Sheltering the Elderly

...Admittedly, emptying a few of them throws off relatively trivial savings...

...He would do away with as many homes as possible...

...His analytic and aphoristic prose, a joy to read incidentally, acknowledges dilemmas that are sometimes impolitic to mention...

...Those expected to recover or die would be cared for in hospitals, until discharge or death...

...Some of the deinstitutionalized may be seen wandering about on the street and in the subways...

...in his view only the government is fair game...

...3. Create about 250,000 additional units of congregate housing...

...There, too, the cry once went up against "warehousing" the mentally ill and retarded in inadequate institutions called state hospitals...

...A proprietary nursing home administrator, feeling free to be candid for the first time because, he earnestly said, I was no longer New York City's First Deputy Health Commissioner, explained to me the operational distinction in the nursing home business between the term "clean stealing" and the term "dirty stealing...

...But the former patients have received few of the promised supportive services since returning to the community...

...Get them out of the hospital warehouses and back to the community where they can receive the supportive ambulatory mental health services they need...

...But the question about the best method of reimbursement remains perplexing...

...Compounding tensions is the situational reality of predominantly white patients served by predominantly black and Hispanic nonprofessional workers, who are grievously underpaid, receive inadequate training and suffer a paucity of formal education...

...Inflating costs meant more profits, so nursing home operators inflated them actually and fraudulently...

...What managerial control would supplant the existing managers and owners of the proprietary nursing homes...

...neither the state nor the city has been willing to pay for them...

...Vladeck is frankly repelled by the noisome atmosphere of even the best nursing homes...

...Vladeck prints a hypothetical quality distribution graph reflecting his impressionistic views—to wit, that (1) the very best nursing homes tend to be voluntary, (2) the very worst tend to be proprietary, but (3) in the middle range, where the great majority of proprietary and voluntary nursing homes fall, there is substantial overlap of quality...

...For example, it has been suggested that to save public moneys, families should be granted a subsidy as an incentive to care at home for their elderly and infirm parents, rather than send them to a nursing home at Medi-care/Medicaid expense...

...And the current shrinkage of hospitals in number and size—due to multiple bankruptcies, to pressures from Health Systems Agencies, and to assessments by the Professional Standards Review Organizations and state agencies—ultimately will increase the percentage of bed occupancy within the surviving hospitals...

...The state's reimbursement rates remain the sticking point...

...Those less drastically disabled would stay at home, albeit with supportive services...

...The mentally ill and retarded were vigorously deinstitutionalized all right, and the states saved enormous sums of money...

...At an impromptu exploratory meeting with administrative executives from some of the major private voluntary hospitals in New York City, I proposed as the then City Health Commissioner that we discuss the possibility of "deproprietarizing" the proprietary nursing homes...

...Vladeck reports that as of the writing of this book, no nonprofit organization has expressed a willingness to assume managerial control of the Park Crescent, a Manhattan 500-bed nursing home currently in receivership...

...Hemakesa good case about the ephemerality of the SNF/ICF distinctions and associated distribution of patients in nursing homes...

...Vladeck summarizes the evolution of the thinking, policies and legislation that helped get us into the present nursing home mess...

...Does intelligent social policy compel the supplanting of proprietary nursing homes by voluntary homes under nonprofit auspices...

...But the administrators at the meeting promptly voiced their unanimous disinterest...

...And so the dismal story of the nursing home industry, with its attendant periodic scandals, is clearly more than an updated medieval morality play where good and evil contend in categorical costume...

...The question of desirable auspices—leaving aside one's ideological proclivities—is no less perplexing than that of a proper method of reimbursement...

...It therefore becomes imperative to transfer the "inappropriate" hospital patient to an alternative facility, not for reasons of spurious cost savings but in order to make room for the sick patient who desperately needs it...

...Where nursing homes are concerned, categorization takes the form of deciding whether the patient should be placed in a skilled nursing facility (SNF) or in an intermediate care facility (ICF...

...2. Convert 100,000-125,000 unused or underused acute-care hospital beds to "extended-care facility" beds, for use only by those patients expected to die or be discharged home in six months...

...The informative administrator said with pride that he had never knowingly indulged in dirty stealing...

...Yet they would surely demand whatever sum they might become legally entitled to if granting such subsidies were to become a national program...

...If success in a health care facility is to be measured in terms of cure, or at least of palpable physiological improvement, one encounters precious little of either in the nursing home...

...A lamentable characteristic of American public administration is the asynchrony between the time available before the next election and the time it takes for any substantive policy to be formulated, implemented, monitored, assessed, and modified...

...A large number of families already do this unaided...

...If the government chooses to subsidize, in part or in full, a "needed" social service—like nursing homes, or congregate housing, or meals-on-wheels—steps must be taken to prevent an overwhelming influx of those who have hitherto managed well enough without the service, or have purchased it on their own...

...Here is an excerpted summary of his maximalist program for reform of nursing home and long-term care: 1. Close down nursing homes of the lowest quality to reduce capacity by one-third over a five-year period...

...In the long run, this would cost the taxpayer more than leaving bad enough alone...

...This was opposed by the industry and eventually abandoned because it failed to meet the real costs of rendering proper nursing home care...

...We already see the phenomenon at work in New York City...

...He discusses a system of pre-Great Depression public welfare that was based on the principles of the post-1834 English poor laws...

...In the hospital, categorization takes the form of transferring the patient who is "inappropriately" filling a bed to the nursing home, whose per diem is about 80 per cent lower...

...Vladeck insists that the cost of filling that hospital bed was marginal in the first place, and that the saving claimed by advocates of such patient transfer is illusory...

...Clean stealing, I thus learned, denotes stealing from the government, not from the patient—as, for example, when the home bills Medicaid for 1,000 Thorazine tablets where only 500 tablets are needed, distributes 500 as prescribed for patients, and then splits the profits from selling the remaining 500 in a collusive arrangement with the pharmacist...

...Vladeck suggests that the government "nationalize" a small part of the industry, to establish a yardstick for assessing the performance of the private sector...

...Vladeck is skeptical of a cost-controlling device he considers obsessive and excessive: the attempt to categorize the precise level of care a patient's biological status requires for the purpose of assigning him to the therapeutically optimal facility...

...Instead, these sick, helpless souls have become the prey of muggers and the tenants of rapacious landlords who foster their own brand of warehousing...

...The per diem reimbursement, in their opinion, was ludicrously inadequate for providing the level of patient care that would dispose the hospitals to lend such a scheme their managerial talents and institutional prestige...

...The biological status of the patient is usually so much in a state of flux that if the SNF/ICF approach were really to be taken seriously, patients would be condemned to repetitive transfer and transfer trauma with consequent misery and mortality...

...We have arrived at the present miasma not so much through the corruption of legislators, wicked conspiracy, or unbridled lobbying as through good-faith incremental responses to perceived social needs...

...The shattering experience with the deinstitutionalization of the mentally ill and retarded ought to give one pause...

...Vladeck does not succumb to the journalistic practice of simplisticai-ly villainizing the nursing home proprietor, the elected legislator and the governmental regulator...

...States used to reimburse nursing homes on a flat-rate basis...

...Before the 1975 scandals, the state employed only 14 auditors to examine the detailed reports of more than 800 facilities...

...Eventually the most dedicated staff becomes demoralized...

...Both classifications, says Vladeck, have proven inoperable...

...New York State's eccentric disinclination to police the system or enforce its requirements also helped foster larcenous behavior...

...There are bound to be errors and arbitrariness at times on the part of that agency...

...Are there practical alternatives to the current approach...

...Government officials with responsibility for the aged might well glue the poignant lines to the walls of their offices and ponder their implications for policy and program: "Reject us not in our old age...

...As Vladeck points out, the practice of reimbursing nursing homes on the basis of actual costs incurred set the original stage for abuse...

...Government, it should be reiterated, now has the reputation of having sold programmatic snake oil to the mentally ill and retarded, among whom are many elderly...

...Dirty stealing, in contrast, denotes stealing from the patient as well as from the government—as for example, when the home bills Medicaid for food, but to the detriment of the patients withholds this food...

...I must qualify my otherwise complete agreement with Vladeck's critique of categorization, or what he derisively calls "the game of levels...

...But closing entire hospitals attacks substantive fixed costs...

...Disappointed, I asked: "Are you then saying that the proprietary nursing home owners are not totally wrong when they claim that Medicaid and Medicare are not paying enough, and that government thereby implicitly encourages the brigandage that has been going on...

...Patient transfers from hospitals are another story, though...

...He feels that whatever the operative deficiencies of this policy, the elderly can certainly be no worse off than they would be in nursing homes...

...5. Redouble regulatory and other quality control mechanisms in nursing homes...

...It is not simply a question of coordination...

...Unsurprisingly, worker turnover is phenomenally high in nursing homes, adding discontinuity of care to the ambiance.Vladeck argues that almost any other facility is better than a nursing home...

...I fear that should the nursing homes empty too quickly in the name of better and more frugal care, many of the elderly will fail to find the congregate and other supportive housing they require...

...It is a question of governmental good faith...

...I suggested that the city's voluntary hospitals assume the responsibility on an affilia-tive basis...

...Remember the rhetoric...

...For instance, is it better for a patient to receive care from a crooked but competent nursing home owner than from an honest but incompetent one...

...Golden Agers are wont to quote a relevant passage from one of the Biblical psalms...

...Consequently, any nursing home reform must include a gatekeeper agency to enforce eligibility rules...

...But Americans will simply have to develop a greater tolerance of honest governmental errors...

...Things change slowly...

...The nation has 100,000 or more excess hospital beds...

...4. Expand services at home under the direction of local gatekeeping agencies...

...I am less confident...

...I would suggest a cautious and gradual deinstitutionalization—and only so long as each elderly patient is promptly picked up in accordance with the community's capacity to provide a real domiciliary-cum-therapeutic alternative...

...Reviewed by Lowell E. Bellin Professor of Public Health, Columbia University School of Public Health Two instructive encounters of my own inevitably came to mind as I read Bruce C. Vladeck's superb study...

...Those of us who supported that stand were deceived...

...As for nursing home reform, which also means some introduction of alternatives to the homes, a major problem is determination of eligibility...

...Bruce Vladeck places his faith in the deinstitutionalization of the frail elderly...

...He writes of the poor farms or poorhouses, Social Security, Old Age Assistance, Hill-Burton legislation, Kerr-Mills legislation, Medicare and Medicaid...

...The second encounter took place in 1975, during the height of the nursing home scandal...

...Under this plan, only people with moderate to advanced senility or other severe psychiatric or physical disabilities, such as the entirely bedridden, would occupy nursing homes...

...One occurred in 1973, at a conference on health care...