An 89-year-old woman, crippled by arthritis and partly senile, lives alone in a Washington apartment. She has outlived all of her friends. Her remaining kin are distant relatives living in faraway cities. A neighbor looks in or her occasionally, but she sometimes wanders in the hall-way or falls while trying to reach the bathroom.
Under present conditions in the District, this woman will get the care she needs only if someone dies and vacates one of the increasingly scarce nursing home beds available to the city's elderly poor.
At least 1,600 other city residents are known to live in similar circumstances, according to the department of human resources.
Lillian Teitelbaum, chief social worker for the Visiting Nurses Association, who described the 89-year-old woman, said she is tyical of hundreds of city residents being maintained by "piecemeal" care from DHR and nonprofit agencies such as VNA.
"What do you do with a lady like this?" Teitelbaum wondered. "There isn't anything. Just keep on patching."
The city's long-standing shortage of nursing home beds for the poor has been intensified recently by the growing number of persons needing them; deficiencies at D.C. Village, the only city-owned home for the elderly, and a newly effective District law setting more stringent standards for the smaller private homes here.
The problem is heightened by more than half the city's licensed private homes' refusal ot accept Medicaid patients because DHR's $20 a day maximum payment is not enough to pay for their keep.
"We're down to nothing as far as beds available," DHR social services chief George Robt said. "The few facilities that are licensed and certified (for Medicaid patients) are all filled and have long waiting lists."
In addition to DHR's estimate of 1,600 persons needing nursing home care, about 365 who are not mentally ill are mixed in with patients at St. Elizabeths mental hospital, a hospital spokesman said.
Many others in the city are uncounted, Roby surmised. "When people find out you don't have a service they stop applying," he said.
The District inability to provide for its aged poor has become a crisis that "gets worse by the day," Roby said.
Visiting nurses, contacted by hospitals when indigent elderly patients are discharged and have no help at home, find that they can supply only temporary and partial help, Teitelbaum said.
"They might be getting a $167.80 SSI check (supplement security income, and monthly federal aid to aged, blind and disabled adults) or Social Security or a small pension, but not enough to pay for a nursing home," Teitelbaum said.
Lacking proper care, these persons "become dehydrated because they don't get enough liquids, they have nobody to help take their medicine, or they fall and injure themselves," Teitelbaum said."They go in and out of hospitals" with injuries that proper nursing care might prevent, she said.
Hospitals often cannot discharge such patients to their homes when acute care is no longer needed, according to several hospitals social workers. Hundreds of patients spend unnecessary stays in acute care hospitals that cost the city many times the price of nursing home care, health officials have said.
D.C. Village, the 700-bed city facility in Southwest, stopped taking patients two months ago in an attempt to reduce its population to 400 by death or discharge in order to comply with federally required staff to patient ratios. The facility is threatened with loss of over $5 million in Medicaid funds if the standards are not met by Jan. 31.
A class action suit filed against DHR last week charged that the health and survival of these indigents is endangered because the city does not pay private nursing homes reasonable rates for Medicaid patients.
Acting DHR director Albert Russo announced last week that a $6.2 million congressional supplement to the department's budget has been requested to provide for increases in the medicaid payments. DHR is preparing to begin paying the higher rates Feb. 1, official said.
While DHR officials complain that staff shortages and underfunding have caused the bed shortage, some critics attribute it partly to poor management.
Most of the claims in the suit are consistent with the "crisis" situation described by Roby and several nonprofit or community agencies that provide care for the neglected nursing home candidates, including VNA.
Although DHR officials complain that staff shortages and underfunding are to blame for the bed shortage, some critics of the agency attribute it partly to poor management.
"If you look at it logically, it is costing the D.C. and federal governments more money" in hospital bills and alternate care than nursing home rates, Teitelbaum said. "It is penny wise and pound foolish."
Another District official pointed out that the 250-bed J. B. Johnson nursing home at 901 K Street NW has stood vacant since it was built in 1972. The group of doctors who built it defaulted on a $2.6 million federal loan and the Department of Housing and Urban Development took over the property last July. An HUD official said the department is attempting to sell it for nursing home use.
DHR spends $700,000 a year to provide chore services, such as shopping, cooking and cleaning for some of the patients in their homes. Another $1.2 million is paid to a contractor for professional homemaker aides.
Roby said the budgets for these services will probably not last through this fiscal year because "the demand for these services is out of sight" with the increasing need.
A number of small personal care homes, providing essentially room and board, have in the past alleviated the nursing home shortage. They have been declared substandard under federal regulations and no longer qualify for Medicaid payments. The District, having no alternative placement for patients in these homes, began paying the entire $360 a month per patient, but is currently phasing them out, Roby said.
Another group of nursing homes, with up of 25 patients each, may have to close because of the new strict city law governing them that took effect Jan. 1. Owners say they cannot afford the professional staffs, closed circuit television security, intercom systems and other items the law requires.
"I don't understand what the D.C. government is doing to the elderly.It seems that they don't care," said Linda Purdue, director of the Gerus Society, an elderly care group that has protested the law.
"We don't want to put people out in the cold," said Robert J. Sauls, DHR's licensing chief, who is enforcing the new standards. "We knew tahy couldn't comply. It's just a matter of trying to enforce what the Council has legislated."
City Councilwoman Polly Shackleton has set a hearing on March 1 to air the owner's objections to the law.
Roby said the quality of care in existing homes is secondary to the problems of those who are without care entirely.
"I worry about the ones we have no place for," Roby said. "Our (social) workers are frustrated and drained from trying to place them and knowing there is nowwhere to put them. We have gone beyond anger at the way this society treats its elderly."