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Mrs. MCDERMOTT. In defense of Grandview Nursing Home, this is a lovely facility and it is a Medicare facility. We have staffed it with a very competent staff and the care is excellent. When the patients are admitted to me they are positive they are going to be covered in the nursing home for 100 days. This is not the case. They are entitled to it, but very few patients get it. I am contacted by the social workers of the hospital, and they tell me the name of the patient. My next questions to the social worker are, "What type of care is this patient going to need? Is it skilled care?" Skilled care is determined and defined by guidelines, that are put out by the Social Security Administration. If this type of care doesn't fall under the skilled category, then this patient is not going to be approved in an extended care facility. The social worker talks with the family, or with the patient, and starts to explain to the patient that probably Medicare will not pay-depending, again, on the level of care.

Senator PELL. Excuse me, but it is very important that everybody can hear you, Mrs. McDermott. If you will hold the microphone about 3 inches from your mouth. And I might also say to the people in the back, there are some seats down here if you want to sit down. There are plenty of seats right back here. Continue, Mrs. McDermott.

Mrs. MCDERMOTT. The social worker tries to explain the Medicare to the patient. The first 20 days are free. The next 80 days a charge is made in the extended care facility of $7.50 a day. When the patient is admitted to me, I have no assurance that Medicare will pay. I must request an approval from Medicare the level of care is a determining factor. When the patient is admitted to me, I explain to him that I have no assurance that Medicare will pay. I ask that they sign a statement-after I have explained the Medicare to them-stating that they are aware that Medicare may not pay. The majority of the older people are positive that they are going to be covered in the extended care facility for 100 days; this is what they are entitled to, but they don't get it.

The approval, from Medicare, takes a week to 14 days after admission to the E.C.F. A copy of the records of the patient-and the forms that come in from the social worker in the hospital-are sent to Medicare. This is what they make their determination on. The doctor's orders are sent, and his recommendation for the stay in the extended care facility. If I get the approval-it is not for 100 days, it is, possibly, for 2 weeks-2 weeks later we send forms to Medicare that are reviewed again, by a medical team there. This is on paper, and they are not looking at the patient. They will either continue the coverage-again, possibly, 2 weeks-depending on the diagnosis, the type of care, and the progress the patient is making. Any time after this initial approval, Medicare can-and does-terminate.


When I admit the patient, they say that I am wrong when I explain Medicare to them. They have been told by their Medicare

booklet they do have 100 days, and that the doctor has recommended an extended care facility for them, so who is going to say to them that they are not covered? Medicare still terminates, or no approval is granted.

Senator PELL. Thank you very much.

Mrs. MCDERMOTT. Now, the problem with Mrs. Chauvin is a very common problem-very, very common-with every patient that I have in the nursing home where care has been covered for a period of time. The patient, by X-ray, isn't ready for therapy-or the type of care to warrant extended care. If you are going to do more damage by insisting on this type of care-until the patient is ready-simply to get Medicare coverage, you haven't accomplished very much. The type of care is also very, very important, the way skilled care is defined. It is very unfair-I am a nurse, and if it were my own mother-like in many cases that I had to care for, 24 hours a dayit would be impossible to do so. The patient may have bowel or bladder incontenence, is unable to turn himself in bed, and unable to feed himself. This is custodial care and not skilled care. It is constant care, and it is the hardest type of care to give. But by the present guidelines-the way the Medicare is presently set up-these patients are terminated; or, in many cases, not covered from the day of admission. If the patient is terminated, all of a sudden their world falls apart. They don't understand. This has been explained to them, but they didn't think it would happen to them. It creates many hardships-financial hardships for the patients; or, most often, for the person who is responsible for them. It leaves many bills that are very hard to collect in the nursing home.

The patient can be transferred out to lesser facilities or to the waiting lists of chronically-ill hospitals. But the lists are so long for these hospitals, that if the patient stays at Grandview, it is still creating a bill there. This review that I am talking about-that we request the approval-I think, they do a fair review. In general, judging by the guidelines that we have to go by for skilled care, they are doing their job. But many times it isn't skilled care but very ill patients. I think the guidelines are wrong. Also, when the patients are admitted to mebefore I can bill Medicare their attending physician certifies that they are in need of extended care. They give us the orders to render this care. We have a Utilization Review Board, which is made up of at least three doctors, that reviews all the Medicare patients at least once a month-and more often on questionable cases. Many times the attending physician will certify that the patient is in need of extended care; and this is reviewed by the Utilization Review Committee. If it passes this board, Medicare can override or overrule their decision. This creates a conflict.

I am sent-from the Utilization Review Board, when they have terminated someone-a letter with the actual date that Medicare is terminating. If Medicare terminates or overrules this board wtihout my knowledge, they also send out the letters, so they get a letter from the Department of Health, Education, and Welfare making them aware that coverage has terminated. This letter and the letter that I send out from the Utilization Review Committee, many times have dates that are in conflict. If the Utilization Review Board terminates coverage,

I have to give a 3-day notice. But Medicare can terminate retroactively or without any notice-so these dates or who is terminating, are very conflicting, and very confusing to the patient.


The Department of Social Welfare for Medicaid patients has a prior authorization in this State; where, before the patient is admitted to the nursing home, the patient knows if his Medicaid is going to cover or not-and usually for the number of days. This can be extended. There must be some method that the Federal Government can come up with such as this so that the patients who are admitted to E.C.F.'s know if they are going to be covered or not, under Medicare. If a patient is admitted to me under Medicare and declined-but is covered under Medicaid-I can't keep the patient, simply because the rate of reinbursement is too low. It doesn't pay for the cost of the patient in the nursing home. This is also explained to the patient who is admitted upon admission. Many of them express a desire to supplement Medicaid payments because they want to keep them at Grandview; they like the type of care they are receiving, and they like the nursing home. They want to keep them at Grandview, but simply can't afford this. The State doesn't allow this; therefore, the patient has to transfer to another home or remain as a paying patient. There are so many things with Medicare that I personally think are unfair; I don't know the answer to them, but there must be an easier way.

Senator PELL. I don't know the answers either. One of the reasons we are here is to define the problems and even then some of the problems, some of the solutions seem unattainable but this is one of the reasons we are having this hearing.

Thank you. We will come back with some questions.

The next witness now is Miss Gray who is a Director of Social Services at the Woonsocket Hospital and sees this problem from the viewpoint of the hospital which is different from that of the nursing home.



Miss GRAY. All the referrals for nursing home, extended care facilities and Home Health Care programs are referred by the attending physician to my department for disposition. The problems are many and arise when the family is made aware that: first, the patient is no longer in need of hospital-type care-regardless of the number of days the patient has been hospitalized; that the patient requires 24-hour nursing care; but that the Medicare program will not necessarily pay for such. The families cannot understand why-the patient, if he is ill enough to be hospitalized, and ill enough to need 'round the clock care-the condition does not warrant Medicare approval to the extended care facility. By that I mean-so many families will say my parents are in bed, and not able to get up. If they just have to have medication, their meals, and give them a bath, they cannot understand why they cannot be qualified for an extended care facility. It is a terrific problem to explain this to them.

I feel that Medicare has falsely conveyed to the public a glorious expanded health program, only to have it interpreted as a controlled, limited health program. When the patient transfers to an extended care or nursing home, should they not qualify for an extended Federal Medicare home for Medicare payments? They are penalized the number of days that they remain in the E.C.F. as applied against a new benefit period. Even if the Federal Medicare has cut off payment in the home, and they remain as a private patient, those days are deducted from their number of days when they return, if they do, to the hospital. I feel a physician should be given the opportunity to justify to the Utilization Committee-and by the Utilization Committee I mean a team of doctors that meet every week and review the patients' charts, not necessarily their own patients-and they have the right to say to the attending physician, this patient can be taken care of in an extended care or a nursing home; and, we will write a letter to the attending physician and to the family that the payments will no longer be made after 3 days.

Now, another terrific problem is the ambulance services which are limited to the distance of the nearest facility-and there are very few in this area. Now, regardless of whether there is a vacancy or not, there are only two extended care facilities-one about 6 to 7 miles, and the other may be 12 miles from Woonsocket. If they go to a home-say in Warwick or Westerly-the Government will not pay for the ambulance charge, the 80 percent, and with just two in the area it is a terrific problem.

Senator PELL. Would you identify the names of the two for the record?

Miss GRAY. Grandview, where Mrs. McDermott is administrator; and Waterman Heights in Greenville.

Senator PELL. What is the population, how many beds are in each one?

Miss GRAY. In Grandview, 72, and Waterman Heights would be about the same.

Senator PELL. The charges are similar?

Mrs. MCDERMOTT. Senator Pell, we have a 70-bed facility-37 beds are the extended care beds.

Senator PELL. Just for the nursing home?

Mrs. MCDERMOTT. That is correct.


Miss GRAY. And sometimes there is a waiting period getting into these homes; and, in the meantime, what happens to the patient? We can't keep them and we can't find a bed for them. It has created a terrible, terrible problem for the hospital, for the doctors, and myself. The State government controls what type of facility care welfare recipients need. By that I mean—if it is a State case, an Old Age Assistance, or aid to the disabled-we have to wait for a prior approval from the State to find out what type of home this patient is eligible for. If they are approved for a nursing home, fine; then they can go, and we know that the State will pay for the home. But, under the Federal Medicare it is a gamble. Now, waiting to get a patient into a chronic hospital, the waiting period-especially for femalesis 2 to 3 months. What to do with the patients in the meantime is the

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problem. When the patient is granted a week extension by this team of doctors-which we call the utilization committee-the family feels so pressured when they are approached repeatedly by hospital personnel, who come to check on placement progress, that they contact their local or State politicians who will state, "You tell the hospital they must keep them, they have 90 days." When I try to explain to them, no, the number of days only-if needed-and then they blame the hospital. The hospital is to blame and no one else, because they feel as though we are insisting that these patients that are ill-must leave. Now, I can say that Medicare has done well in many, many areas; but not so well in other areas. It certainly has given a lot more work, a lot more time into talking to families to both the doctors and my own department. It has made me aware, that from now on I will read the fine print in anything issued by the Government. Senator PELL. Thank you very much.

Miss Huggins, would you give your statement and we will come back to a couple of questions after. Miss Huggins is the executive director of the Visiting Nurse Service of Woonsocket.

I had the pleasure of being with them and talking with them the other evening when they had their State convention and what we see here are the three areas of care that can be given patients and our older citizens. You have Miss Gray representing the hospital care and then the next stage is your nursing home care with Mrs. McDermott and then you have the Visiting Nurse Service with Miss Huggins.

Now, I believe from the taxpayer's viewpoint if the services can be rendered at Miss Huggins' end of the scale with more support and more visiting nurses and more money into her program we can resolve some of the load further up the scale in the nursing home and the hospital, but the present approach often seems to me to pump the money into the hospital for persons of acute state of health rather than on the other end with Miss Huggins.



Miss HUGGINS. I am speaking for the Home Health Agencies of Rhode Island.* As you say most people know us as the visiting nurse services. Our concern is over the plight of the aged, and when Federal Medicare first came out it was to solve all of the health problems of the aged. Now they are finding that the services are severely limited. We feel fortunate in Rhode Island that we do have home health agencies that cover the entire State-many States do not.

When Federal Medicare legislation was being drafted the home health agencies were considered an important resource for health. It was felt that health maintenance and prevention at home would prevent the person having to go into the hospital, or extended care facility, and be able to stay in his home environment with his family and be able to receive care with the guidance and instructions from their visiting nurse. However, the conditions of participation have severely restricted this and limited what we consider an important health resource. For instance, in order for a patient to receive 100

*See appendix 1, p. 191.

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