Sitting in the courtyard of Grant Park Care Center, we watch the sparrows peck at pieces of white bread being tossed on the ground – the only happening worth observing aside from cars pulling into the parking lot. The woman next to me, dressed in a red t-shirt and sitting comfortably in a wheelchair, reprimands the fellow doing the feeding, informing him that the birds like their food broken up into little chunks. Time stands still as we watch the birds; a few nurses come and go behind us in a trail of cigarette smoke, chatting with each other or on cell phones. I ask the woman next to me how she likes her living situation, if she has any stories to tell. “You don’t want to hear my stories,” she says.

Her stories should be of interest, if not out of individual concern then for what they represent: the District has a rapidly aging population with 12.2 percent of residents now 65 or older; that percentage is expected to increase to 13.4 percent by 2030, according to the American Association of Retired People. Many more aging people soon will be in need of some type of long-term care or service. Currently, the District counts the largest percentage of young people (under the age of 65) in nursing homes in the country.

With two of the District’s largest nursing home facilities announcing impending closures in recent months, hundreds of beds once available for long-term care will soon be no more. Meanwhile, other relevant long-term care options like assisted-living facilities have been compromised by a seven-year delay on the part of the Department of Health to implement mandated licensing standards that would protect residents from illegal transfers, physical abuse, identity theft and a host of other harmful behaviors. Without a proper license, many DC facilities are unable to qualify for insurance monies that could provide residents with resources and keep providers in business.

And business it is. Nursing homes that serve a majority low-income patients, like Grant Park, say their budgets are shrinking as Medicaid reimbursement rates remain at low levels, compromising reasonable profit margins. Yet there are experts who contend the financial troubles some homes claim to face is exaggerated and self-created by a tax fund setup in part by the nursing home industry that now has millions tied up in funds at the DOH. Others suggest the financial woes and threat of closure is motivated by greed.

What’s the real financial story of long-term care in the District? Why after almost eight years is the DOH only now beginning to institute licensing standards in assisted living facilities to protect residents? Are nursing homes and assisted living facilities the only real option for low-income residents who need regular help?

Where Money Matters: Is Quality Care Reduced to the Bottom Line?
Grant Park Care Center is situated in Ward 7 close to Michigan Avenue: it is an unremarkable brown building with a decrepit sign out front and a small patio where residents sit outside in wheelchairs or lean against the building for fresh air. The facility houses 296 residents, 98 percent of whom are on Medicaid, and is one of only two homes in the city with an in-house dialysis center – the other is at Beverly Living Center-Northwest, the city’s largest nursing home, which in June announced their decision to close. Grant Park also has filed for closure with the DOH.

“That’s where we are,” says John Darden, who became chief administrator for Grant Park five months ago. “I don’t think the owners of the building want to see the building close, it’s just unfortunate that it’s a reality and that it will happen.”

The for-profit facility is said to have lost approximately $2.5 million over the last few years and can no longer foot the bill.

According to Darden, Medicaid reimbursement rates are too low, and healthcare costs are on the rise. “The [Medicaid] rates were established in 2000 and have not been adjusted since,” Darden says. No cost of living increase was given to nursing homes, and they lost $13 per patient per day due to a change in pharmacy billing rules, according to Darden. To keep the facility open, they are asking Medicaid for an additional $35 per day per patient on top of the current $117 per day, per patient; something they are unlikely to get.

Some speculate that Grant Park’s convoluted ownership and business structure is the source of its financial woes. It is operated by a DC limited partnership of several individuals and Atlanta-based Centennial Service Corporation but outsources the management and accounting duties. Centennial Service is owned by Centennial HealthCare Corporation, a division of Hilltopper Holding Corporation, both of which filed for bankruptcy in 2002.

Some experts suggest additionally that greed is motivating the closure.

“Every year [they complain about] inflation and increased costs with the facility and upkeep and that the meals cost more,” says Bobby Coward, director of the nonprofit Direct Action which advocates for independent living.

“They have a monopoly,” Coward continues, “and the idea is, ‘if we close our doors now, you have to give us what we want or you’re going to suffer.’ Where you going to put [the patients]?” Due to a shortage of nursing home beds in the city, facilities like Grant Park can leverage their position for increased funds, according to Coward. “They push the District into a corner to force them to comply and give them what they want. That’s the basic political strategy – give us more money,” he says.

According to Darden, however, Grant Park went into the red in the last few years because “[we were] willing to put into our operation to meet our resident’s needs.”

That willingness may be questionable, however, with the number of state and federal violations slapped on the facility in the last few years, including basic care violations for failing to supervise residents properly to prevent accidents.

Additionally, the DOH fined Grant Park July 6 for an illegal practice known as “dumping” – dropping residents off at local hospitals and telling them they can’t come back.

Still, other reputable nursing homes in the District contend that dealing with quality patient care and rising healthcare costs is difficult. “We don’t have the high percentage of Medicaid patients that Grant Park has…but as it is now in DC, [Medicaid] certainly doesn’t cover our costs,” says Sandy Douglas, chief financial officer and administrator for the Methodist Home of DC located in Northwest.

To make matters worse, millions of dollars that could be going back to District nursing facilities are tied up in a government fund created with proceeds of a “provider tax,” a District levied tax on District nursing facilities and a 70-30 match by the Centers for Medicare and Medicaid Services. The fund is meant to “pay for the increase in rates that has been given to the nursing homes for quality of care initiative,” according to Leila Abrar, director of communications for the DOH. “Quality of care” would be for things like staffing increases, staff trainings, fixing medical equipment and the like.

To date, the fund has $9,355,853.52 available, yet providers say they have not seen a dime.

“None of [the provider’s tax] money is coming back to us,” says John Darden, “and we are still paying into it.”

According to DC’s long-term care ombudsman, Gerald Kasunic, the DC Health Care Association penned the law for the city and “wrote that the funds (both collected by the nursing home providers and federal draw down moneys) will be placed in an account under the [Medical Assistance Administration].”

However, the MAA, which administers and oversees the District Medicaid program, does not have the legal authority to release these funds, according to Kasunic. Ten percent of the funds are going to DC Medicaid administration, though the DOH could not give specifics on how the other 90 percent is currently being used.

Bureaucratic Bungling Leaves Assisted Living Residents without Recourse
The District also has managed to fail its residents in assisted living facilities, who are not protected by any licensing standards mandated by the DC Council seven years ago.

The egregious delay recently led the DC Long-Term Care Ombudsman Program and Legal Counsel for the Elderly to file a suit with the DC Superior Court against the District government. The lawsuit is meant to force the District of Columbia to create and implement a licensure system that measures quality of care by developing individual plans for individual residents and prevents harmful behaviors.

Assisted living facilities, designed for those who need extra help in their day-to-day lives but do not require 24-hour skilled nursing care, are under different regulations than traditional nursing homes.

Yet in the District, assisted living facilities haven’t been regulated at all; without a system of licensing, and without definitions for quality care, regulations for admission or definitions of residents’ rights, although all are required by the Regulatory Act by the DC Council in 2000.

In 2004, the DOH was even given $350,000 (from the provider’s tax fund) to research and implement a “quality care measurement tool” which would get standards for assisted living in place.

According to Vera Mayer of the DC Coalition on Long-Term Care, however, the report covered existing research on assisted living facilities without any real plans for implementation and individual care.

Hence the lawsuit was born out of sheer frustration, says Kasunic. The writ of mandamus is a complaint lawsuit (not monetary) that demands the department follow the legislation and (finally) create licensing protocols.

“In my opinion, [the industry] doesn’t want to be regulated,” says Kasunic, of the lawsuit. “I’m sure there are drawbacks to this because I’ve had complaints that long-term care insurance companies are not honoring or covering the residents since the [facility] is not licensed either,” he added.

The insurance issue makes assisted living more difficult for low-income residents. Currently the only option is to get a Medicaid waiver to attend an assisted living facility, but according to Kasunic such allowances for the waiver are very strict. “You have to meet certain criteria to get on there, you have to be…below poverty to get on there. It’s just not everyone applies and you get it; as it stands now, assisted living facilities are pretty much for the rich,” Kasunic says.

Advocates are hopeful that regulation would open the doors to more insurance monies and more access not to mention safer facilities.

“If you have a family member in assisted living…[if] someone is being exploited or physically abused or neglected, there’s no place to lodge that complaint except my office,” Kasunic says. The ombudsman office does not have the authority to act on such complaints without a regulatory authority, however, and according to Kasunic, the complaints are currently “collecting dust.”

New Political Will?
At-Large District Councilmember Phil Mendelson (D), a member of the Committee on Health, should have the issue of nursing home care close to heart. His mother wrote the landmark book “Tender Loving Greed” in 1975 which raised questions about business practices of the American nursing home industry. Yet the council has only recently begun to get the DOH to move in the direction of regulations with Councilmember Catania (I) chairing the Committee on Health since 2005.

Councilmember Catania could not be reached for comment on the question of oversight of the implementation of regulations.

The directors at the DOH won’t say why it took so long to begin implementing the mandated assisted living regulations; some think it’s rather straightforward: “I don’t think it’s a top priority,” says Mayer.

It seems, however, that some change may be on its way.

Perhaps under pressure from the lawsuit, the DOH hired Dr. Feseha Woldu in January as senior deputy director for its licensing and health administration. According to local advocates, Woldu moved swiftly to study appropriate standards and to move the department toward action; it seems that he may provide the impetus for a culture change at the DOH.

“What Dr. Woldu did was to say, ‘what’s the best system in the country?’ and to go out and study it and bring it back to DC,” says Mayer.

After traveling to Wisconsin to study their model of assisted living regulation, Woldu decided he would return to implement the changes.

“I was impressed by what I saw in Wisconsin,” says Woldu, “at how well people have adjusted, how the facilities are run and how it’s provided increased services to the elderly.”

People seemed happier, Woldu says, with “privacy and a choice that we are looking for…nursing homes are really for people who cannot take care of themselves…this is an alternative.”

At most nursing homes in contrast, facilities limit individual choices by design. Curmet Forte, a 67-year-old resident at Grant Park Care Center and advisor to the resident council believes the uniformity can affect quality of life. “You have to eat at the same time, bathe at the same time, wake up at the same time,” he says. Forte says staff wake patients up as early as 5 a.m. and take them out of their rooms; residents often can be seen with their heads down on a table, trying to go back to sleep.

Another Way Home
When I met Bobby Coward, he was anything but what his last name describes. We met by chance in front of Grant Park as I sat in the small courtyard chatting with residents. He approached me, sporting a gold earring in the shape of a wheelchair and (not knowing I was a reporter) asked if I could help him with some medication found in his backpack.

Such is Coward’s style: to strike out on his own and find ways to get assistance while living. He is a national and local advocate for finding ways for those who could move from nursing homes to live with more independence and choice. Coward is a voice especially for young disabled patients as the founder of “Direct Action,” a nonprofit that advocates for local and national reforms to help residents at places like Grant Park find more independent living options.

According to Coward, a community-based service program that allows a person to have at-home care is a cost-effective option for independence. “The annual cost is $54,000 for one person in a nursing home per year whereas it is $37,000 per year for community-based services in 2007,” he says.

Coward says he speaks with a lot of nursing home residents who are eager to hear how they can live more independently, especially young people. Coward is currently advocating for a program known as “money follows the patient” that would provide Medicaid funds to hire private nursing aids for particular duties and allow the patient to make choices about how and where to live.

Vera Mayer agrees that options such as Medicaid home-based care and adult day care, which allows seniors to attend classes and get basic medical care at a local community organization, provide a viable alternative to nursing homes for those who don’t need round the clock care. Giving residents options and the least restrictive environment possible is what the DC government should focus on in the face of these closures, Mayer says.