Calling all 77 million baby boomers! This blog site encourages feedback and discussion on how we will spend our concluding years and what quality of life we will have. Change is needed -- we, the people need to fuel change before our time comes!
Google PageRank Checker - Page Rank Calculator

Tuesday, August 21, 2007

The Long Term Care Staffing Connundrum

Elderpride: Chapter 6

We have discussed the underlying payment methods to nursing homes and how the manner in which they have been structured leads to problems in the Long Term Care industry. But that is only the tip of the iceberg. Let’s pile on another layer….let’s start examining what it costs we,the people to care for patients in skilled nursing facilities and nursing homes. The layers are ultimately all connected and interwoven, but by examining them one at a time, I hope to increase your understanding of the magnitude of the multiple issues facing legislators, nursing home administrators, physicians, nurses, therapists, and aides; and, how those issues are in the forefront of what patients and families experience. It is frustrating for everyone involved and a very heavy burden for families and patients.

There are many things that happen in a nursing home that make the administrator and staff feel like victims of the system. We will just talk about one of those today. Let’s begin with the staff that cares for our loved ones. We all want to see people paid fairly for a day’s work – what I am talking about are the hidden costs involved in employing staff in the Long Term Care industry.

If you can, put yourself in their place for a moment, think about coming to work everyday, and each day a quarter of the staff doesn’t show up. Yes, that’s right – 25% of the staff, on average, call in sick on any given day! I suppose some are legitimately ill, however I think many of the “call-ins” are due to frustration with the work environment, discouragement with the system, disenchantment with the work, and lack of a plan to improve their circumstances.

The daily round of the Nursing directors include hours on the phone trying to find someone to come to work on their day off to fill vacancies left by “call-ins”. As the days go by staff begin telling the nursing director they have plans they can’t change that day – or they don’t answer the phone at all, now that Caller ID tells them they are once again being asked to work an extra shift. Aggravating to both the Nursing Director and the staff, there seems to be no way out of what they see as their plight. Whether you are the Nursing Director who is responsible for seeing that all the patients are cared for, or the staff who is continually asked to work extra shifts, job satisfaction is less than what any of us would want for ourselves.

The cost of absenteeism to the industry as a whole is $832 million annually in “sick pay” and replacement costs. Even if we could afford this price tag who wants to live this way? Productivity suffers. Morale suffers. Imagination for creating a better environment suffers. Going all out for the patient suffers. Reimbursement suffers. We have come full circle!

Added to this staffing concern is another even bigger concern. The average turnover of staff on an annual basis is 89%. Astounding, yes – but understandable when given the environment created by the issues we have already discussed. This kind of turnover generates another series of problems. When 89% of the nursing home staff is turning over each year, the staff available for your own elderly parent has likely only worked at the nursing home for 6 months or less. The corollary to that is the staff member you are meeting today is likely to be leaving for another job within the next 6 months. What is the motivation here for the staff members to get to know your auntie? Or your Mom?

Is it important that the staff understand that your Mom is a diabetic and shouldn’t be allowed to have cake at the birthday party being held in the dining room? What about your auntie? Is it important for staff to understand that she was an artist in her own right and has only had fuzzy thinking since her stroke? Yes, to both of these questions. It is important that your Mom and your auntie be well known to the staff in order for the staff to provide the best care; in order to provide Elderpride. Treating patients as the individuals they are is the hallmark of Elderpride. Treating patients as though they have lived their life and are now expendable is part of the problem we see in nursing homes.

There is a big price tag to the employee turnover that is rampant in the industry too. It is costing the American taxpayer a lot of money. The cost of employee turnover in nursing homes is an astonishing $7.1 billion each year in recruiting and training new staff.

It is an easy leap from here to see that accountability for the right task, at the right time for the right patient is impossible to establish. Administrators live in fear that the dedicated staff who do show up for work when they are supposed to will crumble under that kind of pressure. The resulting low productivity costs from absenteeism, high turnover and the paucity of accountability for the work performed is costing we, the people another $13 billion.

It seems to me there is a lot of room for improvement here. In how the industry faces issues, how these issues are allowed to impact the very people charged with the care of our loved ones and how our nation spends its tax dollar on eldercare.

Tuesday, August 7, 2007

Medicaid Reimbursement – Yet Another Puzzle Piece

Elderpride: Chapter 5

In a similar fashion to Medicare, Medicaid also reimburses nursing homes for care of patients and residents. I have an opinion about what makes an individual a resident of a nursing home rather than a patient. Shouldn’t nursing home care be transitional? And resident implies that this is where you live! I don’t want to live in a nursing home! Do you? I don’t want to be a resident! Do you? So in this blog we will always refer to individuals being treated in nursing homes or skilled nursing facilities as patients.

Medicaid is partially funded by revenue sharing to the 50 states from the federal government. The individual states also provide funding to the program. And the individual states are able to determine who qualifies and who does not although there are some broad federal requirements as well. Medicaid is basically healthcare provided for low income populations with a focus on children, pregnant women and the elderly. Therefore states may differ in who qualifies for Medicaid and who does not. The view I am giving here is a global view and there may be differences state to state. I encourage you to check your individual state requirements by searching on “Medicaid your state”.

Medicaid basically covers non-rehabilitative and unskilled care for elderly persons. This means care that usually can be given by an untrained person. No education or licensing is required for unskilled care. Some of the non-rehabilitative care may be given by licensed practical nurses, however it is not at the same level as skilled care covered by Medicare and does not cover therapies. Most states require that the individual is poor. This means if you are not, then you will need to spend down your assets to a specified level. In my own state, if there is a spouse then an individual can have a house, a car and enough money in the bank for burial – and that is all. If they individual does not have a spouse then they can only have enough money in the bank for burial. A patient must apply for Medicaid and qualify in order to receive these benefits. Once approved, however the individual is a Medicaid recipient.

Once an individual spends down their assets, they have fewer choices about their care. The patient (Medicaid recipient) is totally dependent upon the system at this point and if the system fails them, they are doomed. They will have no funds to implement another solution.

The reimbursement system works much like Medicare in that the nursing home completes a claim for services rendered and submits it to the appropriate state office. The claim is reviewed and either approved or denied. A denial can be appealed. However the similarity ends there. Medicaid coverage is much less of a mystery and the provider (nursing home facility) usually knows what is covered in advance because it is much more “cut and dried”. Therefore, there are fewer denials. Consider however that we are talking fewer dollars because skilled care is not covered by Medicaid and unskilled care is paid at a much lower rate. The rate varies state by state. Therefore, even though the dollars are more of a “sure thing” than Medicare, it is fewer dollars and unless a Long Term Care facility has a high percentage of “private pay patients” (patients who are paying the nursing home bill themselves, frequently in spend down mode), they cannot make it financially on Medicaid patients alone. The term “payer mix” refers to the ratio of patients who are on Medicare, Medicaid and Private Pay.

Many SNF and nursing homes are teetering on the brink of financial disaster if their payer mix is tipped toward the lower paying Medicaid patients. This impacts what they can offer patients in terms of treatment as well as amenities although what is considered an amenity (buildings in good repair, for instance) in a nursing home might be thought of as basic by most of us.

And yet, because the dollars lean towards being a “sure thing”, the tendency to move patients off Medicare, into spend down and subsequently Medicaid is rampant in the industry. And I don’t think it is even done consciously, it is simply done because it works marginally. But guess who is caught in that net? Yes, of course, the patient because had they received their full entitled Medicare benefits instead of the shift to spend down/Medicaid, a high percentage would be discharged home or graduate to a lower level of care. And, as I am going to show you later, restoring patients would save the government lots of dollars.

Please feel free to comment or share your stories of eldercare on my blog. It will take a nation to change things – that means all of us. I will try to be a catalyst, but I can’t do it alone!