Testimony on 2000-090 CI - Homes for the Aged
(Consumer and Industry Services Bureau of Family Services)
November 3, 2003
Good Morning, my name is Rosemary Ziemba. I strongly support the
need to revise the rules governing Homes for the Aged, however,
I am in favor of additional revisions in order to protect the elderly
and their families.
Specifically, I recommend:
1. Clarification and inclusion of Assisted Living Residences (ALR);
2. Additional language to ensure the presence of and define the
role of registered nurses in Homes for the Aged and Assisted Living
Residences.
Who do I represent in this testimony? I am a Registered Nurse, with
a doctorate-a Ph.D-in nursing, and was once a Licensed Practical
Nurse. I am currently funded by the National Institute on Aging
in a research traineeship on family caregiving of the elderly at
the School of Social Work at the University of Michigan. My research
goal is to help elders and their families choose among various long-term
care alternatives. My research activities are partially funded by
the John A. Hartford Foundation through a grant to the University
of Michigan School of Nursing.
I have over 25 years of experience in nursing at a variety of settings
including hospital, home care, nursing homes, nursing education,
research, consumer education, and assisted living.
INCLUSION OF ASSISTED LIVING RESIDENCES
I'm very concerned about the lack of oversight of Assisted Living
Residences for the elderly, including Homes for the Aged, Adult
Foster Care Homes, and other types of settings, and the resulting
confusion among families and elders when they are considering a
change of residence. I am far from alone in my alarm about the differences.
In 2001, Karen Love, the co-chair of the board of directors of the
Consumer Consortium on Assisted Living (CCAL) testified to the Senate
Committee on Aging that states currently "use over two dozen
designations to refer to what is commonly known as assisted living."
(Love, 2001).
And, in Michigan, the confusion is no less (Citizens for Better
Care., 2003; Mickus, 2002). Assisted Living is a generic term in
Michigan, and includes Homes for the Aged, Adult Foster Care Homes
and homes that are not licensed. But they are not all accountable
for the same standards, and the unlicensed homes are not accountable
for any standards. What standards can families and elders expect
when they are seeking housing and services from Assisted Living
homes in Michigan?
Although "Assisted Living" is technically a marketing
term, facilities labeled as "Assisted Living" are voluntarily
surveyed as a Home for the Aged. Therefore for the purposes of my
testimony, I am speaking to oversight of Assisted Living and Homes
for the Aged as one.
Across the state of Michigan and throughout the U.S., there continues
to exist a wide variety in the services, affordability and standards
in assisted living residences or their statutory equivalents. In
response to public outcry in 2001, the U.S. Senate Committee on
Aging commissioned the "Assisted Living Workgroup", a
taskforce of over 200 stakeholders in the industry, to come up with
a clear and differentiating definition of assisted living and recommendations
for standards in several key areas, many of those areas coincide
with the concerns voiced here today.
The final report of the Assisted Living Workgroup to the U.S. Senate
is almost 400 pages long (Assisted Living Workgroup, 2003). It makes
for interesting reading, as it reports the consensus recommendations
of the group (consensus means at least 2/3's of the stakeholders
agreed), as well as the opinions of those who disagreed. The lack
of consensus on key issues such as a definition of Assisted Living,
as well as the variety of state labels and limits across the country
underscores the confusion facing elders, families and the industry,
and indicates the continued need to work further toward design of
clear guidelines to promote uniform standards.
Instead of merely revising the existing Homes for the Aged regulations,
it would seem that our state has an opportunity to be leaders in
this arena by focusing on how to REPLACE existing Homes for the
Aged and Adult Foster Care rules with new and clear Assisted Living
rules.
THE ROLE OF PROFESSIONAL NURSING IN ASSISTED LIVING
The vague, contradictory, and limited inclusion of nursing authority
in the proposed rules Homes for the Aged is alarming, particularly
concerning the comfort and safety of elderly people and their families,
as well as the protection of nurses practicing in assisted living
residences, and for the protection of those administrators and other
staff that provide excellent services.
The degree of nursing services varies widely across ALRs in the
country and in the State of Michigan. Across the country, a majority
of Assisted Living Residences offer nursing services (Hawes, Rose,
& Phillips, 1999; Mitty, 2003). What is clear is that many ALRs
voluntarily include licensed professional nurses on their staff,
or have collaborative agreements with nurses from other facilities
or agencies. Unfortunately, at least In Michigan, including a licensed
professional nurse in the mix of services offered by a Home for
the Aged or an Adult Foster Care Home is totally left to the discretion
of each home, as both sets of regulations are silent on the need
for nursing service.
What is often debated is the value of nursing services to the comfort
and quality of life of the elderly and the peace of mind of their
relatives and caregivers. This debate takes shape in definitions
such as "continuous nursing care" or "skilled"
vs. "basic" nursing care which are found in nursing home
regulations. These definitions need to be revised because they reflect
an outdated view of nursing that does not reflect the true contribution
that expert nursing services can provide in or to Homes for the
Aged and other Assisted Living Residences.
Please don't misinterpret my concerns about the standards for Assisted
Living or for Homes for the Aged as an indictment of the industry.
"Assisted Living" done well is a fabulous option. The
diversity of my background tells me that nursing happens everywhere.
Not just where people are acutely ill, like the hospital. Or when
they fit a certain definition, like "HOME FOR THE AGED."
Nursing should be included wherever personal care for a frail, vulnerable,
or disabled population is being given.
Twenty years ago, I was a nursing supervisor in what could have
been called an "assisted living" facility. Following is
a brief historical case study of that experience, the lessons of
which represent an opportunity to improve long-term care for the
elderly.
In response to the results of what is now termed "aging in
place, " nursing services were added in a retirement residence
of about 300 apartments. The original group of residents had moved
in several years prior, with an average age in their 70's. After
several years, the average age increased to 84. This is similar
to the average age in ALR today (Hawes et al., 1999; Mitty, 2003)).
In the 80s' we started seeing dramatic changes in trends affecting
the elderly, such as Diagnostic Related Groupings (DRGs) leading
to patients being discharged from the hospital quicker and sicker.
In response, we developed a continuum of supportive nursing services
to PREVENT hospitalizations; to PREVENT or delay moving to a nursing
home, and to provide better access to a variety of solutions to
problems via case management with the residents' physicians and
family. We collaborated with the geriatric specialist team from
a major hospital to provide an on-sight clinic and even made "house
calls." Nurses delivered medications to those who could no
longer do it themselves or simply preferred not to. Many times,
medication administration was the ONLY service we provided-and the
person was otherwise independent. This deceptively simple act made
all the difference in a person's ability to continue to live at
our facility instead of moving to a nursing home.
Nurses were on call 24 hours a day to respond to emergency calls
such as falls or missing persons. What happened before the ambulance
arrived made a crucial difference in cardiac events and resident
outcomes, such as first aide to control blood loss, CPR, etc. Nurses
could TRIAGE before calling "911", and often assisted
during transfer to the ER. Then the nurse provided coordination
with the hospital throughout the patient's stay, facilitating individualized
care and appropriate discharge planning.
Was this "continuous" nursing care? No. But the availability
of a nurse was constant and necessary for the overall well-being
of the resident. In a recent national study of 278 Assisted Living
Residences across the country, it was found that elders in facilities
with a full-time Registered Nurse were at HALF THE RISK of being
transferred to a nursing home (Phillips et al., 2003).
The professional nurse's role is not limited to the above. The
following observations are made with a concern for the safety and
quality of services provided by unlicensed staff, particularly the
direct care worker, or nurse's aide. Sometimes the elder had other
needs that could be as simple as having a bedside commode emptied,
or help with getting their shoes on. We also maintained a private
duty nurse aide service, and I supervised, hired, trained, and sometimes
fired, the nurse aides. Previously, the nurses had not been able
to address the training, hiring, and supervision of the nurse aides.
The nurse aides NEEDED someone to consult with about their concerns
about the patient, and they did not have anyone qualified to help
them before I took on this role.
A similarity among many of the options in the current long term
care continuum is that personal care or assistance with activities
of daily living is provided in the main by minimally trained and
marginally paid nurse aides. Nurses need to be available to the
direct care workers providing personal care and to act as a liaison
between them and the resident's health care team of physician's
and therapists. The proposed rules also list medication assistance
as an activity of daily living. The nurse aide's education and training
is task oriented and does not include the complexities and judgment
needed to adequately care for the wide range of illnesses and complications
that plague an aging populace. A nursing education does.
CONCLUSION: A NEW CLIMATE FOR OVERSIGHT AND REGULATION
When we looked to the current state rules about housing for the
elderly 20 years ago, we couldn't easily locate our services. We
did more than a Home for the Aged. We were more like a continuing
care retirement center, with elements of a nursing home, in that
we often cared for very disabled elders with a mix of private duty
nurse aide care and nursing case management. We were able to provide
those intermittent services both basic and skilled as appropriate
to the situation. We were very much like a home health care agency,
but if we had pursued accreditation according to Medicare guidelines
we would have had to pass on exorbitant charges. Plus, many of our
services wouldn't have fit the Medicare home care criteria, making
Medicare home care certification unfeasible, given our limited clientele.
The downside of having almost 30 years nursing and teaching experience
is that I've aged quite a bit myself along the way!! But the upside
is watching how things change and "grow up". I urge the
committee to think about these rules in preparation for the future.
The definitions of ALR and HFA, of nursing services as "continuous"
or skilled vs. basic need to be re-thought to allow for greater
flexibility and tailoring of services to the locale, and the clientele,
and to facilitate trends such as aging in place. The Assisted Living
Workgroup did not reach consensus on many recommendations for several
reasons; most prominent among them were that some states already
had higher standards than proposed, and that many organizations
feared regulatory practices that overburdened ALR rather than facilitated
delivery of high quality care in innovative ways.
You've heard the saying, "You're not getting older, you're
getting better." Maybe its true in some contexts, but research
indicates that the number of morbid events increases as people age.
The oldest are the most vulnerable to accident, chronic disease,
and functional limitations, and they don't like to move! It takes
a team of professionals to trouble-shoot and problem-solve in order
to provide quality care and a comforting golden age, in innovative
systems that increase consumer choice. Nurses are a vital component
of that team.
References
Assisted Living Workgroup. (2003). Assuring quality in Assisted
Living: Guidelines for federal and state policy, state regulation,
and operations. A report to the U.S. Senate Special Committee on
Aging from the Assisted Living Workgroup.: Available from the American
Association for Homes and Services for the Aging.
Citizens for Better Care. (2003). What is "Assisted Living?"
Citizens for Better Care. Available: http://www.cbcmi.org/publications/assist.htm.
Hawes, C., Rose, M., & Phillips, C. D. (1999). A National study
of Assisted Living for the frail elderly: Results of a National
survey of facilities. (on-line report): U.S. Department of Health
and Human Services; Myers Research Institute.
Love, K. (2001). Testimony from Karen Love before the Senate Committee
on Aging, April 26, 2001. Available: http://www.ccal./testimony_love.html
[2002, 10/16/02].
Mickus, M. (2002). Complexities and Challenges in the Long-term
Care Policy Frontier: Michigan Assisted Living Facilities. East
Lansing: Michigan State University.
Mitty, E. L. (2003). Assisted Living and the role of nursing. AJN,
103(8), 32-43.
Phillips, C. D., Munoz, Y., Sherman, M., Rose, M., Spector, W.,
& Hawes, C. (2003). Effects of facility characteristics on departures
from assisted living: Results from a national study. The Gerontologist,
43(5), 690-696.
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