Long-term care facilities face immigration crackdown and looming Medicaid cuts

Jackline Conteh is a nursing assistant in Va. She emigrated 
to the U.S. from war-torn Liberia. (KFF News photo)

Long-term care facilities call for immigration reform and push against Medicaid cuts as the sector faces "a double whammy from President Donald Trump’s crackdown on immigrants and the GOP’s proposals to reduce Medicaid spending," reports Jordan Rau of KFF Health News. "More than 800,000 immigrants and naturalized citizens comprise 28% of direct care employees at home care agencies, nursing homes, assisted living facilities, and other long-term care companies."

While labor shortages are not new to the eldercare sector, once the Trump administration canceled the industry's "protected" status in January and allowed Immigration and Customs Enforcement to raid health care facilities, the dynamics changed. Katie Smith Sloan, president of LeadingAge, an association of nonprofits that care for older adults, told Rau, “People may be here on a green card, and they are afraid ICE is going to show up."

The long-term and senior care industries are "urging the federal government to expand legal immigration channels for essential workers in healthcare and other sectors," reports Kimberly Bonvissuto of McKnights. "The Essential Worker Immigration Coalition sent a letter to Homeland Security Secretary Kristi Noem that [said] the shortage of legal immigration channels for essential workers 'threatens the stability of our supply chains, the viability of small businesses and the strength of the American economy.'"

Besides additional staffing shortages brought on by immigration issues, long-term care facilities continue to lobby against the Republican party's Medicaid spending cuts, which passed the House and are under Senate review. Rau writes, "Federal spending cuts under negotiation may strip nursing homes of some of their largest revenue sources by limiting ways states leverage Medicaid money and making it harder for new nursing home residents to retroactively qualify for Medicaid."

Given the current issues, providers, patients and employees all have reasons to be concerned. "The long-term care industry expects demand for direct care workers to burgeon with an influx of aging baby boomers needing professional care," Rau writes. Jackline Conteh, a U.S. nursing assistant originally from Liberia, told him, "If all these people leave the United States, they go back to Africa or to their various countries, what will become of our residents? What will become of our old people that we’re taking care of?"

Rural elders are estimated to endure much more abuse than what is reported. Protecting them comes with speaking up.

Rural adults are less likely to report
abuse. (Photo by Danie Franco)

While research on elder abuse in rural areas may be limited, evidence shows that one in 10 elders report being abused. A report from the National Center on Elder Abuse said that for every report of abuse ”there are 24 incidents that may go unreported,” according to Liz Carey in an article for the Daily Yonder.

“Older adults living in rural and remote areas are at greater risk of abuse because of their geographic isolation, lack of support services, and poorer health,” Carey said.

These conditions may work to conceal abuse. Rural elders tend to have less education and fewer financial resources that could, “possibly [create] barriers to leaving abusive situations,” according to a Rural Health Research Center (RHRC) study quoted by Carey.

Alexis Swendener, co-author of the RHRC policy brief, told the Daily Yonder that it was difficult to know the scope of the problem. “Some of the laws are about vulnerable adults or dependent adults. Some of them have age defined in them and some of them don’t.”

The study looked at reports of emotional abuse, financial abuse, physical abuse, sexual abuse, neglect and self-neglect. Swendener told the Daily Yonder that sexual abuse and self-neglect were the least likely to be “clearly mentioned.”

Nels Holmgren, the director of Aging and Adult Services in Utah, said in an interview with the Daily Yonder that a key element to protecting elders is reporting. However, he also said due to a sense of independence and lack of services in rural areas, people are less likely to ask for help.

Private equity-owned health care is guided by expansion and profits; many are calling for more regulation

As Americans age, the home health care sector will
continue to grow. (Photo by G.A. Pflueger, Unsplash)

Home health care businesses may go by nurturing names, such as "Senior Helpers" or "At Home Angels," but the much industry is funded by private equity investors looking to make hefty profits, reports Anna Claire Vollers of Stateline. "Proponents of private equity investment in health care say the infusion of capital helps smaller companies expand into new markets." But skeptics point to places where care companies suddenly pulled out of entire regions when profits waned, leaving elderly people at home with no care.

Private equity-owned health care companies exist to make money for investors. "Private equity firms pool investments from pension funds, endowments, sovereign wealth funds and wealthy individuals to buy controlling stakes in companies," Voller explains. "In health care, critics say, that business model can diminish the quality of care, increase costs and narrow access for patients — particularly in more lightly regulated industries such as home care and hospice care."

Home health care is an appealing business venture because it doesn't face the same level of scrutiny as hospitals and nursing homes, the profit margins are robust, and there's an aging population where "around 10,000 baby boomers turn 65 every day," Voller reports. There will be "millions of people who will need care in the coming years," which will guarantee strong business growth. Plus, insurance companies encourage their customers to use home health care, which again, bolsters profits.

Even with all those benefits, private equity firms tend to pile debt on their companies to fund expansion. "Private equity firms typically aim to acquire a company and boost profits before selling it within five to seven years," Voller reports. "They often purchase companies with borrowed money, using the company's assets as collateral for the loans."

Mary Bugbee, senior research and campaign coordinator for health care at the Private Equity Stakeholder Project, a research and advocacy group, told Voller, "We leave a lot to the whims of the market and allow private players to dictate access to and quality of health care."

State policy and lawmakers are looking at home health care companies as businesses needing more regulatory oversight. "Improving transparency, requiring certain health care staff-to-patient ratios and boosting wages for health care workers can also help protect patients and communities," Voller reports. 

Proposed new rules for nursing homes have sparked warnings and fear; rural residents are the most vulnerable

National Cancer Institute photo, Unsplash

The Centers for Medicare and Medicaid's new staffing mandates were met with alarm and fear, with descriptions including 'a disaster,' 'insanity', and 'catastrophic.' The Biden Administration's "proposed federal staffing mandate will be impossible for the nation's nursing homes to meet, limiting access to care for our seniors," reports The American Health Care Association. "CMS released the one-size-fits-all mandate earlier this year, despite its own study finding no level of staffing guarantees quality of care."

The angry reaction and warnings are particularly problematic for rural Americans. "As nursing home closures continue across the country, 'nursing home deserts' are expanding, and the proposed federal staffing mandate is expected to exacerbate the problem," reports Amy Stulick of Skilled Nursing News. "This is despite attempts to make the potential policy change easier for providers in rural markets, which are especially vulnerable to access issues. Operators in these areas point to the 24-hour RN requirement as being especially devastating."

Finding nurses, let alone 24-hour nurses, is impossible in certain areas. Nate Schema, CEO of the Evangelical Lutheran Good Samaritan Society, "says the organization's facilities located in 'deep rural communities' will struggle the most with the 24-hour RN rule," Stulick writes. "In communities like Bloomfield, Nebraska, pop. 1,000, or Miller, South Dakota, pop. 1, 300, Schema isn't sure where Good Samaritan will find even six RNs; the Miller facility hasn't had a night nurse for upward of three years."

"The ability to have a nursing home open in a small town is getting more difficult because of the disparity between Medicaid reimbursement and overall costs, says Accura HealthCare CEO Ted LeNeave," Stulick reports. "Accura operates 34 communities across Iowa, Minnesota, Nebraska and South Dakota." LeNeave told Stulick: "The provider relief fund helped to mask how bad those problems were. Once that cash dried up, buildings started closing. This concept of a nursing home desert is an area where residents need nursing home care, but there's no access to them. Then they have to drive 45 minutes to an hour to be somewhere else."

Michael Beal, CEO of Care Initiatives, told Stulick, "It doesn't matter if it's 5, 10 or 15 years, if there's no additional reimbursement, it's just a timing question on when that will affect [rural operators]; it just kicks the can down the road." Stulick reports: "Beal added that the suggested rule of 'adding that an arbitrary number of staff hours per resident day without a reimbursement mechanism, and the ability to actually hire staff puts rural operators in an 'untenable situation.'"

Proposal for more nursing-home staff seen as unattainable by many owners; resident advocates say it's not enough

Nursing homes may not be ready for 'tsunami' of baby boomers.
(Photo by G.A. Pflueger, Unsplash)

Nursing homes have struggled for decades to find a sustainable business model that provides optimal staffing numbers for resident care. Now federal officials have released "a proposed rule requiring the nation’s nursing homes to hire minimum numbers of front-line caregivers, a long-anticipated response to decades of complaints about neglect and abuse in an industry that critics say is unprepared for the tsunami of seniors heading its way from the baby boom," reports Christopher Rowland of The Washinton Post.

The Centers for Medicare and Medicaid Services proposed "minimum nurse staffing standards . . . per resident for registered nurses and . . . nurse aides," as well as a requirement to have a registered nurse at the nursing home around the clock. Many industry stakeholders consider the proposal futile. Rowland explains, "Without a supply of prospective workers, it will be impossible to meet the requirements of minimum staffing, the industry has argued. They also contend that Medicaid reimbursement rates need to be significantly increased if more workers are required in facilities." Nathan Schema, president and chief executive officer of the Evangelical Lutheran Good Samaritan Society, which operates a large chain of nonprofit nursing homes, told Rowland: "I just can’t understand how CMS is effectively trying to fix the roof while the house is on fire. It’s the beginning of the end for small-town nursing homes."

Rowland adds, "A fifth of nursing homes would have to hire registered nurses to meet the requirement, the government estimates." LeadingAge, the largest association for nonprofit nursing homes, told USA Today that the proposed regulation would be impossible for many nursing homes to meet. “There are simply no people to hire—especially nurses,” said Katie Smith Sloan, the group's president and CEO. “America’s under-funded, long-ignored long-term care sector is in a workforce crisis.” Sloan said nursing homes would have to “reduce admissions or even close” if the rule takes effect.

"While the industry reacted negatively to the proposed rule’s release, the guidelines also disappointed advocates for better treatment of residents in chronically short-staffed nursing homes, who contend the rule does not go far enough and enshrines substandard levels of care," Rowland reports. "Advocates for better quality care in nursing homes say the industry’s high staff turnover rates point to the true problem: insufficient pay and poor working conditions."

Rural nursing homes closing, creating hardship, heartbreak

"More than 440 rural nursing homes have closed or merged over the last decade, according to the Cowles Research Group, which tracks long-term care, and each closure scattered patients like seeds in the wind," Jack Healy reports for The New York Times. "Instead of finding new care in their homes and communities, many end up at different nursing homes far from their families."

Ramona Labrensz with a photo of her husband Harold
(Photo by Kristina Barker, The New York Times)

Healy's story begins with the tear-jerking tale of Harold Labrensz, an 89-year-old man in South Dakota who has to move to a North Dakota nursing home 220 miles away because his 87-year-old wife Ramona "could not find any nursing home nearby to take him, and she could not help him if he took a fall at home." Then he shows the problem's broad scope in rural America: "There are few choices for an aging population. Home health aides can be scarce and unaffordable to hire around the clock. The few senior-citizen apartments have waiting lists. Adult children have long since moved away to bigger cities."

Healy gives the business side: "Thirty-six rural nursing homes across the country have been forced to close in the last decade because they failed to meet health and safety standards. But far more have collapsed for financial reasons, including changing health care policies that now encourage people to choose independent and assisted living or stay in their own homes with help from caregivers. Some nursing homes cannot find people to do the low-paying work of caring for frail residents. Others are losing money as their occupancy rates fall and more of their patients’ long-term care is covered by Medicaid, which in many states does not pay enough to keep the lights on."

Healy adds, "On paper, South Dakota and other rural states still have enough long-term care beds for people who need round-the-clock care. The problem is where they are. When a nursing home closes in a small town, the available beds are often so far away that elderly spouses cannot make the drive, and the transferred residents become cut off from the friends, church groups and relatives they have known all their lives."

As young leave Appalachia, who's left to care for elderly?

The decline of coal in Central Appalachia has led to an out-migration of people who are needed to take care of the region's aging population, Kara Leigh Lofton reports for West Virginia Public Broadcasting.

Programs that "serve the state’s aging population are overburdened, with waitlists that can stretch months or years, or require applicants to qualify for Medicaid," Lofton reports. "This leaves the older population dependent on younger family members to fill caregiving roles. Meanwhile, to find work, the state’s young people are leaving the state and thus moving away from their elders, causing those over age 65 to be the fastest-growing segment of West Virginia’s population."

This chain of events "is creating a critical gap in services needed by the elderly," Lofton says, citing a recent report by the state Department of Health and Human Resources. "In West Virginia today, about 16 percent of the population is 65 and older, according to the DHHR report. It’s projected to grow to about a quarter of the total population by 2030. So who is going to pay for the services needed by aging West Virginians and who will help care for them if the bulk of the young people leave?"

Report shows seniors' health rankings by state, says rural seniors face 'significant health challenges'

Rural seniors face "significant health challenges" when compared to their suburban and urban counterparts, according to an annual report on the well-being of American senior citizens by America's Health Rankings. Some of the report's findings:

• More rural seniors are physically inactive in rural areas at 34.3 percent, compared to 30.4 percent of suburban seniors and 30.1 percent of urban seniors. 
• That disparity is reflected in seniors' own assessment of their health: 36.8 percent of seniors report their health as "very good" or "excellent" compared to 42.0 percent in suburban areas and 41.4 percent in urban areas.
• Significantly more rural seniors (32.4 percent) report falls than suburban seniors (28.5 percent) and urban seniors (29.5 percent). 
• Only 57.2 percent of rural seniors got the flu vaccine this past year, compared to 61.4 percent of urban seniors (suburban figures were not shown for this statistic). 
• Rural seniors receive health screenings at a lower rate than their counterparts, with 66.4 percent of rural seniors compared to 74.3 percent of suburban seniors and 75.3 percent of urban seniors.
• The five states with the healthiest seniors are Colorado, Minnesota, New Hampshire, Hawaii, and Utah in the top spot. The same five held the top spots last year.
• The least healthy states for seniors are Oklahoma, Arkansas, Kentucky, Mississippi, and Louisiana in last place.
• Utah, Alaska and Rhode Island have improved the most in health rankings in the past five years, while Vermont, Arizona, Kansas and Nebraska have seen the biggest declines in health rankings.
• With America's senior population now at 15 percent of the total population and rising, senior health-care issues will become increasingly important.

Drones are being used in many new ways, including wildlife research and preservation

Drones are being used in a variety of new ways, such as wildlife research and preservation, elder and end-of-life care, fitness and catching rogue drones, Steven Overly reports for The Washington Post. (National Marine Fisheries Service photo: Scientists fly drones over humpback whales to collect breath samples.)

A Samford University biology professor used drones to discover two species of endangered fish in Alabama’s waterways, "in part because the unmanned aircraft can reach areas not easily accessible by boat and can survey the water from a closer distance than a helicopter," Overly writes. Also, the Woods Hole Oceanographic Institution, a private research facility in Massachusetts, "has used the flying devices to collect photographs and breath samples from humpback whales for scientific research. A drone affixed with petri dishes hovers over the animal’s blowhole as it exhales, then returns to a ship where the sample is immediately frozen, said assistant scientist Amy Apprill. Scientists then study the microbes in each breath sample, and compare them across different species and environments."

A Cleveland-based business is using drones "to show people with terminal illness and living in hospice their beloved locations, such as a childhood hometown or favorite vacation spot, one final time," Overly writes. Drones are being used to enhance athletics, such as one "that monitors the path of blind runners using a pair of cameras and emits sound to guide those runners as they make their way around a track." In Japan, officials are using drones to use nets to catch rogue drones. (Read more)

New rules will make it harder for many elderly, poor, black and Latino voters to cast ballots

New rules created ostensibly to stop voter fraud are making it more difficult for poor, black, Latino and elderly Americans, particularly in the South, to register for elections, Sari Horwitz reports for The Washington Post. "In November, 17 states will have voting restrictions in place for the first time in a presidential election. Eleven of those states will require their residents to show a photo ID. They include swing states such as Wisconsin and states with large African American and Latino populations, such as North Carolina and Texas. Many of the residents struggling to obtain a valid photo ID are elderly and poor and were born in homes rather than hospitals. As a result, birth certificates were often lost or names were misspelled in official city records."

Supporters of the laws argue that everyone should easily be able to get a photo ID, while "opponents say that the laws were designed to target people more likely to vote Democratic," Horwitz writes. "Many election experts say that the process for obtaining a photo ID can be far more difficult than it looks for hundreds of thousands of people across the country who do not have the required photo identification cards." (Post map)

In Texas, which has one of the strictest voter laws in the nation, a federal court found that "608,470 registered voters don’t have the forms of identification that the state now requires for voting," Horwitz writes. Overall, "about 11 percent of Americans do not have government-issued photo identification cards, such as a driver’s license or a passport, according to Wendy Weiser of the Democracy Program at the Brennan Center for Justice at New York University School of Law."

University of California at San Diego researchers analyzed turnout in elections between 2008 and 2012, finding "substantial drops in turnout for minorities under strict voter ID laws.” The study's authors wrote: “These results suggest that by instituting strict photo ID laws, states could minimize the influence of voters on the left and could dramatically alter the political leaning of the electorate."

Sequester cuts could leave 15,000 rural people without their rental subsidies, Vilsack says

Tom Vilsack

Federal budget cuts from the "sequester" legislation could cost 15,000 low-income elderly and disabled people in rural areas their rental subsidies, Agriculture Secretary Tom Vilsack told the House Appropriations Committee today.

USDA's rural rental assistance program helps low-income tenants live in government-funded housing," Mary Clare Jalonick reports for The Associated Press. "Vilsack said the money for that program could run out in August or September and the lack of rental assistance could not only have an impact on the tenants but also the owners of the apartment complexes." (Read more)

Appalachia's aging population could be 'canary in the coal mine' for rest of country, scholars write

"With its higher proportion of older residents, Appalachia may be America’s 'canary in the coal mine,' an early warning system of problems and possibilities that come with an older population. Paying close attention to what is happening in the Appalachian region will benefit everyone interested in the future of older Americans," write Phillip Obermiller and Robert Ludke of the University of Cincinnati in their journal article, "Appalachia and its Aging Cohort: An Early Warning System for American Aging," published in the most recent edition of Aging Today.

More than 15 percent of the region's residents are 65 or older, compared to the national average of 13 percent. The share is expected to reach 20 percent by 2025. "Appalachia's older-than-age-65 population is growing faster than in the United States or even in the 639 counties adjoining the region," Obermiller and Ludke write. Men aged 65 to 74 form the fastest-growing segment of the population, at triple the rate of women in the same age range. The authors write that they have no specific cause for this, except that women may move from the region more frequently.

The authors say Appalachia's population is older than average because of "the constant flow of younger people out of the region." The greater percentage of elderly doesn't mean they have longer life spans than the average non-Appalachian. Mortality among those aged 35 to 64 is higher in Appalachia than in the rest of the country, most likely the result of higher rates of chronic disease, including cancer, heart disease and diabetes. Poor diet and poor environmental, social and economic conditions contribute to health disparities, the authors write.

"Creative responses to both the challenges and opportunities of an older population are already underway at the local level" in Appalachia, the authors write. In West Virginia, there are six designated retirement communities, counties in which elderly can find affordable housing, healthcare and recreational opportunities. The Christian Appalachian Project provides service for elderly people in Kentucky in the hope they can remain in their homes longer. In North Carolina, the Appalachian Heritage Crafters train senior citizens how to make, market and sell homemade crafts.

To gain full access to the journal article, click here.

Telehealth lets rural seniors be independent longer

"Revolutionary telehealth approaches across the United States are helping senior citizens continue to live independently in their own homes," Candi Helseth of the Rural Assistance Center. Those approaches include a research project that uses telehealth and motion sensors to track and report residents' daily vital signs; integration of telehealth and home nursing care; and management of chronic diseases from home.

The LivingWell@Home program is a five-year Good Samaritan Society telehealth research project being conducted in 40 communities in the Dakotas, Minnesota, Iowa and Nebraska. Participants in the program wear personal emergency response systems that "automatically summon help if they are unable to do so," Helseth writes. The system also directs participants through vital sings checks, and motions sensors installed in homes monitor movement and sleep quality 24 hours a day. Data is sent to Good Samaritan's headquaters in Sioux Falls, S.D., where it's analyzed by nurses who report it to designated care providers.

Windsor Place At-Home Care in Kansas has provided long- and short-term care to seniors since 1997. Ten years later, it started using telehealth, and Executive Director Monte Coffman says the integrated program "improves continuity of care and reduces hospitalizations," Helseth reports. Coffman also said the because keeping seniors at home longer requires less labor, his organization is able to do more with less workers. The Geriatric Assessment Program in New York state allows elderly patients with chronic health problems to connect with doctors via telehealth to develop a care plan. (Read more)

Tool allows detailed examination of inspection reports from nursing homes all over the U.S.

Journalists now have a tool at their fingertips that will allow them to find out about problems in their local long-term care facilities. (iStock photo)

The application is operated by ProPublica, a nonprofit, investigative news group, and allows "anyone to easily search and analyze the details of recent nursing home inspections, most completed since January 2011," report Charles Ornstein and Lena Groeger.

The tool has features that the federal government's Nursing Home Compare tool lacks, including the ability to search using any keyword. Results can also be sorted according to the severity of the violation, and by state. It has already resulted in several significant news stories, Ornstein reports, giving examples and tips on how to use the application.

About 1.5 million people still live in nursing homes nationwide, though more seniors are living at home or in assisted-living facilities. The reports show there were almost 118,000 deficiencies cited against 14,565 homes. According to the Centers for Medicare and Medicaid Services, the average number of deficiencies for a nursing home inspected in the U.S. is eight. ProPublica's analysis shows Texas had the most deficiencies in the country by far, with 183. 

While ProPublica ranks the states, nursing-home industry officials say "inspectors in different regions of the country have different thresholds for issuing a citation, and that could unfairly make one state's homes appear worse than another's," Ornstein and Groeger report. (Read more)