Wednesday, October 1, 2008

Hey Congress - reign in Nursing Homes before adopting "universal health care"

There is yet another issue that we as a country must ethically resolve before we allow a wholesale change in our current health care system. The issue is the systemic problems in the nursing home system. These problems are longstanding, largely ignored and a national disgrace.

The Health Highlights from 29 September 2008 ( provide that:

More than 90 percent of U.S. nursing homes were cited last year for violating at least one federal health and safety standard, The New York Times reported Monday.

About 17 percent of nursing homes had violations that led to "actual harm or immediate jeopardy" to residents, according to the report by the inspector general to the U.S. Department of Health and Human Services.

Citations were issued for violations including infected bedsores, drug errors, resident malnutrition, and patient abuse or neglect, the newspaper reported.

About 37,150 complaints were sent to inspectors last year about nursing home conditions, of which 39 percent were validated, the report said. Some 20 percent of the verified complaints involved patient abuse or neglect.

Two-thirds of nursing homes are owned by companies that make a profit, 27 percent are owned by nonprofit corporations, and 6 percent are owned by government entities.

Some 94 percent of for-profit homes were cited last year, as were 88 percent of nonprofit homes, and 91 percent of government-owned homes, according to the report by HHS Inspector General Daniel R. Levinson.

Levinson said Medicaid was sometimes charged for services that "were not provided, or were so wholly deficient that they amounted to no care at all."

More than 1.5 million people live in 15,000 U.S. nursing homes. Violation rates ranged from 76 percent in Rhode Island to 100 percent in Alaska, Idaho, Wyoming and the District of Columbia, the newspaper reported.

In related news, state Medicaid organizations will spend an estimated $1.6 trillion on long-term care over the next two decades, a study by America's Health Insurance Plans (AHIP) found.

When federal matching funds are added to the tab, total government expenditures for long-term care will burgeon to $3.7 trillion, the analysis predicted.

It would mean that Medicaid spending for long-term care would rise faster than overall health care spending, Medicare, or the Gross Domestic Product, according to an AHIP media release.

While 15 states are expected to spend $1 billion or more this year on long-term care services, that number is expected to rise to 25 states by 2027, the release said.

Most nursing home patients are elderly. Of course, some nursing home patients are under age 65. But, regardless of age, all nursing home patients have a few conditions in common. The patients are vulnerable and weak. Most cannot advocate or even speak for themselves.

Patients enter nursing homes for different reasons.

1. Some patients are in the nursing home for a short period as they are recuperating from an injury or illness.

Lack of support resources and a safe living arrangement necessitate these patients be cared for until their strength is regained. There is an expectation that these patients will leave the nursing home after a period of time. The goal is for the patient to return to home under either self care or home health care.

2. Some patients are placed in nursing homes for an indefinite period.

These patients cannot be safely cared for in a home environment. Physicians or other medical care professionals have determined that these patients are unlikely to ever regain the strength and good health necessary to resume a safe life in a home setting under self care (or even home health care).

Adopting a system of universal health care (while systemic problems in the nursing home system continue to exist) would be disastrous.

Currently, there is absolutely no accountability for the mistreatment of nursing home residents. The general public cringes at the news stories, thanks God it did not involve one of their family members and then move on. We have become a society that is unimpressed by the plight and needs of the elderly. Our "Obama nation" mentality has morphed into a sense of self entitlement. The dangerous mentality simply does not offer room for those vulnerable and elderly among us.

"Universal health care" is intended to increase access to medical care. By any reasonable standard, too many nursing home patients are ignored and mistreated. It is outrageous that in 2008 nursing home patients are still dying from infected bed sores. It is outrageous that in 2008 nursing home patients are left for hours with infected catheters.

Perhaps the most shocking aspect of nursing home neglect is that nurses and physicians accept the failures as the status quo.

Within the last year, my father has been hospitalized and then discharged to home. There was always the option of discharging my dad to a skilled nursing home so that he could regain strength before returning home.

As I was faced with the decision about whether to place dad in a SNH for a rehab period, I asked the physicians and nurses:

1. precisely what care dad would receive at the SNH facility and

2. how I could be certain that my dad would actually receive the physical therapy and encouragement to eat meals.

Without hesitation, the physicians and nurses told me that there was no guarantee that dad would get the scheduled physical therapy or any other scheduled service. I was told that if the PT went into my dad's room and dad was not cooperative (i.e. he was cranky and not motivated to exercise) then the PT would move on to the next patient.

Okay. Nearly all older, sick patients are cranky. (Sorry, dad.)

I was told by all medical professionals that my physical presence and advocacy was required in order to assure my dad received adequate care at the SNH. I would need to be at the SNH as many hours as possible (read: 24/7) for the one or two weeks that he would be in the facility.

In the words of dad's physician, "the squeaky wheel gets oiled." My decision was to bring dad to his home and I cared for him there. In so doing, I avoided the possibility of UTI caused by constant cathing, the possibility that dad would be cranky and never get physical therapy and the inevitability of just plain loneliness.

And that gets me right back to my mantra - if you have a loved one that is unable to advocate for themselves then you cannot wait for someone else to advocate - you must advocate yourself.

That resolves the issue for a daughter such as me that will put my entire life on hold to take care of dad. But, frankly and humbly, most families do not have the emotional fortitude to give the level of care that I have given. I am the equivalent of a soccer mom that goes to every game. Dad's "games" just happen to be at doctors' offices and hospitals.

Elderly, vulnerable and nursing home (or home care) patients probably do not recover as well as those with the equivalent of a "soccer mom" daughter. But those patients without the benefit of a pushy daughter should certainly not be ignored or abused.

There must be a basic level of protection for nursing home patients.

I am not a fan of increased regulation. I am not really certain how we can protect nursing home patients.

I do believe that in many ways, demanding "accountability" is an empty requirement in the nursing home situation. It has been my experience that nursing homes (and even to a certain extent medical hospitals) are increasingly hiring poorly qualified sub-paraprofessionals with little or no education or training.

I have asked nursing aids to leave my father's hospital room when their presence is unproductive or counter-productive to dad's health. The most horrifying (of the many) experience was when a nursing aid entered my dad's hospital room during a period of time when he was recovering from a severe UTI and subdural hematoma. Dad was less confused but still had some difficulty remembering all of the people in the hospital. The nursing aid asked dad if he remembered her. Dad said "yes." And the nursing aid challenged dad with "who am I"? After she ordered a pizza to his room, I asked her supervisor to make sure she never comes in contact with my dad again. Period.

And dad's bad experiences with uncaring and hurtful medical staff occurred in medical hospitals. I shutter to think how poorly he would be treated in a SNH (where the sub para-professionals significantly out number the medical professionals).

In the event we succumb to any form of universal health care, the nursing homes are going to become a real dumping ground. Patients who should only be there for a week or two are going to assume permanent residency.

It will be cheaper, more economic and, therefore, more advantageous to the universal health care system to take the "expensive patients" out of the system and put them in a facility where they can linger and die. It will be cost effective. And if there is no family around to be a squeaky wheel, who will ever know?

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