A Shift From Nursing Homes to Managed Care at Home

Faced with soaring health care costs and shrinking Medicare andMedicaid financing, nursing home operators are closing some facilities and embracing an emerging model of care that allows many elderly patients to remain in their homes and still receive the medical and social services available in institutions.

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Dr. Fredrick Sherman at Harlem PACE with Edna Blandon. “My spirits would drop if I went to a nursing home,” she said.

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The rapid expansion of this new type of care comes at a time when health care experts argue that for many aged patients, the nursing home model is no longer financially viable or medically justified.

In the newer model, a team of doctors, social workers, physical and occupational therapists and other specialists provides managed care for individual patients at home, at adult day-care centers and in visits to specialists. Studies suggest that it can be less expensive than traditional nursing homes while providing better medical outcomes.

The number of such programs has expanded rapidly, growing from 42 programs in 22 states in 2007 to 84 in 29 states today. In New York City, a program run by a division of CenterLight Health System, formerly known as the Beth Abraham Family of Health Services, has over 2,500 participants at 12 sites in the metropolitan area.

“It used to be that if you needed some kind of long-term care, the only way you could get that service was in a nursing home, with 24-hour nursing care,” said Jason A. Helgerson, the Medicaid director for New York State. “That meant we were institutionalizing service for people, many of whom didn’t need 24-hour nursing care. If a person can get a service like home health care or Meals on Wheels, they can stay in an apartment and thrive in that environment, and it’s a lower cost to taxpayers.”

The recent influx of adult day-care centers and other managed care plans for the frail elderly is being driven by financial constraints as President Obama and Congressional leaders seek hundreds of billions of dollars in savings in Medicare and Medicaid. Nursing homes, which tend to rely heavily on Medicare and Medicaid dollars, are facing enormous financial pressure — Mr. Obama’s proposed budget includes a $56 billion Medicare cut over 10 years achieved by restricting payments to nursing homes and other long-term care providers.

Nationally, the number of nursing homes has declined by nearly 350 in the past six years, according to the American Health Care Association. In New York, the number of nursing homes declined to 634 this January from 649 in October 2007, and the number of beds to 116,514 from 119,691.

Over the next three years, New York State plans to shift 70,000 to 80,000 people who need more than 120 days of Medicaid-reimbursed long-term care services and are not in nursing homes into managed care models, Mr. Helgerson said.

The move away from nursing homes was highlighted on Thursday when Cardinal Timothy M. Dolan announced that the Archdiocese of New York, one of the state’s largest providers of nursing home care, is selling two of its seven nursing homes and opening or planning to open seven new adult day-care centers over the next three years.

“Seniors and others who have chronic health needs should not have to give up their homes and independence just to get the medical care and other attention they need to live safely and comfortably,” Cardinal Dolan said in a statement before he opened a 250-patient program at Saint Vincent de Paul Catholic Healthcare Center in the South Bronx.

These new adult day-care centers, known around the nation by the acronym PACE — Program of All-Inclusive Care for the Elderly — provide almost all the services a nursing home might, including periodic examinations by doctors and nurses, daytime social activities like sing-alongs and lectures, physical and occupational therapy and two or three daily meals. All the participants are considered eligible for nursing homes because they cannot perform two or more essential activities on their own like bathing, dressing and going to the toilet. But they get to sleep in their own beds at night, often with a home health care aide or relative nearby.

The nonprofit groups that operate them receive a fixed monthly fee for each participant and manage their entire care, including visits to specialists, hospitalizations, home care and even placement in a nursing home. Because Medicare and Medicaid pay set fees instead of paying for specific procedures, center operators are motivated to provide preventive care to avoid costly hospitalizations or nursing home care.

Some elderly people, however, spurn PACE programs because under managed care, they would have to switch their physicians to those at the PACE center or in its network. Most elderly people want to live out their lives at home, a desire evident in interviews in the PACE center the archdiocese opened in 2009 in Harlem, which has a staff of three doctors and is visited regularly by a dentist, a podiatrist and a psychiatrist.

Todd Heisler/The New York Times

Rick Leeds, who teaches yoga and other wellness programs at the ArchCare PACE Center in Harlem, gives a massage to Edna Blandon, who goes to the center three times a week.

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Edna Blandon, 74, a diabetic weakened on her left side by a stroke who relies on a wheelchair, is transported by specialized van to the Harlem PACE center three days a week and appreciates that it provides not only a home care attendant but sends a nurse every two weeks to change pills in her pillbox and load a 14-day supply of insulin into syringes that she will inject.

“My spirits would drop if I went to a nursing home,” she said. “I love the fact that I can go home at night. There’s no place like home. I can sit down, look at the TV and go to bed when I want.”

James Harper, 70, a retired bank employee who spent 10 months at the archdiocese’s Kateri Residence, a nursing home on the Upper West Side, after a stroke paralyzed his right side, enjoys yoga breathing classes and discussions about black history. Yet he gets to spend nights and weekends with his wife, Albertene, and daughter, Traci, both of whom work during the day and are not around to care for him.

“This way I’m around people,” he said.

Dr. Fredrick T. Sherman, the Harlem PACE medical director, said that a 2009 study showed that PACE programs reduce lengths of stays in hospitals and delay assignments to nursing homes.

The archdiocese, whose new centers will serve a total of 1,500 people, receives an average of $4,000 a month from Medicaid for each participant and $3,300 from Medicare. By comparison, said Scott LaRue, the chief executive of ArchCare, the archdiocesan health care network, a month of nursing home care can cost the government $9,000.

Ultimately, the archdiocese hopes that half of its elderly clients will be served in community settings rather than in nursing homes, which currently serve about 90 percent of the archdiocese’s clients. For-profit companies have not yet moved into the managed care market, in part because of uncertainties about reimbursement formulas and the risks of taking on a nursing home population.

The PACE population tends to be younger than that at nursing homes, which raises the question of whether many PACE clients would really need nursing homes without PACE. Dr. Sherman replies to such skepticism by saying that his clients “need that level of service — the question is where they’re going to get it.”

Without PACE, he said, “they’re going to end up in nursing homes.”

Robert Pear and Christopher Reeve contributed reporting.

Local Civil Registry


Health-care costs: Debt talks boost Medicare reform plans – CSMonitor.com

Health-care costs: Debt talks boost Medicare reform plans

Health-care costs for seniors have been largely picked up by government. But their health-care costs could rise under various Medicare reform plans.

Members of Progressive Change Campaign Committee upset over potential cuts to Medicare, Medicaid, and Social Security walks to President Obama’s campaign headquarters to deliver 200,000 signatures from people who are refusing to donate or volunteer for his re-election campaign if Obama cuts entitlement programs,July. 15, 2011, in Chicago. The debt talks in Washington are breathing new life into plans that would raise health-care costs for seniors.

David Banks/AP

via Health-care costs: Debt talks boost Medicare reform plans – CSMonitor.com.

Puppy Love: Pet Owners Are Happier, Healthier – FoxNews.com

Pets are good sources of social and emotional support for everyone, not just people facing health challenges, new research suggests.

“We observed evidence that pet owners fared better, both in terms of well-being outcomes and individual differences, than nonowners on several dimensions,” study researcher Allen McConnell, of Miami University in Ohio, said in a statement. “Specifically, pet owners had greater self-esteem, were more physically fit, tended to be less lonely, were more conscientious, were more extroverted, tended to be less fearful and tended to be less preoccupied than nonowners.” [America’s Favorite Pets]

Pet ownership has been on the rise the last few decades. A study in 2006 by the American Pet Products Manufacturers Association determined that about two-thirds of American households (71.1 million) have at least one pet. In comparison, 56 percent of households had a pet in 1988, the first year the survey was conducted.

McConnell’s group conducted several studies of pet owners.

First they surveyed 217 people, determining differences between pet owners and nonowners in terms of well-being, personality type and attachment style. They found that pet owners were happier, healthier and better adjusted than were nonowners.

The researchers then studied 56 dog owners, finding that pet owners who thought their dogs increased their feelings of belonging, self-esteem and meaningful existence had greater well-being than those who didn’t perceive that their pet fulfilled their social needs.

They then asked 96 pet owners who were undergraduates to remember and write about a time they were excluded. They were then asked to either write about their favorite pet, their favorite friend or to draw a map of their college campus. Both writing about a pet or a friend reduced the feelings of rejection brought forth by thinking about being excluded. Surprisingly, both pets and friends staved off the feelings of rejection equally.

All in all, the researchers found that even healthy people benefit from pets. Pet owners are just as close to key people in their lives as to their animals, which serve as important sources of social and emotional support.

“The present work presents considerable evidence that pets benefit the lives of their owners, both psychologically and physically, by serving as an important source of social support,” the researchers wrote in the paper, published online by the Journal of Personality and Social Psychology. “Whereas past work has focused primarily on pet owners facing significant health challenges… the present study establishes that there are many positive consequences for everyday people.”

via Puppy Love: Pet Owners Are Happier, Healthier – FoxNews.com.

Healthcare reform: Obama administration eases requirements for states’ insurance exchanges – latimes.com

By Noam N. Levey, Los Angeles Times

July 12, 2011

Reporting from Washington— The Obama administration moved Monday to ease some requirements on states to help them set up new insurance exchanges in 2014, a key feature of the healthcare law the president signed last year.

The state-based exchanges are intended to make buying health insurance comparable to shopping the Internet for an airline ticket or a hotel room.

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And by 2019, the exchanges are expected to provide insurance for an estimated 24 million Americans who don’t get their health insurance from their employer, according to the nonpartisan Congressional Budget Office.

Small employers with fewer than 100 workers also will be able to use the exchanges, which will have to offer plans with a minimum level of coverage. No plans will be able to deny coverage to people with pre-existing conditions.

The administration’s action Monday drew praise from consumer groups, including Small Business Majority, an advocacy group for small employers.

“The most important component of healthcare reform for small businesses is the creation of state health insurance exchanges. They will lower the high cost of insurance premiums and reduce the administrative costs that are so often the driving force behind skyrocketing rates for small group plans,” said Terry Gardiner, the group’s vice president of policy and strategy.

But creating the exchanges has proven a major challenge in many statehouses nationwide, some controlled by Republican lawmakers and governors openly hostile to the new healthcare law.

In a nod to this resistance, the Obama administration proposed regulations that will give states wide latitude in deciding how to regulate insurance companies that sell plans in their exchanges.

“Flexibility is the name of this game, and we are going to work very hard to meet the needs of each and every state,” said Dr. Don Berwick, head of the Centers for Medicare and Medicaid Services, which is overseeing the exchange regulations.

Under the new rules, some states may exercise relatively little control over the plans while others may place stringent requirements on insurers before allowing them to sell policies in the exchange, including controlling premiums.

The administration also proposed Monday to give states more time to set up their exchanges before the federal government would step in to do the job.

The new law requires the Department of Health and Human Services to operate an exchange in any state that does not create its own. Obama administration officials, as well as many insurers, would prefer that states run their own.

Thus far, 12 states, including California, Connecticut and Maryland, have enacted laws creating state-based insurance exchanges in 2014, according to a tally by the National Conference of State Legislatures.

Massachusetts and Utah already had exchanges before the federal law was passed.

And in Illinois, Gov. Pat Quinn, a Democrat, is deciding whether to sign a bill to develop an insurance exchange.

It is unclear whether the proposed regulations will speed development of exchanges in other states.

Louisiana Gov. Bobby Jindal, a Republican, has announced that his state will not run an exchange. And Oklahoma Gov. Mary Fallin, also a Republican, recently returned federal grant money to set up an exchange.

But insurance both industry leaders and consumer advocates said that the administration’s proposed regulations would give states the flexibility that many have been demanding.

“The regulation is a strong message to states that they are in charge,” said Karen Ignagni, who heads America’s Health Insurance Plans, the industry’s Washington-based lobbying arm.

The Obama administration is still developing other rules for the exchanges, including regulations outlining what benefits the insurance plans must cover. Administration officials said Monday that those additional regulations would probably be completed later this year.


Chicago Tribune staff writer Bruce Japsen contributed to this report.

Copyright © 2011, Los Angeles Times

via Healthcare reform: Obama administration eases requirements for states’ insurance exchanges – latimes.com.

Reciprocity Information: Check if you can have your license verified at Nursys.com


Nurses Licensed in Another State

If you are licensed as a nurse in another state, you must provide the New York State Education Department with verification of that licensure. The National Council of State Boards of Nursing (NCSBN) handles verification of licensure for a majority of states through their Nurse System (Nursys). You can check to see if the state(s) where you are licensed as a nurse participates in Nursys by visiting their Web site at www.nursys.com External Link Icon or by calling them at 1-866-819-1700.

If the state(s) where you are licensed as a nurse participates in Nursys, you must request verification of your licensure from Nursys, not the state(s).

If your state(s) of licensure does (do) not appear on the Nursys list, you must use the Verification of Other Professional Licensure/Certification form (Form 3) to verify your licensure to New York State.


Please note, if you hold any other professional licenses in states other than New York, you must also use Form 3 to verify that licensure to New York State.

UCLA medical records: UCLA hospitals to pay $865,500 in settlement over breaches of celebrity patients’ records – latimes.com

UCLA Health System has agreed to pay $865,500 as part of a settlement with federal regulators announced Thursday after two celebrity patients alleged that hospital employees broke the law and reviewed their medical records without authorization.

Federal and hospital officials declined to identify the celebrities involved. The complaints cover 2005 to 2009, a time during which hospital employees were repeatedly caught and fired for peeping at the medical records of dozens of celebrities, including Britney Spears, Farrah Fawcett and then-California First Lady Maria Shriver.

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Violations allegedly occurred at all three UCLA Health System hospitals — Ronald Reagan UCLA Medical Center, Santa Monica UCLA Medical Center and Orthopaedic Hospital and Resnick Neuropsychiatric Hospital, according to UCLA spokeswoman Dale Tate.

The security breaches were first reported in The Times in 2008.

The violations led state legislators to pass a law imposing escalating fines on hospitals for patient privacy lapses.

After the law took effect on Jan. 1, 2009, state regulators fined Ronald Reagan UCLA Medical Center $95,000 in connection with privacy breaches that year that sources said involved the medical records of Michael Jackson, who was taken to the hospital after his death in June 2009.

The same month, the U.S. Department of Health and Human Services’ Office for Civil Rights began investigating alleged violations of the federal Health Insurance Portability and Accountability Act at the hospitals, according to the settlement agreement.

Investigators found that UCLA employees examined private electronic records “repeatedly and without a permissible reason” in 2005 and 2008, including an employee in the nursing director’s office, according to the agreement reached Wednesday.

The employee was not named in the agreement, and the hospital spokeswoman declined to identify who it was. But the timing and description of the alleged violations cited in the agreement suggest that it may have been Lawanda Jackson, an administrative specialist at Ronald Reagan UCLA Medical Center who was fired in 2007 after she was caught accessing Farrah Fawcett’s medical records and allegedly selling information to the National Enquirer.

Jackson later pleaded guilty to a felony charge of violating federal medical privacy laws for commercial purposes but died of cancer before she could be sentenced. Fawcett died of cancer in 2009.

Federal investigators faulted the hospital system for failing to remedy the problems, discipline or retrain staff.

“Employees must clearly understand that casual review for personal interest of patients’ protected health information is unacceptable and against the law,” Georgina Verdugo, director of the Office for Civil Rights, said in a statement Thursday, adding that healthcare facilities “will be held accountable for employees who access protected health information to satisfy their own personal curiosity.”

As a condition of the settlement, UCLA Health System was required to submit a plan to federal regulators detailing how officials would prevent future breaches. They agreed to retrain staff on privacy protections, formulate privacy policies, appoint a monitor to oversee improvements and report to regulators for the next three years.

UCLA Health System released a statement Thursday noting that, “Over the past three years, we have worked diligently to strengthen our staff training, implement enhanced data security systems and increase our auditing capabilities.”

“Our patients’ health, privacy and well-being are of paramount importance to us,” said Dr. David T. Feinberg, chief executive of the UCLA Hospital System. “We appreciate the involvement and recommendations made by OCR in this matter and will fully comply with the plan of correction it has formulated. We remain vigilant and proactive to ensure that our patients’ rights continue to be protected at all times.”

Tate said the money would be paid to federal health regulators.


via UCLA medical records: UCLA hospitals to pay $865,500 in settlement over breaches of celebrity patients’ records – latimes.com.

Study Finds Benefits in Health Insurance for the Poor – NYTimes.com

When poor people are given medical insurance, they not only find regular doctors and see doctors more often but they also feel better, are less depressed and are better able to maintain financial stability, according to a new, large-scale study that provides the first rigorously controlled assessment of the impact of Medicaid.

While the findings may seem obvious, health economists and policy makers have long questioned whether it would make any difference to provide health insurance to poor people.

It has become part of the debate on Medicaid, at a time when states are cutting back on this insurance program for the poor. In fact, the only reason the study could be done was that Oregon was running out of money and had to choose some people to get insurance and exclude others, providing groups for comparison.

Some said that of course it would help to insure the uninsured. Others said maybe not. There was already a safety net: emergency rooms, charity care, free clinics and the option to go to a doctor and simply not pay the bill. And in any case, the argument goes, if Medicaid coverage is expanded, people will still have trouble seeing a doctor because so few accept that insurance.

Until now, the arguments were pretty much irresolvable. Researchers compared people who happened to have insurance with those who did not have it. But those who do not have insurance tend to be different in many ways from people who have it. They tend to be less educated and to have worse health habits and lower incomes, said Dr. Alan M. Garber, an internist and health economist at Stanford. No matter how carefully researchers try to correct for the differences “they cannot be completely successful,” Dr. Garber said. “There is always some doubt.”

The new study, published Thursday by the National Bureau of Economic Research, avoided that problem. Its design is like that used to test new drugs. People were randomly selected to have Medicaid or not, and researchers then asked if the insurance made any difference.

Health economists and other researchers said the study was historic and would be cited for years to come, shaping health care debates.

“It’s obviously a really important paper,” said James Smith, an economist at the RAND Corporation. “It is going to be a classic.”

Richard M. Suzman, director of the behavioral and social research program at the National Institute on Aging, a major source of financing for the research, said it was “one of the most important studies that our division has funded since I’ve been at the N.I.A.,” a period of more than a quarter-century.

In its first year of data collection, the study found a long list of differences between the insured and uninsured, adding up to an extra 25 percent in medical expenditures for the insured.

Those with Medicaid were 35 percent more likely to go to a clinic or see a doctor, 15 percent more likely to use prescription drugs and 30 percent more likely to be admitted to a hospital. Researchers were unable to detect a change in emergency room use.

Women with insurance were 60 percent more likely to have mammograms, and those with insurance were 20 percent more likely to have their cholesterol checked. They were 70 percent more likely to have a particular clinic or office for medical care and 55 percent more likely to have a doctor whom they usually saw.

The insured also felt better: the likelihood that they said their health was good or excellent increased by 25 percent, and they were 40 percent less likely to say that their health had worsened in the past year than those without insurance.

The study is now in its next phase, an assessment of the health effects of having insurance. The researchers interviewed 12,000 people — 6,000 who received Medicaid and 6,000 who did not — and measured things like blood pressure, cholesterol and weight.

The study became possible because of an unusual situation in Oregon. In 2008, the state wanted to expand its Medicaid program to include more uninsured people but could afford to add only 10,000 to its rolls. Yet nearly 90,000 applied. Oregon decided to select the 10,000 by lottery.

Economists were electrified. Here was their chance to compare those who got insurance with those who were randomly assigned to go without it. No one had ever done anything like that before, in part because it would be considered unethical to devise a study that would explicitly deny some people coverage while giving it to others.

But this situation was perfect for assessing the impact of Medicaid, said Katherine Baicker, professor of health economics at the Harvard School of Public Health. Dr. Baicker and Amy Finkelstein, professor of economics at M.I.T., are the principal investigators for the study.

“Amy and I stumbled across the lottery in Oregon and thought, ‘This is an unbelievable opportunity to actually find out once and for all what expanding public health insurance does,’ ” Dr. Baicker said.

They had just a short window of time. Within two years, Oregon found the money to offer Medicaid to the nearly 80,000 who had been turned down in the lottery.

As an economist, Dr. Finkelstein was interested, among other things, in whether Medicaid did what all insurance — homeowner’s, auto, health — is supposed to do: shield people from financial catastrophe. Almost no one had even tried to investigate that question, she said.

“It is shocking that it is not even in the discourse,” Dr. Finkelstein said.

The study found that those with insurance were 25 percent less likely to have an unpaid bill sent to a collection agency and were 40 percent less likely to borrow money or fail to pay other bills because they had to pay medical bills.

Dr. Finkelstein said she had thought that the people were so poor to begin with that they just did not spend very much out of pocket on medical care when they did not have insurance. “Yet look at the results,” she said.

Dr. Baicker interviewed people for Part 2 of the study and was impressed by what she heard.

“Being uninsured is incredibly stressful from a financial perspective, a psychological perspective, a physical perspective,” she said. “It is a huge relief to people not to have to worry about it day in and day out.”

A version of this article appeared in print on July 7, 2011, on page A14 of the New York edition with the headline: First Study of Its Kind Shows Benefits of Providing Medical Insurance to Poor.Study Finds Benefits in Health Insurance for the Poor – NYTimes.com.

Study: Medicaid Coverage Makes a ‘Big Difference’ – Health Blog – WSJ

A new research paper gives the clearest answer yet to a key question: how are people affected by gaining health insurance?

A study of people who got new Medicaid coverage shows that they received significantly more care, including preventive checks and hospital admissions, improved their financial situation, and felt better. “Having Medicaid made a big difference in many dimensions,” Amy Finkelstein, an MIT economics professor and lead author of the paper, tells the Health Blog.

The issue is more important than ever, with a huge new influx of Medicaid beneficiaries and other newly-covered people expected in 2014 due to the health-overhaul law. But it’s always been tough for researchers to get a good picture of the effects of new health coverage. In the real world, there are likely inherent differences between people with and without insurance, making it hard to get an answer by simply studying those groups.

The new paper, published by the National Bureau of Economic Research, focuses on an Oregon program that let certain low-income adults qualify for Medicaid through a random lottery process. That conveniently established the conditions for the gold standard of scientific research, a randomized controlled trial. The only similar study to take place in the U.S., Rand’s Health Insurance Experiment, which began in 1971, looked just at the effects of different levels of out-of-pocket charges on insurance enrollees.

The new study used surveys, hospital discharge data and other sources to compare the roughly 30,000 people who were selected in the lottery to 45,000 people who signed up and didn’t get chosen. It examined approximately the first year of coverage.

Overall, health-care expenditures for those who got coverage went up by roughly a quarter, which translated into about $778 a year. Those who received Medicaid were around 60% more likely to get mammograms — the proportion receiving the screening test rose to nearly 50% from 30%. Medicaid recipients were 55% more likely to have a regular primary-care doctor. They were also in better shape financially, roughly 25% less likely to have an unpaid medical bill sent to collections.

Those who got Medicaid were also far more likely to report themselves in good or excellent health. That may set up a contrast with the Rand research, which generally showed little difference in health outcomes for those with more generous insurance, even though they used more health services.

“If it holds up, it would be a very important difference,” said Joseph Newhouse, a Harvard professor who was also an author of the new study. He said the researchers plan to look at actual health outcomes for the Oregon population, as opposed to self-reported status, in a future paper.

But emergency-room admissions didn’t decline –  and actually rose slightly, though not significantly — for those who got Medicaid.

Also, the researchers are cautious about whether their results can be extrapolated to the huge new population of Medicaid beneficiaries that will be created by the health-overhaul law; the folks in Oregon may not be nationally representative.

Image: iStockphoto

via Study: Medicaid Coverage Makes a ‘Big Difference’ – Health Blog – WSJ.

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