A Nursing Home Stay Can Be Temporary

EDITOR'S NOTE: This article was originally published in the June 2012 issue of Kiplinger's Retirement Report. To subscribe, click here.

Many people view the move to a nursing home as a one-way trip. But new government initiatives, combined with nursing homes' shifting business models, are encouraging more seniors to return home. Unfortunately, not all round trips are voluntary: Nursing homes are forcing out some residents.

Under federal rules implemented in 2010, all nursing-home residents are asked every few months whether they want to talk to someone about returning to the community. If a resident is interested, nursing homes must help the senior get more information on a potential move.

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What's more, the federal Centers for Medicare and Medicaid Services is working with states to help Medicaid beneficiaries who have been in an institution for more than 90 days to move back to the community. This "Money Follows the Person" program, enacted in 2006 and extended under the 2010 health care overhaul law, had overseen nearly 17,000 moves from institutions to community settings as of August 2011. The program encourages more flexible use of Medicaid funds, allowing that money to "follow" beneficiaries to the home or community setting they choose.

Separately, some advocates say they're seeing a growing number of residents improperly evicted by nursing homes. Such evictions may happen when a resident's Medicare coverage is terminating. (Medicare typically covers up to 100 days of skilled-nursing care after a discharge from a hospital.) After that, if a resident can't afford to pay the costs, a nursing home may receive a Medicaid reimbursement, which is usually lower than the Medicare rate. In some cases, the resident's condition requires an extended period of care. "It comes down to money. They're consuming more resources than other residents," says Tony Chicotel, a lawyer at California Advocates for Nursing Home Reform.

Leaving on Your Own Accord

Some residents who leave nursing homes voluntarily may simply need help with dressing and eating. Others have dementia. Before you or a loved one agrees to move, carefully weigh potential pitfalls. Nursing-home residents returning home must have affordable, accessible housing and home health care aides -- two things currently in short supply.

As care plans are passed from one setting to the next, it's easy for someone to drop the ball on issues such as properly administering medications. Among the earliest participants in Money Follows the Person, only 85% were able to live in the community for a full year after the transition, according to Mathematica Policy Research, which tracks the program's progress.

Managed properly, however, a move from the nursing home can bring great benefits. Many residents need a relatively low level of care and are seeking more flexible living arrangements, such as an assisted-living facility. Eighty percent of Money Follows the Person participants were satisfied with their lifestyle after a year of living in the community, according to Mathematica, up from 60% before the transition.

Housing remains a major challenge. Nursing-home residents often spend down all their assets in a matter of months, selling their homes along the way. Some are able to live with relatives, but others are left without community connections.

Aging & Disability Resource Centers can help seniors explore their housing options. To find your local center, go to www.adrc-tae.org. Eldercare Locator (www.eldercare.gov; 800-677-1116) also provides housing information. The site's guide, "Housing Options for Older Adults," reviews questions to ask about alternatives such as board and care homes and assisted-living facilities. Seniors should ask to go see their housing choices before they make a decision, and consider mobility issues as well as lifestyle questions like who the neighbors are and how they'll spend their time, says Susan Reinhard, senior vice-president at AARP.

As for in-home health care, many seniors returning home rely on family members -- making it essential to involve relatives in any transition decisions. This can be a difficult discussion for families that have recently completed the process of placing a loved one in a nursing home and making her comfortable there, says Janet Williams, a transition specialist in Overland Park, Kan. Eldercare Locator and the Aging & Disability Resource Centers can connect family members with in-home health care providers, home-delivered meals and transportation services. Families could hire a geriatric-care manager, who can create a care plan and find resources in the community. To find a care manager, go to the Web site of the National Association of Professional Geriatric Care Managers at www.caremanager.org.

Seniors and families should ensure they have adequate in-home help before leaving the nursing home. "There are not enough qualified people to support a major shift from nursing-home care to community care," says Molly Rees Gavin, president of Connecticut Community Care, in Bristol, Conn.

Red tape can get in the way, too. In Connecticut, transitions under Money Follows the Person have been limited in part because the state typically requires that registered nurses administer medications for people living at home -- a costly proposition. State lawmakers have proposed a bill to loosen those restrictions.

Other items to consider before making a move: required medical equipment, help with paying bills, and a list of medications and medical appointments. A guide for people leaving nursing homes is available at Medicare.gov. (Enter "discharge" in the search box to find "Your Discharge Planning Checklist.")

When a Move Isn't Your Choice

While a voluntary move out of the nursing home requires deliberation, an involuntary move may require residents and families to act quickly to assert their rights. Carmen MacLeod's mother, 84-year-old Leonarda Gomez, entered a nursing home late last year, with Medicare covering her stay. Early this year, the facility attempted to discharge her, saying her condition had improved. Through the Medicare appeals process, which entitles beneficiaries to an independent review of discharge decisions, MacLeod fought off two of the attempts. But her third appeal was denied, and Gomez had to leave the nursing home to live with another daughter, MacLeod's sister.

The transition "was a disaster," says MacLeod, 68, of Sunnyvale, Cal. Gomez, who suffers from dementia, didn't have the proper medical supplies and became severely agitated, MacLeod says. After just one day at home, Gomez had to be hospitalized, where it was discovered that she had water in her lungs, a bacterial infection and other problems, according to a California Department of Health Care Services report.

Under federal law, there are only six reasons that nursing homes can evict residents: The nursing home is going out of business, or the resident fails to pay, no longer needs nursing-home care, has needs that can't be met in a nursing home, endangers others' safety or endangers others' health. A nursing home typically must give 30 days' written notice, which must include instructions on how to appeal.

Residents and families should not hesitate to appeal evictions, advocates say. Many residents are simply told to leave when their Medicare reimbursement ends, but these moves are often improper, says Eric Carlson, directing attorney at the National Senior Citizens Law Center. A growing number of nursing homes are trying to market themselves as short-term rehabilitation centers focused on Medicare beneficiaries who have just been discharged from the hospital -- a business model that may be "based on bringing people in and getting them out as soon as the reimbursement changes," Carlson says.

Residents sometimes receive no notice that they're getting kicked out. Larisa Babayants, 74, lived at Greenhills Manor nursing home in Campbell, Cal., for more than ten years before being briefly hospitalized last year. When the hospital was ready to discharge her, Greenhills refused to readmit her, says her daughter, Eleonora Babayants of Redwood City, Cal. Though Babayants appealed to the California Department of Health Care Services, and won, the facility still wouldn't readmit her mother, she says. Babayants has sued the nursing home, seeking about $25,000 in damages. James Napoli, a San Francisco lawyer who is representing Greenhills, says, "We'll vigorously defend the lawsuit."

Advocates say they're hearing more about such "hospital dumping." Most of the victims are Medicaid beneficiaries, advocates say. When Medicaid residents are hospitalized, federal law requires nursing homes to hold their beds for a certain period, which varies by state -- but advocates say the law isn't always strictly enforced. When residents are refused readmission after a hospitalization, families should complain to the state licensing and certification agency and demand immediate action, Carlson says. In many cases, "the facility is taking advantage of residents," Chicotel says. But he adds, "in federal and state laws, there's a lot of protection for residents."

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