Letter to the Editor: Complexity in Care

I submitted this letter to the editor and the Star Tribune chose not to publish it but I think the information is important so I’m placing it here.

I am writing in response to the article published in the Sunday, September 11th edition of the Star Tribune titled, Troubled Twin Cities nursing home ordered to pay millions in neglect cases. I want to applaud the Star Tribune for making this a front page story, and I want to add a bit more information and complexity in order to help educate families about the current state of our healthcare system. 

I worked at what is now known as the Estates at St. Louis Park when it was run by a different for-profit company and also worked at one of the largest healthcare companies in Minnesota. Currently, I’m an Associate Professor teaching and researching healthcare policy and practice. While the for-profit status and limited enforcement of safety standards are critical components of quality care, the process of discharging patients from hospitals to different levels of care is a complex one that is driven by health economics. 

The more complex the healthcare needs of a patient, the more expensive they are to any healthcare system. The patients with the most complex health needs are often the ones who are most difficult to discharge to skilled nursing facilities. Complex health needs vary from cognitive declines (e.g. dementia), high skilled needs (e.g. wounds, tracheostomy), any history of physical violence, non-compliance, severe and persistent mental illness, or active substance use (including tobacco), and expensive treatments (e.g. IV antibiotics). These needs are partially the result of the cumulative effects of economic status. Patients with the most complex healthcare needs are typically those who have had inconsistent access to health insurance and healthcare over their lifespan, have a history of physical labor, and minimal assets. 

The difficulty of discharge is exacerbated if the patient doesn’t have quality insurance to cover these expenses. When they need skilled nursing care, they often have to rely solely on Medicare and Medicaid to pay for their care. If they don’t have the needed coverage, they continue to experience more and more health care problems leading to more complex health needs and decreasing their access to highly rated skilled nursing facilities. 

The skilled nursing facilities with Medicare Quality Ratings for 4-5 stars rarely accept medically complex patients unless they have a previous relationship with the patient or the patient has the financial ability to cover costs. Their high Medicare Quality Rating allows them to cherry pick patients that have simple healthcare needs that require less intensive care and allows them to make more money.  

Social workers are often the people who are helping to facilitate the discharge plan. Frequently, these plans are made with families who have limited experience and understanding of the process during a health crisis. While employed by healthcare systems, social workers should prioritize advocating for patients. To do this, they need to engage the family early in discharge planning, encourage families to tour facilities and ask questions, and explain the patient rights.

Social workers also have the inside knowledge and understanding about how difficult it might be to find placement for patients with complex health needs. They know which of the nursing homes are willing to accept these complex patients and which systems always have beds available. And they know that oftentimes these are the facilities with Medicare Quality Ratings of 1-2 stars. These facilities need to fill their beds so they accept patients with complex needs that require intensive care and staffing which then feeds right back into their low ratings. 

As reported in your article, Tobey Eldeman from the Center for Medicare Advocacy in Washington, D.C. “We are far too tolerant of poor care.” Our tolerance for poor care isn’t from lack of enforcement, but tolerance of the vast wealth that is accumulated by for- and non-profit healthcare administrators on the backs of people with complex health needs. While we need to be willing to fund the care people need, we also need to examine how those funds are being used in the provision of healthcare. This means not only reviewing and adjusting Medicare case mix to increase reimbursement rates to cover the complexity of need, but increasing the wages of healthcare workers who often have to risk their own physical and mental health to provide care in these underfunded, understaffed healthcare system, and demanding transparency between cost of care and how funds are being spent.