SR-106-023-02 (6)
e
\o-A
fEB 0 9 1988
Santa Monica, California
e
RP: DTA: lb
city council Meeting February 9, 1988
IP6 ..-(:)Z3-02.
STAFF REPORT
TO:
Mayor and city council
FROM:
Commission on Older Americans
SUBJECT:
RECOMMENDATION TO ENDORSE REPORT ON PROBLEMS WITH
PLACEMENT OF MEDI-CAL PATIENTS IN SANTA MONICA
NURSING HOMES
INTRODUCTION
This report requests City Council's endorsement of a newly
completed publication produced by the Commission on Older
Americans and the Santa Monica Area Health Action Coalition.
BACKGROUND
The Commission on Older Americans and the Santa Monica Area
Health Action Coalition have completed a report entitled
"Problems with Placement of Medi-Cal Patients in Nursing Homes in
the Santa Monica Area." The report addresses specific problems
and makes recommendations in connection with placement of
Medi-Cal patients in nursing homes. Nursing homes prefer not to
accept Medicaid (Medi-Cal in California) patients because of low
reimbursement rates and bureaucratic difficulties. Concern has
been expressed in Santa Monica that local hospitals are having
significant difficulties placing Medi-cal patients in area
nursing homes. Further, because of recent changes in state law,
some nursing homes have been decertifying and "discharging"
Medi-Cal patients. These placement problems have placed
tremendous physical and emotional stress on already burdened
- 1 -
lo-A
R:a 0 9 1988
e
e
patients and their families as well as on health care
professionals involved in the care and placement of Medi-cal
patients. A copy of the report is attached for council review
(Attachment I) .
The Commission and the Coalition plan to hold a press conference
in order to inform the pUblic of the existence of the report.
FISCAL IMPACT
The cost of distribution of the material will be minor and can be
absorbed within the approved budgeted amount for FY 1987-88.
RECOMMENDATION
The Commission respectfully requests that the city Council
endorse the report on Medi-Ca1 patients in nursing homes prepared
by the Commission on Older American and the Health Action
Coalition.
Prepared by: Donald T. Arnett, Director
Recreation and Parks Department
coarprt:tb
- 2 -
;
e
AM~chmc!'l'It T
PROBLEMS WITH PLACEMENT OF MEDI-CAL PATIENTS IN NURSING HOMES
IN THE SANTA MONICA AREA
--I JoInt report fram the Santa Monica Area Health Action
Coalition and the CommIssion on Older Americans of the City of
Santa Monlca*
by
Gene L. Oppenheim. M.D.. M.P.H.
Judy Gewertz. R.N., B.A.
Sharman Ober-Reynolds, R.N., H.N.
November 29, 1987
-The Santa Monica Area Health Action Coalition ($KAHAC) Is an
organization of health care consumers. providers.' and
c~nlty-based organizations which serves as an advocate at
local. state. Ind national levels for the health needs of Santa
Monica area low in-come. working class. and middle-class people.
The Commission on Older AmerIcans of Santa Monica (ODA) Ie
appointed by the City Council and acts In In advIsory and
advocacy capacity to the City Council and City Management on
matters pertainIng to older adults.
e
e
$UMMARY
NursIng homes prefer not to accept Medicaid (Medl-Cal
In California) patients because of low reimbursement rates
and bureaucratic difficulties. Concern has been expressed
In Santa Monica, CalifornIa, that the local hospitals are
having significant difficulties placing Hedi-Cal patients
in local nursing homes. Further, because of recent changes
in state law. same nursing homes have been decertifyIng and
'dumpIng' "edl-Cal patients. ~ recently sIgned state law
may solve this problem. However, these occurences have
placed tremendous physical and emotional stress on already
burdened patients and their iamllles. In addition, the
professionals involved In their care and placement have
been burdened with unusual pressures. Several
recommendations are presented which address these problems.
BACKGROUND
Medicaid Is the primary funding source for nursing homes in
the United States. Approximately forty percent of the Medicaid
budget nationwide Is directed to nursIng homes. Some patIents
enter nursing homes as Medl-Cal beneficiaries. Many others pay
their own way initiallY but receive Medl-Cal after they exhaust
their savings.
Nursing homes with low vacancy rates, however, prefer not
to accept Medl-eal recipients. For one thing, Medl-Cal
reimbursement rates tend to be far lower then the amount these
instItutIons can charge their private pay patients. Moreover,
accepting MedI-eal typically Involves a number of bureaucratic
dIfficultIes.
Santa Monica has a very high proportion of elderly
residents. Although 10.1 percent of the population of the State
of California is over the age of 65, 16.3 percent of Santa
Monica residents are over 65. This community also Is rich In
nursing home facilities. There are fourteen nursing homes wIth
a total of 1,157 beds In Santa Monica, and ten In the Immediate
surrounding area with a total of 670 beds.
At a community meeting organized by the Santa Monica Area
Health ActIon Coalition in November. 1986, several
representatIves of local socIal service agencies expressed
concern that nursing homes In the area were dropping provider
agree~ents with (i.e., decertifying from) Medl-Cal. Therefore,
it was becomIng increasingly more diffIcult to fInd places for
"edl-Cal eligible patients. Soon after thIs meeting, the Santa
Monica Area Health Action Coalition and the Commission on Older
1
e
e
Americans of the City of Santa Monica decided to study the Issue.
A report! Issued by the LIttle Hoover CommissIon In May.
1987. called attention to an additional problem, This report
noted that. although legislation passed in 1985 (Nursing Home
Patients Protection Act of 1985> prohibits the forced removal of
nursing home residents from a faCility when they .spend down-
their private funds and convert to Hedl-Cal. nursing homes can
-decertify from the "edi-Cal program. evict their Medi-Cal
patients. and then seek recertification In the Medi-Cal program
at a later date once the facilIties have increased their census
with additional private paying residents who are more
profitablel, By December. 1986. twenty-six facilities
throughout the state had decertified. causIng -the forced
eviction of more than 550 Medl-Cal residents., Same residents
had paid as much as '100.000 of their own money for cafe prior
to evIction. As the LIttle Hoover CommissIon noted. .These
residents understood at the time of their admission that the
facility would allow them to remain once they exhausted their
private funds and converted to Medl-Cal.- Involuntary transfers
were often Itraumatic. and resulted In a Ivariety of diffIcult
emot~ona\, flnancla\. and health prOblems both for the residents
who must be moved and for theIr loved ones.1 Recent legislation
has been signed into Jaw that Irequires nursing facilities
which withdraw fram the Hedi-Cal program to continue caring for
current and potentIal "edl-eal patients who are In the facility
when decertification takes place.12 It Is hoped this answers the
prOblem of placement of patients on Kedi-Cal who are already in
extended care facilities. The chief concern of this report Ls
the question of the InitIal placement of KedI-Cal patients from
hospItals and homes. and this concern Is not addressed by that
law.
METHODOLOGY
This report describes a study conducted during May and June
of 1987. It consisted of two parts. First. a survey Instrument
was administered by phone to either the facIlity administrator
or the head nurse of all but two of the 24 nursing homes In
Santa Monica and the surrounding Zip code areas. The two
exceptions consisted of a 'Iockedl faCility for mentally III
patients and a faCility which limits admission to members of a
particular secular order. (The questionnaire is included in
Appendix I.)
Second. discharge planners In the two hospitals In Santa
lNew and Continuing Impediments to Improving the Qu~llty of Life
and the Qualitvof Care in CalifornIa's Nursina Horoes--a report
of the Commission on California State Government OrganizatIon
and Economy. Prepared by Stephen R. Blum. Mav. 1987.
2AB 688 <Isenberg>. SENIORS IN SACRAMENTO. VOL. XV NO. 10. PAGE
4. OCTOBER 15. 1987.
2
e
e
Monica (Saint John~s Hospital and Health Center and Santa MonIca
Hospital MedIcal Center> were asked for Information about their
experiences placing Medl-Cal elIgible patients In nursing homes.
DIscharge planner! are employed by hospitals to coordinate the
care and placement of patients beIng discharged from their
hospitals. They typically work In conjunctIon with patients,
family members, frIends, and/or conservators.
RESULTS
(1) Phone Survey of Nursing Hames
Of the 13 nursing homes surveyed In Santa "onlca, eight had
Medl-eal certification; four lacked It~ an additional facIlity
had decertified but had plans to recertify. Seven of the nIne
nursing homes in the surroundIng area had certification.
Moreover, one facilIty located In Santa Monica was planning to
drop Its certification. and one In the area next to Santa Monica
recentlY had decertified. The latter faCility currently Is
being remodelled as a .prlvate only. facility.
Administrators and nurses at some of the facilities who do
have Medt-eal prOVider agreements stated that they accepted only
Medicare or private pay patIents but refrained from Info~lng
the public about this practice. Several respondents also
complained about the taw reimbursement rate of Meal-Cal, ~hlch.
they argued, prevented them from deliverIng high quality care.
They also complained about .hassles. with the Medl-Cal
bUreaucracy.
Overall, the nursing homes In both Santa Monica and the
surrounding area reported occupancy rates of between 90 and 100
percent.
(2) Interviews with Discharge Planners
DISCharge planners stated that, although several nursing
homes In the Santa Honlca area currently have MedI-Cal
certification. the number had dropped by fifty percent (from 14
to 7) during the past two years. Moreover. because many prIvate
pav patients eventually convert to Medl-Cal, many facilities
reserve their Medl-Cal beds for such patients. As a result, it
Is extremely dIfficult to place Medl-Cal eligible patients who
are released from their hospitals. As one dIscharge planner
remarked. "It Is with great rarity that my co-workers and I are
successful In placIng these patients locally. We view thIs as a
critical Issue and have real concern that soon no spaCe will
exist In Santa Monica for the "edi-eal status patient." A
second dIscharge planner called the problem a .human tragedy".
Three case studies reported by discharge planners at the
two hospItalS Illustrate the dImensions of this tragedy. All
three had Medi-Cal coverage.
11 Mr. B., a Chronically ill 82 year-old patient, was
3
e
e
admitted to the hospItal f~am a local nursIng home with
two stage IV decubitus ulcers and various other acute
medical problems. His hospItalizatIon lasted several
weeks; the nursing home could not hold his bed open. and
hIs wIfe. a KedI-Cal recipient as Is the patIent. could not
afford to reserve It. The patIent was quite confused and
needed total care. He was Incontinent and suffered frem
contractures whIch permanently fixed his body Into a fetal
positIon. HIs decubItus ulcers. though Improved. requIred
regular and constant treatment. A thorOUgh search was
launched by the hospital discharge planner for a bed in a
local facIlIty. Though several weeks were spent In this
search. the only avaIlable bed whIch could be located was
In Hollywood. a 40 minute drive by car and a most diffIcult
bus ride. Because the patIent could not remaIn in the
hospital IndefInitelY. the patIent's wife had no recourse
but to accept the bed.
This caused a great hardshIp in several ways. Though
the patient was confused. he always knew when his wife was
present and was most comforted by her presence. She would
no longer be able to visit dally because she did not drive
and the bus ride was too arduous. according to her
physician. She had to rely on friends and family. most of
whom worked durIng the day. In addition. because the
patient could not express his needs. his primary advocate.
his wife. would not be regularlY avaIlable to ensure that
staff were maximally responsive to him. Finally. the
patIent was forced to give up his regular physicIan. which
was extremely stressful for the patient's wife and family.
12 Mr. and Mrs. D. are in their 80's. Mr. D. has
dementia. possibly early AlzheImer's DIsease. He has a
secondary diagnosis of a previous heart attack and
respiratory problems. Mrs. D. has been caring for him at
home with little relIef for the past 3 years. The patient
has become belligerent. Incontinent at times. and
non-compliant with his medications. Hr. D. Is not elIgible
under Medicare coverage for help at home. Mrs. D. can no
longer maintain her husband at home. and has been
struggling with the guilt of placing hIm in an extended
care facility. The husband has Hedl-Cal and must be placed
In a nursing home that accepts "edl-Cal. Mrs. D.'s only
transportation is the bus. and she wanted to visit her
husband dally. No nursing home In the Santa Monica area
would admit Hr. D. because he was Medi-Cal qualified only.
He was placed in a facility In downtown Los Angeles. and
Mrs. D. was devastated. She can only make Infrequent
visits to her husband. The patient's phYSicIan of many
years WiS unable to follow him at the faCility.
.3 Mrs. W. Is a wIdowed. childless woman. Who has been
reSiding In a local nursIng care facIlIty, with only one
4
e
e
good friend as & contact. She is alert. oriented and
wheelchal~-bound. When she was admitted to the hospital,
he~ nu~slng home bed was given away by the local facility
after seven days. They then stated that they could not
readmit her. She was transferred to a distant facility
where her contact with her one signifIcant frIend. who is
also elderly, wi]1 be greatly limited.
One discharge planner commented, "These situations are
tragIc, typical and on the Increase. Our elderly deserve
better than to end up as same undesirable and unwanted
commodity--undesirable and unwanted because they will have an
adverse effect on some corporate bottom line. They deserve
dignity and adequate care regardless of their ability to pay."
CO~CLUSION
Because nursing homes have few empty beds, it Is diffIcult
to find places for any patient released from acute-care
hospitals. The problems are compounded for Medl-Cal patients.
Although a number of nursing homes have Medi-Cal provider
agreements and claim to accept new Medi-Cal patients. discharge
planners at Santa MonIca and Saint John~s Hospitals report that
they are unable to place the great majority of "edi-Cal
beneficiaries in local facilities. Patients placed In
facilities a distance from their family and friends suffer fram
both placement in the institutIon and separation from friends and
familY, Without these people to act as advocate. these same
patients often receive the poorest quality of care.
The number of nurSing homes accepting Kedi-Cal patients has
fallen dramatica]ly during the past two years and continues to
drop. One institutIon in the area adjacent to Santa Monica
recently relinquiShed Its Medi-Cal provider agreement. and one
in Santa Monica had plans to decertify. The situation has
reached crisis proportion.
RECOMMENDATIONS
1. California should enact legislation requiring nursing homes
to reserve a set percentage of beds for Medi-Cal recipients.
2. The State and federal Governments should investigate the
effect of low reimbursement rates from Medicaid for the care of
nursing home patients. In particular, It should address the
question of reasonable cost of caring for these patients.
3. The State should make timely evaluations regarding the
effects of Assembly Bil] 686.
4. The Federal Government should adopt a plan to pay for the
long term care of its growing, frail elderly population.
5
I .
. ~
e
e
'- -. ~~
. ,
SURVEY OF WESTSIOE NURSING HOMES REGARDING THEIR
MEDI-CAL PROVIDER AGREEMENT
1. Name and address of nurslng home...
2. Contact person...
3. How many staffed beds do you have?
4. What 1S your average occupancy rate (percent)?
5. 00 you have a Med1-Ca1 Prov1der agreement? Yes No
IF THE ANSWER TO NUMBER 5 IS "YES"~ SKIP TO NUMBER 9.
6. Have you had one 1n the last 3 years? Yes No
If no, why not?
7. If number 6 is yes: When was 1t discontinued?
8. If number 6 is yes: Why was it dlscontlnued?
ANSWER 9-11 ONLY IF THE ANSWER TO NUMBER 5 IS YES. IF NO, SKIP TO 12.
9. What 1S the average number of beds accupled by Medl-Cal patients?
10. Are you presently acceptlng new Medl-Cal patlents? Yes No
1,. Do you plan on maintainlng your Medi-Cal Provider agreement? Yes No
If no, when will it end?
If no, why will 1t be dlscontinued?
12. Do you have any comments?
THANK YOU VERY MUCH
AppendlX I