Billing improperly for 1:1 with the licensed therapist can be an issue, I expect, both unintentionally and otherwise. If the billing error, possibly due to code numbers was not accidental, then I would be inclined to think the therapy discipline was working either in-house (directly for a facility) whose management's "unofficial" productivity pressure contributed -- no professional excuse for the therapy that succumbed -- or that this was a contracted therapy group, part of a medium to large, maybe national, therapy company excessive-profit-driven chain.

If 3 patients were being treated at once, it may be that Assistants were involved. Billing is different in those instances. All therapy disciplines have been pressed by many sources in recent years to create lower level Assistants or Aides who are to provide only certain treatments during sessions. Strict guidelines and limitations are prescribed as to what they can and cannot do. My own profession has not been immune to this pressure and a few years ago created an Asst. level due to a shortage of licensed professionals. I did train to be able to supervise an Asst. if needed, but the settings in which I work have not evidenced a need for such additional help. Some in my profession do not embrace utilizing Assistants and I would only do so in certain highly controlled-by-me situations. Their utilization would have to be understood between Dr., patient, therapist and Asst. and billing would be accordingly.

Licensed therapists in all disciplines using Assistants/Aides are responsible for using them properly, and the Assistants/Aides also are supposed to know the limits of what they can and cannot do. I saw that process successfully in action preventing abuse of the requirements when a supervisor (non-therapist with a medium-size therapist-owned company) tried to bring pressure to bear on a therapist to act beyond the prescribed limitations and the therapist refused, potentially a employment jeopardizing act. (While a therapist couldn’t lose a job for that specific act, an employer can almost always find ways to circumvent or use other informal punitive measures.) I have no difficulty believing that somewhere, in some situations this unacceptable behavior continues. I would expect it would occur most frequently with business-person-owned therapy companies (rather than therapist-owned) and may increase in likelihood with the larger companies and the more therapists they have working for them plus is more prevalent in the wider geographic areas they serve in the State, Interstate and Nationally.

I am also inclined to believe that MedPac's statement of over-payments to therapy (what kind? All disciplines?) may be true in select instances, but is a gross over-statement to apply to all disciplines everywhere across the nation. I would like to see effort made to pinpoint those individuals, groups, companies responsible for false billing. I believe to arbitrarily penalize all therapies everywhere for the sins of some would be unfair and could further impact patients by lessening the amount of meaningful care they would receive.

Simply cutting reimbursements to all therapies under the guise of dishing out punishment intended to serve as a deterrent to future therapy billing misdeeds reads good in the press but is little more than an easy, quick and dirty way to appearing as though the problem is being solved. Make no mistake, for those organizations with the deep pockets paying out $$$ fines is just a cost of doing business, and then it's eventually back to business as usual. Same is true for all the $$$ fines they impose on these offending SNFs who say they're already hurting for funds.

Where do SNFs get the money to fix their problems if they're paying it out in fines? You can bet it doesn't come out of salaries of those at the top any more than that's what happened with all the financial entities in our national financial system's collapse.

Health care cuts are made where it will be most visible to the public -- directly effecting the patient -- so we'll know the health entity needs money.

This way of thinking permeates everywhere -- schools are short on funds, and what gets cut are items or activities directly effecting our children, what's most visible to the public, so we'll know the schools need money.

Everywhere I look in most other business organizations, the same approach to cost cutting applies.

Perhaps I've enjoyed fostering and participating in a team operational approach in too many situations in which I've been -- both during the good times and the not so good. Would be nice if our Congress could think of themselves as a team working toward what's best for each of us. Hopefully, President Obama can successfully herd those spewing feral cats that fill our Congressional Houses. (Sorry, Saul, guess I got carried away here. Probably should have put this on my blog.)

Thanks for article. It is really informative article and the links will be helpful to many of us, I'm sure. It is good to know that there would be developments in care area.

The aim of the CLASS Act is not to create a new government entitlement program. It will be funded by the premiums of the participants (similar to Medicare Part B). And the $50 per day "average benefit" (not $100 as you stated in your post) will only cover a small portion of the $60,000+ per year most Americans pay right now for in-home care.

People who have savings and want to protect it will still need to purchase long term care insurance to supplement the CLASS Act benefit. And those who are already retired won't be covered under the CLASS Act.

The biggest problem we face is that most Americans still think that Medicare or their medical insurance covers the cost of long term care. The CLASS Act addresses this problem by making a very clear statement: Unless you are poor, you have to pay for your own long term care. You either have to pay for your own long term care by using your savings, the meager $50 per day CLASS Act benefit, long term care insurance, or a combination of all three.

Most of the ten million Americans who own long term care insurance, own it because they've seen friends or family have to spend down their assets before qualifying for Medicaid. The CLASS Act will help alert the rest of the country to the fact that they need to financially plan for their future long term care needs.

Scott A. Olson

Thank you Saul and everyone for this information filled post...having experienced both our Moms in Nursing Homes - Thank God fairly good ones, near our house...I only wish that Euthanasia was an allowable choice when the option for Nursing Home Care is necessary. Since we are low income SS only and virtually broke, just the thought of our children burdened with handling our affairs, such as they are, are intolerable to me. I personally would just want to end it all....Thanks again for this information.

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