Consumer backlash could mean more cogs in federal regulatory machine

Consumer group’s study highlights different perspectives on subacute care

A new report on subacute care has confirmed nursing home providers’ suspicions that while they feel their industry self-regulates and needs fewer — not more — mandates, consumers across the country are arguing the opposite and have drawn the proverbial "line in the sand."

Providers want to see certain nursing home regulations made less stringent for subacute care patients, whereas consumers say they oppose weakening any regulations and support developing new regulations, says Cynthia Rudder, PhD, director of the Nursing Home Community Coalition of New York State (NHCC) in New York City.

NHCC, which produced the January 1997 report titled Subacute Care in Nursing Homes based on nationwide response, is a consumer advocacy group that represents a coalition of 33 consumer, civic, and professional organizations. Nursing home providers are not members. (See study’s recommendations for mandates, p. 51.)

"The basic difference between providers and consumers on this issue is that providers don’t want it to be mandated; they’d like to see these guidelines, but they want to have flexibility to do certain things," Rudder says. "But consumers believe it must be mandated because they’re concerned about those providers who won’t give good care."

A survey was sent to consumer advocates nationwide, and a slightly different version was sent to New York nursing home providers.

Nursing home administrators who answered the survey said they wanted to see the following changes in subacute care:

More flexible rules for transferring and discharging patients. Specifically, some administrators objected to a Medicare and Medicaid requirement that a patient must be given a 30-day notice before being discharged. Also, New York state requires a 30-day notice given to residents who are going to be moved from their room to another location in the facility, unless there’s an emergency or the resident requests the move. Providers say this can tie up subacute beds unnecessarily.

More flexible requirements for social activities and dental care for subacute patients. New York state has strict rules for completing oral examinations and screening for dental problems soon after a patient is admitted to a nursing home.

Different time schedules for assessments and shorter assessment tools to suit short stays. Federal regulations say a patient must be assessed within 14 days of being admitted and anytime the patient’s condition significantly improves or declines. Providers thought the requirements were too cumbersome and not appropriate for short-term stays.

Consumer advocates also had concerns about transferring and discharging patients. Some said they were worried that facilities were not preparing patients for the moves.

"They were concerned about what would happen to patients who no longer needed subacute care," Rudder says, explaining that some patients who start in subacute care units might need long-term nursing home care when their subacute care ends. The consumer advocates expressed concerns that these types of patients would be discharged when insurance benefits ran out.

"What they were also afraid of was that the traditional nursing home residents would be forced to leave a room or floor that they had been living in for years so a subacute unit could be put in," Rudder adds.

The coalition mailed 660 surveys going to every nursing home provider in New York state and had a response rate of 37.3%.

The survey was delivered to 301 consumer advocates (including each state ombudsman) in every state except New York because subacute care wasn’t a strong force in New York when the survey started and the group didn’t think consumers would have much knowledge of it. The consumer surveys were sent to more consumer advocates in states that have high numbers of subacute care services: Arizona, California, Ohio, Massachusetts, Florida, and Texas. The response rate was 46.5%.

Two-thirds of the 245 New York nursing home providers who responded to the survey said the existing nursing home regulations should be changed for subacute care providers. But most of these providers said the current regulations should be waived or changed to be more flexible for subacute care.

Of the 140 consumer advocates in 37 states who responded to the survey, 53.4% said the current regulations should remain the same, and in some instances, strengthened.

Cobble Hill Health Center of Brooklyn, NY, which recently opened a subacute care unit, has some problems with current regulations about transferring and discharging subacute patients. This also was mentioned by many of the providers surveyed. "It’s a very big issue," says Ida Campomanes, RN, assistant administrator.

"I wish the state of New York would expedite changes on these issues," Campomanes says.

The 30-day notice for discharging patients doesn’t work for short-term patients, she says.

The requirement doesn’t mandate a 30-day notice when the patient won’t be admitted for that long, but that hasn’t been made clear to many nursing homes, the report said.

Campomanes says Cobble Hill now gives a discharge notice to a two-week patient when the patient is admitted.

Cobble Hill has 520 nursing home beds, 80 medical subacute beds, 40 short-term rehabilitation beds, 80 beds for Alzheimer’s patients in the beginning stages of the disease, and 40 for advanced Alzheimer’s patients.

Campomanes also says she disagrees with the state requirement to provide a dental screening for all nursing home patients within seven days. "But if a resident needs dentures, do we close our eyes and say you must wait until you go home," she asks, "or is it our obligation to provide dental care during the 30 days the patient is here?"

As other New York providers indicated, Campomanes says she’d also like to see changes in requirements of recreation and activities for the short-term subacute patients.

One provider told Rudder in a follow-up phone call that subacute patients tend to be younger than the long-term nursing home patients. So they have little need for the type of daily activities the long-term residents enjoy. For one thing, these patients often have therapies during the day, so they can’t participate in many scheduled activities.

Cobble Hill’s subacute patients tend to be much younger than the typical nursing home population, Campomanes says.

The New York providers who answered the survey also said the current state and federal mandates, combined with accreditation agency requirements, provide enough regulations, so there shouldn’t be a national move to add more subacute mandates. (See Story on Joint Commission’s suggestions for national mandates, p. 53.)

They said they already are meeting the stringent requirements of the Joint Commission on Accreditation of Healthcare Organizations in Oakbrook Terrace, IL. Some providers also are accredited by the CARF ... The Rehabilitation Accreditation Commission in Tucson, AZ.

"Without question, I think the state, federal, Joint Commission, and in our particular case, CARF accreditation requirements clearly meet the requirements of excellent care," says Eric Kalt, MBA, FACHCA, administrator of Clove Lake Health Care and Rehabilitation Center in Staten Island, NY. The facility has 576 beds, including 100 subacute short-term beds that combine medical and rehabilitation services.

Kalt says he has briefly reviewed the report, and he thinks the coalition missed an opportunity to assess customer satisfaction with subacute facilities in New York. "If you’re going to present a report of this magnitude, it’s important to have a data delivery system in this state," he emphasizes.

[Editor’s note: You can obtain a copy of the 110-page report for $21.50, which includes postage and handling. Also, the coalition sells an 18-page booklet titled Subacute Care in Nursing Homes — What You Should Know, written for consumers for $2. The total price for both is $23.50. For more information, write to the Nursing Home Community Coalition of New York State, 11 John St., Suite 601, New York, NY 10038. Telephone: (212) 385-0355. Fax: (212) 732-6945.]