Wednesday, May 26, 2021
Medicaid Estate Claims: Perpetuating Poverty & Inequality for a Minimal Return was released last month by the California Advocates for Nursing Home Reform (CANHR), Justice in Aging, National Academy of Elder Law Attorneys (NAELA), National Health Law Program (NHeLP), and Western Center on Law & Poverty.
Federal law requires state Medicaid programs to seek repayment of specified Medicaid benefits, even if the state would prefer not to seek such recovery. The Medicaid program’s claim is enforced against the heirs of now deceased persons who relied on Medicaid, forcing the heirs in many cases to sell a family home that otherwise would have been passed down. The burden of estate claims falls disproportionately on economically oppressed families and communities of color, preventing families from building wealth through home ownership, which has been historically denied to communities of color through discriminatory public policy. The burden also falls inequitably on families due to medical unpredictability – for example, because their family member developed Alzheimer’s Disease, needing months or years of nursing home care or equivalent home and community-based services. This unpredictability is exacerbated by inequities in our health care system that particularly harm lower-income and older adults of color. All these factors contribute to estate claim collections being unfair and societally counterproductive. Congress should amend Federal law to eliminate Medicaid estate claims. Alternatively, the law should be amended so that states have the choice of whether to use Medicaid estate claims, as recommended in a recent report to Congress by the Medicaid and CHIP Payment and Access Commission (MACPAC). (Citations omitted)
The full brief is available here.
Tuesday, May 18, 2021
Still emerging is the COVID impact on the SNF model of nursing home care. Take a look at these recent articles to note the trends.
- Medicare requiring nursing homes to report weekly vaccination statistics.
- Nursing Homes Must Educate, Offer Covid-19 Shots, HHS Says (1) and the corresponding interim rule, here.
- How Vaccine Hesitancy Is Driving Breakthrough Infections in Nursing Homes.
- Big Investors Push Nursing Homes to Upgrade Care and Working Conditions.
- Covid Forces Families to Rethink Nursing Home Care.
- Covid awakened Americans to a nursing home crisis. Now comes the hard part.
These are all worth the time to read. Stay tuned-there's no clear cut path yet.
Tuesday, April 20, 2021
Kaiser Health News recently provided an overview of the changes proposed by the Biden Administration to long term care. Biden Seeks $400 Billion to Buttress Long-Term Care. A Look at What’s at Stake provides this overview:
The services in question. Home and community-based services help people who need significant assistance live at home as opposed to nursing homes or group homes.
* * *
The need. At some point, 70% of older adults will require help with dressing, hygiene, moving around, managing finances, taking medications, cooking, housekeeping and other daily needs, usually for two to four years.
* * *
Medicare limitations. Many people assume that Medicare — the nation’s health program for 61 million older adults and people with severe disabilities — will pay for long-term care, including home-based services. But Medicare coverage is extremely limited.
* * *
Medicaid options. Medicaid — the federal-state health program for 72 million children and adults in low-income households — can be an alternative, but financial eligibility standards are strict and only people with meager incomes and assets qualify.
* * *
The article additionally reviews the impact on family caregivers and the workforce, questions about the Administration's proposal and some suggestions for reform. Stay tuned; this isn't going to be a quick or easy journey.
Tuesday, April 13, 2021
WGBH, a PBS station, ran this story a bit ago. New Studies Show Dire State Of Nursing Homes Even Before The Pandemic opens with a focus on staff turnovers and highlights recent studies:
The pandemic has shined a harsh spotlight on nursing homes. Despite less than 1% of the population living in nursing homes and longterm care facilities, they account for about a third of all COVID-19 deaths. Now, two new national studies show that, even before the pandemic, the nursing home industry was in a dire situation. The studies paint a picture of places where it is unappealing to work and risky to stay.
[T]he first national study of staff turnover in nursing homes before the pandemic, published this month in Health Affairs. The study found an extraordinarily high rate of staff turnover, with an average of over 100%.
“That means the average nursing home in the U.S. has their entire nursing home staff change over the course of the calendar year,” [said one study author]. “And we found that some nursing homes had turnover as high as 300%, suggesting the staff is turning over every four months.”
That doesn't necessarily mean that all employees leave during a year. A facility with 10 staff members could have 100% turnover if everyone leaves and is replaced by a new person or if one job is filled 10 different times because the new hires keep leaving.
The article also discusses private equity involvement in the long term care industry.
Tuesday, January 5, 2021
The Wall Street Journal published this piece back in December. Covid Spurs Families to Shun Nursing Homes, a Shift That Appears Long Lasting explains the trend
The pandemic is reshaping the way Americans care for their elderly, prompting family decisions to avoid nursing homes and keep loved ones in their own homes for rehabilitation and other care.
. . .
The drop-off has persisted since spring, including at times when the virus’s spread was subdued. In the summer, when many hospitals were performing near-normal levels of the kinds of procedures that often result in nursing-home stays, referrals to nursing homes remained down.
Occupancy in U.S. nursing homes is down by 15%, or more than 195,000 residents, since the end of 2019, driven both by deaths and by the fall in admissions, a Wall Street Journal analysis of federal data shows.
The decline in nursing-home patients covered by Medicare, which provides payments vital to the homes’ business model, is even steeper. That has left the industry in precarious financial shape. The biggest U.S. nursing-home company said in August it might not have enough money to pay its obligations.
I always ask my students two questions when we cover the topic of nursing homes: 1. do they believe nursing homes are important to our society for the provision of long term care? (they answer yes). 2. How many of them want to reside in a SNF at some point in their lives? (they answer no).
Surveys have long shown many patients don’t want to go to nursing homes. The pandemic has made them even less popular, according to a September survey of adults 40 and older by AARP. Just 7% said they would prefer a nursing home for family members needing long-term care, and 6% said they would choose one for themselves. Nearly three in 10 respondents said the pandemic had made them less likely to choose institutional care.
The article notes that the SNF industry has already begun to pivot, and home health care agencies are expanding their services. Medicare's changes to allow for more services in homes also help as some of the Advantage plans have already moved in that direction. The article provides some interesting anecdotes about some of the services available. It's past time for us to rethink how we provide long term care in this country. Long past time....
A subscription is needed to access the full article.
Thanks to Professor Dick Kaplan for sending me this article.
Monday, January 4, 2021
Happy 2021. Several articles have been published examining the pandemic's longer-term impact on SNFs. I wanted to point out two. First, consider the Washington Post article about how SNFs are structured, Profit and pain: How California’s largest nursing home chain amassed millions as scrutiny mounted.
More than 70 percent of the country’s nursing home providers use operating funds to pay themselves through so-called related parties — companies they or their family members partially or wholly own. In 2018, Brius nursing homes paid related parties $13 million for supplies, $10 million for administrative services and financial consulting, and $16 million for workers’ compensation insurance, state records show. The homes also sent a total of $64 million in rent to dozens of related land companies.
The practice is legal and widely supported by the industry, which argues that related parties help control costs and limit financial liability. Watchdog groups counter that nursing home owners can reap excessive profits from public funds by overpaying their own companies. Related parties generally do not have to disclose profits, leaving regulators with little way to assess the financial gains of owners.
Covid has changed the "business as usual" model, it would seem, as the article notes that "scrutiny has mounted in recent months as the federal government delivered about $54 million to Brius homes in coronavirus relief aid, meant as a lifeline for providers struggling to protect residents amid an unprecedented health crisis that has killed more than 92,000 nursing home residents nationwide." The Washington Post did an in-depth look at this SNF chain. The article details what the reporters discovered regarding finances and taxes. There are California groups that have called for the California legislature to revise the oversight of SNFs. The article indicates that efforts may also be made at a federal level. This detailed article is well worth reading and I plan to assign it to my students, so they can have a better understanding of the structure of SNFs.
The first coronavirus outbreak in the United States occurred in a nursing home near Seattle, in late February. Since then, the country has endlessly revised its hot spot map. Yet the situation in nursing homes and assisted-living facilities has only gotten worse: More than 120,000 workers and residents have died, and residents are now dying at three times the rate they did in July.
Long-term care continues to be understaffed, poorly regulated and vulnerable to predation by for-profit conglomerates and private-equity firms. The nursing aides who provide the bulk of bedside assistance still earn poverty wages, and lockdown policies have forced patients into dangerous solitude.
Fortunately... and maybe hopefully...., with the COVID vaccine and priority given to those who work and reside in SNFs, this won't be a story that continues in the same vein. But the author of this piece aren't telling us we will return to the prior way of things. "When the pandemic is finally history, we’ll need to deal with all of this: the staffing shortages, low pay and lack of accountability — the many ways we have failed residents, family members and staffers. The awful truth is that long-term care was designed to fail years before Covid-19." Why is this? Various stressors combined push the need for change in how long term care is provided. "Over the past few decades, the popularity of “aging in place,” combined with new medical technologies and longer life spans, has changed the nature of care for seniors and people with disabilities. Residents of the nation’s 15,400 C.M.S.-certified nursing homes are much older, sicker and poorer than they used to be." The article mentions the health of the residents, low pay for employees, employees working jobs at different facilities as contributing to the crisis.
The author makes a number of suggestions for changing long-term care in the U.S. and concludes with a call for action from the incoming administration
Most important, we must transform the way we think about long-term care — treating it not as human warehousing or the duty of underpaid women, but as an integral part of our medical system.
All of these changes are possible — and modest, really, given the magnitude of the emergency. By 2050, 19 million people will be 85 or older, and many will require help to live with comfort and a modicum of dignity. What we really need, for all Americans, is single-payer health insurance that covers quality long-term care. But short of that, Mr. Biden and Kamala Harris have a chance to make amends for the deadly failures of the current administration.
Friday, December 4, 2020
The Tampa Bay Times ran a profile of a local long term care facility that experienced a significant COVID outbreak last spring. Death at Freedom Square is an in-depth story about the people who live and work at Freedom Square and the spread of COVID within that facility. The article provides detailed reporting (In fact the TBT refers to this story as a "project"). The article is written in a way that tells the story of the people impacted, which makes it a compelling--- and sad---- read.
Nine months into the pandemic, the virus has killed more than 19,000 Floridians. About 40 percent of the deaths have been among senior care residents. In Pinellas County alone, more than 2 out of 3 coronavirus deaths are connected to nursing homes and assisted living centers.
Freedom Square, a 15-acre retirement complex built around a town square and a gazebo, was the early epicenter in Tampa Bay.
Of course, we all know that this is not the only facility that experienced a COVID outbreak, whether inside Florida or in other states. The human interest angle makes this a compelling read, but it also includes important information about the Florida responses and about the corporate structure for this facility.
The article is as gripping as it is saddening; the reporters use of the human interest angle helps remind us that we aren't talking about numbers---we are talking about people.
December 4, 2020 in Consumer Information, Current Affairs, Dementia/Alzheimer’s, Federal Statutes/Regulations, Health Care/Long Term Care, Medicaid, Medicare, State Statutes/Regulations, Statistics | Permalink | Comments (0)
Thursday, December 3, 2020
Maryland elder law attorney Morris Klein sent me a link to an article recently published in the Washington Post. How government incentives shaped the nursing home business — and left it vulnerable to a pandemic explains
Federal money, through the Medicare and Medicaid systems, has long shaped the nursing home business — and in ways that left it completely vulnerable when the viral pandemic arrived in March.
For years, extra money has gone to pay for extra services, encouraging some nursing home owners to game the system and tempting unscrupulous operators to file false claims for reimbursement. In the recent past, the gold standard was physical and occupational therapy; now it’s respiratory care.
But stringent infection control, which might have kept the coronavirus at bay, has never been a revenue producer, even now during the pandemic. Similarly, there is no monetary incentive to hire more registered nurses, although studies suggest they have been crucial in minimizing covid-19 casualties in nursing homes.
According to the article, the fee for service model is centered on additional care that will bring in additional funds to the provider, "and one consequence is that employees who handle general care of residents — nursing assistants, primarily — rather than the specialty services are a low priority for operators. They are underpaid and in chronically short supply at nursing homes across the country."
The article includes specific resident stories during the time of COVID and compares the financials for SNFs from resident stays covered by Medicare and Medicaid. When COVID rampaged, folks put off surgeries, which affected the bottom line of many SNFs, per the article.
The temptation of the funding system leads some facilities to cross the line. "Working in a system that requires nursing homes to decide what extra services a resident needs, then provide those services, then bill the government, tempts some operators to game the rules and a few to commit outright fraud. Patients can be pushed into higher-paying categories of need. Services can be billed that were never rendered."
The lengthy article gives a really good picture of the funding system, how it works, the oversight and the remedies available to redress wrongdoing. I'm recommending this article to my students.
Friday, November 27, 2020
This is not a happy article for the day after Thanksgiving-but it is a darn important topic. The Conversation published this article, Nearly two-thirds of older Black Americans can’t afford to live alone without help – and it’s even tougher for Latinos explains that
Older Americans who want to live independently face serious economic challenges. Half who live alone don’t have enough income to afford even a bare-bones budget in their home communities, and nearly 1 in 4 couples face the same problem.
Those numbers add up to at least 11 million older adults who are struggling to make ends meet, a new analysis shows.
The numbers are worse for older people of color. Dramatically higher percentages of Black, Latino and Asian older adults live on incomes that don’t meet their cost of living, even with Social Security. That can mean skipping needed health care, not having enough food, living in unhealthy conditions or having to move in with family.
These disparities often reflect lifelong disadvantages that add up as people of color encounter structural racism and discrimination that shape their ability to buy property and save for the future.
The authors used some data available about elders "to measure the true cost of living for older adults. It tracks expenses for housing, health care, transportation, food and other basics, county by county. We paired the index with state-level income data to determine the percentage of people who don’t have enough income to cover their cost of living." The results show that "disadvantages people of color face can extend through their lifetimes and can pass on to future generations." Not only is income security an issue, so is health security "[s]ecuring and protecting health into later life is also more challenging for many people of color."
The results also showed state by state variations. The article concludes with various recommendations:
Today’s older adults who are struggling financially can’t go back, but there are several ways to help them now:
Policies can promote affordable housing and affordable health care, which represent the biggest components of older Americans’ budgets.
Governments can promote mechanisms that allow people to keep working into later life, which allows people to continue generating income and building wealth, and also delays drawing down other income sources such as pensions or Social Security benefits.
Social Security and Medicare — the foundations of a secure retirement for millions of Americans — are essential for these groups. Older people of color rely more heavily than their white counterparts on Social Security and are at heightened risk when these programs are threatened.
Making sure government assistance programs such as SNAP benefits for food and housing subsidies are accessible to the people who need them can also help. Ensuring access includes providing information in multiple languages and hiring outreach workers who understand the population’s needs.
Thanks to Professor Naomi Cahn for sending me the link to the article.
Wednesday, November 25, 2020
Remember those cool tools on Medicare.gov that allowed you to compare nursing homes, doctors, hospitals and more? They are being retired as of the end of the year, and replaced with Medicare's Care Compare. All the info about the various services are there-but located on one page. It's easier since you can go to any of the 8 compare services from one landing page, rather than hunting for each one from the Medicare.gov website. Here's what CMS has to say about this new website:
We’ve combined our 8 original provider compare sites, giving you one place to start finding any type of care you need. New features include updated maps, new filters that help you identify the providers right for you, and a clean, consistent design that makes it easier to compare providers and find the information that’s most important to you.
. . .
What can this tool do for me?
For people with Medicare or their caregivers who want to choose a Medicare provider (like physicians, hospitals, nursing homes, and others), this tool provides a single source search and compare experience, that lets you:
- Find information about providers and facilities based on your individual needs
- Get helpful resources to choose your health care providers
- Make more informed decisions about where you get your health care
The information here should be used with other information you gather about providers and facilities in your area. In addition to reviewing the information here, you should talk to your doctor, social worker, or other health care providers when choosing a provider.
. . .
Although the tool was created for people with Medicare in mind, many of the measures shown here apply to people who may not have Medicare.
Tuesday, November 24, 2020
Last week I tweeted a link to an article from the AP about poor care in SNFs that wasn't due to COVID, Not just COVID: Nursing home neglect deaths surge in shadows. The National Consumer Voice for Quality Long Term Care wrote a response; and their full statement is available here.
Consumer Voice has heard from hundreds of families whose loved ones have been harmed by neglect. Family members report that many residents have experienced significant physical decline, such as losing their ability to move, or sit up or stand up without assistance. Others no longer talk because almost no one has spoken to them since March. There are residents who have not been bathed nor had their teeth brushed for months, and residents who have been confined to their rooms -while missing their eyeglasses and hearing aids. One resident sat in her room with a fractured hip for a month – the result of a fall and lack of medical attention, despite complaints of pain for weeks. Weight loss, bed sores, infections, and cognitive decline are ravaging nursing home residents. Much of this suffering could have been prevented.
The statement called on Congress for changes, including '"[ensuring] adequate numbers of well-trained and well-compensated staff. ... [and] [opposition of] any kind of immunity from civil liability for nursing homes" They also called on CMS to "[i]ncrease oversight of resident care ... [and] [r]equire facilities to permit family to conduct compassionate care visits."
November 24, 2020 in Consumer Information, Current Affairs, Elder Abuse/Guardianship/Conservatorship, Federal Statutes/Regulations, Health Care/Long Term Care, Medicaid, Medicare | Permalink | Comments (0)
Thursday, November 5, 2020
I think we can all recite the COVID #s from the spring vis a vis SNFs. Is the infection control process enough? Is more needed? The Washington Post recently published this story, As pandemic raged and thousands died, government regulators cleared most nursing homes of infection-control violations.
At the outset of a looming pandemic, just weeks after the first known coronavirus outbreak on U.S. soil, the woman responsible for helping to protect 1.3 million residents in America’s nursing homes laid out an urgent strategy to slow the spread of infection.
In the suburbs of Seattle, federal inspectors had found the Life Care Center of Kirkland failed to properly care for ailing patients or alert authorities to a growing number of respiratory infections. At least 146 other nursing homes across the country had confirmed coronavirus cases in late March when Seema Verma, the administrator of the Centers for Medicare and Medicaid Services, vowed to help “keep what happened in Kirkland from happening again.”
And yet, we know what happened. The plan was for complete "a series of newly strengthened inspections to ensure 15,400 Medicare-certified nursing homes were heeding long-standing regulations meant to prevent the spread of communicable diseases. It was another key component of a national effort, launched in early March, to shore up safety protocols for the country’s most fragile residents during an unprecedented health emergency." With that in mind, the Washington Post conducted an investigation and found that "during the first six months of the crisis [the inspectors] cleared nearly 8 in 10 nursing homes of any infection-control violations ...." The article notes that these facilities included those that had COVID outbreaks before the inspections and others that had outbreaks after inspections concluded there were no violations. We can all realize that with COVID, not every transmission can be prevented, but the article notes that "the number of homes flagged for infection-control violations remained about the same as last year."
The article gives examples of violations and fines discusses actions taken by CMS, the lack of consistency, the imposition of small fines, and gaps in communication, postponement of collecting fines and more. This is a lengthy detailed article that is important to read to order to have some understanding of how COVID was able to rampage through SNFS.
The Executive Director of the Long Term Care Coalition observed "“Nursing home residents were never more vulnerable in our lifetime, if ever... I don’t like to overuse the expression, but we literally abandoned them when the need for monitoring was the highest, when the need for quality assurance was the highest. They needed that oversight more than ever.”
And let's remember, the numbers of cases are spiking again. Have we learned any lessons from the spring?
Thursday, October 29, 2020
Earlier this week I posted about the nursing homes seeking additional $ from the federal government because of the number of COVID 19 cases. I thought this article in TIME magazine, COVID-19 Is Still Devastating Nursing Homes. The Trump Administration Isn't Doing Much to Stop It, provided a nice follow up.
Ar least 75,000 Americans in nursing homes and other long-term care facilities have already died from COVID-19—and the devastation is far from over. After a decrease earlier this summer, the death toll is now rising once again, and as the country heads into the fall and then flu season, millions of Americans who require institutional long-term care remain at the greatest risk.
But, so far, the Trump Administration has talked a big talk—and mostly failed to deliver.
There have been issues with the amount and quantity of the PPEs sent to facilities, CMS hasn't ensured that SNFS will have s sufficient supply of COVID test kits and there was nothing specific for SNFs in the latest relief package. The article discusses the lack of a coordinated federal response and what assistance is provided comes with new requirements. For example, as pertains to the new testing requirements:
The Administration’s new testing schedule assigns counties to “green,” “yellow” or “red” categories based on their rate of positive COVID-19 tests, and requires that nursing homes test their staff as often as twice weekly depending on the severity of their location. They must also test all residents during any outbreak or whenever a new COVID-19 case is identified. Facilities can face steep fines if they don’t comply and must keep up with testing to receive Medicare and Medicaid reimbursement, which are the industry’s main source of income.
So why is this problematic? The article offers this insight
Those requirements are fine in theory, industry experts say, but they don’t reflect the reality on the ground. If nursing homes test at the required frequency, the supply of free tests provided by HHS will run out rapidly. Long-term care facilities, which are often financially stretched, will be required to purchase more tests on their own.
There is also concern about the sustainability of the current model of nursing home care and notes the problem with adequate staffing.
The staffing issue is even thornier. Nursing homes typically operate on thin margins, and long-term care workers—mostly poor women of color—are underpaid and overworked in the best of times. During the pandemic, staffers have been falling ill themselves, staying home to care for family members or children who are attending school remotely, and leaving the field for less dangerous jobs. While Congressional Democrats pushed for hazard pay for frontline workers this spring and included it in their relief bill that passed the House in May, no federal plan has been approved. Without specific money dedicated to worker salaries, long-term care facilities say they can’t hire the staff they need.
Thursday, September 24, 2020
Not a day goes by, or so it seems, that thee isn't some new article or announcement or data released about SNFs. Here, in no particular order, is some of the recent ones that I've collected in my inbox.
New York Times: Inside a Nursing Home Devoted to Treating Those With Covid-19
Wednesday, September 16, 2020
The New York Times asked the hard question, whether COVID deaths in SNFs were preventable, in a recently published opinion from the editorial board. How Many of These 68,000 Deaths Could Have Been Avoided?
Around 40 percent of all coronavirus-related deaths in the United States have been among the staff and residents of nursing homes and other long-term care facilities — totaling some 68,000 people.
Those deaths were not inevitable. The novel coronavirus is adept at spreading in congregant living facilities, and older people face an increased risk of contracting and dying from it. But most of the nation’s nursing homes had months of warning about the coming threat: One of the first coronavirus outbreaks in the country was in a nursing home near Seattle, making it clear that such facilities ought to prepare.
The opinion discusses steps SNFs could have taken to reduce the chances of spread, the financial model for SNFs in the US. The opinion also discusses the reduction of oversight and notes
Every effort should be made to ensure that the bulk of the money that the government puts into this industry goes to patient care, not providers’ pockets. An investigation started by the House of Representatives into the nation’s largest for-profit homes is a meaningful step in this direction. The Justice Department should follow suit.
The opinion discusses the way SNFs get supplies for their PPEs, etc. as well as staffing shortages. The editors conclude with 3 recommendations
In the near term, lawmakers should provide for hazard pay for nursing home workers in the next relief package and should require all nursing homes to enact non-punitive sick-leave policies so that workers don’t infect colleagues or residents.
In the longer term, federal officials need to consider revising Medicaid reimbursement rates for long-term care so they support higher than minimum-wage salaries, and shifting reimbursement policies so at least some long-term care can be reimbursed with Medicare dollars.
Lawmakers and nursing home operators also would do well to consider a national initiative, perhaps involving student volunteers and internship programs, to recruit future workers to nursing home care. That work, which can be deeply rewarding, will remain urgently needed long after this crisis passes.
Monday, September 14, 2020
Mark your calendars now for a free webinar on How Health Plans Serving Dual Eligibles Can Center Equity During COVID-19. The webinar is set for October 6, 2020 from 2-3:30 p.m. Here's a description of the webinar.
The COVID-19 pandemic has brought to the forefront longstanding racial disparities in our healthcare system, and data show that older adults – especially older adults of color and those in residential congregate settings – are disproportionately impacted by the virus. Aging advocates play a key role in holding health plans and government agencies accountable to meeting the needs of those most at risk during this time. In this webinar, How Health Plans Serving Dual Eligibles Can Center Equity During COVID-19 , we will provide an overview of dual eligibles and the types of health plans that serve them. We will also present specific programmatic recommendations that advocates can push health plans with dual eligible members in their community to adopt. These recommendations are measures that plans can take to center equity in their ongoing response to COVID-19 and ensure they are meeting the needs of older adults of color during this challenging time.
To register, click here.
Sunday, August 23, 2020
Inevitably ... the virus has found its most ideal conditions in the warehouses storing America’s elderly population. No one knows the current death toll. As of early July, CMS put the number at 33,509, but the count covered only federally regulated nursing homes, not assisted-living communities. The homes, moreover, were not required to report deaths that occurred before May 8, although the agency said it was confident that “the vast majority” did so. One in five nursing homes didn’t bother to report their numbers at all. A New York Times study in late June put the number of deaths in U.S. nursing homes at a staggering 55,000, but even this figure did not necessarily include all of those who became infected in a home but died in a hospital, as was the case for Sharon Mitchell. In some states, the vast majority of COVID-19 deaths were in homes: 64 percent in Massachusetts, 68 percent in Pennsylvania, 77 percent in Minnesota. In New Jersey, one in every ten people housed in nursing homes or assisted-living centers died. This was a helpless population, helpless because so often confined in a state of neglect and squalor. But despite or perhaps because of their conditions, they were worth a lot of money. In effect, they were being harvested for profit.
The article looks at the financial model of long term care facilities in the U.S. It offers a comprehensive history of the development of LTC facilities in the U.S., culminating with a discussion of the ownership of LTC facilities by private equity firms. The article covers the impact of the pandemic and the efforts by the industry to get shield laws to provide them immunity.
As noted by the article, it's not only U.S. facilities that have faced these deaths from the pandemic. It notes one company that made changes early in the pandemic, which resulted in less cases, at least in some facilities. If we are to change the way we provide ltc in this country, in my opinion, this article is important. I'm assigning it to my students.
Thursday, July 23, 2020
Politico reported that the Trump team relaxed training rules for nursing home staff just as pandemic hit.
Shortly after the first coronavirus outbreak ravaged a nursing home in Kirkland, Wash., the Trump administration moved to fulfill a longstanding industry goal — waiving the requirement that nurse’s aides receive 75 hours of training and allowing people who study only eight hours online to become caregivers during the pandemic.
The industry had been fighting for years to reduce training requirements, saying they make it harder to recruit staff. The day after the administration announced the change, the industry rolled out a free online training program for certifying the new role — called a "temporary nurse aide" — that has since been adopted by at least 19 states.
The article reports that advocates for elders and others think this was poorly timed and may have resulted in the spread of COVID in SNFs, especially when considering that CNAs are typically "the main caretakers of residents, some of whom need round-the-clock monitoring; nurse’s aides are also on the front lines in implementing the cleaning and disinfecting practices that prevent the spread of Covid-19." CMS emphasized this is temporary and as soon a COVID is done with us, the CNA 75 hour training requirement will resume.
However, we don't know how well this is working. "[C]ritics are questioning why the waivers were applied so quickly and broadly, and why they’re lasting months into the pandemic when little is known about whether there are, in fact, larger-than-usual staff shortages in nursing homes. They also question the wisdom of waiving the rules for removing residents and making quarterly reports on their condition, which are among more than two dozen regulations temporarily suspended by the administration."
Tuesday, July 21, 2020
Charlie Sabatino, the rock star of elder law and the Director of the ABA Commission on Law & Aging recently wrote an opinion piece for Next Avenue on this important topic. OPINION: It’s Time to Defund Nursing Homes: How the traditional nursing home model can be replaced. Sabatino writes that:
[T]he COVID-19 pandemic ravaging nursing home residents underscores a deep-seated ageism inherent in our institutional model of nursing home care. I believe it is time to defund the institutional model and replace it with a radically different model.
Today’s typical nursing home has never come close to meeting the public’s desire for humane and dignified long-term care. Warehousing large numbers of frail elders in hospital-like buildings with residents in double or triple rooms along with staff turnover as high as 100% unavoidably creates a high risk for resident safety and compromises quality of care.
We've all read the stories about the horrors occurring in the nursing homes as the pandemic rolls across the country (for patients and caregivers too). A number of calls for change have been made, but as Sabatino aptly observed, "
[M]ultiple recommendations for change have gained attention. They include ensuring adequate personal protective equipment in nursing homes; disaster plans that facilitate quarantining; more and better trained staff and heightened monitoring and oversight of care.
But let’s be clear: These measures do little more than rearrange the deck chairs in a failing system.
The COVID-19 pandemic is a 9/11 moment for nursing home care and a test of our ability to reimagine nursing home care that puts the “home” into nursing homes.
Sabatino then turns to specifics regarding change and suggests the key to change is to tie it to Medicare and Medicaid funding.
As the largest payor for nursing home care, Medicare and Medicaid hold the key. Now is the time to change facility requirements to gradually limit participation in the program only to facilities that provide the following:
Small home-like facilities
Single rooms and bathrooms
A flattened, more flexible staff hierarchy with cross-trained staff
A culture focused first on residents’ goals, interests and preferences.
Sabatino concludes "[a]s long as the nursing home industry can rely on the flow of federal money for the current model of care, it has no financial incentive to change, not even after the coronavirus catastrophe. ... Change that flow, and a major cultural change in long-term care will follow."
Stay safe and healthy everyone.
Sunday, June 28, 2020
A few days ago CMS released a four page FAQ re: visiting residents in SNFs. Frequently Asked Questions (FAQs) on Nursing Home Visitation.
The FAQs include
1.What steps should nursing homes take before reopening to visitors?
2. The reopening recommendations maintain that visitation should only be allowed for
“compassionate care situations.” Do compassionate care situations only refer to
3. Can facilities use creative means, such as outside visits, to begin to allow for
visitation within the CMS and CDC guidelines; even before reaching phase three?
4.Can nursing home residents participate in communal activities before reaching
phase 3 of the nursing home reopening plan?
5.What factors should nursing homes consider when making decisions about
6. Should residents or visitors who have tested positive for COVID-19 participate in
7. Are nursing homes required to allow visits from the ombudsman when requested by