The room closing in: Part 5, An economic kiss of death

February 27, 2017 | Adulthood, Aging, Apartments, Assisted living, charity, Elderly, Housing, independence, Innovation, Nursing homes, Regulation, Technology, US News | No comments 19 views

[Continued from the preceding Part 1, Part 2, Part 3, and Part 4.]


By: David A. Smith


He started to rise, then sank, back in the chair again. It was no dice. Just talking to someone or looking in on the place wasn’t being there.

– Clifford D. Simak, Huddling Place, 1952


Ever since I was a little boy, I’ve had a fear of nursing homes. 


Calling it a ‘convalescent hospital’ doesn’t really change what it is


Evolution has wired us to delight in and protect the young and to fear and shun the extremely old:


Sacramento Bee (June 13, 2015), pickle font

Sources used in this post


Marblehead Messenger, January 10, 2013 (brown font)

Boston Globe, May 19, 2014 (Forest green font)

Sacramento Bee, June 13, 2015, (midnight font)

New York Times, January 27, 2017

The history of nursing homes, Foundation Aiding the Elderly, pdf, brick red font)


While hospitals were certainly a place to avoid, a boy goes to the hospital to get fixed, either from illness or injury, and he expects to emerge from it good as new.  In Marblehead, that was the Mary Alley Hospital, which on nostalgic impulse I have just looked up, discovering that like our previously profiled General Sternberg, Mary Alley was a Reconstruction/ Gilded Age progressive:


During the Civil War, Mary Alley formed a Soldiers Aid Society with Mary Graves. Their object was to perform work for the comfort of the soldiers, and to collect clothing, medicine and ‘delicacies’ for use in Union hospitals. They raised $500 in the first week, a large sum of money in 1862. Additional money came from Marblehead teachers, who pledged 6% of their annual salaries.


Town benefactress. Mary A. Alley


[When Mary Alley died in 1904], in her will she donated her land and house at 6 Franklin Street to the Town, along with a $30,000 endowment, to be converted int4o a hospital when her family members no longer needed it.  That happened in 1920, the same year the 19th Amendment gave women the vote, and in 1922 the hospital opened.  This was the first and only hospital in Marblehead.  The building was remodeled in 1953 [The year I was born – Ed.] and finally closed in the mid-1960s.


Whereas one left a hospital healthy again, and that was always a happy day, a nursing home was a place that one’s elderly relative entered and never left – and we who were younger would go to visit, be at loose ends, and leave saddened.  These complicated and in many ways unworthy feelings arise even in good nursing homes – what about bad ones?


We need redress – but can we get it?



5. Redress


A valuable right back when postage was ten cents


Even before the updated regulations, regulators always have a nuclear option – they can shut down a facility entirely, or cut off all its Medicare/ Medicaid funding:


Between October and January, three of Shlomo Rechnitz’s facilities, including South Pasadena, were decertified by the federal government, an economic kiss of death that is extremely rare. The punishment strips a nursing home of its crucial Medicare funding until it can demonstrate improvement, or is closed or sold.


Since 2010, the federal Centers for Medicare and Medicaid Services has decertified only six out of more than 1,200 nursing homes in California.


Short of the nuclear option, the Federal government does little except have each facility rated and publish the ratings:


Overall, those aren’t good scores


Yet ratings, helpful though they are, merely guide the choice before one moves in.  After the loved one is admitted, what can you do about neglect or abuse?  This being America, you can sue … or can you?


One major change, a ban on the binding arbitration agreements that nursing homes frequently require at admission — before any dispute arises — has already stalled.


Giving residents and families the right to take nursing homes to court could bring far-reaching results, Ms. Grant said.   Arbitration proceedings typically remain confidential, and monetary awards can be modest.


True enough, but if litigation can be filed, that can lead to class-action litigation, which creates its own potential for abuse:


The American Health Care Association, which represents most for-profit nursing homes — 70% of nursing homes in the United States are for-profit — filed suit to stop the change. In November, a federal court in Mississippi granted a preliminary injunction.


Even without the nuclear option, fines and charges can easily drive a nursing home operator out of business, whether that operator is private or a public agency, and when a nursing home closes entirely, that’s a loss of inventory:


Mr. Rechnitz, looking pensive and sad at the thought of being unfairly driven out of business


Shlomo Rechnitz explained that his business model is to rescue failing facilities and turn them around. Of his 81 nursing homes, he said, 59 were considered “distressed” when he acquired them, meaning that they were insolvent or on the verge of decertification or closure for poor performance.


Is Mr. Rechnitz a double-bottom-line social entrepreneur?


Officials in San Mateo County, for instance, credit Rechnitz with preserving nearly 300 needed beds and dozens of jobs when he took over management of the Burlingame Long Term Care facility in 2012.  Formerly operated by the county, the facility had been headed for closure because of financial problems and concerns about the building’s age and safety.


Likewise, Mr. Rechnitz has improved another private nursing home:


A Rechnitz success story: Fullerton


When Rechnitz took over the Fullerton facility, it was in deep trouble – only one of California’s roughly 1,200 nursing homes had more serious violations in 2013. Under EmpRes’ control, a survey in October 2013 resulted in 52 health-related deficiencies, eight of them so serious that residents were harmed or deemed in immediate jeopardy.


When inspectors visited the facility for a survey again in December 2014, after Rechnitz had taken over, they found 17 health violations, none of them serious.


“It was a horrible facility,” said Rechnitz. “That thing was going to be shut down. We met with the health department and (they) said, ‘Shlomo, go in and do what you can do. Try to fix it.’ And we went in and, in fact, we did fix it.”


Social entrepreneur, or a smooth-talking mediagenic serial acquisition-predator?  Though the Sacramento Bee (June 13, 2015, midnight font) published a long and well-researched article on the subject, the writers could come to no conclusion, and nor could I.


Sacramento Bee series on nursing homes in California


Shlomo Rechnitz vs. California: Key documents

Nine stories from Rechnitz’s California nursing homes

Help for consumers: How to research California nursing homes

Unmasked: See who owns every California nursing home and how those homes stack up

Part 1: How California’s largest nursing home chains perform

Part 2: Who owns California’s nursing homes?

Part 3: California falls short in disclosing nursing-home ownership


The end game: what supplants the nursing home?


AHI multi-part posts on unusual emerging housing tenures


April 16, 2007: Mobile homes: how they got here (5 parts)

May 18, 2009: Outlaw in-laws (accessory dwelling units, 2 parts)

July 22, 2011: Campus of the university of independence (veterans housing’, 2 parts)

June 27, 2013: NORCs like us (mobile home parks as elderly housing; 6 parts)

January 6, 2016: Sprouting innovation (co-living; 3 parts)

February 9, 2016: The hipster’s mobile home (tiny houses; 6 parts)

September 28, 2016: Ask after me tomorrow (funeral homes; 8 parts)



Wars stimulate housing innovation because they displace vast numbers of people: soldiers fighting far from home, and civilians whose homes are disrupted or destroyed by the war’s passage. 


Surgical kit, Civil War


When the war ends, as thankfully they eventually do, those displaced by the call to arms or the effect of arms return to what they remembered as home, only to find that both it and they have changed:


Union hospital, Civil War


1.     The Civil War gave us the hospital; its ending brought the funeral home.

2.     World War I’s end saw the rise of urban social-reformer public housing.

3.     After World War II came the mobile home and the convalescent home that became the nursing home.

4.     The wars in Kuwait and Iraq are bringing us new supportive housing and veterans’ housing.


Each type of housing is specialized, and most of the innovations are most sophisticated, more technological, and more able to extend our lifespan and expand our mental frontiers even as they cater to our extended frailty. 


He shut his eyes and fought down the chill that crept across his body. He couldn’t let it get him now, he told himself. He had to stick it out.

– Clifford D. Simak, Huddling Place, 1952


Today’s nursing homes are a business model designed in the 1950s and obsolete by the 1980s, yet kept on financial life support by $155 billion annually in Medicare/ Medicaid payments. 


Who’s going to be in charge of my future?


Though the new regulations are a major improvement, the industry needs not better regulation but a comprehensive reinvention.


The younger you feel, the longer you live

The room closing in: Part 4, Close down rather than face violations

February 24, 2017 | Adulthood, Aging, Apartments, Assisted living, charity, Elderly, Homes, Housing, independence, Innovation, Nursing homes, Regulation, Technology, US News | No comments 25 views

By: David A. Smith

[Continued from the preceding Part 1, Part 2, and Part 3.]

So far in this post looking at the first update to nursing home regulations in a quarter of a century I’ve covered three of the five big principles of consumer protection – freedom, choice, and security.

Here was another huddling place. Not a huddling place for one’s body, but one’s mind. A psychological campfire that still held a man within the circle of its light.

– Clifford D. Simak, Huddling Place, 1952

That leaves two more: quality and redress.

Is anybody home?


4. Quality


Markets are premised that we can get quality for our money when we have choice and the mental capacity to use it, and markets work for Lockean independent adults.


“All mankind being all equal and independent, no one ought to harm another in his life, health, liberty, or possessions.”


Markets don’t work for impaired consumers: children (who lack judgment), the cognitively impaired (whether by misfortune, booze, or drugs), and the elderly, who lose faculties slowly and randomly.  All of these groups are expected to be sheltered from predation:


·         Children are to be protected by their parents, and by lockout laws like the age of consent, drinking, or smoking.

·         The cognitively impaired are to be protected by trustees or custodianship.

·         The elderly are to be protected by their families (before 1946) or the government (increasingly, after 1946).


Importantly, protection of the weak or vulnerable works best when the guardian is both personally close to the vulnerable one and emotionally connected to him or her.  A government guardian is emotionally distant and cognitively schizophrenic (Alan Turing was unable to demonstrate that bureaucracies think, though his theorem that their simulated thinking could halt).


For ‘program’ read ‘bureaucracy’ and you will see why a general halting law is impossible


As our mental capacity wanes, we may be unable to complain – about either the nursing home or the government – which means that relying on the tenderness and mercy of the government is asking to be exploited.


Sources used in this post


Boston Globe, May 19, 2014 (Forest green font)

New York Times, January 27, 2017

The history of nursing homes, Foundation Aiding the Elderly, pdf, brick red font)


Elderly advocates understand this; they don’t trust the operator to do the right thing over the profitable thing, and they don’t trust the government to oversee with the attentiveness and concern one expects from loved ones (because the government doesn’t love anybody).


You’re really important to the government … aren’t you?


Hence the natural desire of advocates to mandate proxies for service, such as staffing levels.


[The new regulations] also declined:


1. To incorporate specific staff ratios or minimum hours of care in the new regulations, or

2. To require nursing homes to have registered nurses on site around the clock. (Current rules require RNs only for eight hours.)


Both such steps may improve service, but they certainly would decrease nursing home owner flexibility.


Instead, homes must develop assessments of their resources and residents’ needs and hire accordingly. 


And they would increase costs:


Federal regulators feared that some homes, particularly in rural areas, might find higher staff requirements unnecessary and impossible to reach, and close down rather than face violations and fines.


Seems entirely reasonable – especially as America’s urbanization is mainly mobility of the young, leaving behind the older and elderly, who have less ability to move and little if any desire to do so.


Advocates are fuming, however, because better staffing has been shown to improve quality of care. 


Obviously there will be a correlation between having more staff and having better care, but will it be cost-effective? 


Without standards, “it’s completely left to the nursing homes, and they’re not going to change because there’s no incentive to,” said Charlene Harrington, a longtime nursing home researcher at the University of California, San Francisco.


Harrington wants standards


“They can cut staff, keep their wages low and pocket the profits,” she said.


“From our perspective, it’s a mixed bag,” said Robyn Grant, public policy director at the National Consumer Voice for Quality Long-Term Care.


Translation of ‘mixed bag’: We didn’t get everything we wanted.


The regulations disappointed nursing associations and many advocates by declining to set minimum staffing standards.


I can see why advocates would want specified ratios – it’s a safe harbor against obvious operator neglect – but to lock a number into regulations is to freeze the standard of service to a current-technology model, and to substitute a proxy (people at the property) for the desired goal (quality service and resident self-actualization). 


AHI multi-part posts on unusual emerging housing tenures


April 16, 2007: Mobile homes: how they got here (5 parts)

May 18, 2009: Outlaw in-laws (accessory dwelling units, 2 parts)

June 27, 2013: NORCs like us (mobile home parks as elderly housing; 6 parts)

January 6, 2016: Sprouting innovation (co-living; 3 parts)

February 9, 2016: The hipster’s mobile home (tiny houses; 6 parts)

September 28, 2016: Ask after me tomorrow (funeral homes; 8 parts)


I can also see why others would object – it’s an irreversible increase in cost without compelling evidence of benefit.  Lacking evidence of domain knowledge myself, I can’t say for sure, but as the law of bureaucratic entropy states that regulation expands without limit and well beyond the point of cost-benefit utility, I am very much inclined not to regulate the process but only to regulate the outcome.


Good thing OSHA can’t see this


[Continued tomorrow in Part 5.]


The room closing in: Part 3, Once they’re out the door

February 23, 2017 | Adulthood, Aging, Apartments, Assisted living, charity, Elderly, Housing, independence, Innovation, Nursing homes, Regulation, Technology, US News | No comments 33 views


By: David A. Smith


[Continued from yesterday’s Part 2 and the preceding Part 1.]


A society of robots for humanity’s physical needs, dogs for our emotional ones


He stayed close to the wall to keep out of people’s way, headed for a chair in one corner. He sat down and huddled back, forcing his body deep into the cushions, watching the milling humanity.  Strangers-every one of them. Not a face he knew. People going places. Heading out. Anxious to be off. Worried about last details. Rushing here and there.

– Clifford D. Simak, Huddling Place, 1952


As we’ve seen in the preceding two parts, the older one gets, the less one wants to travel physically, and the more one wants to remain alert and active mentally, but safe and secure and in a familiar environment – a place, in fact, envisioned at least in spirit by Clifford D. Simak, whose haunting novel City imagines a future in which humanity has ceded control over its physical environment to perfectly protective robots, and of its emotional environment to the faithful dogs.


The doctor’s simulacrum will see you now


As technology revolutionizes how we age and how we live the extra decades technology is giving us, it is time to reinvent what we mistakenly call the nursing home around five core elements that arise as themes within these updated regulations: freedom, choice, security, quality, and redress. 

Sources used in this post


New York Times, January 27, 2017

The history of nursing homes, Foundation Aiding the Elderly, pdf, brick red font)



1. Freedom


Even if a person is impaired, dependency in one aspect of daily living shouldn’t invalidate the resident’s right to freedom and independence in other things, such as who she sees:


1.A. Residents deserve freedom to host whom they want, when they want


Those of us who live independently take for granted that we can admit into our home anyone we choose, at any time of day or night, for any purpose that doesn’t violate the law or ruin the neighbors’ quiet enjoyment.  In a hospital, that notion of privacy is one of the first rights we lose, as people come and go at all hours, with lights and sounds and traffic in the corridor.


It’s out there, it’s loud, and I’m afraid of it


The regulations strengthen residents’ control over certain decisions important to their daily lives. For example, the rules allow people to receive any visitor they choose (not just relatives) whenever they choose, without restricted hours, as long as visitors don’t disturb other residents.


That change is also important because twenty-first century relationships come in many more varieties than they did a quarter-century ago.  Even as gay relationships have normalized, the nuclear family has undergone household fission.


Nuclear era, nuclear family


Just having family members around in the evening, when homes have fewer staff members, might improve attention and care, Dr. Castle pointed out.


We’re all so cool our kids fold their arms to show their self-satisfaction


Likewise, with ubiquitous cell phones, broadband, and increasingly cheap and high-quality videoconferencing, strong and meaningful friendships can be formed between people who live far away from each other – and with Facebook and similar social-media networks, people can find good friends they lost decades earlier. 


2. Choice


A toast to the choice of power relationships


Choice is an illusion, created between those with power and those without.

The Merovingian, The Matrix Reloaded


When you take away my choice, I lose some of my humanity, so as long as I can choose, I should be able to choose – and among the most fundamental rights of being at home is choosing with whom one is at home.


2.A Choice of roommate


The requirements also allow residents to choose their roommates when both parties agree, making it easier for friends, siblings or same-sex couples to share living quarters.


It’s a measure of my naivete that I didn’t know nursing home residents could have a roommate foisted upon them without their consent.  Thank goodness this was added.



2.B Choice of schedule


I choose to like olives … what do you choose?


Adults choose when and what they eat; those whose meals are chosen for them, we call children.


You’re violating my autonomy!


The regulations require facilities to make meals and snacks available when residents want to eat, not only at predetermined mealtimes.


Again my ignorance is showing; I’d never given thought to when and how residents in a nursing home should be able to eat, but certainly few thing are more frustrating, even humiliating, than being hungry or thirsty while unable to provide for oneself. 


3. Security


Among the core benefits of home (whether ownership or rental) is physical security, for ourselves, our possessions, and our loved ones.  Patients don’t have such rights; residents do.

AHI multi-part posts on unusual emerging housing tenures


April 16, 2007: Mobile homes: how they got here (5 parts)

May 18, 2009: Outlaw in-laws (accessory dwelling units, 2 parts)

June 27, 2013: NORCs like us (mobile home parks as elderly housing; 6 parts)

January 6, 2016: Sprouting innovation (co-living; 3 parts)

February 9, 2016: The hipster’s mobile home (tiny houses; 6 parts)

September 28, 2016: Ask after me tomorrow (funeral homes; 8 parts)


Indeed, unless the regulatory changes merely codify what has already become standard in the industry, then nursing homes must be dismal places where residents have little security over the most basic decencies of life.


3.A. Security from contagion through carelessness


The rule requires a nursing home to designate an infection-control officer and to establish a system to monitor antibiotic use.


3.B. Security of personal possessions


For the first time, nursing homes must take “reasonable care” of residents’ personal belongings and can’t shrug off responsibility for theft or loss by requiring residents to sign waivers. “That’s been a big complaint,” Ms. Grant said.


That such basics of proper accommodation weren’t required is further evidence nursing home regulations were horribly out of date.


I mean, horribly out of date


Times author Mr. Span adds this poignant note:


Moving into a nursing home already requires giving up so many possessions that “losing something can be devastating” — especially when eyeglasses, hearing aids or dentures go missing.


While some people in a nursing home will have all their faculties intact, some – perhaps many – will not, and I’ve experienced at first hand that when someone’s mind goes, he or she can no longer distinguish one door from another, one pair of glasses, one hearing aid. 


3.C. Security from abuse


Worse, demented patients are emotionally fragile, and for those who take care of them, few things are more upsetting than being shrieked at by an incoherent, undersized, and yet furiously aggressive oldster. 


The regulations call for expanded staff training in preventing elder abuse and in caring for patients with dementia. Dr. Phillips calls the latter critically important; most residents have moderate or severe dementia, Medicare statistics show.


Just as parents lose patience with their children, it’s easy enough to understand staff losing patients with their residents – but it’s still wrong, and it’s still elder abuse.


There’s one more bit of insecurity:


I mean, the worst


3.D. Security of tenure


This last element of insecurity is the worst:


Long-term-care ombudsmen report frequent complaints of “dumping”.


Too bad about Mildred, but somebody’s got to go


The existing regulations provide a lot of protection against being bounced from nursing homes.


But there is a loophole:


A nursing home sends a resident, often someone whose dementia causes problematic behavior, to a hospital. 


The ‘health care system’ (a misnomer as triply wrong as the Holy Roman Empire) functions as an assembly line operating in the dark, staffed by workers with attention deficit disorder and neuromuscular decay, and overseen by an addled bureaucracy.


After she is discharged, the home won’t readmit her.


Yes, you’re located somewhere in the system


“Once they’re out the door, it’s a lot easier to just evict someone,” Ms. Grant said.


It certainly is, and it has all the earmarks of corner-cutting shenanigans.


The new rule extends those protections to someone who’s been hospitalized but intends to return.


“That resident has all the rights that go with discharge and can appeal the decision.”  Nor can the facility transfer the resident while she is appealing.


Thank goodness – though of course, residents whose faculties are dimming will need their relatives to defend them as energetically as if in a case of mistaken identity, grandma had been taken into protective custody by the inept constabulary of Information Retrieval.


Whoever she is, she’s never getting out


[Continued tomorrow in Part 4.]

The room closing in: Part 2, Halfway between society and the cemetery

February 22, 2017 | Adulthood, Aging, Apartments, Assisted living, charity, Elderly, Housing, independence, Innovation, Nursing homes, Regulation, Technology, US News | No comments 30 views

By: David A. Smith


[Continued from yesterday’s Part 1.]


Slowly he turned away from the railing and headed for the administration building. And for one brain-wrenching moment he felt a sudden fear-an unreasonable and embarrassing fear of that stretch of concrete that formed the ramp. A fear that left him shaking mentally as he drove his feet towards the waiting door.

– Clifford D. Simak, Huddling Place, 1952


In yesterday’s Part 1 of what has expanded into a five-part post (that has taken me a couple of weeks to read enough to fill in the chasm of my ignorance on the topic), we discovered that new regulations covering Medicare/ Medicaid-reimbursed nursing homes (nearly all of them) are the first updates in a quarter of a century.


It was so long ago he wasn’t married to a Czech


Sources used in this post


New York Times, January 27, 2017

The history of nursing homes, Foundation Aiding the Elderly, pdf, brick red font)


And that fact sent me back into the Google-archives to discover that like funeral homes, about which I posted at length, nursing homes are a residential modality from a time before – pioneered in Post-WW2 urban diaspora where the automobile enabled substantially greater inter-generational mobility, and as the Boomers’ parents fled the city for the suburbs, they left their elderly behind, giving rise in 1946 to the enactment of the Hill-Burton Medical Facilities Survey and Construction Act.



AHI multi-part posts on unusual emerging housing tenures


April 16, 2007: Mobile homes: how they got here (5 parts)

May 18, 2009: Outlaw in-laws (accessory dwelling units, 2 parts)

June 27, 2013: NORCs like us (mobile home parks as elderly housing; 6 parts)

January 6, 2016: Sprouting innovation (co-living; 3 parts)

February 9, 2016: The hipster’s mobile home (tiny houses; 6 parts)

September 28, 2016: Ask after me tomorrow (funeral homes; 8 parts)


“The most comprehensive hospital and public health construction program ever undertaken,” Hill-Burton authorized the creation of ‘health centers and mandated that states develop plans for creating enough beds to provide a continuum of care (I am paraphrasing into modern terminology). 


The impetus for Hill-Burton


By 1954 the regulated nursing home had emerged as an asset class, one that got a huge boost with the next game-changer, a part of LBJ’s Great Society:


Bringing America up from rural poverty, one handshake at a time: Appalachia, 1964


In 1965, the passage of Medicare and Medicaid provided additional impetus to the growth of the nursing-home industry, which, while it had been increasingly steadily since the passage of Social Security, grew dramatically. Between 1960 and 1976, the number of nursing homes grew by 140%, nursing-home beds increased by 302%, and the revenues received by the industry rose 2,000%.


Twenty-fold revenue growth is an explosion.  Medicare/ Medicaid, created the nursing home business out of nothing, and that business needed new facilities that were neither hospital nor apartment (as evidenced by the curious concatenation of calling the place a ‘home’ but its residents ‘patients’), and the results was a building boom:


To a great extent, this growth was stimulated by private industry. By 1979, despite the ability of government homes to provide care, 79% of all institutionalized elderly persons resided in commercially run homes.


Booms often lead to excess – especially when, as here, the customers lack either choice (shortage of nursing home beds) or the capacity to make better choices (because they’re failing and the government is paying):


What you could look forward to: Foothill Acres Nursing Home, Neshanic, NJ, 1965


According to investigations of the industry in the 1970s, many of these institutions provided substandard care. Lacking the required medical care, food, and attendants, they were labeled “warehouses” for the old and “junkyards” for the dying by numerous critics. The majority of them, proclaimed Representative David Pryor in his attempt to initiate legislative reform in 1970, were “halfway houses between society and the cemetery” (Butler, p. 263). 


Note desk plate: Arkansas Comes First


And, like the almshouses of old, people feared ending their days in the wards of these institutions and relatives felt guilty for abandoning their elders to nursing-home care.


Though the full history of nursing homes is a topic for another future investigative post when I find the right starting material (which might be this, but first I have to read it), in the 1980s nursing homes went through a consolidation (likely paralleling the consolidation of hospitals) as they became vassals of Medicare and Medicaid, and shortly thereafter, HHS issued the regulations that now, a quarter of a century later, have finally been updated.


The regulatory update was absurdly overdue.


In the last quarter century alone, American life expectancy has lengthened two or three years.  Hundreds of new life-extending pharmaceuticals have been invented.  The Web has revolutionized remote monitoring:


Cybex-Humac, 1981: it looked cool at the time


Microsurgery has become commonplace.  And I’m sure that I’m overlooking scores more innovations.


What the heck are those buttons, anyhow?


Medicare/ Medicaid have continued to expand, now consuming 23% of the Federal budget versus roughly 12% in 1992.



An ever-bigger bite


Along the way, nursing homes have become a $155 billion industry, housing over 1,400,000 very elderly people whose arc of independence has fallen and continues to decline. 


[The revised rules] emerged from a four-year process involving many meetings and almost 10,000 comments from interested parties.


Amending Federal regulations is a process that itself is governed by a statute – the Administrative Procedures Act – and its regulations, and as you might expect the APA emphasizes public hearing, public comment (both verbal and written), and structured written responses to comments.  Further, when Medicare/ Medicaid pay a nursing home owner/ operator, the regulations have to protect two constituency who are not present to protect themselves:


1.     The nursing home residents (whom the industry insists on calling “patients,” a term that is itself demeaning with its overtones of dependency and illness).

2.     Taxpayers, who are ultimately writing the checks.


In view of the billions at stake and the helplessness of both nursing home residents and taxpayers to [protect themselves against nursing home abuse, four years from initial overhaul notice to their new effective date seems if not speedy then at least reasonable.


Will the new requirements help improve care for the country’s 1.4 million nursing home residents? 


Age is not an illness, though the medical system treats it like one.


“Overall, we are really pleased with the focus on person-centered care, trying to transform the nursing home environment,” said Dr. Cheryl Phillips, head of public policy for LeadingAge.


Nursing homes should be homes before they are anything else, including nursing stations, and there should be oriented around five great principles of effective markets: freedom, choice, security, quality, and redress. 


[Continued tomorrow in Part 3.]

The room closing in: Part 1, The first updates since 1991

February 21, 2017 | Adulthood, Aging, Apartments, Assisted living, charity, Elderly, Housing, independence, Innovation, Nursing homes, Regulation, Technology, US News | No comments 36 views


By: David A. Smith


We say we fear death, but really we fear not death itself but its harbingers: pain of course, but even more than pain we fear helplessness, because in losing our independence we lose our adulthood.


Webster stiffened, felt chill fear gripping at his heart. Hands groping for the edge of the desk, he sat down in the chair, sensed the walls of the room closing in about him, a trap that would never let him go.

– Clifford D. Simak, Huddling Place, 1952


The worst of both ends: infantilized and decrepit


The independence of our lives is a broad arc with adulthood at its apex.  Born small, clueless, and helpless, we depend on our parents, and our childhood, adolescence, and young adulthood are all about prying ourselves free of parental dictation (if not from parental financial largesse).  Before us stretches adulthood, a heady time indeed, and as the years roll into decades and we accumulate partners, homes, children, careers we see our life as a purely upward path, an arc without a downward bend no matter what the optometrist, scales, and unforgiving mirrors say.



Sources used in this post


New York Times, January 27, 2017

The history of nursing homes, Foundation Aiding the Elderly, pdf, brick red font)


As we age, we unwillingly and randomly give back the faculties that we so proudly gained in growing up, and as we do, we lose the capacity for independence.  That loss is reflected in our shifting housing accommodations: from the homestead house (shovel your own parking space and sidewalk) to the condo (call the superintendent), to live with our children (in accessory dwelling units or customized tech-centric wings), to congregate living (dine together, socialize together), to assisted living (help with activities of daily life), to a nursing home. 



AHI multi-part posts on unusual emerging housing tenures


April 16, 2007: Mobile homes: how they got here (5 parts)

May 18, 2009: Outlaw in-laws (accessory dwelling units, 2 parts)

June 27, 2013: NORCs like us (mobile home parks as elderly housing; 6 parts)

January 6, 2016: Sprouting innovation (co-living; 3 parts)

February 9, 2016: The hipster’s mobile home (tiny houses; 6 parts)

September 28, 2016: Ask after me tomorrow (funeral homes; 8 parts)



Few of us take all these steps. Some of us tarry longer on some of them.  Some of us skip a step or two.  Many of us step off the staircase before we reach that a bottom riser.  And each step we take with great reluctance, but each step down costs us a bit of our autonomy – a little or a lot – which we trade for more service – a little or a lot – being provided to us by others, using the money we have accumulated in our lives to buy the services that we no longer wish to do ourselves or no longer can do for ourselves.


Just as our physical and spiritual independence is an arc that flattens and then declines, so too is our financial independence another arc, and depending on how much we made and how we age, it becomes a race to between them.  As our independence withers away, we would like to be protected by our spouse or our children – but many of us will lose a spouse, not all of us have children, and some of us cannot rely on our children. 


And will my teeth be serpent-sharp?


Where the family does not provide, the market will – but the market’s motivations are seldom those of the family.  When we’re adult consumers we can navigate the market, because we have choice and capacity to choose, but as we age, our capacity diminishes, and with that diminishes our choice and our vigilance.  We become vulnerable to exploitation – what is worse, by those whom we previously entrusted to care for us, and in what we have chosen as our home, a place from which we cannot escape.


For that among many reasons, most of us think about nursing homes as places we wish not to have to go, and we wish our relatives not to have to go – and, as reported in the New York Times (27 January 2017) by Paula Span, who has been writing about ‘the new old age’ (as she calls it) for years, our instinctive and under-informed impression is probably just, possibly even generous:


Ms. Span and her father in 2011


If you had to give the nation’s nursing homes a letter grade for quality, what would it be?


Experts tend to sigh at this question –


Bloggers sigh at badly-opened newspaper articles


– and point out, correctly, that the country’s 15,600 facilities are vastly different — rural and urban, for-profit and nonprofit and government-run, home to the reasonably healthy and the extremely sick, high-quality operations and appalling ones. 


Assigning grades can be folly.


Sorry, Ms. Span, that last sentence is utter nonsense. 


Let’s not give nonsense a bad name, shall we?


We assign grades to everything, from school child performance to Airbnb accommodations.  Of course nursing homes should be graded, possibly on multiple dimensions.


When prodded, they come up with decidedly middling assessments.


Not surprisingly, everyone talking to a reporter wants to hedge.


Dr. Cheryl Phillips, head of public policy for LeadingAge, which represents 2,200 nonprofit nursing homes: C-minus.


Offering the entire class a tepid C.


That C-minus is as revealing as a poker tell – Dr. Phillips thinks that nursing homes as a cohort are terrible, but she doesn’t want to be vilified for saying so.


Nicholas Castle, a health policy researcher at the University of Pittsburgh: B-minus.


Though Mr. Castle’s kinder, not so the next judge:


Robyn Grant, public policy director at the National Consumer Voice for Quality Long-Term Care [Not to be confused with Robyn Stone, SVP of Research at LeadingAge – Ed.], a leading advocacy group: No grade. 


In my long-ago school days, Incomplete was the most dread grade of all – it branded your failure so appallingly bad that your very attempt would be expunged from memory.  That is clearly how Ms. Grant intends her ‘no grade’:


“Far too many have a long way to go to give residents the quality of care and quality of life they deserve.”


Loss of capacity and loss of choice leads to loss of quality.  Who then protects us when we cannot protect ourselves? 

Enter the government, properly exercising its role as defender of those who need defense:


The Centers for Medicare and Medicaid Services [Confusingly, the acronym is CMS – Ed.] last fall issued a broad revision of nursing home regulations; the first batch took effect in late November, with the rest to be phased in this year and in 2019.


Readers may wonder where the Federal government gains statutory authority to regulate nursing homes, and the answer is simple: Medicare and Medicaid.  The regulations don’t cover every nursing home in America, it covers only those nursing homes that receive Medicare or Medicaid payments because they chose to admit Medicare or Medicaid residents – and that is by far the lion’s share of them:


Spending for freestanding nursing care facilities and continuing care retirement communities (CCRC’s) increased 2.7% in 2015 to $156.8 billion.


Yes, you read that correctly: between CCRC’s and nursing homes, housing the frail elderly consumes a sixth of a trillion dollars a year.


The slightly faster growth in 2015 (from 2.3% growth in 2014) was mainly due to the faster growth in Medicare spending of 5.6% versus 2.5% in 2014.


This seldom ends well


Medicare is rising because we Boomers are living longer (taking our gerontological revenge on every generation to follow us)


Financially, that is


They were long, long overdue:


“These are the first comprehensive updates to long-term care requirements since 1991,” said Dr. Kate Goodrich, the centers’ chief medical officer.


[Continued tomorrow in Part 2.]