I have always said there is a right place, for the right person at a right time, and while we really would like to avoid a placement in a Nursing Home facility for a family member, there are situations when the degree of frailty prevents us from keeping our loved one at home. For those occasions when the medical and custodial care goes beyond our physical and emotional resources a Nursing Home place could be the only solution to our dilemma. While I am a true believer in Community Based Care as proven by my record as Secretary (1999-2001) I also believe we need to have a viable Nursing Home provider Network. But the plan is not for this to happen.
For the last three years the argument that policy makers have been hearing is that people like to stay in their homes and in their communities, and while this is an important issue, we need to understand that what we want and what we need may or may not be the same. This is particularly true if the funding for community based care is not increasing in proportion to the need. This is particularly true if waiting lists are beginning to escalate and Medicaid funding is being realigned in a way that they will offer fewer services to participants or will certify as eligible only those participants that suffer from extreme frailty. In the meantime, to cope with the gap between need for services and appropriate funding to address those needs, family members are being exhorted to continue their work as caregivers while being told that the Nursing Home Industry is so expensive that they are driving the Medicaid and aging budget, leaving no money for other options.
It is known that Nursing Homes have powerful lobbyists who year after year donate to political campaigns. The Nursing Home Industry has political muscle, so to avoid a confrontation with donors and financial supporters the administration’s plan calls for a diversion strategy that indirectly will force some Nursing Homes out of business without the administration being to blame. First, if the reimbursement rate to Nursing Homes is kept in control with no significant increases; and second, if new regulations and demands for compliance increase, some Nursing Homes will not be able to financially survive, particularly if their occupancy rate continues to decrease.
Third, to control the federal deficit and to bring balance to states’ budgets, the eligibility criteria to qualify for Nursing Home placement has been “unofficially” changed from having 3 impediments in the activities of daily living to have 4 impediments, and in some cases, 5 impediments in the activities of daily living. This translates into a less number of individuals qualifying for Nursing Home placement. This strategy is politically astute because it does not impose a Moratorium in the number of Nursing Home beds nor does it argue the merits of the placement, but simply rations access to those beds by silently modifying the frailty level that makes a future resident eligible to be in that facility. How can the Nursing Home Industry argued with something they are not able to see?
To improve the economy the administration is dependent on controlling the Medicaid program, privatizing Social Security and moving as many elders as they can to HMO Medicare programs. The Nursing Homes are therefore in a collision course with the administration’s plan, but if confronted, the administration already has a fallback position; a position that uses the Family Caregivers mandate to divert more money to community based care but are we really diverting more money? The sad part is that Family Caregivers are not aware the diversion of dollars is not coming to community based services, but to other non elder or disabled adult’s budget categories. Without their knowledge or even consent Family Caregivers are providing a buffer of protection from any potential confrontation between our elected officials and the weakening of the Nursing Home industry.
Under the plan the Nursing Home Industry has a very limited future. First, more and more Medicare HMO entities will accept payment capitation for both the acute and the long term care responsibilities. The majority of the Medicare HMOs do not own a Nursing Home nor are Nursing Homes part of the Integrative model of care therefore; more frail individuals will not be given the option of a placement in those facilities regardless of the degree of frailty they experience and the ability of the family to care for them at home.
What would happen if Nursing Homes begin to close? What are we going to do with those frail people? What about if the closest Nursing Home to me is 350 miles away? Can I visit my family member regularly if that person is 350 miles from my home?
When it comes to addressing the needs of individuals throughout the continuum of care, all the pieces and options should remain viable, including the Nursing Home. And if the argument is that government needs to realign or rebalance the community based funding, then let us make sure the savings generated from keeping a person in the community are reinvested in community programs and not in unrelated budget categories to the detriment of elders, disabled adults and family caregivers. One of the lessons learned from the Florida Nursing Home Diversion Program in Palm Beach and Orlando is the fact that some family members disenrolled from the program or refused to participate in the program because they offer very limited choices of Nursing Homes, and some of the Nursing Homes included in the program were miles away or were ranked in the lowest quality categories.
Government should disclose to the Caregivers the plan and Caregivers should be aware that even though we don’t like to place a family member in a Nursing Home, Nursing Homes could be the right place, for the right person at the right time.
Dr. Gema Hernández
