Nursing Home Care Is Found Wanting

Source: AARP Bulletin Today | June 23, 2003

Armed with a new federal study that details inadequate staffing in more than 90 percent of the nation's nursing homes, some Capitol Hill lawmakers are stepping up their efforts to impose minimum standards on the industry.

The draft study finds that the vast majority of the nation's 17,000 nursing homes have too few workers to care properly for residents, putting them at significant risk for such health problems as bedsores, bloodborne infections, dehydration, malnutrition and pneumonia.

The Bush administration had not yet officially released the two-volume study, which was prepared for the Department of Health and Human Services, as the AARP Bulletin went to press. It was expected to submit the final report to Congress in late March or early April.

"The study confirms what millions of nursing home residents know all too well—that their care and their health often suffer because of inadequate staffing," Rep. Henry A. Waxman of California told the Bulletin. Waxman, the ranking Democrat on the House Government Reform Committee, has introduced legislation that would mandate minimum staffing levels for most of the nation's nursing homes.

"We're going to be stepping up our efforts to get minimum standards," Rep. Jan Schakowsky, D-Ill., told the Bulletin. "This new report dramatically confirms everything we've been hearing. We can't afford to keep putting the issue on the back burner."

The nursing home industry blames inadequate reimbursement rates under the Medicaid and Medicare programs for the chronic understaffing. Residents covered by Medicaid, the federal-state program for low-income Americans, account for about two-thirds of the nation's 1.6 million nursing home residents.

The industry has been lobbying Congress to increase the rates nursing homes receive under the two programs, or at least to block cuts in Medicare that are scheduled to take effect on Oct. 1.

Charles H. Roadman II, M.D., president and CEO of the American Health Care Association, says the nation's nursing homes are "losing money" because Medicaid and Medicare are "too underfunded" to provide adequate reimbursement rates.

"Our nation has no long-term nursing care strategy," Roadman told the Bulletin. "Medicaid and Medicare are not a strategy. We've got to transition to a long-term care public/private insurance program in order to take care of those 80 million people who'll need these services by 2050. The further we go into the future, the more trouble we'll be in."

A MATTER OF MONEY?

In 1987, responding to a study by the National Academy of Sciences that found many residents received "shockingly inadequate care," Congress passed the Nursing Home Reform Act. The law requires nursing homes to have "sufficient nursing staff" to care for residents but contains no minimum staff-to-patient standards.

Although a chapter of the HHS study—written by experts in geriatric care—suggests that "some minimum staffing ratio is needed to protect nursing home residents," the Bush administration has said it has no plans to implement minimum standards or propose additional funds for nursing homes.

The study estimates it would cost at least $7.6 billion for the nation's nursing homes to reach adequate staffing levels—chiefly by hiring at least 77,000 more registered nurses, 22,000 more licensed practical nurses and 181,000 more nurse aides.

The typical nursing home resident, according to the study, requires an average of 4.1 hours of care each day—2.8 hours from nurse aides and 1.3 hours from registered nurses or licensed practical nurses.

Sen. Chuck Grassley of Iowa, the ranking Republican on the Senate Finance Committee, says the correlation between low staffing levels and inadequate care "is staring us in the face." But he has repeatedly expressed misgivings about writing what he calls "a blank check" to the nursing home industry.

"The answer isn't to give more money to the industry," says Toby Edelman, an attorney in the Washington office of the Center for Medicare Advocacy. She says the government reimbursement rates to nursing homes more than doubled from 1992 to 1998, but even then "the facilities still didn't put that money into staffing," choosing instead to use it to finance takeovers or boost profit margins.

The American Association of Homes and Services for the Aging, which represents not-for-profit nursing homes, opposes minimum staffing ratios. But William L. Minnix, Jr., its president and CEO, says the organization's members don't object to having Congress stipulate that increases in Medicaid and Medicare spending go directly into higher wages for direct-care staff.

The debate "always comes down to the … trade-off between costs and improvement in care," says Janet Wells, the director of public policy for the National Citizens' Coalition for Nursing Home Reform in Washington. Wells says most progress is likely to come in the states, some of which have already enacted more stringent staffing requirements.

AARP has mounted campaigns in the states to improve the quality of long-term care. It backs mandated staffing levels for nursing homes as well as strong enforcement of standards, including action against facilities that fail to maintain sufficient staff. It also supports better training and pay for direct-care staff so that nursing homes can hire and retain the employees needed to provide quality care.

"We're advocating more adequate staffing in the homes as the foundation for good quality care," says AARP policy director John Rother. He adds that some nursing homes already provide high-quality care.

LACK OF FEDERAL OVERSIGHT

Some experts say the deficiencies documented in the latest study—and mirrored in numerous government reports over the past decade—are attributable, at least in part, to a lack of aggressive federal oversight.

"The federal government has been lax in holding states accountable" for regulating nursing homes, says Walter Ochinko, an assistant director of the General Accounting Office, the investigative arm of Congress. He says it wasn't until the late 1990s that nursing home operators were sanctioned for harming residents. Even then, he adds, "it didn't happen very often."

The HHS study cites the low pay, meager benefits and difficult working conditions at many long-term care facilities. Many nurse aides earn little more than the minimum wage and receive inadequate training for demanding jobs that call for them to monitor and care for residents and to move frail and disabled residents with little or no assistance. By some estimates, annual staff turnover in the nursing home industry is as high as 100 percent.

Some 27 members of the Senate, led by Barbara Mikulski, D-Md., and Tim Hutchinson, R-Ark., have introduced legislation that would establish a "Nurse Corps" scholarship program and finance recruitment and retention programs aimed at addressing the nationwide shortage of nursing personnel. "There is no doubt," Hutchinson says, "that there is a correlation between adequate staffing and quality health care."

NEW NEWS OR OLD NEWS?

To some, however, the new federal study—which Congress ordered in 1990 and was supposed to have been completed by 1992—seems like so much old news. For decades, federal and state investigations of nursing homes have repeatedly documented widespread understaffing, the misuse of medication and restraints and even the physical and sexual abuse of residents.

Anna Spinella of Tampa, Fla., has seen it all firsthand. Spinella, 67, had to move her own relatives from nursing home to nursing home in a futile attempt to find adequate care. The experiences so dismayed her that she formed Advocates Committed to Improving Our Nursing Homes, a Florida-based advocacy group.

"I had three family members in nursing homes at the same time," Spinella told the Bulletin. "Their day-to-day care just stunk. They were left unchanged, unfed and unwashed. The only care they get is while you're standing there [watching them] or doing it yourself."