Two articles reported on a groundbreaking study from the Journal of the American Medical Association that has proved the use of restrains to be unnecessary in nursing homes.  According to a study, nursing homes that simply increased staff training and provided supportive equipment had a lessened need for the use of restraints.   "Nursing home care does not necessitate the administration of physical restraints, as demonstrated by our own epidemiological research," the authors of the study said. "We found pronounced center variation, with best-practice centers applying very few physical restraints.”

In the study the experimental group received an intervention where they were trained and taught alternative methods to care for fall prone residents other than simply belting them down to their bed or wheelchair. The study proved the alternative intervention to be just as effective at preventing falls and fall related fractures as the use of restraints. 

It is obvious that there are much better alternatives than simply tying down a resident yet, today restraints are still being used on more than 20% of residents in U.S. nursing homes. Why is there still such a high prevalence of restrains when more effective, humane methods have been proved to be just as effective? The additional cost of the intervention could be the reason more nursing homes are not participating. Sadly, many nursing homes are of the mentality that if the method they have works why spend unnecessary funds on an alternative method, even if the new method could greatly improve their residents’ quality of life.

See articles at MSN Health and  Find Study at JAMA. 2012;307(20):2177-2184. doi:10.1001/jama.2012.4517 orhere.

John Belissary wrote the following Opinion piece at SC Now promoting the cost effective idea of using Medicaid funds to keep people in their homes instead of being neglected in an institutional setting.

In recent weeks, the South Carolina Department of Health and Human Services has been working with interested parties to explore ways to more efficiently manage our state’s Medicaid program. The agency and work groups are specifically debating how to address the needs of a growing population of elderly and disabled with a dwindling revenue stream.

The agency and stakeholders agree the goals of all services should be to:

Protect medically necessary benefits,
Provide access to all individuals who are eligible,
Ensure no one recipient category or provider group is disproportionately harmed,
Encourage value over volume,
Embrace multiple forms of care coordination and
Conform the federal requirements.

There is consistently one area of services that meets all these criteria – home and community-based services. Home and community-based services focus on programs to help individuals who want to live at home, need assistance with their care, and are financially eligible for Medicaid. Under this option individuals can remain at home and avoid unnecessary or premature nursing home placement. Services are available for persons age 18 years or older who are unable to perform activities of daily living such as bathing, dressing, and toileting due to illness or disability. In order to meet the qualifications to enroll into this waiver program, the individual must meet the same level of care that is needed to enter a nursing facility.

Services offered include assistance with general household activities, help with activities such as bathing, dressing, preparing meals, housekeeping, and observing health signs, companion services that provide short-term relief for caregivers and needed supervision of clients, home delivered meals, adult day health care (medically supervised care and services provided at a licensed day care center), transportation to and from the home for medical appointments, and temporary relief for the client’s caregiver.

These options are cost efficient and provide services that have a higher return on investment. Currently nursing homes account for slightly more than 43 percent of the state’s long-term care expenditures which include home and community-based services, residential care and other waiver programs. Community choices services cost on average of $32 per day while nursing homes cost $127 per day. Nursing home patients are decreasing while costs are increasing. There are currently about 12,000 served by home and community-based services while there are about 10,500 served by nursing homes.

Home and community-based programs contribute in so many other ways to the stability of the family. Without these services, families would lose income because a family member would have to give up a job to take care of a loved one. This can be a drain on family finances and take its toll on middle income families. In most cases, it is the woman who gives up her career to take care of a love one; when the caregiver returns to work the earning potential is usually lower. If we are going to continue to meet the needs of our elderly and disabled population, we need to use our state’s monies in the most economical manner and the manner in which this population receives the best quality of life. That is most definitely through home and community based services.

Editor’s note: The author serves as legal counsel and assistant administrator for New Generations Home Care and New Generations Adult Day Center. He is currently vice president / president elect of the South Carolina Association of Personal Care Providers.


The Wall Street Journal had an article about families that compensate family members for caring for loved ones at home. According to a report by the National Alliance for Caregiving and AARP, 43.5 million Americans looked after a friend or relative age 50 or older in 2009, 28% more than in 2004. In a survey conducted for Home Instead Senior Care, a home-care franchiser, nearly 7% of respondents said they receive compensation for providing care to a relative.

Under federal law, when annual compensation exceeds $1,700, an employer and employee each owe federal payroll taxes of 6.2% for Social Security and 1.45% for Medicare. The employer must generally also pay 6.2% on the first $7,000 in wages in federal and state unemployment tax, says Melissa Labant, a CPA with the American Institute of Certified Public Accountants.

Many factors contribute including the high unemployment rate, the rising cost of nursing-home care, an aging population and a 2006 change in Medicaid law that makes it difficult for people who wish to qualify to give away assets.



Two advocacy groups, the Arc of Texas and the Coalition of Texans with Disabilities, filed a class-action lawsuit against Texas because more than 4,500 people with intellectual and developmental disabilities are "trapped" in nursing homes recieiving inadequate care.  The class would receive better care in a community-based facility or their own homes, but the state unfairly restricts access to the programs and services.

According to a 2010 report by the Texas Council for Developmental Disabilities, Texas ranks 49th among 50 states in providing community-based services to people with developmental disabilities.   The multibillion-dollar state budget shortfall will prompt lawmakers next year to cut spending in ways that will only exacerbate the problem.  Mental health advocates say there is a long waiting list for spots in community-based programs that might better serve many people with disabilities.

Texas is violating the American with Disabilities Act, and not following the federal Nursing Homes Reform Amendments to the Medicaid Act which require states to screen residents of nursing homes for developmental disabilities to see if their needs can be served within the community or with less restrictive methods than at a nursing home.  It also requires states to provide "specialized services and intensive treatment" so the developmentally disabled can live as independently as possible and to prevent regression.

Texas is not providing those services therefore the developmentally disabled have suffered regression or stagnation in nursing homes.  A similar lawsuit in Massachusetts was successful and led to better care for more than 1,000 people.


Christine Vestal of Stateline wrote a great article on Tennessee’s new plan to change its health care system aimed at elderly and disabled residents. More of them are getting the assistance they need in their homes — at a much lower cost than at a nursing home.  
Just a few years ago, only a few hundred Tennesseans were able to get Medicaid funding for anything but a nursing home. Now, it is one of a handful of bellwether states that offer a broad range of alternatives to nursing home care.
“It’s a good thing to do and it probably can save some costs, but more importantly it really is an easy way to keep an awful lot of people in their homes, which is what I would want. I know it’s what my mother wants,” Governor Bredesen said in an interview with Stateline.
Like every other state, Tennessee is bracing for an avalanche in demand for long-term care as the biggest generation in American history — 77 million so-called Baby Boomers born between 1946 and 1964 — begins to hit retirement age next year.
Occupying more than 30 percent of states’ Medicaid bills, which in turn occupy more than 20 percent of overall state budgets, long-term care costs are growing faster than any other state expense.
That’s partly because Americans are living longer. By 2020, the number of people aged 85 years and older — those most likely to need long-term care — will increase by more than 40 percent, according to U.S. Census Bureau estimates. Even without those demographic pressures, states’ long-term care costs are daunting. The elderly and disabled represent about 25 percent of the total Medicaid population, but they account for more than 65 percent of the spending, according to the most recent federal data available.
It is well known that the vast majority of people with long-term care needs want to remain in their homes. And research shows that the cost of providing care in the community can be as little as one-third the amount of a comparable nursing home stay.
But the road to reforming state Medicaid plans is long and arduous because Medicaid — which pays nearly 50 percent of all nursing home bills in the country and 45 percent of all long-term care — is biased in favor of institutional care.

In 2008, the Legislature unanimously approved a bill that would make Tennessee one of just a few states to contract out its long-term care program to managed health care organizations. 
Like laws in Arizona and New Mexico, Tennessee’s new law counts on private companies to ensure that a broad array of services — from so-called personal services such as meal preparation, bathing and dressing to home improvements, including wheel chair ramps and even pest control — are provided without additional cost.
Two months ago, TennCare CHOICES, opened its doors statewide with the goal of helping 11,000 people remain at home or return to their homes in the first year — all for the same amount the state paid in 2009. “The change is like night and day,” says Wilo Clarke, a caseworker for a managed care company in central Tennessee where the program started as a pilot earlier this year. “More and more, people in the nursing facilities are hearing about this program. They want to do whatever it takes to go home.”
Under the plan, low-income frail elders and adults with disabilities who are medically eligible for nursing home care may opt to receive the services they need in their homes, as long as the total cost is equal to or lower than the cost of a nursing home stay.
It’s too early to tell whether CHOICES will accomplish its goals. But so far, more than 40 percent of some 3,300 new enrollees are opting either to move out of a nursing home or avoid going to one in the first place. In addition to allowing Medicaid to pay for alternative services, Tennessee’s CHOICES makes it easier for people to sign up for the program by providing a single point of entry — a caseworker with a local managed care organization.
For the managed care organizations, the financing structure is straightforward. The state gives them a flat monthly fee for each eligible long-term care recipient — whether in a nursing facility or living at home. Some patients will cost more and others will cost less. It’s the company’s job to ensure that the average cost for all enrollees does not exceed a specified level. 

The AARP, which advocates for the elderly, says that three people can receive long-term care services in the community for the cost of serving just one person in a nursing facility. Still, the big fear in offering more home-based services is that people who never would consider entering a nursing home “will come out of the woodwork” and apply for Medicaid. Surveys have shown that for each patient in a nursing facility, two more with the same level of disability are making do at home.
Bredesen acknowledges the state’s new program will result in Medicaid serving more people. But he says it’s a good thing, as long as overall costs do not climb.
Although the social and fiscal benefits of public funding for home- and community-based services are clear, states have been slow to take the steps required to bring about change. In the mid-1990s, a few states began recognizing the value of serving more long-term care patients in their homes. Alaska, California, Minnesota, New Mexico, Oregon and Washington State now spend more than half of their long-term care dollars on alternatives to nursing facilities. Colorado, Idaho, North Carolina, Texas and Vermont are moving in the same direction. But Tennessee and 23 other states have made less progress, spending less than one-quarter of their long-term care budget on non-institutional care.
The new federal health care law — the Patient Protection and Affordable Care Act — has a chance of changing that. It includes financial incentives for states to spend at least 50 percent of their long-term care dollars on non-institutional services and offers a grant for every person who leaves a nursing home to receive services in the community. 


National Public Radio had an article about the benefits of "Granny Pods" which are mini mobile homes. The granny pod’s real name is the MEDCottage mobile home that rents for about $2,000 a month. You park one in the backyard, hook it up to your water and electricity, and it becomes a free-standing spare room for Grandma and Grandpa. The concept is catching on all over the country, but nowhere more so than Virginia, where the state government has eased zoning restrictions on these high-tech hideaways, which go on the market early next year.

The MEDCottage is homey on the outside, with taupe vinyl siding and white trim around French doors. Inside, it looks like a nice hotel suite, complete with kitchen and bathroom — and security cameras.  On the inside, the MEDCottage is equipped with advanced health monitoring equipment and a lift that can carry an immobile resident to the bathroom.

"This is something that we call ‘Feet Sweep,’" Dupin says as he shows off a floor-mounted camera. It monitors only about 12 inches off the floor, or high enough to see a person’s feet — but if that person fell, you’d see them lying on the floor.

Dupin says falls are one of the main reasons people end up in nursing homes, so the MEDCottage’s technology could help them stay independent longer. The cottage also has safety lighting along the floors, a lift that can carry an immobile resident to the bathroom, and monitoring systems that let you check on Grandma’s temperature, heart rate and whether she’s taken her medicine.

It might seem a little odd, parking your loved one in a shed in the backyard, but Dupin says the MEDCottage is designed with Americans’ independent nature in mind. "That space there provides a level of independence that is very important to Americans," he says.

"Really — this is one of those studies that we really can never publicly say — but we don’t want them in our house," Dupin says. "Nor do they want to be in our house."

Still, having the family nearby and maybe having grandchildren running in and out of the cottage could potentially improve an elderly person’s quality of life.

While Dupin says his parents probably won’t end up in a granny pod, it’s definitely something he sees in his own future. "As I’m thinking about my life, I’ll probably be in one of the backyards of one of my kids," he says.

The Providence Journal had a great article on a government program ––called Shared Living––  which is part of Rhode Island’s effort to save nursing-home costs while allowing people to stay in their homes.  States have been offering the Shared Living program for people with developmental disabilities and now is expanding the concept to frail elderly people and adults with disabilities who are eligible for Medicaid. The first participants are expected to be paired up in about four weeks.

Through two agencies selected by the state, the program provides caregivers with money ($13,000 to $18,000 a year, nontaxable), nurses, caseworkers, training and respite. The caregiver lives with the elderly or disabled client and helps with such tasks as bathing and dressing. Typically the caregiver and patient know each other, may be related and may already be living together.

Shared Living bolsters efforts to care for people at home so they are less likely to need a nursing home. “It’s not just the money, but the support behind it,” said Jane E. Korb, program director for the Homestead Group, one of the two companies that will run the program. The other is Caregiver Homes of Rhode Island.

In Rhode Island, the Shared Living program sprang from the state’s “global waiver” to its Medicaid program, which frees the state from Medicaid rules to allow innovative programs.

The state has focused its efforts on reducing nursing-home use in favor of community-based programs. Long-term care accounts for nearly a third of Medicaid spending, and more than half of that long-term care money pays for nursing homes, according to 2007 data from the Kaiser Family Foundation.

The agencies that will run the program are not licensed. The Health Department has no oversight, even though it regulates nursing homes, assisted living and home care. The state Department of Human Services plans to monitor client and caregiver satisfaction, length of stay in the program, caregiver retention rates and complaints. 

The Homestead Group has been running the state’s Shared Living program for developmentally disabled people for years. Caregiver Homes is among the agencies that have been providing a similar service in Massachusetts. Its Rhode Island program director, David E. Bell, was formerly director of elder services at Child and Family Services of Newport County.





Read More →