Kicked to the Curb: Nursing homes reveal their profit-minded side
Rose was sitting comfortably in her bedroom chair when an attendant walked in with a wheelchair and helped her to be seated in it. She knew she would be off to her morning activities. Today, however, the morning activities were dramatically different from those she had experienced in days past.
Outside, the spring air was crisp with a hint of the sun beaming through the morning clouds. Wheeling toward the front doors, Rose thought this might be an unexpected day trip to some pleasant area where she could enjoy the interaction with a fellow resident. Rose was wrong.
A small van, equipped with a sliding door that would accommodate her wheelchair and lift her into the van, pulled up to the curb. The attendant wrapped Rose in a blanket and waited patiently for the driver.
Once inside the van with her wheelchair strapped securely into place, Rose was off and alone in the van except for the driver. Where could she be going? The van was usually filled with other residents. Today, she was the only one in it. Was this something special?
Yes, this was something quite special. Rose would not be the only one to take one of these “special” trips alone in the van. The elderly resident with a hearing deficit and who was outspoken in her opinions was taken to the doors of the local hospital emergency room. Once at the hospital, Rose would be dumped for “psychiatric evaluation.”
The nursing home claimed she’d been irascible, refusing to follow staff orders and instigating arguments between residents; all of it was untrue. Rose had opinions and valued her independence, but the nursing home found this upset their routine with otherwise subservient residents.
Insurance dilemma for the elderly
The Centers for Disease Control (CDC) indicates that the number of nursing homes in the United States in 2016 was 15,669. Sixty-nine percent of these were for-profit nursing homes. The number of licensed beds in these facilities was 1.7 million. The number of residents living in nursing homes, according to the CDC, numbered 1.3 million in 2015.
“In 2016, there were an estimated 286,300 current participants enrolled in adult day services centers, 1,347,600 current residents in nursing homes, and 811,500 current residents living in residential care communities. In 2015, about 4,455,700 patients were discharged from home health agencies, and 1,426,000 patients received.”
Residents, who enter with private funding disallowing them Medicaid, use up their funds and Medicaid may not be an option. They are left penniless without any insurance and the bill must be paid.
Unscrupulous nursing home operators have found a way around regulations that would require them to keep long-term nursing home residents within their facility on Medicaid. Some facilities limit the number of beds allocated for Medicaid patients.
One thing that the insurance companies require is that once a patient reaches a certain point in the number of days they have been in the nursing home, no more payments are available. But that’s only a mild blip in the flow of payments.
Realizing that this is a deficit situation for them, nursing home operators will do one of two things. First, they may deliver the patient to a hospital emergency room in distress of some type. Second, the staff leaves the patient at the door of the hospital emergency room. The resident is usually in a wheelchair without accompaniment. It is an abominable practice of “eviction” through no financial resources.
If the patient is admitted for three days, they can be readmitted to the nursing home, and the payment clock begins again.
When a nursing home resident is a patient in a hospital and is considered ready for discharge, the nursing home may refuse to take them back. The refusal is based on several factors, which may include an inability to manage a psychiatric disorder or an extremely combative patient or they require services the nursing home cannot provide. Payment is never mentioned.
Of course, charting in the nursing home will have been prepared to substantiate these psychiatric claims. Sometimes, when the patient is on psychotropic medications, the staff will be instructed to stop the medicine. Documentation will verify that this was “medically necessary”. The patient’s symptoms then re-emerge.
This re-emergence makes it possible for the nursing home to report that they are unable to care for someone in such psychiatric severe distress. It has been my professional experience, working at a very large psychiatric hospital, that the elderly were left at our hospital door. After a few days of psychiatric evaluation, almost 100% of the time the nursing home refused to readmit the patient.
One resident stated the situation in these words, “You’re just a piece of garbage.”
Who’s on the case?
Advocacy groups and states are acting on behalf of nursing home patients and the elderly. The patient-advocacy group, California Advocates for Nursing Home Reform, has provided a rationale for the situation.
“Perhaps the main reason for hospital dumping is that it’s highly profitable for nursing homes. Residents who are refused readmission following a hospitalization are almost uniformly Medi-Cal beneficiaries. Replacing a ‘Medi-Cal resident’ with a resident whose stay is covered by Medicare can garner a facility tens of thousands of dollars in additional revenue over the course of a few months.
“From the dumped resident’s perspective, they are utterly abandoned, not only losing their home but also their care services and the relationships they may have developed with staff members and other residents. The loss of the nursing home bed eviscerates the resident’s sense of safety, exploiting their vulnerability, and powerlessness. The loss of one’s home, without warning or legal remedy, can cause incalculable upheaval and damage. Residents who are dependent on others for most or all of their care needs are particularly vulnerable to transfer trauma that can send their health spiraling downward and occasionally cause death.
“The illegal dumping of nursing home residents into hospitals is also a tremendous drain on state resources. Residents who needlessly sit in hospitals often spend weeks or even months in residential limbo, while running up an expensive bill paid for by the state.”
The group sponsored AB 1752 (Yamada), the Bed-Hold Protection Act of 2012, which imposes mandatory, daily fines on nursing homes that refuse to readmit residents.
AARP (formerly the American Association of Retired Persons) has also indicated they support changes to protect elderly nursing home residents from illegal evictions, aka, dumping.
“We appreciate that CMS (Centers for Medicare and Medicaid Services) plans to examine and mitigate the illegal discharge — or ‘dumping’ — of residents of federally funded long-term care facilities,” said William Alvarado Rivera, AARP Foundation’s senior vice president for litigation. “We urge CMS — as we have in the past — to use all available enforcement tools at its disposal to ensure that states and facilities comply with the laws that protect vulnerable residents from being involuntarily removed from their homes.”
A burgeoning aging population means there is a growing need for various types of care, whether it be in nursing homes, residential care facilities, or group-home situations. The demand will be great, but the protection of patients’ rights and their dignity cannot be overlooked in the mix. Dumping patients is anathema to all that this country stands for in terms of care of our elderly.
The opportunity for creativity in care and facilities for both the aged, who can no longer care for themselves in their homes or those who have disabilities, should be viewed in a positive light. The light, however, must not shine on only the financial gains but the emotional benefits, as well.
An Initiative to Address Facility Initiated Discharges that Violate Federal RegulationsCA Advocates for Nursing Home Reform (CANHR)
Centers for Medicare & Medicaid Services
Long Term Care Community Coalition
Quality of Mental Health Care for Nursing Home Residents: A literature review