National Nurses United

5 pg_6 pg copy 6/2/11 3:16 PM Page 16 J onica brooks' days at the California East campus of California Pacific Medical Center in San Francisco are filled with the constant scurrying, checking, and rechecking that's familiar to any hospital nurse. She checks IV antibiotics and IV catheters to hearts. She double-checks wound vacs. She is in constant communication with the doctors, physical therapists, speech therapists, and occupational therapists in other parts of the hospital that treat her patients. It's a hard but rewarding job. 16 N AT I O N A L N U R S E rates and benefits compared with freestanding facilities, which often offer no health benefits, terrible pay, and high turnover." I t used to be that if a patient needed to be nursed back to health after an acute event, she would stay in the hospital until she was well. We all know what happened to that system. With the advent of HMOs and when the Centers for Medicare and Medicaid Services (CMS) in the 1980s changed its payment system from a fee-for-service to flat-fee model through its prospective payment system, hospitals began unloading patients as quickly as possible to bring in new patients and cut costs. Under these conditions, the hospital-based skilled nursing facility was born. "All these people were released quicker and sicker and they weren't ready to go home," said R. Tamara Konetzka, assistant professor of health services research at the University of Chicago. "The hospitals thought, 'Why not open a hospital-based nursing home and wheel those patients down the hall, where they could charge a fee for service all the time?'" Many did. By the mid 1990s, there were more than 2,500 SNFs around the country. Hospitals had found a way to get paid twice for the same patient: Once for the initial admission and stay under the acute-care prospective payment system, and then for every service provided to patients at the SNF. By the mid 1990s, the fastest-growing part of the CMS was postacute care, sometimes rising by an "astronomical" 30 percent a year, according to the University of Chicago's Konetzka. CMS caught on to the double billing game, and in 1998 imposed a flat-fee prospective payment system on post-acute care facilities similar to the kind it had imposed more than a decade before for acute-care services. When hospital administrators argued that the quality of care was higher at hospital-based SNFs than freestanding nursing homes and that they therefore deserved a higher flat fee, CMS balked. CMS leveled the rates, and the SNF freefall began. Just like that, hospitals started to see their SNFs not as cash cows, but as money losers. In the first 10 years after the new payment system was imposed, 1,000 SNFs closed around the country, accounting for nearly half of existing facilities. But observers and critics of SNFs say that while hospitals may whine about losing money on their skilled nursing facilities, what W W W. N A T I O N A L N U R S E S U N I T E D . O R G M AY 2 0 1 1 PREVIOUS PAGE: GEORGE SHEWCHUK | GETTY IMAGES; OPPOSITE: LAUREN REID But there's a big difference between Brooks and her colleagues on other floors of the hospital. Brooks works on the hospital's skilled nursing floor. Technically, what she does is considered nursing home care, according to the laws of the state. That means that while she's doing much the same work as her colleagues—with the additional responsibilities to feed, bath and do daily ambulatory care—she doesn't have the staffing minimums of other RNs at her hospital. And while other nurses are in high demand and have some job security, Brooks could lose her job. Indeed, her skilled nursing facility was scheduled to close by the end of 2010 but remained open due to public outcry. It could close any day now. The San Francisco Bay Area, where Brooks' employer is located, serves as a microcosm of what's happening to skilled nursing facilities across the country. Two other major hospitals just miles south of San Francisco, Seton Medical Center and Mills-Peninsula Health Services, are also planning to shut down or sell their attached SNFs. The proposed closures are part of an epidemic of hospital-based SNF shutdowns that started in the mid 1990s. In the decade between 1998 and 2008, nearly 1,000 skilled nursing facilities—representing about half of total SNFs—across the United States have disappeared, according to a January article published in the Archives of Internal Medicine titled "Geographic Concentration and Correlates of Nursing Home Closures." Yet patients need skilled nursing facility care now more than ever. Because they often lack regular access to healthcare and delay treating medical problems, hospital patients are of higher acuity with more complex conditions than in the past. And, because they can maximize profits through shorter stays, hospitals are discharging these fragile patients earlier than ever before. The closures are a sign, experts say, of what happens when healthcare is provided under a profit-driven healthcare system where hospitals chase the dollar instead of considering what patients and communities need. "It's a shame SNFs are closing, because a lot of these hospital-based nursing homes have better quality, fewer deficiencies, and much better staffing than freestanding nursing homes," said Charlene Harrington, professor emeritus of sociology and nursing at University of California San Francisco's National Center for Personal Assistance Services. "Hospital-based nursing homes are usually unionized, so for the most part they have good RN staffing and good overall staffing and much better pay

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