St. Louis American/New America Media, News Feature, Rebecca S. Rivas
ST. LOUIS—The call comes in about four times a week.
Nursing-home residents call in a panic: First they are sent to a hospital for a medical or mental health condition. Then, when the hospital discharges them, the nursing homes won’t take them back.
It’s called “hospital dumping,” said Marilyn McCormick, regional coordinator for St. Louis Long-Term Care Ombudsman Office, which is funded under the federal Older Americans Act.
The dumping of mostly low-income nursing-home patients—including a growing number of African-American elders, such as those in North St. Louis—is a nationwide problem, one involving a complicated dance between nursing homes that complain of low Medicaid payments, hospitals put on the spot to find another facility that will take the person, and frail elders and their families.
Federal law requires skilled-nursing facilities to give residents 30 days notice if they want them to leave. As nationally mandated advocates for elders, local ombudsman offices in every American community receive complaints about legal violations at long-term care facilities.
Nursing-home administrators have various reasons for hospital dumping, McCormick said. Perhaps the residents require extreme care or have behavioral issues, such as emotional agitation or abusive outbursts. Professional training is available to help employees handle these situations, but the cost is not covered by the already low Medicaid reimbursement.
Whatever the reason, McCormick emphasized, “they can’t just leave the resident in the hospital.” If a nursing home can’t meet a resident’s medical needs, the staff should call the state department of health and senior services, she said.
Too Many Times
Patient dumping hurts seniors in every community. At Christian Hospital, in North St. Louis County, it happens “too many times not to be addressed by the state,” said Diana Tucker, the medical center’s social work case manager.
At Barnes-Jewish Hospital, a senior is dumped about once a month, said Thomas Dinwiddie, the medical center’s clinical social worker.
But the Missouri Department of Health and Senior Services contends patient dumping is rare. “We don’t see it as a huge problem,” said spokesman Kit Wagar. “We don’t see that many complaints.”
However, Wagar conceded, the state can’t quantify the number of dumping cases because citations are not computer-searchable by the type of violation. The only way to get an accurate count would be to examine the files of each nursing home, he said, adding that there is no easy way to find out how often dumping happens.
Cheryl Wilson, who directs the St. Louis ombudsman service, said the issue keeps her team running in circles, leaving little time to attend to other advocacy duties.
Who pays the bill?
Recently, McCormick said, a nursing facility told a hospital that a patient could not return because her cost of care was higher than the state Medicaid rate. And the nursing home’s staff complained that it had too many of these types of residents already.
“That’s discrimination,” McCormick said. In this case, the facility administrators were still required to take the patient back. After doing so, they gave her the 30-day eviction notice, she said.
Nursing-home representatives argue that if they took every difficult low-income case, they would go broke.
Sheronda Brown, director of marketing at Northview Village nursing home in St. Louis, said the state pays the facility — Missouri’s largest nursing home, with 310 beds — $132 a day for a Medicaid patient. The certified nursing assistants, who do most of the grunt work, are paid minimum wage.
“They will cite us for not taking these patients, when we will be losing money if we take them,” Brown said. “We do it sometimes because we care. I tell people, ‘Don’t rush to judge the city nursing homes.’”
Mental Health Spill
Besides struggling with tight Medicaid budgets — a situation that has been worsened by the recession—both the ombudsman program and nursing homes are burdened with the surge in mental-health patients.
Missouri’s mental-health budget is dwindling every year. With psychiatric facilities closing, patients are now moving into nursing homes, ombudsman director Wilson said.
This year, lawmakers severely slashed funds for the state’s two remaining psychiatric emergency rooms, as well as long-term care for the mentally ill and home care for elders.
Brown said Northview has felt both the cuts and the resulting increase in patients with psychiatric problems. Now the facility is planning to add a floor that will be a “key-entry” floor to meet these special needs. However, Northview does not get more money from the state to care for these patients, even though their care is more intensive, Brown said.
McCormick said the most common kind of dumping is when nursing homes refuse to take patients back because of behavioral issues. In these cases, nursing facilities usually send the residents to hospitals with behavior units to get assessed or have their medications regulated.
Adverse reactions to prescription drugs frequently aggravate an elder’s behavioral or mental problems.
When the hospital has stabilized the patients’ condition, the nursing homes will refuse to readmit them. Facilities say they would rather be cited by the state than take the resident back, Wilson said.
Brown said that when Northview can’t manage certain residents, administrators send them to the hospital.
“Our goal is to stay compliant with the state,” Brown insisted. “The ombudsman office doesn’t understand that. We are not going to risk other residents getting hurt. That’s our responsibility.”
Sometimes, she said, residents are hospitalized for mental health or dementia treatment after becoming violent. When that happens, a nursing home cannot allow that patient to return, for the safety of the facility’s staff and other residents.
Brown explained that no 30-day notice is needed when a resident is violent and the hospital must help them or find another facility. When hospitalization is not involved, under Missouri regulations, a nursing home can make an “emergency discharge,” if the violent resident presents a danger to others.
Some people come out of prison and go straight into nursing homes, Wilson said. Nursing homes are allowed to conduct background checks on new patients, but many balk at doing so because of the added expense.
Nursing homes can reject prospective residents. But sometimes employees don’t realize they have a sexual offender in their facility until a parole officer comes by six months later, she said. The homes can’t issue a dismissal at that point because the 30-day trial period for new patients has passed.
Resolutions and Solutions
Helping a dumped patient usually starts when a hospital social worker asks the nursing-home administrator for confirmation that a patient was given due notice, said Christian Hospital’s Tucker.
Tucker said she was surprised by how many administrators are not aware that a patient must get 30 days notice before being evicted. Generally, dumped patients return to the nursing home while she works with the administrator to find them another place to stay.
Fortunately, Tucker said, few nursing homes in her area are repeat offenders because they must deal with the hospital regularly.
Patients who are wards of the state are among the prime candidates for getting dumped, Tucker said. These elders usually have no family members and often have legal guardians appointed by the state. Guardians in Missouri are typically attorneys. When residents go to a hospital, their guardians should be notified but rarely are, Tucker said.
What’s worse, the patients are not informed that of their right to the 30-day eviction notice, she added.
In the end, Tucker said the responsibility lies with the state. “I feel the solution comes from more effective supervision from the Department of Health and Senior Services,” Tucker said. “I understand they have a lack of staffing and case managers. But a lot of facilities are not being monitored as often and effectively as we would like.”
This is the first of three articles on African-American elders in St. Louis. The series was developed through a fellowship with the New America Media Ethnic Elders program, sponsored by the The Atlantic Philanthropies.