The Wall Street Journal’s Health Blog profiles an interesting partnership between nursing home operator Hebrew SeniorLife and local colleges that allows students in the areas of medicine, social work, dental school and business to complete internships and the company’s Hebrew Rehabilitation Center facility.  Here’s a link and an excerpt:

For the first time this year, all second-year Harvard medical students are doing two-week rotations through Hebrew SeniorLife’s nursing homes, learning how to examine patients. Boston University sends its dental students, Boston College and University of Massachusetts send nursing students, and Simmons College social-work students pass through as well. All told, some 750 students rotate through the group’s biggest nursing home, Hebrew Rehabilitation Center.

And this spring, Brandeis University’s Heller School for Social Policy and Management is announcing a new concentration in aging services for its MBA program, giving students training in managing geriatric services at Hebrew SeniorLife.

At the other end of the pay scale, Hebrew SeniorLife offers nurse aides a day off a week, plus training, remedial classes and child-care, to work toward becoming a licensed practical nurse, or LPN. It isn’t cheap: A state grant pays $250,000 of the costs, and donations cover the remaining $200,000, says Len Fishman, Hebrew SeniorLife’s president and CEO. “It’s a way of saying to people, long-term-care is not a dead end.”

Such arrangements are rare, largely thanks to the cost – and staffing pressures. “The first thing you need are patients, and the second thing you need are health-care professionals who have a spare moment to be providing high-quality teaching,” Fishman, a former New Jersey Commissioner of Health and Senior Services, tells Health Blog. “Most long-term-care facilities are small; they don’t have medical staffs.”

Ultimately, as Baby Boomers age, much of the slack will have to be taken up by non-specialists. It’ll help if docs and others remember that, unlike some kinds of medical specialties, geriatrics is more about juggling a patient’s many conditions and risks. Does the chance that a drug makes a patient dizzy and raises their chance of falling outweigh the benefit from lowering their blood-pressure?

“Physicians are interested in what causes the problem, but the patients are interested in what the problem will cause in their lives,” says Fredrick T. Sherman, a professor of geriatrics and medicine at the Mt. Sinai School of Medicine in New York. “What they really want us to do is to maintain and improve their function.”

There is a nice article in Nurse.com that profiles issues face by elderly gay and lesbian nursing home residents including outreach efforts by Boston Senior Home Care. Here is an excerpt of the article:

Massachusetts Groups Reach Out to Gay and Lesbian Elderly Population

Cathryn Domrose

Monday March 10, 2008

Even in Massachusetts, which is considered a beacon of tolerance and diversity for many gay, lesbian, bisexual, and transgender Americans, the older members of this group remain in the shadows, as in the rest of the country.

Many fear going into assisted-living or skilled nursing facilities, or getting home health care, say those who work in agencies serving gay and lesbian elders. They retreat into the closet rather than face scornful remarks of fellow residents or possible discrimination from caregivers.

But a growing number, led by aging gay and lesbian baby boomers, are starting to assert themselves. They are familiar with anti-discrimination laws and are not afraid to make sure those laws are enforced. They are looking for retirement complexes, assisted-living facilities, and skilled nursing facilities that not only tolerate them, but welcome them.

“I think people are gradually coming out more,” says Linda S. George, RN, MA, CAN, executive director of Boston Senior Care, a home health agency that serves about 3,000 people in the city. “And young gay people are very much out. I think things will be equal in 50 years, maybe 40.”

Agencies Join Efforts
In the meantime, some agencies and companies that serve the elderly — including Boston Senior Home Care — are actively working with staff and clients to become more welcoming to lesbian, gay, bisexual, and transgender elders, including offering training for nurses and other healthcare workers. A skilled nursing facility in the Boston area, the Chelsea Jewish Nursing Home, plans to break ground next year for a unit specifically for elderly gay and lesbian residents.

About 2.4 million Americans older than 55 are gay, lesbian, or bisexual, according to researchers at the University of California in Los Angeles. But many hide behind a wall of fear and isolation, says Lisa Krinsky, director of the LGBT Aging Project in Massachusetts. The project’s services include cultural competency training sessions for agencies and facilities that work with aging adults.

Gay and lesbian elders are more likely to live alone, without children or other family members to care for them. They may limit visits from friends for fear their neighbors may guess they are not heterosexual. “I know how older people have a secret life,” says Michael Ridolfi, RN, BSN, MEd, director of health services at BSHC. “They weren’t raised to be out in the open the way people are today.”

Friendly Visits
Studies of gay, lesbian, bisexual, and transgender elders show their greatest fear in going into retirement communities, assisted-living, or skilled nursing facilities is for their safety. The next greatest fear is they won’t be cared for properly. If gay and lesbian elders know a facility will be friendly and welcoming to them, many of them are more likely to self-identify rather than return to the closet, say those who work with lesbian, gay, bisexual, and transgender elders.

Krinsky says a lot of nurses want to know why they should care whether someone is gay or lesbian, if all they are doing is managing a patient’s health.

“The fact is that folks may simply feel better about their treatment if they’re not holding a secret and if they know that their provider knows and respects them.”

If gay and lesbian elders know a facility will be friendly and welcoming to them, they are more likely to self-identify rather than to return to the closet, say those who work with lesbian, gay, bisexual, and transgender elders. They are more likely to have friends visit and less likely to become isolated, lonely, or depressed.

On home-care visits, Ridolfi looks for certain clues — someone living alone with no children or photos featuring a specific person. They may never openly tell him they are gay, he says, but they often relax and start talking. “They are always glad to have somebody to talk to,” Ridolfi says. “And they always look forward to my visits.

The publication Consumer Reports maintains a useful site with information on nursing home selection. They also maintain a state-by-state report nursing homes to avoid and nursing homes to consider using their own Nursing Home Quality Monitor. The main site can be found here and the Massachusetts listings can be found here.

More information on Consumer Report’s ranking criteria is available here, and the following is a list of the Massachusetts Nursing Homes to avoid that were on Consumer Report’s August 2006 list:

ANN CARROLL NURSING HOME
66 JOHNSON ST
LYNN, MA 01902

CEDAR HILL HEALTH CARE CENTER
49 THOMAS PATTEN DRIVE
RANDOLPH, MA 02368

CHAPIN CENTER
200 KENDALL STREET
SPRINGFIELD, MA 01104

COHASSET KNOLL SKILLED NURSING & REHAB FACILITY
1 CHIEF JUSTICE CUSHING HIGHWAY
COHASSET, MA 02025

COLONY HOUSE NURSING & REHABILITATION CENTER
277 WASHINGTON STREET
ABINGTON, MA 02351

HOLYOKE REHABILITATION CENTER
60 EASTHAMPTON ROAD
HOLYOKE, MA 01040

KENOZA MANOR CONVALESCENT HOME
190 NORTH AVENUE
HAVERHILL, MA 01830

LOOMIS HOUSE NURSING CENTER
298 JARVIS AVENUE
HOLYOKE, MA 01040

MOUNT SAINT VINCENT NURSING HOME
35 HOLY FAMILY ROAD
HOLYOKE, MA 01040

PIETY CORNER NURSING HOME
325 BACON STREET
WALTHAM, MA 02154

PROVIDENT SKILLED NURSING CENTER
1501 COMMONWEALTH AVENUE
BRIGHTON, MA 02135

SUNBRIDGE CARE & REHAB-BROADWAY
281 BROADWAY
METHUEN, MA 01844

SUNBRIDGE CARE CENTER-GLENWOOD
557 VARNUM AVENUE
LOWELL, MA 01854

The OCULAR SURGERY NEWS reports on a case in which a doctor was alleged to have made false claims to Medicare and Medicaid for office and nursing home visits performed by a nurse practitioner without proper supervision. Interestingly, the case was reported to authorities by a whistle blower who was able to keep $50,000 of the $250,000 settlement.

Here’s the article:

Incident to’ rules violation results in false claims allegation against physician

The case is believed to be the first of its kind to focus exclusively on this type of violation.

By Alan E. Reider, JD

A Massachusetts physician has agreed to pay $150,000 to settle allegations that he submitted false claims to Medicare and Medicaid for office and nursing home visits performed by employed nurse practitioners and physician assistants without appropriate supervision. It is believed to be the first case of its kind to focus exclusively on violations of the “incident to” rules.

In addition to the physician, the medical billing company responsible for submitting the bills also settled and agreed to pay $100,000 to avoid further litigation. This case is particularly significant in light of the fact that a review of compliance with the incident to requirements was one of the items listed on the Office of the Inspector General Work Plan for fiscal year 2007, as reported in this column in the Dec. 1 issue of Ocular Surgery News.

Physicians who employ nurse practitioners, physician assistants and other health professionals in their practice – and who bill for services performed by those professionals under the “incident to” rules – should take note to be sure they are operating in compliance with applicable Medicare rules.

‘Incident to’ rules

The “incident to” rules allow a physician to bill under his or her number for services performed by nurse practitioners, physician assistants and nurses, as long as the following requirements are met:

The services performed are integral, though incidental to a physician service and plan of care;

The services are of the type commonly furnished in physician’s offices or clinics;

The service may not have its own benefit category; and

The service is performed under the direct supervision of the physician.

“Direct supervision” requires that the physician be on-site in the office suite where the service is being performed. It does not require that the physician be in the room or have “hands on” the patient; importantly, however, it does not allow the physician to be in another location (ie, performing surgery in a hospital or ASC, or seeing patients in another office) when the service is being performed.

Failure to meet this fourth criterion is the most common problem in complying with the “incident to” rules.

The case in Massachusetts was based on a failure to comply with the fourth criterion, i.e., the failure to provide direct supervision.

In an interesting twist related to this case, but not generally found in connection with “incident to” situations, nurse practitioners and physician assistants, professionals who do not require direct supervision by physicians and whose services may be billed directly to Medicare under their individual number, performed the services in question.

In those cases, however, Medicare will pay only 85% of the physician fee schedule. Therefore, the Massachusetts physician could have billed for the services to reflect that they were performed by these professionals, rather than as “incident to” services. Although he would have received a slightly reduced amount, he could have avoided the liability imposed.

The Massachusetts case arose as a result of a whistleblower who recovered $50,000 of the total $250,000 paid by the physician and the billing company.

Whistleblowers continue to be a significant source of information for government investigations. And, although violations of the “incident to” rule generally would not be considered fertile ground for new cases, the successful resolution of this case from the government’s perspective may trigger closer scrutiny of this area.

Attorney General Tom Reilly obtained an emergency court order to take over the 91-bed  Governor Winthrop Nursing Home over allegations that it failed obtain adequate supervision of its 60 residents over the holidays.  According to the AG’s press release the facility did not have a director of nursing, a nurse manager, or a nurse unit supervisor, and the administrator had given notice that he was resigning effective December 29, 2006.  The nursing facility is owned by defendant Winthrop Healthcare Investors, L.P., of Roswell, Georgia.  Here is the full press release:

December 22, 2006

Attorney General Tom Reilly and Department of Public Health (DPH) Commissioner Paul J. Cote, Jr. have obtained an emergency court order against the owners of a 91-bed nursing home in Winthrop based on allegations that the nursing home failed to arrange for adequate staffing and supervision of its 60 residents over the holidays.  The AG’s action also alleges that the owners failed to meet their financial obligations or to correct problems with the facility previously identified by DPH, putting the residents’ health, safety and welfare at immediate risk.

The order, entered by Suffolk Superior Court Judge Charles T. Spurlock, appoints Attorney Robert J. Griffin as temporary receiver to manage the Governor Winthrop Nursing Home, located at 142 Pleasant Street, Winthrop, Massachusetts, and, if necessary, to close the nursing home and safely transfer its residents. The facility, which currently houses 60 residents, is licensed by DPH and operated by defendant Winthrop Healthcare Investors, L.P., of Roswell, Georgia.  Other entities and individuals owning stakes in the Facility, and named as defendants in this case, are Westburg Healthcare Investors, L.P. of Alpharetta, Georgia; HP/Salisbury, Inc. of Alpharetta, Georgia; and Douglas K. Mittleider of Adairsville, Georgia. 

AG Tom Reilly and Commissioner Cote filed for receivership after the nursing home’s administrator told DPH investigators that the facility was experiencing financial difficulties and did not have adequate staffing or supervision of residents over the holidays.  In fact, the facility did not have a director of nursing, a nurse manager, or a nurse unit supervisor, and the administrator had given notice that he was resigning effective December 29, 2006.  In their petition for appointment of the receiver, AG Reilly and Commissioner Cote also alleged significant problems with the facility that put the residents at risk, including safety code violations, incidents of patient neglect, only one working shower for all 60 residents, and a broken washing machine that did not reach the appropriate temperature necessary to prevent the spread of infection.  Finally, the facility has significant unpaid debts, including unpaid utility bills and unpaid nursing facility user fees totaling more than $68,000. 

As a result of AG Reilly and Commissioner Cote’s action, receiver Robert Griffin is now in control of the facility.

In addition to the receivership, AG Reilly also sought and obtained an emergency order freezing the assets of the facility and the other defendants. The order also attaches $900,000 of the real estate on which the nursing home is located. 

In his lawsuit, AG Reilly alleged that the facility and its owners violated the Massachusetts Patient Protection Receivership Statute and the Massachusetts Consumer Protection Act.  In addition to the emergency orders, AG Reilly is seeking to recover civil penalties and costs from the defendants.

Assistant Attorneys General Stephanie Kahn and Jean Healey of AG Reilly’s Consumer Protection & Antitrust Division are handling the case.

The Cape Cod Times reports that two nurse’s aides were fired from Harborside Healthcare in Falmouth after one allegedly bruised a resident’s hand and the other twisted the neck of the same patient’s stuffed animal.  State DPH officials had previously sited the 120 bed facility with deficient care issues in September 2006.

The facility is owned by Harborside Healthcare a company that is headquartered in Boston, and operates 53 facilities nationwide including these eight other failities in Massachusetts Cedar Glen (Westfield); Danvers Twin Oaks (Danvers); Maplewood (Amesbury); Mashpee Harborside (Mashpee); Northshore Harborside (Saugus); The Stone Institute (Newton Upper Falls); Wakefield Harborside (Wakefield) and Westfield Harborside (Westfield).

 Here is the Cape Cod Times article:

 FALMOUTH – Two nurse’s aides were fired from a local nursing home after one allegedly bruised a resident’s hand and the other twisted the neck of the same patient’s stuffed animal in September, the home’s administrator said Thursday.
 State Department of Public Health officials last week called on Harborside Healthcare in Falmouth to fix the problems that led to the alleged abuse and other incidents of ‘’substandard quality of care.”
They also recommended that the Center for Medicare and Medicaid Services impose fines of $50 to $3,000 a day for every day Harborside is not in compliance with regulations and possibly terminate the home’s ability to take Medicare or Medicaid patients.
 John Bonfardeci, administrator for Harborside Healthcare, said the alleged actions by the nurse’s aides constitute abuse, although he said both denied the accusations. Staff members have begun retraining to ensure there are no future incidents.
 ”We have a responsibility to educate our staff and I think we have been very thorough with that. But we are doing it all over again,” Bonfardeci said.
 Harborside in Falmouth is one of nine nursing homes the national company owns in Massachusetts, including one in Mashpee.
 The Falmouth home has 120 staff members and as many beds for patients, according to the company’s Web site.
 The nursing home’s array of services includes a special program for patients with dementia.
On Sept. 29, a nurse’s aide squeezed and bruised the hand of a ”combative resident,” according to Bonfardeci. Nursing home officials did not learn about the incident until the following day, the administrator said. Federal regulations require nursing home staff members to immediately report any suspected abuse.
Based on interviews with staff, Bonfardeci learned that a second nurse’s aide had twisted the teddy bear in front of the patient.
 ”It’s definitely a form of mental anguish,” he said.
 In total, six staff members witnessed or heard about the alleged abuse, but did not immediately report it.
The two aides, who had never been disciplined previously, were terminated. The other staffers received a written warning in their files. All employees were retrained and tested on the proper notification procedures, Bonfardeci said.
 ”I believe my staff does a really good job,” Bonfardeci said. ”Do I believe there are bad apples in that those people did something wrong? Absolutely.”
The recent incident comes on the heels of a poor evaluation during the state’s September recertification review of the home. The inspectors found them deficient in the area of ”quality of care.”
 According to DPH’s September report, the staff failed to initiate treatment for pressure sores in a timely fashion and failed to provide a program to prevent or fully investigate falls.
 ”The question is, why are the residents developing bedsores? That is significant. Why are people falling? What is being done to prevent them from falling?” said Caronanne Procaccini, program director of Cape United Elders, which administers a nursing home ombudsman program under the Community Action Committee. ”These are two significant quality of care issues.”
 Bonfardeci said the staff adequately treated and assessed sores and falls.
 But Harborside did not have the proper documentation to back up their work to prevent patient falls.
”What we are doing now is documenting that intervention better,” Bonfardeci said.
 State officials referred Harborside to the Center for Medicare and Medicaid Services – an arm of the U.S. Department of Health and Human Services that oversees all things related to Medicare and Medicaid – for reprimand.
 The agency has yet to issue a decision, spokeswoman Helen Mulligan said.
 By AMANDA LEHMERT
Cape Cod Times
October 30, 2006

Today’s Wall Street Journal has a long (3000+ words) front page article on a year-old Vermont program called Choices for Care which allows the use of Medicaid and other sources of funding to be used to pay for personal care givers in the home.   While it has always been possible to create a nursing home environment in a person’s home or apartment, cost is the issue.  For seniors that do not require round-the-clock care or supervisions, in-home care options are more attractive and programs like Vermont’s make it more attractive.  Here are some excerpts from the article:

[ . . .]

Mr. Blow, a former security guard felled by a heart attack and stroke, had gone to the nursing home for what he hoped would be a few months of rehabilitation. Paralyzed in an arm and a leg, his stay grew to more than a year. He feared he would never live independently again.

Now Mr. Blow, 71 years old, is back in his own place, thanks to an unusual Vermont experiment that seeks to shift government money from nursing homes into private homes. The state pays for his ex-wife to care for him.

In an effort being watched around the nation, Vermont is trying to give elderly people a choice of where they want to be cared for: in an institution or at home. To create more home-care workers, the state has been paying for family members to care for aging relatives, at about $10 an hour. If Vermont’s program works, it could influence a wider change in the multibillion-dollar industry that cares for the aged.

[. . .]

As the number of older Americans — and the cost of caring for them — soars, the federal government is pushing efforts like the one in Vermont. Advocates say in-home care could improve the lives of many seniors, while saving the government money. But the idea faces huge hurdles, including opposition from the nursing-home industry and a culture of dispersed, busy families that has become accustomed to having others care for their loved ones.

[. . .]

Vermont is one of the first states to get federal approval to offer home care as an option equal to nursing-home care under Medicaid, the government program that subsidizes health care for the poor. The state is calling home care an “entitlement.” Under Vermont’s “Choices for Care” program, Medicaid sets a budget limit for the state to care for seniors and people with disabilities. Vermont then uses a combination of federal and state money to reimburse in-home caregivers.

[. . .]

With help from the nonprofit agency, Mr. Blow moved out of the nursing home. His Social Security and pension money now go to pay for a one-bedroom apartment geared to the disabled. The state uses Medicaid funds, distributed through a home-health agency, to pay Charlene Anair, 56, his ex-wife, to care for him.

[. . .]

Yet, as a former licensed nurse, she was moved to see the man she had known as tough reduced to helplessness and despair. She now earns $9.27 an hour caring for him. Ms. Anair helps him dress, escorts him to cardiac therapy twice a week, shops for groceries, and even takes him to visit his parents’ graves. Asked why she devotes herself to his recovery, she laughs: “I really don’t know — the nurse in me.” She adds: “It is like this is where I am supposed to be.”

[. . .]

Under the Vermont program, elderly people typically receive 25 to 30 hours of care a week. If caretakers live with an elderly relative, they aren’t compensated beyond a set number of hours. Seniors who live on their own may be unattended for significant stretches, including nights or weekends, because of limits on the number of hours of care they can receive or because of a shortage of available home-care workers.

The state says that not every elderly person needs 24-hour care. Officials contend that even in a nursing home, residents don’t get around-the-clock attention. A state analysis found that nursing homes provide one-on-one care only a couple of hours day, if that, says Bard Hill, a state official who works closely with the Vermont commissioner.

[. . .]

So far, Vermont has found it isn’t easy to change the flow of dollars. One year into its “Choices for Care” program, Vermont has achieved incremental results: There are 2,131 residents in nursing homes, 155 fewer than in October 2005. There are 1,111 people receiving home care, or 123 more than last year at this time. Another 500 or so Medicaid patients — who aren’t quite eligible for nursing homes yet need help — were able to get care at home under this program, according to the state.

 

Olden Days
Seniors in Vermont
Are Finding They
Can Go Home Again

In Shift From Nursing Homes,
State Has Family Members
Care for Elderly Relatives
Helping Gram at $9.25 an Hour
By LUCETTE LAGNADO
Wall Street Journal
October 23, 2006; Page A1

The Boston Globe has a font-page article on a new type of nursing home that will be opening in Chelsea in 2008.  The new model is called a “Green House” and will be structured as a self-contained set of 10 bedrooms clusted around an open Kitchen and living area and serviced by 2 personal care attendants.  The expansion of the Green House concept is being funded by a $10 million grant from the Robert Wood Johnson Foundation.  Here are some excerpts from the article:

A nursing home with the potential to transform elder care is coming to Massachusetts.

Its hallmarks: A self-contained house for 10 private rooms, home-cooked meals, and daily routines set by the residents. Scheduled to open in Chelsea in 2008, the new facility represents the cutting edge of a national movement to replace institutional care with a more home-like atmosphere.

The Leonard Florence Center for Living will contain 10 “Green Houses” — each with 10 bedrooms clustered around an open kitchen and living area — that will be stacked in a five-story condominium-style structure. The Chelsea units will be the first urban Green Houses, designed to provide an example for the nursing home industry nationwide.

Conceived by a Harvard-trained geriatrician, Dr. William Thomas, the first Green Houses opened in Tupelo, Miss., in 2003 to provide seniors of all incomes with more dignity, autonomy, and choice in long-term care. The name stems from the focus on encouraging personal growth among residents.

Since then, two sets of suburban-style Green Houses with yards have opened in Michigan and Nebraska, and 25 more are in the planning stages nationwide.

[. . . ]

To drive change nationwide, the Robert Wood Johnson Foundation, a healthcare philanthropy, awarded $10 million last year to a nonprofit development corporation, NCB Capital Impact, to help bring the Green House model to every state.

“We hope that we are pushing the envelope to really rethink nursing homes,” said Jane Isaacs Lowe, a senior program officer at the foundation.

The Chelsea Jewish Nursing Home, a nonprofit organization that has been providing care since 1919, won the development corporation’s help a few months ago, beating out dozens of other proposals. The aid comes in the form of technical and planning expertise. The corporation also helped Chelsea Jewish secure $5 million in tax credits to help offset the estimated $20 million cost of the project, which they are raising from private donors.

[. . .]

Each of the 10 Green Houses will be managed by the residents and two primary caretakers on each day shift, one of whom is “devoted to loving cooking,” Berman said. The caretakers will also do light housework and help residents with bathing, grooming, and dressing.

The residents in each Green House will determine their own daily routine, menu, and activities. Meals generally will be served family-style, around one long table, with staff and visitors joining in. Residents can volunteer to help keep the household running by doing chores like cooking, folding laundry, and accompanying the cook to the grocery store.

“That’s a more important activity for some residents than anything we could provide,” Berman said.

One nurse will serve two 10-resident Green Houses, but medical trappings will be kept to a minimum.

The Green Houses typically cost no more to run than traditional homes, even though there are more caretakers per resident, because they have less waste and do not need such infrastructure as dietary departments. As at conventional homes, most of the bills will be paid by the Medicaid program for low-income seniors and the disabled .

[. . .]

A two-year study that compared the Tupelo Green Houses with two traditional nursing homes found that quality of life was better in the Green Houses, with residents saying they had more dignity, privacy, meaningful activity, relationships, and autonomy, according to Rosalie A. Kane, a professor at the University of Minnesota School of Public Health.

Kane said the Green Houses provided small benefits in the quality of care — residents showed less depression, less incontinence, and less of a decline in the ability to feed themselves.

[. . .]

Staff turnover, which averages 71 percent annually in nursing homes, fell to just 10 percent, according to the Green House national staff.

[. . .]

‘Green Houses’ for golden years
Innovative units come to Mass.
Boston Globe

By Alice Dembner, Globe Staff
September 30, 2006