Steve Gold, The Disability Odyssey continues

CMS' 2007 Nursing Home Data Compendium was recently released. In this and in the next two succeeding Information Bulletins, we will break down some of the findings. To review your state, go to the CMS website and scroll down to Nursing Home Data Compendium 2007 - Parts 1 and 2 .

Why are people in these facilities?

Nursing facilities, especially those reimbursed with federal Medical Assistance reimbursements, require a "medical necessity" for such institutionalization. That is, legally, a person should not be admitted unless the person has a "medical necessity" for institutionalized nursing facility services.

The following are the two most frequently used indica of such "medical necessity" - (1) Need for help with Activities of Daily Living and/or (2) Cognitive Impairments.

• Regarding whether a person's condition severely affects his/her "Activities of Daily Living," CMS evaluated ability to get in and out of bed, dressing, eating, transferring and toileting. A condition was noted only when the resident required "extensive assistance" with the activity.
• Regarding whether a person had a cognitive impairment, CMS used the Cognitive Performance Scale.

States normally require a person to have a certain number of ADL or cognitive impairments to either be admitted into or stay in a nursing facility. In order to receive federal nursing facility Medicaid reimbursements, documentation of "medical necessity" is required. Obviously, a person can have both, but CMS does not provide a cross tabulation for persons who have both ADLs and cognitive impairments.

Here's what CMS surveys found regarding these two conditions:

ADL Impairments:

Nearly 30.3% of persons in nursing facilities had NO impairment of ADL; that's more than one million persons institutionalized in nursing facilities at sometime during the year who had no ADL impairment. Another 8.3% had only one ADL impairment. More than 46% of the persons had two or fewer ADL impairments. (Table 3.3.(e)).

The following states have the largest percentage of persons with NO ADL impairments, far above the national average of 30.3%:

Oklahoma 44.6% Missouri 41.4% Illinois 40.7% Arkansas 39.3% Kansas 38.2% Louisiana 37.8%

Why are any persons in nursing facilities with no or even only one or two ADL impairments? If they are in these facilities only due to ADLs, can't these people be provided Personal Attendant Services in the community?

Why are States, for those residents on Medical Assistance, permitting these people to be admitted into nursing facilities and then paying extremely large payments for them to be unnecessarily institutionalized?

Why aren't advocates making the States "Close the Front Door" and not admit or pay for these persons? Why aren't advocates demanding their states to offer persons with no or only one or two ADLs less expensive community-based services?

If people are in nursing facilities and do not have impairments of no or few ADLs, then presumably they are institutionalized because they have a cognitive disability. If that is correct, did these people receive PASSAR evaluations before they were admitted, and are they receiving appropriate services for their cognitive impairments? If they have only a cognitive impairment, how do they otherwise meet the "medical necessity" standard for nursing facilities?

Cognitive Impairments:

Nearly 31% of residents had NO cognitive impairment; that's nearly one million persons without any cognitive impairments. Another 12.2% had only a "very mild" and 14.5% have a "mild" cognitive impairment. Therefore, nearly 58% had either no or only a mild or less cognitive impairment. (Table 3.5.(e))

The following states, in descending order, have the largest percentage of persons in nursing facilities with NO cognitive impairments, far above the national average of 30.9%:

Arizona 45.3% New Jersey 42.0% DC 41.2% Florida 39.5% Maryland 38.4% Nevada 38.3%.

Interestingly, the national average was only 11.5% of the residents had a "severe" or "very severe" cognitive impairment, far lower than what is commonly believed.

The following states, in descending order, far exceeded the national average for the percentage of people in nursing facilities with a severe or very severe cognitive impairment:

Georgia 17.4% Arkansas 15.5% South Carolina 15.5% Louisiana 13.9% Kentucky 13.8% Maryland 13%

Advocates should ask their MA officials for a breakdown of persons with a combined ADL and cognitive impairments.

Are people with severe or very severe cognitive impairments receiving specialized services, as Congress required in the Nursing Home Reform Act.

When one looks at both ADL and cognitive impairments, a frightening picture emerges. Have nursing facilities become the last refuge for many persons who are mentally ill, homeless, developmentally disabled? Are States permitting them to stay in nursing facilities because that's where states can receive federal reimbursements and funds?

Why is your State wasting Medical Assistance dollars on those persons who could easily be treated appropriately in the community? Think how many more persons could be served in the community with better use of these funds.