Ritch Steven, volunteer AARP Advocacy Network presenter and 30-year retirement-community veteran administrator, provided a wealth of excellent handouts and information on senior living options at yesterday’s lunch-time presentation. The venue was one-year-old Palos Verdes Senior Living, in Peoria. What a beautiful place! I toured the facility after the presentation with JoAnn Greeney, the center’s outreach coordinator. I was especially impressed with the wing designed for folks with Alzheimer’s and dementia issues. It was bright, warm, and cheery, with a lovely outdoor enclosed patio, and an indoor look that gave me the feel of a stroll through a 50’s-error smalltown community. At first glance, I could see myself or a loved one here.
Steven took the time before his presentation to hear from the audience about their specific concerns and questions.
Here are the myriad things we learned:
- Skilled nursing facilities are encountering huge financial challenges, being held accountable by state and federal regulators as never before. An administrator for an SNF must be licensed, with either an MBA in the field or a BA with field-related training. In contrast, hospital administrators need no license.
“Skilled nursing is the most regulated industry in the U.S., with perhaps the exception of the nuclear industry,” Steven told us.
- 1.5 million people in the U.S. reside in nursing homes or comparable senior communities.
- The variety of Arizona senior living facilities is amazing, including, for instance, 168 assisted living centers, two assisted living homes, 12 facilities offering intermediate care for the mentally retarded, 112 SNFs with dual certification, and myriad hospice centers, home care services and homes, and CCRC / life care centers. Many, if not most, are in the metro Phoenix and Tucson areas, where the most of the state’s elderly reside.
- Nursing homes average 128 residents each. These facilities face budget constraints, because as Medicare struggles with its own financial challenges it reduces the per-resident money it returns to these facilities.
- There are 1800 assisted living homes in AZ, with only 17 state employees to inspect them. They’re all regulated by the state, not the federal government. They average 118-120 beds each. These facilities tend to be owned by larger corporations who have money and reputations they want to protect. They’re either private pay or paid with long-term-care insurance. Once a resident can no longer afford the facility, she or he goes to a nursing home. Assisted living homes offer a lot more flexibility in services than do nursing homes.
- Long-term-care facilities, which, in contrast to “nursing” homes, focus on the social aspect of senior living rather than the medical. Folks living in these facilities typically have the normal aging issues without any intense medical or rehabilitition needs. Long-term care facilities are generally more costly and are paid for through private funding. They do not accept Medicare. You pay a fee to go live there and a monthly assessment on top of that. Generally they have predominantly independent living people. The average age is 75, and three out of four residents are female. Into the campus you have assisted living and home care and many times SNF or arrangements for SNF. “Their incentive is to keep you independent because if you go to their assisted living side or SNF it’s going to cost them a whole lot more,” Steven said.
- An SNF is for those who have medically complex and rehabilitation needs – it might be someone who is diabetic, and additionally has a heart problem and high blood pressure, for example.
“Once upon a time most nursing homes were long term homes locally owned and you stayed 10-12 years and paid privately or through Medicaid,” said Steven. “But as hospitals started discharging earlier people needed rehab. That’s where SNFs now come in, specializing in rehab for 14-21 days, and then the patient might go to home care. Each step down is a little less expensive and everyone is watching the dollars. SNFs offer less memory care then they used to, so now those folks usually go to an assisted living care environment.”
- 20 percent of Medicare patients who come to a hospital for a particular thing are returning 30 days later for the same issue. Steven said had that hospital kept them longer the issue might well have been resolved on the first visit. That return figure should be 8 percent, he told us.
“The largest hospital returns [for the same unresolved issue] are from home care environments,” he said. “That figure is closer to 30 percent. That doesn’t mean that home environment is bad. It means that somebody didn’t make a good decision about whether the patient was ready to return to home care.”
- The new Affordable Care Act, which took effect throughout the U.S. October 1, 2011, has hospitals scrambling. This legislation provided that if Medicare patients return to a hospital for the same issue within 30 days of their first visit, the hospital would be financially penalized.
As a result, Medicare is funding grants all over the country, so hospitals and senior facilities can determine ways to make better discharge decisions.
Catholic Health Care, for instance, with 73 hospitals in 19 states has said it would look regularly at the SNFs that its facilities send discharged patients to. They’d study the number of beds at each, the number of patients, their discharge status and their length of stay. They’ll be asking, “How many did you send back to us in 7 days, 20 days and 30 days and do you specialize in rehab?” They’ll keep track of each Functional Independent Measure (FIM) score.
CHC will ask each facility if it has done a patient/family survey and request to peruse it if so. If the survey shows need for improvement, CHC will ask what improvements are in process. Catholic Health Care will also ask, “How many people did you send to one of our ERs, where they stayed for hours , weren’t admitted but went back to you?” SNF facility infection rates will be studied as well.
“These things have never been asked before [by hospital administrators], but they’re asking now,” Steven said. “This will really produce better quality care from the hospital because it will assure better quality care from the nursing homes. As well, smart SNFs are being proactive to hospitals, saying ‘Look at how well we do, so send folks to us, hospital.’ ”
Steven gave us many ideas on how to determine if a senior facility was the right place for our loved one.
“When visiting a facility, ask for its state inspection and if not understandable to you, say ‘who do you have on your staff who could explain this?’ he said.
Other questions to ask:
- Are you Medicare and Medicaid certified?
- Was your license ever revoked? If so, tell me more about that.
- How long has the current administrator been at this facility? (Annual turnover is 55-60 percent, due to low pay, long hours, hard work.)
- Do you have a director of nurses? How long has that person been here?
“Those two people [administrator and director of nursing] do more to define the standard and quality of care than anything else,” Steven said. “People define the quality, not the pretty buildings. It’s a people-intensive industry.”
Other assessment suggestions:
- Visit the facility unannounced at 3pm Sunday, the lowest staffing time of the week. You end up with a tour with someone at a lower level of authority who might be apt to speak more freely. Then go again, at different times of different days.
- Use the smell test. Every facility will smell once in awhile. But it shouldn’t happen each time you’re there.
- Ask to see a menu. Ask, “If I had a special food need how would you take care of it?
- Facilities who pass inspection with no deficiencies are not inspected by the state for another two years. So ask what has changed since the last inspection. A LOT can change since then.
- Arizona Care Check – a state dept. of health services site that provides a three-year history of all senior facilities in the state. You can see state-run-survey results, complaints, and enforcement actions.
- http://www.medicare.gov/nhcompare – I tried out this helpful online resource myself, asking to peruse nursing homes within 10 miles of my home. There were ten, and their overall ratings ranged from one to five stars. Ratings were also visible in each category studied. These included health inspections, staff, and quality measures. About each it displayed participation (or not) in Medicare and/ or Medicaid, number of certified beds and the type of ownership. What I found interesting was that the one with the best overall, and category-specific ratings, Maryland Gardens Care Center, is a for-profit center and also the smallest. It offers both SNF and assisted living levels.
“We don’t do linear aging in this country,” Steven told us, towards the end of his presentation. “People bounce back and forth between the levels all the time. It’s amazing how people recover these days. So just because you’re in an SNF DOESN’T mean you’ll always be or you’re on the way out. Picking quality care is about your proximity to people who love you, want to come see you and care about you.”