Budgets Strained, States Move More Patients Out of Nursing Homes

Jul 13, 2016

Barre Dowd now lives in his own apartment, with a little help from housing specialist Jeanette Conway, left, and case manager Maria Haddad, right.
Credit Kristin Gourlay / RIPR

State health officials say we’re spending too much on nursing homes. Instead, they say, we could be caring for people, for less money, at home.

 There’s a new effort to do that. But making the transition from a nursing home isn’t always easy.

Barre Dowd finally has his own place.

Dowd is a tall, trim 67 year old. He’s sitting on a brand new couch in his very own living room. Just a few months ago, Dowd was living at Bannister House in Providence.

“I didn’t think I’d ever be in a nursing home period," he says. "But I guess as you get older things pile up.”

A previous head injury left his memory shaky. Then he fell down some stairs and broke his spine. He couldn’t walk. Even worse, he was homeless. So he went to Bannister House, which accepts patients with state medical insurance, or Medicaid.

“When I got there I couldn’t walk. They gave me a walker-thing. Then a cane." says Dowd. "Then I got this thing, a girdle they made me wear. Then I started exercising. I was able to walk around.”

As he got hardier, a Neighborhood Health Plan of Rhode Island housing specialist started visiting. Jeannette Conway asked Dowd if he was ready to leave.

“And I said, ‘I’m not going nowhere because I got nowhere to go. She said, 'Hang in there.' But then one time she came and said, 'Are you ready to go?' I said 'Where?' I said, 'Let’s go!'”

Conway had put him on the waiting list for a low income apartment in a Providence high rise. His name came up.

“I’m happy here," he beams. "My own room, my own bathroom. Jeannette got me going to therapy.”

And it’s a lot cheaper – he paid more than $600 at Bannister house, and now pays less than $200 for his apartment. But it’s taken a village to get him here and make it work. From the housing specialist and case manager to weekly visits from a nursing assistant to help him with chores. Dowd’s case manager, Maria Haddad, says Dowd is relatively self-sufficient. But people who are more frail can make it work, too.

“We do have someone people that are out there that people may look at and say, 'Geez, they shouldn’t be home,'" says Haddad. "But if we give them the proper assistance and help that they need, a lot of people are able to be transitioned to the community.”

Rhode Island health officials hope to do just that with many more people currently in nursing homes. The goal is to re-balance how Medicaid long term care dollars are spent – to about 60 percent of the state’s long term care budget on nursing homes, which are the most expensive level of care, and about 40 percent on home and community based services. Right now the split is about 80 /20, with a lot more spent on nursing homes than most states.

Of course, nursing homes are the best option for some people, and many nursing homes have been working to become more like homes than institutions. 

But without help, people like Barre Dowd might just linger in nursing homes when they don't have to.

Maybe something like this has happened to one of your family members.

“Maybe they broke a hip or they broke a knee. And they had some surgery," says Alison Croke, who heads up a program at Neighborhood Health Plan of Rhode Island for dual-eligibles. Those are people who receive Medicare and Medicaid. Medicare is federal health insurance for older or disabled Americans. Medicaid is state health insurance for the poor. Dual eligibles are some of the state’s most vulnerable, and sometimes most expensive patients. And they’re the target of a new effort to reduce spending on nursing homes.

Back to our scenario. Croke says what might happen next, after breaking a hip, a patient might go to a nursing home for rehab.

“And they got to a place where they sort of plateaued and they didn’t necessarily get any better," she says. "And while they didn’t necessarily need the skilled services any more, they weren’t necessarily able to meet all of their activities of daily living. Things like bathing and dressing, preparing meals, toileting. They still needed help with that.”

At that point, says Croke, there’s often a family discussion: does mom really need to be in a nursing home? Can we afford it? Can anyone take her in? Often, families are stretched too thin to say yes. And that’s where Neighborhood comes in. Rhode Island has asked the insurer to assess every one of its members in nursing homes.

“Neighborhood has today around 2800 nursing home residents that are our members. What neighborhood does is conduct a discharge opportunity assessment," Croke says. "And what that does is look at their willingness to leave the nursing home and whether they have supports in the community that will allow them to live independently in the community.”

The most important thing? A safe place to live. And that’s not always available. So Neighborhood deploys a whole team to find a place and arrange all the services a person might need to live there.

“So it consists of not just nurses but we have social workers, we have housing specialists, we have rehab specialists – a rehab specialist is someone that would go into the home and look at, are there carpets in the way that someone would trip and fall, you know really making it safe so someone could get around,” Croke says.

Croke says they’ve moved about 11 percent of their nursing home members back into the community. But the process is slow. And there are some big stumbling blocks. One is a shortage of safe, low-income housing for the elderly or disabled in Rhode Island. Another? A shortage of home-care workers, people who can help bathe, cook for, or dress someone who needs help.

Brown University researcher Susan Allen studied nursing home transitions for the state of Rhode Island. She says Rhode Island is not alone.

“Billions and billions of dollars have been spent on this effort to get people out of nursing homes. And I think the estimate as of last year was about 51,000 people.”

That’s the number of people who have transitioned out of nursing homes nationwide. Allen says the number may sound small, but it’s taken some up-front investments to get to this point – in things like hiring more home care workers, or creating more affordable housing. States are more willing to make those investments because of the growing population of older people and the cost of nursing home care. And Allen says the demand for long term care options is only growing.

What used to be the norm – aging parents moving in with their grown children – isn’t a viable option for most people any more, says Allen. Around the 1960s, more people started moving into nursing homes as family structures changed.

“I think the main driver of increased reliance on nursing home care is women in the workplace, because who are the caregivers to the elderly?" asks Allen. "To the best of my knowledge the statistic has remained stable for many years. That of caregivers to the elderly, about 70 percent are women.”

Now, more women work, and families are having fewer children who could step in to help. What’s more, Allen’s research finds baby boomers don’t want to go into nursing homes. So, she says, as boomers age, they’re going to need even more alternatives – and more efforts like Rhode Island’s - to accommodate everyone who wants to stay in the community.

“I like to think that we are creative enough to come up with some alternatives," she says, "to think hard. I don’t know if we’ll go back to communes, with core caregivers in them, but it’s not impossible!”

In the meantime, programs like Neighborhood Health Plan of Rhode Island’s are helping those who are willing and able return to the community – one at a time.