AARP report: States’ care for seniors “painfully inadquate”. Major gaps in RI

Published in RINewsToday on October 2, 2023

Last week, the Washington, DC-based AARP released its latest Long-Term Services and Supports (LTSS) Scorecard, calling care provided to seniors and persons with disabilities during the last three years after the COVID-19 pandemic “painfully inadequate.”  This nine-page report detailed state specific data, finds major gaps in providing care in every state, including Rhode Island, especially in these categories:  “Housing for Older Adults”, “Home Care Costs” and “Home Health Aide Supply”. 

The LTSS Scorecard, consisting of 50 indicators, focused on: affordability and access; choice of setting and provider; safety and quality; support for family caregivers; and community integration, using data from a variety of publicly available sources, such as the Centers for Medicare and Medicaid Services, American Community Survey, and Bureau of Labor Statistics.

Many benefits of accessing the data

According to AARP, this Scorecard can be a roadmap for improving the LTSS systems and the lives of those who rely on assistance.  Many others will benefit by reviewing this data, too. Federal, state, and local policy makers can identify priorities and ensure resources are allocated equitably. Aging advocates can glean public data and hold government officials accountable. Family caregivers can identify needed resources and become actively involved in policy discussions and advocacy. Seniors relying on long-term care programs and services can learn to inspire culture change and demand available tools. Finally, employers can improve workplace policies and practices to assist caregivers and healthcare groups so they can explore public-private partnerships and alliances. 

Like the findings reported in AARP’s LTSS Scorecard in 2020, Rhode Island ranked 12th in the country in 2023, but this year’s Scorecard reveals that the state has made some progress in improving care options for older Rhode Islanders, specifically the enrollment in the Program of All-Inclusive Care for the Elderly (PACE), as well as the availability of Adult Day Services.

“The pandemic reinforced the need to strengthen long-term care for countless loved ones across the country, including here in Rhode Island,” said AARP Rhode Island State Director Catherine Taylor in a Sept. 28th statement announcing the release of the 2023 LTSS Scorecard. 

“AARP’s Scorecard shows that there are many roads to meet the needs of all Rhode Islanders who deserve the very best care, including the 121,000 family caregivers in our state. The overwhelming majority — 87% — of Rhode Islanders age 45+ would prefer to receive care for themselves or loved ones at home with caregiver assistance. Yet, our low rankings in Housing for Older Adults (51st), Home Care Costs (43rd) and Home Health Aide Supply (41st) underscore how difficult it is for them to age the way they choose. It’s time to accelerate our efforts, for the sake of saving more lives,” she says.  

RI is dead last in housing

“In particular, Rhode Island’s dismal ranking for Housing for Older Adults – dead last – points to the urgent need to increase the supply of affordable, accessible housing. We can do that by passing legislation early in 2024 to strengthen homeowners’ ability to build an accessory dwelling unit (ADU) to allow them to age in place, support a family member, or house a caregiver,” Taylor said.

A national snapshot of the LTSS Scorecard’s 2023 Data

According to Scorecard, 12 states, including Rhode Island, have enacted paid family leave laws and 18 states have paid sick day laws, which can be used to assist caregivers. AARP’s latest Scorecard also reported that only 6 states provide a tax credit for family caregivers’ out-of-pocket expenses. Rhode Island does not provide a tax credit – nor is it among the 7 states that have statewide laws protecting caregivers from discrimination in the workplace that ensure they are not unfairly treated due to caregiving duties outside of work.

Meanwhile, it was reported that dozens of states experienced declines in the number of care choices that help support family caregivers. For instance, 16 states, including Rhode Island, had declines of 10% or more in access to home health aides since 2019. 

Regarding Home and Community-Based Services (HCBS), the LTSS Scorecard reported that 11 states, including Rhode Island, had state policies that improve presumptive eligibility for Medicaid HCBS at the time of data collection, making it possible for people to go home to receive care after being in the hospital – rather than having to be admitted to a nursing home while their eligibility for Medicaid payments is being determined.

The research indicated that many states also have large numbers of people with low care needs living in nursing homes, indicating a lack of HCBS access and services. More than 20% of nursing home residents in Rhode Island have low needs – compared to 9% nationally.

Data confirms Major Workforce Crisis in nursing facilities across US

As to nursing homes and institutional care, the AARP’s 2023 Scorecard confirmed that a  major workforce crisis exists in facilities across the country. Across all states, wages for direct care workers are lower than wages for comparable occupations, with shortfalls ranging from $1.56 to $5.03 per hour. In Rhode Island, wages are $1.79 lower than other entry level jobs.   

Nationally, more than 50% of nursing staff in nursing facilities leave their job within a year (53.9% turnover rate). However, in Rhode Island, the rate is slightly better than the average, at 49.3% – with Montana, Vermont, and New Mexico experiencing the highest averages in staffing turnover.  

Staffing disparities are also a significant challenge, say researchers, noting that residents of nursing facilities with high admissions of Black residents receive almost 200 fewer hours of care per year compared to residents of facilities with high admissions of white residents. 

According to the LTSS Scorecard, only 22% of nursing facility residents live in a facility with a 5-star rating in the US – with less than the national average, about 20.2%, of Rhode Island residents living in a 5-star facility. Gaps in workforce and equity result in persistent problems in care, say the researchers. One measure, pressure sores, can be life-threatening as they can lead to bone or joint infections, cancer, and sepsis. In this measure, 10% of facility residents nationwide experienced a pressure sore.

Finally, this year’s Scorecard announced that there is progress being made to create innovative and effective alternatives to traditional nursing facility models. Specifically, the researchers say that 10 states, including Rhode Island, made strides in nursing home innovations, such as by utilizing Green House® Nursing Home availability and policies, which includes small facilities, private rooms, and other best practices.

AARP’s 2023 LTSS Scorecard identified recommendations that can fix the nation’s delivery of long-term care programs and services to enable seniors to age in place in their communities. It called for increasing support to the nation’s 48 million family caregivers, “who are the backbone of the long-term care system, providing over $600 billion in unpaid care, such as with paid leave, tax credits, and other mechanisms to address health and financial needs.”

AARP Rhode Island continues to call on the Rhode Island General Assembly to support the state’s 121,000 family caregivers by advocating for enhancements to the state’s Temporary Caregivers Insurance program.

Recommendations on enhancing Long-Term Services and Supports

The Scorecard’s recommendations also called for investing in states’ Home and Community-based Care Infrastructure, by increasing support and training for home health aides and home visits, supporting the ability to access and use medical devices and equipment, and updating key Medicaid regulations and payment models.  

To tackle the workforce crisis, a recommendation suggests that it is crucial to support both nursing facility and in-home workforce by improving recruitment and training, increasing pay, and expanding the ability of trained nurses, aides, community health workers and other paraprofessionals to take on some aspects of care. States can choose to enact and enforce staffing and related care standards.

A recommendation also calls on States to expand the use of innovative, effective models for nursing homes can improve both quality of care and quality of life, such as with smaller facilities and private rooms and to address inequities by investing to close the staggering gaps in access to quality care and facilities and staffing shortages.

(Editor’s Note:  During the pandemic, then Governor Gina Raimondo allocated $5 million towards 2 changes in nursing homes – making all rooms private and providing non-shared, private bathrooms – for all residents – efforts to follow up on this effort have not resulted in what happened to that initiative according to the RI Department of Health).

Another recommendation urges states to create multisector plans for aging and building of coalitions and age-friendly health systems, to help seniors to age in place at home by having affordable and accessible housing and transportation, improved community design, and comprehensive emergency preparedness plans.

Researchers also suggested the advancing innovation in cities, counties, and states by supporting comprehensive state- and community-wide aging plans and piloting new approaches and programs, like Green House® Nursing Homes and presumptive eligibility, that can then be scaled.

Finally, Climate Change is increasing national disasters, and the LTSS Scorecard recommends that every state have a sound emergency preparedness plan to support nursing home residents, in particular, in times of crisis – including natural disaster.

“AARP’s LTSS Scorecard shows some progress and innovation, but there’s still a long way to go before we have systems that allow people to age well, and independently, for as long as possible and support the nation’s 48 million family caregivers. It’s also clear some emerging issues deserve more attention – from whether nursing homes are prepared to confront natural disasters, to whether they have plans in place to maintain and grow their workforces,” says Susan Reinhard, Senior Vice President, AARP Public Policy Institute.

The LTSS Scorecard is a charitable project made possible by a grant from AARP Foundation, with support from The SCAN Foundation, The Commonwealth Fund, and The John A. Hartford Foundation, and has been updated every three years since 2011.

To view the full Scorecard and state-by-state information visit https://ltsschoices.aarp.org/ 

To view the Scorecard for specifically Rhode Island, go to:  https://ltsschoices.aarp.org/scorecard-report/2023/states/rhode-island.

To view Previous Scorecards (2011, 2014, 2017 and 2020) go to https://ltsschoices.aarp.org/scorecard-report/report-archive/

Increased funding must be tied to nursing home mandated minimum staffing

Published in RINewToday on Sept 25, 2023

The Centers for Medicare and Medicaid Services (CMS) issued a proposed rule to establish comprehensive staffing requirements for nursing homes—including, for the first time, national minimum nurse staffing standards. The proposed rule seeks to would ratchet up the quality of care in the nation’s 18,700 skilled nursing facilities, delivering care to 1.2 million residents each day.

“Establishing minimum staffing standards for nursing homes will improve resident safety and promote high-quality care so residents and their families can have peace of mind,” said HHS Secretary Xavier Becerra in comments on Sept. 1, 2023. “When facilities are understaffed, residents suffer. They might be unable to use the bathroom, shower, maintain hygiene, change clothes, get out of bed, or have someone respond to their call for assistance. Comprehensive staffing reforms can improve working conditions, leading to higher wages and better retention for this dedicated workforce,” says Becerra.

The Nuts and Bolts of CMS’s proposed ruling

Under CMS’s proposal, nursing homes participating in Medicare and Medicaid would be required to meet specific nurse staffing levels that promote safe, high-quality care for residents. Nursing homes would need to provide residents with a minimum of 0.55 hours of care from a registered nurse per resident, per day, and 2.45 hours of care from a nurse’s aide per resident, per day, exceeding existing standards in nearly all states. CMS estimates approximately 75% of nursing homes would have to strengthen staffing in their facilities. As the long-term care sector continues to recover from the COVID-19 pandemic, the proposed standards take into consideration local realities in rural and underserved communities through staggered implementation and exemptions processes.

In addition, nursing homes would also be required to ensure a registered nurse is on site 24 hours a day, 7 days per week, and to complete robust facility assessments on staffing needs. Facilities would continue to be required to provide staffing that meets the needs of the individual residents they serve, which may require higher levels of staffing above the proposed minimum standards.  

CMS also proposed to require states to collect and report on compensation for workers as a percentage of Medicaid payments for those working in nursing homes and intermediate care facilities. These policies build on CMS’ recent proposals to support compensation for direct care workers in home and community based settings and to publish Medicaid data on average hourly pay rates for home care workers. This enhanced transparency will aid efforts to support and stabilize the long-term care workforce across settings strengthening access to high-quality long-term care both at home, in the community as well as in nursing homes and other facilities.

Attracting and supporting Nursing Home staff

Additionally, CMS announced a national campaign to support staffing in nursing homes. As part of the HHS Workforce Initiative, CMS will work with the Health Resources and Services Administration and other partners to make it easier for individuals to enter careers in nursing homes, investing over $75 million in financial incentives, such as scholarships and tuition reimbursement. This staffing campaign builds on other actions by HHS and the Department of Labor to build the nursing workforce.

More than 500,000 direct care workers provide care in nursing homes, assisting residents with daily tasks, such as bathing, dressing, mobility, and eating. This work, often performed primarily by women of color, is significantly undervalued. Direct care workers across long-term care settings earn low wages, rarely receive health and retirement benefits, and experience high injury rates. Improving working conditions and wages will lead to improvements in the recruitment and retention of direct care workers and enable nursing staff to provide safer care.  

CMS and the HHS Office of the Inspector General called for increased transparency and enhance enforcement of existing standards. This would result from increased audits of nursing homes’ staff, improving nursing  home inspections, oversight as to how nursing homes spend taxpayer dollars and cracking down on prescribing inappropriate antipsychotic drug prescribing practices.  The proposed rule would also undertake new efforts to improve resident safety during emergencies. 

Mandating more staffing during a severe labor shortage – pushback on an unfunded mandate

“It is unfathomable that the Biden administration is proceeding with this federal staffing mandate proposal. Especially when just days ago, we learned that CMS’ own study found that there is no single staffing level that would guarantee quality care, says Mark Parkinson, President and CEO of the American Health Care Association, a national nursing home trade group representing 14,000 nursing homes and other long-term care facilities across the nation taking care of five million residents each year.

“At the very same time, nursing homes are facing the worst labor shortage in our sector’s history, and seniors’ access to care is under threat. This unfunded mandate, which will cost billions of dollars each year, will worsen this growing crisis, warns Parkinson, noting that the proposed rule requires nursing homes to hire tens of thousands of nurses that are simply not there and then penalizes the facilities and threatens to displace hundreds of thousands of residents.

“Already, hundreds of nursing homes across the U.S. have closed because of a lack of workers,” states Parkinson. 

​John E. Gage, President, and CEO of the Rhode Island Health Care Association, with offices in Warwick, agrees with Parkinson’s assessment of the harm such proposals will trigger and its devastating impact on nursing homes and residents. “The federal staffing proposal is unfunded and is being implemented at a time when additional staff is simply not available,” he said.  

According to Gage, six Rhode Island-based facilities have closed since the beginning of the pandemic in March 2020. Three others are currently in receivership. Arbitrary federal staffing mandates will result in more closures, and residents will be displaced from their homes just as they were most recently when Charlesgate Nursing Center in Providence was forced to close because of skyrocketing costs, a scarcity of staff and chronically inadequate Medicaid funding. 

Unintended consequences of mandating minimum staffing

James Nyberg, president, and CEO of LeadingAge Rhode Island, with offices in East Providence, views see a staffing ratio mandate as a blunt enforcement instrument that does not consider the numerous challenges facing providers, including Medicaid underfunding, lack of workforce, and the diversity of resident needs. Moreover, the imposition of severe financial penalties on homes that are unable to meet a staffing ratio is counterproductive: fines siphon off scarce resources that providers need as they seek to address their workforce and resident care needs,” he says. 

“Our state’s experience illustrates the numerous challenges and unintended consequences of a staffing ratio mandate: the severity of fines, how compliance is measured and calculated, compliance costs, backlogs of people in hospitals waiting for skilled nursing care after admissions have been reduced due to a lack of staff and other access-related issues,” notes Nyberg, noting that even those homes that are currently able to comply with the staffing ratio are doing so at an unsustainable cost. 

While Kathleen Heren, executive director of the Alliance for Better Long-Term Care and the state’s Long-Term Care Ombudsman, supports HHS’s minimum staffing standard, the administration must adequately fund to train recruited workers and to pay a livable wage to retain them. “Rhode Island doesn’t have an issue with its nursing home inspection process as other states do, she says, noting that newly hired RI Department of Health surveyors are “doing a great job.” 

“RIDOH surveyors only cite facilities, when necessary,” says Heren, noting that administrators can challenge any cited deficiency if they view it as unfair, and she doesn’t see a problem in the use of antipsychotic medications in Rhode Island facilities “but acknowledges that there’s always room for improvement.”

Direct Caregivers, mainly women, undervalued despite significant work demands

“Almost 80 percent of nursing home care is paid for with government programs (Medicare and Medicaid), so it is hugely important that those dollars provide quality care,” says Maureen Maigret, chairperson of the aging in community subcommittee for the Long Term Care Coordinating Council.  She noted that studies show a clear relationship between staff levels and quality care but there is tremendous variation across the states in hours of direct care staff provided in nursing homes. 

“Rhode Island has required 24/7 RN staffing for many years and a 2021 state law requires minimum direct care staffing levels although implementation has been challenging due to the critical workforce shortage. Importantly, the proposed federal regulation would require states to report on compensation for workers as a percentage of Medicaid payments. For too long our direct care workers, mostly women, have been undervalued despite the significant demands of their work. It is time for them to receive a living wage and  shedding light on where our Medicaid dollars are going will help advocate for better wages helping to recruit and retain these essential workers,”  she says.

There will be a 60-day comment period for the notice of proposed rulemaking, and comments must be submitted to the Federal Register no later than November 6, 2023.  

For a copy of the federal register detailing CMS’s proposed rules on minimum staffing issued on Sept. 6, 2023, go to 

https://www.govinfo.gov/content/pkg/FR-2023-09-06/pdf/2023-18781.pd

For a copy of a CMS Fact Sheet on CMS’s proposed rules on minimum staffing, go to https://www.cms.gov/newsroom/fact-sheets/medicare-and-medicaid-programs-minimum-staffing-standards-long-term-care-facilities-and-medicaid

The Village helps grandparent/kinship caregivers in need

Published in RINewsToday on September 18, 2023

When we dream about our retirement years, these dreams most likely don’t include images of diapers, children’s tantrums, and school buses. However, for some grandparents and other kinship caregivers, their later years include these images, as they become primary caregivers for their grandchildren/kin children.

Nationally, more than 2.5 million children are being raised in kinship families which includes grandparents, other extended family members, or anyone with an existing relationship with the child or family. When these children cannot be with their parents, the next best thing is being placed with kin.

There are many benefits to staying with kin rather than being placed into the state’s foster care system. These can include experiencing less trauma; increased stability, higher rates of permanency; better behavioral and mental health outcomes; more feelings of belonging and being accepted, increased likelihood of living with or staying connected to their siblings, and a greater sense of cultural identity and connections to family.  

Additionally, kinship caregivers save the U.S economy approximately $ 6 billion dollars per year by keeping children out of formal foster care. Across the nation, there is a growing recognition of the importance and value of kinship caregivers. However, all of this comes at a physical, mental and financial cost to the kinship

The challenges of being a kinship caregiver

A new research study, Caregiver Profile: A Closer Look at Grandparents Caring for Grandchildren, by the National Rehabilitation Research and Training Center on Family Support (NCFS) at the University of Pittsburg, grandparent caregivers are experiencing a litany of adverse effects causing them to become a particularly vulnerable group. Grandparents are facing a higher rate of disability, lower employment, and a greater likelihood of poverty, says the study’s findings. One quarter of grandparents raising grandchildren live below the poverty line.

“Many challenges exist for grandparent and kin caregivers of children when it comes to navigating the legal and custody landscape while supporting their own needs, from physical and mental health to financial and employment security. We think this data [detailed in the 16 page report released in Sept. 2023] showcases the need to move forward on the recommendations developed by the Advisory Council to Support Grandparents Raising Grandchildren (SGRG) and the Recognize, Assist, Include, Support, and Engage (RAISE) Act Family, Caregiving Advisory Council that can help to support grandparent and kin caregivers,” said Meredith Hughes, JD, MPH, Senior Policy Analyst at University of Pittsburgh Health Policy Institute and Assistant Professor in the School of Public Health.”

 It is important to provide supportive services for grandparents raising grandchildren as many of these caregivers lack the necessary resources to fully support the children in their care. Support in areas such as kinship navigator programs that provide a single-entry point for learning about housing, health services, and financial and legal assistance, along with improved household resources and access to mental health services are needed. Rhode Island has a kinship navigator program for families involved with the department, but currently one does not exist for those who are not involved.  For every family involved with the Rhode Island Department of Children, Youth & Families, (DCYF), there are 5 who are not.

Grandparenting in the Ocean State

cording to the U.S. Census bureau, over 13,968 children are living with and being raised by their grandparents in Rhode Island, who make up the largest percentage of relative caregivers. Some kin families are involved with the child welfare system when children have to be removed from their home on an emergency basis. Rhode Island is one of the leading states in the nation in finding and placing children with kin. The state’s long-held philosophy is that children do better by living with kin. Of all the children in the state’s foster care system, around 70% are placed with kin.

For families involved with the DCYF, (known as “formal” kin caregivers) while it can be a distressing experience, they do gain access to needed resources and services, as well as receive monthly stipends and other supports to care for the children. For families who have private arrangements and are not involved with DCYF (“informal” caregivers), finding those resources and services can be challenging. Many if not most of kinship families are not involved with the child welfare system and have no idea that there are any resources. Finding and supporting those families has become one mission of the Cranston-based The Village for RI Foster and Adoptive Families (The Village) and the Warwick-based Hispanic Foster and Adoptive Parents Organization of Rhode Island (The Heart Tree).

The Village, established in 2016 by a group of five foster and adoptive families, provides peer support to all RI foster, adoptive and kin families. The Village provides support through peer mentoring, peer-led support groups and family events, as well as running a “Closet” where families both donate and receive material things such as clothing, toys, diapers etc. The Heart Tree, a sister organization, also provides those same supports in a culturally appropriate manner to our Spanish speaking families. The Heart Tree was established in 2021 to meet the unique needs of Spanish speaking foster, adoptive and kin families.

Sixty-three-year-old Laurie Tapozada is a kinship caregiver who sees the value of the assistance provided by the The Village in raising her 8-year-old grandson. “When it first happened and I was suddenly raising a baby at age 55, I didn’t know one single other family like mine, she said.

“My life was turned on its head, I was struggling to manage my hectic work schedule with a baby and dealing with all sorts of messy and painful family dynamics that come with being a kinship caregiver,” says Tapozada.

According to Tapozada, she had to re-educate herself as to how to safely raise a baby without getting support from family and friends who thought she was “crazy” for taking this on. It was overwhelming and distressing until she received a call from a friend who suggested that she “call the Village and they will understand.”  From that point Tapozada has become actively involved in the kinship community and network, “It been a life changer for me,” she says.

Although Rhode Island is recognized as a leader in ensuring that children removed from homes are placed with kin, increasing support for kin families is a pressing need.  In 2022, the Rhode Island Office of Healthy Aging awarded a grant (through funding from the U.S. Administration for Community Living overseen by the U.S. Department of Health and Human Services) to the Village and the Heart Tree, to identify informal kin families and help connect them to existing resources, and to the growing kinship caregiver community. 

RIOHA’s grant also funded a multi-faceted effort, in person and online activities, and incorporating traditional print, broadcast, digital and social media communication and training.  Throughout the year, exhibit tables were placed at family events, informational meetings and festivals to get the word out about available resource for kindship caregivers. This grant also created a statewide website where these individuals could go and learn more about resources, as well as find out what is happening in the kin community. This website is www.kinshipcommunityconnections.org.

Project Director Shannon Dos Santos, of the Village, sees the value and positive impact of this grant on Rhode Island’s kinship caregiver families. “I have seen the joy on the faces of many Kinship Caregivers aged 55 and over and their families over the last fifteen months as a result of this grant,” she says, noting that reaching out to this population and getting them to engage has been a challenge. “But when they do – it is beautiful to watch.”

According to Dos Santos, many just feel isolated, overwhelmed and alone. “This grant has allowed us to focus on community outreach and engagement as well as provided us with opportunities to enhance what we at the Village do so well – peer support and family activities!  “It has been a blessing to watch these families come together at these events, form relationships with others in  similar situations and feel safe sharing their experiences,” she says.  

The Village’s Chairman of the Board, Sue Babin, who is also full-time employee and a kinship caregiver, too, added, “This exciting grant initiative has provided The Village with an opportunity to continue to do what we do best… peer outreach and support from people with lived experiences.” And, while RI OHA’s grant ends this month, additional funding will extend the program for 12 months, she says.

For info about The Village for RI Foster & Adoptive Families (The Village), go to https://www.rivillage.org/. Or call (401) 481-5483.

For info about Hispanic Foster and Adoptive Parents Organization of Rhode Island (The Heart Tree), go to https://sites.google.com/view/thehearttree/homeinicio?authuser=1.  Or Call (401) 306-9652.

For info about Kinship Community Connections, go to https://kinshipcommunityconnections.org/

WPRI 12’ s Rhode Island Video on Foster Care Month, go to https://www.youtube.com/watch?v=AhI206EXBfQ.

For a copy of the recently released research study, Caregiver Profile: A Closer Look at Grandparents Caring for Grandchildren, by NCFS at the University of Pittsburg, go to

https://www.caregiving.pitt.edu/caregiver-profile-closer-look-grandparents-caring-grandchildren