Sunday, January 29, 2012

Are we Abandoning our Nursing Home Residents?

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

Uncertain Futures, McKnight’s Long Term Care News.

Making Sense of Medicaid Block Grant Proposals, Marshall Elder and Estate Planning Blog.

States Seeking Major Changes in Medicaid Programs, Marshall Elder and Estate Planning Blog.

Bringing Long Term Care Home, Pennsylvania Home Care Association


Alastairvagle said...
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justin said...
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