PROTECTING SENIOR'S ACCESS TO HOUSING OF THEIR CHOICE

SENATOR BARBARA MIKULSKI (D-MD)

Earlier this year I introduced with Senator Lauch Faircloth (R-NC), S. 1997, the 'Seniors' Access to Continuing Care Act of 1998.' Our measure would protect seniors' access to treatment in the setting of their choice and ensure that seniors who reside in continuing care communities, nursing facilities, and other facilities have the right to return to that facility after a hospitalization. As our population ages, more and more elderly will become residents of various long-term care facilities. These include independent living, assisted living, and nursing facilities, as well as continuing care retirement communities (CCRC), which provide the entire continuum of care. In Maryland alone, there are more than 12,000 residents in 32 continuing care retirement communities and 24,000 residents in more than 200 licensed nursing facilities.

I have visited many of these facilities and have heard from both residents and operators. They have told me about a serious and unexpected problem encountered with returning to their facility after a hospitalization. Many individuals have little choice when entering a nursing facility. They do so because it is medically necessary, and because they need a high level of care that they can no longer receive in their homes or in a more independent setting, such as assisted living. But residents are still able to form relationships with other residents and staff and consider the facility home.

More and more individuals and couples are choosing to enter continuing care retirement communities because of the community environment they provide. CCRCs provide independent living, assisted living, and nursing care, usually on the same campus - the continuum of care. Residents find safety, security, and peace of mind. They often prepay for the continuum of care. Couples can stay together, and if one spouse needs additional care, it can be provided right there, where the other spouse can remain close by.

Today, more and more seniors are joining managed care plans. This trend is likely to accelerate given the expansion of managed care choices under the 1997 Balanced Budget Act. As more and more decisions are made based on financial considerations, choice often gets lost. Currently, a resident of a continuing care retirement community or a nursing facility who goes to the hospital has no guarantee that he or she will be allowed by the managed care organization (MCO) to return to the CCRC or nursing facility for post acute follow-up care.

The MCO can dictate that the resident go to a different facility that is in the MCO network for that follow-up care, even if the home facility is qualified and able to provide the needed care.

A FEW EXAMPLES

In the fall of 1996, a resident of Applewood Estates in Freehold, New Jersey, was admitted to the hospital. Upon discharge, her health maintenance organization (HMO) would not permit her to return to Applewood and sent her to another facility in Jackson. The following year, the same thing happened, but after strong protest, the HMO finally relented and permitted her to return to Applewood. She should not have had to protest, and many seniors are unable to assert themselves.

A Florida couple in their mid-80s were separated by a distance of 20 miles after the wife was discharged from a hospital to an HMO-participating nursing home located on the opposite side of the county. This was a hardship for the husband, who had difficulty driving, and for the wife, who longed to return to her home, a CCRC. The CCRC had room in its skilled nursing facility on campus. Despite pleas from all those involved, the HMO would not allow the wife to recuperate in a familiar setting, close to her husband and friends. She later died at the HMO nursing facility, without the benefit of frequent visits by her husband and friends.

An elderly couple in Riverside, California, encountered the same problem when the husband was discharged from the hospital and retained against his will at the HMO skilled nursing facility instead of the couple's community. At 25 miles apart, it was impossible for his wife and friends to visit at a time when he needed the tenderness and compassion of loved ones.

Another Florida woman, a resident of a CCRC, fractured her hip. Her HMO wanted her to move into a nursing home for treatment. She refused to abandon her home and received the treatment at the CCRC. Her HMO refused to pay for the treatment, so she had to pay out of her pocket.

Collington Episcopal Life Care Community, in my home state of Maryland, reports ongoing problems with its frail elderly having to obtain psychiatric services off campus, including medication monitoring, even though the services are available at Collington - how disruptive to good patient care!

On a brighter note, an Ohio woman's husband was in a nursing facility. When she was hospitalized, and then discharged, she was able to be admitted to the same nursing facility because of the Ohio law that protected that right.

Seniors coming out of the hospital should not be passed around like a baton. Their care should be decided based on what is clinically appropriate, not what is financially mandated. Why is that important?

Residents consider their retirement community or long-term care facility home. And being away from home for any reason can be very difficult. The trauma of being in unfamiliar surroundings can increase recovery time. The staff members of the resident's home facility often know best about the person's chronic care and service needs. Being away from home separates the resident from his or her emotional support system.

Refusal to allow a resident to return to his or her home takes away the person's choice. All of this leads to greater recovery time and unnecessary trauma for the patient.

Should a woman's husband have to hitch a ride or catch a cab in order to see his recovering spouse if the facility where they live can provide the care? No. Retirement communities and other long-term care facilities are not just health care facilities. They provide an entire living environment for their residents, in other words, a home. We need to protect the choice of our seniors to return home after a hospitalization. That is what my bill does.

It protects residents of CCRCs and nursing facilities by enabling them to return to their facility after a hospitalization and requiring the resident's insurer or MCO to cover the cost of the care, even if the insurer does not have a contract with the resident's facility.

In order for the resident to return to the facility and have the services covered by the insurer or MCO: The service to be provided must be a service that the insurer covers; The resident must have resided at the facility before hospitalization, have a right to return, and choose to return; The facility must have the capacity to provide the necessary service and meet applicable licensing and certification requirements of the state; and The facility must be willing to accept substantially similar payment as a facility under contract with the insurer or MCO.

My bill also requires an insurer or MCO to pay for a service to one of its beneficiaries, without a prior hospital stay, if the service is necessary to prevent a hospitalization of the beneficiary and the service is provided as an additional benefit. Lastly, the bill requires an insurer or MCO to provide coverage to a beneficiary for services provided at a facility in which the beneficiary's spouse already resides, even if the facility is not under contract with the MCO, provided the other requirements are met. U