No one wants to end up in a nursing home. But, most of us recognize that someday we may
need the level of medical and nursing care and rehabilitation services that can
be best provided in a skilled nursing facility. Placement into this high level of care may be
temporary or permanent. Either way, it will most likely unpleasant and expensive
but necessary.
For many years federal and state governments have been emphasizing
the benefits of keeping people out of nursing homes and at home or in more
home-like settings liked assisted living facilities. This movement was spurred on by the 1999 U.S.
Supreme Court decision in Olmstead v. L.C.,
527 U.S. 581 (1999).
In Olmstead, the
Court held that the unnecessary placement of individuals in nursing homes constitutes
discrimination under the Americans with Disabilities Act (ADA). This means that
states are required to serve individuals with disabilities in community settings
rather than in institutions if it is appropriate and reasonable to do so.
In addition to this legal requirement, states have a strong financial
incentive to keep people at home. Home care is generally accepted as costing much
less than nursing facility care. Supposedly,
Medicaid dollars can support nearly three older people and adults with physical
disabilities in home and community-based settings for every person in a nursing
facility. States that invest in keeping
people at home may thus be able to reduce their rate of Medicaid spending on
long-term care.
Politics also dictates that states favor home care. Voting
consumers prefer the idea of staying home. Who doesn’t want to remain
independent and live at home as long as possible? Politicians universally express
support for this strong voter sentiment.
The confluence of these powerful factors is pushing our long
term care delivery system towards care provided at home rather than in a
nursing home. Home health agency franchises are growing rapidly, while skilled nursing
homes are closing or transitioning to a lower assisted living level. This
sounds like a good trend, doesn’t it? The
answer is - maybe not for everyone.
The truth is, much as we all want to stay out of a nursing
home, some of us may someday require a level of nursing care that cannot be
provided at home. The placement of a parent,
or spouse, or yourself in a skilled nursing facility might be the best choice –
and the only reasonable choice. We are not going to be able to do away completely
with the need for nursing home care.
Because of the growth in home and community based alternatives,
the people residing in nursing homes are older and sicker than ever. They usually need to be where they are. For
many of them, there are no other appropriate options.
In most of our nation’s nursing homes a majority of the
residents have exhausted their ability to pay in full and are on Medicaid. Now,
Medicaid reimbursement rates to nursing facilities are being cut back. This is perhaps consistent with our attitude
of general disfavor for this care setting. But, Medicaid residents were already
not profitable for many facilities, and the reimbursement reductions will make
the situation even worse. Medicare
payments are being cut as well. So it is
no wonder that few new skilled nursing facilities are being built. And existing
nursing homes are cutting staff and services and other costs wherever possible.
I fear that an undesirable result of the growing focus on home care may
be a continuation of the trend toward ever more inadequate care being delivered
to ever sicker residents in outdated nursing homes by overworked and underpaid
staff. This downward spiral will likely accelerate
if proposals to “block
grant” Medicaid in order to “free” states from federal regulations (e.g.
regarding nursing home staffing levels) are enacted by Congress.
Another undesirable result may be that many of
our sickest and most disabled, those who really need the care provided in a
skilled nursing home, may be forced to receive inadequate services in an
unregulated and inappropriate home environment.
Are we moving toward abandoning the sickest of our elderly
under the guise of providing them with the “option” to stay home? Don’t we need to provide care to those who
can no longer remain home? Don’t we need
to build some new nursing facilities and pay their operators enough to have
enough trained staff to provide adequate care?
In Olmstead the
Supreme Court held that states should serve disabled individuals in community
settings if it is appropriate and reasonable to do so. But we must not
let the trend towards often desirable and cost effective home and community
based care blind us to the needs of those for whom the only appropriate and
reasonable care setting is a skilled nursing facility.
Nursing home residents are not the detritus of our society. They
are our parents and grandparents, brothers and sisters and, perhaps someday,
ourselves. There are currently between 1.5 million to 1.8 million nursing home
residents in the United States. They are among our society’s most dependent and
defenseless individuals. How can a moral society abandon them?
Further reading
The
Coming Nursing Home Shortage, Steve Yoder, The Fiscal Times.
New 50 State Avalere Analysis: U.S. Nursing Home Sector Projected to Face $65 Billion in Cumulative Medicare Funding Reductions Over Next 10 Years; Nearly $4 Billion 2013-2014
New 50 State Avalere Analysis: U.S. Nursing Home Sector Projected to Face $65 Billion in Cumulative Medicare Funding Reductions Over Next 10 Years; Nearly $4 Billion 2013-2014
Nursing homes, patients' families fear further funding cuts Jill King Greenwood, Pittsburgh Tribune Review
Home
Health Care Franchises on the Rise as Boomers Age, Costs Rise, Fox Business.
Needy Patients Facing Double Setback, Steve Twedt, Pittsburgh Post-Gazette
Needy Patients Facing Double Setback, Steve Twedt, Pittsburgh Post-Gazette
Obama
Administration Approves new California Medicaid cuts while Supreme Court
Decision on prior cuts is pending, Marshall Elder and Estate Planning Blog.
Low
Staffing and Poor Quality of Care at Nation’s For-Profit Nursing Homes,
University of California San Francisco.
TennCare
wants home-based care for more seniors: Change could save Tennessee millions, The Tennessean.
Uncertain Futures, McKnight’s
Long Term Care News.
Making
Sense of Medicaid Block Grant Proposals, Marshall Elder and Estate Planning
Blog.
Medicaid
Block Grant Would Shift Financial Risks and Costs to States, Center for
Budget and Policy Priorities.
States
Seeking Major Changes in Medicaid Programs, Marshall Elder and Estate
Planning Blog.
Bringing Long Term Care Home, Pennsylvania Home Care Association
Bringing Long Term Care Home, Pennsylvania Home Care Association