Here are takeaways from an episode of Kentucky Health focusing on challenges to the state’s long-term care facilities and how they’ve been affected by the COVID-19 pandemic. Host Dr. Wayne Tuckson welcomed Elizabeth Johnson, president and executive director of the Kentucky Association of Health Care Facilities and Kentucky Center for Assisted Living.
A Model for Elder Care in Need of Reform
In the year 2000, about one in eight people in the U.S. were age 65 or older. By the year, 2040, one in five people will surpass that age. Questions about self-sufficiency are rarely pondered during youth and early middle age, but as they grow older, many Americans are increasingly becoming concerned with how they will be able to live during their senior years when they may become physically and/or mentally limited.
The COVID-19 pandemic and the virus’s spread in many nursing homes has brought attention to problems with the long-term health care system in the U.S. Johnson gained a deep understanding of the long-term care industry during her time as Kentucky’s Medicaid commissioner and as an attorney representing providers. She says the industry developed during the 1960s when the federal government enacted Medicare to provide health care to seniors.
“What the government learned is that it was becoming very expensive for people to stay in the hospital longer,” she says. “So the policy makers built a model of a long-term care setting. That’s why a lot of times when you walk into a skilled nursing facility it looks like a hospital, it has different wings. We didn’t think of it as a home-like environment, we thought of it as a transition or a step-down from the hospital. Unfortunately, as those services have become more needed, we haven’t changed the model. It’s a very antiquated model.”
While the term “nursing home” is commonly used by regular folks, Johnson says that the industry prefers the term skilled nursing facilities when referring to these long-term care settings, which participate in the Medicaid and Medicare programs. “Skilled nursing facilities are the most heavily regulated health care providers in our country,” she says.
In Kentucky, seniors receive four levels of services, Johnson explains. They can reside in independent living communities, which are not regulated at all and offer close-knit community amenities and activities. They can stay in assisted living facilities, which are certified by the state Cabinet for Health and Family Services and may provide limited services such as apartment and grounds upkeep. The next level is personal care facilities, which are licensed and regulated by the CHFS’s Office of Inspector General. This in-between category offers extra care with personal needs such as taking medications but stops short of the final level: skilled nursing facilities.
“Skilled nursing facilities, that’s the highest level of care,” Johnson says. “You’re talking about people who need assistance with possibly eating, dressing, transferring to a wheelchair, bathing – those types of services.”
Johnson says that many people who register to stay at skilled nursing facilities are only there temporarily. These are mainly folks who were discharged from the hospital after an operation and then undergo rehabilitation until they are well enough to go home safely. Johnson says that Medicare reimburses up to 100 days of temporary residence in a skilled nursing facility.
“The other part of it is really, truly long-term care,” she says. “You are unfortunately unable to care for yourself at home and you may not have the family support, so you go to a skilled nursing facility where those caregivers will help you with making sure you get proper nourishment, helping you bathe, making sure you are safe from falling, and those types of services.”
Medicare does not reimburse those who are permanent residents of skilled nursing facilities, Johnson explains. Residents who do not have long-term care insurance (or whose policies have reached their limit) must pay out of pocket to stay there – and for most people, the expense will quickly exhaust their savings, making them eligible to qualify for Medicaid.
“Skilled nursing facilities are very dependent on Medicaid, and in fact it’s the primary payer for those services,” Johnson says. “To qualify for Medicaid, you have to be ‘aged’ – that’s the old term that they use in Medicaid – and you have to be poor.” Johnson explains that most people will have to spend their savings, sell all of their securities if they have any, and even sell their home to pay for services at a skilled nursing facility, until they reach the income threshold to become Medicaid-eligible. After that, all their needs, from housing to food to constant medical care, will be reimbursed by that federal program.
Improving Long-Term Care for a Post-COVID Era
A year in, the COVID-19 pandemic has brought to light some of the challenges facing the long-term care industry, Johnson says. In Kentucky, around 66 percent of deaths from COVID-19 have occurred in skilled nursing facilities. “We are the underappreciated health care provider in this country, in my opinion,” she says, “so I don’t shy away from any of those spotlights.”
The day-to-day operations of these facilities – close living, a high-touch environment as caregivers attend to residents – meant that conditions were ripe for high COVID-19 cases, hospitalizations, and deaths in long-term care. Still, Johnson acknowledges that some of the criticism directed at the industry during COVID-19 is valid.
“Anyone working inside long-term care will admit that we can improve and that we should improve,” she says. “But in order to do so, we need the support of our government, the family members, and the workforce. Everybody needs to work together to figure out what we need to do to support these elders – because if we don’t, it’s the elders that suffer.”
Johnson says that in the beginning, skilled nursing facilities did not have the personal protective equipment (PPE) they needed to fully equip their staff and residents. This was major factor in high cases and deaths, and something that the industry and government will need to prepare for in advance to handle the next pandemic. Even though most residents and staff at skilled nursing facilities in Kentucky have received their COVID vaccines, Johnson says that new hires still need to be vaccinated.
Figuring out a way to increase pay for staff at skilled nursing facilities is another goal for Johnson and other industry leaders. “Our margins were thin before COVID, and then all of a sudden it hits, and the government says that you have to wear an N-95 mask 24-7, you have to put masks on your residents, you have to buy gloves and gowns, you have to test your staff,” she says. Her association is currently asking state government for additional funding for long-term care, and Johnson believes this increase in support is necessary for the industry to make necessary improvements going forward.
Making the Decision to Move to Long-Term Care
Johnson says that asking a parent or other elder loved one about possibly moving to a skilled nursing facility is a difficult topic to bring up; she has had to do it herself.
“I would hope that everyone has an involved family,” she says. “Because I think that it’s a family decision. We know that we have a lot of elders in our state who are not connected and don’t have the resources that they need. But if you have your family, I recommend that you start talking to them about it now.”
Some facilities in Kentucky offer all four levels of care discussed above, Johnson says. They have independent living sections, areas where assisted care is provided, and then a skilled nursing facility, “so if you need a higher level of care, you are guaranteed a spot,” she explains.
Johnson says that skilled nursing facilities are mainly staffed by persons with a nursing background, from the director of nursing down to therapists and certified nurses’ aids. Each facility has a medical director, but that person is not present every day at the facility.
Certified nurses’ aids are “the backbone” of these facilities, Johnson says. “These are the people who are transferring you to your wheelchair, they’re turning you if you are unable to get out of bed on your own, they are taking you to the bathroom. They are doing a lot of wonderful things to care for these elders.”
Johnson advises individuals searching for a long-term care facility to live in or families seeking one for a family member to be patient and thorough, and says that she learned early on in her job while traveling the state to, as the saying goes, never judge a book by its cover.
“What matters is the people inside,” she says. “You will know, I believe, immediately, if you get a good feeling from the administrator, the director of nursing, the caregivers.” She recommends visiting the Medicare website to view ratings, but says that personal visits and conversations with facility staff are more important – and so are referrals from family members of prior residents.
