A new "snapshot" report on the state of California nursing homes has been published by the California Healthcare Foundation. This report suggests at least in this state there is cause for concern. Link to the California Healthcare Foundation See attached PDF of the report:
Download FragileNursingHomeIndustrySnapshot2005.pdf
WHY SHOULD THIS BE OF CONCERN TO THOSE OF US IN PALLIATIVE CARE?
It is increasingly likely that Americans will spend some time in a nursing home prior to death and that more of us will likely die in nursing homes. If this is news, it probably is not welcome news. The reasons for this are complex, but relate to an aging population (baby boomers coming 'on-line' as elders), gender roles (women less likely to accept caregiving roles at home because of dual incomes etc.), and geographic dispersion (children moving far from parents etc.) Nursing home deaths will likely rise to greater than 40% of all deaths from the current 25% over the next decade or so.
Despite what has been called the "demographic imperative" driving a need to build nursing home capacity, in many regions (definitely in California) there has been virtually no growth in nursing home capacity in our state. As outlined in the report, currently 45% of all California nursing homes are running in the red - not exactly a great recipe for growth. If, as I would predict, demand soon exceeds capacity, a number of bad things will likely happen (and likely are already happening sporadically):
1. Nursing homes will "cherry-pick" for high paying, medically straightforward patients.
2. Other, less desirable patients (poor, medically complex, the dying) will "stack up" in other venues, unable to admit their patients. Families (and hospices) struggling with a a family member at home may have little option but to to struggle a little harder and longer or.... Have their loved one admitted to an acute care hospital, where they will similarly "stack up" waiting for a nursing home bed. The result will likely be systemic "impaction," which will, in the long run, cost all of us a lot of money and a great deal of anguish.
3. Dying patients in nursing homes are somewhat more complex and need special attention. If the system is stressed, as the current report strongly suggests, it seem probable that the quality of care dying patients who do manage to get into nursing homes will receive will likely fall.
Personally, I would peg my odds of dying in a nursing home (currently being 52) at roughly 50-50 in my lifetime. Already, my odds of receiving some care in a nursing home prior to death are greater than that (about 65%). Given this and similar reports, I'm worried about the type of care I might receive. It is probably safe to guess that most of us hope we will avoid nursing homes in our old age - I certainly do. But would our attitudes toward nursing homes change if we viewed the possibility of nursing home care for what it may in fact be, a probability? Perhaps then as a culture we would get serious about building a nursing home culture which is true to the mission implied in the term - a home where we could be kindly and respectfully nursed.
So for readers - don't know how things are going in your neck of the woods, but here's the progress report from sunny California:
Key findings 2003 data (copied from summary of Snapshot report):
- Only a small percentage of the state’s freestanding nursing homes meet the standards recommended for staffing levels to provide good nursing care.
- Continuing high staff turnover threatens quality of care. More than two-thirds of the nursing staff in
California’s nursing homes left their jobs in 2003.
- Many residents show clinical signs of poor care as a result of being left in bed all or most of the time, or being placed in physical restraints.
- Most nursing homes do not meet government compliance standards for care and safety. Fifteen percent of homes were cited for very serious quality of care problems or substandard care, which causes harm or jeopardy to the health of residents. Some 77 percent had serious noncompliance with federal care and safety regulations during their most recent mandatory inspection.
- Half of the state’s nursing homes reported negative or zero profit margins.
COMMENTARY ON REPORT:
The findings of poor quality of care are obviously concerning (especially for all of us who live in California.
I would highlight a few specific findings:
· Only 5% of nursing homes meet CMS (Medicare and Medicaid) staffing guidelines of 4.1 hours per patient day. 24% of nursing homes had less than 3.2 hours per patient day.
· Use of physical restraints (15%) is more than twice the national average (7%)
· 88% of facilities were found to be in either serious or very serious non-compliance with federal care and safety regulations on their last inspection. (Only 8% of facilities found to be in compliance or substantial compliance.)
The document also demonstrates that over 2 years (2001-2003) the number of facilities with either zero profit or a negative profit increased by 30%. Currently, 6% of nursing homes showed no profit and 45% were in the red. While not included in this report, prior projections (predicting exactly what happened – an increasing number of nursing homes running in deficit) are for decreases in the number of nursing home beds (capacity), as nursing home companies pull out of the state (or the business) at the same time demand for beds will increase with the baby-boomer generation coming on-line. This bodes poorly for future nursing home capacity in California.
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