HEALTH CARE/Joan Retsinas

Enroute to the Nursing Home: A Detour

A fall. Confusion. Missed Medication. Illness. Whatever the trigger, in the not-too-distant past, an elderly patient would rush to a nursing home, sometimes from a hospital, as a distraught planner sought a speedy discharge, sometimes from home, as a distraught family sought relief. Everybody would lament, “It’s too bad, but we had no choice,” as Mom, Dad, or the eccentric recluse in apartment 12 settled into a single bed in a double room in a place that looked like a cross between a motel and a hospital.

For fifty years, the government has greased that route. Medicare pays only for skilled nursing care (including tube feeding and wound care), generally for no more than 3 months; but most nursing home patients don’t require that oversight. Medicaid, however, sets no such stringent criteria. People who cannot safely live at home can enter one of the nation’s many nursing homes. New residents may enter as “paying patients;” but once they have “spent down” to a set level of impoverishment, Medicaid (the state and the federal government sharing the tab) will pay. In time, most nursing home residents end up “on Medicaid;” and overall Medicaid picks up most of the tab – at roughly $6300 a month, an expensive tab. Understandably, the nursing home industry is robust.

Admittedly, the government has directed a spigot of money at “home and community-based services,” to pay for home health care, senior centers, meals-on-wheels, respite care, homemakers, home modifications; but that spigot has been disjointed, with varying guidelines, and timetables that do not mesh with a patient’s immediate need for care. And that spigot has not been generous. (Witness the long waiting lists for Meals on Wheels, their battles to wrest a smidgen of governmental budgets). States have also had the bureaucratically complicated option of diverting Medicaid monies to home care, including assisted living (“waivers”).

But the route-to-institutionalization is no longer so well-greased. The baby boomers that visited their parents, or grandparents, in nursing homes are speaking up: they are investigating assisted living, continuing care retirement communities, planning for aging-in-place. They are not only healthier than their forbears, but they don’t want to go that nursing home route, unless they must. Not surprisingly, the home-care industry today is more robust, with more resources a paying client can draw on. And states themselves have balked at the mega-nursing home bills. Many states have upped their requirements for nursing home entrance; still others have aggressively sought the “waivers” to detour people from nursing homes.

The Affordable Care Act gives states more leeway to redirect long-term care monies. Briefly, “Balancing Incentives Payments” promises to do just that: reallocate monies. This program throws a $3 billion carrot at states, giving them more leeway to spend Medicaid dollars to anchor people at home. States that participate will get a higher federal contribution until September 2015 than usual. The caveat: states must truly reduce the red-tape barriers that steer people to institutions. There must be a “no wrong door” policy: clients must have case managers with no ties to the nursing home industry; and all social workers must be trained to steer clients to the menu of services they need to stay home. In the past, distraught families often received a list of phone numbers of agencies to call. States that are spending less than 50% of their long-term care money on home and community-based services can apply. To date, 17 states have been approved to participate.

Keeping people at home who are frail, often confused, almost always needing a pharmacopoea of medications, is difficult. When they live alone, or with aged caregivers, institutionalization may cost less than a comprehensive set of home-based services. Indeed, the isolation of living alone may contribute to depression for some clients.

Nevertheless, as our population ages, we need more routes – not just the well-greased one to institutions. The Affordable Care Act has given states one more tool to keep patients home.

Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email retsinas@verizon.net.

From The Progressive Populist, March 15, 2014