Financial tangles can trap poorer residents in costly nursing homes

calmattersnhomestrandcover-300x256As experts drill down to discover why nursing homes and other long-term care facilities are not playing a vital role in the U.S. health system by admitting improving patients from costly care in overwhelmed hospitals, a disconcerting explanation is emerging on who is filling some of the invaluable institutional space.

They might be called system hostages of sorts, poorer residents of nursing homes and other facilities whose condition has gotten better but who are trapped in institutions for distinct reasons, including the grim reality that they owe money they cannot pay, according to Jesse Bedayn of the nonprofit news site CalMatters. As he reported of the situation in the Golden State and nationally:

“While elder care advocates sound the alarm about patient ‘dumping’ by some California nursing homes — kicking out their mentally ill or bereft patients who need stable housing and care — a parallel dilemma is also threatening vulnerable residents: how to get out of a nursing home. The vast majority of people admitted to California skilled nursing facilities stay for less than three months to rehabilitate a broken limb or recover from a stroke or other ailment, according to the California Association of Health Facilities, an industry trade group. After these short-term stays, residents typically return home. But for thousands of poor nursing home residents … a temporary stay can become indefinite. Saddled with hefty Medicare copayments that can reach $5,000 a month — and later stripped of Social Security income, diverted to pay ongoing nursing home costs — they are often unable to hang onto their former housing. They become effectively stranded, with Medi-Cal and Social Security paying for housing and daily living in the facility.”

The situation for these facility residents has only worsened during the coronavirus pandemic, Bedayn found:

“Covid has only intensified the urgency some residents feel to leave their nursing homes, where more than 73,000 have been infected and 9,522 have died as of Jan. 17, according to the California Department of Public Health. The department and Gov. Gavin Newsom have faced criticism of the state’s nursing home oversight as the public health crisis deepened and the death count climbed. ‘Everybody wants out right now,’ said Karen Stuckey, who has been transitioning residents out of nursing homes and into the community for 11 years with the nonprofit Choice in Aging. ’They’re just there because they have no place to go.’”

In health care parlance, the innocuous term transitioning carries considerable freight, whether in California or in the District of Columbia (which experts have rated as having greater challenges with the issue) or in Maryland or Virginia (rated better than California). As CalMatters reported:

“Over 9% of California nursing home residents, an estimated 37,000, have low-level care needs and could potentially live in the community, according to a 2017 estimate by the American Association of Retired Persons. In the organization’s 2020 long-term services scorecard, which analyzed the quality of life, living options and nursing home transitions in every state, California ranked 35th in ‘effective transitions.’ Federal regulations require nursing home staff to ask residents four times a year about their health and welfare — including whether they would like to speak to someone about leaving the facility. The requirement was adopted in 2010 by the Centers for Medicare and Medicaid Services, which regulates nursing homes that receive federal money. At the state level, the California Department of Public Health is tasked with ensuring that homes meet both federal and state rules. If residents answer ‘yes’ to the question of leaving — or ask to leave without any prompting — they are supposed to be referred to a program that can fund and organize their moves back into the community. But thousands of residents’ appeals for help moving out have gone unanswered.”

Nursing home owners and operators — stop if this sounds familiar — cried “poor us” and told CalMatters that residents’ transition requests aren’t “an issue on their radar,” because they have struggled so much in dealing with the pandemic. The state agency with responsibility for helping those who want out of institutions declined to discuss their efforts or lack of same. But CalMatters found that regulators rarely penalized institutions for failing to assist in residents’ transitions.

The process, to be sure, can be challenging and has its costs. One of the giant hurdles can be blamed on the reality that affordable housing has disappeared and become a crisis across the country, CalMatters found, also noting the fiscal benefits of “transitioning” residents to Medi-Cal, the state’s health coverage for the poor:

“California has 18 transition programs charged with finding affordable housing; paying for a resident’s deposit, first month’s rent and furnishings; and organizing in-home care. Nationally, the program has moved nearly 100,000 nursing home residents back into the community since 2008, including some 4,000 in California. Though an average of $8,000 is needed to transition one resident, that person’s Medi-Cal costs drop from $85,000 a year to $18,000 on average, once outside the nursing home, according to the state Department of Health Care Services, which manages the program in California. ‘Nobody gets up in the morning and goes, “Bucket list, I hope I break my hip today and go to a nursing home for the rest of my life,” said Karen Jones, ombudsman in San Luis Obispo County, ‘and yet we have a huge expense to make people have that bucket list item.’ Those seniors who do make it out report a higher quality of life and are estimated to have saved California taxpayers hundreds of millions in Medi-Cal costs, according to a 2017 report to Congress.”

In my practice, I see not only the harms that patients suffer while seeking medical services, but also the damage that can be inflicted on them by neglect and abuse in nursing homes and other long-term care facilities. In our fast-graying nation, we need these facilities’ services and taxpayers have spent billions of dollars in recent days to assist long-term institutions deal with the pandemic, even while reeling at the significant problems the virus has laid bare in nursing home and others facilities.

Have we seen, however, major reforms in long-term care, especially by profit-ravenous owners and operators? They tell us they are losing staff in droves, yet they don’t seem to be taking steps to retain underpaid, overworked, and exhausted workers. Nor have they persuaded them to get vaccinations that would safeguard them and the elderly, debilitated, and ailing residents of homes. We’re learning how coronavirus infections and deaths are increasing again in facilities, which, at points, have accounted for 1 of 3 fatalities in the pandemic. And, of course, the institutions have lagged in getting residents vaccinated.

With all the visible shortfalls in nursing home care, is it surprising that residents who think they can would want to get out of them? This, as CalMatters underscores in its report, is not a casual wish by the vulnerable but a fundamental right, as underscored by federal courts and civil rights officials. We have much work to do to improve nursing home care and to ensure that facilities are safe, healthy, affordable, and welcome places for those who need them.

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