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January 28
1850 - Death Valley '49er William Robinson dies in Soledad Canyon from drinking too much cool water [story]
Leaving Death Valley

Commentary by Gene Dorio, M.D.
| Saturday, May 17, 2014

genedorioWithin the confines of a hospital nursing station, it is hard not to overhear conversations concerning patient care. Typically not knowing names maintains confidentiality and does not encroach on HIPAA violations. But because computers, phones and premium space are shared by doctors, nurses, discharge planners, social workers and case managers, separation of airway boundaries is impossible.

Recently as I scrutinized my patient’s chart on the computer, I overheard a sad phone conversation between our discharge planner and family member:

“I’m sorry, but your husband’s HMO insurance only allows him to go to this nursing home for rehabilitation after his hip surgery.” Pause. “I know it’s 60 miles away from your home…” Pause. “I know you don’t drive, but maybe a family member or friend can take you to visit.” Pause. “You’ve been married 62 years?” Pause. “I know he told you he doesn’t want to be in a nursing home.”

Our hospital discharge planner listened carefully, as there were many long pauses in their discussion. It seemed as though all options for this patient’s wife were exhausted, not leaving many worthy choices.

Besides the insurance difficulties this patient faced, a looming fear for many of my elder senior patients is being told they must go to a nursing home. As we have formalized many names, nursing homes have been relabeled “skilled nursing facilities” (SNF, pronounced “sniff”) to glamorize and enhance palatability.

As a geriatric physician, I have visited patients in nursing homes for more than a quarter of a century. (Personally, I have vowed to make sure this stop is not on my bucket list.) Why do so many of my elder senior patients already know about the care rendered at these facilities? Easy. They see their parents, spouses, family members and friends arrive there, never to leave.

From a physician’s perspective in our country, hospitals admit the patient, make a diagnosis, start treatment, then triage them out as quickly as possible to save money. Because home care, assisted-living facilities and board-and-care homes are not capable or legally allowed to continue this care, patients have no choice but to go to a nursing home.

Here are the problems:

* Once a patient is admitted to a SNF, continuity of care is lost. Only one doctor sees the patient, and that is once a month. You will not see a neurologist, orthopedist, gastroenterologist, pulmonologist, nor any other specialist once you are admitted, as they do not go to nursing homes. Any ensuing medical problem or complication can easily be missed.

* Nursing homes are underfunded. Not only do they have to jump through the medical and legal hoops of state and federal regulations; they also must budget based upon low Medicare-Medicaid-insurance reimbursement. Sometimes the level and quality of care is minimal.

* In the past in our community, we had a hospital-based Transitional Care Unit (TCU) which acted as a stepping stone for our elder senior patients in going home. But it was closed for purely financial reasons and not for community good, relegating one less option for our seniors to have on their life’s itinerary. Without this alternative, and many of my patients’ reluctance to go to a nursing home, the job of the discharge planner was made harder.

Standards have forced nursing homes to improve, but unfortunately funding has not. Medicare publishes data rating these facilities, and even with online virtual tours, the glorified photos and videos are overwhelmed by the odiferous “sniff” reality. Visit your nearest SNF and take one. You will realize why our elder seniors hesitate about admission.

What are the solutions?

* Allow primary care physicians more frequent visits, and entice specialists to join in and make visits, too.

* Reconsider monetary SNF reimbursements to an adequate level that will provide appropriate care.

* Improve state and federal laws that now restrict care in their home, assisted-living or board-and-care, allowing our elder seniors to remain in their comfort zone, instead of a nursing home.

When grandma is told she must go to a SNF, the psychological effect is devastating. The present level of nursing home care rendered should not be imposed on the Greatest Generation. Roosevelt told them not to fear fear, but sadly this reality in their older years has been forced upon them.

Without much needed change, this option should not be on anyone’s bucket list.


Gene Uzawa Dorio, M.D., is a housecall geriatric physician on staff at Henry Mayo Newhall Memorial Hospital and has been engaged as an advocate in many community activities. The views expressed in this column as his alone.

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1 Comment

  1. Carole Lutness says:

    Gene’s article fails to point out the greatest flaw in Nursing Home care. Almost always they are For Profit institutions which means the owners are going to do what is minimally allowable (staffing shortages, lack of programs,
    shabby equipment, etc) so they can maximize their profit. For Profit is great when you are selling shoes but not health care.

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