Sister Bernadette made the decision to serve the elderly as a nun in college, but she’s been drawn to service of her elders since she was a child.
Kyle Grantham/The News Journal
Facing a silver tsunami in the coming decades, Delaware health care advocates warn of a widening gulf in the supply and quality of nursing home care between the haves and the have-nots.
By 2040, the statewide population of residents age 65 and older is projected to nearly double, topping 258,000.
Sussex and Kent counties rank among the top 5 percent of areas nationwide experiencing an influx of relocating retirees. More than half of patients in public and private nursing homes in Delaware rely on Medicaid, a major cost driver for the state health department.
On paper, nearly 93 percent of the state’s more than 5,000 nursing home beds are certified to accept Medicaid patients. In reality, fewer than 3,000 of those slots are filled by people on Medicaid, a 5 percent decrease from five years ago.
The reasons are varied, but virtually all involve putting a lid on spiraling costs. Delaware’s Medicaid budget from state and federal sources exceeds $2 billion.
With 40 dedicated beds available for 24-hour nursing care, Little Sisters of the Poor near Ogletown has a waiting list stretching two years, according to Kari Lockwood, the home’s admissions coordinator.
Run by nuns, the nonprofit residence has one of the highest occupancy rates in the state. It’s also the only nursing facility in Delaware that has received five-star ratings across the board from federal regulators, despite serving a mostly Medicaid clientele.
“I get a lot of families who are in a desperate situation,” Lockwood said, explaining that people often wait until they are seriously ill before investigating long-term care options. “A lot of times there’s nothing I can do for them.”
More than a decade ago, Delaware operated four nursing homes for the poorest residents, totaling 652 beds. Today, the state runs two homes — Governor Bacon Health Center in Delaware City and the Delaware Hospital for the Chronically Ill in Smyrna — with fewer than 200 residents combined.
Private nursing homes in Delaware and across the country are phasing out Medicaid beds — in some cases, converting them to more lucrative short-term rehabilitation beds — because of stagnant reimbursement rates, according to Dr. Chris Casscells, an orthopedic surgeon at Christiana Care who also directs the Center for Healthcare Policy at the Caesar Rodney Institute.
Casscells recalled shopping for nursing homes recently for his 89-year-old mother-in-law. After selling her home and liquidating all her other assets, she found a spot at Sunrise of Wilmington. The previous occupant had to be moved to a less expensive facility after running out of money, Casscells said.
“The bottom line is they don’t want those (Medicaid) patients,” he said of private nursing homes.
The state Division of Medicaid and Medical Assistance doesn’t keep historical data on the number of Medicaid beds available as a percentage of total nursing home beds statewide, nor does it track the quality of nursing home care for Medicaid patients compared to private clients.
“That’s something that we really have to look into,” division director Stephen Groff said recently. While the state can’t force private facilities to serve Medicaid clients, their needs are being met, he said.
“The people who choose to receive nursing home care are receiving it,” Groff continued. “We are not denying care for lack of beds.”
In recent years, state and federal health leaders have promoted community-based care alternatives, focused on helping people age in place. Research shows that Baby Boomers would prefer to remain in their homes with access to community health services, such as geriatric care, occupational and physical therapy, transportation, nutrition counseling and social outings. The Brandywine Village Network in north Wilmington and Saint Francis Life Center on the Riverfront, reflect this burgeoning model.
Community-based programming provides “all the wraparound supports an individual needs,” Groff said. “Our goal is to support individuals in the community.”
The approach also makes financial sense. In 2015, the median annual cost of nursing facility care was more than $91,000, compared to less than $46,000 for 44 hours a week of home health aide services and $18,000 for adult day care five days a week, according to a Kaiser Family Foundation report. In Delaware, community-based care costs about a third of traditional nursing home care and saves the state an estimated $41.6 million a year, a state health department spokeswoman said.
It’s not surprising, then, that the number of Delawareans on Medicaid receiving long-term care services in their homes has more than doubled to nearly 3,800 this year from about 1,700 in 2009. Last year marked the first time that more Medicaid members were treated at home than in Delaware nursing facilities, according to state records.
But local health care experts caution that community-based care models need more monitoring of health outcomes.
“It’s something we’re going to have to track carefully … It’s evolved so quickly,” said Yrene Waldron, director of the Delaware Health Care Facilities Association, a nursing facility lobbying group.
Casscells agreed. The home-based approach represents a “lower tier” of care, he said, because the infrastructure isn’t fully developed yet. What happens if someone falls and hits his head and no one is around? Or if recurrent belly pain goes undiagnosed?
“It’s not nearly as safe as the hospital or the nursing home,” he said.
While the state is funneling Medicaid dollars into keeping seniors in their homes longer, the long-term care industry is luring healthier, younger and more affluent residents by guaranteeing them around-the-clock care when the time comes.
Several of these “continuing care retirement communities,” like the top-rated Stonegates in Greenville, won’t accept outsiders into their skilled nursing facilities. Instead, they draw from their existing pool of independent residents who eventually transition into a higher level of care.
“It’s a form of long-term care insurance,” explained Michael Smith, a spokesman for Acts Retirement Life Communities, with three properties in Delaware. “Skilled nursing care is the highest cost people face in retirement.”
Acts’ top-rated Country House in Wilmington, for instance, requires an entry fee of $147,000 to $622,000 for residents to move into independent living apartments and cottages, plus a monthly fee of $3,300 to more than $5,000. The monthly rate doesn’t increase when a resident moves into 24-hour nursing care, Smith said. The 62-acre community off Kennett Pike doesn’t accept Medicaid.
By encouraging buy-in early, continuing care facilities are spared from being inundated with people in their 80s and 90s who require the most expensive care. Cash-strapped hospitals are increasingly sending these patients to nursing homes following brief stays, according to local health care experts.
“The nursing homes of today are more like the hospitals 10 years ago,” said Mary Peterson, director of the state’s Division of Long Term Care Residents Protection. “Patients are going into nursing homes when they are still acutely ill.”
The state division received nearly 400 complaints about Delaware nursing homes in the most recent fiscal year, roughly the same number as five years ago. They range from gripes about cold food and dust bunnies to staff assaulting residents and suspicious deaths.
In fiscal 2016, Atlantic Shores Rehabilitation and Health Center in Millsboro tied Westminster Village in Dover for receiving the highest number of verified complaints: 3.
Atlantic Shores, formerly Green Valley Terrace, is the lowest-rated nursing facility in Delaware, according to federal Medicare data. It receives 1 out of 5 stars overall. Records show that Atlantic Shores failed to properly report to state authorities two resident allegations of staff abuse or mistreatment last year. The 181-bed facility, recently acquired by Summit Healthcare Real Estate Investment Trust, has 117 residents on Medicaid, according to state records.
Gary Nitsche, a Wilmington attorney who has specialized in nursing home litigation for 15 years, has noticed a common theme among the personal injury cases he has handled: Staff neglect. Corporate-run homes try to trim costs, he said, while juggling a high-acuity population with complex problems.
“The demand for care is outpacing the ability to provide the care that’s needed,” he said.
Contact Margie Fishman at (302) 324-2882, on Twitter @MargieTrende or firstname.lastname@example.org.