What nursing homes can teach us about health care in a post-pandemic world

by Richard Asinof, ConvergenceRI

Photo: by Rupert Whiteley, Nursing assistant Vincent White, left, helps Village House resident Carolina Vincent prepare for a meal.

The world is not held together by a cosmic, cause-and-effect glue

What the “facts” tell us about the world we live in mean nothing if we do not capture their nuance.

On Friday, June 5, there were 772 deaths from COVID-19 in Rhode Island – and counting, according to the latest statistics compiled by the R.I. Department of Health.

Approximately 76 percent of all deaths that have occurred in Rhode Island are connected to nursing homes, skilled nursing facilities and assisted living facilities in the state, according to data analysis cited by Gov. Gina Raimondo at a news briefing on Tuesday, June 2.

The problem with attempting to connect Rhode Island’s death toll with nursing home operations is, as data scientists and epidemiologists will drum into you: “Correlation does not imply causation,” making it an illegitimate exercise to seek to determine a cause-and-effect relationship between two sets of variables, based upon an apparent observed association between them.

Still, it is not surprising that numerous questions have been raised by critics of Gov. Gina Raimondo about the reasons why there has been such a high death toll related to nursing homes.

When asked at a recent daily news briefing about the problems at Rhode Island’s nursing homes caused by the coronavirus pandemic, Raimondo said: “It’s like the perfect storm,” a politician’s classic answer by suggesting that it was a problem that no one could have anticipated, prevented or controlled. To quote WPRO’s Steve Klamkin, “Really?”

Raimondo then quickly pivoted in her response, deflecting from any acknowledgement of personal responsibility for the mounting death toll in nursing homes. She redirected the conversation to focus on potential policy fixes in the future.

“I think what we need to start asking ourselves is, long term, is it the healthiest way to take care of our elderly loved ones to put them in congregate care settings?” she said. “Or is it time to get serious about investing in more in-home care supports so that – God forbid – next time this comes around, we’re not as vulnerable?”

The problem, however, is that many of the previous attempts at “public policy fixes” championed by the Raimondo administration – including Rhody Health Options, the Reinvention of Medicaid, and the Unified Health Infrastructure Project – have all been dismal, abject failures, the bad results of which have played a critical role in precipitating the current COVID-19 crisis in nursing homes.

Scott Fraser, the president and CEO of the Rhode Island Health Care Association, responded to the Governor’s intimation of her desire to seek major changes in the long-term care system by asking for a seat at the table in the decision-making process.

“We want to be clear that skilled nursing facilities in Rhode Island were not the cause of the COVID-19 virus,” Fraser said. “We were the victims of having this virus introduced to our homes. Long before the coronavirus hit Rhode Island, we were told that seniors, those living in ‘congregate care’ and those with underlying health issues would be most susceptible to COVID-19. This describes the population of our homes and sadly, has proven to be true.”

Fraser continued: “Will there be changes to future living arrangements in nursing homes? Most likely. We have ideas as to how best these changes can be accomplished. All we ask is to be a part of these discussions with the state.”

Fraser then spoke about the importance of the continuum of care. “We in the nursing home industry believe in the continuum of care. If someone can be adequately cared for at home, that’s where they should be. If assisted living is the best answer for a person’s needs, then, so be it. But make no mistake, those who are cared for in our homes reside with us because 24-hour medical, physical, and personal care best suits the needs and medical frailties of these individuals.”

Could it have been anticipated, prevented or controlled?
On Thursday, June 4, Gov. Raimondo signed an executive order supporting the development of a long-term health plan, work that has begun under the auspices of the Rhode Island Foundation, which has pledged $1 million to support the effort to make Rhode Island the healthiest state in the nation. [See link below to ConvergenceRI story, “Will the health care industry willingly relinquish its economic power?”] Among the promised agenda items in the long-term planning exercise will be a look at the nursing home industry.

There are, of course, many ways to attempt to answer questions about the apparent problems with nursing homes in the aftermath of the COVID-19 pandemic, but all too often, in ConvergenceRI’s opinion, the answers are filled with “facts” that appear to leave out both the context and nuance, focused on correlation but not causation.

• One such answer is that nursing homes and assisted care facilities, being by definition congregate living situations, make them the perfect Petri dish for an aggressive respiratory virus such COVID-19. The residents are elderly, and they have numerous co-morbidities that put them at greater risk.

That answer serves as a restatement of obvious, known facts. What is missing is the larger context, the larger problem being that Rhode Island has no accurate data for a census of skilled nursing facility patients – who they are, how old they are, and what are their chronic medical conditions, such as dementia, Parkinson’s and Alzheimer’s disease, diabetes as well as behavioral health issues such as depression. And, also, what has been their “determination of care” – the diagnosis that will define what the resident’s needs are.

While we can identify the demographic trend that Rhode Island has the highest percentage of “old old” residents in the nation – people who are 85 years and older, we have no comprehensive database upon which to track how services are being delivered to one of the state’s most vulnerable populations. We do not know who is “providing” those services, and which insurance plans are paying for the delivery of those services, except in terms of the claims database, which looks upon the delivery of service in the narrow context of a cost-benefit analysis, without any value quotient around “human” services.

What happens when you can no longer take care of yourself and need someone else to meet the day-to-day needs, often made more difficult by deteriorating medical conditions? Heroic efforts by families to provide 24/7 care to someone with dementia strains the resources of most family budgets. Paying for in-home, 24/7 care is cost prohibitive.

The option of living in a nursing home has often been presented as a distorted, binary choice – either you can live at home, or you can be “sentenced” to live in a nursing home. Many of the state’s public policy initiatives of the last decade have sought to exploit that emotional tug of “staying at home” and by promising to maintain a person in his or her home as the preferred choice, often under the guise of “saving money” for the state, where some one-third of the state budget, including both federal and state funds, goes to pay for Medicaid services, and nearly two-thirds of the costs are for long-term supports and services for people living in skilled nursing facilities.

What is missing from that cost-analysis argument is the fundamental, intimate relationship: nursing homes, skilled nursing facilities, and assisted living facilities are very much part of an interconnected chain of continuum of care with hospitals.

Coordination and a continuum of care can be a good policy choice, for sure. But, at the same time, it is important to recognize that skilled nursing facilities and hospitals are in bed together, so to speak. Because inpatient care of patients is so expensive, hospitals utilize a kind of “just-in-time” distribution system, with patients shifted as quickly as possible to skilled nursing facilities for rehabilitation following most surgeries and procedures. Most commercial insurance plans have a standard, 21-day benefit package to pay for the “extended” rehab stint.

At many skilled nursing facilities in Rhode Island, before COVID-19, rehabilitation services comprised as much as 30 percent of the patient flow. It is not surprising that the Hospital Association of Rhode Island and RIHCA have expressed opposition to a new 50-bed rehabilitation facility proposed by Encompass, which the Health Services Council recently approved by a 3-2 vote [with only five of the 11-member council voting], saying that it would “destabilize the existing inpatient rehabilitation in Rhode Island,” according to a consultant’s report by The Faulkner Group.

Cause and effect
Another focus in attempting to define a cause-and-effect relationship with the problems at nursing homes and what made them vulnerable to the coronavirus pandemic has been to look at the staffing at skilled nursing facilities. Most staffing at such skilled nursing facilities are lower-paid employees that have received less education and training, creating a constant churn in turnover. Why is that?

Consistent with the lack of data around who the residents are in skilled nursing facilities, there is also a complete absence of accurate data about the workforce that is taking care of patients in these facilities, such as the answers to basic questions such as: how old are they, what is their training, how much do they make an hour, and what is the rate of turnover and churn, etc. [The lack of data around health care workers, particularly nurses, reflects the tendency to measure health care in terms of physicians, not health care workers.]

Many nursing home employees often have to work at two or three jobs to survive, which some believe has increased the likelihood that they might be asymptomatic spreaders of the virus. Many are women; many are people of color; many have been deemed “essential” workers. Would an accurate data analysis give us a better picture of how the health inequities in Rhode Island are being played out in the workforce of nursing homes?

But something more fundamental may be at play in the economics of nursing homes and what they pay their staffs. To better understand the financial squeeze that many nursing homes are under, the reality is that cost of living increases mandated by law have been consistently “legislated” away behind closed doors at the R.I. General Assembly – for years.

Further, the financial backbone of the 2015 Reinvention of Medicaid initiative that had been championed by the Raimondo administration were cuts to Medicaid reimbursements.

Then came the disastrous launch of UHIP in 2016, where the failure to process Medicaid eligibility claims in a timely basis pushed many nursing homes to the brink of bankruptcy, forcing R.I. EOHHS to make more than $100 million in interim payments to keep the facilities afloat. In December of 2019, three and a half years after UHIP was first launched, there were still some 800 applications for Medicaid eligibility for long-term care and support services pending longer than 90 days, in contravention of state law.

A final financial trend worth noting: Medicaid has become the payer of last resort for nursing home care once a patient’s assets have been used up. The problem is that many wealthy folks in Rhode Island, encouraged by an aggressive legal community, have place their assets in trusts, so that their accumulated wealth can be passed on to their relatives, without ever being tapped to pay for Medicaid services. The burden of paying for care falls upon the state.

The workers at nursing homes, even as the coronavirus pandemic bloomed in its lethal cloud of death, still received “no respect” from the Raimondo administration in its initial efforts to fight the spread of the virus. The Governor was at first resistant to the suggestion that the front-line workers in nursing homes should be receiving extra hazardous pay. On April 1, ConvergenceRI had asked: Would you be willing to make an emergency funding request through Commerce RI to increase the hourly wages of CNA (certified nursing assistant) workers in nursing homes, hospitals, and the home health agencies?”

Gov. Raimondo responded by saying that she trusted that hospitals and health care providers to do the right thing. “Soon the federal stimulus money will be made available to hospitals and other health care providers,” she said. “And then, at that point, I would say that the individual institutions – health care institutions – will have to figure out how to use that additional capital to keep the lights on and keep folks employed and to have the PPE necessary. And I would just encourage each institution to do what they think is in the best interest of their employees and their patients.”

Three weeks later, on Friday, April 24, Gov. Raimondo dramatically changed her tune, creating the “Congregate Care Workforce Stabilization Fund” for private providers, providing temporary pay increases to low-wage frontline workers at eligible Medicaid-funded residential facilities, through which qualifying employees earning $20 an hour or less would be eligible for up to a $200 increase each week through June 1. The Governor’s latest executive order will continue support for low-wage workers at nursing homes through June 15. What happens after that is anyone’s guess.

There are also continuing issues about access by workers in skilled nursing facilities to personal protection equipment.

Budget decisions have consequences
One salient point in the investigation of what went wrong at the Soldier’s Home in Holyoke, Mass., where some six-dozen residents have died from coronavirus, has begun to look at state budget decisions that were made “to rein in spending” under the leadership of Gov. Charlie Baker.

The previous superintendent of the facility had stepped down in 2015, declaring that the home could not safely care for the population on the existing budget, because it had created persistent shortfalls in staffing and unplanned double shifts, according to a recent story in The New York Times.

All of this was well known before the coronavirus arrived in the state this spring, Erin O’Brien, an associate professor of political science at the University of Massachusetts, Boston, told the Times reporter. “All these regular Massachusetts folks that are now outraged, I don’t disagree, but veterans’ programs require funding,” she said. “When you vote to shrink government, it has ramifications.”

Another salient data point missing from the discussion around nursing homes is the current consolidation of skilled nursing facilities being purchased from local owners by national chains, a trend apparently precipitated by the continuing financial fallout from the UHIP scandal.

How many skilled nursing facilities in Rhode Island are owned by out of state companies? One source counted 25 such homes owned. That trend has accelerated since 2016. Exactly what role the interim payments played in precipitating such transactions is a topic that needs further investigation.

I say goodbye, you say hello
Since its launch in September of 2013, ConvergenceRI has covered the successive scandals: Rhody Health Options [which was abandoned after five years in 2018] because of poor results and outcomes, costing the states tens of millions of dollars paid in administrative fees to Neighborhood Health Plan of Rhode Island]; the Reinvention of Medicaid [where, five years later, despite a legal mandate, there is still no “accountable entity” established by R.I. Medicaid Office to long-term care and services, which has the largest share of costs in the state’s Medicaid budget]; and the fallout of the UHIP scandal, which persists to this day.

The temptation is to cite the dozens of stories written, with details and documentation, but to what purpose? One particular deep dive, “When it comes to UHIP, money talks, the needy walk,” may suffice. Also, one of the first stories published by ConvergenceRI, “Costs and fees at issue as state rolls out Rhody Health Options.” [See links below to ConvergenceRI stories.]

Moving forward, as the state embarks on its long-term planning exercise for Rhode Island, what is needed first, perhaps, is better data:

• We need to create a statewide database in Rhode Island that tracks patients in skilled nursing facilities, their medical conditions, and the workforce taking care of them [on a de-identified basis].

Without being able to quantify the demand, the unmet need, or the financial realities of the workforce and the facilities employing them, Rhode Island will continue to be dancing in the dark.

We will become spectators at our own destruction, waiting for the next perfect storm to happen, like those “100-year storms” that now seem to happen every few years or so as a result of the impending climate change crisis and our perverse relationship with the fossil fuel industry.

As the coronavirus pandemic has made self-evident, health inequities based upon race and ethnicity are a persistent disliked fact of our society and culture.

What does accountable mean?
When I began to write this story, my initial lede graph began: “Call them a power couple. Elizabeth Roberts is now the director of the Academic Health Collaborative at the University of Rhode Island, a position she was appointed to April. Michael DiBiase is now the executive director of the Rhode Island Public Expenditure Council, a position he assumed in January.

“Four years ago, Roberts and DiBiase had shared the podium together, promoting the launch of the Unified Health Infrastructure Project, known as UHIP, which turned into an unmitigated disaster.

“At the time of UHIP’s disastrous launch on Sept. 13, 2016, DiBiase was serving as the director of the R.I. Department of Administration, and Roberts was serving as the secretary of the R.I. Executive Office of Health and Human Services, under Gov. Gina Raimondo.
“In the weeks leading upon to the UHIP launch in 2016, Roberts and DiBiase promoted to the news media that the adoption of the new technology platform built by Deloitte would save money for the state and pay for itself within a year by reducing labor costs and cutting down on fraud while increasing efficiency in delivering services to the most vulnerable Rhode Island residents. Few knew that in their personal lives, Roberts and DiBiase had become partners. [It was apparently an open secret among high-level members of the Raimondo administration.]

“Later, as the scandal around UHIP grew, Roberts resigned. But she and DiBiase were, for whatever reasons, never held accountable for their roles in the disaster – either by the R.I. General Assembly, by the Raimondo administration, or by the R.I. Attorney General.

“Whether or not their romantic involvement represented a conflict of interest was not something that the chair of the House Oversight Committee, Rep. Patricia Serpa told ConvergenceRI, she felt was worthy of investigation.”

It was a bit surprising, then, to find DiBiase in his new role of executive director of RIPEC, being featured in a recent item in the weekly political column by WPRI’s Ted Nesi, talking about the budget, citing a story by WPRI’s Eli Sherman?

The item read: “When you’re in a hole, you have to stop digging,” said RIPEC executive director Michael DiBiase, who recently departed as Raimondo’s Department of Administration director, during a panel discussion hosted by Bryant University. “We need to bring our spending under control,” he said, noting that most of the state’s top officeholders don’t know what it’s like to tax and spend during times of austerity.

The item continued: “We haven’t had to do that for a while,” [DiBiase] said, adding that even if the federal money is made available, the state shouldn’t increase spending this year because the federal assistance will only be there for one year, while the economic fallout from COVID-19 could be long lasting. As for keeping public employees employed, DiBiase said that shouldn’t be a high priority when it comes to budget decisions, especially while there are so many other people who have lost their jobs.”

DiBiase, the person who helped to direct the disastrous launch of UHIP, which had helped to precipitate the financial crisis at skilled nursing facilities in Rhode Island, making them more vulnerable to the coronavirus pandemic, is now busy dispensing his “wisdom” about budgets and digging holes. What is wrong with this picture? Are you listening, Rhode Island?,5814

Richard Asinof

Richard Asinof is the founder and editor of ConvergenceRI, an online subscription newsletter offering news and analysis at the convergence of health, science, technology and innovation in Rhode Island.