Nursing Homes Unprepared for Natural Disasters

Although natural disasters are uncommon, like fires, blackouts, domestic and workplace violence, terrorism, and disease outbreaks, they are a foreseeable risk.  One hopes that particularly institutions responsible for caring for vulnerable groups like the sick, impaired,end elderly, would foresee these event and have contingency plans in place.  Not so, says Sen. Ron Wyden (D-OR), ranking member of the Senate Committee on Finance, who concluded nursing homes were woefully unprepared for natural disasters.  He made public his concern, and called for greater oversight in a recent report.

Wyden said hurricanes Harvey and Irma caused problems that were not accidents, including the well-reported deaths of 12 seniors at one facility. He called them “preventable tragedies that resulted from inadequate regulation and oversight, ineffective planning and communications protocols, and questionable decision-making by facility administrators.”

“My investigation found that in too many cases, nursing homes were ill-equipped to keep their residents comfortable and safe in the face of natural disasters, in some cases with fatal consequences,” he said in a statement. “This is a failure of responsible governing from top to bottom.”

The Democratic senator said that federal rules need to be “more robust and clear,” along with “dramatically” improving planning and communication between local and state officials, and nursing home leaders.  “Until changes are made, seniors in America’s nursing homes will continue to be at risk when disaster strikes,” he said.

In a lengthy statement, LeadingAge President and CEO Katie Smith Sloan acknowledged that the nursing home field shares senators’ concerns. She noted that the deaths of more than a dozen residents at a Hollywood Hills, FL, facility in 2017 “should never have happened."  "We make no apology for poor quality nursing home care. Errors should be addressed. Continual improvement is a must,” she said.

She noted that substantial changes were put into place in late 2017, as part of new Centers for Medicare & Medicaid Services (CMS) regulations, in response to concerns arising from hurricanes. She suggested that elected officials should wait for those new rules to take hold, along with speaking to nursing home leaders before enacting any further regulations.  “Room must be allowed for human judgment in emergency and disaster situations,” Smith Sloan said.

“Nobody entrusted with making the decision to evacuate or shelter in place takes it lightly. As we’ve seen, lives depend on leaders making the right decision — and learning from what happened before,” she said, later adding, “Let’s give the new system a chance to work.”

According to an article in Skilled Nursing News, in a separate statement, American Health Care Association (AHCA) President and CEO Mark Parkinson noted that the “vast majority” of long-term care facilities have successfully implemented their emergency response plans. The industry’s focus is learning from best-in-class operators.  “Unfortunately, this report largely focuses on isolated incidents with tragic outcomes where existing regulations were ignored,” he said.

Parkinson added that nursing homes and assisted living facilities “must be a priority” for power restoration and supplies in emergency situations. And systems must be put in place so that providers can work more closely with authorities when deciding whether to evacuate or shelter in place.

The report, entitled "Sheltering in Danger,"produced by minority staff of the Finance Committee, comes in response to hurricane-related deaths that followed Irma, along with incidents at Texas long-term care facilities after Harvey. It asserts that rules put in place by CMS are “wholly inadequate” when it comes to giving nursing homes direction in an emergency.

The report offers 18 recommendations that officials can take to help providers better prepare for such natural disasters.  The recommendations range from revising the safe and comfortable temperature standard, to highlighting the vulnerability of seniors in heat emergencies. A two-page summary of the report and its recommendations can be found here.

Eldercare Locator Service Gets Facelift

The Administration for Community Living ("ACL) announced the launch of its newly redesigned Eldercare Locator website. Located online at eldercare.acl.gov, the updated website makes it easier for older adults and their caregivers to find essential aging resources. Launched in 1991, the Eldercare Locator is a national information and referral resource providing support to consumers across the spectrum of issues affecting older Americans.

According to the announcement, new features include:

• A mobile-optimized design to easily access the Eldercare Locator on a computer, phone, or tablet;
• A geographical search bar allows visitors to search for local aging resources from any page on the site;
• Caregiver Corner with answers to the most frequently asked questions the Eldercare Locator Call Center receives from caregivers;
• A new “Learn More About” section that provides information on popular topics like transportation, support services, elder rights, housing, health, and insurance and benefits;
• A centralized location that enables older adults and caregivers access Eldercare Locator brochures on topics important to their health and well-being.

For more than 25 years, the Eldercare Locator Call Center and website have served as critical tools to assist older adults and those who support them in navigating the range of services and options available to seniors. In 2017, more than 470,000 visitors accessed the Eldercare Locator’s website. The Call Center receives more than 350,000 calls every year and answered its 4 millionth call earlier this year.

ACL encourages all consumers to explore the new website. ACL will continue to expand and update resources to provide valuable information for older adults and their caregivers to serve its vital and ever growing aging population.

Study Confirms that Quality of Care Higher in Non-Profit Nursing Homes

Older adults who reside in for-profit nursing homes are nearly twice as likely to have health problems linked to poor care than those in nonprofit nursing homes and those who live in private homes.  This is the conclusion of newly released research published in the Journal of Gerontology. 

According to a press release from the University of Illinois at Chicago, the researchers, led by Lee Friedman, associate professor of environmental and occupational health sciences in the University of Illinois at Chicago School of Public Health, also found that community-dwelling adults 60 years old and older who need assistance with tasks related to daily living but do not live in a nursing home had the fewest number of clinical signs of neglect compared with those living in any type of nursing facility.

"We saw more -- and more serious -- diagnoses among residents of for-profit facilities that were consistent with severe clinical signs of neglect, including severe dehydration in clients with feeding tubes which should have been managed, clients with stage 3 and 4 bed sores, broken catheters and feeding tubes, and clients whose medication for chronic conditions was not being managed properly," said study leader Lee Friedman in the press release.  Friedman added that substandard care falls within the definition of elder abuse.

The study included more than 1,100 people, aged 60 and older, who were seen in five Chicago-area hospitals between 2007 and 2011 for health problems that could be related to poor care.

Along with finding that neglect-related health problems were more common in for-profit nursing homes than in nonprofits, the researchers also found that community-dwelling patients had fewer of these problems than those in any type of nursing home.  Community-dwelling patients need help with daily living but live in private homes, often with family members or friends.

According to the researchers:

"For-profit nursing facilities pay their high-level administrators more, and so the people actually providing the care are paid less than those working at nonprofit places, so staff at for-profit facilities are underpaid and need to take care of more residents, which leads to low morale for staff, and it's the residents who suffer."

Friedman said more oversight of nursing homes is needed, along with improved screening and reporting of suspected neglect.

This study is unique in that it also included consideration of community based health care residents.  The conclusion that non-profit homes are superior to their for-profit competitors, however, is well established. According to the report:

"As reported in prior research, for-profit facilities caring for the patients in this study were  significantly inferior across nearly all staffing, capacity, and deficiency measures. Furthermore, the most serious clinical signs were consistently more prevalent among residents of for-profit facilities, including dehydration with presence of gastrostomy, not being provided basic medications to manage chronic conditions, stage 3 or 4 pressure ulcers, and complications with urinary catheters and feeding tubes.

Many studies show that neglect is the most common form of elder mistreatment but is more likely to be overlooked because of its muted nature, although the outcomes of neglect can be as pernicious as physical abuse. 

Aging in Place requires planning and accurate information.  Implementing an objective to remain at home, a senior or family member acting on his or her behalf may nonetheless be forced to institutional care, even if for only a short period of time.  Selecting the institution most likely to provide positive health outcomes is paramount, as is acknowledgement that short-term institutional care can result in long term institutional care if health outcomes are negative.

Feds Release New Quality Data Online

McKnight's Long Term Care News reports that the federal government has released new data on the quality of care delivered in skilled nursing facilities.  Centers for Medicare & Medicaid (CMS)  added five brand new quality-related measures to Nursing Home Compare. 

Transparency of outcomes “continues to intensify,” with this posting of the inaugural SNF Quality Reporting Program (QRP) measures, said Amy Stewart, RN, curriculum development specialist with the American Association of Directors of Nursing Services.  She encouraged nursing homes to check their scores on the five newly published SNF measures as soon as possible to know what the potential clients are seeing, and be ready to discuss the results. Scores will be of more interest than ever before to hospitals and other healthcare entities looking to partner with SNFs.

The five quality measures included in this latest release include:

• Percent of residents that developed new or worsening pressure ulcers during their stay in an SNF (1.7% is the nationwide rate in SNFs according to CMS);
• Percentage of patients whose activities of daily living and thinking skills were assessed and related goals were included in treatment plan (95.8% nationally according to CMS);
• Percentage of patients that experienced a fall resulting in a major injury during their stay in a SNF (0.9% nationally according to CMS);
• Medicare spending per beneficiary for patients in SNFs (showing whether Medicare spends more, less or about the same, per episode of care for a patient treated in a SNF compared to how much Medicare spends on an episode of care across all SNFs nationally);
• Rate of successful return to home or community from a SNF (48.57% nationally according to CMS).

CMS decided not to include a sixth quality measure it had previously planned to employ: Potentially preventable 30-day post-discharge readmission. Instead, the agency will allow for additional time to test and determine if there are modifications needed to better display this measure.

CMS has posted a FAQ (Frequently Asked Questions) on its website to answer some of the most common questions related to this release.

While some measures may seem duplicative of those used in the Five-Star Rating System, which includes all residents, these SNF QRP measures are specific to Medicare Part A residents only.

2019 Medicare Advantage Plans Incorporate Long Term Care, Aging in Place Benefits

Some Medicare Advantage Plan (hereafter simply "Plan") issuers are quietly and carefully adding home-based and community-based long-term care (LTC) benefits for 2019, according to Allison Bell, ThinkAdvisor's insurance editor. According to an excellent ThinkAdvisor article, officials at the Centers for Medicare and Medicaid Services (CMS). estimate that about 1.5 million of the 2019 enrollees, or 7.5% of Medicare Advantage plan enrollees, may have access either to support services in the home or community, or to extra benefits designed to help enrollees cope with the burden of diabetes or other chronic conditions. CMS officials have not, however, estimated how many enrollees might have access solely to the new home- or community-based services.  

A previous blog article discussed these changes; see the article entitled, "Trump Administration Embraces Aging In Place- 2019 Advantage Plans Permitted to Incorporate Long Term Care," available by clicking here. 

In Arizona and California, for example, units of Anthem Inc. are openly stating that they will use the new flexibility to beef up the benefits offered by some plans.  Enrollees in certain Anthem plans will have access to what amount to LTC benefits provided for a short period of time:

• Three meals delivered per day for up to 42 days.
• Four four-hour shifts of in-home assistance with daily living activities, such as laundry.
• 40 hours of respite care for caregivers per year.
• One visit per week for adult day care center services, for older adults who need supervision.
• Health care appointment transportation services.

Traditionally, commercial insurers have referred to benefits for small amounts of LTC-type services with terms such as “convalescent care benefits,” or “short-term care benefits.”  SCAN Health Plans of Long Beach, California, says it will offer new in-home benefits through most plans in Southern California, but it’s not easy to tell which new benefits will be related to the new rules.

UnitedHealth Group Inc.’s UnitedHealthcare unit says it will make telemedicine services available to 1.7 million enrollees through phones and computers, and health-related transportation services available to 1.7 million enrollees. The company is also offering a care management and care planning service for caregivers to most of its Medicare Advantage plans. It’s not clear from the company’s 2019 plan announcement whether those beneits are related to the new CMS rules.

Lack of clarity is a real problem. Unfortunately, for someone looking at the CMS 2019 Plan Information or even the plan issuers’ own benefits summary sheets, it is not easy to tell which plans will take advantage of the new CMS benefits flexibility.  Moreover, the value of these additional services, and possible resulting costs are difficult for a lay person to evaluate.  For these reasons, we strongly urge clients to establish a relationship with a trusted advisor.  Locally, many of our clients use the advisors at Harding, Harding & Associates. 

Traditionally, Medicaid has been the government health program that pays for nursing home care.  Federal rules have blocked Medicare from paying for long-term care.  Medicare has paid for skilled nursing care for people recovering from serious acute health care problems, and promised to pay for limited home health care services.

But Medicare has not paid for nursing home care for people who are in a nursing home simply because they are frail or have trouble with the activities of daily living, such as bathing or eating.  Medicare has also avoided paying for other types of in-home services, such as help with cleaning or laundry, that might help keep older people in their homes.

In May, CMS said it would change Medicare Advantage benefits rules, to give issuers ways to offer new benefits for the “social determinants of care” that might help reduce overall medical spending.  Officials suggested, for example, that, in some cases, spending a little money on transportation services or meal delivery for someone with serious health problems might be a good way to avoid spending a lot of money on hospital care. 

CMS Announces 2019 Medicare Premiums and Deductibles

On October 12, 2018, the Centers for Medicare & Medicaid Services (CMS) released the 2019 premiums, deductibles, and coinsurance amounts for the Medicare Part A and Part B programs.

Medicare Part B Premiums/Deductibles

Medicare Part B covers physician services, outpatient hospital services, certain home health services, durable medical equipment, and certain other medical and health services not covered by Medicare Part A.  

The standard monthly premium for Medicare Part B enrollees will be $135.50 for 2019, an increase of $1.50 from $134 in 2018. An estimated 2 million Medicare beneficiaries (about 3.5%) will pay less than the full Part B standard monthly premium amount in 2019 due to the statutory hold harmless provision, which limits certain beneficiaries’ increase in their Part B premium to be no greater than the increase in their Social Security benefits. The annual deductible for all Medicare Part B beneficiaries is $185 in 2019, an increase of $2 from the annual deductible $183 in 2018. Premiums and deductibles for Medicare Advantage and Medicare Prescription Drug plans are already finalized and are unaffected by this announcement.

Since 2007, a beneficiary’s Part B monthly premium is based on his or her income. These income-related monthly adjustment amounts (IRMAA) affect roughly 5 percent of people with Medicare Part B.  The total premiums for high income beneficiaries for 2019 are shown in the following table:

Premiums for high-income beneficiaries who are married and lived with their spouse at any time during the taxable year, but file a separate return, are as follows:

Medicare Part A Premiums/Deductibles

Medicare Part A covers inpatient hospital, skilled nursing facility, and some home health care services. About 99 percent of Medicare beneficiaries do not have a Part A premium since they have at least 40 quarters of Medicare-covered employment.

The Medicare Part A inpatient hospital deductible that beneficiaries will pay when admitted to the hospital will be $1,364 in 2019, an increase of $24 from $1,340 in 2018. The Part A inpatient hospital deductible covers beneficiaries’ share of costs for the first 60 days of Medicare-covered inpatient hospital care in a benefit period. In 2019, beneficiaries must pay a coinsurance amount of $341 per day for the 61st through 90th day of a hospitalization ($335 in 2018) in a benefit period and $682 per day for lifetime reserve days ($670 in 2018). For beneficiaries in skilled nursing facilities, the daily coinsurance for days 21 through 100 of extended care services in a benefit period will be $170.50 in 2019 ($167.50 in 2018).

Enrollees age 65 and over who have fewer than 40 quarters of coverage and certain persons with disabilities pay a monthly premium in order to voluntarily enroll in Medicare Part A. Individuals who had at least 30 quarters of coverage or were married to someone with at least 30 quarters of coverage may buy into Part A at a reduced monthly premium rate, which will be $240 in 2019, an $8 increase from 2018. Certain uninsured aged individuals who have less than 30 quarters of coverage and certain individuals with disabilities who have exhausted other entitlement will pay the full premium, which will be $437 a month, a $15 increase from 2018.

For more information on the 2019 Medicare Parts A and B premiums and deductibles (CMS-8068-N, CMS-8069-N, CMS-8070-N), please visit https://www.federalregister.gov/public-inspection.

Social Security Announces 2019 Changes

The Social Security Administration (SSA) has released the 2019 benefit changes.   Based on the increase in the Consumer Price Index (CPI-W) from the third quarter of 2017 through the third quarter of 2018, Social Security and Supplemental Security Income (SSI) beneficiaries will receive a 2.8 percent increase or COLA for the year 2019. 

SSA also announced an increase in the SSA taxable maximum amount to $132,900. The indivdiual's amount for SSI for 2019 will increase to $771 per month. 

The tax rate for most people is 7.65%, the combined rate for Social Security and Medicare. The Social Security portion (OASDI) is 6.20% on earnings up to the applicable taxable maximum amount. The Medicare portion (HI) is 1.45% on all earnings. Also, as of January 2013, individuals with earned income of more than $200,000 ($250,000 for married couples filing jointly) pay an additional 0.9 percent in Medicare taxes (not reflected in the 7.65% combined rate reported above). 

The detailed fact sheet is available here.

Declining SNF Utilization

There is increasing evidence that either (1) utilization of nursing homes is rapidly diminishing, or (2) utilization of nursing homes has reached saturation, and competition is closing less competitive operations.  One would like to think that seniors and their families are implementing "Aging in Place" planning in order to avoid institutionalization. The issue is complicated, however, and although what is occurring is demonstrable, the underlying causes are unclear. 

The New York Times recently published an article discussing the phenomenon entitled "In the Nursing Home, Empty Beds and Quiet Halls,"explaining that a once vibrant facility now stands closed due to a drop in demand.  According to the article, "[t]he most recent quarterly survey from the National Investment Center for Seniors Housing and Care reported that nearly one nursing home bed in five now goes unused. ... Occupancy has reached 81.7 percent, the lowest level since the research organization began tracking this data in 2011, when it was nearly 87 percent."  

The occupancy rate for skilled care nursing homes has been trending downward, and as a result facilities close.  According to the article, somewhere between 200-300  close annually.  The article  offers some possible explanations for the phenomenon given the number of baby boomers that one might think would cause an increase in demand.  The article suggests the decreasing utilization is caused by:  

• Increased regulations and more financial belt-tightening;
• Hospitals' use of observation status,which affects Medicare coverage for subsequent SNF care;
• More surgeries on an out-patient basis;
• Increasing number of Medicare Advantage plans;
• Increased competition through other housing options;
• The shift to Medicaid covering care in the community, with "Money Follows the Person [having] moved more than 75,000 residents out of nursing homes and back into community settings."

The article speculates whether this trend will reverse itself once the boomers start reaching age 80 and beyond. The article also discusses whether the lower demand provides more options for those in need of nursing home care.

Conservator Owes Duty to Nursing Home to Timely Apply for Medicaid

A Connecticut appeals court has held that a nursing home resident's conservator owes a duty of care to the nursing home to timely apply for Medicaid on behalf of the resident. Bloomfield Health Care Center of Connecticut, LLC v. Doyon (Conn. App. Ct., No. AC 40281, Oct. 9, 2018).

A nursing home petitioned the court to appoint a conservator for one of its residents, Samuel Johnson, to assist him with his Medicaid application. The court appointed Jason Doyon as conservator in April 2014. Mr. Doyon waited nine months to file a Medicaid application on Mr. Johnson's behalf. The state denied Mr. Johnson's first Medicaid application due to lack of information. Mr. Doyon filed a second application, which the state approved, but Mr. Johnson did not receive any Medicaid benefits before May 2015.

The nursing home sued Mr. Doyon for negligence in failing to apply for and obtain Medicaid benefits on behalf of Mr. Johnson in a timely manner. Mr. Doyon asked for summary judgment, arguing that he did not owe a duty of care to the nursing home. The trial court granted Mr. Doyon summary, holding that the conservator owed no duty to the nursing home.  The nursing home appealed the lower court's judgment.

The Connecticut Court of Appeals reversed.  The court held that Mr. Doyon owed the nursing home a duty of care. The court rules that it was "readily foreseeable that, if [Mr. Doyon] failed to timely obtain Medicaid benefits for [Mr.] Johnson, the [nursing home] would suffer harm as a result because it would not be reimbursed for the cost of [Mr.] Johnson’s care." The court also concludes that "the benefits of encouraging conservators to carry out their duties with care and preventing financial harm outweigh any corresponding minimal increase in litigation."

The decision continues a trend of decisions favoring nursing homes when eligibility applications for Medicaid are not timely or properly prosecuted.  The decision should also concern family caregivers; the trend might foreshadow greater success on the part of nursing homes in disputes with family members who act as fiduciaries without court appointment.  Family often acts in court-appointed roles, or more informal roles without careful consideration of the liabilities of service. The bottom line is that Medicaid applications should be taken seriously, and the applications completed and submitted as quickly as possible.   

Wealthy Nursing Home Residents Would Prefer to Age in Place- Would Pay Family For Care

A new survey of wealthy seniors suggests that many of nursing homes’ potential residents would prefer to receive long-term care at home, and would be willing to pay their own family members for it.

That’s according to responses of more than 1,000 U.S. adults, age 50 or older, with an annual household income of $150,000 or more. The Harris Poll, conducted on behalf of the Nationwide Retirement Institute, found that about 71% of seniors would prefer to rely on a family member for long-term care. And 70% of those surveyed would not expect that help, unless they were able to pay relatives.

About 56% of respondents said that they “would rather die” than live in a nursing home, and 47% said they’re worried about becoming a burden to their families.

“Affluent adults fear nursing homes but are concerned their care needs will challenge their family if they require caregivers,” Nationwide VP Holly Snyder said in a press release.

About 77% of respondents said, if needed, they’d most prefer to receive long-term care at home. That’s compared to 1% preferring to receive skilled care in a nursing home. Reasons for those worries included loss of control of their lives (68%), detachment from the community (32%) and seeing family less often (30%).

More details from the seventh annual survey can be found on Nationwide’s website here.