Elmhurst Extended Care has been recognized as a leader in nursing home “culture change” efforts, which seek to improve quality by caring for each person as an individual, creating homier, less-institutional facilities, and empowering the staff to do their best.
The 194-bed nonprofit home has also worked to diversify its services and revenue stream, setting aside 20 beds for short-term, rehabilitation-focused stays covered by Medicare – and on the other end of the spectrum, a specialized unit for people with dementia.
There are a few residents, administrator Richard E. Gamache will acknowledge, who could live at home with the right services, or in an assisted-living or other less-restrictive facility.
But they lack the money or the family support, so they’re here instead, paid for by Medicaid.
And they need a lot of care, Gamache says. Overwhelmingly, the seniors at Elmhurst are so sick and so frail that they can’t do without 24/7 skilled care. And Gov. Donald L. Carcieri’s deficit-closing plan, Gamache and others in his industry say, threatens that care.
Carcieri wants to save $67 million by reforming the long-term care system so more seniors get home- and community-based care instead of going into nursing facilities. The state’s nursing home population, now about 6,500, would be cut by more than 600, starting July 1.
Not only are the alternatives cheaper, Carcieri has said, but they’re preferred by most seniors and their families, and they result in greater longevity and improved quality of life.
“We have one of the highest percentages of seniors in nursing homes when compared with other states,” Carcieri said in his State of the State address last January. “5.2 percent of Rhode Island seniors are in nursing homes, more than twice the rate of leading states. We will change that emphasis… our seniors deserve to live independently and with dignity.”
The problem is – and on this the nursing homes are backed by a chorus of advocates for the elderly, including Lt. Gov. Elizabeth H. Roberts – that human services officials have yet to say how they’re going to make that change, other than to say that for seniors, it will be voluntary.
And even if the shift is seamless, nursing home operators say they fear they could be driven out of business. That’s because not only will they have less revenue overall, but the residents they’ll keep will be, on average, sicker, so they’ll need proportionally more services – meaning a 10-percent drop in residents, for example, can’t be offset by a 10-percent cut in staff.
“What the governor is doing is creating policy based on fiscal need, trying to use the budget… to dictate health care, and I think that’s dangerous,” Gamache said. Plus the rush to cut spending by July 1, he added, creates a greater risk that seniors will be “railroaded.”
“The governor’s staff is saying, ‘We’d love to design a good program, but we don’t have time… we just need to get this done,’” he said. “That’s a scary proposition.”
Moreover, Carcieri also plans to save $2.4 million – industry leaders say it’s more – by cutting back on payments to homes such as Elmhurst that spend more than average on labor (now anything above 125 percent of the average is denied; it would drop to 110 percent).
Combined with a delay in an inflation adjustment valued at $1.9 million, and the loss of matching federal dollars, the Rhode Island Health Care Association, which represents nursing homes, says those two cuts alone would cost the industry $9 million.
Add the expected drop in residents, and the impact would be even greater. For Elmhurst alone, Gamache said, it would be about $1 million out of its $16 million annual budget, or 10 percent of its main source of revenue, Medicaid. That could be devastating, he said.
“Nursing home care needs to be better, and this is a formula that will cause it to deteriorate,” he said. “I think you will see some good elder care organizations that will close … and you will see people who remain in the field become very disenchanted. … I think it’s going to be the beginning of the end.”
Yet outside the nursing home industry, the predictions are not so dire.
That’s because the principle at the core of Carcieri’s plan – that seniors should be cared for at home or in the community to the extent possible – is widely embraced by advocates for the elderly. It’s the basis of a 2006 reform passed by the General Assembly that sought to gradually steer resources away from nursing homes and into community-based care.
It’s also the basis of two pieces of legislation being considered by the General Assembly now: one requiring that by July 1, 2009, the R.I. Department of Human Services have a system in place to screen seniors and steer them, in an expedited fashion, toward the “least restrictive setting” where their needs can be met, and another calling for 50 percent of the state’s Medicaid long-term care funding to be used for home- and community-based services by July 1, 2012 – up from 10 percent now.
Roberta B. Merkle, president and CEO of Cornerstone Adult Services Inc. in Warwick and an active member of the Rhode Island Senior Agenda Coalition, which supports the reforms, said “in concept,” she supports the governor’s plan, “but I think it’s important when we make a shift that we have all the components in place.”
There are plenty of organizations that can meet seniors’ needs, Merkle said – Cornerstone itself has an Alzheimer’s unit and serves people with severe disabilities and medical problems – but too many families and even doctors aren’t aware of these options.
“I think the problem that we see is that people think they don’t have a choice,” she said. And while most people in nursing homes may need to stay there at this point, she added, “it’s about the 80 or 90 percent of people in the community” who can still avoid institutions.
The current system also makes it easier to go into a nursing home than to get community-based alternatives, Merkle noted, because the latter can involve long delays, whereas nursing home admission can be immediate, so that hurdle needs to be removed as soon as possible.
Roberts, who was involved in the 2006 reforms, backs the current proposals. Last week she led a state Long Term Care Coordinating Council meeting to push for details from state officials on where the governor’s plan stands, said things could go badly, or they could go well.
“I think many on the Long Term Care Council want to be their partners in making this happen,” she said. “My big concern is that if it’s not done right, we could move backward instead of forward. We need to invest in community-based services. We need to know that people know what they are and how to access them. And in fairness to nursing homes, as their patients are sicker, we need to pay them to care for those sicker patients.” •
