Aging poorly – The class divide and nursing home care

April 2018 Nursing home handsBy SARAH MILLER

— LANCASTER, Pa. — Another missed call, another voice mail. I look at my phone and recognize the number. The call was from the daughter of an elderly hospitalized patient. The social workers have been pushing to get her mother out of the hospital and to a nursing home, but the daughter wanted to visit potential facilities before agreeing to placement. I press play. “My mother is not going to that place. I wouldn’t even put my dog there! Please call me back.”

In hospitals, elderly patients wait in their rooms for days, weeks, and sometimes months. Cleared for discharge by the physicians, they have no place to go. Too sick or debilitated to return home and no family willing or able to care for them, their only option is nursing home care.

Hospital social workers provide a list of local facilities to the families. Invariably, they choose the highest rated with the best reputations. After all, they want their loved ones to get the most quality care possible. But that is out of reach for most. The social worker will call the posh nursing homes to inquire about admission, but the behind-the-scenes conversation is always the same: “There’s no way the family can afford that facility.”

It isn’t until the daughters and sons visit the few homes that will accept patients with low incomes that they fully realize the disparity that exists between the care provided for the rich and the treatment of the poor. The first thing that hits you as you walk in the door is the smell. It is a distinct odor of human urine, processed institutional meals, and old construction. Every nurse knows about the “nursing home funk.”

Then you see the surroundings—fluorescent lighting, old linoleum, a magnet board declaring the current weather, “cool, cloudy,” the date, and the next holiday. The bustling nurse’s station is a flurry of activity—bells ringing, charts stacked on the counter. Residents yell from various reaches of the hallways, sometimes words or names but often just screams. The sensory overload is enough to make you want to turn around and run out the door.

First impressions are not always accurate but state inspections of these nursing homes often tell harrowing tales. Violations in various for-profit facilities in 2016 included physician-ordered testing not being completed, increases in bed sores, residents kept in restraints beyond the legal maximum time limit, over-medication with anti-anxiety and sedating medications, and unsafe food storage. Staffing and turnover is also an issue. In one facility, each resident received 30 minutes of direct care from an RN daily compared to the state average of 58 minutes.[i]

But what about the other retirement communities? The ones with sprawling campuses, activities coordinators, and no violations? Families see the billboards encouraging older people to “Live Life Here” and “Be A Part of Our Community!” The advertisements don’t lie. There is gorgeous landscaping, activity buses taking residents to shops and local attractions, multiple restaurants and spas. For those in need of skilled care, they have private, well-furnished rooms and private baths, low nurse to patient ratios, and minimal medication errors. There is no “funk” in the air, just the smell of freshly disinfected hallways.

The most expensive retirement community in Lancaster County, Pa., charges an entrance fee between $99,000 and $419,000 depending on the amenities and type of residence chosen. Monthly fees range from $1814 a month for a studio apartment to $5004 per month for a two-story town home. If a spouse or significant other is also residing there, an additional $26,000 to $45,000 entrance fee and another $1226 per month applies. Community members can be moved to skilled care if the need arises without any additional costs.[ii] Another private, church-affiliated facility charges $439 per day for skilled care or $13,170 per month.[iii]

Daily nursing-home care in Pennsylvania averages at $228 a day for the least expensive facilities. Most of the residents choose these facilities because they have no other choice. The entire cost is paid for by Medicaid. Reimbursement rates are determined by the state and are often less than what the facilities normally charge and sometimes much less than what it costs to provide care.[iv]

So one would think that it would be advantageous and more cost-effective to provide in-home assistance. The average rate for a home health aide is $20/hour. These aides are non-nurses and are trained to help with tasks like bathing, dressing and light housekeeping. Having an aide eight hours a day averages to be $160/day or $4800/month. Compared to $6840/month for nursing-home care, it seems like the obvious choice.[v]

But private insurance, Medicare, and Medicaid pay nothing for in-home care. Financial assistance exists only for those in poverty. To qualify for home-care waivers in Pennsylvania in 2016, the recipient must earn less than $2205 a month and own less than $8000 in assets. There are waiting lists in areas where demand outnumbers availability, causing many in higher populated cities to be without help.[vi]

Most patients I have encountered in my years of nursing only want one thing—to be at home. Elderly women in dementia wards will grab me by my arm, pull me close and, in an urgent tone, ask me when they are going home. When I ask patients in the ICU what they want to see happen with their care, they say, “I just want to go home.”

I listen to children of sick patients tearfully tell me that they want to care for their ill parent, but they have to work or they do not have anyone else to rely on. After all, no one person can provide care 24/7. Help is needed to both provide quality home care and maintain the caregiver’s well-being.

Why doesn’t the state and, more broadly, the nation, advocate for patients? Why won’t they pay for the sick and elderly to be cared for at home? In a word—capitalism. No one benefits from for-profit nursing-home care except the companies who own the facilities. A 2011 study showed that the 10 largest for-profit nursing homes had the greatest number of violations, the lowest nurse to patient ratios and, often, the sickest patients.[vii]

Gone are the days of the “county home” or the “poor house.” For-profit nursing care facilities dominate the field. Locally, the Lancaster County “almshouse” was sold by the county in 2005 for $13.8 million. In response to local controversy over the sale, county commissioners quipped, “The County shouldn’t be in the health-care business.”[viii] What they meant was, “We are losing money by caring for our most vulnerable people.”

The daughter who left me a desperate voice mail did eventually agree to place her mother in a different, yet still substandard, nursing home. In a country where some can spend millions on comfortable retirement and quality care, daughters should not lie awake at night, wondering if their mothers are being mistreated.

The class divide is laid bare in the nation’s nursing homes. The rich plan to retire with the rich while the poor are forced to have inadequate care alongside the poor. There is no reason why we cannot provide for the elderly, regardless of class status and income. Without equal health-care availability to everyone, our society cannot improve. Daughters will continue to cry, the sick will perish in greater numbers, yet profits will continue to increase. Elderly people are our parents, grandparents, neighbors and fellow humans. They are not a source of capital.

This article originally appeared on-line in Red Flag Politics.

[i]       “Nursing Care Facility Information.” Accessed June 4, 2017.

[ii]      “Fees & Services.” Willow Valley Communities. Accessed June 04, 2017.

[iii]     “Rates.” LandisHomes. Accessed June 04, 2017.

[iv]    “How to Pay for Nursing Home Care.” Paying for Nursing Home Care: Medicare, Medicaid & Other Assistance. Accessed June 04, 2017.

[v]     “Calculating the Cost of Assisted Living vs. Home Care.” Assisted Living vs. Home Care Affordability Calculator. Accessed June 04, 2017.

[vi]   “PA.Gov,” PA DHS – Aging Waiver. Accessed June 05, 2017.

[vii]   Kaye, H. Stephen, Charlene Harrington, and Mitchell P. LaPlante. “Long-Term Care: Who Gets It, Who Provides It, Who Pays, And How Much?” HealthAffairs 29, no. 1 (2010): 11-21

[viii] Harris, Bernard. “Nothing can stop Conestoga View sale, Shaub told.” LancasterOnline, September 27, 2005. Accessed June 4, 2017.



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