Nursing Home Evictions: What this could mean for OT

Nursing Home Evictions: What this could mean for OT

Recently NPR ran a story discussing evictions from nursing homes and that this is causing patients to have costly hospital stays. The story focuses on one individual, Bruce Anderson, who began living in a nursing home after he suffered a brain injury due to oxygen loss during a heart attack. He had lived in a California nursing home until he was hospitalized for pneumonia. After his hospitalization, the nursing home told Anderson’s family that he would not be allowed to return to his home this has led to Anderson living in the hospital for 9 months. To read or listen to the original story follow this link: http://www.npr.org/sections/health-shots/2016/02/25/467958665/nursing-home-evictions-strand-the-disabled-in-costly-hospitals

The Issue

There are federal laws in place that are supposed to protect nursing home residence from being forcibly removed from their homes and placed into hospital care; this includes refusing to allow patients back into their home after a short hospitalization. Unfortunately these laws are not being enforced; there are no measures in place that will penalize these actions. Even when the state of California ruled that Anderson needed to be allowed back into his home, the nursing home did nothing.  This is an issue not only for individuals and their families but taxpayers as well, who are going to be responsible for covering the much more expensive cost of a long hospital stay rather than a nursing home.

System that should address the issue

The federal laws that have been put in place are not being enforced at the state level, this means it is necessary for federal enforcement of the laws. The Department of Health and Human Services Office of Civil rights is responsible for enforcing items such as HIPPA, and discrimination violations and this issue should be treated similarly.  The elderly and disabled are an at risk population and if laws are not being upheld at a state level, laws must be created instituting a penalty that will be enforced by the Office of Civil rights.  

It is also important to note that one potential reason to evict a client is to replace a client who requires a great deal of time in terms of care and services with an individual who requires less time and services and is therefore a more lucrative client; nursing homes may also be turning out Medicare and Medicaid clients, who bring in less money, in hopes of filling that space with someone who will be using private insurance and bringing in more money. This is discrimination based on a disorder or socioeconomic status and it is within the scope of DHHS to step in.  

How can we support the creation of this policy?

Data needs to be collected in order to determine exactly how frequent this occurrence is, according to NPR there are between 8,000 and 9,000 patients that make this complaint annually. It will then be important to look at the costs that were created as a direct result of the eviction through long-term hospitalizations compared to what would have been spent in skilled nursing.  It is also important to look at the quality of life of these individuals who are being displaced from their homes.

Implications for OT

Evicting individuals from a nursing home may be completely barring them from receiving appropriate OT services. In the NPR article the focus was on Bruce Anderson; using this example of an individual who suffered an anoxic brain injury four years prior, this patient will not be appropriate for receiving OT in a hospital setting where the goal is to have an individual medically stable and prepared to transfer into their homes. In a hospital setting the priority will be given to individuals who have a medical need for OT services, and Bruce will receive very little enrichment or stimulation. Little enrichment or opportunity for occupation means that Bruce will have very little opportunity to perform meaningful occupations, this can negatively affect his sense of self and his quality of life. The same would be true of other patients who is displaced and required to stay in the hospital unnecessarily. In addition to this, depending on the presentation of Bruce’s injury he could begin to lose the ability to perform movements or specific tasks because he spends so much time sedentary.

If Bruce does qualify for OT services in the hospital, the resources necessary for him to practice his activities of daily living may not be readily available or the setting may be so different that any of the skills learned will not carry over to his home outside of the hospital.  For the therapist, this would also mean working with a client who is medically stable and this could take time away from patients who are in need of more intensive therapies. For the OT this also means working with an individual who is very dissatisfied with their environment and living situation. If Bruce were in a nursing facility he would be able to receive enrichment and OT services that can help to increase his ability to be independent as well as offering some meaning and enjoyment to his daily life. Having these patients placed in more appropriate long-term care is also helpful for practitioners who can create a more appropriate treatment environment and will be better able to address the needs of their whole clientele.

Health Care Costs and Low Income Families

The Henry J. Kaiser Family Foundation recently published an article titled "Health Care Spending Among Low-Income Households with and without Medicaid" http://kff.org/medicaid/issue-brief/health-care-spending-among-low-income-households-with-and-without-medicaid/ This article takes a look at the amount of the total household income spent on medical costs. The affordable Health Care Act made it so that families are covered by Medicaid so long as they are at or below 138% of the federal poverty level, according to the article that means an income of $27,310 for a family of 3 in 2014.   For families that have an income this low, the priority for spending is on food and if the family does not qualify for Medicaid they may not be able to afford other kinds of health coverage.   The article looked at the differences in spending habits between families that have Medicaid benefits vs families that do not have Medicaid benefits. I have inserted the pie chart of their findings below 

The issue: In looking at this data you can see that low income individuals such as those who are on a fixed income or receive social security and those who are unemployed or single income families have to make decisions about how their money is spent. When the health care spending increases, there is less money that can be spent on food and housing. This also means that these families are probably prioritizing their medical spending on things that are medically necessary. The researchers also suggest that individuals that have no health coverage are more likely to postpone receiving health care as well as going without care because of costs, this could be incredibly detrimental to young children who are in need of early interventions because this could slow their entire developmental trajectory.

How can we fix this issue: Changes need to be made at a nationwide level affecting policy. Expanding the individuals who receive healthcare coverage for free or at a lower cost can lead to a decrease in medical spending by the family, ensuring that there is money for food and housing  as well as ensuring that there is money for interventions that are not only medically necessary but interventions that may improve their quality of life or improve everyday functioning such as Occupational Therapy.

In order to prove that this works there should be research done to see how the spending habits of families change after they receive health care, data can also be collected regarding the types of care individuals receive and the amount of preventative care that they receive as well as how long they go without care. While this data has been collected in a number of studies, as Medicare is expanded this information could be taken using the same families.

What does this mean for OT: Occupational Therapy is not always considered to be "necessary" this means  that this could be one of the services that families elect to go without when they are unable to pay. Expanding Medicare could expand the availability of Occupational Therapy. This also means that without Medicare coverage Occupational Therapy could be out of reach for many individuals who have low income.