Thursday, September 24, 2020

Updates on SNFs and COVID

Wednesday, September 16, 2020

Coronavirus Commission Releases Report on SNFs

Hot off the press.  CMS has released the report of the Coronavirus Commission for Safety and Quality in  Nursing Homes.  The purpose and objectives of the Commission:

Convene a commission of experts to address safety and quality in nursing homes in relation to the public health emergency. The main purpose of the independent Coronavirus Commission for Safety and Quality in Nursing Homes (Commission) was to solicit lessons learned from the early days of the pandemic and recommendations for future actions to improve infection prevention and control measures, safety procedures, and the quality of life of residents within nursing homes. 

The 25 member commission met 9 times and made the following:

27 recommendations and accompanying  action steps organized into 10 themes. These themes intersect with the Commission’s four objectives, and reflect responses to:
• Ongoing supply and affordability dilemmas related to testing, screening, and personal
protective equipment (PPE)
• Tension between rigorous infection control measures and quality of life issues that exist
in cohorting and visitation policies
• A call for transparent and accessible communications with residents, their representatives
and loved ones, and the public
• Urgent need to train, support, protect, and respect direct-care providers  Outdated infrastructure of many nursing-home facilities
• Opportunities to create and organize guidance to owners and administrators that is more
actionable and to obtain data from nursing homes that is more meaningful for action and
research
• Insufficient funding for quality nursing home operations, workforce performance, and
resident safety.

The commission did not unanimously adopt the report. The 186 page report is available here. Stay tuned.

September 16, 2020 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Health Care/Long Term Care, Medicare | Permalink | Comments (0)

COVID and SNFs: Deaths Preventable?

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.

September 16, 2020 in Consumer Information, Current Affairs, Federal Cases, Federal Statutes/Regulations, Health Care/Long Term Care, Medicaid, Medicare, Science | Permalink | Comments (0)

Monday, September 14, 2020

Dual Eligibles and COVID Coverage

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.

September 14, 2020 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Health Care/Long Term Care, Medicaid, Medicare, Programs/CLEs, Webinars | Permalink | Comments (0)

Sunday, August 23, 2020

Elder Abuse, SNFs & COVID. An Article in Harper's Magazine

The September issue of Harper's Magazine has a compelling article, Elder Abuse, Nursing Homes, COVID and the Bottom Line.  Just a warning-parts of this article are heart-rending.

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. 

August 23, 2020 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Health Care/Long Term Care, Housing, Medicaid, Medicare | Permalink

Thursday, July 23, 2020

Reduced SNF Training Requirements Because of COVID

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."

Stay tuned.

July 23, 2020 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Health Care/Long Term Care, Medicaid, Medicare | Permalink

Tuesday, July 21, 2020

Has the Time Come to Reinvent the Nursing Home? Or Change the Funding?

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."

Hello Congress??

Stay safe and healthy everyone.

July 21, 2020 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Health Care/Long Term Care, Medicaid, Medicare | Permalink

Thursday, July 2, 2020

CMS Coronavirus SNF Commission

More good news from CMS-the members of the Independent Coronavirus Commission on Safety and Quality in Nursing Homes have been announced.  The 25 experts

The commission members are:

  • Roya Agahi, RN, MS HCM, WCC; Chief Nursing Officer, formerly of NYC Health + Hospitals, soon to be of CareRite, New York
  • Lisa M. Brown, PhD, ABPP; Professor of Psychology, Palo Alto University, California
  • Mark Burket, CEO, Platte Health Center Avera, South Dakota
  • Eric M. Carlson, JD; Directing Attorney, Justice in Aging, California
  • Michelle Dionne-Vahalik, DNP, RN; Associate Commissioner, State Health and Human Services Commission, Texas
  • Debra Fournier, MSB, BSN, ANCC RN-BC, LNHA, CHD, CPHQ; COO, Veterans’ Homes, Maine
  • Terry T. Fulmer, PhD, RN, FAAN; President, The John A. Hartford Foundation, New York
  • Candace S. Goehring, MN, RN; Director, State Department of Social and Health Services, Aging and Long-Term Support Administration, Washington
  • David C. Grabowski, PhD; Professor of Healthcare Policy, Harvard University, Massachusetts
  • Camille Rochelle Jordan, RN, BSN, MSN, APRN, FNP-C, CDP; Senior Vice President of Clinical Operations & Innovations, Signature Healthcare, Kentucky
  • Jessica Kalender-Rich, MD, CMD, AGSF, FAAHPM, FACP; Medical Director, Post-Acute Care, University of Kansas Health System, Kansas
  • Marshall Barry Kapp, JD, MPH; Professor Emeritus of Law, Florida State University, Florida
  • Morgan Jane Katz, MD, MHS; Assistant Professor of Medicine, Johns Hopkins University, Maryland
  • Beverley L. Laubert, MA; State Long-Term Care Ombudsman, State Department of Aging, Ohio
  • Rosie D. Lyles, MD, MHA, MSc, FACA; Director of Clinical Affairs, Medline Industries, Illinois
  • Jeannee Parker Martin, MPH, BSN; President and CEO, LeadingAge California
  • G. Adam Mayle, CHFM, CHC, CHE; Administrative Director of Facilities, Memorial Healthcare System, Florida
  • David A. Nace, MD, MPH, CMD; President, AMDA – The Society for Post-Acute and Long-Term Care Medicine, Pennsylvania
  • Lori Porter, LNHA, CNA; CEO, National Association of Health Care Assistants, Missouri
  • Neil Pruitt, Jr., MBA, MHA, LNHA; Chairman and CEO, PruittHealth, Inc., Georgia
  • Penelope Ann Shaw, PhD; Nursing Home Resident and Advocate, Braintree Manor Healthcare, Massachusetts
  • Lori O. Smetanka, JD; Executive Director, National Consumer Voice for Quality Long-Term Care, Maryland
  • Janet Snipes, LNHA; Executive Director, Holly Heights Nursing Home, Colorado
  • Patricia W. Stone, PhD, MPH, FAAN, RN, CIC; Professor of Health Policy in Nursing, Columbia University, New York
  • Dallas Taylor, BSN, RN; Director of Nursing, Eliza Bryant Village, Ohio

Here's the info about the Commission's mission:

The Commission will conduct a comprehensive assessment of the overall response to the COVID-19 pandemic in nursing homes. Based on its assessment, the Commission will make recommendations on actions and best practices for immediate and future actions.  Three key areas of focus for the Commission include:

  • Ensuring nursing home residents are protected from COVID-19 and improving the responsiveness of care delivery to maximize the quality of life for residents;
  • Strengthening efforts to enable rapid and effective identification and mitigation of COVID-19 transmission (and other infectious disease) in nursing homes; and
  • Enhancing strategies to improve compliance with infection control policies in response to COVID-19.

Crossing my fingers....

July 2, 2020 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Health Care/Long Term Care, Medicare | Permalink | Comments (0)

Wednesday, July 1, 2020

Using Advanced Age as a Factor in Rationing Health Care? Consider the Arizona COVID-19 Crisis Plan

I've recently returned from a week in Arizona with family.  I managed to arrive in Phoenix just in time for a surge in COVID-19 cases, traffic headaches connected to President Trump's campaign visits, a couple of new wildfires, and a few more degrees up the summer temperature gauge.  Probably the most newsworthy part of the trip was the announcement by Arizona authorities that the state was activating a COVID-19 crisis plan that involves triage -- or "rationing" as some  people interpreting the plan are calling it.  One component of the Arizona plan involves "protocols for scarce resource allocation."  An Arizona public statement describing the protocols attempts to reassure the public (emphasis provided with blue color):

If resources are sufficient, all patients who can potentially benefit from therapies will be offered therapies. If resources are insufficient, all patients will be individually assessed. No one will be categorically denied care based on stereotypes, assumptions about any person’s quality of life, or judgement about a person’s “worth” based on the presence or absence of disabilities.


All patients, regardless of resource availability, will be treated with respect, care, and compassion. Triage decisions will be made without regard to basis of race, ethnicity, color, national origin, religion, sex, disability, veteran status, age, genetic information, sexual orientation, gender identity, quality of life, or any other ethically irrelevant criteria.

When resources become inadequate -- implicit in the Governor's recent news conferences -- triage involves a color-coded system of triage "priority scores."  According to the statement, "All patients will be eligible to receive critical care beds and services regardless of their triage score, but available critical care resources will be allocated according to priority score, such that the availability of these services will determine how many patients will receive critical care."

The guidelines indicate health care providers must make an active assessment of the "patient's goals of care and treatment preferences.  It is imperative to know whether aggressive interventions such as hospitalization, ICU admission or mechnical ventilation are consistent with a patient's preferences.... All hospitalized patients should be asked about advance care planning documents, goals of care, and are strongly encouraged to appoint a proxy decision-maker (e.g., medical durable power of attorney... or health care agent) if not previously in place.  Patients in nursing homes, skilled nursing facilities, other long-term care settings, and outpatient care settings should also be asked about their goals of care and advanced care planning documents.... If advance clare planning documents are in place and available the healthcare provider should verify the patient's goals of care and treatment preferences remain the same....."

Will the patient's age, especially an advanced age, be relevant to a Arizona's Covid-19 crisis plan?  On the one hand, the guidelines indicate "age" is  expressly "removed ... as a specific factor for Triage Priority scores or Triage Color Groups."  On the other hand, when determining the Triage Priority Score, points assessed must reflect an evaluation of whether the patient is "expected to live more than 5 years if patient survives the acute illness [zero points added]" or whether death is "expected wtihin 5 years despite successful treatment of acute illness [2 points added]." If "death [is] expected within 1 year regardless of successful treatment of the acute illness," 4 points are added.  The patient's prioritization for critical care resources is best with a low score (1 to 3 total points), while priority is reduced to "intermediate" (4 to 5 points) or "lowest," if they are assessed with more than 6 total points.  Further, "age" is implicitly involved as the prioritization process somehow examines the specific patient's "opportunty to experience life stages (childhood, young adulthood, middle years, and older years)."

These are obviously tough calls in any health care assessment contect, but especially so in the middle of a pandemic.  Public health professionals have experience with these kinds of assessements. I suspect that many families also have engaged in a type of informal assessment when serving as a loved one's health care spokesperson or agent. 

My sister and I were thinking about last summer as I visited this summer.  Last summer, the two of us talked about similar factors when making the call on whether our mother would have hip-surgery at age 93 following a fall-related fracture.  The doctor said that without the surgery our mother was unlikely to walk again because of pain; with the surgery there was a significant chance she would be able to walk without pain.  She ended up sailing through the surgery -- and began taking steps again the same day.  Ironically, probably because of her increasing dementia, she had no fear of falling nor any memory of the surgey and thus was soon fully ambulatory (although she did sometimes substitute a walker for her occasional cane) and remained so for all but the last few days if the next six months of life.  That took her into the summer of 2019 in Arizona.

If the cornonavirus pandemic had occurred in the summer of 2019, and if safe access to hospitals and surgery were the issues, my best guess is Mom would probably have had a "high" score on any health care triage assessment -- in other words, not good news.  We are glad we never confronted decisions about respirators or ventilators.  We do know that our very elderly mother had a much better quality of life with major surgery than she would have had without it. Just one case, of course.  Again, tough calls (and yes, expensive calls for Medicare) with or without a pandemic to complicate the decision process.  

July 1, 2020 in Advance Directives/End-of-Life, Cognitive Impairment, Current Affairs, Ethical Issues, Health Care/Long Term Care, Medicare | Permalink | Comments (2)

Monday, June 29, 2020

CMA Releases Family Caregiver Brief

The Center for Medicare Advocacy (CMA) has released an issue brief on Medicare and Family Caregivers. "This Issue Brief examines the role Medicare currently plays, and could play, in assisting
beneficiaries and their family caregivers." The issue brief covers Medicare law, the need for coverage, issues with receiving Medicare home health care services, problems with access to coverage, the limited number of aides, and more. The Brief also discusses Medicare Advantage and in-home services.

CMA makes theses recommendations 

  1. Ensure the scope of current allowable home health benefits, generally, and home health aides, specifically, are actually provided. Simply put, ensure that current law is followed;
    2. Create a new stand-alone home health aide benefit that would provide coverage without the current skilled care or homebound requirements, using Medicare’s existing infrastructure as the vehicle for the new coverage; and
    3. Identify other opportunities for further exploration within and without the Medicare program, including additional Medicare revisions, demonstrations, and initiatives overseen by the Center for Medicare and Medicaid Innovation (CMMI).

After providing some actual examples, the Brief provides insights into other additions to Medicare that would provide more services to beneficiaries.  The conclusion  provides that "Medicare home health coverage is not being implemented to the full extent of the law. If it were,
countless beneficiaries and families would be better off. Nonetheless, at best, the current Medicare benefit leaves far too many patients and caregivers behind. In order to provide quality home-based
care for individuals, and support for their caregivers, significant changes are needed to the
Medicare program and the broader health insurance system." (citations omitted).

June 29, 2020 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Health Care/Long Term Care, Medicare | Permalink | Comments (0)

Sunday, June 28, 2020

FAQ from CMS on SNF Visits

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
end-of-life situations?

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
visitation?

6. Should residents or visitors who have tested positive for COVID-19 participate in
visits?

7. Are nursing homes required to allow visits from the ombudsman when requested by
a resident?

June 28, 2020 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Health Care/Long Term Care, Medicaid, Medicare | Permalink | Comments (0)

Friday, June 26, 2020

Nursing Homes: Making Room for COVID-19 Residents?

Each day I get a email from Kaiser Health News (KHN) that contains articles collected from the prior day on various health topics.  Since COVID-19 arrived, the number of articles concerning nursing homes has greatly increased. I've refrained from writing about those-mainly because there are so many of them.  But here's a recent article that I felt was too important to pass by.

The New York Times,ran an article with this eye-popping headline:  ‘They Just Dumped Him Like Trash’: Nursing Homes Evict Vulnerable Residents. "Nursing homes across the country are kicking out old and disabled residents and sending them to homeless shelters and rundown motels." The article makes the point that caring for COVID-19 patients is more lucrative than long-term care residents. 

"Many nursing homes are struggling in part because one of their most profitable businesses — post-surgery rehab — has withered as states restricted hospitals from performing nonessential services. ... Treating Covid-19 patients quickly became a popular way to fill that financial void... Last fall, the Centers for Medicare and Medicaid changed the formula for reimbursing nursing homes, making it more profitable to take in sicker patients for a short period of time. COVID-19 patients can bring in at least $600 more a day in Medicare dollars than people with relatively mild health issues, according to nursing home executives and state officials."  Don't forget, however, that profit isn't the motive in every instance-remember back when the hospitals were jammed with COVID-19 patients and asked nursing homes to take some?

With SNFs shut down to outside visitors, Ombudsman visits may also be curtailed. And although the law requires that SNFs "find a safe alternative location for the resident to go, whether that is an assisted living facility, an apartment or, in rare circumstances, a homeless shelter... some homes have figured out a workaround: They pressure residents to leave. Many residents assume they have no choice, and the nursing homes often do not report them to ombudsmen."  Only a handful of facilities have a moratorium on resident evictions during the pandemic.

Hello CMS-are you watching this?

 

June 26, 2020 in Consumer Information, Current Affairs, Federal Cases, Federal Statutes/Regulations, Health Care/Long Term Care, Medicare | Permalink | Comments (0)

Wednesday, June 17, 2020

This "Should" Be Easy: Support DACA Workers in Health Care and Long-Term Care

The Supreme Court 's ruling on the fate of DACA-residents and workers in the U.S. could be issued this week.  Regardless of the outcome on the case itself, everyone who cares about quality of health care, including long-term care, should also care about the United States' need to be honest about how much health care depends on the hard work and commitment to care provided by temporary-status and undocumented-status  workers in health and personal care jobs.  I've seen DACA workers in action in elder care, and I've seen their families ripped apart by harsh immigration rulings.

NPR's Morning Edition had a short and yet deeply important segment today on Health Care Workers Who Are Awaiting Supreme Court DACA Decision.   Do listen to the podcast replay --  it is just 4 minutes -- and think about whether this is a key opportunity for a true, bipartisan solution for DACA-children (families) who so often are working in some of the most challenging (and dangerous) U.S. jobs during the COVID-19 pandemic.  Let's do the right thing.  

June 17, 2020 in Consumer Information, Current Affairs, Ethical Issues, Federal Cases, Federal Statutes/Regulations, Health Care/Long Term Care, International, Medicaid, Medicare | Permalink | Comments (0)

Thursday, June 11, 2020

Nursing Homes and the Right to Visitors During a Pandemic

The seminal 1987 Nursing Home Reform Act requires all nursing facilities to care for their residents in a manner that that "will promote ,maintenance or enhancement of the quality of life of each resident." 12 USCA Section 1396r(b)(1)(A).  The same law, at Section 1396r(e)(3),  addresses "access and visitation rights:" 

A nursing facility must - ... 

(B) permit immediate access to a resident, subject to the resident's right to deny or withdraw consent at any time, by immediate family or other relatives of the resident;
 
(C) permit immediate access to a resident, subject to reasonable restrictions and the resident's right to deny or withdraw consent at any time, by others who are visiting with the consent of the resident;
(D) permit reasonable access to a resident by any entity or individual that provides health, social, legal, or other services to the resident, subject to the resident's right to deny or withdraw consent at any time .... 
During the pandemic lockdown, states prohibited most visitations, citing the risk of infection from the outside community that could endanger not just the visitor's loved one, but potentially all residents.  States are now beginning to lift or at least ease visitation restrictions, and families are beginning to talk more openly about the impact of the isolation on residents who have not contracted the virus.  
 
This week, NPR has begun airing stories about the challenge of balancing the risks of visitors against the benefits of not just family member visits, but family member involvement in care and socialization for residents.  From one story about Luann Thibodeau and her husband Jeff, who has multiple sclerosis:
 

It wasn't candlelight and soft music that made the 40th anniversary of Luann and Jeff Thibodeau so memorable. It was gazing at each other through the window of Jeff's nursing home in Texas and eating carryout from the Olive Garden. Just the two of them. And a nursing assistant.

 

"She fed him, and I ate mine, and that was it," Luann Thibodeau says. "So that was our 40th wedding anniversary."

 

Luann Thibodeau would bring her husband, Jeff, dinner every night, except Tuesdays, when she had Bible study. Since she's been unable to visit, she says that her husband has become increasingly disinterested in food as his multiple sclerosis has worsened.
 

The Thibodeaus have not been in the same room since mid-March. That's when visitors were banned from nursing homes to slow the spread of the coronavirus. But family members say that talking via FaceTime and holding up signs at windows are no substitute for the hands-on care and emotional support their visits provide.

 

Family members often are an integral part of the care residents in nursing homes receive. They make sure meals are being eaten, clothes are being changed. They also offer invaluable emotional support. . . . 

 

Luann Thibodeau has seen that decline in her husband. She used to bring dinner for him every night except Tuesdays when she goes to Bible Study. She says that as his multiple sclerosis has worsened, he's become increasingly disinterested in food. [She explains]. "I bully him into finishing a meal. And I'll say to him, 'Jeff, you know, this is what an adult man eats. So you need to eat this.' "

 

A staff member can't do what she does. Nursing home residents have rights. So if Jeff Thibodeau tells a nursing assistant that he's done eating after three bites, she has to abide by his wishes.

 

Without his wife's push, the results of her absence is striking.

For more, listen to the NPR podcast or read the parallel written narrative in "Banned From Nursing Homes, Families See Shocking Decline In Their Loved Ones." 

The federal Nursing Home Reform Act's Bill of Rights has never been an easily enforceable mandate, and particularly in a global crisis the needs of the many can override the rights of individuals.  But there does need to be a long-range plan on how better to facilitate visitation, recognizing it as an important part of any person's quality of life.  

 

June 11, 2020 in Consumer Information, Current Affairs, Dementia/Alzheimer’s, Elder Abuse/Guardianship/Conservatorship, Ethical Issues, Federal Statutes/Regulations, Health Care/Long Term Care, Housing, Medicaid, Medicare | Permalink | Comments (2)

Friday, June 5, 2020

Medicare Trustees Report 2020

And you know when the SSA Trustees Report is out, the Medicare Trustees Report is soon to follow. The Medicare Trustees report is available here.   There's no quick summary available, but the introduction and the overview provides some helpful info.

First, and importantly, this report doesn't take COVID-19 into account: "The projections and analysis in this report do not reflect the potential effects of the COVID-19 pandemic on the Medicare program. Given the uncertainty associated with these impacts, the Trustees believe that it is not possible to adjust the estimates accurately at this time."

Second, "Projections of Medicare costs are highly uncertain, especially when looking out more than several decades. One reason for uncertainty is that scientific advances will make possible new interventions, procedures, and therapies. Some conditions that are untreatable today may be handled routinely in the future. Spurred by economic incentives, the institutions through which care is delivered will evolve, possibly becoming more efficient. While most health care technological advances to date have tended to increase expenditures, the health care landscape is shifting. No one knows whether future developments will,on balance, increase or decrease costs."

Third, "Notwithstanding recent favorable developments, current-law projections indicate that Medicare still faces a substantial financial shortfall that will need to be addressed with further legislation. Such legislation should be enacted sooner rather than later to minimize the impact on beneficiaries, providers, and taxpayers."

Fourth, "The estimated depletion date for the HI trust fund is 2026, the same as in last year’s report. As in past years, the Trustees have determined that the fund is not adequately financed over the next 10 years. HI income is projected to be lower than last year’s estimates due to lower payroll taxes. HI expenditures are projected to be lower than last year’s estimates because of lower-than-projected 2019 spending, lower projected provider payment updates, and incorporation of time-to death into the demographic factors used in the projection model. Partially offsetting this decrease in expenditures is higher projected spending growth for Medicare Advantage beneficiaries." (citations omitted)

Fifth, for Part B, "The SMI trust fund is expected to be adequately financed over the next 10 years and beyond because income from premiums and general revenue for Parts B and D are reset each year to cover expected costs and ensure a reserve for Part B contingencies."

Finally, note this: "The Trustees are issuing a determination of projected excess general revenue Medicare funding in this report because the difference between Medicare’s total outlays and its dedicated financing sources is projected to exceed 45 percent of outlays within 7 years. Since this
determination was made last year as well, this year’s determination triggers a Medicare funding warning, which (i) requires the President to submit to Congress proposed legislation to respond to the warning within 15 days after the submission of the Fiscal Year 2022 Budget and (ii) requires Congress to consider the legislation on an expedited basis. This is the fourth consecutive year that a determination of excess general revenue Medicare funding has been issued, and the third
consecutive year that a Medicare funding warning has been issued."

June 5, 2020 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Health Care/Long Term Care, Medicare | Permalink

Thursday, June 4, 2020

When Push Comes to Shove: Will Post Covid-19 Mean Better Government Support for In-Home Care?

Pittsburgh-based elder law attorneys Frank Petrich and Julian Gray write regular columns for the Pittsburgh Post-Gazette.  Recently they pulled out their crystal ball to gaze into the future, with the hope that positive change is possible if we pay heed to the lessons we are learning during the response to Covid-19.  In looking at long-term care, they write:

It has been difficult for families, as well as elder law attorneys, over the past few months to connect with clients in long-term care facilities. It’s understandable that restricting access to hospitals, nursing homes and other long-term care facilities saves lives and reduces exposure for all parties.

 

However, given the significant concentration of COVID-19 cases within nursing homes and the inability for families to be with loved ones in person, a radical shift in the delivery of long-term care services is on the horizon.

 

For now, this points toward more people wanting to receive assistance in their homes versus moving into a long-term care facility. Like many states, Pennsylvania has talked about developing programs to keep people in their homes since the Rendell administration.

 

Maybe now that push has come to shove and large stimulus packages are happening weekly, our government can truly live up to its promise of helping people stay in their homes while receiving their long-term care services and support.

 

For more, read Elder Law Guys: Long-term Care after COVID-19, posted May 25, 2020 for the Pittsburgh Post-Gazette.  

 

June 4, 2020 in Consumer Information, Current Affairs, Ethical Issues, Health Care/Long Term Care, Medicaid, Medicare | Permalink | Comments (0)

Friday, May 29, 2020

SNFs and COVID: Going Forward

Looking forward from COVID , here is a story from Wired, Some Nursing Homes Escaped Covid-19—Here's What They Did Right.

The story focuses on steps that can be taken, and the importance of doing so early. But even more so, the story examines the design of nursing homes. Think about it.  As the article points out

Residents, who are older, frail, and often have comorbidities like heart disease or diabetes, are more susceptible to severe Covid-19 infections. Many need help performing basic tasks like eating, dressing, or bathing—care that can’t be delivered through a video appointment, making it more likely they could get an infection from the aides who help them, or pass the virus along to their caretakers. Those aides may work at several different facilities, and unknowingly carry it from one home to another.

The layout of these facilities also furthers contact in various areas. Most residents share bedrooms, bathrooms, activity rooms, and dining rooms—and staffers share a break room. Those group spaces are designed partly to cut costs, and also to encourage socializing. But shared spaces have also helped spread the virus. Senior facilities do have protocols to handle outbreaks like the flu, but the pandemic arrived so quickly and the SARS-CoV-2 virus is so contagious that many facilities were caught unprepared. “There’s an extent to which this virus just had the upper hand,” says Anna Chodos, a geriatrician at the UCSF. Unlike hospitals, most nursing homes aren't ordinarily well stocked with gear like masks and gowns, which aren’t necessary when containing the flu.
The article examines the challenges as restrictions are lifted and the path forward for SNFs in navigating the challenges of the world with COVID-19. We all know this won't be easy.

[P]recautions are only helpful to a point, according to [one expert]. “These outbreaks are continuing and they’re going to continue in nursing homes,” she says. There are still a lot of unanswered questions about how and why the virus has spread so quickly in some homes, but not in others. Based on early data, she says: “It’s about the size of the facility and the amount of spread in your community.”

Nevertheless, [she] warns that while researchers are working furiously to figure out solutions, they still don’t have all the answers: “It's a turbulent time and we're trying to make clinical and operational decisions with incomplete information.”

The article then discusses caring for elders in their homes rather than SNFs and what it would take for that to become a common occurrence.  With potential looming budget cuts from states, the potential for that shift may be a long time coming.

This article does a good job in covering the various issues faced by those who run SNFs as well as those faced by individuals who have family in SNFs.  Read it!

May 29, 2020 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Health Care/Long Term Care, Medicaid, Medicare, State Statutes/Regulations | Permalink

Wednesday, May 27, 2020

Looking at Reasons for Opposition to Federal Immunity for Long-Term Care Facilities Related to Covid-19

A long-time friend and advocate for quality of life as we age contacted me today to discuss what to think about any attempts at federal legislation to immunize long-term care facilities from liability related to Covid-19.  I admitted I hadn't had time to think about this yet!  So, I'm starting my thinking now.   My blogging colleague, Becky Morgan, said earlier this month that even at the state level, immunity is not an "easy" issue.  

Historically, when Congress passed the Nursing Home Reform Act of 1987, it was an important attempt to create minimum national standards for quality of care, in light of a long nightmare of horror stories about inadequate care across the nation.  But, even as it established standards (such as a prohibition on "restraints" without documented medical necessity), it did not establish a "right to sue" by individuals claiming failure to comply with the standards.  That was probably a compromise worked out with the various lobbying groups, but the consequence of that was states were left to decide on their own about whether and to what extent rights exist for a patient to sue for negligent care. So, one could say that it would be "unprecedented" for Congress to actively shield the long-term care industry from quality of care standards, stepping on the toes of the states.   (Plus, at first blush, I don't see how Congress has any authority to craft immunity for facilities that are not subject to Medicare/Medicaid funding and oversight).

On the other hand, depending on how broad or narrow any such legislation was drafted, limited immunity might be appropriate on a narrow ground.  States have been relying on existing federal Medicare/Medicaid law that effectively prevents nursing homes from turning away Covid-19 infected residents as long as they have open beds and the patient qualifies for Medicaid/Medicare.  So those nursing homes have been, in effect, forced to take infected patients, which greatly increases the potential for cross infection, even with "good" infectious disease procedures in place.  But isn't this a "problem" that should be fixed, rather than pasted over?  

Advocacy groups on behalf of older persons, disabled persons, and consumers and workers are making it clear they oppose broad federal immunity.  See the May 11, 2020 letter to Senate Chairman Graham and Ranking Member Feinstein, signed by California Advocates for Nursing Home Reform, The Center for At Risk Elders (CARE), Center for Medicare Advocacy, Community Legal Services in Philadelphia, Justice in Aging, Long-Term Care  Community Coalition, National Association of Local Long Term Care Ombudsmen, National Academy of Elder Law Attorneys, National Association of Social Workers, National Association of State Long Term Care Ombudsman Programs, the National Disability Rights Network, Services Employees International Union, as well as individual law firms.  

See also the letter of May 11, 2020 sent by AARP.

Addendum:  See also  140 Groups Now Oppose Immunity; Nursing Homes Want Immunity and New York Regrets Giving It to Them, posted May 14, 2020 on Public Citizen.

May 27, 2020 in Consumer Information, Current Affairs, Ethical Issues, Federal Statutes/Regulations, Health Care/Long Term Care, Housing, Medicaid, Medicare, State Statutes/Regulations | Permalink | Comments (0)

Sunday, May 24, 2020

Is What CMS Doesn't Say as Important as What CMS Does Say in Recommendations for "Reopening" Nursing Homes?

On May 18, 2020, Centers for Medicare and Medicaid Services (CMS) released a ten-page Memorandum making recommendations to state and local officials for operation of "Medicare/Medicaid certified long term care facilities (hereafter 'nursing homes') to prevent the transmission of COVID-19." 

In some ways, nursing homes may be breathing a sigh of relief as the memo does not use any mandatory language directed at the operators.  In some instances CMS identifies "choices" for the states, such as whether to require all facilities in a state to go through reopening phases at the same time, by region, or on individual bases.  The memo says that facilities "should" have CDC-compliant testing plans, including "capacity" for all residents and staff members to have a single baseline test with retesting until all test negative. What does that mean?  You should be able to test everyone before you ease visiting restrictions, but you can choose not to do so?   On page 4, CMS cross-references ("cross-walk") to reopening phases for all "senior care facilities" under President Trump's Opening Up America Again plan.  The document describes "surveys that will be performed at each phase" of the reopening process, referring to the states' obligations to conduct surveys on prioritized timelines, although with no hard numbers for such oversight suggested.

CMS recommends that each nursing home "should spend a minimum of 14 days in a given phase, with no new nursing home onset of COVID-19 cases, prior to advancing to the next phase," and CMS says states "may choose to have a longer waiting period (e.g., 28 days) before relaxing restrictions for facilities that have had a significant outbreak of COVID-19 cases." 

Significantly, there is nothing in the latest CMS guidelines regarding staff members who work at more than one facility, thus posing a clear potential for cross-contamination.  That seems to me, at least, especially short-sighted.  

May 24, 2020 in Consumer Information, Current Affairs, Ethical Issues, Federal Statutes/Regulations, Health Care/Long Term Care, Medicaid, Medicare, State Statutes/Regulations, Statistics | Permalink | Comments (0)

Friday, May 15, 2020

Is "What Kinds of Tests?" Just As Important As "Whether to Test" in LTC?

Another interesting conversation with a long-term care administrator this week was about "what kind of tests" are important in the Covid-19 context, especially for older adults in a congregate setting.  A first question is whether every member of the staff and the residents should be tested regardless of the presence or absence of any symptoms.  A Washington Post editorial on May 14, 2020 called for "extreme measures"  Of course, the utility of such threshold testing mandates depends upon the availability of the means to test and how quickly the results of the tests will be processed.  It is unlikely that the nation's  number of residential care facilities will have the White House's "instant" testing equipment, right? 

But when Covid-19 is present in any congregate care setting, the administrator explained a second test may be even more important.   The test is for oxygen levels, taken with a monitoring device, sometimes referred to as an oximeter and often attached to a finger of the person in question. She explained to me that with Covid-19, the impairment of the lungs can occur with dramatic quickness and not necessarily with any complaints from the patient about shortness of breath.  The director explained that donations of oxygen concentrators to her community meant they are able to respond to lowered oxygen levels within seconds -- rather than within life threatening minutes or hours -- to provide enhanced oxygen for the resident.  Further, many at-risk people resident not in nursing homes, but in the many other variations of congregate senior care. 

Have you tried to convince a person with a cognitive impairment or an anxiety disorder to wear a mask or agree to keep that oximeter attached to their hand?  Will "extreme measures" include funding to support needed increases in care-staff ratios?  

May 15, 2020 in Advance Directives/End-of-Life, Cognitive Impairment, Current Affairs, Ethical Issues, Health Care/Long Term Care, Housing, Medicaid, Medicare | Permalink | Comments (0)