Results tagged “nursing homes” from Caring For Our Parents

Money Follows the Person is a cornerstone of the federal government's effort to move Medicaid beneficiaries from nursing homes into the community. But a new study commissioned by Medicaid itself shows how difficult those transitions can be. In the 30 states that have been testing the program over the past three years, only 8,500 people have used MFP to return to their communities.

That's just a tiny fraction of the nearly 1 million people who are eligible, and only about one-quarter of the 35,000 the participating states initially hoped to move. And of the 8,500 who have enrolled in the program, one-third lived in just one state--Texas. By contrast, California has signed up only 186 people since MFP began, and New York only 165, according to the study done by Mathematica Policy Research Inc.  

The concept makes great sense. Move people out of nursing homes, where most don't want to live and where the costs to Medicaid are extremely high, and help them get back to their homes or other community residences. Unfortunately, states have struggled to turn this concept into reality.     

Most troubling for the frail elderly, it turns out that while three out of every four people eligible for the program are age 65 or older, only one-quarter of participants are seniors. Money Follows the Person has been far more successful for younger adults with physical and developmental disabilities than for the frail elderly. 

Mathematica identified several reasons why so few frail elders participate. The biggest may be that they have no home to return to. In the original design, MFP participants had to have been nursing home residents for at least six months. Because many elderly people sold their homes or given up their apartments when they moved into a nursing facility, it was not possible for them to return to their communities. In addition, in many states participants were not allowed to move into assisted living facilities.

Just as troubling, many states don't have enough subsidized rental housing or funding for necessary home and community based services, such as personal aides or transportation. Unfortunately, the growing wave of state budget cuts is likely to make that problem even worse.  

Still, there is some good news. The 2010 health reform law (the Affordable Care Act) allows people to use the program after only 90 days in a nursing facility, instead of six months. That will make another 112,000 people eligible to participate. The health law also promised an additional $1.75 billion in funding, gives states new flexibility in providing community-based services, and continued MFP experiment until 2014.

Long-term care experts and top government officials have had high hopes for Money Follows the Person. They see it as key to helping both the frail elderly and younger people with disabilities receive the supports and services they need at home and not in nursing facilities. But as the Mathematica study suggests, MFP has so far fallen far short of those expectations.   

The news for critical long-term care services and supports provided by the states--either through Medicaid or other funding--keeps getting worse. The toxic combination of a still-slow economy, huge structural budget pressures on all levels of government, and growing demands for aging and disability services is leading to ongoing cuts in both critical benefits to individuals and payments to providers.

The latest evidence comes from two new reports. Following an extensive survey of state officials, AARP reports that 31 states cut their non-Medicaid long-term care services programs in Fiscal Year 2010 and at least 28 expect to slash them in the coming budget year. These essential programs include home-delivered meals, transportation, adult day care, housing, and foster care.

At the same time, a report by the American Health Care Association--which represents mostly for-profit nursing homes-- concludes that skilled nursing facilites are losing increasing amounts of money on their Medicaid long-term care beds. It concludes that nursing facilities are paid $17 per day less for long-term care than it costs them to provide these services. It is easy to criticize these results as self-serving, but the general trend is hard to dispute. And it could result in dramatic cuts in these long-term care resources. While this may not be a short-term problem in communities with an oversupply of nursing homes, this trend may already be curbing services in low-income areas. 

The AARP study reported that only a handful of states cut Medicaid benefits last year, but that was because the federal government, as part of its stimulus effort, increased its share of program payments. In addition, states that took the extra federal money were barred from cutting Medicaid benefits--although they could trim or freeze provider payments. Normally, the federal government pays about 60 percent of the cost of Medicaid while the states pay the rest (the amount varies from state to state).

However, this additional federal Medicaid funding is already winding down, and will disappear completely on July 1. Even more troubling, AARP found many states built the higher federal payments into this year's budgets, a decison that will force even deeper cuts in state programs as those dollars dry up. Just this week, lawmakers in Texas and Ohio proposed major cuts in Medicaid.  

AARP also asked state officials whether they intended to pursue additional federal funding for home and community based services that's been promised under the 2010 health reform law. Despite their serious financial shortfalls and the growing interest among policy analysts and advocates in expanding community services, state officials were remarkably cautious about whether they'd embrace these initiatives.

I'll have more to say about these studies soon, but they are both worth reading.       

In the decade between 1999 and 2008, almost 3,000 nursing homes closed while the number of skilled nursing facility beds shrunk by nearly 100,000, or about 5 percent, according to a new study in the Archives of Internal Medicine. In a nation with more nursing homes than McDonald's, and at a time when long-term care can be provided in other settings, that may not be a bad thing. These days, many frail elderly receive care at home or in assisted living facilities, settings they often prefer to skilled nursing facilities.

But the Archives study by Zhanlian Feng and coauthors also raised some serious concerns. The report concluded that many of these closures occured in minority and low-income communities, the same areas where other care alternatives may be unavailable.

Other studies have shown that relatively few assisted living facilities--which are overwhelmingly private pay--are located in these neighborhoods. In addition, while data are scarce, it appears that many low-income and minority serniors may have limited access to high-quality home care. In other words, for one segment of the population, good care may increasingly be unavailable. 

A study published last year in Health Affairs, David Stevenson and David Grabowski of the Harvard Medical School found that larger assisted living facilities (those with 25 beds or more) were far more likely to be located in higher income counties than in poor jurisdictions. 

As a result, low-income seniors who are unable to live at home--perhaps because there may be no one to care for them or because their home may not be suitable for someone with disabilities--have very few options. Many may move to small board-and-care homes--often a room they rent in a local home where assistance is provided by an unlicensed caregiver. Others may get no care at all.  

From the perspctive of the long-term care industry, the Archives paper reflects another troubling trend. Most long-term care in SNFs is paid by Medicaid, and reimbursements for these patients are often lower than the cost of providing care. By contrast, Medicare, which pays for post-acute and rehabilitation services, is far more generous. Medicare typically pays $500 or more per day for these services while Medicaid may pay just $125 for a long-term care bed (these payments vary by state and Medicare payments are adjusted to reflect patient needs).

The result: Growing industry consolidation and an increasing shift away from long-term care and towards more lucrative post-acute services. These choices make perfect economic sense. And they are often praised by advocates for the elderly, who argue that aging services should be provided in the community. However, for some seniors, including some with dementia or those with no family members to help provide care, nursing homes or assisted living facilities may be their only alternatives. Sadly, for many, those options are increasingly unavailable.           

More than half of long-term care residents in skilled nursing facilities made at least one emergency room visit in 2006. A quarter had two or more. Even more troubling, 38 percent were admitted to the hospital at least once that year, and nearly half were admitted twice or more. In all, one-quarter of all hospitalizations for nursing home residents were potentially preventable.

These very troubling statstics are included in a new study released today by the Kaiser Family Foundation. Even more worrisome were the reasons why: Kaiser does not have good statistics on this, but it hired Lake Research Partners, a survey research firm, to ask physicians, nurses, social workers, and family members about these hospital visits. The responses are hair-raising--not because they show uncaring or greedy docs, or sleazy nursing homes, but because they expose the routine systemic problems that drive hospitalizations.

Among the reasons so many nursing home residents land in the hospital:

The Friday effect: Nursing homes don't have the staff to deal with medical issues, especially on weekends. So they send them to the ER.

Nursing facilities and family members prefer that residents die in the hospital.  

Docs would rather care for patients in the hospital, in part because it is more convenient  or because they get test results quicker.

Financial incentives: Physicians think they get paid more for caring for a patient in the hospital, and nursing homes may get paid more after a long-term care resident has been hospitalized for at least three days and returns to their facility.

Lack of a relationship between nursing homes staff and residents: It turns out that residents are more likely to get sent to the hospital in the first months of their nursing home stay.

Families consent.They don't object, perhaps because they believe their loved one will get better care in the hospital. This is especially true if the resident has no advance directive.

Malpractice fears. Docs were afraid they'll be sued if they don't hospitalize a sick resident. 

Dr, Cheryl Phillips, the immediate past president of the American Geriatrics Society and a member of the panel that discussed the studies at Kaiser today, described a typical situation. Imagine, she says, you are a doctor who has several patients in your waiting room. You see patients at multiple nursing homes and you get a call from a nurse at one. One of your patients--a resident in the facility--"is not doing well," the nurse says.She doesn't know quite what's wrong, but things are not right. You could leave your patients in the waiting room and drive to the nursing home. Or you could say, "Send her to the hospitall." It isn't hard to guess what happens.

Thse potentially needless trips to the hospital cost Medicare a bundle, and, most important, hospital stays can be bad for chronically-ill elders. The new health reform law will drive many patients out of the hospital sooner, and many are likely to be cared for in nursing homes. These important studies raise some important questions about whether those facilities are prepared to take on those sub-acute patients.   

The other day, Josh Wiener, who is one of the nation's experts on long-term care, presented three papers on certified nursing assistants (CNAs) in nursing homes. Josh and his colleagues at the consulting firm RTI International looked at quality of care, immigration, and injuries. And some of what they found may surprise you. The papers are available here (some may require subscriptions)

The first question they asked was what workforce issues determined quality of care in nursing facilities. Lots of research has identified the problems: worker shortages and high turnover, low wages and few benefits, poor training, and a sometimes-hostile relationship between aides and managers. But which of these problems could be linked to low quality?

Surprsingly, Josh and his colleagues did not find much difference in some of these characteristics between high- and low-quality facilities. For instance, wages didn't seem to matter much. Neither did staffing levels. But access to health insurance and paid days off did matter and so did a more collegial organizational culture. This last finding suggests that the culture change movement in nursing homes, which attempts to create an environment where aides are given both more authority and responsibility, may be on to something.  

Their second paper looked at immigration, an important issue since about 20 percent of CNAs are foreign-born. Some results were not surprising. For instance, Wiener found only about half of immigrant CNAs reported English as their primary language. And half reported problems communicating with residents. But it turns out that nearly as many (41 percent) native born workers also reported these problems.

Other results were just as interesting. Foriegn-born workers were older, more likely to be married, and better educated than their U.S-born colleagues. Their average wages were about 10 percent higher and while fewer reported getting bonuses or reimbursement for training, more said they got paid holidays and subsidized child care. And immigrants were more likely to work for the highest quality facilities (based on the government's five-star rating system)

Finally, Josh and his colleagues looked at injuries. Aides have among the highest injury rates of any occupation in the country--the Labor Department reports that almost nine percent were hrt on the job in 2006, the third highest among any occupation in the U.S.

But Josh found many more injuries than were officially reported. He found that nearly 60 percent of nursing home aides reported suffering some injury during the course of the year. While most were back injuries caused by lifting, many others were inflicted by residents (12 percent were a result of bites).

One way to reduce back injuries is through the use of mechanical lifts. Josh found that 88 percent of facilities had these devices available, but only 61 percent of aides said they always used them. The research also found that madatory overtime, inexperience, lack of training, and lack of time to spend with residents all contributed to injury.  

These results are contrversial, espcially some of the conclusions about the relatonship between pay and staffing and quality. But, as with all of Josh's research, it is worth looking at.

Instead of admitting patients, hospitals are increasingly keeping them under "observation status." This decision results in lower Medicare payments to the hospitals and more out-of- pocket costs for patients. But it also means that Medicare is no longer paying for some admissions to nursing homes, and is instead shifting those expenses to residents and their families. 

What's going on? It is complicated. But here is the story: In the past, if a physician felt it was appropriate, a patient was admitted to a hospital for care. However, hospitals, which are under increasing pressure from Medicare to reduce costs, are becoming more cautious about formally admitting people who may not meet government criteria for in-patient care but are too sick to go home. 

These days, this decision is often not made by a doctor, but by a computer program called InterQual.Why InterQual? Because it is the software used by the Medicare inspectors, hospitals rely on it as well. Hospitals do this because if they do admit a patient and Medicare determines later that she should have been kept under observation, the hospital must return part of its Medicare payment to the government.  

The consequences of this situation reach far beyond hospitals, however. Medicare provides limited payments for nursing home care, and in fact is the biggest payer of post-hospitalization skilled nursing care. But it will pay only after a person has been in the hospital for at least three days. And time under observation does not count towards those three days. As a result, nursing homes are not being reimbursed by Medicare for these stays, and patients are being billed for their care, sometimes without advance notice.

A few weeks ago, Medicare held a meeting about all of this and got an earful--from hospitals, physicians, nursing homes, patients, and advocacy groups. Most agreed that time spent in a hospital under observation status should count against the three day rule.

This issue begs for clarification from Medicare. The agency needs to better explain the rules for admission and observation. It should rethink a system that relies on commerical software to make these determinations. And it should require nursing homes and hospitals to explain to patients in plain language who is paying for their stay, and why.    

I spent yesterday with more than a hundred elder care professionals at the Seven Acres senior care campus in Houston. For a while they listened to me, but for much of the time I had the opportunity to listen to them. And what I heard was striking, and an important addition to the HSC Foundation's recently published study based on listening to family caregivers.

We had a wide range of professionals at this program, the 24th annual Lou Lewis Symposium in Gerontology: executives from nursing homes, assisted living facilites, and home health agencies; case managers, social workers, nurses, and maybe even a physician or two. Early in the program I asked how many had also been caregivers for their own family members. At least 80 percent raised their hands.

After I spoke, the participants broke up into a dozen small groups to come up with their own ideas for improving today's long-term care system. Not surprisingly, there were many suggestions. But there was also a striking consensus on a few broad themes.

Participants were tremendously frustrated at how poorly the system works today. Their biggest frustration may have been over the lack of communication between families and professionals and the absence of care coordination within the health system itself.

A word I heard over and over again was education. These professionals felt passionately that family members, aides, doctors, and--yes--politicians need to learn much more about how elder care works, not at a broad policy level but for individuals. The resources out there today, such as Area Agencies on Aging and Aging and Disability Resource Centers, help. But the participants thought they need to do much more. 

We talked about the need for better training for all caregivers, both family members and aides.

The participants felt strongly that community groups, local businesses and, especially, faith-based organizations need to play a greater role in caring for the frail elderly. We talked about the village movement, where seniors join together to form community non-profits to help one another. But many participants felt that churces, synagogues and other religious institutions could do much more to aid their own congregants. This assistance could come from volunteer committees who help arrange rides, friendly visits, and phone calls.

We also discused the importance of financing long-term care. This group, at least, was skeptical about whether young people would enroll in the voluntary CLASS Act. Even though this was Texas, some even felt the country would do better with a social insurance design for long-term care. But, once again, they felt that better education is the key to encouraging people to begin preparing for future long-term care needs.

I learned a lot yesterday, and I hope the participants follow up on some of their teriffic ideas. 

The Stanford University Center on Longevity has just released a trove of information on the health, living arrangements, and demographics of an aging America. The study, "New Realities of an Older America" tells the story of an independent, remarkably healthy population, but one that will present unique challenges as it lives well into its 80s and, eventually, reaches frail old age.

For example, authors Adele Hayutin, Miranda Dietz, and Lillian Mitchell paint of picture of serniors increasingly living alone and in the suburbs--housing patterns that will make caregiving especially difficult.These seniors want to age in place, but providing assistance to a population that may become trapped in their own subdivisions will be a huge challenge. Caregivers battling traffic. Elders no longer able to drive to the doctor or the grocery store, or to even visit with friends. These are not pleasant images.

Yet, the current population of elders has made their opinion clear. In 2005, even among those with functional limitations, 85 percent lived at home or with a relative. Just 10 percent lived in skilled nursing facilities and only five percent lived in assisted living facilities. Even among all those 85 or older, three-quarters lived in traditional housing. 

The great challenge will be finding new ways to deliver care to this population--a challenge that will be compounded by the growing prevalence of dementia among those 85 or older. While this study finds that disability rates among the elderly are falling (a conclusion that is disputed by other research), it also estimates that the population with dementia will more than double, to nearly 11.4 million, by mid-century. 

There is lots more to chew over in this paper. Take a look at it.

Private long-term care insurance got a nice boost from a new study by the federal Department of Health and Human Services. The report, by the consulting firm LifePlans Inc, concluded that nearly 98 percent of those filing claims against their LTC policies received benefits, despite articles by The New York Times and others suggesting that claims denials are widespread. The study also showed the insurance helped many frail elderly receive the care services they needed.  

The researchers observed nearly 1500 long-term care policyholders over a period of 2 1/2 years, all of whom had either made claims or said they were about to. One important caveat: the report studied seniors claims history only from 2003 to 2007.

About two-thirds of those studied were receiving care at home-- 37 percent used paid assistance, while 26 percent did not, even though insurance may have funded outside help. This may have been because these seniors had limited insurance coverage and wanted to preserve benefits until they needed more help.

About 23 percent of this insured population resided in assisted living facilities, and only about 14 percent in nursing homes. The share of those in assisted living was noticeably higher than among the frail elderly as a whole, often estimated at less than 10 percent.One possible reason is that Medicaid, which pays for more than 40 percent of long-term care, rarely pays for assisted living and, when it does, only finances care and not room and board. Thus those using insurance to "private pay" seem more likely to be residing in assisted living facilities.  

While some researchers have concluded that the frail elderly often move from home to assisted living to skilled nursing facilities as their care needs grow, this study found relatively little movement. For the most part, those who started the 2 1/2 year period living at home stayed there, and so did those in assisted living facilities. By contrast, a large percentage of those who were in nursing homes at the beginning of the study either died or moved to a lower level of care.

You hear it all the time: "Medicare will only pay for rehab or personal care as long as you are getting better. If you are no longer improving after, say, a stroke, these benefits will stop."

But according to the Center for Medicare Advocacy, a non-profit patient's rights group, this "improvement standard" may have become ingrained in the care system, but it has no legal basis. "It is" says Vicki Gottlich, a senior attorney with the center, "an urban myth."

The center argues that Medicare must continue to pay for care as long as a patient needs skilled services to maintain their health status. In other words, Medicare should continue to pay for treatment as long as a doctor certifies it will prevent you from getting worse or even help you maintain your functional abilities, not just because it will help you get better.

There is no doubt this improvement requirement is hard-wired among providers such as home care agencies or nursing homes. Even advice columns get it wrong. Here is a typical one. Agencies tell clients all the time that they can no longer provide physical therapy or an aide to help with bathing or dressing because Medicare won't pay any more. If you want that extra care, they say, you'll have to pay for it out of your own pocket. Similarly, nursing homes will stop physical therapy once a physician no longer certifies you are improving. "Medicare won't pay anymore," they will tell you. Once again, they'll say you can still get therapy, but you'll have to pay yourself, and few can afford it. 

Oddly, Gottlich says the Medicare law and even the regulations "are pretty clear." But, somehow, over the years, providers have come to believe that Medicare will cut off patients who are not showing improvement. 

The center is now embarking on a full-blown effort to get Medicare to clarify its rules and make clear to home health agencies and skilled nuring facilites that it will indeed pay for services a patient needs to maintain health status.  

One warning: Even a Medicare clarification won't help if your care is paid by private insurance. Individual policies have their own standards for when they will pay for rehab or home health care, and there is nothing to prevent them from limiting benefits only to those who are improving. So, the usual rules apply: When you buy private insurance, read the fine print.     

When family caregivers are under a lot of stress, the chances increase that their loved ones will have to move to a nursing home. That's the conlusion of an important new study by my Urban Institute colleagues Brenda Spillman and Sharon Long.

That conclusion may seem obvious to caregivers, but Spillman and Long back it up with some hard data. They found that when family members suffer physical strain, lack of sleep, or financial pressures, their elders are far less likely to be able stay at home. Their research squares with what I saw over and over again with the families in my book Caring for Our Parents.

One family, Steve and Judy Dow of Burlington, Vermont were trying to care for Steve's mom, Judy's parents, and raise two high school kids while working full time--Steve as a contractor and Judy as a public school teacher. It finally became too much, especially with Steve's mother who suffered from severe dementia, and the couple made the decision to move her into an assisted living facility.

There are lots of other reasons why chronically ill seniors are no longer able to stay at home, including their own declining health. But Brenda and Sharon conclude that if severe caregiver stress could somehow be eliminated, nursing home admissions could be cut by more than 70,000. 

Finding ways to reduce these crushing levels of stress is not easy, but this research, which expands on the results of some earlier studies, shows why it is important to try.