Oversight for elderly poor cut in budget

About 500 mostly elderly, poor New Hampshire residents are losing case managers hired by the state to ensure they receive proper care while living in generally small, community facilities instead of nursing homes.

The state expects the facilities - some with only a handful of clients - to perform the same functions as case managers, but some question whether that provides adequate oversight for the clients.

Gov. John Lynch recommended the cut to save $1 million, and lawmakers approved it. It affects residents covered by the state-federal Medicaid program who qualify for more expensive care in nursing homes but choose instead to live in alternative settings.

Acting Adult and Elderly Services Administrator Diane Langley says state rules already require the facilities to do the same work. About 65 facilities are licensed to serve the Medicaid clients under a federal waiver that allows them to receive services in a community setting, she said.

Six agencies offer independent case management services, which range from doing residents' paperwork to ensuring they maintain their Medicaid eligibility to helping them move to a different facility.

The state is paying the case managers for the next 90 days while it seeks approval from the federal Centers for Medicare & Medicaid Services to amend the state's Medicaid plan to reflect the change.

CMS spokeswoman Roseanne Pawelec said she is not aware of a federal law that prohibits the change, but CMS will wait for the state's plan amendment before deciding if the state can proceed with dropping the case managers.

John Poirier, president of the New Hampshire Health Care Association, estimated that of those licensed to serve Medicaid clients, about 30 facilities actually have residents. He said some facilities have as few as three to four beds.

'Their ability to be case managers is limited. They're cooking the meals, helping provide transportation, making sure the doors are locked at night,' he said.

Independent case managers are needed to determine if the resident is receiving the right care, he said. Smaller facilities don't have the trained staff to perform all the functions the case managers perform, he said. If the state drops their services, some facilities will have to hire people to do the work, he said.

'It would be a shift of the state paying for it to the provider paying for it,' he said.

Poirier and others also argue it could pose a conflict of interest for a facility if a client is unhappy and wants to leave because the facility would lose money if the resident moves. Currently, a case manager handles moves, but the facility will perform that function under the change.

'If you look to the facility - I'm not saying they won't do it - but their motivation to get them out of there is significantly less than someone who is independent,' Poirier said.

Gary Cahoon, owner of Friendship Manor in New Ipswich, said the amount of help provided by case managers to facilities varies by the needs of the facility. He has been in business 26 years and is better able to handle the loss of the case managers than some, he said.

Still, Cahooh said he will have to hire someone to do annual assessments now done by case managers on services residents need that help decide if they are properly placed. His wife is a nurse who could do the assessments but refuses because she believes it is a conflict of interest.

Cahoon said if someone wants to move and has no family or friends to help, it will fall to him to find the resident another home. Most of Friendship House's 20 residents are Medicaid clients, many who have no family, he said.

'Obviously there is a conflict of interest there. I won't deprive them from leaving,' he said.

The cuts may be discouraging some from providing the services.

Jan Barnes, executive director of Prospect Place in Keene, is considering opening her facility to the nursing home-eligible Medicaid clients but is holding off because of state budget cuts. Prospect Place would have an easier time than some without independent case management services, but she worries about the impact of other current or future cuts to the program.

'We've waiting to see where the state is going with financing people in assisted living on Medicaid,' she said.

Carolyn Virtue's Heritage Case Management in Concord provides case management services to 137 people throughout New Hampshire. Case managers are required at a minimum to visit clients every other month, she said. The state pays $8.52 per day per client for five days each week. Virtue is paid the same rate regardless of the number of visits to see a client. Virtue said she is breaking even providing the service and the budget cut means she must reassess her staffing levels.

'Certainly I don't want to lay anybody off, but my bigger concern is the clients and their health and safety,' she said.

Eldon Munson, president of the Association of Residential Care Homes, agrees with the state that many of the services provided by the case management agencies duplicate what the homes provide or can provide.

'They do provide an ear, someone to listen when a resident has an issue,' he acknowledges.

Langley said the state inspects the facilities annually, though facilities with two deficiency-free surveys are skipped for a year.

But Virtue said the reason case managers were hired in the first place, about a decade ago, was because of problems with residents getting proper care. Eliminating them removes important advocates for residents and oversight of the facilities, she said.

Virtue believes the oversight goes beyond listening to complaints.

'We're trying to take somebody who should be in a nursing home and put them in a less restrictive type of environment,' she said. 'Because they're for the most part frail elderly, that's one of the reasons why case management is needed.'