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Cancer Patients in Nursing Homes


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Elderly nursing home residents receive relatively few cancer care services, according to a study published in the Journal of the National Cancer Institute. Few studies have examined cancer treatment and care among elderly patients residing in nursing homes. Yet, as the population ages, more people will move into nursing homes, many of whom will later be diagnosed with cancer. Cancer risk increases as people age.

http://www.sciencedaily.com/releases/20 ... 004314.htm

Congress has introduced the "Nursing Home Transparency and Quality of Care Improvement Act of 2008." The bill increases the transparency of nursing home ownership, ensures that residents and their families have information about the quality of care at these facilities, and strengthens enforcement of nursing home compliance with quality of care standards.

The Nursing Home Act enables nursing home residents and government regulators to better know who actually owns the nursing home and who controls the decision-making that impacts the quality of care provided. In addition, the bill improves the reporting of information on staffing levels and direct patient care expenditures.

http://www.bestsyndication.com:80/?q=20 ... lation.htm

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Improve transparency and accountability in the ownership and operations of nursing homes

Corporations would be required to disclose their owners, operators, financers, and other related parties. Facilities that were part of chains would be required to submit annual audits. Purchasers would have to demonstrate that they were financially able to run facilities.

Require disclosure of how Medicare and Medicaid funds are spent

Providers would have to report wage and benefit expenditures for nursing staff on cost reports. Cost reports would be revised to categorize spending for direct care, such as nursing and therapies; indirect care, such as housekeeping and dietary services; capital costs, including buildings and land; and administrative costs, which often include the company’s profits.

Establish independent monitoring of chains

The federal government would develop a protocol for an independent monitor of chains to analyze their financial performance, management, expenditures, and nurse staffing levels. It would provide for corrective action and collection of civil monetary penalties.

Collect accurate information about nurse staffing

The government would collect data electronically from nursing homes on the number of RNs, LPNs, and nursing assistants, using payroll records and contracts with temporary agencies as the source. Data would include turnover and retention rates and hours of care per resident provided by each category of worker.

Provide better public information about nursing homes

Nursing Home Compare would be updated with more timely reporting of surveys; ownership information; accurate nurse staffing data, including turnover and retention rates; links to survey reports (Form 2567) when states put them online; enforcement actions; and all Special Focus Facilities identified for three years. The government would undertake a study on how to improve the website to make it more useful and understandable.

Implement new consumer complaint processes

The government would develop a standardized form consumers could use in filing complaints with the state regulatory agency or ombudsman. States would be required to establish a complaint resolution process for residents’ representatives who were retaliated against, including denied access to residents, if they complained about quality of care or other issues.

Provide for higher civil monetary penalties and other CMP reforms

Federal civil monetary penalties would be increased for the first time since the 1987 Nursing Home Reform Act – up to $100,000 in the case of a resident’s death. Fines would be held in escrow during appeals of deficiencies, no longer delayed until appeals were resolved. Federal CMP funds, which are now returned to the U.S. Treasury, are encouraged to be used for the benefit of residents.

Provide for reporting of closures and continuation of federal payments

Nursing homes would be required to give 60 days notice of closure, including a relocation plan and assurances that residents would be transferred to the most appropriate facility or other setting. No new residents could be admitted after the notice was given, and the federal government could continue Medicare and Medicaid funding for residents until relocation was completed.

Authorize studies of temporary management; special focus facilities; culture change; and nurse aide training

The bill provides for studies of temporary management; the characteristics of Special Focus Facilities, including ownership; best practices in culture change; and training of nurse aides and supervisors. Dementia management would be added to the initial 75-hour nurse aide.

The one provision that is utmost important is "Mandatory Staffing Levels." That provision was taken out of the bill, probably thinking that it had a better chance of being approved without it. It needs to be put back in!

Many states fought twenty world-wars to get mandatory staffing levels, even then, it was constantly being attacked. In one state, when there was a possibility of cutting Medicaid funding, the industry jumped at the chance to use that funding cut as an excuse to abandon the staffing level requirements.

Federal law only requires nursing homes to provide sufficient staff and services to attain or maintain the highest possible level of physical, mental, and psychosocial well-being of each resident, and we know this is insufficient.

There have been numerous federal bills requiring various mandatory staffing levels, only to be defeated or die on the vine. Now is the time for those mandatory staffing levels!

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Nursing home residents (including any cancer patients) are already supposed to be receiving 24/7 care. The hospice service is an additional $130 a day the home receives. Because Medicare does not collect detailed data about the medical treatments a hospice patient receives, there is very little information about what services are actually being provided.

Neglect is the silent killer in nursing homes. By some estimates, malnutrition, dehydration, bedsores and infection - caused by neglect - account for half of nursing home deaths and injuries.

A recent indication of negligent care for cancer patients at nursing homes involved a woman in Pennsylvania who was put on the chemotherapy drug Nexavar. Its side effects include decreased blood flow to the heart, heart attack and high blood pressure. The woman was supposed to get emergency care immediately if she started to exhibit any signs of the side effects.

The woman reported a dull heavy chest pain and a severe band-like pressure around her head. Her blood pressure (200/123) was far higher than normal. There was no evidence that a physician was contacted about the situation. Later, a physician said she would have sent the woman to a hospital emergency room immediately.

Instead of calling the physician or getting the woman to the emergency room, the nursing home nurse gave the woman her scheduled dose of painkiller. Two hours later, the woman was found face-down in a small puddle of blood.

The home was cited for violating regulations relating to quality of care, management, patient rights, records and more. The home had previously been cited for similar violations.

There would be a much higher level of care given to residents if adequate staffing were provided. But, "for-profit" nursing homes, the desire for profit margins translates into less staffing at nursing homes, less training for the staff that they do have, less food (or a lower quality of food) for the residents, and less management and oversight.

A conflict arises between saving dollars and providing good care. Administrators benefit from the amount of profit generated by the nursing home they manage, usually paid annual bonuses based on bed-count. They must choose between increasing the profit margins of their individual facilities or supplying more support staff for the care of residents.

Even nursing home abuse may occur because of the desire for profit. Caregivers who work in nursing homes are often stretched beyond their ability. They try to do the best job that they can, but the lack of additional support restricts what they can do to help residents.

The House Energy and Commerce subcommittee on oversight and investigations had not held an oversight hearing about nursing home care since 1977. The last significant change in nursing home regulations was the Nursing Home Reform Act of 1987.

Now is the time for caregivers of loved-ones in a nursing home, to call/write their federal legislative representatives to pass the "Nursing Home Transparency and Quality of Care Improvement Act of 2008," with "mandatory staffing levels" put back into the bill.

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  • 1 month later...

The CMS (Centers for Medicare & Medicaid Services) has issued quality ratings for 15,800 nursing homes throughout the USA that participate in Medicare or Medicaid. Each nursing home is assigned a star rating, from one to five - with five being the best. The ratings are based on health inspection surveys, staffing information, and quality of care measures.


State Surveys are independent evaluations of nursing facility performance. Annual surveys are conducted by state survey agencies, usually the state's department of health, using protocols, procedures, and forms developed by the Centers for Medicare & Medicaid Services (CMS).

A consumer concern about surveys is the repeated finding by the Government Accountability Office (GAO), in a series of reports issued since 1998, that surveys understate deficiencies and cite deficiencies as less serious than they actually are.

The survey component of CMS's proposed ranking system provides a more positive statement about quality than justified. States are increasingly using their state enforcement systems, instead of the federal system, to sanction facilities for noncompliance with standards of care. State enforcement actions do not appear on Nursing Home Compare.

The National Senior Citizens Law Center recommends that consumers use the new rating system with caution, and only as an aid while also pursuing other information and strategies. Consumers need to understand that the five-star system is a beginning, not an end.

A nursing home's quality can shift from month to month, so you have to be savvy in asking the right questions. Existing residents and their family members should be asked for their opinions.

Inspection data is mostly based on a once-a-year survey and may not accurately reflect the nursing home's performance today. Staffing information and quality measures are "self-reported" data by the nursing homes themselves. Self-reported data makes nursing home quality "appear" to be better than it actually is. It cannot easily be reduced to a star rating.

A recent GAO study found that nursing homes over-report staffing levels compared with staffing reported on audited Medicaid cost reports. Over-reporting of nursing coverage is associated with for-profit ownership of nursing homes.

Researchers recommend more careful scrutiny of staffing levels in for-profit facilties during the survey process and that improvements be made to the process of public reporting of staffing levels.

CMS should provide more and better information on Nursing Home Compare, including links to the actual survey forms and information about staff turnover. Also, CMS should use payroll data to report staffing information.

Anything to do with "quality indicators" is bogus. When de-regulation failed under the present administration, they wanted, among other things, the "quality indicator" process to eventually replace traditional annual surverys because it relies upon self-reported, unaudited data supplied by the facilities themselves and is without consequences for failures. But it still relies upon self-reported, unaudited data supplied by the facilities themselves.

It leaves you with that warm-n-fuzzy "we'll-help-them-fix-their-problems," even though 99% of their failures are failures of practices they should already be experienced in before they are granted a license. It is part of the "kid-gloves," don't be-so-hard-on-the-poor-poor-nursing-homes" from the Bush administration.

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The for-profits are taking over hospices the same way they have taken over nursing homes. The Kaiser Network noted that hospice care was designed to be delivered mainly by not-for-profit groups with affiliations to religious and community groups, but the June 2008 MedPAC report found that since 2000 mostly for-profit companies and hospices have been providing such care.

Manor Care operates hospice under their for-profit nursing homes as Heartland Hospice Care. On top of receiving an additional $130 a day for hospice service, above the daily payment they receive providing nursing home care, they take donations to their Heartland Hospice Fund.

For-profit hospices, like for-profit nursing homes are run by corporations the are coldly efficient, according to a leading palliative care specialist. If there is a way to play the system to make a higher profit, they will. Nursing home residents are already receiving 24/7 care. The hospice service is an additional $130 a day the home receives.

In their quest for Medicare dollars, for-profit hospices don’t provide all the care that they should in order to fulfill the hospice mission of maximizing patients’ quality of life.

In fact, a 2004 Medical Care study of 2,080 patients enrolled in 422 hospices across the country found that terminally ill patients who receive end-of-life care from for-profit hospice providers receive a full range of services only half the time compared with patients treated by nonprofit hospice organizations.

That’s because for-profit hospices like to keep costs low by skimping on services, particularly so-called “non-core” services like medications and personal care. For example, families of patients receiving care from a for-profit hospice received counseling services, including bereavement counseling, only (45% as often) as those in a nonprofit hospice.

When researchers controlled for differences across patients, sicknesses, and conditions, those at for-profit hospices were only half as likely to get the same support provided at nonprofit hospices. A 2005 follow-up study confirmed that for-profit patients receive a narrower range of services than nonprofit patients.

But it’s not just “non-core” services that for-profit hospices are skimping on. For-profit hospices are only half as likely as nonprofits to provide palliative radiotherapy (RPT), a radiation therapy that has been shown to effectively reduce pain and other symptoms related to tumor growth.

The dearth of for-profit RPT probably has a lot to do with the fact that for-profit hospices take on a smaller share of patients with cancer than do nonprofits—in part because it costs a lot to care for cancer. In addition, it’s much easier to predict how soon cancer patients will die. They rarely stay in a hospice for more than six months.

Indeed, for-profit hospices tend to “cream-skim” patients, both by taking on fewer cancer patients and having a greater share of patients who require a relatively long stay (In this regard, MedPAC’s fears are warranted).

Worse still, according to research from the University of California, Irvine, patients who stay longer at for-profit hospices receive less high-skilled nursing care—such as tracheotomy care, wound care, and suctioning or feeding tubes—because skimping on these services keeps costs down. In sum, research shows that patients stay longer at for-profit hospices, yet receive less personal care, symptoms management and spiritual support during their stay.

This is a pretty good way to make money, and indeed, the largest for-profit hospices are doing very well: a 2005 study in the Journal of Palliative Medicine found that large hospices owned by publicly traded companies generate profit margins nine times higher than those of large nonprofits and three times higher than privately owned for-profit hospices of similar size. In other words the "corporatization" of nursing homes seems to be a major part of the problem.

Among them are VITAS, the country’s largest for-profit, publicly-owned hospice, which cares for more than 11,000 patients in 16 states; the publicly-owned Odyssey Healthcare and Vista care and the private Heartland Hospice, which is a division of HCR Manor Care.

Back in 2007, the major private equity firm The Carlyle Group bought up Manor Care for $6.3 billion. A New York Times story covering the privatization of elderly care noted that large nursing home chains owned by an investment company in 2005 earned $1,700 a resident and were, on average 41% more profitable than the average facility.

Like for-profit hospices, these nursing homes cut services in order to reduce costs, but the health care industry isn’t like other industries. What may count as “efficiencies” in other fields - reduced labor costs, more streamlined services, etc - compromise the quality of health care to such an extent that patients die. There’s just no way around it, health care is labor intensive.

What’s so frightening about the case of for-profit hospices in particular is that cutting corners undermines the whole mission of hospice care. For-profit hospices risk losing sight of the fundamental principles of hospice because they are not doing all they can to support and comfort patients and families during the final stages of life.

There’s really no way to do a half-way job with hospice care. You’re either doing everything you can to make dying people and their families feel better, or you’re not. This is not a calculus that comes down to dollars.

More and more, it looks like the business plan of for-profit hospices is to provide relatively minimal care to people who will take a long time to die. If ever there were a strategy antithetical to the principles of hospice, this is it.

Source: Niko Karvounis and Maggie Mahar, Health Beat

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  • 2 months later...

Senators Chuck Grassley and Herb Kohl will reintroduce the Nursing Home Transparency and Improvement Act yesterday. The bill, which would require disclosure of nursing home ownership and operations and give consumers better information about nursing home quality, deficiencies, nurse staffing, expenditures and adherence to federal regulations, will contain most of the provisions that were in the legislation when it was first introduced in February 2008.

However, this version of the bill will not require increases in civil monetary penalties, and the focus on independent audits of facilities that are part of chains has shifted to internal quality assurance and compliance and ethics programs (i.e., self-policing) that include procedures to detect criminal, civil and administrative violations. Congress should increase those penalties to as much as $100,000 if a resident is harmed or dies due to negligent care. If simply composing a typical generic Plan of Correction, often repeatedly, is the only remedy required for verified violations, where is the motivation for the facility to change their practices?

The most critical aspect of nursing homes is the lack of adequate staffing. In simple terms, under-staffing results in the loss of the most basic humane care; i.e., adequate nutrition, hydration, personal hygiene, repositioning to prevent pressure sores, timely and/or correct dispensing of medications. Lack of staffing, in turn, creates a constant high turnover among even the most highly-trained, dedicated workers. Mandatory staffing levels were taken out of last year's bill, apparently to improve its chances of being passed. The emphasis should not be put into simply passing a bill, but rather passing a bill that truly addresses the current shortcomings. Mandatory staffing requirements should be reincorporated into this legislation.

House sponsors of the legislation, Representatives Pete Stark and Jan Schakowsky, are expected to reintroduce their version of the bill in April. Now is the time for caregivers of loved ones in a nursing home, and hopefully anyone else, to call/write their federal legislative representatives to pass this bill, with "mandatory staffing levels."


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