Advocates criticize bill to reform nursing home staffing levels

( SPRINGFIELD – Advocates for the elderly and disabled feel disappointed and betrayed after legislation resolving two years of debate on minimum staffing levels in nursing homes passed the Illinois General Assembly.

A spokeswoman for the nursing home industry said last week that the legislation – crafted without input from the advocates – won’t chip away at the state’s landmark 2010 nursing home reform law.

But others said residents of long-term care facilities could suffer as a result of the bill, which is expected to be signed into law by Gov. Pat Quinn.

Regardless of who is right, the way the issue was resolved demonstrates how influence can shape policy in the Capitol.

“It’s just sad,” said Wendy Meltzer, director of Chicago-based Illinois Citizens for Better Care. “People are going to be neglected.”

Pat Comstock, executive director of the Health Care Council of Illinois, which represents for-profit nursing homes, disagreed with Meltzer’s interpretation of Senate Bill 2840. Comstock said the bill actually increases nurse-staffing requirements beyond what the 2010 law provided.

“It’s above the ratios we have now, and it’s above the ratios that are in the reform legislation,” Comstock said.

The reform law was sparked by a series of articles in the Chicago Tribune about inadequate staffing in Illinois nursing homes and dangerous situations connected with housing psychiatric patients alongside elderly and disabled patients.

JCAR talks

The 2010 law contains gradual increases, through 2014, in the amount of “nursing and personal care” that must be provided to each resident.

Meltzer said groups working with lawmakers to come up with the law’s language – who included Illinois Citizens for Better Care, AARP Illinois and the Health Care Council – agreed to work out later what types of nurses should provide the care.

That negotiation process was taking place at the General Assembly’s bipartisan Joint Committee on Administrative Rules, which has the power to approve binding rules. The Illinois Department of Public Health earlier this year proposed rules to JCAR that would have required at least 20 percent of the care to be provided by registered nurses rather than a combination of RNs and lesser-trained licensed practical nurses.

State Sen. Jacqueline Collins, D-Chicago, and other advocates for patients supported the 20 percent RN level. Advocates said it was backed by research, would lead to less neglect of nursing home residents and, at the same time, would hold facilities accountable for the additional $105 million in federal matching Medicaid funds they will receive annually through a new bed tax approved by the Legislature in January 2011.

HCCI contended research didn’t support the 20 percent level. The council had proposed to JCAR that RN care make up 10 percent of the nursing and personal care.

But there was no resolution of the issue as the Quinn administration and the General Assembly began to wrestle with other pressing issues this spring, including rate cuts to Medicaid providers.

HCCI was part of private meetings convened by Michael Gelder, Quinn’s senior health-care policy adviser, on potential Medicaid cuts. “Staffing was a natural part of that discussion,” Comstock said.

‘End run’

The resulting agreement, which is part of SB 2840, includes about $70 million in Medicaid cuts – a 2.7 percent cut rather than the 15 percent cuts that nursing homes feared.

The agreement also included HCCI’s preference for 10 percent RN staffing levels.

The pact infuriated Collins, who said a lack of RNs is a particular problem at Chicago-area nursing homes in which a majority of residents are black.

Collins said she was assured by Gelder that the RN staffing issue would be resolved in negotiations after the state budget was passed by the General Assembly – not through closed-door meetings and budget-related deals with the powerful nursing home industry, one of the state’s largest contributors to political campaigns.

“To me, that was betrayal,” Collins said, adding that the 10 percent level is too low to achieve meaningful improvements. “There will be very little change in staffing. Seniors are going to be extremely disadvantaged. The weak are victimized. They don’t have lobbyists down here.”

Collins voted “present” on SB 2840 in protest and said on the Senate floor that HCCI did an “end run on the process . . . leaving the residents and their advocates out of the room when deciding their fate.”

Comstock said she had nothing to apologize for.

“The reason we were invited to the table is because we represent 75 percent of the residents in the nursing-home population,” she said.

She said most of the state’s 800 nursing homes will have to hire more RNs under the legislation.

In Collins’ Senate floor speech, she also criticized Quinn, a fellow Chicago Democrat.

“So governor,” she said, “it appears to me that once again, with your consent and complicity, the needs and concerns of black and brown nursing-home residents have been trampled by the clout, money and influence that dishonors and disrespects the democratic process and disenfranchises the well-being and welfare of our most vulnerable populations.”

Quinn aides wouldn’t respond to Collins’ statements.

Reimbursements change

The legislation includes a move toward reimbursement based on the medical needs of the patient – a 1 percent cut in Medicaid reimbursements for high-need patients and a 10 percent cut for low-need patients.

The bill also calls for a broader change in the reimbursement system, over the next 18 months, to a “Resource Utilization Group”-based system. The RUG system aligns Medicaid payments with “the level of need by facility residents,” according to Melaney Arnold, spokeswoman for the Illinois Department of Public Health.

Comstock said HCCI didn’t oppose the new system; Meltzer said HCCI did oppose the system, at least initially.

Life Services Network, which represents not-for-profit nursing homes, enthusiastically supports the system, a spokesman said. But patient advocates have concerns because the legislation takes the additional step of tying the overall RN staffing levels to the RUG system.

Linking staffing levels to the new system, something that Comstock said the Quinn administration wanted in the bill, will make it harder for nursing home inspectors to gauge whether a facility is staffed adequately, according to David Vinkler, associate state director of AARP Illinois.

“They are more likely to miss understaffing,” he said. “It doesn’t have to be so complex.”

Meltzer said the RN staffing level specified in the bill is “definitely more than we have now,” but there’s no research showing the overall impact when RN staffing is tied to a resource utilization system.

She said she worries that certain patients, such as those with mental illness and dementia, will be neglected under the new system.

Sen. Heather Steans, D-Chicago, the sponsor of SB 2840, said it was unfortunate that the Quinn administration didn’t include patient advocates in the negotiations. But she said it’s unclear whether the lawmakers on JCAR could have resolved the staffing issue on their own.

“I think we made a lot of movement in the right direction on nursing-home policy in this bill,” Steans said.