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More Schools Stock Overdose Reversal Meds, but Others Worry About Stigma

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Rae Ellen Bichell and Virginia Garcia Pivik
Tue, 03 Oct 2023 09:00:00 +0000

Last year, a student fell unconscious after walking out of a bathroom at Central High School in Pueblo, Colorado. When Jessica Foster, the school district's nurse, heard the girl's distraught friends mention drugs, she knew she had to act fast.

Emergency responders were just four minutes away. “But still four minutes — if they are completely not breathing, it's four minutes too long,” Foster said.

Foster said she got a dose of naloxone, a medication that can rapidly reverse an opioid overdose, and gave it to the student. The girl revived.

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Forty-five miles away in Colorado Springs, Mitchell High School officials didn't have naloxone on hand when a 15-year-old student overdosed in class in December 2021 after snorting a fentanyl-laced pill in a school bathroom. That student died.

Colorado Springs' school district has since joined Pueblo and dozens of other districts in the in supplying middle and high schools with the lifesaving medication, often known by one of its brand names, Narcan. Since passage of a 2019 state , Colorado has had a program that allows schools to obtain the medicine, typically in nasal spray form, for free or at a reduced cost.

Not all schools are on board with the idea, though. Though more districts have signed on since last year, only about a third of Colorado districts had enrolled in the state's giveaway program at the start of this school year. And within the dozen counties with the highest drug overdose death rates in the state, many school districts had not signed up in the face of ongoing stigma around the need for the overdose reversal medication.

The federal Substance Abuse and Mental Health Services Administration recommends that schools, including elementary schools, keep naloxone on hand as fatal opioid overdoses rise, particularly from the potent drug fentanyl. And 33 states have laws that expressly allow schools or school employees to carry, store, or administer naloxone, according to Jon Woodruff, managing attorney at the Legislative Analysis and Public Policy Association, which tracks naloxone policies across the country.

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Among those, about nine states require at least some K-12 schools to store naloxone on-site, including Illinois, whose requirement goes into effect in January. Some states, such as Maine, also require that offer training to students in how to administer naloxone in nasal spray form.

Rhode Island requires all K-12 schools, both public and private, to stock naloxone. Joseph Wendelken, a spokesperson for the Rhode Island Department of Health, said in the past four years naloxone was administered nine times to people ages 10 to 18 in educational settings.

In early September, the medication also became available over the counter nationally, though the $45 price tag per two-dose package has some addiction specialists worried it will be out of reach for those who need it most.

But the medicine still isn't as publicly widespread as automated external defibrillators or fire extinguishers. Kate King, president of the National Association of School Nurses, said reluctance to stock it in schools can stem from officials being afraid to provide a medical service or the ongoing cost of resupplying the naloxone and training people to use it. But the main hang-up she's heard is that schools are afraid they'll be stigmatized as a “bad school” that has a drug problem or as a school that condones bad choices.

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“School districts are very careful regarding their image,” said Yunuen Cisneros, community outreach and inclusion at the Public Education & Business Coalition, which serves most of the state's school districts. “Many of them don't want to accept this program, because to accept it is to accept a drug addiction problem.”

That's the wrong way to think about it, King said. “We really equate it to our stock albuterol for asthma attacks, our stock epinephrine for anaphylactic reactions,” she said.

Colorado health officials could not say how often naloxone had been used on school grounds in the state. So far this year, at least 15 ages 10 to 18 have died of fentanyl overdoses but not necessarily in schools. And in 2022, 34 children in that age group died, according to the state Department of Public Health and Environment. That included 13-year-old José Hernández, who died in August 2022 from a fentanyl overdose at home just days after starting eighth grade at Aurora Hills Middle School. His grandmother found his body over the bathroom sink in the early morning.

With the arrival of this new school year, supplies of naloxone are on hand for kids in more Colorado schools. Last year, state lawmakers appropriated $19.7 million in federal aid to the Naloxone Bulk Purchase Fund, which is accessible to school districts, jails, first responders, and community service , among others.

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“It's the most we've ever had,” said Andrés Guerrero, manager of the state health department's overdose prevention program.

According to data provided by Colorado's health department, 65 school districts were enrolled in the state program to receive naloxone at low or no cost at the start of the school year. Another 16 had reached out to the state for information but hadn't finalized orders as of mid-August. The remaining 97 school districts either didn't stock naloxone at their schools or sourced it from elsewhere.

Guerrero said the districts decide whom to train to administer the medicine. “In some cases, it's just the school nurses. In some cases, it's school nurses and the teachers,” he said. “And in some cases, we have the students as well.”

In Durango, the 2021 death of a high schooler galvanized students to push for the right to carry naloxone with them to school with parental permission — and to administer it if need be — without fear of punishment.

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It took picketing outside a school board meeting to get permission, said Hays Stritikus, who graduated this spring from Durango High School. He's now involved in drafting legislation that would expressly allow students across the state to carry and distribute Narcan on school grounds.

“The ultimate goal is a world where Narcan is not necessary,” he said. “But that's just not where we live.”

Some health experts disagree that all schools should stock naloxone. Lauren Cipriano, a health economist at Western University in Canada, has studied the cost-effectiveness of naloxone in secondary schools there. While opioid poisonings have occurred on school grounds, she said, high schools tend to be really low-risk settings.

More effective strategies for combating the opioid epidemic are needle exchange sites, supervised drug consumption sites, and medication-assisted treatment that reduces cravings or mutes highs, Cipriano said. But those approaches can be expensive compared with naloxone distribution.

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“When the state makes a big, free program like this, it looks like they're doing something about the opioid epidemic,” she said. “It's cheap and it looks like you're doing something, and that's, like, political gold.”

Denver Public Schools, the largest school district in Colorado, started stocking naloxone in 2022, said Jade Williamson, manager of the district's healthy schools program.

“We know some of the students are on the forefront of these things before older generations,” Williamson said. “To know where to find it, and to access it when needed through these adults who've trained, whether that's a school nurse or a school administrator, I think it brings them some sense of relief.”

The state's seven largest districts, with more than 25,000 students each, all participate in the state program. By contrast, a KFF Health News analysis found, only 21% of districts with up to 1,200 students have signed up for it — even though many of those small districts are in with drug overdose rates higher than the state average.

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Some school districts figured out a path to getting naloxone outside of the state program. That includes Pueblo School District 60, where lead nurse Foster gave naloxone to a student last year.

The Pueblo school district gets naloxone at no cost from a local nonprofit called the Southern Colorado Harm Reduction Association. Foster said she tried signing up for the state program but encountered difficulties. So she decided to stick with what was already working.

Moffat County School District RE-1 in Craig, Colorado, gets its naloxone from a local addiction treatment center, according to district nurse Myranda Lyons. She said she trains school staffers on how to administer it when she teaches them CPR.

Christopher deKay, superintendent of Ignacio School District 11Jt, said its school resource officers already carry naloxone but that the district enrolled in the state program, too, so that schools could stock the medication in the nursing office in case a resource officer isn't around.

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“It's like everything — like training for fire safety. You don't know what's going to happen in your school,” said deKay. “If the unthinkable happens, we want to be able to respond in the best way possible.”

This story was produced with assistance from El Comercio de Colorado.

——————————
By: Rae Ellen Bichell and Virginia Garcia Pivik
Title: More Schools Stock Overdose Reversal Meds, but Others Worry About Stigma
Sourced From: kffhealthnews.org/news/article/schools-narcan-naloxone-overdose-reversal-colorado/
Published Date: Tue, 03 Oct 2023 09:00:00 +0000

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Kaiser Health News

California Health Care Pioneer Goes National, Girds for Partisan Skirmishes

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Samantha Young
Mon, 15 Jul 2024 09:00:00 +0000

SACRAMENTO — When then-Gov. Arnold Schwarzenegger called for nearly all Californians to buy health insurance or face a penalty, Anthony Wright slammed the 2007 proposal as “unwarranted, unworkable, and unwise” — one that would punish those who could least afford coverage. The head of Health Access California, one of the 's most influential consumer groups, changed course only after he and his allies extracted a deal to increase subsidies for people in need.

The plan was ultimately blocked by Democrats who wanted the state to adopt a single-payer health care system instead. Yet the moment encapsulates classic Anthony Wright: independent-minded and willing to compromise if it could help Californians healthier lives without going broke.

This summer, Wright will assume the helm of the health consumer group Families USA, taking his campaign for more affordable and accessible health care to the national level and a deeply divided Congress. In his 23 years in Sacramento, Wright has successfully lobbied to outlaw surprise medical billing, require companies to report drug price increases, and cap hospital bills for uninsured patients — policies that have spread nationwide.

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“He pushed the envelope and gave people aspirational leadership,” said Jennifer Kent, who served as Schwarzenegger's head of the Department of Health Care Services, which administers the state Medicaid program. The two were often on opposing sides on health policy issues. “There was always, like, one more thing, one more goal, one more thing to achieve.”

Recently, Wright co-led a coalition of labor and immigrant rights activists to comprehensive Medicaid to all eligible California residents regardless of immigration status. The state funds this coverage because the federal government doesn't allow it.

His wins have mostly under Democratic governors and legislatures and when Republican support hasn't been needed. That will not be the case in Washington, D.C., where Republicans currently control the House and the Senate Democratic Caucus has a razor-thin majority, which has made it extremely difficult to pass substantive legislation. November's elections are not expected to ease the partisan impasse.

Though both Health Access and Families USA are technically nonpartisan, they tend to align with Democrats and lobby for Democratic policies, abortion rights. But “Anthony doesn't just talk to his own people,” said David Panush, a veteran Sacramento health policy consultant. “He has an ability to connect with people who don't agree with you on everything.”

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Wright, who interned for Vice President Al Gore and worked as a consumer advocate at the Federal Communications Commission in his 20s, acknowledges his job will be tougher in the nation's capital, and said he is “wide-eyed about the dysfunction” there. He said he also plans to work directly with state lawmakers, including encouraging those in the 10, mostly Republican states that have not yet expanded Medicaid under the Affordable Care Act to do so.

In an interview with California Healthline senior correspondent Samantha Young, Wright, 53, discussed his accomplishments in Sacramento and the challenges he will face leading a national consumer advocacy group. His remarks have been edited for length and clarity.

Q: Is there something California has done that you'd like to see other states or the federal government adopt?

Just saying “We did this in California” is not going to get me very far in 49 other states. But stuff that has already gone national, like the additional assistance to buy health care coverage with state subsidies, that became something that was a model for what the federal government did in the American Rescue Plan [Act] and the Inflation Reduction Act. Those additional tax credits have had a huge impact. About 5 million Americans have coverage because of them. Yet, those additional tax credits expire in 2025. If those tax credits expire, the average premium will spike $400 a month.

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Q: You said you will find yourself playing defense if former President Donald Trump is elected in November. What do you mean?

Our health is on the ballot. I worry about the Affordable Care Act and the protections for preexisting conditions, the help for people to afford coverage, and all the other consumer patient protections. I think reproductive health is obviously front and center, but that's not the only thing that could be taken away. It could also be something like Medicare's authority to negotiate prices on prescription drugs.

Q: But Trump has said he doesn't want to repeal the ACA this time, rather “make it better.”

We just need to look at the record of what was proposed during his first term, which would have left millions more people uninsured, which would have spiked premiums, which would have gotten rid of key patient protections.

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Q: What's on your agenda if President Joe Biden wins reelection?

It partially depends on the makeup of Congress and other elected officials. Do you extend this guarantee that nobody has to spend more than 8.5% of their income on coverage? Are there benefits that we can actually improve in Medicare and Medicaid with regard to vision and dental? What are the cost drivers in our health system?

There is a lot we can do at both the state and the federal level to get people both access to health care and also financial security, so that their health emergency doesn't become a financial emergency as well.

Q: Will it be harder to get things done in a polarized Washington?

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The dysfunction of D.C. is a real thing. I don't have delusions that I have any special powers, but we will try to do our best to make progress. There are still very stark differences, whether it's about the Affordable Care Act or, more broadly, about the social safety net. But there's always opportunities for advancing an agenda.

There could be a lot of common ground on like health care costs and greater oversight and accountability for quality in cost and quality in value, for fixing market failures in our health system.

Q: What would happen in California if the ACA were repealed?

When there was the big threat to the ACA, a lot of people thought, “Can't California just do its own thing?” Without the tens of billions of dollars that the Affordable Care Act provides, it would have been very hard to sustain. If you get rid of those subsidies, and 5 million Californians lose their coverage, it becomes a smaller and sicker risk pool. Then premiums spike up for everybody, and, basically, the market becomes a death spiral that will nobody, healthy or sick.

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Q: California expanded Medicaid to qualified immigrants living in the state without authorization. Do you think that could happen at the federal level?

Not at the moment. I would probably be more focused on the states that are not providing Medicaid to American citizens [who] just happen to be low-income. They are turning away precious dollars that are available for them.

Q: What do you take away from your time at Health Access that will help you in Washington?

It's very rare that anything of consequence is done in a year. In many cases, we've had to run a bill or pursue a policy for multiple years or sessions. So, the power of persistence is that if you never give up, you're never defeated, only delayed. Prescription drug price transparency took three years, surprise medical bills took three years, the hospital fair-pricing act took five years.

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Having a coalition of consumer voices is important. Patients and the public are not just another stakeholder. Patients and the public are the point of the health care system.

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

——————————
By: Samantha Young
Title: California Health Care Pioneer Goes National, Girds for Partisan Skirmishes
Sourced From: kffhealthnews.org//article/anthony-wright-qa-families-usa-health-policy/
Published Date: Mon, 15 Jul 2024 09:00:00 +0000

Did you miss our previous article…
https://www.biloxinewsevents.com/states-set-minimum-staffing-levels-for-nursing-homes-residents-suffer-when-rules-are-ignored-or-waived/

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Kaiser Health News

States Set Minimum Staffing Levels for Nursing Homes. Residents Suffer When Rules Are Ignored or Waived.

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Jordan Rau, KFF Health News
Fri, 12 Jul 2024 09:45:00 +0000

For hours, John Pernorio repeatedly mashed the call button at his bedside in the Heritage Hills nursing home in Rhode Island. A retired truck driver, he had his spine in a fall on the job decades earlier and could no longer walk. The antibiotics he was taking made him need to go to the bathroom frequently. But he could get there only if someone helped him into his wheelchair.

By the time an aide finally responded, he'd been lying in soiled briefs for hours, he said. It happened time and again.

“It was degrading,” said Pernorio, 79. “I spent 21 hours a day in bed.”

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Payroll records show that during his stay at Heritage Hills, daily aide staffing levels were 25% below the minimums under state . The nursing home said it provided high-quality care to all residents. Regardless, it wasn't in trouble with the state, because Rhode Island does not enforce its staffing rule.

An acute shortage of nurses and aides in the nation's nearly 15,000 nursing homes is at the root of many of the most disturbing shortfalls in care for the 1.2 million Americans who live in them, many of the nation's frailest old people.

They get festering bedsores because they aren't turned. They lie in feces because no one comes to attend to them. They have devastating falls because no one helps them get around. They are subjected to chemical and physical restraints to sedate and pacify them.

California, Florida, Massachusetts, New York, and Rhode Island have sought to improve nursing home quality by mandating the highest minimum hours of care per resident among states. But an examination of records in those states revealed that putting a law on the books was no guarantee of better staffing. Instead, many nursing homes operated with fewer workers than required, often with the permission of regulators or with no consequences at all.

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“Just setting a number doesn't mean anything if you're not going to enforce it,” said Mark Miller, former president of the national organization of long-term care ombudsmen, advocates in each state who help residents resolve problems in their nursing homes. “What's the point?”

Now the Biden administration is trying to guarantee adequate staffing the same way states have, unsuccessfully, for years: with tougher standards. Federal rules issued in April are expected to require 4 out of 5 homes to boost staffing.

The administration's plan also has some of the same weaknesses that have hampered states. It relies on underfunded health inspectors for enforcement, lacks explicit penalties for violations, and offers broad exemptions for nursing homes in with labor shortages. And the administration isn't providing more money for homes that can't afford additional employees.

Serious health violations have become more widespread since covid-19 swept through nursing homes, killing more than 170,000 residents and driving employees out the door.

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Pay remains so low — nursing assistants earn $19 an hour on average — that homes frequently lose workers to retail stores and fast-food restaurants that pay as well or better and offer that are far less grueling. Average turnover in nursing homes is extraordinarily high: Federal records show half of employees leave their jobs each year.

Even the most passionate nurses and aides are burning out in short-staffed homes because they are stretched too thin to provide the quality care they believe residents deserve. “It was impossible,” said Shirley Lomba, a medication aide from Providence, Rhode Island. She left her job at a nursing home that paid $18.50 an hour for one at an assisted living facility that paid $4 more per hour and involved residents with fewer needs.

The mostly for-profit nursing home industry argues that staffing problems stem from low rates of reimbursement by Medicaid, the program funded by states and the federal government that covers most people in nursing homes. Yet a growing body of research and court evidence shows that owners and investors often extract hefty profits that could be used for care.

Nursing home trade groups have complained about the tougher state standards and have sued to block the new federal standards, which they say are unworkable given how much trouble nursing homes already have filling jobs. “It's a really tough business right now,” said Mark Parkinson, president and chief executive of one trade group, the American Health Care Association.

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And federal enforcement of those rules is still years off. Nursing homes have as long as five years to comply with the new regulations; for some, that means enforcement would fully kick in only at the tail end of a second Biden administration, if the president wins reelection. Former President Donald Trump's campaign declined to comment on what Trump would do if elected.

Persistent Shortages

Nursing home payroll records submitted to the federal government for the most recent quarter available, October to December 2023, and state regulatory records show that homes in states with tougher standards frequently did not meet them.

In more than two-thirds of nursing homes in New York and more than half of those in Massachusetts, staffing was below the state's required minimums. Even California, which passed the nation's first minimum staffing law two decades ago, has not achieved universal compliance with its requirements: at least 3½ hours of care for the average resident each day, including two hours and 24 minutes of care from nursing assistants, who help residents eat and get to the bathroom.

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During inspections since 2021, state regulators cited a third of California homes — more than 400 of them — for inadequate staffing. Regulators also granted waivers to 236 homes that said workforce shortages prevented them from recruiting enough nurse aides to meet the state minimum, exempting them from fines as high as $50,000.

In New York, Gov. Kathy Hochul declared an acute labor shortage, which allows homes to petition for reduced or waived fines. The state health department said it had cited more than 400 of the state's 600-odd homes for understaffing but declined to say how many of them had appealed for leniency.

In Florida, Gov. Ron DeSantis signed legislation in 2022 to loosen the staffing rules for all homes. The law allows homes to count almost any employee who engages with residents, instead of just nurses and aides, toward their overall staffing. Florida also reduced the daily minimum of nurse aide time for each resident by 30 minutes, to two hours.

Now only 1 in 20 Florida nursing homes are staffed below the minimum — but if the former, more rigorous rules were still in place, 4 in 5 homes would not meet them, an analysis of payroll records shows.

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“Staffing is the most important part of providing high-quality nursing home care,” said David Stevenson, chair of the health policy department at Vanderbilt University School of Medicine. “It comes down to political will to enforce staffing.”

The Human Toll

There is a yawning gap between law and practice in Rhode Island. In the last three months of 2023, only 12 of 74 homes met the state's minimum of three hours and 49 minutes of care per resident, including at least two hours and 36 minutes of care from certified nursing assistants, payroll records show. One of the homes below the minimum was Heritage Hills Rehabilitation & Healthcare Center in Smithfield, where Pernorio, president of the Rhode Island Alliance for Retired Americans, went last October after a stint in a hospital.

“From the minute the ambulance took me in there, it was downhill,” he said in an interview.

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Sometimes, after waiting an hour, he would telephone the home's main office for help. A nurse would come, turn off his call light, and walk right back out, and he would push the button again, Pernorio reported in his weekly e-newsletter.

While he praised some workers' dedication, he said others frequently did not show up for their shifts. He said staff members told him they could earn more flipping hamburgers at McDonald's than they could cleaning soiled patients in a nursing home.

In a written statement, Heritage Hills did not dispute that its staffing, while higher than that of many homes, was below the minimum under state law.

Heritage Hills said that after Pernorio complained, state inspectors the home and did not cite it for violations. “We take every resident concern seriously,” it said in the statement. Pernorio said inspectors never interviewed him after he called in his complaint.

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In interviews, residents of other nursing homes in the state and their relatives reported neglect by overwhelmed nurses and aides.

Jason Travers said his 87-year-old father, George, fell on the way to the bathroom because no one answered his call button.

“I think the lunch crew finally came in and saw him on the floor and put him in the bed,” Travers said. His father died in April 2023, four months after he entered the home.

Relatives of Mary DiBiasio, 92, who had a hip fracture, said they once found her sitting on the toilet unattended, hanging on to the grab bar with both hands. “I don't need to be a medical professional to know you don't leave somebody hanging off the toilet with a hip fracture,” said her granddaughter Keri Rossi-D'entremont.

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When DiBiasio died in January 2022, Rhode Island was preparing to enact a law with nurse and aide staffing requirements higher than anywhere else in the country except Washington, D.C. But Gov. Daniel McKee suspended enforcement, saying the industry was in poor financial shape and nursing homes couldn't even fill existing jobs. The governor's executive order noted that several homes had closed because of problems finding workers.

Yet Rhode Island inspectors continue to find serious problems with care. Since January 2023, regulators have found deficiencies of the highest severity, known as immediate jeopardy, at 23 of the state's 74 nursing homes.

Homes have been cited for failing to get a dialysis patient to treatment and for giving one resident a roommate's methadone, causing an overdose. They have also been cited for violent behavior by unsupervised residents, including one who shoved pillow stuffing into a resident's mouth and another who turned a roommate's oxygen off because it was too noisy. Both the resident who was attacked and the one who lost oxygen died.

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Even some of the nonprofit nursing homes, which don't have to pay investors, are trouble meeting the state minimums — or simply staying open.

Rick Gamache, chief executive of the nonprofit Aldersbridge Communities, which owns Linn Health & Rehabilitation in East Providence, said Rhode Island's Medicaid program paid too little for the home to keep operating — about $292 per bed, when the daily cost was $411. Aldersbridge closed Linn this summer and converted it into an assisted living facility.

“We're seeing the collapse of post-acute care in America,” Gamache said.

Many nursing homes are owned by for-profit chains, and some researchers, lawyers, and state authorities argue that they could reinvest more of the money they make into their facilities.

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Bannister Center, a Providence nursing home that payroll records show is staffed 10% below the state minimum, is part of Centers Health Care, a New York-based private chain that owns or operates 31 skilled nursing homes, according to Medicare records. Bannister lost $430,524 in 2021, according to a financial statement it filed with Rhode Island regulators.

Last year, the New York sued the chain's owners and investors and their relatives, accusing them of improperly siphoning $83 million in Medicaid funds out of their New York nursing homes by paying salaries for “no-show” jobs, profits above what state law allowed, and inflated rents and fees to other companies they owned. For instance, one of those companies, which purported to provide staff to the homes, paid $5 million to the wife of Kenny Rozenberg, the chain's chief executive, from 2019 to 2021, the said.

The defendants argued in court papers that the payments to investors and owners were legal and that the state could not prove they were Medicaid funds. They have asked for much of the lawsuit to be dismissed.

Jeff Jacomowitz, a Centers Health Care spokesperson, declined to answer questions about Bannister, Centers' operations, or the chain's owners.

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Miller, the District of Columbia's long-term care ombudsman, said many nursing home owners could pay better wages if they didn't demand such high profits. In D.C., 7 in 10 nursing homes meet minimum standards, payroll records show.

“There's no staffing shortage — there's a shortage of good-paying jobs,” he said. “I've been doing this since 1984 and they've been going broke all the time. If it really is that bad of an investment, there wouldn't be any nursing homes left.”

The new federal rules call for a minimum of three hours and 29 minutes of care each day per resident, including two hours and 27 minutes from nurse aides and 33 minutes from registered nurses, and an RN on-site at all times.

Homes in areas with worker shortages can apply to be exempted from the rules. Dora Hughes, acting chief medical officer for the U.S. Centers for Medicare & Medicaid Services, said in a statement that those waivers would be “time-limited” and that having a clear national staffing minimum “will facilitate strengthened oversight and enforcement.”

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David Grabowski, a health policy professor at Harvard Medical School, said federal health authorities have a “terrible” track record of policing nursing homes. “If they don't enforce this,” he said, “I don't imagine it's going to really move the needle a lot.”

Methodology for Analysis of Nursing Home Staffing

The KFF Health News data analysis focused on five states with the most rigorous staffing requirements: California, Florida, Massachusetts, New York, and Rhode Island.

To determine staffing levels, the analysis used the daily payroll journals that each nursing home is required to submit to the federal government. These publicly available records include the number of hours each category of nursing home employee, including registered nurses and certified nursing assistants, worked each day and the number of residents in each home. We used the most recent data, which included a combined 1.3 million records covering the final three months of 2023.

We calculated staffing levels by following each state's rules, which specify which occupations are counted and what minimums homes must meet. The analysis differed for each state. Massachusetts, for instance, has a separate requirement for the minimum number of hours of care registered nurses must provide each day.

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In California, we used state enforcement action records to identify homes that had been fined for not meeting its law. We also tallied how many California homes had been granted waivers from the law because they couldn't find enough workers to hire.

For each state and Washington, D.C., we calculated what proportion of homes complied with state or district law. We shared our conclusions with each state's nursing home regulatory agency and gave them an to respond.

This analysis was performed by senior correspondent Jordan Rau and data editor Holly K. Hacker.

——————————
By: Jordan Rau, KFF Health News
Title: States Set Minimum Staffing Levels for Nursing Homes. Residents Suffer When Rules Are Ignored or Waived.
Sourced From: kffhealthnews.org/news/article/nursing-home-minimum-staffing-state-laws-enforcement-residents-suffer/
Published Date: Fri, 12 Jul 2024 09:45:00 +0000

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How to Find a Good, Well-Staffed Nursing Home

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Jordan Rau, KFF News
Fri, 12 Jul 2024 09:45:00 +0000

Few people want to go into a nursing home, but doing so can be the right choice if you or a loved one is physically or cognitively disabled or recovering from surgery. Unfortunately, homes vary greatly in quality, and many don't have enough nurses and aides to give residents the care they need.

Q: How do I find nursing homes worth considering?

Start with Medicare's online comparison tool, which you can search by city, , ZIP code, or home name. Ask for advice from people designated by your state to people who are older or have disabilities search for a nursing home. Every state has a “no wrong door” contact for such inquiries.

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You can also reach out to your local area agency on aging, a public or nonprofit resource, and your local long-term care ombudsman, who helps residents resolve problems with their nursing home.

Find your area agency on aging and ombudsman through the federal government's Eldercare Locator website or by calling 1-800-677-1116. Identify your ombudsman through the National Consumer Voice for Quality Long-Term Care, an advocacy group. Some people use private placement agencies, but they may refer you only to homes that pay them a referral fee.

Q: What should I find out before visiting a home?

Search online for news coverage and for reviews posted by residents or their families.

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Call the home to make sure beds are available. Well-regarded homes can have long waiting lists.

Figure out how you will pay for your stay. Most nursing home residents rely primarily on private long-term care insurance, Medicare (for rehabilitation stays) or (for long-term stays if you have few assets). In some cases, the resident pays entirely out-of-pocket. If you're likely to out of money or insurance coverage during your stay, make sure the home accepts Medicaid. Some won't admit Medicaid enrollees unless they start out paying for the care themselves.

If the person needing care has dementia, make sure the home has a locked memory-care unit to ensure residents don't wander off.

Q: How can I tell if a home has adequate staffing?

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Medicare's comparison tool gives each home a rating of one to five stars based on staffing, health inspection results, and measurements of resident care such as how many residents had pressure sores that worsened during their stay. Five is the highest rating. Below that overall rating is one specifically for staffing.

Be sure to study the annual staff turnover rate, at the bottom of the staffing page. Anything higher than the national rate — an appalling 52% — should give you pause.

You should also pay attention to the inspection star rating. The “quality” star rating is less reliable because homes self- many of the results and have incentives to put a glossy spin on their performance.

Q: Does a home with three, four, or five stars good care?

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Not necessarily. Medicare's ratings compare the staffing of a home against that of other homes, not against an independent standard. The industry isn't as well staffed as many experts think it needs to be: About 80% of homes, even some with four and five stars, are staffed below the standards the Biden administration will be requiring homes to meet in the next five years.

Q: How many workers are enough?

There's no straightforward answer; it depends on how frail and sick a nursing home's residents are. Medicare requires homes to prominently post their staffing each day. The notices should show the number of residents, registered nurses, licensed vocational nurses, and nurse aides. RNs are the most skilled and manage the care. LVNs provide care for wounds and catheters and handle basic medical tasks. Nurse aides help residents eat, dress, and get to the bathroom.

Expert opinions vary on the ideal ratios of staffing. Sherry Perry, a Tennessee nursing assistant who is the chair of her profession's national association, said that preferably a nursing assistant should care for eight or fewer residents.

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Charlene Harrington, an emerita professor of nursing at the University of California-San Francisco, recommends that on the day shift there be one nurse aide for every seven residents who need help with physical functioning or have behavioral issues; one RN for every 28 residents; and one LVN for every 38 residents. with complex medical needs will need higher staffing levels.

Staffing can be lower at night because most residents are sleeping, Harrington said.

Nursing home industry officials say that there's no one-size-fits-all ratio and that a study the federal government published last year found quality improved with higher staffing but didn't recommend a particular level.

Q: What should I look for when I visit a home?

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Watch to see if residents are engaged in activities or if they are alone in their rooms or slumped over in wheelchairs in hallways. Are they still in sleeping gowns during the day? Do nurses and aides know the residents by name? Is food available only at mealtimes, or can residents get snacks when hungry? Watch a meal to see whether people are getting the help they need. You might visit at night or on weekends or holidays, when staffing is thinnest.

Q: What should I ask residents and families in the home?

Are residents cared for by the same people or by a rotating cast of strangers? How long do they have to wait for help bathing or getting out of bed? Do they get their medications, physical therapy, and meals on time? Do aides quickly if they turn on their call light? Delays are strong signs of understaffing.

Medicare requires homes to allow residents and families to form councils to address common issues. If there's a council, ask to speak to its president or an officer.

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Ask what proportion of nurses and aides is on staff or from temporary staffing agencies; temp workers won't know the residents' needs and likes as well. A home that relies heavily on temporary staff most likely has trouble recruiting and keeping employees.

Q: What do I need to know about a home's leadership?

Turnover at the top is a sign of trouble. Ask how long the home's administrator has been on the job; ideally it should be at least a year. (You can look up administrator turnover on the Medicare comparison tool: It's on the staffing page beneath staff turnover. But be aware the information may not be up to date.) You should also ask about the tenure of the director of nursing, the top clinical supervisor in a home.

During your tour, observe how admissions staff members treat the person who would be living there. “If you walk in to visit with your mom and they greeted you and didn't greet your mom or focused all their attention on you, go somewhere else,” advised Carol Silver Elliott, president of the Jewish Home Family, a nonprofit in Rockleigh, New Jersey.

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Q: Does it matter who owns the home?

It often does. Generally, nonprofit nursing homes provide better care because they can reinvest revenue back into the home rather than paying some of it to owners and investors.

But there are some very good for-profit homes and some lousy nonprofits. Since most homes in this country are for-profit, you may not have a choice in your area. As a rule of thumb, the more local and present the owner, the more likely the home will be well run. Many owners out of state and hide behind corporate shell companies to insulate themselves from accountability. If nursing home representatives can't give you a clear answer when you ask who owns it, think twice.

Finally, ask if the home's ownership has changed in the past year or so or if a sale is pending. Stable, well-run nursing homes aren't usually the ones owners are trying to get rid of.

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By: Jordan Rau, KFF Health News
Title: How to Find a Good, Well-Staffed Nursing Home
Sourced From: kffhealthnews.org/news/article/nursing-home-shopping-staffing-resources-red-flags/
Published Date: Fri, 12 Jul 2024 09:45:00 +0000

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