Her legs propped up on a chair, 80-year-old Viola Braxton sits quietly day after day in her room at D.C. General, making shaggy dogs out of yarn as the soap operas drone on. She has been there a year waiting for a new home -- a nursing home bed that never seems to open up.
"If they get a bed, I'll go someplace else," she says. "If they don't, I'll be right here."
It could be another year before Braxton leaves. She is one of 111 elderly or disabled patients who tie up almost one-quarter of D.C. General's beds while they wait as long as two years for a spot in a nursing home.
They no longer need to be in the hospital, and keeping them there costs the city more than $10 million a year. But because of a shortage of nursing home beds in the District of Columbia they have nowhere else to go.
Many of these patients are ravaged by diseases, senile and prone to get bedsores because they never move around. More than 50 have not had a visitor for a year, and one surgeon, Dr. Lewis Kurtz estimates that 60 percent will die before they ever leave D.C. General.
Most were sick when they came to the hospital, and their illnesses -- a broken hip, a limb that had to be amputated because of bad circulation -- left them unable to go home and too helpless for relatives to care for. Braxton, for example, had lived with her sister and brother-in-law in Southeast Washington and was able to get around with a cane until she had a stroke in February 1979 that left her dizzy and unable to walk.
Now, using a walker and hanging onto walls, she can barely make her own bed. "I feel like I'm rocking all the time," she said. "People go up in the air. It's the worst feeling."
Patients like Braxton, once they have overcome the illness that brought them to D.C. General, enter a kind of limbo world -- no longer in need of a hospital bed and unable to leave until they are placed in a nursing home.
"They're just here. One day is like the next," said Kurtz who runs Howard University's surgery program at the hospital.
Although other local hospitals also have beds tied up by such patients, D.C. General has the largest portion. Of 271 such patients in District hospitals last July, a survey showed, 116 were at D.C. General. Most are waiting for a permanent home at a facility offering "intermediate care," the most common kind of nursing home. Such homes provide care supervised by nurses [including a certain number of registered nurses] and can handle bed-ridden patients and those on oral medications or insulin but not intravenous lines or intensive physical therapy or tube-feeding, which require "skilled care" facilities.
The District has 1,737 intermediate-care beds, but it needs 1,019 more to take care of all the people in the city who need one right now, according to Robert Oshel, a planner at the State Health Planning and Development Agency. Sometimes a month goes by and not a single D.C. General patient gets into a nursing home.
The long wait for a place in a nursing home exists only for patients who cannot pay. Those who can -- such as patients at private hospitals who can afford nursing home charges -- get beds almost immediately, according to social workers and doctors.
But the elderly and disabled patients waiting at D.C. General cannot pay. For a time, those over 65 qualify for Medicare -- but Medicare's coverage of an elderly patient's hospitalization ends after 150 days, and the program does not pay for an intermediate-care nursing home bed.
Once Medicare coverage ends, most of the patients qualify for Medicaid because they are indigent. Medicaid pays for 83 percent of their hospital fees as long as they wait for a nursing home bed. It also covers the nursing home bed. But nursing homes often are reluctant to take Medicaid patients because the program pays only part of their charges.
So nursing home proprietors compete to fill their rooms with private, full-paying patients, and let Medicaid patients sit in hospitals. They are under no obligation to take any fixed percentage of Medicaid participants.
A 1979 survey of the District nursing homes found that only 60 percent of beds approved by the government as eligible for Medicaid patients were actually occupied by Medicaid patients.
Proprietors deny that they keep beds that could be used for Medicaid patients empty while they wait for private patients. But some do follow that policy, according to Karyn Barquin, long-term care coordinator at the District's Office on Aging.
In addition, many homes maintain separate waiting lists for private and Medicaid patients. And hospital social workers trying to place Medicaid patients have no way of knowing whether waiting lists are kept fairly, said Helen Brown, D.C. General's director of social work.
For all these reasons, D.C. General has between 110 and 130 patients -- they're known as "disposition patients" -- waiting for nursing home beds at any given time. Medicaid pays their hospital fees with federal and city funds -- $10 million a year, according to executive director Robert Johnson.
Next year the price may rise as high as $15 million because D.C. General raised its charges in May.
Keeping the same patients in nursing homes would cost Medicaid -- and the taxpayer -- only about $2 million a year.
But the cost to D.C. General must be reckoned in more than dollars. Having so many old, homeless patients makes it hard to attract residents (doctors in training) and nurses to work there, and dampens the morale of those who do.
"Everybody works less efficiently because they know they've got these chronic care patients," sayd Dr. Lay Fox, former head of the Georgetown University medical program at the hospital.
Residents say they are frustrated caring for so many disposition patients. because their medical problems are often untreatable. And by tying up beds they limit the number of younger, sicker patients whose illnesses the young doctors can treat and study.
Dr. Stanford Roman, the medical director, said the problem has been especially grave during the last few months, when nearly all the hospital's medical and surgical beds have been full and the patients have kept emergency cases from being given beds.
The disposition patients try the endurance of nurses, because many of them must be bathed, dried, turned over, fed and helped onto bedpans and into chairs. They cut into the time that nurses have to care for sicker patients, and the discouragement that ensues from caring for them, contribute to a high absentee rate among nurses at the hospital.
And the patients themselves suffer from having to stay at the hospital longer than necessary. They risk getting infections from roommates. They are watched by nurses who, for the most part, are not specially trained or motivated to work with the elderly. And because there are so many disposition patients, D.C. General administrators say they are unable to provide them with services that would be routine in most nursing homes, such as physical therapy.
Braxton said that for several months she took daily physical therapy to recover from her stroke. But last fall, she and a number of other patients were moved to the third floor of the pediatrics building, which is separate from the main hospital, in an attempt to free up beds during a shortage. Since then, she said she has not been taken for therapy.
"They don't give it to me now," she said. "They'd have to take you through that long tunnel (between the buildings)."
D.C. General's social workers, who bear the burden of finding places for elderly patients in nursing homes, also try to address their emotional needs. Since 1977, two social workers have intermittently led a therapy group where some of the more articulate disposition patients could meet to vent their feelings about being stuck in the hospital.
Some patients became more communicative as a result of the meetings and adjusted better to their eventual transfer to a nursing home, according to Saundra E. Miller, one of the leaders. She said one woman even dressed up in her street clothes each week to come to the meetings.
But last year, one group member who had seemed the healthiest of them all died unexpectedly of a heart attack. Miller said the other members, although old and frail themselves, were so shocked by his death that they temporarily stopped meeting, and some dropped out.
The District's nursing home bed shortage has developed only in the last two or three years, fueled by the aging of the population, by the court ordered transfer of mental patients out of St. Elizabeths Hospital, and by condominium conversions, according to James Klimcheck, vice president of the National Capital Area Association of Homes for the Aged.
District health planners predict that the shortage will end within two years, but their calculations have assumed that all the new facilities that have been issued the necessary city certificates will be built and that no homes will close.
One home, the 202-bed Mar-Salle Convalescent Center 2131 O St. NW, has lost its license. In April the center received a court order to bring its staffing and sanitary conditions into line with city regulations by October or close -- relocating all its residents in other nursing homes.
And several planned nursing homes have been held up by construction costs and financial problems, according to Oshel of the health planning agency.
Administrators at D.C. General are working on a plan with the D.C. Office on Aging to lighten the burden carried by the hospital. If the plan succeeds, this fall the Office on Aging will open a new nursing home in the building now being vacated by the National Lutheran Home, which is moving to Rockville. The home will accept about 100 of D.C. General's patients in return for a payment by the hospital of between $1 million and $2 million.
After the transfer, D.C. General will close 100 beds temporarily to make renovations. When they reopen, executive director Johnson said, he can only hope that they will not fill up at once with 100 more patients who need to be in nursing homes.