Nursing Home Selectivity

Blog#64- 3/18/21

Richard Davis

Nursing homes are the kind of places that care for the sickest and most vulnerable among us. That is certainly true and, for the most part, these facilities do an excellent job of caring, comforting and maximizing the potential of their residents.

But there is one area of nursing home policy that has always bothered me and when I talk to people about it they are surprised unless they have had experience with the rules around admission and discharge.

Nursing homes interview patients before admission to make sure they can provide the proper care for a potential resident. That is a standard process and it protects both the patient and the facility. There are times when admission is not appropriate and when that happens families end up in a state of chaos.

Also keep in mind the reality that nursing homes are mostly owned by for-profit corporations and they have to guard the bottom line carefully in order to stay in business. That means that they have to make sure that they do not have too many residents whose payment source is Medicaid because Medicaid underfunds nursing home care.

Let me give you a fictional example based on cases I have seen. Joe is an 85 year old man who has been hospitalized for pneumonia and he is weak and needs more time to recover. His family believes it is assured he will be transferred to an extended care facility for recovery and to regain his strength. But there is one problem.

Joe has dementia and during his hospital stay he has been belligerent to the staff and has presented what are called “behavioral problems”. The nursing home his family had hoped to place him in has reviewed his case and denied him admission based on his behavior. It is also clear to the family, as well as the nursing home, that Joe may never return home and end up a long-term nursing home resident.

Nursing homes can deny admission to people they believe will upset other patients or who require a level of care they feel they cannot provide. Joe’s family has to now shop around for a facility that will admit Joe as a possible long-term resident. The discharge planning nurses at the hospital provide the family with a list of facilities to contact.

They find a nursing home that has a special dementia unit and they arrange for the admission official at that facility to interview Joe. They are willing to admit him but they tell the family that if Joe’s behavior gets worse and he becomes more difficult to care for they will have to discharge him.

The facility willing to accept him is an hour drive from the family’s home and they make plans to have Joe admitted because they have no other options. If they are lucky Joe will be able to stay at that nursing home. He may be eligible for 100 days of care paid for by Medicare as part of his recovery. After that, the family will have to pay about $10,000 a month ( a variable figure that is facility dependent) to keep him in the nursing home.

Families I have worked with in the past have always been shocked when they find out that a father or mother will not automatically be placed in a nursing home if things get worse. It is stressful enough caring for an ailing parent at home and placing a loved one in a nursing home is traumatic for everyone. Once that placement happens a person would hope for some sort of relief but knowing that they may get a call to bring their mother or father home because of bad behavior makes life difficult.

I am writing about this situation not to blame anyone for what happens, but to alert families to a potential problem they may have to deal with as they care for aging family members.

Comments | 1

  • bothers me also

    What happens to those who have no family who can care for them? If they do have family caring for them how does the family cope with that same belligerence? Are those behavioral problems a danger to the family and to neighbors? It all seems like yet another failing of the USA health care system; care at end of life is mostly ignored. Long term care insurance (if you can even find it any more) only covers 3-5 years which is often not enough. The problems are strongly related to the poor health care people with other mental issues receive, and that is related to the fact that psychiatry doesn’t really have much in the way of understanding why these things happen or ways to improve outcomes, as they will be the first to admit (I’ve worked with psychiatrists on research projects.) Drugs are often used whose main purpose seems to be controlling behavior to make people more manageable through sedation. The fundamental cause of the problems of poor care seems to be that people are afraid of people who act strangely, a kind of xenophobia, that has resulted in pushing away and ignoring the problems. Everyone pushes the problem away from themselves until the music stops and somebody is left without a chair. Yet who can afford to give up years to a decade of their life to care for someone? Long term care is the very first form of Medicare-for-all (and Medicare itself should do better at it) that should be implemented as part of becoming a sane and caring society.

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