Ohio Receives Near Failing Grade on Nursing Home Report Card

Families for Better Care ("FBC"), recently  published its state-by-state nursing home report card. Ohio received  a near failing "D" grade, ranking fortieth among the fifty states. The current ranking represents a decrease in Ohio's relative ranking, down from 34th last year, but no change in Ohio's near failing "D" grade from last year. 

FBC scores, ranks, and grades states on eight different federal quality measures ranging from the number of caregiver hours residents received on a given day to the percentage of nursing homes cited severe deficiencies. The Report Cards include information from the newly revamped Nursing Home Compare reporting, requiring nursing homes to prove staffing levels, a sharp departure from previous administrations that accepted, without proof, representations from nursing homes regarding sufficiency of staffing.  More than one-third of nursing homes saw CMS ratings drop under the new, more deliberate, and more reliable system.

Regarding the Ohio ranking, the Report Card noted:

• "Ohio’s nursing home care continued its ratings slump, falling to No. 40 after dropping six spots.
• Ohio is a testament to nursing home mediocrity as the state failed to muster a Top Ten ranking or above average grade in any quality measure.
• Severe deficiencies in Ohio’s nursing homes swelled six percent, pushing the number of potentially dangerous nursing homes to nearly 1 in 5 statewide.
• Seventy-five percent of Ohio nursing homes failed to score an above average health inspection.
• Nearly 90 percent of Ohio’s nursing homes cited a regulatory deficiency—the state’s highest percentage thus far.
• Ohio’s nursing home residents received little more than 2 hours and 18 minutes of direct care each day.
  

Families for Better Care, Inc., is a Texas-based nursing home resident advocacy group dedicated to creating public awareness of the conditions in our nation’s nursing homes and other long-term care settings and developing effective solutions for improving quality of life and care.

“This year’s nursing home report card exposed an alarming trend that should serve as a wake-up call for us all,” said Brian Lee, Families for Better Care’s executive director. “Nursing home inspection ratings have soured.”

According to survey data collected by federal and state governments, fewer than 30 percent of nursing homes were capable of scoring an above average inspection rating, that’s nearly a 15 percent decline since the last reporting period.

“America’s nursing home care is worsening,” Lee exclaimed. “Erratic inspection performance is, by and large, traceable to a singular reason, the failure by so many nursing home operators to hire enough staff to safely care for residents.”

While Families for Better Care has repeatedly warned that nursing home staffing shortfalls are a grievous problem, the organization is calling for a new solution, one that the nursing home industry should welcome and would be embraced by residents and their families.

“The best way to heal America’s nursing homes is to appropriate additional funding to be used solely for hiring more staff,” Lee stated. “No more excuses, no more threats, no more scare tactics from lobbyists, politicians, operators—or anyone else for that matter—it’s time to do what’s right and stop the infliction of our loved ones with unnecessary injury or harm because of negligent policy making.”

According to the report’s findings, the majority of nursing homes (54 percent) were incapable of scoring an above average staffing rating. Residents received just 2 hours and 33 minutes of direct care daily—an average that’s unchanged from the previous report card. Nearly every state—with the exception of Alaska, the District of Columbia, and New Mexico—suffered a net loss in the percentage of nursing homes with above average staffing levels over the past three report cards.

“Before any checks are written to nursing homes, a rock solid staffing standard must accompany any new funding; otherwise, taxpayer monies could end up being diverted to subsidize the lifestyles of the rich and not-so-famous instead of getting back to the residents and their care,” Lee stated. “Too many nursing homes have demonstrated an unfaithfulness in self-governing their staffing levels to safely care for residents, so it’s time we help them out a little, as a nation, by federally mandating the most stringent staffing requirement that leaves no loopholes through which violators could squeeze.”

 As for the state’s nursing home rankings, the states highly rated in past report cards, once again, dominated the top spots while the chronic underachievers continued to disappoint.

 This year’s top nursing home states were Hawaii, Delaware and Alaska while Texas, North Carolina, and Illinois scraped the bottom of the barrel. States with the biggest gains in overall ranking were New York (↑20), Mississippi (↑17), and Nevada (↑14) while Vermont (↓27), Massachusetts (↓24), and Arkansas suffered the biggest losses.

Three of the last report card’s best nursing home states slid out of the top ten, including Vermont, which plunged from No. 3 to No. 31 overall. The remaining states were New Hampshire (down from No. 2 to No. 11) and Florida (falling seven spots from No. 6 to No. 13).

Other key findings included:

• 500,000 elderly living in dangerous conditions—Nearly half-a-million elderly nursing home residents are living in facilities that tolerate below average staffing scores.
• Abuse and neglect vexes nursing home quality—1 in 5 nursing homes abused, neglected, or mistreated residents in almost half of all states for the second consecutive report card.
• States that are downright awful—Texas, Illinois, New Mexico, Michigan, Oklahoma, Louisiana, and Indiana consistently linger at, or near, the bottom in state nursing home care, scoring failing grades in every nursing home report card.

Families for Better Care argues that America desperately needs a nursing home cultural transformation, and the best way for that to happen is for nursing homes to saturate facility hallways with a brigade of well-trained frontline caregivers.

“Nursing home staffing levels must be ratcheted up if care is ever going to improve,” said Lee. “Since nursing homes rely so heavily on federal and state reimbursements, it’s incumbent upon us to pull up our bootstraps and find a way to inject much needed staffing currency as soon as possible.”


Readers of this blog should not be, and probably are not, shocked by either the report card grades, or the news that nursing home quality is generally worsening. These are compelling, but hardly new, reasons for implementing an Aging in Place plan.  If you haven't already, ask to attend an Aging in Place workshop.  

More:

State's [Pennsylvania] Failing Grade for Nursing Home Care is Unconscionable
Nursing Home Care Declines in Florida
Illinois Nursing Homes Rank Third Worst in the Country
Texas Ranked Last on 2019 Nursing Home Report Card
Delaware Ranked No. 2 on Nursing Home Report Card
Hawaii Grabs Nursing Home Report Card's Top Spot
Strong Staffing Boosts Alaska To No. 3 On 2019 Nursing Home Report Card
Rhode Island Slips to No. 4 On 2019 Nursing Home Report Card
Utah Ranks No. 5 On 2019 Nursing Home Report Card
Idaho Ranks No. 6 in 2019 Nursing Home Report Card
Arizona Ranked No. 7 on 2019 Nursing Home Report Card
Washington D.C. Surges To No. 8 On 2019 Nursing Home Report Card
Maine Drops to No. 9 on 2019 Nursing Home Report Card
North Carolina Drops to Second Worst in Nursing Home Quality

Nursing Home Occupancy Rates Rise- Financial Struggles Persist

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According to an article in McKnight's Long-term Care News, nursing home occupancy had its first year-over-year increase since January 2015, reaching 83.7% in the first quarter of 2019.  The statistics come from the National Investment Center for Seniors Housing & Care (NIC).  

The continuing upward trend likely relates to more than just  flu cases and other seasonal factors, said Bill Kauffman, senior principal at NIC:  

“Occupancy was also up between March 2018 and 2019, suggesting supply and demand are becoming more closely aligned,” he said in a statemet. “NIC will continue to monitor reimbursement, labor costs and other data to see if any of these factors might be contributing to facility closures, especially in some rural areas.”

Despite the increase in occupancy, facilities continue to struggle financially, however, due to case mix, specifically since Medicaid patients account for most of the patient population in skilled nursing facilities, NIC experts said.

“Skilled nursing is increasingly reliant on Medicare Advantage and Medicaid for revenue, which is challenging many facilities’ financial wellbeing,” Beth Mace, NIC’s chief economist, said in a statement. “Reimbursement rate pressures, competition from other care settings, and high personnel costs are also impacting the sector.”

Aging in Place: New CMS Policies are Changing the Way Investors View Home Health

"Patients have always had a preference for 'aging in place;' being cared for in the comfort and familiarity of their homes and communities. But for providers, bringing consistent, high-quality care to a patient’s home—and getting paid for it—has presented challenges.  Recent changes at the Centers for Medicare & Medicaid Services (CMS), however, are making these solutions even more practical. Changes to reimbursement guidelines have shifted how skilled home care is valued and has breathed new life into unskilled home care and telehealth services." So begins an excellent article penned by Barry Freeman and Michael Weber and published in FierceHealthcare.   The article, and the health care industry developments described therein, are welcome, because if the industry does not react to health care policy changes with acceptance, investment, an implementation, there can be no tangible change for consumers. 

The market incentives for investment to accommodate the desires of consumers wanting to Age in Place are undeniable; with 10,000 Baby Boomers turning 65 each day in the U.S., the market for home services is growing rapidly. The home care industry has exploded over the past decade, thanks in part to private equity interest and to older adults’ overwhelming preference to age in place. The good news is that the market opportunities and changes in health care policy are combining to attract new investment to specifically expand home care options and availability, benefiting both patients and investors.

CMS policies through the Patient-Driven Groupings Model (PDGM) going into effect in 2020 represent a major reform to the existing payment paradigm for the industry.  Skilled home health agencies are traditionally compensated in a way that penalizes providers for providing required services to patients with complex needs, while rewarding agencies that use higher volumes of therapy services for patients with less complex or simple needs. According to the authors, the new payment model envisaged by CMS will be based on each patients’ clinical condition, functional level and individual care needs, rather than the therapeutic intensity of the care provided.

The authors conclude that these changes are affecting how investors view the skilled home health market and paving the way for reform. Evidence demonstrating the interplay between social determinants of health and health outcomes is "shedding new light on the non-medical home care sector." Regulators, payers, providers and employers are "rethinking the role that social programs, like personal assistance services,  such as non-medical home care delivered by an attendant or aide, play in cost containment, outcomes-based care, and patient satisfaction."  

Readers of this blog are aware that CMS rolled out a disruptive and monumental change, last April, that permits private Medicare insurers to cover non-medical in-home care as a supplemental benefit for Medicare Advantage plans. For the first-time, aging Americans are able to purchase a Medicare Advantage policy that will cover bringing a home health aide to their home to help support their daily living; from getting dressed, to bathing, tidying up, cooking and combating senior loneliness, home health care can empower seniors, their families, and caregivers to provide home care  This policy change "created a new paradigm for the non-medical in-home care industry—expanding the addressable market by the more than 20 million seniors enrolled in Medicare Advantage plans."

Although few insurers managed to incorporate non-medical in-home care in time for the 2019 plan year, the authors concluded that there, nonetheless, "remains an enormous growth opportunity for non-medical care providers and their investors." Even with a short period of time in which to reorient plans for the 2019 plan year, according to an AARP analysis, three percent of Medicare Advantage plans managed to offer these services in 2019. If consumers get good advice and prefer the additional benefits, there is little that number of plans providing the additional benefits will escalate as insurers vie for market share. 

These same reforms have also spurred investment in telehealth, already a growing segment in broader health care.  According to the authors, telehealth services have for decades helped keep employers’ and certain commercial plans’ healthcare costs lower, especially for under-served or rural populations. But, they write, "Medicare, Medicaid and providers have faced challenges getting paid for these tech-enabled services, which include video consultations, Personal Emergency Response Systems (PERS), or remote vitals monitoring."

The authors conclude that many of these challenges have likewise changed with the recent reform, specifically because CMS approved a final rule giving Medicare Advantage plans more flexibility to cover telehealth services in the home setting, even for patients in urban areas, where there is rarely a dearth of quality providers. CMS had only allowed telehealth reimbursement in situations where patients were managing a clinical condition without ready access to care, thus excluding most patients from access to the Aging-in-Place-technology.

The authors suggest that telehealth solutions will expand rapidly and naturally:

The convenience and affordability of telehealth solutions resonates with many patients and their families. According to Deft Research’s 2019 Medicare Shopping and Switching Study, the majority of Medicare Advantage members would change plans in order to procure access to telehealth services. Physicians and other clinicians benefit from the enhanced visibility they gain into their patients in real-time, as well as the stronger patient engagement in care that results from these tech-enabled tools. The addressable market for telehealth solutions is expanding rapidly as patients desire the convenience, providers appreciate the assistance, and health plans cover their use.

The authors see investment and capital following the opportunities: 

Private equity firms and strategic corporations are shaking up the landscape—to patients’ benefit, encouraging flexible treatment solutions that are becoming more innovative and widespread.  Large private equity funds like Welsh, Carson, Anderson & Stowe and KKR have already made investments in home and community-based care in anticipation of the tremendous future growth opportunities.

Skilled and unskilled home care markets and companies like Amedisys, Kindred at Home and Elara Caring are likely to consolidate, building a continuum of care from post-acute to sub-acute home and community-based capabilities. In the telehealth space, already established players are being challenged by newcomer startups offering to place quality care in the palm of patients’ hands.

The future is promising for both those planning to Age in Place, and for those seeking to invest and profit in making the option of Aging in Place viable and cost-effective.  This is welcome and disruptive reform to a senior health care system that has too long preferred long-term institutional care.

State's Medicaid Lien Filed After Death of Recipient Enforceable

An Ohio appeals court has ruled that the state has priority over a nursing home in a claim for Medicaid recovery against the estate of a nursing home resident even though the state did not file a lien against the resident's property until after the resident died. Wiesenmayer v. Vaspory (Ohio Ct. App., 2ndDist., No. 27931, May 10, 2019).

The decision carves out special treatment for the state when enforcing liens for Medicaid, because generally, a lien filed on real estate after the death of the debtor is not enforceable.  See Dressler v. Bowling, 24 Ohio St.3d 14, 492 N.E.2d 446 (1986); Brandon v. Keaton, 90 Ohio App.3d 542, 630 N.E.2d 17 (2d Dist.1993).  In Dressler, the Ohio Supreme Court wrote, “[i]t is well-settled that no lien is obtained by a certificate of judgment filed after the judgment debtor’s death, since his real property descends to his heirs at the time of death.”  Dressler at 16. This had been well-settled law, until the advent of Medicaid resource recovery and the need to protect state lien rights, since many Medicaid recipients pass away before the state has an opportunity to perfect its rights by filing a lien against property.  Notwithstanding the well-settled law, the courts afford the state special protection and the opportunity to enforce liens filed after the death of the debtor, an opportunity not afforded to other creditors.

The following are the facts in the case: Nursing home resident Margaret Edwards received Medicaid benefits for five months before she died. After she died, the state recorded a lien on her property in order to recover Medicaid benefits it paid on her behalf.  The probate court appointed R.C. Wiesenmayer administrator for Ms. Edwards' estate, and he requested authority to sell Ms. Edwards' property. The nursing home filed a claim against the estate for unpaid bills. The state also filed a claim to recover Medicaid benefits. The trial court ruled that the state's lien was valid and had priority over the claim of the nursing home. The nursing home appealed, arguing that the state's lien was not valid because it was not recorded before Ms. Edwards died.

The Ohio Court of Appeals, Second District, affirmed the trial court's decision, holding that the state's lien is valid and has priority over the nursing home's claim. Noting that "the estate recovery program contemplates the recovery of Medicaid costs from the assets of deceased recipients," the court ruled that the state's Medicaid lien law "does not apply exclusively to living, permanently institutionalized recipients of Medicaid benefits, and consequently, that [the state] was not required to record its lien against [Ms.] Edwards’s property before she died."

Chubb Insurance Offers Free Home Accessibility Consutation Service

A new survey from Chubb finds that the majority of homeowners are underestimating the likelihood of disability, especially during retirement years, and the impact it can have on their everyday life. Despite the fact that the Centers for Disease Control and Prevention reports that one in four U.S. adults lives with a disability, Chubb's "Home Accessibility" survey found that close to half of homeowners (44%) say they are not prepared to care for themselves or loved ones with a serious illness, disability, or simply aging in place. Among their top concerns, more than a third (38%) of homeowners are worried about the need for home renovations in the event they or their family member becomes disabled, whether due to accident, illness, injury or another cause.

Chubb's "Home Accessibility" survey analyzed individual preparedness for disability and aging in place, potential future disability concerns, personal retirement preferences as well as attitudes on home renovations pertaining to accessibility and design. The nationwide survey was fielded between March 20, 2019 and March 30, 2019 and conducted by Research Now. The results are based on 1,201 responses, of which a quarter (25%) of respondents each came from the middle class ($50,000-$99,999 in annual household income), upper middle class ($100,000-$499,999), mass affluent ($500,000-$999,999) and high-net-worth ($1,000,000 or more). Fifty four percent of respondents were male and forty six percent were female.

Recognizing this growing need, and timed in conjunction with Global Accessibility Awareness Day, Chubb launched a new complimentary accessibility consultation service intended to give existing Chubb homeowner clients advice on how to make their homes more accessible, without compromising structural integrity or diminishing the fair market value of the home. This consultation service provides a homeowner an independent opportunity to assess and evaluate the advisability of modifications to the home.

"Our team of national risk consultants has been trained by some of the leading accessibility experts in the country, including specialized architects," says Jennifer Naughton, executive vice president at Chubb Personal Risk Services. "Leveraging their expertise in design and accessibility, our risk consultants can advise clients on home design elements that might impede accessibility and how to retrofit accordingly."

"Coupled with the fact that 10,000 Baby Boomers turn 65 each day and that Chubb's survey found 72% of homeowners want to remain in their home as they age, addressing existing home design elements that might hinder long-term accessibility is paramount," added Naughton.

Fortunately, many homeowners are starting to recognize such hurdles and the importance of related improvements, but they have a way to go. The vast majority—81% and 82%—of homeowners would need to make changes to their home to accommodate caring for a loved one with a disability or to support aging in place, respectively. However, Chubb Masterpiece^® homeowner clients have access to vetted, trusted professionals, such as architects, designers, and licensed contractors, who can assist them with making their home more accessible and beautifully designed.  

In addition to consulting with clients, trained risk consultants will work with independent agents and brokers. "Accessible design renovations may require meaningful financial investments from clients. Our risk consultants can assist agent and broker partners to help them understand the exact replacement cost value of their clients' investments to ensure they are fully protected," said Naughton.

To help agents and brokers learn about the market need and opportunity as well as key principles and design considerations of universal residential construction, Chubb is launching a new resource center that includes "rich multimedia marketing materials such as videos, infographics and collateral," some of which have been produced in partnership with the Cerebral Palsy Foundation. Agents and brokers can access the resource center at: www.chubb.com/accessibilityisbeautiful.