Long-Term VA Patients Fear Transfers

Since he suffered a massive cerebral hemorrhage eight years ago, World War II veteran Arthur Stein has been completely disabled except for the use of his right arm.

When his insurance coverage ran out five years ago, Stein, 68, was admitted to the Nursing Home Care Unit at the federal Department of Veterans Affairs medical complex in West Los Angeles.

“When I took him in, my first question was: ‘How long can he stay?’ ” said his wife, Joyce. “I was told by a doctor, by everybody, that he could stay forever.”

Now Joyce Stein and relatives of other veterans at the 240-bed nursing home are worried that the VA may discharge their disabled loved ones from the first-rate Westside facility and place them in lower-quality private nursing homes.

Their fears were triggered by a letter from Dr. Michael E. Mahler, the VA complex’s director of geriatrics and extended care services, outlining changes to be implemented at the nursing facility.

The changes include new assessments of patients’ treatment needs every 90 days--assessments that Mahler’s letter said could lead to a patient being discharged to a private nursing or board and care home.

The changes are a consequence of increased demands for treatment and a shrinking budget at the VA facility, forcing officials to find ways to make treatment available to more veterans, Mahler said.

A few patients have already been discharged to private facilities and others will be, VA officials said. The VA inspects the homes to make sure that they meet “certain levels of care,” said Mahler. “They may not be the best. They certainly are not the worst.”

Mahler said there are no plans to discharge “long-term” patients like Stein--those who have been at the facility for more than a year.

However, he acknowledged that the anxiety of relatives of long-term patients reflects a communication breakdown in the nursing facility’s effort to implement 90-day assessments.

“We touched the wrong nerve,” he said. “They may have thought we were planning to discharge those patients. The assessments were to determine patient needs--not to see who has passing score and stays or a failing score and leaves. It’s not like someone has a three-month lease and it is going to change every three months.”

As patients undergo successful rehabilitation therapy, some will no longer require long-term nursing care and can be transferred to private facilities, Mahler said. “Because of that, we will have a larger turnover of patients in the nursing home and will be able to serve more veterans,” he said.

Nonetheless, Joyce Stein said families see Mahler’s letter “as a threat. There is no reason to bring [patient discharges] up unless there is something going on. They have been very secretive.”

Patients who have been transferred to private nursing homes, Mahler said, generally had been admitted to the VA facility within the past year.

“At the time of admission, those patients and their families were told this would not be permanent,” Mahler said.

But Joyce Stein takes little comfort from that comment. Mahler’s letter, she notes, says: “There has never been a policy that patients will live in the [nursing home] indefinitely.”

Stein claims that violates the promise she says the VA made her husband. So does Virginia Cooley, whose husband Warren, 82, has been at the VA nursing home for 2 1/2 years since suffering a stroke.

“I walked in one day and he was crying,” said Cooley, 74. “When I asked him why, he said his doctor had told him that he would be there for the rest of his life.”

VA administrators say that they can find no such promises in writing, and that their lawyers have told them that no oral contract exists with those families.

“This is change,” said VA spokeswoman Harriet Bordenave. “I understand the uncertainty and the confusion that comes with change, but everything is changing for all government agencies. If there is no money, what do you do?”

While there are no plans to discharge long-term patients, Congress or the Department of Veterans Affairs could change those plans, Mahler said.

“I can’t say to any patient: ‘You will never be discharged.’ ” he said.

It is that reality that sends chills through the ranks of patients and families with relatives at the VA nursing home.

“This is like a family,” said 87-year-old former U.S. Navy Lt. Forest Yarnall, who was admitted to the nursing home two years ago after a second stroke. “I don’t want to be discharged. I have no place to go.”

The VA facility “is the best there is,” said Yarnall, adding that his only living relative is a 93-year-old cousin. “I hear that the civilian homes are terrible.”

Another worrisome change for families is a switch to so-called “patient-focused care,” in which some duties performed by registered nurses are turned over to “technicians” who may have been trained for only a matter of weeks.

As used at some hospitals, patient-focused care has been sharply criticized as a dangerous way to cut costs.

These technicians may take vital signs and answer call buttons at some hospitals. Registered nurses have reported close calls at several hospitals using patient-focused care when technicians did not recognize a life-threatening situation.

Mahler recognizes that patient-focused care has become a euphemism for staff reductions “and using less expensive people.” But the VA is not putting such care in place to cut costs, he said.

“Some families are concerned that people other than trained nurses will be giving medications,” he said. “We will still have licensed people [doing that]. Some care does not need licensed staff--drawing blood, for example.”

He said patient-focused care will be evaluated in about six months. “If we get negative feedback,” he said, “we probably won’t continue it.”