Serving the Underserved:
The Case for Supporting and Sustaining
a Mission of Value
Recommendations from the
Inner City Brain Trust
American Association of Homes and Services for the Aging
November 2009
American Association of Homes and Services for the Aging
2519 Connecticut Avenue, NW
Washington, D.C. 20008-1520
1
Members of the Inner City Brain Trust
Neil Roberts
Moderator
Schuylerville, New York
Jerry Blackmore
Administrator
St. Augustine Manor
St. Augustine Health Campus
Cleveland, Ohio
Harvey M. Shankman
Executive Director
Eliza Bryant Village
Cleveland, Ohio
Pat Gareau
Chief Executive Officer
St. Augustine Health Campus
Cleveland, Ohio
Patricia B. Mullins
President/CEO
Isabelle Ridgeway Care Center
Columbus, Ohio
Jeanine M. Reilly
Executive Director
Broadway House for Continuing Care
Newark, New Jersey
Richard Binenfeld
Executive Director
Mary Scott Nursing Center
Dayton, Ohio
John Meacham
Administrator
St. Ignatius Nursing Home
Philadelphia, Pennsylvania
Tim Middendorf
Vice President of Senior Development
Augustana Care Corporation
Minneapolis, Minnesota
Pam Mammarella
Vice President, Communications
New Courtland Elder Services
Philadelphia, Pennsylvania
Christia L. Hicks
Administrator
Lockefield Village
Indianapolis, Indiana
2
Individuals Who Assisted the Brain Trust
Over the course of three meetings and additional conference calls, these individuals took
part in the discussions of the Inner City Brain Trust:
Tom Slemmer
Chair, AAHSA Board of Directors
President and CEO
National Church Residences
Columbus, Ohio
AAHSA Staff:
Larry Minnix
President and CEO
Susan Weiss
Senior Vice President, Advocacy
Maria Moreno
Senior Vice President
Aon Association Services
Chicago, Illinois
Cory Kallheim
Senior Attorney
Wayne A. Evancoe
CEO/Renal Administrator
The Hortense & Louis Rubin Dialysis
Center Inc.
Troy, New York
Peter Notarstefano
Director, Home & Community-Based
Services
Scot Scurlock
Vice President, Shared Services and
Group Purchasing
Bill Healey
Regional Vice President, Operations
Catholic Health East
Newton Square, Pennsylvania
Robyn Stone
Executive Director, Institute for the
Future of Aging Services
Senior Vice President of Research
3
Table of Contents
Overview ………………………………………………………….
5
Section I: Introduction …… ……………….. …………………..
6
Section II: The Heroic Stories of ICBT Facilities ……………….
11
Section III: Recommendations ……………………………………
16
Section IV: Other Strategies to Assist ICBT Facilities ………….
27
Section V: Conclusion ……………………………………………..
30
Appendices …………………………………………………………
31
Appendix A: ―Separate and Unequal: Racial Segregation and
Disparities In Quality Across U.S. Nursing Homes‖ ………………….
31
Appendix B: ―Lower Standards‖ (The Chicago Reporter) …………….
34
Appendix C: ICBT Facility Statistics from Nursing Home Compare ….
39
Appendix D: Model Program Comparison Chart ………………………. 40
Appendix E: Workforce Training Programs ……………………………. 42
Appendix F: Summary of Legislation to Designate Health
Empowerment Zones ……………………………………………………. 46
4
Overview
A heroic group of AAHSA members is struggling against myriad challenges to bring highquality long-term services and supports to chronically indigent older people living in medically
underserved areas. These nursing homes have long and distinguished histories in their
communities. They were established to meet a pressing need and they have worked diligently –
sometimes for more than a century – to improve the lives of older people who might otherwise
go without needed care and services.
The willingness of nursing homes to respond to these pressing needs comes with a price,
however. Most nursing homes serving underserved populations face stiff challenges as they seek
to (1) fund a variety of services; (2) serve residents who have complex social, financial and
health issues; (3) employ local residents who may lack basic life skills; and (4) operate in what
are often unsafe environments.
AAHSA convened the Inner City Brain Trust (ICBT) in 2008 to identify and recognize the value
that its member nursing homes bring to underserved areas. The association also sought to devise
strategies that would help these providers obtain the resources needed to continue their missions
of service. Ten AAHSA members participated in the ICBT from May 2008 to July 2009.
After much deliberation, the Brain Trust defined ―ICBT facilities‖ as:
“Homes serving America’s chronically indigent who need
long-term care services in medically underserved areas.”
The Brain Trust also called on AAHSA to:
Continue to advocate for increased government support for ICBT facilities.
Seek to include ICBT facilities in pending federal legislation that supports the provision of
long-term services and supports.
Target AAHSA educational programs to ICBT facilities.
Provide ICBT facilities with increased access to AAHSA leadership programs.
Provide ICBT facilities with workforce training resources.
Increase educational sharing among all types of AAHSA members.
Help ICBT facilities attract good leaders.
Continue to research issues affecting ICBT facilities.
Use research and other strategies to raise awareness of ICBT facilities among policymakers
and the public.
Revise the marketing strategies for AAHSA insurance and purchasing programs.
Help ICBT facilities capitalize on their social capital.
ICBT members are grateful to AAHSA for its attention to the needs of these important nursing
facilities. The very existence of the Brain Trust gives ICBT members hope that they are not
alone and that their work in medically underserved communities is valued and will be sustained.
5
Section I: Introduction
In 2007, a study by researchers at Temple University in Philadelphia concluded that black
nursing home residents are more likely than whites to live in poor-quality nursing homes marked
by significant deficiencies on inspection reports, substantial staffing shortages and financial
vulnerability.
―Separate and Unequal: Racial Segregation and Disparities in Quality Across U.S. Nursing
Homes,‖ which appeared in the September/October 2007 issue of Health Affairs,1 ranked
metropolitan statistical areas based on the disparities that existed in the access that blacks and
whites in those areas had to quality nursing homes. Researchers reported that black nursing home
residents were:
1.41 times as likely as whites to be in facilities cited with a deficiency causing actual
harm or immediate jeopardy to residents.
1.7 times as likely as whites to be in a nursing home that was subsequently terminated
from Medicare and Medicaid participation because of poor quality.
1.12 times as likely as whites to reside in a nursing home that was greatly understaffed.
2.64 times as likely as whites to live in a facility that housed predominantly Medicaid
residents. (See Appendix A for a summary of the article.)
Genesis of the Inner City Brain Trust
The Temple University study captured the attention not only of long-term care providers but also
of the general public. Articles about the academic study soon began appearing in mainstream
1
Smith, D.B., Z. Feng, M. L. Fennell et al. 2007. Separate and Unequal: Racial Segregation and Disparities in
Quality across U.S. Nursing Homes. Health Affairs, 26(5):1448–58.
6
media outlets, including USA Today. Questions about the quality of care in nursing homes
serving African Americans surfaced again in July 2009 when the Chicago Reporter, a monthly
newspaper published by the Community Renewal Society, identified Illinois as the ―worst state
in the nation for black senior citizens seeking quality nursing home care.‖ During its
investigation, the Reporter found that ―the staff at Illinois’ black nursing homes spent less time
daily with residents than staff where a majority of the residents are white.‖2 (See Appendix B for
a full copy of the article.)
For AAHSA, the Temple study and the Chicago Reporter article underscored two pressing
needs: the need to recognize the tremendous challenges facing nursing homes serving
underserved populations and the need to provide those facilities with additional resources to
meet these challenges. Indeed, the Temple report recommended several policy changes that
would help ensure equal access to high-quality care for all nursing home residents, regardless of
their race or ethnic origin. Specifically, the authors called for improvements in the payment
structures for nursing homes serving a high proportion of Medicaid residents and advocated for
measures that would help close the gap between the amount paid to nursing homes by Medicaid
and private payers.
Seeking a more comprehensive examination of the nursing homes in question, AAHSA
convened the Inner City Brain Trust (ICBT) in 2008. This group of nursing home providers
agreed to help AAHSA identify and recognize the value that providers of long-term services and
supports bring to underserved areas, and to devise strategies to help those providers obtain the
resources they need to continue carrying out their missions of service in what can sometimes be
hostile operating environments. AAHSA invited 50 association members to participate in the
ICBT. Twelve members initially accepted that invitation and 10 members remained active ICBT
members throughout the group’s tenure. The ICBT worked from May 2008 though July 2009.
2
The Chicago Reporter article also reports that, nationally and locally, for-profit homes have received lower ratings
than nonprofit facilities. In Chicago, for example, 24 of the city’s 75 for-profit homes received the lowest ratings
from the Centers for Medicare and Medicaid Services’ Nursing Home Compare Web site, while none of the 17
nonprofit homes earned the same mark. By contrast, six of the 17 nonprofit facilities received the top rating
compared with just eight of the 75 for-profit facilities.
7
“ICBT Facilities”
From the start, AAHSA’s Inner City Brain Trust found it extremely difficult to devise a good
definition of the nursing homes that it had been charged with identifying, studying and assisting.
While published reports referred to these facilities as ―inner-city nursing homes,‖ ICBT members
wanted to devise a more inclusive definition that would encompass all nursing homes that serve
a preponderance of low-income residents with complex medical needs, are often located in
economically and socially unstable communities, and are almost entirely dependent on Medicaid
funds to cover the cost of care. While many of the facilities facing these challenges are, indeed,
located in inner-city neighborhoods, nursing homes located in rural, suburban and tribal
communities also face similar challenges. The ICBT did not want to exclude these non-urban
nursing homes from its definition – or from any forthcoming government assistance programs.
The Brain Trust also dealt with more complex, definition-related issues, which are described in
more detail later in this report. These issues related to the ICBT’s desire to develop an objective,
data-based definition for nursing homes serving at-risk communities. The Brain Trust felt that
such a data-driven definition – based on a home’s location in a qualified census track or its
percentage of indigent residents, for example – would allow ICBT facilities to fit more easily
into accepted categories that already govern existing assistance programs for providers in other
care sectors who also serve traditionally underserved populations. The ICBT theorized that
policy makers already familiar with these criteria, and with the assistance programs that employ
them, would be more likely to approve a similar assistance program for long-term care providers.
While no data-driven definition proved inclusive enough to accurately define its constituent
nursing homes, the ICBT finally decided to define these facilities as:
Homes serving America’s chronically indigent who need
long-term care services in medically underserved areas.
Throughout this report, nursing homes that meet this definition are referred to as ―ICBT
facilities.‖
8
Reconciling Printed Reports with Member Experience
Members of the ICBT took very seriously the reports about nursing home disparities that
appeared in Health Affairs and the Chicago Reporter. Without exception, ICBT members
expressed a strong commitment to initiatives aimed at helping ICBT facilities provide their
residents with high-quality care. At the same time, however, ICBT members caution policy
makers and members of the general public against using the data from either report to make
sweeping generalizations about the care provided in ICBT facilities.
To obtain a more balanced picture of the quality of care in ICBT facilities, the Brain Trust
conducted its own research on nursing home staffing ratios and deficiencies, as reported by the
Centers for Medicare and Medicaid Services (CMS) on the Nursing Home Compare Web site.3
Studying data from the 12 nursing homes represented in the ICBT’s original membership, the
Brain Trust found that, contrary to the findings published by Temple University researchers, the
level of deficiencies and staffing ratios in ICBT homes were comparable to those found in other,
similar-sized AAHSA members. (See Appendix C for more information.) Similarly, an AAHSA
survey conducted before the first Brain Trust meeting found that ICBT facilities also struggle
with the same core challenges facing most AAHSA-member skilled nursing facilities: staffing
and funding.
This ICBT research, and the personal experiences of group members, led the Inner City Brain
Trust to conclude that it is inaccurate and unfair to characterize all ICBT facilities as places of
poor care and discrimination. Such generalizations fail to recognize the value that these homes
offer both their residents and the communities in which those residents live. In spite of the
media’s recent descriptions of these nursing homes, many facilities – and, in particular, the small
sample represented on the ICBT – share striking histories of service to the most disadvantaged
individuals in their communities. All of these facilities live out an unwavering commitment to
their missions. The quality of that commitment – and the quality of care that flows from that
commitment – cannot be overstated or missed during a visit to these homes.
3
The ICBT recognizes that AAHSA’s own Survey and Certification Task Force discounts the usefulness of Nursing
Home Compare data. However, the ICBT used this information because no other comparable data was available.
9
Unfortunately, the heroic stories being told by ICBT facilities, on a day-to-day basis over many
decades, are not widely known to the public or to members of Congress and their staffs.
AAHSA’s Inner City Brain Trust is committed to correcting this knowledge gap.
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Section II: The Heroic Stories of ICBT Facilities
Eliza Bryant Village has been telling its own heroic story for over a century in the inner city of
Cleveland, Ohio. The Inner City Brain Trust chose to include that facility’s story here because it
is similar to the stories being told each day by nursing homes providing long-term services and
supports to chronically indigent elderly in medically underserved areas around the country.
Like other ICBT facilities, Eliza Bryant Village was established in response to specific and
pressing needs in its community.
Thirty-one-year-old Eliza Bryant came to Cleveland in 1858 after her mother, Polly Simmons,
had been freed from slavery in North Carolina. Bryant and her mother soon earned a reputation
throughout Cleveland for their uncompromising willingness to provide African Americans who
were newly arrived in the city with basic essentials like food, shelter, clothing and guidance until
they could find work and support themselves.
In 1893, at the age of 66, Bryant began targeting her life-long generosity to a specific group:
older African Americans, who were not receiving the long-term care they needed due to
segregation. Bryant conducted a three-year campaign to convince friends, community groups,
church groups and members of the business community to care as much about the fate of these
elderly as she did.
Like other ICBT facilities, Eliza Bryant Village has always relied on strong support from
community residents to fulfill its mission of service.
In the early years of her service to Cleveland’s black elderly, Eliza Bryant managed a cadre of
volunteers who went door-to-door to raise money and collect food and clothing for needy older
people living on their own in the community. That active community involvement continued
after Bryant and her trustees established the Cleveland Home of Aged Colored People in 1896.
The home became the first nonreligious welfare institution supported by Cleveland's African
American community, and boasted three auxiliaries that were highly effective in raising money
for the home. The Lady Board of Managers and the Junior Board held numerous events that
11
encouraged local residents to donate canned goods, flour, clothing and money to supplement the
home’s meager budget.
Community support is still an essential part of Eliza Bryant Village. Today, approximately 100
volunteers serve the facility through three auxiliaries, which raise funds to support programs and
services, provide leadership and hold positions on the board of trustees.
Like other ICBT facilities, Eliza Bryant Village has grown and expanded in response to
community need.
For its first five years, the Cleveland Home of Aged Colored People was located in a modest
home that lacked both a furnace and baths. Soon outgrowing these facilities, the home moved in
1901 to a larger house that contained 19 nursing care beds. As the need for long-term care
services grew dramatically over the next decades, the Cleveland Home – later renamed Eliza
Bryant Village – grew with it. Today, Eliza Bryant Village offers a comprehensive array of
geriatric services, including adult day care; transportation, nutrition, primary health and
community-based service programs; 149 senior housing apartments; and a 175-bed skilled
nursing facility that includes a special wing to care for residents with Alzheimer's disease.
Equally important to the health of its community, Eliza Bryant Village is its neighborhood’s
largest employer, with more than 250 full- and part-time staff members.
Challenges Faced by Inner-City Facilities
ICBT facilities like Eliza Bryant Village provide critically needed care and services to older
people in their communities. In addition, as major employers and active community partners,
many of these facilities serve as stabilizing forces in at-risk, low-income neighborhoods. Playing
these important roles comes with a price, however. Most ICBT facilities face stiff challenges as
they seek to fund a variety of services; serve residents who have complex social, financial and
health issues; employ local residents who may themselves struggle with financial problems and
lack basic life skills; and operate in what often are unsafe neighborhoods.
Financial challenges. Homes that offer long-term services and supports to chronically indigent
Americans in medically underserved areas do not all have the same financial structures or face
12
the same financial challenges. It is safe to assume, however, that no ICBT facility serves a high
number of private-pay residents, a fact that makes these facilities less financially secure than
other nursing homes. Different ICBT facilities take different approaches to compensating for this
dearth of private-pay residents. Some have been able to develop services that are reimbursed by
Medicare, which helps to improve their financial picture. Others have not.
Most ICBT facilities serve a very high percentage of Medicaid residents. In some cases,
Medicaid beneficiaries make up between 70 and 99 percent of the resident population. In almost
every case, Medicare is the second most common payer.
Staffing challenges. ICBT facilities have trouble attracting professional staff to their locations
but they have far less trouble recruiting frontline workers from the local community.
Unfortunately, these frontline workers are more difficult to train because they are often illprepared for the discipline of work in a long-term care facility.
ICBT members report that many of these local residents lack the ―life skills‖ necessary for
successful employment. Many employees face personal life challenges such as poverty,
inadequate housing and family-related problems. One ICBT member reported that up to 70
percent of staff at his facility is eligible for services at a needs-based food pantry. Other
employees experience a persistent level of grief because of the violence they witness in their
lives.
ICBT providers cannot ignore these employee issues. Instead, they must take on the significant
responsibility and cost involved in teaching local residents the clinical skills they need to care for
older people as well as the more general skills they need to be successful in any job. If a facility
doesn’t invest upfront in helping employees obtain these requisite life skills, say ICBT members,
it will find itself paying a premium to deal with unusually high staff turnover.
These issues of poverty, violence and undeveloped life skills also present challenges to a facility
recruiting community members to serve in staff leadership positions or on its board of directors.
Many ICBT facilities report that talented community members, who might be tapped for
leadership positions, often leave the community after a number of years to live in more affluent
13
neighborhoods. Prospective leaders who stay within the community have abundant choices
regarding where to use their time and talents. Despite these obstacles, however, members of the
Brain Trust remain committed to finding good leaders from within the local community to serve
on their boards. Tapping local talent helps an ICBT facility establish trusting relationships with
neighborhood residents who have many reasons to distrust institutions and organizations.
Residents with complex needs. In many cases, older people who move into ICBT facilities are
experiencing the first organized medical intervention of their lives. Years of medical neglect
have taken a toll on these residents, who typically suffer from chronic diseases that have gone
untreated for decades. Because ICBT facilities are often the last safety net of care in their
neighborhoods, residents often arrive with a plethora of issues, including psychiatric illness,
chemical dependency, AIDS and homelessness. ICBT facilities are likely to encounter unusually
high care costs as they help new residents deal with physical and emotional complications that
stem from lives filled with hardship.
In addition to medical issues, residents of ICBT facilities experience their fair share of economic
and social problems. For example, residents who experienced economic insecurity before
admission to an ICBT facility may find themselves in an even more precarious situation if
discharge from the facility becomes appropriate. In particular, discharge can be extremely
complicated if a resident was homeless prior to admission. Even those residents who lived in
subsidized housing before admission could find that their Section 8 ―slot‖ is filled when they
enter a nursing home, despite the nursing home’s best efforts to inform the housing provider
about the possibility of discharge.
The lack of a supportive family can make the lives of ICBT facility residents even more difficult.
Brain Trust members report that many family members are simply not familiar with how to be
supportive to an older relative. In these cases, the ICBT facility may have to take on the
responsibility of completing almost all of the required work to certify a resident for assistance
under the Medicaid program. Family cooperation in the resident’s care may also be negatively
affected if families have depended heavily on the resident’s Social Security and other income
before nursing home admission. These families may have a significant need for social services
after the older person’s income is diverted to pay for care.
14
Security concerns. Because of their location in unsafe neighborhoods, ICBT facilities face
unique challenges as they strive to ensure the physical security of their premises. The perception
that an ICBT facility is located in an unsafe neighborhood could make it hard for that facility to
recruit and retain staff and obtain reasonably priced insurance policies.
No time for planning. In the midst of day-to-day crises, strategic planning often becomes an
unattainable luxury for ICBT facilities. Instead of looking ahead and planning for the future,
many facilities find themselves devoting all their available time, energy and resources to the
struggle for survival. Financial limitations can also make strategic planning impractical. As one
member observed, ―We have a strategic plan and no resources to implement it.‖
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Section III: Recommendations
During its 14 months of work, AAHSA’s Inner City Brain Trust identified a number of relatively
simple actions that AAHSA could take to ease the way for ICBT facilities as they work to fulfill
their missions in underserved areas. In this section of its report, the ICBT makes 11
recommendations for AAHSA action in the areas of advocacy, research, education, promotion of
AAHSA member benefits and guidance on ways to translate the social capital of ICBT facilities
into tangible support. In Section IV, the Brain Trust shares a number of resources and strategies
that ICBT facilities might tap in order to improve their training programs, financial viability and
care.
Advocacy in Washington
Continue to advocate for increased government support for ICBT facilities.
Seek to include ICBT facilities in pending federal legislation that supports the provision
of long-term services and supports.
When the Inner City Brain Trust gathered for the first time in May 2008, members were in
general agreement about the characteristics and needs of ICBT facilities. Despite this agreement,
however, group members and AAHSA staff had considerable difficulty developing a clear
definition of the facilities that shared these characteristics and needs.
From the beginning, the Brain Trust’s goal was to lay the groundwork for a federal support
program for ICBT facilities that could be modeled after existing programs that assist providers of
other levels of care. The Brain Trust hoped to find a data-driven definition – based on a home’s
location in a qualified census track or its percentage of indigent residents, for example – that
would allow ICBT facilities to fit more easily into accepted categories that already govern these
existing assistance programs. The group theorized that policy makers already familiar with these
16
criteria, and with the assistance programs that employ them, would be more likely to approve a
similar assistance program for long-term care providers.
Unfortunately, no preexisting federal definition fit the group’s needs. The group finally decided
to focus its definition on the fact that ICBT facilities offer services within medically underserved
areas (MUA). Therefore, the official definition, approved by the Brain Trust, describes ICBT
facilities as
Homes serving America’s chronically indigent who need
long-term care services in medically underserved areas.
The ICBT believes that the MUA designation provides AAHSA with the best chance of
successfully advocating for the creation of a formal system for federal support of ICBT facilities.
This designation could help to encourage advocates and policy makers to work together to design
a support initiative for ICBT facilities that is modeled on existing, Medicare-funded programs
currently supporting the delivery of other levels of care in MUAs.
Federal Program Models
Before settling on its final definition, the ICBT analyzed a variety of existing federal and state
programs that might offer a model upon which an ICBT support program could be based. Those
programs included the Empowerment Zone4 and Renewal Community5 initiatives, and the LowIncome Housing Tax Credit (LIHTC) program.6 In particular, four designations and programs
4
Selected communities, designated as Empowerment Zones (EZ), can share in billions of federal dollars in tax
incentives and grants. HUD has designated 30 EZs while the U.S. Department of Agriculture manages 10 EZs. The
Empowerment Zone designation was awarded in three competitive rounds in 1994, 1999 and 2002. Despite some
local successes, most of the EZ initiatives have been viewed as unsuccessful.
5
The Renewal Communities (RC) initiative is a HUD designation that allows 40 selected communities (28 urban
and 12 rural) to share about $17 billion in tax incentives to stimulate job growth, promote economic development
and create affordable housing. Renewal Communities were established by the 2000 Community Renewal Tax Relief
Act and were awarded based on a competitive application process.
6
The Low-Income Housing Tax Credit Program, created by the Tax Relief Act of 1986, provides incentives for the
utilization of private equity in the development of affordable housing aimed at low-income individuals. The credits
provide a dollar-for-dollar reduction in a taxpayer’s federal income tax. The units and tax credits are allocated to
states on an annual basis. For 2006, 74,278 units were allowed nationwide, totally over $758 million in tax credits.
17
stood out as having the most relevance to ICBT facilities: the Qualified Census Tract
designation, Federally Qualified Health Centers, Disproportionate Share Hospitals, and the
Pennsylvania Disproportionate Share Incentive Payments program.
Qualified Census Tract. The Qualified Census Tract (QCT) designation appeared to most
closely mirror the kind of support mechanism that the Brain Trust had in mind for ICBT
facilities. A QCT is an area where 50 percent or more of the households have incomes below 60
percent of the area median income or where the poverty rate is 25 percent or higher. The
population of designated QCTs in a metropolitan area is restricted to 20 percent of the
metropolitan area’s population, which eliminates many potential QCTs.
There are over 8,500 QCTs around the country. The U.S. Department of Housing and Urban
Development (HUD) uses the QCT designation in its Low-Income Housing Tax Credit (LIHTC)
Program as a way to provide additional incentives for the rehabilitation or replacement of
substandard housing. Projects located in QCTs can earn up to 30 percent more tax credits than
identical projects that are not located in QCTs.
The Brain Trust considered using QCT criteria to define ICBT facilities. However, it soon
became clear that creating a definition that mirrored the Qualified Census Tract would be far too
inclusive. Brain Trust members had originally hoped that a QCT-like designation could be more
easily applied to ICBT facilities if restrictions on the population of a QCT in a metropolitan area
were changed from 20 percent to 50 percent. Consultation with QCT experts, however, yielded
the unqualified opinion that this seemingly easy task would be exceedingly expensive and was
likely to yield poor results. Subsequently, the ICBT decided to abandon its hope for a datadefined definition.
Enhanced reimbursement for serving indigent populations. The Disproportionate Share
Hospital (DSH) Program provides special funding to hospitals that treat significant populations
of indigent patients. The program was enacted as part of the Consolidated Omnibus Budget
Reconciliation Act of 1985 and delineates different criteria and payments for Medicare DSHs
and Medicaid DSHs. Hospitals can qualify for DSH status under Medicare if more than 15
percent of their Medicare inpatient days can be attributed either to patients eligible for both
18
Medicare Part A and Supplemental Security Income or to patients eligible for Medicaid but not
Medicare Part A. Large urban hospitals can apply for a special exception if they can demonstrate
that more than 30 percent of their total net inpatient care revenues come from state and local
governments resources for indigent care, other than Medicare or Medicaid.
Under the Medicaid DSH program, the eligibility criteria are different and the payments vary
with each state program. In general, however, eligible hospitals must have a low-income
utilization rate (LIUR) of 25 percent or more, or a Medicaid utilization rate (Medicaid days
divided by total days) that is more than one standard deviation above the mean Medicaid
utilization rate in the state.7
In the primary care sector, nonprofit providers interested in participating in the Federally
Qualified Health Center (FQHC) program must serve a MUA or Medically Underserved
Population and receive grant funding under Section 330 of the Public Health Service Act.
FQHCs are paid on a sliding scale pursuant to a statutory scheme, but their main benefits include
enhanced Medicare and Medicaid reimbursements and malpractice coverage through the Federal
Tort Claims Act (FTCA).8
Because both acute and primary care providers depend heavily on Medicare, their participation
in these programs is effective for them. However, the lack of Medicare density in skilled nursing
facilities in general, and in ICBT facilities in particular, makes it difficult to apply this specific
concept to ICBTs. A better approach might involve a program that could offer ICBT facilities
enhanced Medicaid rates. However, designing such a program would be a challenge since, unlike
Medicare, Medicaid is not a single program. Medicaid rates vary from state to state and, without
a federal mandate, any programs developed by a state to support ICBT facilities would be subject
to annual budget deliberations.
7
The LIUR is the sum of the ratio of Medicaid revenues divided by total revenues and the ratio of inpatient charity
charges divided by total charges. The states allocate funds for distribution on an annual basis. The federal allotment
for FY 2008 was $10.367 billion.
8
Providers that do not receive Section 330 funding can still receive enhanced Medicare and Medicaid
reimbursement but they will not receive the benefits of the malpractice coverage.
19
Pennsylvania’s Disproportionate Share Incentive Payments program. The State of
Pennsylvania provides incentive payments to nursing facilities that serve a high proportion of
medical assistance (MA) residents and have a high overall occupancy rate. To be eligible for the
Disproportionate Share Incentive Payments to Nursing Facilities program, a facility must have
an annual overall occupancy rate of at least 90 percent of total available beds and must have a
MA occupancy rate of at least 80 percent. Facilities participating in the program receive a per
diem incentive payment for MA days of care based on a sliding scale of MA occupancy rates. 9
Exploring the Recommendations
Continue to advocate for increased government support for ICBT facilities.
The Inner City Brain Trust encountered difficulties when attempting to identify existing federal
and state programs that could provide a seamless model for government support of ICBT
facilities. In addition, the ICBT did not perceive any strong support for such a support program
among legislators. The Brain Trust strongly recommends that AAHSA continue its efforts to
raise awareness about ICBT facilities among members of Congress and to identify support
models that could provide ICBT facilities with the financial resources they need.
Seek to include ICBT facilities in pending federal legislation that supports the provision of
long-term services and supports.
AAHSA should continue seeking opportunities to include ICBT facilities in any legislative
initiatives designed to support the work of long-term service and support providers. Specifically,
AAHSA should continue to seek inclusion of long-term care and skilled nursing facilities in
proposed legislation to create Health Empowerment Zones. (See Appendix F for more
information.)
9
Per diem payments for reports ending Dec. 31, 2006, and June 30, 2007 ranged from $7.08 for facilities that had
more than a 90-percent MA occupancy to $.62 for facilities that had a MA occupancy rate between 80 and 82
percent. During the same period, 60 out of 583 facilities – or about 11.8 percent – received incentive payments at a
cost of approximately $16 million.
20
Member Education
Target AAHSA educational programs to ICBT facilities.
Provide ICBT facilities with increased access to AAHSA leadership training programs.
Provide ICBT facilities with workforce training resources.
Increase educational sharing among all types of AAHSA members.
Help ICBT facilities attract good leaders.
Members of the Inner City Brain Trust share the perception that AAHSA’s educational programs
are better suited to the needs of up-scale, long-term care systems than to the needs of ICBT
facilities. Therefore, the members request that, in designing future educational offerings,
AAHSA staff consult with ICBT members to determine their unique information needs and how
educational programs can help meet those needs.
AAHSA staff has already responded to this request by sponsoring a session at the 2009 Annual
Meeting & Exposition entitled ―Inner City Nursing Homes: Challenges and Opportunities.‖ The
session, presented by two ICBT members, explored the difficult issues facing long-term care
facilities serving America’s underserved populations in the inner city. Presenters offered an
update on the Brain Trust’s deliberations and recommendations and shared innovative ideas to
address staff management and other unique issues facing ICBT facilities.
In addition to offering this session, AAHSA identified other annual meeting educational sessions
that might be relevant to ICBT facilities and notified those members about these educational
opportunities. In addition, AAHSA has expressed its willingness to identify and offer financial
assistance to qualified ICBT facilities that apply to Leadership AAHSA, the association’s yearlong leadership development program.
21
Exploring the Recommendations
Target AAHSA educational programs to ICBT facilities.
AAHSA should consider establishing an educational track at its annual meeting that provides
targeted information to ICBT facilities and other facilities that have fewer advantages than the
typical AAHSA member. AAHSA has made modest progress in this regard during 2008 and
2009 and should expand its efforts in 2010.
Provide ICBT facilities with increased access to AAHSA leadership training programs.
AAHSA should provide a way for the cash-strapped ICBT facilities to participate in the
Leadership AAHSA Program.
Provide ICBT facilities with workforce training resources.
AAHSA should make an effort to provide ICBT facilities with the information they need to train
their workers in both clinical and life skills. The association could maintain a database of
community-based life skills training programs and models, as well as other workforce training
programs that might appeal to ICBT facilities. This database, and other training strategies and
resources, could be shared with ICBT facilities through a regular blog and through AAHSA
educational forums. In addition, AAHSA should work to identify existing training models that
address the unique circumstances and needs of ICBT facilities.
Increase educational sharing among all types of AAHSA members.
ICBT facilities could learn a great deal from the experiences of other AAHSA members, but they
don’t always have ample opportunities to interact with these organizations. AAHSA should
explore the possibility of promoting this knowledge sharing among ICBT facilities and other
AAHSA members, including continuing care retirement communities. Such sharing could take
place in formal educational sessions, leadership training workshops and gatherings set up
specifically to bring together ICBT facilities with other AAHSA members.
Help ICBT facilities attract good leaders.
AAHSA should identify strategies to encourage members of minority groups to become board
members or to take on other leadership roles at ICBT facilities.
22
Research
Continue to research issues affecting ICBT facilities.
Use research and other strategies to raise awareness of ICBT facilities among policy
makers and the public.
Throughout its discussions, the Brain Trust acknowledged the need for more research about
ICBT facilities, their residents and communities. The Brain Trust held two conference calls with
Dr. Robyn Stone, executive director of the Institute for the Future of Aging Services (IFAS),
AAHSA’s research affiliate. Dr. Stone helped the group identify and select potential research
topics that could be pursued if funding is secured.
Exploring the Recommendations
Continue to research issues affecting ICBT facilities.
AAHSA should continue to work with IFAS to conduct research and seek grants in support of
the goals identified by the ICBT. The Brain Trust’s research priorities include projects that
study:
1. The impact of ICBT facilities: The ICBT would welcome a research project that tells rich
stories about the history and work of ICBT facilities and the impact their care and services
are having on local communities. These stories could raise awareness about the important
role ICBT facilities play and, as such, could help encourage policy makers to take action to
ensure the sustainability of these organizations.
2. Strategies to expand housing-with-service models. For many years, IFAS has conducted
extensive research on new housing-with-service models that could help older people remain
in their own homes for as long as possible. The Brain Trust expressed interest in having
ICBT facilities included in that research. In response, Dr. Stone agreed to include ICBT
23
facilities in a proposed project to explore expansion of affordable housing for older people, if
funding can be secured.
Use research and other strategies to raise awareness of ICBT facilities among policy makers
and the public.
AAHSA should work to raise public awareness of ICBT facilities through the research projects
mentioned above. In addition, AAHSA and IFAS staff should pursue a strategy to raise public
awareness of ICBT facilities through the media (including but not limited to, AAHSA’s
FutureAge magazine), and through a research grant that allows AAHSA and IFAS to collect the
stories of ICBT facilities and make them available to policy makers and the general public.
Insurance and Purchasing Programs
Revise the marketing strategies for AAHSA insurance and purchasing programs.
ICBT members believe they pay higher prices for insurance and purchasing due to their
locations. The Brain Trust discussed this perception with Ms. Maria Moreno, senior vice
president of Aon Association Services in Chicago, AAHSA’s group insurance program, and
Scott Scurlock, AAHSA’s vice president of shared service and group purchasing.
Ms. Moreno assured the Brain Trust that any incidents of higher insurance rates among ICBT
facilities were most likely due to actuarial risk factors, such as a lack of sprinklers in the facility
or a history of law suits. Ms. Moreno suggested the ICBT facilities have their risks reviewed in
order to ensure that their insurance premiums have been set appropriately.
Similarly, Mr. Scurlock assured Brain Trust members that AAHSA’s group purchasing program
offers the same pricing for ICBT facilities as for other AAHSA members. During the ensuing
discussion, Scurlock discovered that few ICBT facilities use AAHSA group purchasing services.
He suggested that because ICBT facilities are paying ―street prices‖ for the goods they purchase,
they may spend more than facilities that participate in AAHSA’s national purchasing program.
24
Exploring the Recommendation
Revise the marketing strategies for AAHSA insurance and purchasing programs.
Given the misconceptions that ICBT facilities have about AAHSA insurance and group
purchasing programs, AAHSA should ―remarket‖ these programs as a way to ensure that all
association members – particularly ICBT facilities – have a clear understanding of the benefits
and costs of these programs.
Social Capital
Help ICBT facilities capitalize on their social capital.
ICBT facilities have demonstrated their strong commitment to their communities through
decades of service. These facilities typically play a central role in a community’s past history and
in its current life. They serve as a galvanizing force, bringing community residents together to
ensure that older people who require skilled nursing care can stay in their neighborhoods, close
to friends and family and connected to their cultural heritage. This is an important benefit that
other, outside organizations would have difficulty replicating.
In addition to providing high-quality residential care, ICBT facilities actively demonstrate their
passionate commitment to their communities through a wide variety of community outreach
programs. These include adult day services programs and senior centers; transportation, meals on
wheels, wellness and nutrition programs; health and wellness clinics; affordable housing and
services; customized assistance to community residents who want to age in place; and such
social services as family and substance abuse counseling, job training and case management.
ICBT facilities work tirelessly in communities that many other providers might be tempted to
avoid. They care deeply for residents who have unique and complex needs. They were created to
serve the underserved and they have a strong record of doing just that. These homes may have
little tangible capital, but they clearly have abundant ―social capital.‖
25
Exploring the Recommendations
Help ICBT facilities capitalize on their social capital.
ICBT members are tremendously proud of their ―social capital‖ and that pride was contagious
during group meetings. Group members who are not directly associated with ICBT homes felt
the excitement of what was happening in these amazing organizations. That pride, and the social
capital behind it, is an important asset that can be put to work to garner tangible support for
ICBT facilities.
AAHSA should devise strategies for helping ICBT facilities use their social capital to expand
their resources. For example, the association could encourage other AAHSA members, including
CCRCs, to fulfill their own charitable missions and meet their social accountability goals by
partnering with ICBT facilities. Through these partnerships, CCRCs and other AAHSA members
could support ICBT facilities through direct financial assistance or shared training and education
initiatives.
26
Section IV: Other Strategies to Assist ICBT Facilities
In addition to developing formal recommendations for AAHSA action, the Inner City Brain
Trust explored a variety of available resources and strategies that it hoped could help ICBT
facilities improve their financial stability and operational efficiency. During this exploratory
process, the Brain Trust uncovered some strategies that could hold great promise for ICBT
facilities and other strategies that, upon further study, proved impractical.
For example, the Brain Trust explored the possibility that ICBT facilities might consider
establishing facility-based dialysis services as a way to improve their revenue streams while
improving the care they provide to residents suffering from renal failure. However, during a
conference call on the subject, Wayne A. Evancoe, chief executive officer and renal
administrator at The Hortense & Louis Rubin Dialysis Center Inc., in Troy, N.Y., suggested that
while better care might result from on-site dialysis, regulatory issues would make such a venture
impractical for ICBT providers.
Other areas of Brain Trust exploration uncovered promising strategies to help ICBT facilities
improve staff training, align themselves with the Program of All Inclusive Care for the Elderly
(PACE), and use partnerships to strengthen their financial status and operational efficiency.
Improving staff training. Research by AAHSA staff did not yield any specific programs,
operating at the local level, which could offer life skills training to frontline staff in ICBT
facilities. However, AAHSA staff did uncover several organizations that ICBT facilities might
call upon for technical assistance as they sought to meet their unique training needs. (See
Appendix E for a full list of job-training resources.)
For example, Goodwill Industries frequently offers life skills training for individuals who are
enrolled in Goodwill-sponsored job-training programs. In some communities, these courses may
be available to outside organizations in the form of in-service training. In addition, providers
may find it beneficial to consult the local Goodwill program as a way to identify potential
employees that Goodwill has trained through its in-house programs.
27
The aging network in a particular community or state – including the local Area Agency on
Aging – may also be able to help ICBT facilities identify effective job-training programs. In
addition, elder advocacy agencies may have developed their own eldercare job training programs
or may know of existing programs offered in a particular state. The Center for Advocacy for the
Rights and Interests of the Elderly in Philadelphia has developed materials for a 60-hour training
program for direct care workers. The training materials cover such topics as home care, work
ethics and professionalism, scheduling, verbal communications, relationship building,
communication boundaries, care plans, resident dignity, bathing, universal precautions and
infection control. Training tools are available for $150 by mail and can be duplicated by the
facility.
Some states offer grants to long-term care organizations that want to initiate life skills and
remedial job-training programs for their workers. For example, the Extended Care Career Ladder
Initiative, funded by the State of Massachusetts, offers grants to help that state’s providers train
certified nursing assistants and other long-term care workers. Grantees have used program funds
to conduct training on Alzheimer’s disease, English as a Second Language and restorative care.
Aligning with PACE. PACE provides a coordinated package of care and services to frail older
people and people with disabilities who live in the community. PACE organizations use
capitated payments from Medicare, Medicaid and, to a limited extent, private payers to create a
pool of funds that meet the needs of their participants.
The Brain Trust interviewed AAHSA member Bill Healy,10 who established a PACE program in
Detroit, and it toured the PACE program sponsored by New Courtland Elder Services in
Philadelphia. Afterwards, the group concluded that the PACE program is a good fit for ICBT
facilities. In particular, the communities in which ICBT facilities operate have a high
concentration of the type of clients the PACE program was designed to serve: frail elderly who
are eligible for both Medicare and Medicaid.
10
Mr. Healy is chief operating officer of Trinity Senior Living Communities in Livonia, Mich.
28
Unfortunately, ICBT facilities face several obstacles when they attempt to participate in the
PACE program, including the need for a substantial up-front investment. In addition, because
PACE programs are awarded based on their geographic area, a PACE region is typically
assigned to only one provider. In order to make participation more likely, those interested in
starting a PACE program must move quickly to secure a geographic area. AAHSA and the
National PACE Association (www.npaonline.org) stand ready to assist ICBT and other facilities
in this effort.
Improving partnerships. The powerful role that partnerships might play in helping ICBT
facilities meet the challenges they face was a common theme during many of the Brain Trust
discussions. For example, ICBT facilities might be in a better position to establish PACE
programs if they had local partners who could help design and operate the program and bring
needed start-up capital to the venture.
ICBT facilities should take a creative approach to partnerships by proposing collaborations with
organizations that are not currently involved in formal partnership programs. One such potential
partner could be the U.S. Department of Veterans Affairs (VA). While Brain Trust members
were not aware of existing partnerships in which nursing homes collaborated with the VA to
provide specialty care to veterans, they agreed that such partnerships might serve both
organizations by bringing needed revenue to an ICBT facility and saving VA resources. The
Brain Trust agreed to continue sharing creative partnership ideas with AAHSA’s ICBT
members.
29
Section V: Conclusion
As it concludes its work, the Inner City Brain Trust urges AAHSA to remain committed to two
important goals:
1. Raising awareness among AAHSA members, policy makers and the general public about
the value of ICBT facilities and the important role they play in communities around the
nation; and
2. Helping these facilities find the resources they need to carry out their important missions
to serve indigent older people living in medically underserved areas.
On a personal note, ICBT members are grateful to AAHSA for its attention to the needs of these
important nursing facilities. The Brain Trust also recognizes that any success in recognizing and
assisting these facilities will be accomplished over time and through small steps. We do not seek
to change the world overnight; however, we hope that AAHSA will remain steadfast in pursuing
the recommendations enclosed in this report for as long as it takes to bring about meaningful
change.
As its year of deliberations come to a close, ICBT members are convinced that the very existence
of our group has been a major step forward in assisting ICBT facilities and giving them the
resources they need to thrive. Simply knowing that such a group exists – and that the work of our
nursing homes has been acknowledged as an integral part of the field of long-term services and
supports – gives us hope that we are not alone and that our work in medically underserved
communities is valued and will be sustained.
30
Appendix A:
The Commonwealth Fund
In the Literature
SEPARATE AND UNEQUAL: RACIAL SEGREGATION AND
DISPARITIES IN QUALITY ACROSS U.S. NURSING HOMES
David Barton Smith, Ph.D.
Zhanlian Feng, Ph.D.
Mary L. Fennell, Ph.D.
Jacqueline S. Zinn, Ph.D.
Vincent Mor, Ph.D.
Health Affairs
September/October 2007
26(5):1448–58
Full text is available at:
http://content.healthaffairs.org/cgi/content/abstract/26/5/1448?ijkey=etYbkh/J548aw&keytype=ref&siteid=healthaff
For more information about this study, contact:
David Barton Smith, Ph.D.
Department of Risk, Insurance, and Healthcare Management
Temple University
dbsmith@temple.edu
or
Mary Mahon
Senior Public Information Officer
The Commonwealth Fund
212-606-3853
mm@cmwf.org
This summary was prepared by Deborah Lorber.
Commonwealth Fund Pub. 1057
September 2007
In the Literature presents brief summaries of Commonwealth Fund–supported research recently published in professional journals.
THE COMMONWEALTH FUND
ONE EAST 75TH STREET
NEW YORK, NY 10021-2692
TEL 212.606.3800
FAX 212.606.3500
E-MAIL cmwf@cmwf.org
www.commonwealthfund.org
In the last several years, studies have begun to acknowledge the effects of racial segregation
on medical treatment. Researchers have shown that blacks are more likely than whites to seek
care at hospitals with higher surgical mortality rates, receive maternity services at hospitals with
higher risk-adjusted neonatal mortality rates, and receive primary care from physicians who are
less well trained than those who mainly treat white patients.
Now, a new Commonwealth Fund-supported study shows that poorer quality of care in nursing
homes is linked to racial segregation. Black residents, the authors say, are more likely than
whites to live in poor-quality nursing homes marked by significant deficiencies on inspection reports, substantial staffing shortages, and financial vulnerability. The problem seems to be most
acute in the Midwest.
31
In “Separate and Unequal: Racial Segregation and Disparities in Quality Across U.S. Nursing
Homes,” (Health Affairs, Sept./ Oct. 2007), Temple University’s David Barton Smith, Ph.D., and
his colleagues rank metropolitan statistical areas (MSAs) on disparities between blacks and
whites in access to quality nursing homes. Ten of the 20 nursing homes with the greatest
disparities in quality of care, they found, were located in just four states: Wisconsin, Indiana,
Ohio, and Michigan.
How Disparities Were Measured
The authors used 2000 data from the Centers for Medicare and Medicaid Ser-vices and the
nursing home Minimum Data Set to measure the quality of nursing homes and determine the
facilities’ racial composition. To gauge levels of segregation and racial disparities in quality, they
relied on a commonly used index that yields the combined percentage of nursing home
residents of both races who would need to be relocated for there to be an equal proportion of
blacks and whites. The so-called dissimilarity index can range from 0.00 to 1.00, with a score of
1.00 indicating total segregation. The researchers looked at inspection deficiencies, staffing
issues, and financial viability at 7,196 freestanding (i.e., not hospital-based) nursing homes and
their 837,810 residents, representing about 50 percent of homes and 57 percent of residents in
the United States.
Highest Segregation in Midwest
Nationally, the dissimilarity index in 2000 was 0.65, with not-for-profit homes more segregated
than for-profit ones. Region-ally, nursing homes were most segregated in the Midwest and least
segregated in the South. Nursing homes in the Cleveland metropolitan area were the most
segregated, followed closely by Gary, Ind.; Milwaukee; Detroit; Indianapolis; Chicago; St. Louis;
Harrisburg, Pa.; Toledo, Ohio; and Cincinnati.
Blacks make up about 15 percent of all U.S. nursing home residents, yet around 60 percent of
black residents were concentrated in less than 10 percent of those homes, the researchers
found. These homes, they say, tend to be in the bottom quartile with respect to quality.
Black nursing home residents were 1.41 times as likely as whites to be in facilities cited with a
deficiency causing actual harm or immediate jeopardy to residents, and 1.7 times as likely to be
in a nursing home that was subsequently terminated from Medicare and Medicaid participation
because of poor quality. In addition, blacks were 1.12 times as likely as whites to reside in a
nursing home that was greatly understaffed, and 2.64 times as likely to be in a facility housing
predominantly Medicaid residents.
“Blacks and whites aren’t getting different care in the same nursing homes. They’re getting
different care because they live in different nursing homes,” said Vincent Mor, Ph.D., the study’s
lead investigator who chairs the Department of Community Health at Brown University.
According to the researchers, there is a relatively high correlation between nursing home and
residential segregation. Nursing homes may be merely reflecting the racial composition of their
communities, they say.
32
Policy Recommendations
To ensure access to high-quality health care for all nursing home residents, the researchers
recommend the following policy changes:
• Improve payment structures for nursing homes with a high proportion of Medicaid residents;
• Close the gap between the amount paid to nursing homes by Medicaid and private payers;
• Ensure broader regional planning in response to concerns about racial disparities; and
• Monitor admissions practices to ensure they meet the requirements of the Civil Rights Act.
“[D]isparities in treatment will persist even in the absence of any disparities of treatment within
nursing homes because of the differences in the homes providing care to blacks and whites,”
the researchers conclude. “We contend that the same basic message holds, in part, for the
health system as a whole.”
Top MSAs Ranked by Overall Black-White Disparities
Metropolitan Statistical Area
Disparities (1)
Milwaukee-Waukesha, WI
St. Louis, MO-IL
Baltimore, MD
Detroit, MI
Indianapolis, IN
South Bend, IN
Harrisonburg-Lebanon-Carlisle, PA
Hartford, CT
Houston, TX
West Palm Beach-Boca Raton, FL
78
76
71
71
70
67
65
64
64
64
Segregation (2)
0.74
0.70
0.58
0.74
0.72
0.53
0.70
0.64
0.56
0.62
1 A higher overall Disparity Rank Score indicates greater disparity between blacks and whites in access to high-quality nursing
homes in the MSA.
2 Degree of segregation (Dissimilarity Index) among black and white U.S. nursing home residents, 2000.
Adapted from D. B. Smith, Z. Feng, M.L. Fennell, et al, ―Separate and Unequal Racial Segregation and Disparities in Quality
Across U.S. Nursing Homes,‖ Health Affairs, Sept./Oct. 2007 26(5): 1448-58.
33
Appendix B:
The Chicago Reporter
Lower Standards
By Jeff Kelly Lowenstein
Luzella Roberts knew something was wrong when a nurse in the dialysis room at her nursing
home approached her with a syringe and moved it toward her left arm. It was Sept. 25, 2006, and
Roberts’ sixth day at International Nursing and Rehab Center in Chicago’s New City
neighborhood.
There were explicit instructions on her medical chart not to administer dialysis through that arm,
said the family’s lawyer Steven M. Levin. Instead, they were to use a catheter that was surgically
implanted in Roberts’ right arm. It was there for the dialysis treatments that Roberts, an African
American, received three times a week to remove waste from her body, Levin said.
But now, the nurse was preparing to insert the needle in Roberts’ left arm. It was the same arm
that for 60 years had cooked dinner for her husband, dressed her four children, and had three
weeks earlier cupped her newest great-granddaughter.
Roberts didn’t have an M.D. or RN behind her name and thought, perhaps, that the medical staff
knew something she didn’t. So she kept quiet.
An hour went by with the needle still intact. Then two hours. Then three before Roberts’
daughter, Cynthia Wade, stopped by to visit and saw her mother’s arm and face gray and
swollen. Wade began screaming at the nurse to remove the needle. As she did, Roberts’ arm
began to bleed uncontrollably and she was rushed to the emergency room.
An investigation by The Chicago Reporter found that Illinois is arguably the worst state in the
nation for black senior citizens seeking quality nursing home care. There is just one home in
Illinois rated ―excellent‖ by the federal government when more than 50 percent of the home’s
residents are black. In Illinois, these facilities get the worst federal ratings and on average have
more violations than facilities where a majority of residents are white. And in Chicago, on
average, these homes have more medical malpractice and personal injury lawsuits. People in
white homes got better care than those in black homes, even if both were poor.
The Reporter also found that the staff at Illinois’ black nursing homes spent less time daily with
residents than staff at facilities where a majority of the residents are white. Of that time, black
residents got a smaller percentage of time with more-skilled registered nurses than facilities
where the residents were white.
―It is a real big disgrace and another black eye for the state of Illinois and the city of Chicago,‖
said state Rep. Monique Davis. ―It’s almost like being in Mississippi in 1920.‖
A facility can lose its certification and Medicaid funding for failing to meet federal standards.
But the Reporter investigation found that it rarely happens and has occurred with just five of the
34
nearly 16,000 Medicaid-certified U.S. facilities in the past year.
Given the increasing population of seniors nationwide, things could get worse. Experts say the
ranks of seniors who need nursing home and other care will increase from about 8 million in
2000 to 19 million in 2050.
The Reporter analyzed the records of 15,724 nursing homes listed in the federal Nursing Home
Compare ranking database to determine if disparities existed in the quality of care. The overall
rating is based on a combination of health inspection results, staffing levels and how well each
home performs on 10 important aspects of care, like how well residents maintain their ability to
dress themselves and eat. The database includes homes that get some of their money from
Medicaid or Medicare, more than 95 percent of all nursing homes.
The Reporter found that in Chicago, the worst rating—a one on a five-point scale—was given to
57 percent of black nursing homes, compared with 11 percent of white nursing homes.
Excellent ratings were given to no black homes in Chicago and 29 percent of all homes with
majority-white residents. White seniors had qualitatively better nursing home options than black
seniors—in some cases, even when facilities had the same owner.
In Illinois, there is just one excellent-rated nursing home of 51 facilities where more than half of
the residents are black. In nine states—Arkansas, Connecticut, Indiana, Kansas, Kentucky,
Missouri, Oklahoma, South Carolina and Wisconsin— there are none. Illinois, Indiana and Ohio
are the only states in the nation where a majority—more than half—of the black nursing homes
were rated poorly among states with more than three black homes.
Some say the disparities are the result of staffing levels and qualifications. Nearly 85 percent of
the black homes in Chicago received the lowest mark for nursing staff hours. About 21 percent
of the white homes got the same score.
Administrator Joeann Brew of the Avenue Care Center in the Kenwood neighborhood
questioned the ratings because she feels they are given by people who have not stepped inside
any nursing homes. But Francine Rico, who has worked as a certified nursing assistant at the
South Shore Nursing and Rehab Center for 11 years, said the conditions in these homes
negatively impact workers, too.
―Quality care comes when you can give enough time and attention for what the residents need,‖
Rico said.
Wendy Meltzer, executive director of the Chicago-based advocacy group Illinois Citizens for
Better Care, said Illinois is known to have ―ridiculously low‖ minimum staffing ratios. ―We
should adopt the minimum suggested federal staffing ratios, which I think would at least double
the nursing staff, professional and certified, working in Illinois nursing homes,‖ she said.
The quality of staff is also a concern. The Reporter found that white homes were rated
significantly higher for their staffing of registered nurses, who are the most skilled nursing staff.
Excellent ratings were given to white homes 21 percent of the time, compared with just 4 percent
for black homes. Conversely, black homes scored poorly 73 percent of the time, compared with
35
11 percent for white homes.
The Reporter found that poverty did not reduce inequities. Homes where most people were white
got far better care than nursing homes where the majority of residents were black, even if both
were poor.
The Reporter analyzed the ratings for Chicago homes where more than 75 percent of residents’
care was paid for by Medicaid. A quarter of white homes received an excellent rating, compared
with none of the black homes. More than half of the black homes received the worst rating, while
8 percent of white homes earned the same score.
Davis said the disparities demand action. ―We need to pass legislation or withhold the funding
for those locations,‖ she said.
In the past five years, just three Illinois facilities were decertified as a result of their quality
ratings. None were located in Chicago; instead Evergreen Park, Homewood and Urbana.
Janet Wells, policy director for the National Citizens’ Coalition for Nursing Home Reform, said
that shuttering facilities won’t solve the problem because residents often get sent to worse
facilities.
State and federal authorities have taken little action against poorly rated black homes in Illinois.
The International Nursing and Rehab Center, where Roberts began her ordeal, is the only
majority-black facility in Illinois to make a federal list of homes that chronically have poor
ratings. As of May, the home, along with three others, had been on the watch list for 52
consecutive months—longer than any other nursing home in the nation.
―That’s why those homes should be stripped of their funding,‖ said state Rep. LaShawn Ford,
whose Austin neighborhood is predominantly black and has close to 11,000 black senior citizens.
―That’s blatant racism,‖ he said. ―A lot of the times the owners of these nursing homes treat them
[just] as a business. It has to be more of a mission than a business.‖
In 2005, when the International Nursing and Rehab Center first appeared on the list, Cynthia and
Earl Wade weren’t thinking about nursing homes. They were coming up on their 25th wedding
anniversary and wanted to travel. That’s when Cynthia Wade’s father died. After 60 years of
marriage, Wade’s mother, Luzella Roberts, was a widow.
Wade set up a bedroom in the couple’s house and shared evening cocktails of Welch’s grape
juice with her mother, listening to old R&B favorites like The Platters on a record player.
Wade had worked 30 years as an administrative assistant for Central Baptist Church and the
Chicago Public Schools, but realized that she couldn’t take care of her mother and work a fulltime job. So, she quit.
After a few months, Wade realized that she couldn’t care for her mother, even being home all
day. The couple started looking for a nursing home. It wouldn’t be permanent—just 10 days so
that Wade could get a break.
36
The Wades considered homes in the suburbs, thinking they were better. But they were too far to
visit frequently.
Someone suggested they check out International Nursing and Rehab Center. Wade toured the
building, saw the dialysis machine and said the home looked acceptable.
Wade did not know that the home had been sued multiple times since 2004.
The five-star rating system in Nursing Home Compare would not be created for another two
years. With incomplete information, Wade admitted Roberts on Sept. 19, 2006.
Since 2004, International Nursing and Rehab Center has been the subject of 18 lawsuits in Cook
County. It is the fourth highest of the city’s 92 nursing homes analyzed. Seven of the lawsuits
were for medical malpractice or personal injury, and several involved residents’ deaths.
In November 2008, Levin filed a complaint on behalf of Brenda Dawson of Chicago. Her
husband, James Yearwood, was a quadriplegic who required a ventilator and tracheotomy tube to
breathe. The complaint alleged that a nurse, whose job it was to change the oxygen supply, failed
to do so on May 9, 2008. Yearwood went a day without breathing on the ventilator. On May 26,
2008, he died.
South Shore resident Pat Reynolds visits friends and family members at half a dozen nursing
homes. During her visits, Reynolds said staff sometimes did not feed residents dinner. At another
facility, Reynolds saw a woman fall and not get picked up by staff for more than 10 minutes. A
woman from Reynolds’ church was living at the Renaissance at South Shore and complained
about sitting in her feces without help, Reynolds said.
In February, members of the family council at the Renaissance facility at 87th Street sent a letter
to Administrator Juli Foy identifying 11 issues they wanted addressed. Foy did not respond,
according to Lurleatha Ward, the group’s vice president. When contacted by the Reporter, Foy
said she responded to the issues raised in the letter.
The switch to poorer care for black seniors began in the mid-1930s, when the Social Security
Act, which provided money to poor seniors, led to the growth of forprofit homes. This trend
accelerated dramatically with the 1965 passage of the landmark Medicaid legislation.
Susan Reed, a professor and urban health policy researcher at DePaul University’s School for
New Learning, said the new law gave federal money to for-profit homes and had stricter
licensing requirements that homes that were older and operated on smaller budgets, like the Jane
Dent Home on the city’s South Side, struggled to fulfill. This meant that many nonprofit homes
on the city’s South and West sides shut down or moved to the North Side.
For-profit homes have increased their presence in black neighborhoods. In Chicago, all but one,
or 97 percent, of the 30 majority-black homes are for-profit. Schwab Rehabilitation Hospital in
North Lawndale was the exception. By contrast, 29 percent of the 45 majority-white homes were
nonprofit.
Nationally and locally, for-profit homes have received lower ratings than nonprofit facilities. In
37
Chicago, 24 of the city’s 75 for-profit homes received the lowest rating from Nursing Home
Compare, while none of the 17 nonprofit homes earned the same mark. By contrast, six of the
nonprofit facilities received the top rating, and just eight of the for-profit homes got the same
marks.
Vincent Mor, professor and chairman of the Department of Community Health at the Brown
University Alpert Medical School, said the reasons for these different ratings vary. ―There are
big differences in staffing, case mix, location in the country, and [nonprofits] don’t pay real
estate or business tax so [they] can re-invest that money,‖ Mor said.
It was Sept. 25, 2006, and Luzella Roberts’ sixth day at the nursing home, when she was rushed
to the hospital. On Oct. 10, Roberts went to the operating room for a procedure to stem the
bleeding in her arm. The procedure seemed to work, but about a week later, the bleeding
returned. On Oct. 19, Roberts returned to the operating room. And again on Oct. 25.
―I was hoping that [the bleeding] would stop and things would go back to normal,‖ Wade said.
The songs her mother loved no longer moved her. Her smile disappeared and was replaced by a
blank expression.
―Even though she was there, she wasn’t there,‖ Wade said. The physician said they could do
nothing more. On Oct. 29, Luzella was placed on hospice. Two days later, she died.
Lawyers for the nursing home declined to comment. A manager and owners in a statement to the
Reporter denied knowledge of the incident.
Wade filed a lawsuit July 25, 2008, alleging that the home’s negligence led to her mother’s
death. Depositions are currently being taken, and Wade is seeking at least $50,000 in damages.
―I miss my mother,‖ Wade said. ―People have to be accountable for what they are doing to
another person.‖
Stephanie Behne, Jennifer Fernicola, Mike Jakubisin, Marian Wang and Jessica Young helped
research this article.
http://www.chicagoreporter.com/index.php/c/Cover_Stories/d/Lower_Standards
38
Appendix C:
ICBT Facility Statistics from Nursing Home Compare
1
Staff Hours Staff Hours Care
Per
Per
Findings
Resident
Resident
for
for CNAs
11
RN/LPN
1hr, 34m
2hr, 55m
0
2
1h, 8m
1h, 40m
0
3
1h, 15m
2h, 10m
6
6 @ 2 level
4
1h, 53m
2h, 11m
23
5
52m
1h, 44m
4
22 @ 2 level
1 @ 3 level
4 @ 2 level
6
1h, 14m
1h, 46m
2
2 @ 2 level
7
2h, 13m
2h, 7m
1
1 @ 2 level
8
1h, 21m
2h, 8m
16
16 @ 2 level
9
NA
NA
5
10
1h, 5m
2h, 43m
6
11
1h 20 m
2h 18m
12
5 @ 2 level
1@ level
1 @ 1 level
4@ 2 level
1 @ 3 level
12 @ 2 level
12
1h 21m
2h 6m
3
3 @ 2 level
11
Levels of findings
CMS converts the staffing hours reported by the nursing home into a measure that shows the number of staff
hours per resident per day. The staffing hours per resident per day are reported by type of staff, and all staff
combined as a total.
39
Appendix D:
Model Program Comparison Chart
PROGRAM
Low-Income
Housing Tax
Credit
(Qualified
Census Tract
(QCT))
BENEFIT
Dollar-fordollar tax
credit with
special
incentives for
QCT location.
ELIGIBILITY
Acceptance
through state
housing finance
agency. Higher
credits allowed if
located in QCT.
PURPOSE
Spur private
equity to
develop and
increase lowincome
housing.
SIZE
Over $758
million in
credits
available in
2006. More
than 8,500
QTCs.
Empowerment
Zones (EZ)
Grants, tax
incentives to
businesses.
Location in
federally
designated area
determined by
competitive
application
process.
Spur job
growth and
economic
development
in highpoverty areas.
Renewal
Communities
(RC)
Tax incentives
for business.
Location in
federally
designated area.
Federally
Qualified
Health Centers
(FQHC)
Enhanced
reimbursement
rates,
participation
in Federal Tort
Claims Act.
Nonprofits that
provide primary
care services to
all ages of a
Medically
Underserved
Population
(MUP) or in a
MUP.
Spur job
growth and
economic
development
in highpoverty areas.
Help serve
MUPs.
$100 million
to urban EZs
and $40
million to
rural EZs in
1994. In 1999
and 2002, 20
EZs received
$3.8 billion.
Eligible
communities
to share $17
billion in tax
incentives.
40
$778 million
in FY 2004.
OVERSIGHT
U.S.
Department of
Housing and
Urban
Development
(HUD) and
each state’s
Housing
Finance
Agency.
HUD, the U.S.
Department of
Agriculture and
local entities.
HUD and local
entities.
U.S.
Department of
Health and
Human
Services (HHS)
and the Centers
for Medicare
and Medicaid
Services
(CMS).
PROGRAM
Disproportionate
Share Hospitals
BENEFIT
Enhanced
payments
under
Medicare
and
Medicaid
Disproportionate
Share Payments to
Nursing Homes
(Pennsylvania)
Per diem
incentive
payments.
ELIGIBILITY
Medicare DSH:
DSH patient
percentage or
special exception.
Medicaid DSH:
Low-income
utilization rate or
abnormally high
percentage
compared to state
median.
Overall
occupancy of 90
percent or greater
and medical
assistance (MA)
occupancy of 80
percent for
greater.
41
PURPOSE
Designed to
compensate
hospitals that
treat a greater
proportion of
low-income
persons.
SIZE
Medicare
DSH: $8.5
billion in
2004.
Medicaid
DSH:
$10.367
billion in FY
2008.
OVERSIGHT
HHS/CMS.
Incentive
payments to
facilities that
treat high
percentage of
MA
residents.
$16 million
between Dec.
31, 2006 and
June 30,
2007.
Pennsylvania
Department of
Public Welfare,
Office of
Medical
Assistance
Programs.
Appendix E:
Workforce Training Programs
Programs Available Nationally
Simple Savvy
Wisconsin Association of Homes and Services for the Aging (WAHSA)
Madison, Wisconsin
(608) 255-7060
http://www.wahsa.org/simsav.pdf
Description: Well-received by WAHSA members, this program trains certified nursing
assistants (CNA) and other direct care workers using video tapes and/or compact discs,
posters, booklets, games and cards.
Curriculum content: Stress management, personal health, balancing work and home,
handling personal problems on the job, reaching goals, accepting limits, personal
responsibility, anger control, relationships, hygiene, business dress, pager/cell phone
courtesy and body language.
Cost: For one shipment to one address, costs are as follows: Video tape or CD: $10;
booklets (set of 50): $25; cards (set of 50): $10; posters (set of 2): $6; game: $20. For
multiple shipments, costs are $15 for video or CD; $30 for booklets, $20 for cards, $10
for posters and $30 for games.
Competency with Compassion: A Universal Core Curriculum
Center for Advocacy for the Rights and Interests of the Elderly (CARIE)
Philadelphia, Pennsylvania
(215) 545-5728
http://www.carie.org
Description: This training program for direct care workers was developed during the
Better Jobs Better Care grant program, which was managed by AAHSA’s Institute for the
Future of Aging Services. Training materials include written handouts, instructor slides,
teaching manual, a compact disk and teaching games.
Curriculum content: Sixty hours of training cover such topics as: home care, work ethics
and professionalism, scheduling, verbal communications, relationship building,
communication boundaries, care plans, resident dignity, bathing, universal precautions
and infection control.
Cost: Hard copy of training manual and tools: $150; materials plus CD format: $225; CD
alone: $150. All materials may be duplicated by the facility.
42
Building One Team
National Association of Health Care Assistants
Washington, D.C.
(800)784-6049
http://www.nahcacares.org
Description: This training curriculum for administrators, nurses, CNAs and department
heads features written materials, group exercises and a human interaction self-assessment
tool called Johari’s Window. A budgeting course is currently under development.
Curriculum content: Workforce values, team roles and impact, investment in
communications skills and listening, ownership and responsibility for scope of practice,
and expansion of roles.
Cost: $2,000 for a two-day block, plus expenses. Organizations can divide their
employees into two blocks of one day each.
Pep Talks
National Association of Health Care Assistants (NAHCA)
Washington, D.C.
(800) 784-6049
http://www.nahcacares.org
Description: Pep Talks are 20-minute, single-topic presentations, available on DVD,
which are designed to motivate and inspire CNAs. Sessions include humorous, poignant
and practical information.
Cost: $120 per year. A year’s subscription to Pep Talks is included in NAHCA
membership.
Growing Strong Roots: Peer Mentoring for CNAs
Foundation for Long Term Care (FLTC)
Albany, New York
(518) 449-7873
http://www.nyahsa.org/foundation/55112501.pdf
Description: The focus of this training program is how to be a peer mentor to new CNAs.
However, the program also emphasizes effective communication within and outside the
nursing home. Participants consistently report that the training is useful in helping them
state needs and handle conflicts in their personal lives. The training materials consist of
three training manuals: one for administrators who will implement the program; one for
the original training sessions and one for booster sessions. A CD contains all training
materials and handouts. The program can be taught by nursing home staff, but FLTC also
provides a training package with an experienced trainer.
43
Cost: $200, postage paid, for three training manuals and all Power Points and handouts
needed for training. The cost is $5,000 for materials and a professional trainer who
conducts two on-site training sessions. FLTC recommends that state associations sponsor
the training so many providers can benefit and share the cost.
B & F Consulting
Description: B&F Consulting offers separate training programs for direct care staff,
managers and leaders of long-term care organizations. Training programs are customized
for each client. Trainers help employers identify particular needs and adjust training
accordingly.
Curriculum content: Training for direct care staff covers such topics as: communication,
relationship building, teamwork, collaborative problem-solving, diversity, leadership
development, peer mentoring, person-centered care, stress reduction and self care.
Cost: A full day, one-time training costs $3,000-$4,000, plus expenses. A series of
training programs over longer period would be billed at a discounted rate.
Programs Available Locally
Project STRIDE
University of Arizona Cooperative Extension
Maricopa County Cooperative Extension
Phoenix, Arizona
(602) 470-8086
http://ag.arizona.edu/impacts/2001/14.pdf
Description: Through this program, which is funded by a grant from the City of Phoenix,
the University of Arizona Cooperative Extension offers life skills training to low-income
families, unemployed individuals and people who are hard to place in permanent
employment. During this intensive program, participants attend eight-hour classes that
meet five days a week for nine weeks. This demanding time commitment makes Project
44
STRIDE impractical for current nursing home employees. However, the program could
be a source of prospective employees.
Curriculum content: Personal development, time management, resources for
emergencies, budgeting, conflict resolution, self esteem, teamwork, parenting, balancing
work and family, computer skills and preparation for the General Education Development
test.
Goodwill Industries
Cleveland, Ohio
(800)942-3577
http://www.goodwillclevecanton.org/?p=work-adjustment
Description: This Work Adjustment Program serves individuals who exhibit a lack of
understanding of work demands, inappropriate work behaviors, marginal productivity, limited
work skills and insufficient job survival skills. Most participants are referred to the program,
which features one-on-one assistance, lectures and discussions.
Extended Care Career Ladder Initiative (ECCLI)
Commonwealth Corporation
Boston, Massachusetts
(617) 727-8158
http://www.commcorp.org/
Description: Funded by the State of Massachusetts, this initiative offers grants to
providers who are seeking to train CNAs and others in the long-term care workforce. The
ECCLI program does not provide direct training. Grants to fund training are available
only to providers in Massachusetts.
Curriculum content: Alzheimer’s disease, English as a Second Language and restorative
care.
45
Appendix F:
Summary of Legislation to Designate Health Empowerment Zones
111th CONGRESS
1st Session
H. R. 2233
To authorize the Secretary of Health and Human Services to designate health empowerment
zones, and for other purposes.
IN THE HOUSE OF REPRESENTATIVES
May 4, 2009
SEC. 3. FINDINGS.
(a) Findings - The Congress finds the following:
(1) Numerous studies and reports, including the National Healthcare Disparities Report and
Unequal Treatment, the 2002 Institute of Medicine Report, document the extensiveness to which
health disparities exist across the country.
(2) These studies have found that, on average, racial and ethnic minorities are disproportionately
afflicted with chronic and acute conditions – such as cancer, diabetes, and hypertension – and
suffer worse health outcomes, worse health status, and higher mortality rates than their White
counterparts.
(3) Several recent studies also show that health disparities are a function of not only access to
health care, but also the social determinants of health – including the environment, the physical
structure of communities, nutrition and food options, educational attainment, employment, race,
ethnicity, geography, and language preference – that directly and indirectly affect the health,
health care, and wellness of individuals and communities.
(4) Integrally involving and fully supporting the communities most affected by health inequities
in the assessment, planning, launch, and evaluation of health disparity elimination efforts is
among the leading recommendations made to adequately address and ultimately reduce health
disparities.
(5) Recommendations also include supporting the efforts of community stakeholders from a
broad cross section – including, but not limited to, local businesses, local departments of
commerce, education, labor, urban planning, and transportation, and community-based and other
nonprofit organizations – to find areas of common ground around health disparity elimination
and collaborate to improve the overall health and wellness of a community and its residents.
46