Having to place a loved one in a nursing home is never a happy affair.
And the way Eric Carlson sees it, too many of the nearly 300,000 Californians who enter a nursing home each year don't get the care to which they're entitled.
"It's such unfamiliar terrain for people, and so they're taken advantage of because of that," says Carlson, a Los Angeles attorney with Justice in Aging, a national organization that works to fight poverty among seniors.
That's what led Carlson to write "20 Common Nursing Home Problems and How to Resolve Them," a consumer guide available free at www.justiceinaging.org.
In the guide, Carlson writes "too frequently, nursing homes follow standard operating procedures that violate the Nursing Home Reform Law and are harmful to residents."
The nursing home industry vehemently disagrees.
"If the premise were correct — that nursing homes are operating illegally — the state would have shut down nearly every nursing home in the state," says Deborah Pacyna, spokeswoman for the California Assn. of Health Facilities.
Pacyna says California nursing homes rank near the top nationwide on a number of quality measures, including reducing symptoms of depression and injurious falls.
Consumers can see homes' performance for themselves on websites such as CalQualityCare.org and the Medicare.gov website's Nursing Home Compare.
However, Carlson says the most common problems aren't always obvious legal issues or those that necessarily show up in quality ratings. Therefore, consumers who know their rights under the law are better able to advocate to make sure they receive the best care possible.
Carlson and other experts highlight a few of the common problems faced by nursing home residents and their families.
Medicaid discrimination. Nursing homes rely heavily on reimbursement from Medi-Cal, California's health insurance program for people with low incomes. The vast majority of facilities are Medi-Cal certified, meaning that they accept its reimbursement.
In California, about two-thirds of nursing home residents have all or part of their costs paid for by the Medi-Cal program, according to statistics from the California Assn. of Health Facilities.
"If you live long enough in a nursing home and stay long enough, you're going to end up on Medi-Cal," even if you started out paying privately, says Pat McGinnis, founder and executive director of California Advocates for Nursing Home Reform, a statewide consumer advocacy organization based in San Francisco.
"People can't afford eight or nine thousand dollars a month for very long," she says.
But because Medi-Cal pays lower rates than most other sources of reimbursement, advocates say patients often receive second-class treatment.
"You're more likely to get very low-level custodial care" when covered by Medi-Cal, Carlson says.
Nursing home staff may tell you that Medi-Cal doesn't pay for certain types of care, such as rehabilitative services, Carlson says. But if the facility is Medi-Cal certified and the care is medically necessary, it is required to provide it.
Poor care planning. "The biggest complaint we get is the plain lack of care, not letting families get involved in the care planning and not following the care plan," McGinnis says.
The law requires nursing homes to develop a comprehensive care plan for each patient within seven days of the completion of a full assessment of the resident's condition. That plan must then be reviewed again every three months and updated, if needed. Often, however, that doesn't happen, leaving an inadequate care plan in place.
In addition, both the patient and his or her family have a right to be involved in deciding what kind of care will be delivered. Despite that, families are often iced out of the process, Carlson says.
Refusing to readmit after hospitalization. When Medi-Cal-funded nursing home residents are sent to the hospital for treatment, their beds must be held for seven days, during which time the home continues to be paid by Medi-Cal.
Instead, many nursing homes simply refuse to take the patients back — with the hope of replacing them with higher-paying patients.
Nursing homes, McGinnis says, would much prefer to have Medicare rehab patients because they may get paid as much as $600 a day compared with an average of $186 a day from Medi-Cal.
But Pacyna with the California Assn. of Health Facilities says if patients are placed on a ventilator while hospitalized, for example, the nursing home may legitimately refuse to let them return. The facility may not be equipped to care for people on ventilators, she says.
Fight back. Free support is available to families who need help getting the care to which they're entitled.
The California State Long-Term Care Ombudsman Program works with patients and families to identify and investigate complaints: Call 800-334-9473, or contact the California Department on Aging at www.aging.ca.gov
California Advocates for Nursing Home Reform provides legal assistance, and its website, www.canhr.org, has a host of consumer fact sheets and other free resources.
Carlson says families get better care when they know their rights and speak up.
"Stand up for yourself," he says. Doing so will not only help you and your loved ones, Carlson says: "You're benefiting the whole system."
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