Friday, October 21, 2011

Health Tasks Delegated to Personal Care Community Workers.

Health Tasks Delegated to Personal Care Community Workers. Information Bulletin #343 (10/2011).

Many persons with disabilities require various health maintenance tasks to survive. States vary tremendously regarding who can legally perform these tasks. Depending on what State a person resides in, and therefore what health maintenance tasks can be delegated, often determines whether a person is unnecessarily institutionalized.

In Information Bulletin #342, we discussed the recent AARP “Raising Expectations – A State Scorecard on Long-Term Services and Supports for Older Adults, People with Physical Disabilities, and Family Caretakers.” The AARP report analyzes “Nurse Delegation” as one indicator of community integration.

Here are the 16 health maintenance tasks reviewed State by State to determine whether or not they are delegated: (1) administer oral medications; (2) administer medication on an as-needed basis; (3) administer medication via pre-filled insulin or insulin pen; (4) draw up insulin for dosage measurement; (5) administer intramuscular injection medications; (6) administer glucometer test; (7) administer medication through tubes; (8) insert suppository; (9) administer eye/ear drops; (10) gastrostomy tube feeding; (11)administer enema; (12) perform intermittent catheterization; (13) perform ostomy care including skin care and changing appliance; (14) perform nebulizer treatment; (15) administer oxygen therapy; and (16) perform ventilator respiratory care.

Many persons with disabilities are lucky enough to have a family member/other nonpaid caretaker, partner or friend who performs these tasks. Persons with disabilities are fortunate enough to live in a State which permit them to direct their own paid personal care workers to perform these tasks as part of consumer direction.

However, many states have “nurse delegation” requirements that prohibit anyone to be paid, other than nurses, to perform these tasks. In these States, the cost of hiring nurses to perform these tasks can be extremely high. Also, hiring a nurse to perform these tasks, many of which must be done several times a day, increases the community-based costs significantly.

The consequences are important to understand. States permit family members/unpaid caretakers to perform these tasks but do not allow paid trained personal care workers (non-nurses) to perform them, even when the persons with disabilities want their personal attendants to perform these taks. Why should a family member or other non-paid caretaker be permitted to perform these tasks but a paid personal attendant worker – with the permission and under the direction of the person with a disability – not be permitted?

This contradiction cannot be based on the difficulty or health risk of the task because then all States would require only nurses perform these tasks and no States would permit any non-nurses to perform the tasks. Nor is it based on a State’s professed concern about saving money because personal care attendants are much less expensive than nurses. We also know that with proper training and supervision all of these 16 tasks can be AND ARE performed safely and regularly by non-nurses.

Here’s a breakdown by State and number of health maintenance tasks delegated.

The AARP reports notes that five states (AZ, GA, IN, NM, and PA) did not provide information to the survey.

Of the remaining 46, the best five States (CO, IA, MO, NE, and OR) permit all 16 tasks to be delegated.

Ten States (AK, NV, HI, MD, TX, WA WI, ID, MN, ND) authorized the delegation between 13 and 16 tasks.

There were 12 States (AL, CA, CT, DE, IL, MA, MS, SC, TN, UT, VT, and VA) that permitted only 4 or fewer tasks to be delegated.

There were five States (FL, MI, MT, OK, RI and WV) that permitted no delegation of any of the health maintenance tasks – yes, they prohibited the delegation of all 16 health maintenance tasks.

We are confident that those States that permit delegation of all or most of these health maintenance tasks require proper training and supervision. We are also confident that advocates could and should address this historical anomaly. Nurse delegation prohibitions should not be a barrier to residing in the community.

Steve Gold, The Disability Odyssey continues

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To contact Steve Gold directly, write to or call 215-627-7100.

Tuesday, October 11, 2011

State Scorecard on Long-Term Services.

State Scorecard on Long-Term Services. Information Bulletin # 342 (10/2011).

A recent report entitled “Raising Expectations” – “A State Scorecard on Long-Term Services and Supports [LTSS] for Older Adults, People with Physical Disabilities, and Family Caregivers” – was prepared jointly by AARP, the Scan Foundation and the Commonwealth Fund. This report analyzes and scores each State’s LTSS performance regarding, (1) affordability and access, (2) choice of setting and provider, (3) quality of life and care, and (4) support for family caregivers. Twenty-five criteria are used.

You can download how your state scores by going to

The entire report is very important for advocates to use. However, in this era of constant talk about cutting costs, there are a few items that are particularly relevant. The Scorecard estimates per State the “impact of improvement” if your State “improved to the level of the best-performing state.”

The following three items potentially offer your State some BIG DOLLAR savings!!!! The three fit together quite nicely, IF your State really wanted to save Medicaid expenditures and comply with the ADA.

1. The Scorecard lists the number of people on Medicaid who would “first” receive their Long-Term Services and Supports (LTSS) in the home and community based settings INSTEAD OF FIRST RECEIVING MEDICAID in a nursing homes. We know from the Minimum Data Set (MDS) data that more than 10% of people enter nursing homes directly WITHOUT receiving any Medicaid LTSS in their homes and communities BEFORE they are institutionalized. Another 61% go directly from an acute care hospital into a nursing home.

The Scorecard tells you exactly how many people would “first receive” LTSS in the community – IF YOUR STATE really cared about saving Medicaid funds. We all know it is much, much cheaper to provide services in the community than in an institution. We also know that once a person is institutionalized, a lot of support systems fade away. Therefore, “close the front door” by providing services before there is any institutionalization.

2. The Scorecard lists the number of nursing home residents with “low care needs” who would “instead be able to receive LTSS in the community.” Surprise! There are people in nursing homes who have very few Activities of Daily Living impairments. The best states had only 5 percent of nursing home residents with “low care needs” while the worst states had 22% of their residents with low care needs.

Many advocates know that most of the people in institutions can have all their needs met in the community. The Scorecard takes an incremental and pragmatic approach.

Why are people with “low care needs” institutionalized? Why isn’t your State going into the nursing homes and offering these people an assortment of LTSS so they could move back into the community? Why aren’t advocates for older Americans and for people with disabilities doing this?

Again, the Scorecard gives you the number of people in nursing homes with “low care needs” in your State compared to the best State. Your State will save considerable Medicaid funds by offering institutionalized people with “low care needs” community-based services.

3. The Scorecard lists the number of people in nursing homes for whom “unnecessary hospitalizations” would/could/should be avoided. The Scorecard found that the worst states had three times greater the rate of hospitalizations of nursing home residents than the best States - 29% compared to the 10%. Ask your Governor if s/he likes spending Medicaid funds on “unnecessary hospitalizations.”

Guess what was highlighted as one main reason for “unnecessary hospitalizations” people get in nursing homes because the staff does not provide the minimal assistance folks need? Pressure sores, “a condition that is preventable with good-quality care.” The Scorecard states that “this finding is important” because “pressure sores are preventable … and can result in serious, life threatening infections….” The Scorecard also points out that they are costly – Medicaid hospitalization is expensive, especially when it is unnecessary.

We know we are beating the same tune as in other Information Bulletins, but why would your State not want to prevent hospitalizations and save money.

Advocates for older and younger Americans with disabilities in nursing homes have been “nice too long.” We have been so polite and well-behaved by not focusing on the intentional discrimination occurring when a State could avoid unnecessary institutionalized AND save money but does not and when a nursing could have avoided bed sores but did not, especially when the State has surveyed the nursing homes and found them deficient in this area.

Is it asking too much for CMS taking some initiative? The Scorecard found that if all the States achieved the level of the leading states, there would be “significant gains in health, better care experiences and potentially lower costs.”

There would be 201,531 fewer persons with disabilities in costly and unnecessary nursing home admissions -- if all states could do as well as the state with the lowest rate of unnecessary nursing home admissions! That’s a lot of disabled people..

There would be 120,602 fewer avoidable hospitalizations—at a savings of $1.3 billion nationally—if all states could achieve the rate of avoidable hospitalizations of the state that performs best on this indicator.