Name: Roberta Hawkins
Position: Executive Director, The Alliance for Better Long Term Care
A modernized health plan: Supporting cost management and the employee experience.
The Surest health plan came from a group of innovators wondering: What if health care…
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Background: 26 years at the Alliance
Education: High school degree, two years of college studying geriatrics
Family: Married, two daughters, two grandchildren
Residence: Warwick
PBN: Tell me about the Alliance for Better Long Term Care.
HAWKINS: We oversee quality-of-life issues for people living in nursing homes, assisted-living centers, and now we’re monitoring home-health care. We monitor standards and the enforcement of those standards. We look at rules or regulations that should be improved. For example, standards sometimes need to be improved because the level of patients they take in have higher medical needs.
We hear a lot about how the nursing-home industry can’t find enough nurses.
It’s more caregivers. It’s not just nurses. Certified nursing assistants (CNAs) do 90 percent of the work. Over the last five years, we’ve been complaining – along with the industry – about the lack of services, the lack of people coming into this field. They are going into other areas of employment.
What do CNAs get paid?
Today, they are paid maybe between eight dollars and change to 10 dollars and change (an hour). People say ‘Oh that’s not bad.’ But oh yes it is, because CNAs are working like nurses. And the RNs working in nursing homes are working in the same capacity if not more so than the hospital nurses, because they’re doing the same kind of work, mostly with the same kind of patients, and there’s nowhere near the benefits or salary. Who would stay there?
So why do they stay?
Well, you have a lot of people leaving the job, not because they don’t love nursing or don’t love being a caregiver. It’s because they’re not doing the hands-on care as much anymore because they’re doing paperwork. They don’t have enough staff to follow their direction. So their license is hanging out there on the edge, because if it doesn’t get done, the nurse is held responsible. I would not want to be held responsible for a skeleton crew of staff, when you know it’s impossible for them to carry through what needs to get done. I have seen directors of nursing leave nursing homes that they had been in for a long time who did an excellent job, who were totally burnt out from double shifts, 24 hours on call, working seven days a week. They have no life. And they’re going out the door every single night worrying about ‘Did this get done? Did they get this X-ray? What if this broke?’
When you say responsible, you mean they’re legally liable if something goes wrong?
Legally liable, yes. It used to be that nurses in nursing homes took care of less-complicated cases. But that’s changed. And we’re one of only three states that doesn’t mandate continuing education for nurses. So here we are, giving them the kind of patients that have high-tech needs. I mean, we’ve got residents with IV’s in nursing homes with nurses who have no clue how to do IV’s. Why would you want to work in a job if you didn’t have the skills or the tools to do it? So the frustrations mount. And I think that the industry and the system do not support those nurses to have the skills that are needed for the kind of patients they’re forced to take.
So it’s not only a pay issue?
No. CNAs are taking care of people who beat them up daily, with Alzheimer’s or dementia-related illnesses, people with alcoholic dementia. If you were going to come to work everyday and get beaten up and kicked and you were going to be cleaning up people who are incontinent of both bowel and bladder, would you look forward to that every day? And then not have enough assistance to help you, and then turn around and do it two hours later with the same person you just finished with? It’s extremely frustrating, the rewards are little, the education doesn’t match what they need and the money doesn’t match the hard work they do.
What problems specifically do you see in some long-term-care facilities?
People are not getting the quality of care that this industry historically has provided.
Say you have 10 to 15 patients. Most of them will be very old, needy people. Most of them will be incontinent. Some people in the nursing homes do not drink anything because they’re afraid that when they ring the buzzer, nobody will come. And they can’t wait 15 or 20 minutes. So they get dehydrated. If they do drink fluids and somebody doesn’t answer that bell right away because they’re taking care of three other people, then they end up wet and sitting in their own waste. They get urinary tract infections. They can get colds from sitting there wet and possibly get pneumonia. All because there is not enough staff to walk them to the bathroom. And that’s just one issue. You also don’t have enough staff to get up and walk people around. The longer they sit, the more their muscles deteriorate. If they don’t get up to walk they get bedsores.
Do you see abuse at nursing homes?
I do. Some of it’s subtle. Some of it may be just verbal. Some of it is when you neglect somebody and don’t deal with them, that’s abuse. Some of it is – and not to excuse it – but some of it is from the strain of the job. If you are being attacked and abused and whacked as a staff person, you can lose it and do some of that back. Some people just don’t like old people, believe it or not. But that goes for people’s own children. Nursing homes sometimes protect patients from dysfunctional families.
There must be nursing homes in Rhode Island that are doing a good job.
Absolutely.
So what separates the good from the bad?
Well, it’s a combination of things. Nursing homes that are larger and can bring in a combination of payments – Blue Cross, private pay, those kind of things. That makes a big difference because more money means you can put more staff on. Sometimes the payments are not higher, there are just more of them. You also have homes with acute rehabilitation in their facilities, and those homes will bring people in from the hospitals through the Medicare program, which then gives you more money, and they don’t stay as long so the turnover is quicker. Those (homes) can put on the extra staff that is needed to keep the place running well. I have seen both for-profits and not-for-profits do excellent jobs. Do they still have some problems making ends meet? Yeah.
Are assisted-living centers and home-health agencies having these same problems?
Yes they are, because of the shortage of staff. Now, let’s separate the home care from the assisted-living staff. Home-care agencies have licensed, trained staff. Are they getting enough staff to meet the needs of people in the home-care setting? Absolutely not.
Assisted-living has turned into our new nightmare. You have the very large and fancy places and you have the small ones that take in some very difficult clients. Those smaller places are dealing with a little younger population, but it’s a more difficult population to work with because they don’t have the tools like the counseling and the psych people. Most (assisted-living centers) have no licensed staff. They’re just people that have been trained to work with older people. The larger places may have an RN, but most of them don’t. There’s a real problem finding the right kind of people to work in these facilities.
Assisted-living centers aren’t licensed at all?
Well, they’re licensed, only to be assisting people, not to deliver full care. They repeat offenses all the time, and they may get a slap on the hand. We need to be very tough and say ‘When this person gets to the point where he or she needs skilled care, they need to go someplace with a license for skilled care.’ They cannot age in a place when their needs are greater than that place can provide them. What we’re finding is people take in or hold onto residents who have gone over that line of independence – because that’s what it’s supposed to be, assistance only. Not 24-hour assistance with bathing, incontinence, people can’t take their own pills.
I imagine a lot of families are angry at the situation in long-term care, and it seems like the situation can only get worse because of the aging population. What do you think it’s going to take ultimately to effect change?
I really hate to say this, but when enough tragedies happen, that’s what will bring people to the table. As the horror stories mount, that’s when you’re going to finally see changes. The whole nation knows this is a critical problem. It’s been a problem for the last several years. And they’ve watched it get worse and worse and worse. The system – not the nursing homes alone – is causing neglect, abuse, malnutrition, hospital stays back and forth, because it’s not providing what it needs to provide.
