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September 10, 2005

A nursing home consultant responds

Reporter Paul Rioux of the New Orleans Times-Picayune tells us that

Less than 24 hours before Hurricane Katrina began ravaging St. Bernard Parish with 140 mph winds and a 20-foot storm surge, Coroner Bryan Bertucci made an urgent call to the owner of St. Rita's Nursing Home near Poydras.

"I told her I had two buses and two drivers who could evacuate all 70 of her residents and take them anywhere she wanted to go," he said.

But Mabel Mangano refused the offer. "She told me, 'I have five nurses and a generator, and we're going to stay here,'" Bertucci said.

Thanks to Carrie Lucas for alerting us to Rioux's posting on the T-P website.

In light of the above, the email I received yesterday is even more interesting. It was sent by Julianne Haydel, RN, as a result of my long blog entry on the nursing home industry in Louisiana. Here it is:

As a healthcare consultant in Louisiana, I have many clients in the New Orleans area. One in particular has seven nursing homes in the area affected by Katrina. ALL of them were evacuated prior to the storm.

Your concern for the elderly is commendable and I share your passion. But, I think it is erroneous to assume that the tragedy of Saint Rita's is reflective of the nursing home industry at large.

First of all, consider the huge risk my client took by evacuating patients prior to a mandatory evacuation order. He went to a great expense to rent buses for patients and U-Hauls for mattresses. It was not feasible to bring beds. His only options for shelter were his existing nursing homes in Baton Rouge or shelters. He chose the former where his staff could care for his patients. But, the homes are in fact crowded. There are no vacant nursing homes available for evacuees here or anywhere else that I know of. Had anyone died without a mandatory order and had the storm veered away at the last minute, he would have been held accountable. He took the risk and evacuated as the vast majority of homes in the New Orleans area did. But make no mistake. Elderly people die during evacuations. They were not admitted to a nursing home because they were spry and fit!

I further agree that more money should be spent on care delivered in the home. Be advised that the waived programs do not provide skilled nursing care ? ¨  only sitters and unskilled aides. In order to receive skilled nursing care in the home, a medicare or Medicaid recipient must have intermittent needs ? ¨  chronic care is not covered. Furthermore, Medicaid in Louisiana only pays for fifty visits a year. Patients who require the judgment of a licensed professional for wound care, medication management, etc. are not helped by the waived programs. Anyone with a PEG tube for feeding or a urinary catheter cannot be cared for with our current systems. In other words, just because an elderly patient requires nursing care that could be easily delivered in the home does not qualify the patient for home health nursing care. This is a federal CMS guideline and has nothing to do with the state of Louisiana.

The fact that only one nursing home has been closed does seem upsetting on the surface. However, I deal with Jenny Caigle, who is program manager for nursing homes at the Louisiana department of health and hospitals regularly as well as the other program managers. I assure you that I could not bribe them, solicit a favor or in any way gain favor even though we have a very personable relationship. The program managers won't even have lunch with consultants. ¬When they are surveying, they rarely accept coffee. I had one client who tried to pull political strings with a small hospital and it backfired on him so badly he is still recovering from a year ago. What happens more frequently, in the interest of the patients, is that a nursing home owner will be told that he is no longer able to be licensed. In this case, the home owner may sell the home. By taking this approach, the nursing home residents are spared the trauma of having to move out and find another facility. Louisiana is a Certification of Need state and people are not free to simply open another home. With each change of ownership, there is scrutiny from local, state and federal regulatory bodies.

Is there room for improvement in Louisiana Nursing homes? Absolutely. But it must be paid for. I don't know who owns Saint Rita's and I suspect it is a single owner who didn't have an extra $25,000 to rent buses. It is a very low margin business. The guys you read about who make serious money do so because they own many, many homes. One home on it's own cannot support itself much less the owner. When the price cuts were reduced last year, the first thing that my clients did was hire additional staff.

And staff costs money -- especially in New Orleans where the nursing shortage has hit astronomical proportions. Nursing homes are competing with hospitals who are offering as much as $50.00 and hour for ICU shifts. Home health nurses are making between 25.00 and 50.00 per visit depending on the complexity of the visit. What ends up happening is the homes are left with two kinds of nurses. You have the nurses who are truly dedicated to taking care of the elderly and then you have the nurses who can't get a job anywhere else.

Again, I sincerely appreciate and share your passion about care of the elderly. But, often the problem is more complex that it appears on the surface.

As we now know from Rioux's posting, cost did not seem to enter into Mabel Mangano's decision not to evacuate St. Rita's.

Haydel's email is interesting and sheds more light on the kind of intractable situation that exists nationwide within the nursing home industry. The status quo is always easier to maintain than to let go of, and generally things can change radically only by forces imposed from outside. Louisiana has an opportunity -- no, an obligation, now -- to change its antiquated institutional system. We should all be involved in the public debate to see that it does.
COMMENT-BODY:This highlights the need for consumer directed attendant care. In Colorado people with severe disabilities can hire, train, set hours and wages, and if necessary fire PAs. We have near-complete freedom to hire who we wish, as long as we stay within our budget. I and my children need assistance with many "nursing" tasks, but I am perfectly capable of training non-medical personel to do them. I don't need a nurse, and I don't need to pay competetive nursing wages, but I can pay my PAs a living wage, and receive help with the "medical" and "non-medical" tasks I need to live my life independently, and all the while I save the State of Colorado around $8000 a year over what they would pay for a home health agency to provide substandard care that does not meet all my needs.
COMMENT-BODY:The "Had anyone died without a mandatory order" section is going on my fridge.

Posted by mjohnson at September 10, 2005 10:05 AM