The District has failed to use available federal funds to keep elderly residents out of nursing homes, spends disproportionate dollars on institutional care instead of home and community support and, according to a new report, has a regulatory system that does not assure that these vulnerable people will receive high-quality services no matter what the setting.
The report, by a D.C. Council task force, suggests dozens of changes to greatly increase seniors' options for long-term care and improve what they receive. It focuses on the confusion and the paucity of information, which effectively limits their choices further, calling for much more public outreach and coordination among professionals.
These barriers "may result in unnecessary placement of seniors and persons with disabilities in institutional care," the task force warned.
The 17-person panel included researchers and administrators, providers and advocates, even a retired teacher who cares for her 100-year-old mother. Starting this summer, it examined issues of access, quality and the availability and ability of workers.
Some members consider their recently issued recommendations a long-overdue blueprint for reform.
"I'm hoping they'll be enacted and enforced," said task force member Ilene R. Henshaw, a senior legislative representative in AARP's state affairs department. "We have a long way to go."
Health committee chairman David A. Catania (I-At Large) raved about the group's proposals and promised to introduce legislation "that will bring them to life." He said he wants to tip the balance -- and the dollars -- toward care aimed at helping the elderly remain in their homes longer or return there after hospitalization.
The idea is hardly revolutionary; some states started the process a decade or more ago. And with the average nursing home bill running about $65,000 a year in the District, "the cost savings potentially are enormous," Catania said.
But in the District, too many older people "get stuck" in nursing homes because too few options are available or personal finances run out, Henshaw said. The city has money through special Medicaid waivers to provide these residents with home aides, emergency services and respite support for their families. Yet the dollars at times have gone unspent and had to be returned to their federal source.
"We have empty slots going begging," Henshaw said. In fiscal 2005, according to the report, more than 10 percent of 920 Medicaid waiver slots for seniors or disabled individuals were not filled. In fiscal 2006, the total available will exceed 1,200. "It's absurd to not make use of these," she said.
To fully do so could require streamlining a city program that helps elderly residents make their homes more handicapped-accessible or starting an initiative to recruit volunteers who would do yardwork or light home maintenance for these seniors. Both are task force recommendations.
The official whose job touches on all District nursing home residents described the committee's mission as progressive and its several months of work as positive. As for its direction on building a true community network, Gerald "Jerry" Kasunic, director of the long-term-care ombudsman program, said: "Over a long haul, I think it's very doable."
The Department of Health has taken some steps to follow the task force's direction, including tracking Medicaid waivers more closely to increase the number of people signed up. "DOH applauds and supports the work that was done" by the task force, director Gregg A. Pane said, though he cautioned that "as you can imagine, there's a fiscal impact."
Without the dollars, pushing and then ensuring a certain level of care in facilities or home settings will remain a challenge. In the report, the introduction to this issue notes that "the current regulatory and reimbursement system does not guarantee high quality of care." Task force member Sandy Douglass is more blunt: "The quality . . . is perceived to be poor."
The system suffers in part from limited choice, inadequate reimbursements and uneven regulatory standards and enforcement. Douglass, administrator and chief executive at the Methodist Home of D.C. in Northwest Washington, said she wants some of the innovative approaches taking hold around the country to be brought here. These programs, with such names as the Eden Alternative and the Green House Project, emphasize not only a very different nursing home look and feel but also "an organizational culture change" that makes a difference for residents and staff members.
She and fellow task force members also recommended strengthened oversight of facilities and home-based services, increased penalties against repeat offenders and monitoring surveys that are available online.
And for the nursing assistants, home health aides and personal helpers who are the backbone of much long-term care, the task force wants competitive wages through higher Medicaid reimbursement to their agencies and health coverage, possibly through the insurance pool now used by city employees.