Nursing homes: Society gets what it (and the government) pays for
A former nursing home administrator reflects on the realities of nursing home fatalities during the pandemic
Americans want to know why the coronavirus is ravaging the nation’s nursing homes, killing residents and staff.
Regulations only allow the sickest to be admitted. Heart, lung, kidney and liver disease are a given. Diabetes likely. Health is compromised, care needs are high and physical contact is unavoidable.
Hands-on care is the villain. Lots of touching and hugging and TLC is the norm. Good aides use terms of endearment, even kisses. All parties consider one another family. Physical contact is a two-way street. Toileting, bathing, feeding, dressing requires human interaction. Unless staff are in highly sophisticated, expensive facility with frequently disposed personal protective equipment, contagion happens.
Caring for devalued elders is demanding and rewarding work. Who chooses this field to earn their scanty livelihood?
From lower socio-economic backgrounds, nursing home staff grew up making do without or with not enough. Not paid a living wage, the staff often take a second job; private duty or another shift in another facility. More contagion.
As a nursing home administrator, I had employees who bathed in the river when their water was shut off… in northern Vermont. Low pay, not enough washcloths, they lived with it. Today, living without it can mean death.
Who bought the bra for the new resident her children dropped off in her pajamas? Who came in on her day off, smuggling in liver and onions to a lady with a craving? Who collected dollars to buy a dress for the deceased to wear to her own funeral? Who loves on a sobbing resident waiting all day for her MIA son to visit?
My calculus tells me 90 percent of the caregivers are saints and 10 percent are rascals, or worse.
Good nurses and certified nurses’ aides (CNA) have cared for someone vulnerable all their lives. Leading seminars and councils of CNAs nationally, I learned most aides, since childhood, rescued dogs and cats, ran a doll hospital, helped a disabled sibling or parent, tended to live-in grandparents or otherwise watched over someone in need.
Institutional care of elders was a product of Lyndon B. Johnson’s Great Society in the 1960s. Medicaid dollars began paying for long term care, about $8 per patient for 24 hours of care.
Unlike hospitals and public schools, nursing homes aren’t built with public dollars. The Great Society relied upon the free market for construction, a policy decision that doomed the model from Day One.
Real estate developers build to make a profit, to earn an ongoing, robust return on equity. What happens inside their buildings is of little interest; they want their money.
In the people business, schools and hospitals alike, about 70 cents of every dollar spent in a facility is on wages and benefits. Insurance, food costs, utilities, taxes and property maintenance take the other 30 cents. Profit margins are slim pickings, unless the facility has lots of wealthy patients who pay.
Care is therefore highly susceptible to great swings in quality. Add to this instability the ongoing tension between facility operators and the government: there is no real trust.
Because most Americans don’t save for old age, the cost of care defaults to the government. But, we, the people who fund the government, don’t want to pay high taxes. Hence, government, the biggest customer, doesn’t pay the full cost of care for the majority of nursing home patients.
Using a rate setting mechanism, states routinely deny or disallow a portion of the money facilities spend, arguing it is not “care related.” Flowers or plants to brighten a public space is one such disallowance. Staff recognition teas are another.
To further damn this arrangement, another branch of government regulates, inspects and punishes facilities for providing poor care. In their defense, the nursing homes could reply, “You get what you pay for.”
Critics of nursing homes claim Medicaid does pay enough money; investor owners put it toward profit not salaries.
Why are people dying in nursing homes? Because residents are already frail and someone didn’t buy the staff enough PPE.
Bethany McLean Greeley of Clinton is a retired health care executive, nursing home administrator and author of For Goodness’ Sake: A Daily Book of Cheer for Nursing Assistants and Others Who Care. (Hartman Publishing)
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