At age 88, Elizabeth Fee looked pregnant, her belly
swollen after days of intestinal ailments and nausea. A nurse heard a
scream from Fee’s room in a nursing home, and found her retching "like a
faucet" before she passed out.
The facility where she died in 2012 was affiliated with a respected
San Francisco hospital, California Pacific Medical Center, and shared
its name. Fee had just undergone hip surgery at the hospital, and her
family, pleased with her care, said they chose the nursing home with the
Laura Rees, Fee’s elder daughter, said she was never told that the
nursing home had received Medicare’s worst rating for quality — one
star. Nor, she said, was she told that state inspectors had repeatedly
cited the facility for substandard care, including delayed responses to
calls for aid, disrespectful behavior toward patients and displaying
insufficient interest in patients’ pain.
"They handed me a piece of paper with a list of the different
facilities on it, and theirs were at top of the page," Rees said in an
interview. "They kept pointing to their facility, and I was relying on
their expertise and, of course, the reputation of the hospital."
Fee had an obstructed bowel, and state investigators faulted the home
for several lapses in her care related to her death, including
giving her inappropriate medications. In court papers defending a
lawsuit by Fee’s family, the medical center said the nursing home’s care
was diligent. The center declined to discuss the case for this story.
The selection of a nursing home can be critical: 39 percent of
facilities have been cited by health inspectors over the past three
years for harming a patient or operating in such a way that injuries are
likely, government records show.
Yet many case managers at hospitals do not share objective
information or their own knowledge about nursing home quality. Some even
push their own facilities over comparable or better alternatives.
"Generally hospitals don’t tell patients or their families much about
any kind of patterns of neglect or abuse," said Michael Connors, who
works at California Advocates for Nursing Home Reform, a nonprofit in
San Francisco. "Even the worst nursing homes are nearly full because
hospitals keep sending patients to them."
Hospitals say their recalcitrance is due to fear about violating a
government decree that hospitals may not "specify or otherwise limit" a
patient’s choice of facilities. But that rule does not prohibit
hospitals from sharing information about quality, and a handful of
health systems, such as Partners HealthCare in Massachusetts, have
created networks of preferred, higher-quality nursing homes while still
giving patients all alternatives.
Such efforts to help patients are rare, said Vincent Mor, a professor
of health services, policy and practice at the Brown University School
of Public Health in Providence, R.I. He said that when his researchers
visited 16 hospitals around the country last year, they found that only
four gave any quality information to patients selecting a nursing home.
"They’re giving them a laminated piece of paper" with the names of
nearby nursing facilities, Mor said. For quality information, he said,
"they will say, ‘Well, maybe you can go to a website,'" such as Nursing Home Compare
, where Medicare publishes its quality assessments.
The federal government may change this hands-off approach by
requiring hospitals to provide guidance and quality data to
patients while still respecting a patient’s preferences. The rule would
apply to information not only about nursing homes but also about home
health agencies, rehabilitation hospitals and other facilities and
services that patients may need after a hospital stay.
"It has a substantial opportunity to make a difference for patients,"
said Nancy Foster, a vice president at the American Hospital
But the rule does not spell out what information the hospitals must
share, and it has yet to be finalized — more than a year after Medicare
proposed it. The rule faces resistance in Congress: The chairman of the
House Freedom Caucus, Rep. Mark Meadows, R-N.C., has included it on a list of regulations
Republicans should block early next year.
The government has created other incentives for hospitals to make
sure their patient placements are good. For instance, Medicare cuts
payments to hospitals when too many discharged patients return
within a month.
"Hospitals didn’t use to care that much," said David Grabowski, a
professor of health care policy at Harvard Medical School. "They just
wanted to get patients out. Now there’s a whole set of payment systems
that reward hospitals for good discharges."
But sometimes hospitals go too far in pushing patients toward their
own nursing homes. In 2013, for instance, regulators faulted a Wisconsin
hospital for not disclosing its ties when it referred patients to its
own nursing home, which Medicare rated below average. In 2014, a family
member told inspectors that a Massachusetts hospital had "steered and
railroaded" her into sending a relative to a nursing home owned by the
same health system.
Researchers have found that hospital-owned homes are often superior
to independent ones. Still, a third of nursing homes owned by hospitals
in cities with multiple facilities had lower federal quality ratings
than at least one competitor, according to a Kaiser Health News
analysis. (Click to Continue
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Are hospitals helping or hurting the nursing home search?