Sacramento Bee

November 27, 2004

Nursing Homes as Default: U.S. Chides state on Community Care Access

by Nancy Weaver Teicher, Bee Staff Writer

Five years after the U.S. Supreme Court ruled that the elderly and disabled should be able to live in the least restrictive settings, California has yet to act, leaving them in nursing homes, federal officials say.

Advocates backed up by a federal investigation accused the state of a "one size fits all" philosophy on indigent patients who need long-term care: sticking them in a nursing home.
That means many elderly and disabled people are robbed of a better, more independent life with community-based services, advocates say. The U.S. Justice Department said the unnecessary institutionalization amounts to discrimination.

Taxpayers have a stake because the nursing-home route is the most expensive option in many cases, according to cost estimates.

The entire system is flawed, said Cynda Rennie, a Sacramento elder care consultant.
The ongoing Justice investigation concluded in August that the state has failed to ensure nursing home patients access to community-care alternatives.

Community care can include adult day health care, personal assistance in the home, assisted living or residential care facilities for the elderly.

R. Alexander Acosta, assistant attorney general for civil rights, chided state officials that the court's landmark ruling in the Olmstead case "made clear that unnecessary isolation of individuals with disabilities in institutions, including nursing homes, is discrimination."

Stan Rosenstein, deputy director of medical care services for the state Department of Health Services, declined comment on the federal charges, saying his staff is assessing the findings.
But he said the state has created several small but "cutting-edge alternatives" to nursing homes that have helped keep their patient numbers from growing over the past decade.
The federal probe of a 1,200-bed nursing home in San Francisco found that the state routinely authorized placements without assessments to see if home or community-based care would be appropriate.

The Little Hoover Commission has estimated that one-third of those in nursing homes could be cared for in their communities with local services. Rennie believes it's closer to 50 percent.
"There are people who are in nursing facilities who can be treated at home and should be moved," said Rosenstein. "I think that number has declined."

"If you go on Medi-Cal, you're going to have to go into a nursing home - whether that's the level of care you need or not," said Ruth Gay, director of public policy with the Alzheimer's Association in Northern California.

California has prided itself on the In-Home Supportive Services Program (IHSS), which provides personal care assistance to 300,000 more independent low-income seniors and disabled in their own homes.

The problem is the state doesn't offer enough between this and nursing home care, federal officials and others say.

A study by the California HealthCare Foundation found that IHSS is not enough help for many.
California pays an average of $3,600 a month for 65,000 patients on Medi-Cal in nursing homes. The MetLife Market Survey found recently that the average cost of assisted living nationally is $2,524. Some board and care homes charge $1,500 a month.

Rosenstein argued that community care can be equally expensive given the medical needs of some patients.

"They don't actually end up saving money," he said. However, he agreed that "it's a far better way to provide care."

Jack Christy, director of public policy for the California Association of Homes and Services for the Aging, said the state is taking only baby steps toward these alternatives.

"They're doing the minimum possible to live up to the law," he said of state officials.

After the 1999 Supreme Court decision, the state Legislature asked the California Long Term Care Council to come up with a plan to implement it. Since May 2003, that 61-page plan has sat on a shelf.

In September, Gov. Arnold Schwarzenegger vetoed SB 1365, which would have appointed a new Olmstead Advisory Council.

He then ordered state health officials to set up a new Olmstead Advisory Committee, while promising to act to stop unnecessary institutionalization.

Meanwhile, state health officials are preparing their first small pilot programs to experiment with using Medi-Cal to pay for assisted living and relocating some patients out of nursing homes.
Jason Bloome with Connections, a senior referral service in Southern California, said even some of these pilot programs are being badly "bungled" as inefficient and costly, undermining the goal of de-institutionalization.

Senior advocates say families provide care at home themselves or come up with the money to privately pay for community care.

It costs $4,020 a month for Constance Hagen to keep her husband, Erwin, who has Alzheimer's disease, in a home-like residential care facility.

Without his long-term care insurance, the retired teachers could not afford it and he'd be in a nursing home on Medi-Cal.

Rennie found a 12-bed residential care home for Hagen after his wife of 54 years lost 40 pounds and nearly grew ill herself providing full-time care at home.

Erwin "Sonny" Hagen doesn't need a nurse or other medical staff. He just needs someone to spend an hour or more to feed him his meals, lift his arms and legs, tend to his incontinence, shave and shower him, and lift him into his wheelchair.

"He's a hundred times more comfortable here than he would be in a nursing home," said Rennie.
From his favorite recliner, Hagen watched the "Dick Van Dyke" show on television in the family room of the 12-bed Nelu's Home Care. The rooms are arranged as they would be in a home, but there is a staff of six, one awake all night.

Hagen and his roommate sometimes talk about going out to take his sailboat for a spin. Sometimes, he talks to the care home staff as if they were his students.

When asked if he likes his home, Hagen slowly said, "Nice to be here."

About the writer:

The Bee's Nancy Weaver Teichert can be reached at (916) 321-1058 or nteichert@sacbee.com.