My how things change. Just a month ago a healthcare reform bill seemed en route to passage. Now its very existence is in question and, by extension, some key long-term care services are too.

I have been reminded of the precarious state of reform as the therapy caps issue has resurfaced. The Medicare Part B caps, imposing a $1,860 limit on physical and speech therapy, and a $1,860 ceiling on occupational alone, took effect at the beginning of the year. Thousands of nursing home residents are at risk of bumping up against the caps.

This, of course, would not be the case if a bill passed. The healthcare reform bills contained provisions extending an exceptions process that exempted most skilled nursing residents from the limits.

Three senators stressed the need to delay the implementation of the caps in a letter this week to Department of Health and Human Services Secretary Kathleen Sebelius.

Sens. Blanche Lincoln (D-AR), Charles Grassley (R-IA) and John Ensign (R-NV) told the secretary they are concerned that enactment of the caps “is causing undue hardship on Medicare beneficiaries, particularly for those who are recovering from a stroke or a debilitating injury such as a hip or joint fracture.”

A “national provider” reported that more than 1,000 of its patients had hit the cap as of Feb. 1, and several more thousand could reach it by Feb. 28, according to the senators.

Of course, if nursing home residents exceed the caps, they could be forced to go to hospital outpatient settings, which are not subject to the cap. If that is not possible, nursing homes may have to pick up the tab. And the worst-case scenario: Residents would go without therapy.

This is troubling. It's also a reminder of the adage, don't count your chickens before they're hatched (or rehabbed, as the case may be).

That old saying certainly rings true in Washington today.

[Photo: Pinecrest residents and former caregivers Caroline "Dolla Crnich (left) and Hazel Rochon are participating in the walk for healthcare assistants.]

Administrators, don't be alarmed if you notice pedometers around your facilities. Starting today, more than 800 frontline caregivers and their supporters have started to log miles for “Stepping Up for Quality,” a fund-raiser sponsored by the National Association of Health Care Assistants.

This first-time event aims to raise awareness of the hard work of certified nursing aides—those long-term care workers who are often overlooked and underpaid. 

“We try to encourage [CNAs] to be advocates on behalf of their profession, but a lot of them don't have the opportunity,” Lesley Collins, NAHCA's director of strategic initiatives, and event coordinator, told me. “We empower them to speak on their behalf. This walk allows them to do that.”

The event is modeled after the American Cancer Society's Relay For Life, and similar fund-raisers. During the month-long walk-a-thon, participants are accepting pledges—either flat payments or per mile for what they walk while working. Walkers, who wear pedometers to track the number of miles they walk, include everyone from CNAs to their directors of nursing to friends outside of the facility. The money will go to the Academy of Certified Health Professionals, the nonprofit arm of NAHCA, to support educational opportunities for CNAs.

The event has generated excitement at facilities and communities around the country. Longtime CNA Deb Pitts of Pinecrest Medical Care Facility in Powers, MI, has signed up 159 people. Most are employees. About 75 are CNAs.

“There's been a lot of positive feedback,” said Pitts, who is an officer on the NAHCA National Steering Commission.

Facilities are using the walk-a-thon as an opportunity to promote wellness and other causes. The idea has prompted the administrator at Pinecrest to do an employee run for wellness, Pitts said. Employees at a facility in Galena, KS, are going to be hitting the walking track more often during the month of February.

Meanwhile, the Missouri Veterans Home in Warrensburg, MO, is walking for fallen heroes.

“Everyone's kind of put their own spin on it and have embraced it and made it theirs,” Collins said.

In some cases, even residents are “stepping up” for quality. Three examples are Caroline “Dolla” Crnich, Hazel Rochon and Daisy Smith. All are residents of Pinecrest—and former nurses and CNAs. Crnich and Rochon actually worked at Pinecrest.  

“I worked with them. Now I'm taking care of them, said Pitts, who has worked at the facility nearly 38 years.

That sounds like reason enough to put on those walking shoes.

It's not too late to walk or give money. Those wishing to participate or donate should visit http://www.nahcacares.org/sufq.htm.

[Photo by Talia Frenkel/American Red Cross]

They are not all touting their good works, but many long-term care communities and their vendors are providing valuable relief to disaster-stricken Haiti.

The organizations are great and small. Here are a few examples among many:

The Beth Abraham Family of Health Services in Bronx, NY, has donated $7,000 worth of supplies, such as gauze, bandages, canes, wound supplies, aspirin and non-perishable goods, according to Peter Fragale, senior vice president, chief human resources officer. Its linen service producer, Unitex, has donated about six palettes of linen supplies. Employees also have contributed box loads of non-perishable items, Fragale said.

The initiative began when the president sent an e-mail to employees at Beth Abraham, informing them the provider will provide as much help to the country and those affected in the organization as it can.

Besides the monetary and supply donations, the organization has acted on a personal level, Fragale said. He and Chief Operating Officer Clari Gilbert, who is from Haiti's neighbor the island of St. Vincent, toured each of the four nursing homes that make up the Beth Abraham Family and consoled their Haitian workers. The organization continued to pay the salaries of two workers who went to the battered nation to help. (See blog entry from Tuesday.)

Such an outpouring of support has overwhelmed the workers, Fragale said. Many posted the president's e-mail on doors and walls.

The effort reflects the spirit of the organization, Fragale said.

“We're a healthcare organization and that's what we do. We care about people,” he said.

Other good works

Here are other stories of charity in the long-term care field:

— Immediately after the earthquake, Jewish Home Lifecare/Sarah Neuman Center in Mamaroneck, NY, donated 300 mattresses to the AFYA Foundation, which obtains and ships vital supplies to support medical and surgical needs worldwide, said Harriet Rosenberg, director of Public Affairs and Media Relations for the organization. Trustees also have donated $5,000 to the American Jewish Joint Distribution Committee from the Fund for the Aged, she added. Jewish Home Lifecare has 3,561 employees. A sizeable number are Haitian, Rosenberg said.

Staff and tenants also are collecting donations. Social work staff members also are providing counseling to members.

— On a larger scale, the International Association of Homes and Services for the Ageing (IAHSA) is reaching out to Haiti through its partner HelpAge International (HAI).

“HAI is the only relief and development organization focused on the needs of older persons in developing countries and has had a presence in Haiti for eight years,” according to a member letter from IAHSA, an affiliate of the American Association of Homes and Services for the Aging.

— The Assisted Living Federation of America also has established a relief fund to provide financial support to Haitian employees of senior living companies.

The executive committee established the fund with a seed grant of $10,000 from the ALFA treasury.

“Senior living companies rely upon the professionalism and commitment of Haitian employees day in and day out,” said Richard Grimes, president and CEO of ALFA, in a statement. “This is the least we can do to relieve some of their anguish over the loss and suffering of their homeland.”

It's worth noting that Haitian staff across the country are continuing to come to work, despite not knowing the fate of their family members in Haiti. That is dedication.

A few charities offering relief to Haiti are mentioned above. See a list of other organizations accepting donations at AAHSA's “The Future of Aging” blog. 

Feel free to let McKnight's know about what you are doing to help your Haitian employees and the country of Haiti.

[Photo by Matthew Marek/American Red Cross]

Seeing the devastation in Haiti “was emotionally destroying for me,” said Ginette Sangosse, assistant director of nursing for the Beth Abraham Family of Health Services in Bronx, NY. Sangosse, who grew up in Haiti, returned last week to provide medical care.

The earthquake that rocked Haiti has also affected the U.S. nursing home community, which employs large numbers of Haitians. Two medical professionals from Beth Abraham, Sangosse and Dr. Yvonne Jean-Francois, recently traveled with Haitian organizations to help.

Sangosse, who has lived in the U.S. for more than 40 years, spent a week—from Saturday, Jan. 16, to Friday, Jan. 22—at the hospital in Port-au-Prince.

There in the capital city she witnessed “the complete destruction of the town I knew so well,” she told me.

Buildings had crumbled. She saw several dead bodies in the street.

“A lot of us could not stop crying and it was very hard,” said Sangosse, who traveled with the organization Association of Haitian Physicians Abroad.

The hospital where she worked the night shift was missing equipment, personnel and supplies. There were times when the staff worked in the dark, she said.

Working 16-to-18 hour days, she delivered babies, performed wound care services and delivered food and drinks. Nearly all of the patients were amputees “with big wounds and a lot of pain also,” she said.

“I had never seen things like that before because people were crying because they were in pain,” she explained. “They didn't know where their loved ones were.”

She came with 54 other nurses and doctors. They helped establish a post-op ward. When they arrived, there were not enough nurses to take care of the post-op patients and the wounded had just spent a night by themselves. 

More people were working outside the building, she said. Many of the patients, who had been evacuated, did not want to return to the hospital for fear of another earthquake.

Despite her sadness, she also felt proud how well patients behaved at the hospital. No one was looting, she said.

Now that she is back, “I am more depressed … because at least while I was there I was able to help,” said Sangosse, whose great-great aunt, 98, died during the disaster.

She plans to return soon to the area where she received her First Communion and where her mother's childhood house stood.

“Words cannot describe how I felt,” she said.

Stay tuned for more stories of outreach from the nursing home community to Haiti.

Larry Minnix sounded weary but determined. The CLASS Act may become a casualty of healthcare reform, but it is not going away, the head of the American Association of Homes and Services for the Aging assured me Wednesday.

Minnix, whose organization has become a leading backer of the legislation, suggested that the plan, which would provide a cash benefit to workers who become disabled, will live even if the current healthcare bill doesn't.

“We're not going away; we're just going to regroup,”  Minnix said by phone from Washington.

Democrats were dealt a major wallop Tuesday when Republican Scott Brown defeated Democrat Martha Coakley in a special election for the open Senate seat in Massachusetts. The outcome resulted in more than a loss of a seat. It has taken away the party's 60th vote to pass healthcare reform. It is not clear what, if any path, the party will take to pass its package.

If necessary, AAHSA will form a new CLASS Act-type plan with the 200-something organizations supporting it and lawmakers, Minnix said.

“We're not without advocate friends or friends in Congress,” he said. “We may go back and see what could be done on a more bipartisan basis.”

The problems that led to the proposal still need to be solved, he insisted.

“Long-term care has got to be funded differently and Medicaid has got to have some relief, and the CLASS Act does both,” Minnix said. 

It can't be easy for Minnix and the rest of his conscientious team to see their work of the last several years begin to smolder along with the rest of the hard-fought provisions for long-term care and healthcare.

But Minnix, with a hint of defeat in his voice, said the organization and partner organizations should be proud of what they accomplished. The provision made it into both bills and won the support of the president. 

“I don't know what else we would have done,” he said. “A year ago, no one would have given us a chance at getting it done. The thing I can't control is voters in Massachusetts.”

How right you are, Larry.

Silver lining?

Meanwhile, one long-term care expert is seeing the current crisis facing healthcare reform as a positive development for long-term care.

Steve Moses, president of the Center for Long-Term Care Reform, feels like the new setback for the legislation offers Congress a chance to establish a better long-range Medicaid plan for the field.

He recently published a document called  “Doing LTC Right” in conjunction with Rhode Island's Ocean State Policy Research Institute.

The report points out the major problems right now with Medicaid, such as the program's somewhat lax rules regarding financial eligibility. In a nutshell, according to the report, the program is losing money because people who have the means to pay for long-term care are using built-in exemptions to join the Medicaid rolls.   

The program also examines the benefits of Rhode Island's long-term care “global Medicaid waiver.” The waiver allows the state to provide more home- and community-based services in exchange for a five-year cap on federal funding.

Taking several steps could improve the waiver program and make Rhode Island a model for the rest of the country, the report says. These include targeting those who truly need Medicaid, expanding estate recovery, imposing more stringent rules on Medicaid eligibility, encouraging people to use long-term care insurance and other private means to pay for long-term care, and educating people about long-term care planning.

It is an interesting analysis. Those who are serious about finding answers to the long-term care and Medicaid problems would be wise to read it.

The buzz among long-term care providers today, as expected, is the upset in the Massachusetts Senate race. How healthcare reform will play out now is anyone's guess.

To say Tuesday's defeat of Republican Scott Brown over Democrat Martha Coakley has thrown a monkey wrench in the works of reformers is an understatement. A cannonball may be more like it. The Democrats have lost their crucial 60th vote, and therefore, their filibuster-proof majority.

Of course, the dramatic irony is that the new senator, who campaigned on blocking healthcare reform, is taking the seat formerly occupied by the liberal healthcare reform champion Sen. Edward Kennedy.

That the election may is a referendum on the president is arguable, but there is no question that it has jolted Congress about its plans for reform.

“Obviously, the election of Scott Brown brings more questions to the table as to how the administration and Democratic leadership will pursue healthcare reform,” said Susan Feeney, spokeswoman for the American Healthcare Association.

Commented Larry Minnix, president and CEO of the American Association of Homes and Services for the Aging: “I think it puts healthcare reform in a very tight place. There are major things in the bills that could help a lot and, in that respect, it certainly makes things difficult because we thought we were close to a bill. It's disappointing, but the needs and objectives are still the same. There's hope that something will get done.”

Minnix, whose organization has been leading the charge for the Community Living Assistance Services and Supports (CLASS) Act, is hoping that the House will adopt the Senate's version, for the sake of expediency.

Otherwise, it could be back to the drawing board for healthcare reform—and many major provisions, including the CLASS Act, a stronger Medicare commission, nursing education grants, an expansion of Medicaid, transparency requirements and millions of dollars in Medicare cuts. 

Meanwhile, among the thousands of pages of reform legislation is language extending the therapy caps exception process, which expired at the end of the year. Providers have been depending on passage of the bill to resolve this problem.

It appears they will have to wait some more.

A new phrase appears to be emerging in the lexicon of long-term care. That phrase is "long-term services and supports." (Notice the omission of the word “care.”)

The language has received widespread attention as a result of the healthcare reform provision known as the CLASS (Community Living Assistance Services and Supports) Act, which addresses some of the overlapping needs of the long-term care and disability communities. Advocates for the disabled are directly responsible for two key terms in the word CLASS: "services" and "supports."

“In the disability community, long-term care is synonymous with nursing homes,” explained Lauren Shaham, director of media relations with the American Association of Homes and Services for the Aging. “What they have been arguing is disabled people need supports to facilitate independence.”

The phrase now seems to be resonating with AAHSA and other advocacy groups. It certainly fits with the mission of AAHSA, which serves home- and community based care organizations, as well as nursing homes.

Aging people “still want the same kind of independence and choice that has been the mantra in the disability community for years,” Shaham noted.

The National Council on Aging also has taken to the term because it connotes a broader range of services for older adults.

“We don't just mean care,” said Jim Firman, president and chief executive of the council. “We mean services and supports.”

NCO is so serious about using the phrase that “long-term care” is now taboo there. Offenders have to pay a quarter when they use it as an incentive to break themselves of the habit, Firman said. 

The new terminology is important to unite the long-term care and disability communities, he believes. Firman remembers a few years ago when there would be three different bills from three different groups: seniors, long-term care and the disability communities.

“None of the groups realized they were talking about the same thing,” Firman said. “Language does matter in terms of uniting the consumer constituency around these issues.”

The terminology arguably reflects a new way to think about getting older and the living options that are available. To the extent it makes people think more positively about the spectrum of aging services, I, for one, hope the phrase sticks.  

Whether or not you are a fan of healthcare reform, here's one reason Congress should pass it: It would extend the therapy caps exceptions process.

It has been a week since the exceptions process for Medicare Part B therapy caps expired. While there may not be cause for alarm yet, each day that goes by causes residents and nursing homes more consternation.

“I think they'll [Congress] get to it early this month, but we're sort of hanging out there until that gets done,” said Peter Clendenin, executive vice president for the National Association for the Support of Long Term Care.

The Senate bill would extend the exceptions process for one year, while the House bill would extend it for two.

Providers have been here before, he noted. There have been other instances in the last 10 years that Congress has failed to act to extend the exceptions process before the expiration, Clendenin said. Fortunately, this time, the expiration has occurred at the beginning of the year. That means that residents started fresh with their annual allowance for therapy on Jan. 1. The spending limits are $1,860 for combined speech and physical therapy, and $1,860 for occupational therapy. But that is not much consolation, Clendenin said.

What happens?

When a resident exhausts the therapy benefit, it causes a problem for the resident who needs the therapy and the nursing home, which provides it, he explained. Often the options are limited. The facility could tell the resident he or she must pay privately; it could continue to provide the therapy with the expectation it will be reimbursed when the bill passes; or it could suspend therapy. None is a good alternative.

There is also the option of sending a resident to a hospital outpatient facility where there is no limit on the therapy. (Hospitals are not subject to the therapy caps rule.) But that also is not ideal because it entails transporting a resident, who may be frail. The resident who most likely would feel the impact of the cap would be someone who suffered a high-acuity event, such as a stroke or hip or knee replacement, and needs intensive, short-term therapy.

So it seems that the best option is for Congress (OK, Democrats) to pull together one more time and pass its bill. As each day passes, the health needs of residents are depending on it. 

Another therapy challenge

You may have heard some talk regarding a change to Medicare Part A concurrent therapy rule. If not, you will. This therapy topic promises to become a major concern facing long-term care rehab providers as the year continues.

As of Oct. 1, the Centers for Medicare & Medicaid Services wants to allocate therapy minutes between two residents. In other words, if a therapist is working with two residents, the number of minutes would be based on the amount of time a therapist spends with each. Currently, the number of minutes a therapist spends with two residents is based on the resident's time.

As an example, if a therapist is working with two residents for a total of 60 minutes, under the new rule, each resident would be credited with 30 minutes. The current rule allows each to be credited with 60.

Clendenin sees the new rule as a way to discourage the use of concurrent therapy. The result of such a change is that the therapist would have to spend twice as long with a resident for him or her to reach a certain Resource Utilization Group (RUG) category. These new rules could affect placement of residents in RUG categories and, by extension, payment to nursing homes.

Stay tuned for more on this issue.

It's only the first week in January, but 2010 already has served up some exciting developments for the long-term care field.

One is the release of a health policy journal devoted exclusively to long-term care issues. The January issue of Health Affairs sheds light on important issues facing the field. A briefing held Tuesday in Washington helped to publicize the issue's release.

Articles contained in the issue address workforce challenges, palliative care in nursing homes, how to finance long-term care (don't we all want to know!) and the CLASS Act, which would provide working people an opportunity to pay into a trust that could pay them an average daily allowance of $75 a day if they become disabled. The program is part of House and Senate healthcare reform legislation.

The issue offers many interesting study findings and expert insights. One article talks about barriers to growing the long-term care workforce. Two others talk about the importance of expanding palliative care in nursing homes. Also, in the issue, Harvard Medical School experts talk about the need for public-private funding of nursing home care.

I would put this magazine issue at the top of any long-term care professional's required reading list (right next to McKnight's, of course).

The other piece of good news this week is the kick-off of the Long-Term Quality Commission, which will focus on research and best practices to achieve quality care for those needing long-term services and supports and their families. It intends to focus on the broad spectrum of long-term care, beyond institutional care.

Heavy hitters on the board of the commission include former Centers for Medicare & Medicaid Services Administrator Mark McClellan and leaders of the many long-term care organizations. Other policy and healthcare experts on the commission include Mary Jane Koren of The Commonwealth Fund, Judy Feder of the Center for American Progress, Katie Maslow of the Alzheimer's Association and Susan Reinhard of AARP.

Talk about a great start to the New Year!