Under Connecticut law, a home health aide can spend all day caring for you, but if you need help taking your pills, you’ll need a nurse to come give them to you.
Gov. Dannel P. Malloy next week will recommend changing that, a move his administration says could save the state more than $28 million a year and remove a barrier that keeps people from moving out of nursing homes.
The plan is likely win the backing of advocates of efforts to enable more seniors and people with disabilities to receive care at home, who say that the expenses associated with medication administration have made moving out of nursing homes cost-prohibitive for many people.
But it’s also likely to draw opposition from nurses and some home health care agencies, which criticized a similar proposal last year, arguing that the expertise of nurses is needed to safely administer medications to vulnerable patients and identify problems that occur.
“You will find nobody in the state who deals with these patients who is in favor of this, not even if their job depends on the governor’s goodwill,” Rep. Peter Tercyak, D-New Britain, said Friday. Tercyak, who works as a home care nurse and co-chairs the Human Services Committee, said he would fight the proposal “tooth and nail.”
Last fiscal year, the state spent $128.28 million to have nurses administer medication to about 8,500 Medicaid clients, averaging $54 per visit. One client, the heaviest user, received 2,650 nursing visits, costing the state $156,565.24 — not including the cost of the drugs. Another 12 clients also required more than $100,000 apiece in medication administration fees.
Malloy’s proposal will call for alternate methods for people to receive their medication, including allowing trained home health aides to dispense it according to the instructions of a nurse and letting clients use so-called assistive technology such as medication reminders and pill dispensers. The plan assumes that nurses would still administer medication for most clients and would not prevent doctors from requiring that nurses give patients the medication they prescribe.
Allowing for more flexibility in administering medications has been a recommendation of advocates for expanding the use of home-based long-term care. State officials have been working to help people who wish to move out of nursing homes transition to home or community settings through a federal demonstration program called Money Follows the Person. It requires that the cost of community care fall below certain levels that are based on what institutional care costs, and people monitoring the program say the cost of medication administration can stand in the way of people meeting the cost requirement.
“This is turning out to be one of the most significant barriers to success in Money Follows the Person,” said Office of Policy and Management Secretary Benjamin Barnes, Malloy’s budget director.
Connecticut is one of 44 states participating in Money Follows the Person. But during a recent six-month period, the state had 30 percent of the total cases nationally in which the projected cost prevented a person from moving into the community.
In one case cited by the Malloy administration, a 53-year-old man who had been in a nursing home for seven years wanted to move to the community, but couldn’t because it would have been too costly.
The man, who has schizophrenia, diabetes, hypertension, COPD and obesity, as well as opioid dependence, would have received staff supervision for most of the day if he moved out of the nursing home, but they would not have been able to give him the medications he takes four times a day. The cost of separate nursing visits to administer medication would have pushed the cost of caring for him in the community to $143,565, far beyond what would have been allowed.
Another case involved an 87-year-old retired English teacher who was in a nursing home with physical issues including dementia, COPD and hypertension. She was slated to move back home with a 24-hour personal care attendant from an agency. The nursing home staff developed a plan so the woman could administer her medications herself, but she wasn’t able to, and her care plan had to be changed to include at least two medication administration visits a day at $60.52 each, or $43,816 a year. Without those visits, her care would have fallen within the cost limit, but with them, she was well over the limit. She ultimately had to sell her house and remains in a nursing home.
Nurse delegation
The Malloy administration’s plan has four components. They would:
• Expand “nurse delegation” for medication administration, allowing home health aides who are trained and certified to administer oral and topical medications and eye drops. Home health care agencies would have to have specially trained home health aides to do so. Nurses would still be required to administer injections and medications identified by the client’s doctor as having to be administered by licensed providers. Nurses would also be responsible for organizing the medications for home health aides and giving the aides individualized instructions. Some state funds would cover training and implementation costs.
• Allow agency-based personal care attendants to administer medications. Currently, independent personal care attendants hired through a Medicaid waiver program are allowed to administer medications if the clients hire and train them.
• Provide Medicaid coverage for the use of assistive technology such as medication reminders and automatic pill dispensers, which could be used in place of having a nurse administer the medications.
• Reduce the rates paid to nurses for administering medication by 10 percent, saving $10.3 million in the coming fiscal year and $11.2 million a year after that.
Altogether, the administration projected that the changes would save $20.5 million in the coming fiscal year, accounting for time to implement the changes, and $28.6 million annually after that.
The savings figures assume that home health aides would replace nurses in 15 percent of medication administration cases, saving $5.1 million in the first year and $10.4 million a year after that, and that 1 percent of clients getting medication administration would use agency-based personal care attendants, saving $400,000 next fiscal year and $800,000 annually after that.
The administration projected that only about 110 people would use assistive technology, but that doing so could save $4.7 million in the first year and $6.2 million after that because the clients using it would be those who currently get the most medication administration visits.
Barnes said he thinks the assumptions are conservative, and that the savings could be greater.
Nationally, 35 states and the District of Columbia allow medication administration to be delegated to unlicensed personnel, although what they can do and where they can work varies, said Jill Budden, research associate at the National Council of State Boards of Nursing.
Role of nurses
But opponents of nurse delegation say it can be dangerous to replace the contact between patients and nurses, who can recognize symptoms and side-effects and address problems with how people are responding to medication.
“It’s like saying chemotherapy is too expensive, we’re going to do radiation to people now,” Tercyak said.
Tercyak recalled a psychiatric patient he had once cared for who cooperated with the nurses who brought him his medications, but died after his care plan was changed to not require nursing visits. The man later set himself on fire and died in a burn unit.
In testimony on last year’s proposal, Mary Jane Williams, chairwoman of the Connecticut Nurses’ Association’s government relations committee, asked who would be held accountable for problems people experienced.
“The administration of medications is not a usual and routine task. It requires skill, knowledge and judgment related to the assessment of the patient,” she said. “A change from a licensed nurse administering medications in the home care settings as proposed would be a major change in health care policy in this state. It separates the individual who administers the medication from the individual who is responsible for the assessment and the outcome.”
Sen. Toni N. Harp, D-New Haven, and the co-chairwoman of the Appropriations Committee, said Friday that she supports Malloy’s proposal. If there’s already an aide in a person’s home, she said, there are better ways to handle medication than to have a nurse come to the home multiple times a day and get paid for each visit.
“The thing that is important is the fact that we are trying to do Money Follows the Person, and for people who can be served in the community, make sure that we have an affordable community system so that they can participate in this system,” she said.
Harp said the fact that doctors would still be able to require a nurse to handle medications should address any safety concerns. “If the patient is that fragile, then my understanding is that based upon the doctor’s decision, that the nurse will continue to dispense,” she said. “I think that basically takes care of any overall safety issues that you might have.”
Mag Morelli, president of LeadingAge Connecticut, which represents nonprofit providers for the aging, said using more assistive technology makes sense, calling it “the future in community-based delivery of care.”
But she said if the state is moving toward using non-nurses to administer medication, there should be training opportunities for the workers — potentially through high schools or community colleges — rather than requirements that agencies have to find workers and train them.
Tracy Wodatch, vice president of clinical and regulatory services at the Connecticut Association for Home Care and Hospice, said the group had been expecting nurse delegation recommendations and has been discussing models used in other states. She said the key will be how it’s rolled out, and said it’s critical for nurses to have the authority to say whether it’s appropriate for an unlicensed person to handle medication in a particular situation.
“We want to make sure that the quality of care is not impacted,” she said. “We want to make sure that it’s still safe and appropriate, and that the home care aide is trained.”
In some situations, she said, the agency has been seeking to allow home health aides to do things they can’t do now, like using a prescription shampoo on a client or putting an ointment on a client’s rash.
“Those kinds of things really are a barrier to care,” she said. “So we’d like them to be able to have them have the ability to do that as well.”