Bill Protects Nursing Home Residents, Providers

Published in the Pawtucket Times on June 1, 2020

This month, U.S. Senator Bob Casey (D-PA) and Senator Sheldon Whitehouse (D-RI) throw a bill in the legislative hopper to slow the spread of novel coronavirus (COVID-19) in nursing homes. It’s a common-sense legislative proposal and needed.

A recently released Kaiser Family Foundation study reported, “COVID-19 has had a disproportionate effect on people who reside or work in long-term care facilities, including the 1.3 million individuals in nursing homes; 800,000 in assisted living facilities; 75,000 in intermediate care facilities; and 3 million people who work in skilled nursing or residential care facilities.”

Combatting COVID-19 in Congregate Settings

With COVID-19 quickly spreading throughout the nation’s nursing homes and intermediate care facilities, Casey and Whitehouse’s legislative proposal, S. 3768, The Nursing Home COVID-19 Protection and Prevention Act, seeks to provide needed resources to facilities to protect frail residents and staff. Residents in these facilities are among the most vulnerable because of their age and underlying medical conditions. According to an analysis conducted by Gregg Girvan for the Foundation for Research on Equal Opportunity, as of May 22, in the 39 states that currently report such figures, 43 percent of all COVID-19 deaths have taken place in nursing homes and assisted living facilities

As more than 20,000 nursing homes residents and workers have died due to COVID-19, according to the latest reports, on May 19, 2020, Casey and Whitehouse introduced S.3768 to help states, nursing homes and intermediate care facilities put the brakes on the spreading of the deadly COVID-19. The legislative proposal, with 14 Democratic cosponsors (including Rhode Island Senator Jack Reed}, would help states implement strategies to reduce the spread of COVID-19 in congregate settings, including through the purchase of personal protective equipment (PPE) and testing and to support nursing home workers with premium pay, overtime and other essential benefits.

S. 3768 was referred to Senate Health, Education, Labor, and Pensions. As of March 30, 2020, a Congressional Budget Office cost estimate or this measure has not been received.

Days after the introduction of 25-page Senate legislative proposal, a House version (H.R. 6972) was introduced by Rep. Ana G. Eshoo (D-CA), cosponsored by Reps. Janice D. Schakowsky (D-IL), Donna E. Shalala (D-FL), Madeleine Dean (D-PA), Seth Moulton (D-MA) and David N. Cicilline (D-RI). The House bill was referred to House Energy and Commerce

“This virus spares no state, no county, no facility. The unprecedented crisis unfolding in our Nation’s nursing homes demands an immediate, extraordinary response. Reports indicate nursing home residents and workers account for roughly 1 in 4 deaths from COVID-19 in the United States,” said Casey, who serves as Ranking Member of the U.S Senate Special Committee on Aging, in a statement announcing the bill’s introduction. “The Nursing Home COVID-19 Protection and Prevention Act would provide $20 billion in emergency funding [for staffing, testing, Personal Protective Equipment, etc.] to devise a sorely needed national, coordinated response to stem the spread of this terrible virus in nursing homes and intermediate care facilities,” notes Casey.

According to Casey, the Senate bill would also require the U.S. Department of Health and Human Services (HHS) to develop guidance on cohorting best practices, including on how to safeguard resident rights. It would also instruct HHS to collect and publish data on COVID-19 cases and deaths in nursing homes and intermediate care facilities, and finally fund surge teams of nurses, aides, and other critical staff to fill in at facilities where multiple residents and staff members have been infected.

“COVID-19 poses an immediate threat to the more than 1.3 million Americans, including more than 7,000 Rhode Islanders, who live in nursing homes,” says Whitehouse, noting that frontline staff across the nation are “doing heroic work under very challenging circumstances.”

“We need to get vastly more personal protective equipment and tests to nursing homes, which care for the patients who are most vulnerable to the coronavirus. Our legislation would also help states fund surge teams, sending additional staff reinforcements to facilities where they are needed to care for patients and prevent infection,” adds Whitehouse.

Before S. 3768 was officially introduced, in early March, Washington, DC-based AARP announced its support for the Senate proposal. “AARP supports the draft of the Nursing Home COVID-19 Protection and Prevention Act that would help protect the health and save the lives of people in nursing homes and other facilities by supporting testing, personal protective equipment, staffing and more,” said Megan O’Reilly, Vice President of Government Affairs for AARP. “The proposal would also improve public transparency and help protect the rights of residents and their families, adds O’Reilly, calling on Congress “to act immediately to stem the loss of life and slow the spread of the virus.”

In the House Chamber, Rhode Island’s Cicilline, a member of the House Democratic Leadership as Chair of the Democratic Policy and Communications Committee, has also pushed for Congressional funding to stop the spread of COVID-19 in nursing homes. The fifth term Congressman has called for additional funding for the Public Health and Social Services Emergency Fund in the next package for congregate care facilities, including nursing homes. He also signed a letter to HHS Secretary Azar and Administrator Verma, of the Centers for Medicare and Medicaid Services (CMS), urging that HHS and the CMS to ensure that a significant portion of the newly allocated $25 billion for testing in the recently passed CARES Act be utilized for testing in nursing homes and other congregate living facilities.

State-wide Efforts to Combat COVID-19 in Nursing Homes

With Governor Gina Raimondo declaring a state of emergency on March 9, 2020, with the COVID-19 arriving in Rhode Island, the deadly pandemic virus spread quickly throughout the state’s nursing homes. At press time, it has been reported that 75 percent of all related COVID-19 deaths are in nursing homes.

According to Joseph Wendelken, Public Information’s Officer for the Rhode Island Department of Health (RIDOH), the state moved quickly to stop the spread of the COVID-19 virus in the community and in nursing homes. He stated: “We curtailed and then prohibited visiting early on, and we have been doing extensive testing in every assisted living facility in the state. We are doing cyclical testing, meaning that we are continually testing all residents in all homes on a rotating basis. We are giving tailored infection control guidance to specific homes, and we are helping them procure additional PPE.”

Adds Wendelken, RIDOH has established two COVID-19 Specialty Nursing Homes [at Oak Hill Center in Pawtucket and Oakland Grove Health Care Center in Woonsocket] to be a COVID-19 Specialty Nursing Home. “These are centralized facilities to accept patients who are being discharged from the hospital and who are COVID-19 positive but no longer require acute-level care. This strategy allows COVID-19 positive patients leaving the hospital to receive specialized rehabilitation and step-down, post-acute care while reserving hospital beds for patients who need acute-level care,” he said.

On Smith Hill, the Rhode Island House Republican Caucus has recently called for members of the House Committee on Oversight to meet to address the increasing COVID-19 death rate in the state’s nursing and assisted living facilities.

Putting Politics Aside…

With less than 156 days until the upcoming 2020 Presidential election, will S. 3768 reach the Senate floor for a vote. Since the beginning of 2019, more than 350 House-passed bills—including hundreds that have bipartisan support—have been buried by Senate Majority Leader Mitch McConnell (R-Kentucky) in his legislative graveyard. With no Republican Senators supporting Casey and Whitehouse’s COVID-19 bill, will it even reach the Senate floor for a vote?

It’s time for McConnell, who has called himself the “grim reaper” of Democratic legislation, to lay down his deadly scythe, making the safety of millions of residents who reside in the nation’s 15,583 skilled nursing facilities a legislative priority. The GOP Senator from Kentucky, who is in a close Senate race with Democratic opponent Amy McGrath, might consider putting politics aside during a raging COVID-19 pandemic sweeping across the nation to work with Senate Democrats to protect frail residents and nursing home staff. Kentucky voters might view protecting residents against COVID a bipartisan issue.

Senators Seek to Identify Subpar Nursing Homes

Published in the Woonsocket Call on July 14, 2019

Last month, U.S. Senators Bob Casey (D-PA) and Pat Toomey (R-PA) succeeded in prodding the Centers for Medicare and Medicaid Services (CMS) to publicly release the April listing of underperforming nursing homes across the nation that require closer regulatory scrutiny but are not receiving any. Before CMS released the listing of candidates to the Special Focus Facility (SFF) program, the federal agency, charged with overseeing the care and quality in nursing homes, had not publicly identified these troubled facilities.

Less than 6 percent (88 facilities) out of more than 15,700 nursing homes nationwide are participants of the SFF program. CMS publicly identifies these facilities to the public. But an additional 2.5 percent (or approximately 400 facilities) qualify as candidates for the program because of having a “persistent record of poor care” but are not selected because of limited resources at CMS, according to a 26-page report, “Families’ and Resident’s Right to Know: Uncovering poor care in America’s Nursing Homes,” released in June 2019 by Pennsylvania’s two U. S. senators.

Nursing homes that are part of the SFF program have 12 to 18 months to correct any deficiencies and have two clean CMS surveys. If a facility fails to meet that target, it is are subject to increased regulatory enforcement, including being dropped from the Medicare and Medicaid programs.

Calls for Transparency

On March 4, 2019, Casey and Toomey wrote to CMS requesting information on its oversight of nursing homes in the SFF program. In that letter, the Senators requested the federal agency to provide the names of the 400 SFF candidates, calling for details about programs operations, scope and overall effectiveness. On May 3, 2019, CMS provided a written response and two weeks later, on May 14, the Senators received the listing of SFF candidates for April 2019. The names of these SFF candidates were not made public until Cassy and Toomey forced the issue by releasing this information in their report on June 5.

In CMS administrator Seema Verna’s May 14 letter to the two senators, Rhode Island-based participants and candidates in the SFF program were identified. They are: Charlesgate Nursing Center (SFF Candidate); Hebert Nursing Home (SFF Candidate); Oak Hill & Rehabilitation Center (SFF); St. Elizabeth Manor East Bay (SFF Candidate); and Tockwotton on the Waterfront (SFF Candidate).

In responding to the senators, Verma said that regardless of whether a nursing home is part of the SFF program, “any facility that performs poorly on surveys and continues to jeopardize residents’ health and safety will be subject to CMS enforcement,” which includes civil money penalties, denial of payment for new admissions or termination from the Medicare and Medicaid programs. Verma also stressed that in addition to her agency’s regulatory oversight, its Nursing Home Compare website has been improved to include “new, more reliable sources for obtaining staffing and resident census data, as well as including more claims-based quality measures.”

“Regardless of participation in the SFF program, any facility that performs poorly on surveys and continues to jeopardize residents’ health and safety will be subject to CMS enforcement remedies, such as civil money penalties, denial of payment f-or new admissions, or termination,” adds Verma.

Casey and Toomey believe that the list of SFF candidates is information that must be publicly available to individuals and families seeking nursing care for their loved ones. For that reason, the Senators have released the April 2019 list of SFF candidates and are continuing to work with CMS to make future lists public.

Through the release of the SFF candidate list and the Senate report, which details preliminary findings from surveys and public information about these candidate facilities, the Senators aim to provide Americans and their families with the transparency and information needed to choose a nursing home that would provide quality care to a loved one.

CMS Inquiry Identifies Issues

Casey and Toomey’s CMS inquiry into the SFF program put the spotlight on several issues. It became apparent to the two senators that a nursing home’s participation in the SFF program was not easily understandable to the public or would-be residents and their families. It became clear that CMS’s Nursing Home Compare, the agency’s online website, was not consistently updated to reflect any changes in the SFF program. “For example, in March 2019, the small icon used to indicate that a facility is an SFF participant was not on the webpage of five of the 17 newly-added SFF participants,” noted the Senate report. Most important, CMS’ website did not identify SFF candidates.

According to the released Senate report, only CMS and the state regulatory agency in which the nursing home is located and the facility itself, had knowledge of who is an SFF candidate. While CMS requires every nursing home to notify residents and its community of its regulatory SFF participant designation, these requirements do not apply to SFF candidates.

Aside from CMS recently updating its Nursing Home Compare webpage to more clearly indicate which nursing homes are SFF participants, it lacks details about the SFF program. There is no information explaining the reason for a facility’s participation in the program, the length of time it has been in the program or whether it has fixed the care issue. Most important, CMS does not include information on facilities that routinely cycle in and out of the SFF program, says the Senate report.

“There are few decisions more serious or life-altering than that of choosing a nursing home. I am pleased that CMS has taken the work that I have done with Senator Toomey seriously and is heeding our call to release the list of nursing facilities that are nominated to the Special Focus Facility program,” said Casey. “Our bipartisan work will ensure that families have all the information at their fingertips when choosing a nursing home. Now we must work in a bipartisan fashion to ensure the SFF program is working properly and that CMS has the funding it needs to improve underperforming nursing homes nationwide,” he says.

Adds, Toomey, “Ensuring that families have all the information they need about a nursing home will improve the quality of care at facilities across the country.”

Whitehouse Pushes for Medicare to Pay for Person-Centered Care

Published on July 11, 2016 in Pawtucket Times

At a June hearing of the U.S. Senate Special Committee on Aging, Senator Sheldon Whitehouse calls for improving care for over 90 million Americans with advanced illnesses like Alzheimer’s disease, cancer, and heart disease. On the day of this Aging panel hearing, the Rhode Island Senator unveiled his legislative proposal, “Removing Barriers to Person-Centered Care Act,” at this panel hearing that would promote better coordination between health care providers, and place greater emphasis on the care preferences of Medicare beneficiaries with advanced illnesses.

The hearing, titled “The Right Care at the Right Time: Ensuring Person-Centered Care for Individuals with Serious Illness,” explored ways to improve the quality and availability of care and examined care models that are helping people with serious illness and their families.

Having Important Life Conversations

The June 23 hearing pulled together witnesses who called for “about the need for families and health care providers to prioritize these important life conversations, so that individuals’ wishes are known and person-centered care is prioritized,” noted U.S. Senator Susan Collins, who chairs the Senate Special Committee on Aging. In her opening statement the Maine Senator called for federal policies to “support efforts to relieve suffering, respect personal choice, provide opportunities for people to find meaning and comfort during serious illness, and – most important – remain in control of their own care.”

Advance care planning conversations to a patients’ physical, emotional, social and spiritual well-being are important in the care of a patient, says Collins. However, studies reveal that less than one-third of physicians have reported that their practice or health care system has a formal program in place to assess patients’ goals or preferences, she notes.

Collins also shared a personal story of a close friend who benefited from the person-centered care she received while she was a patient at the Gosnell Memorial Hospice House in Scarborough, Maine. “Despite her serious illness, because of hospice care her days were filled with visits from friends and families and many joyful moments, and she was surrounded by her family when she died peacefully,” she said.

“I’ve heard from Rhode Islanders about how difficult it can be for patients battling serious, advanced illnesses to get the care and respect they want,” said Whitehouse.

Whitehouse noted that “We can do better by these patients. Because so many of the rules and incentives in our health care system are tied to the payment structure, we should design payment systems that support models of coordinated care that focuses on the full person. Payment systems should reward providers for honoring patients’ own preferences for their care.

As Dr. Atul Gawande, surgeon and author of the New York Times best-selling book, “Being Mortal, mentioned in his testimony, “people with serious, potentially life-limiting illnesses face substantial and increasing suffering, particularly during the last year of life. Medical care today typically exacerbates this suffering, often without any benefit of lengthened life. We have an opportunity to change this.”

“The goal is not a good death. Instead, the goal is to have as good a life as possible all the way to the very end,” say Dr. Gawande.

In her testimony, Amy Berman, a nurse and senior program officer at the John A. Hartford Foundation, who is living with stage IV inflammatory breast cancer stand stressed the importance of palliative care, which is designed to improve the quality of life for patients with serious illness.

“Palliative care is the best friend of the seriously ill,” said Berman, “Studies have shown that when palliative care is added at the beginning of a serious illness that people feel better and live longer.”

Finally, Dr. Kate Lally, Chief of palliative care for the Providence-based Care New England Health System, Medical Director of the Integra Accountable Care Organization, and Assistant Professor of Medicine at Alpert Medical School of Brown University, urged Congress to consider legislation that would improve the quality, not just the quantity, of life of the seriously ill. “I feel blessed to do this work, and to be able to reflect with my patients on the life they have lived, their joys and regrets,” she said. “I feel I am able to share some of the most sacred moments of their life, and be at their side as they consider what is most important to them in their limited time.”

“The healthcare system as a whole, as well as Medicare and Medicaid, need to face growing expectations about how people with serious or terminal illnesses are treated,” said AARP Rhode Island State Director Kathleen Connell. “We are investing in prevention and early treatment and getting better results. Ultimately, however, people will still face serious illness and palliative care. Person-centered care is the proper prescription, and we must strive to make sure that it’s available. We need to be vigilant when it comes to supporting a healthcare environment in which patients with serious illness feel they are well informed and can remain properly in control of their options. And while families still tend to avoid these discussions in advance, when the time is right proper guidance makes a world of difference.

“People form especially strong opinions about decisions made that may prolong their existence, but add little to the quality of lives and, in fact, can prolong suffering,” Connell added. “Conversations on this phase of life are critical and we applaud Senators Collins and Whitehouse for their contribution to this dialogue.”

Legislation to Support New Models of Coordinated Care

The thrust of Whitehouse’s legislative proposal is to promote better coordination between health care providers, and place greater emphasis on the care preferences of Medicare beneficiaries with advanced illnesses.

“Too many Rhode Island Medicare patients battling difficult illnesses are struggling to get the right care at the right time,” said Whitehouse. “We need to break down the barriers between patients and the care they need. Because so many of the rules and incentives in our health care system are tied to the payment structure, we should design payment systems that support new models of coordinated care that are focused on human beings and not some rule or regulation.”

Whitehouse’s legislation would establish a pilot program administered by the Centers for Medicare and Medicaid Services (CMS) made up of twenty “advanced care collaboratives” of affiliated health care providers and community-based social service organizations. Collaboratives would receive a planning grant to assess the needs of the population of patients it would serve; to purchase or upgrade health information technology to facilitate better coordination of care between providers; and to support education and training on documenting and communicating beneficiary treatment preferences and goals.

Once planning is complete, collaboratives would enter a three-year payment agreement with Medicare to provide coordinated, high-quality care for their target patient population. Under the terms of the pilot program, CMS would waive regulations to promote innovative care for patients with advanced illness.

Waivers would be granted to allow Medicare patients to receive hospice care and curative treatment at the same time. Currently CMS’s regulations force patients to choose one or the other for their terminal illness. Patients would be able to also receive Medicare coverage in a skilled nursing home without a consecutive three-day inpatient hospital stay. Under current Medicare rules, patients are often charged for skilled nursing care after they leave an inpatient hospital stay because they were hospitalized for observation rather than admitted to the hospital.

Whitehouse’s legislative proposal would also allow Medicare patients to receive home health services without the requirement that they be homebound. Under current rules, a patient’s condition must have progressed such that there “exists a normal inability to leave home,” denying these services to those who are seriously ill but still mobile. Finally, it would also allow nurse practitioners to sign home health and hospice care plans and certify patients for the hospice benefit. Right now, only doctors can do so, even though nurse practitioners are often the ones administering home health and hospice care. This forms another barrier for patients seeking these services, especially in underserved and rural areas.

According to Tom Koutsoumpas, Co-Chair of the Coalition to Transform Advanced Care’s (C-TAC) Board of Directors, Whitehouse’s legislative proposal is “a critical step forward to achieving high-quality, coordinated care for those with advanced illness. This legislation allows for important innovations in care delivery and removes obstacles to support patients throughout the care continuum.”