Paula Span, The New York Times
December 6, 2011
The resident will hear The Question again every three months, when her condition is reassessed. She’ll hear it if there’s a significant change in her condition. Whatever her health issues, whoever is paying the bill, Medicare regulations adopted in October 2010 mandate that she (or a family member or guardian, if she’s not mentally competent) be asked it.
A nursing home resident has always had the legal right to leave. In the past, though, “the question was asked, and nothing had to happen as a result of the answer,” said Barbara Edwards, director of disabled and elderly health programs for the federal Centers for Medicare and Medicaid Services.
Now, The Question has been reworded to make its point — you can go home again — more explicit. As important, a resident’s “yes” now triggers contact with an outside agency that will explain how going home might work.
All this can startle or irritate a new resident’s unwitting relatives. “For most family members, it’s taken a long time to convince a loved one to move into a nursing home,” said Lori Smetanka, director of the National Long-Term Care Ombudsman Resource Center, who’s been hearing an earful about the change.
Now, before a resident has fully unpacked, she said, “Here’s the facility asking, ‘Do you want information about moving out?’ It’s caused some real problems.”
You can imagine. So federal officials are reworking the regulation. By April, the resident will be asked whether she wants to hear The Question every quarter. If she declines, she’ll only hear it annually. But she’ll hear it.
The fact that it’s being asked so frequently reflects a fundamental shift in how the federal and state governments view long-term care. For decades, advocates protested that Medicaid, which pays for most long-term care, was spending way too much on care in the places nobody wanted to be — nursing homes — and very little on care in the places almost everyone preferred — their homes, or as close to home as possible.
The effort to change that, called “rebalancing,” has made progress. In 1999, nearly three-quarters of Medicaid dollars went to institutional care, only 27 percent to home- and community-based services. A decade later, spending on institutional care had declined to 55 percent, with about 45 percent going to home and community services.
A program called Money Follows the Person, adopted in 2007, and provisions in President Obama’s health reform law have accelerated that process. Now, some states spend most of their Medicaid budgets to help maintain older and disabled people in their own homes and apartments or in assisted living. Most of the rest are scrambling to follow suit.
Nursing home populations and occupancy rates have been falling for 20 years. With states now moving thousands of Medicaid recipients out of nursing homes, that’s a trend likely to continue, especially since nursing homes are almost always the most expensive option.
“It’s been a tough road for states to set this up,” Ms. Edwards said. Cuts in nearly every state’s social services budgets haven’t helped.
Moreover, many residents are too frail and sick or too demented to function well outside a facility, even with home care aides and meals on wheels and other kinds of support. Or they may fear living alone and answer The Question with a firm no.
“We don’t want to move people out of a nursing home into isolation and depression and decline,” said Sondra Everhart, state long-term care ombudsman in New Mexico, who directs a staff of four helping residents move. “That’s not a successful transition.”
But the exodus, though still modest, is happening.
Texas, a leader in this respect, helped more than 5,000 people move from nursing homes to community housing from 2007 through June 2010. Michigan, New Mexico, Oregon and Washington also have strong programs.
Mississippi and New York, on the other hand, still spend far more money on nursing homes. Between 2003 and 2009, nursing home occupancy barely budged in New York and actually increased in Mississippi.
“The biggest barrier to transition is housing,” said Ms. Everhart. After a couple of months in a facility, old people may no longer have a home to return to, if they gave up an apartment or sold a house and dispersed most of their possessions. Moving into assisted living, which most states classify as returning to the community, may not be what they had in mind.
“At least, it’s not a hospital bed,” Ms. Everhart said.
Her office has also learned that nursing homes are not so keen on discharging residents. “They make money keeping you in,” she pointed out.
But hundreds of New Mexicans are, nonetheless, making the transition. Later this week, I’ll tell you about a 92-year-old who has, so far, pulled it off.