Fragile, pushed out and paying a price: State saves millions by relocating poorest patients
Jeri Ringseth had no business being in an adult family home.
Seattle Times staff writer
How it worksMedicaid: People who cannot care for themselves and have no money are entitled to Medicaid benefits, regardless of age. The state and federal governments each pay about half the costs.
The state: The state DSHS long-term-care program, under Medicaid, has an annual budget of about $1.5 billion.
Adult family homes: Medicaid pays for about one-quarter of the residents in the state's 2,843 adult family homes, or about 4,100 persons.
Payment: DSHS pays an adult-home owner in King County about $17,000 a year to care for a resident. This amount is about one-third of what DSHS would pay a nursing home to care for the same person.
Report abuse: To report abuse of any vulnerable adult or child, call the 24-hour EndHarm hotline, 866-363-4276. You will speak with a real person who will connect you to a direct, local number to make your report.
Call Complaint Resolution: Call a toll-free hotline at 800-562-6078 if the person you suspect is being abused or neglected is living in a nursing home, boarding home or adult family home.
In an emergency: If the person is in immediate danger, call police.
Checking for violationsCall the DSHS regional office for the violation history of an adult family home. DSHS suggests asking for the field manager or regional administrator.
To check those in King County, call 253-234-6001. In Snohomish County, 360-651-6850. In Pierce County, 253-983-3849.
Jeri Ringseth had no business being in an adult family home.
Her physical and mental disabilities are so significant that she's spent most of her adult life in nursing homes or state hospitals. She has diabetes so severe that over the years, surgeons have had to amputate both legs. Without constant care, she often ends up in an emergency room.
Even so, when the state asked Ringseth if she wanted to live in an adult family home — a real home with a bedroom and television — she enthusiastically said yes.
And a home enthusiastically took her, in exchange for state Medicaid payments.
That home didn't work out. Neither did the next, which dispatched her to an emergency room — then refused to take her back.
Ringseth is just one of thousands of Medicaid recipients who have been steered by the state from expensive nursing homes into adult family homes, which cost the state one-third as much.
These homes are a growing, little-regulated housing option for the state's aged — as well as for the poor and frail, such as Ringseth, who cannot care for themselves alone.
There are 2,843 homes across Washington whose owners are paid by the state to provide rooms and care for up to six residents.
But in hundreds of cases, a Seattle Times investigation has found, medically fragile adults such as Ringseth are handed over to amateur caregivers who are inadequately trained to keep them safe.
Adult family homes originally were authorized as less-expensive way stations for the aged who do not require the full services of a skilled nursing home. Increasingly, however, the state Department of Social and Health Services (DSHS) relies on adult homes as places for people who suffer from severe illness or disability, a Times analysis of state records shows.
The state's goal is to save money. Since the 1990s, state caseworkers have been told to meet monthly quotas that dictate how many nursing-home residents must be moved out into the community and adult homes.
One DSHS supervisor wrote in a 2006 memo that most of the "low hanging fruit" — obvious candidates for relocation — already had been steered into adult homes. As a result, the supervisor warned, nursing homes were now dominated by severely impaired patients who might not thrive elsewhere.
But DSHS has continued its effort; it plans to move out 1,100 of its 11,040 Medicaid nursing-home residents by 2012, records show.
This numbers-driven exodus has taken a human toll.
The Times analyzed more than 500 cases of Medicaid residents living in adult family homes from 2005 to 2008. In dozens of instances, relocated residents were overdosed accidentally or were harmed when critical medications were withheld, The Times found.
In a dozen cases of residents with dementia, caregivers with little understanding of the disorder imprisoned residents in their rooms or tied them to chairs with belts or ropes to keep them from walking off.
DSHS said the relocations have saved it an estimated $105 million in 2008 alone. The savings are used to help others who are entitled to long-term-care benefits, said Kathy Leitch, an assistant secretary at DSHS.
State tax dollars pick up about half of the costs for people on Medicaid, the program for people who cannot care for themselves and have no money; federal funds cover the rest.
Asked about quotas, Leitch bristled at using that term to describe the reductions — even though DSHS's documents describe the reductions needed from each caseworker, and include praise for those who exceed the numbers as "high performers."
"We don't have quotas," Leitch said. "We consider them goals."
Problems at first and second adult home
Some people are surprised to learn that Jeri Ringseth, 40, has been married for 16 years. She grew up in Puyallup and met her husband, Gary Ringseth, at Bonney Lake.
She is able to read and write but cannot hold a job. He works for $9 an hour as a driver for a pizza shop and lives in a tiny apartment in Lakewood. They rely on Medicaid for the care that keeps her alive.
They both had high hopes for her first experience in an adult home. It was close to his apartment; he could work full time while others made sure to control her diet and administer her meds, including insulin shots for her diabetes.
It turned out that Ringseth was the only woman living at the Tacoma home, other than the owner. The five men residing there had dementia or other ailments. When she used the bathroom, which had no lock, some of the men would push open the door and watch her.
At times, one of the men would brush his hands over Ringseth's chest.
The owner and Gary Ringseth agreed that the home wasn't suitable for his wife, whose medical needs also were escalating. He found another adult home in Lakewood, which DSHS approved. It was called Helping Hands.
There were problems there, too. Occasionally, when the homeowner's baby crawled around the floor, the caregiver took away Ringseth's motorized wheelchair, concerned that she might run over the baby accidentally.
The owner had difficulty controlling Ringseth's blood-sugar levels. Ringseth could be difficult, too: She sometimes refused anti-anxiety medication and, despite her diabetes, grabbed cookies or treats whenever she could. She would end up in the emergency room.
In February 2008, she was taken, again, to St. Joseph Medical Center in Tacoma. This time, the owner of Helping Hands told the hospital that she refused to take Ringseth back.
With no place to go, Ringseth stayed at the hospital while caseworkers tried to find her a new place. Her room, if billed to private insurance, would cost $1,700 a day. The hospital wrote off her care as charity, a spokesman said.
The search went on for two months, a hospital spokesman said, as social workers contacted more than 40 adult homes and nursing facilities without finding one that would accept a Medicaid resident with her needs.
Ringseth spent much of her days outside her room, roaming the hospital in her wheelchair. She visited the cafeteria, the lobby and other corners of the building, talking to staffers and people she would meet. With the attentive care, Ringseth got her diabetes under control and was perhaps the healthiest she'd been in a long while.
On day 62 of her hospital stay, during a visit from a Times reporter, the telephone in her room rang. Ringseth crossed her fingers.
It was a social worker with good news: A new adult family home had agreed to take her. After hanging up, Ringseth said, "I feel a lot better now."
Reasons for moving Medicaid recipients
The state began moving Medicaid residents, such as Ringseth, out of nursing homes in the early 1990s.
"The whole movement is not a fiscal issue," said Leitch, of DSHS. "It started out with consumers, especially older people, who said they wanted some other way to get assistance with their long-term-care needs than only having a nursing-home option."
By 1993, however, the state faced a budget deficit, and lawmakers approved a DSHS plan to move Medicaid nursing-home residents, when appropriate, into adult homes, senior boarding homes and other, less-costly alternatives.
By 2008 — even with the state's aged population climbing — the state had cut its Medicaid nursing-home population by more than one-third, from 17,448 to a little more than 11,000, saving hundreds of millions of dollars.
The exodus was based on accepted thinking, in the early 1990s, that many Medicaid-eligible people in nursing homes did not require 24-hour skilled nursing care, but stayed there because they had no other place to live. Washington was an early proponent of adult homes.
By 2001, however, some researchers warned that Washington's relocation efforts might need to slow down. A report that year by the U.S. Department of Health and Human Services concluded: "Whether the state will be able to continue to reduce nursing home use is very controversial. According to one observer, the option of moving people out of nursing homes is played out."
In 2007, however, that same federal department was so impressed by Washington's success that it awarded DSHS a $20 million grant to fund the nursing-home exodus of 660 residents over five years.
In reducing its nursing-home population, DSHS used a system that assigned a dollar value to every nursing-home resident. The agency then evaluated caseworkers by how many Medicaid clients they moved to less-expensive placements and how much money it saved, according to DSHS records obtained by The Times.
Depending on the year, employees were given quotas as high as four residents per month; some caseworkers were told they must achieve their quotas in order to justify their jobs.
DSHS says it saves enough money from emptying one nursing-home bed to pay for three residents in adult homes or community options such as assisted-living apartments and home health care.
The agency refers to this process as "rebalancing."
Owners say cuts hurt them, hurt residents
For years, owners of adult family homes have welcomed the nursing-home exodus.
But last year, DSHS reduced Medicaid reimbursements for adult homes by 4 percent. For many owners, this cut wiped out their profit margin, they say.
The state's cuts have reduced the quality of care and caused dozens of homes to go out of business, said Jack Arntzen, director of the Washington State Residential Care Council, which represents adult homes.
"To stay in business, many adult homes have reduced staff, used fewer medical supplies and taken other unfortunate shortcuts," he said.
Arntzen retired from DSHS after 20 years. He and his wife own two adult homes in the Bellingham area.
"Basically, some of them don't have a choice because they are not being supported," he said. "You want to feed residents steak and eggs every day, but when you're not being supported financially, then you can't do that and you're forced into doing other things."
The Times' analysis found that the majority of mistreatment was in homes whose owners had tax liens, bankruptcy filings or other markers of money troubles.
An adult home in King County is reimbursed about $17,000 a year for a Medicaid resident, according to a 2008 DSHS rate sheet. Some 4,100 people on Medicaid are scattered among the state's 2,843 adult family homes, filling about one of four beds.
In a tight economy, with adult-home vacancy rates climbing, some owners have found a new way to profit from their Medicaid residents.
Some owners demand referral fees of $1,000 or more for transferring Medicaid residents to other owners who are desperate to fill their vacant beds, several industry sources told The Times.
A small group of adult-home owners complained to DSHS last summer about the under-the-table deals for low-income residents.
State law does not prohibit these referral fees, DSHS officials say. But a resident must first agree to any transfer.
Arntzen doesn't approve of the buying and selling of residents. "It's atrocious" and gives his industry a bad name, he said.
Nursing-home stay turns out very badly
Last April, Jeri Ringseth packed up her stuffed animals and clothes and prepared to leave St. Joseph hospital for her third adult family home. The new adult home in Lakewood was minutes from her husband's apartment.
"I'll get a room and a TV," she said.
On moving day, DSHS officials said the adult-home placement was unsuitable. It had minor violations that had gone uncorrected from a previous inspection.
Instead, Ringseth was taken to a nursing home, the Nisqually Valley Care Center, in a former logging camp about 23 miles south of Lakewood. She was furious.
Within the first week, she was rushed to a local emergency room as her blood sugar spiked to dangerous levels. The trip was the first of many. Her mental state deteriorated as well, and she threatened to kill herself.
In June, she wheeled herself outside the nursing home and, by most accounts, may have been trying to escape. A nurse's aide spotted Ringseth, ran after her and rolled her back to the home, despite Ringseth's protests.
In a hallway, Ringseth leaned out of her wheelchair, grabbed a pay-phone receiver and struck the aide in the head.
Pierce County sheriff's deputies were called, and Ringseth was taken to a mental-crisis center. Weeks later, she was committed to Western State Hospital — her sixth stay in the psychiatric facility.
"I just want her to get the care she needs," Gary Ringseth said. "I hate that she's back there, but maybe they can help her."
At Western State, Jeri Ringseth's health improved, state records show. Daily counseling and a strict diet eliminated the diabetic crises. To outsiders, she seemed a joyful person, perfectly capable of taking care of herself. "She's really doing great now," her husband said at the time.
Not long afterward, the hospital handed her $40, paid for a cab to take her to her husband's apartment, escorted her to the exit door and said goodbye.
She's on her own; state can't say why
Legally, Western State could not keep Ringseth against her will if an appropriate community placement was available.
Asked by staffers if she wanted to leave, Ringseth told them yes.
But DSHS, when asked, could not explain why she wasn't sent to a nursing home or adult family home, but instead was left on her own.
Ringseth called her husband at the pizza shop to tell him her good news — she was home.
"This is just freaking unbelievable," he told a Times reporter a few minutes later. "Nobody told me this was going to happen. The state dumped her in a cab and sent her away. She needs constant care. She can't live on her own while I work full time."
His wife was ecstatic. "I'm so happy to be home," she said that evening.
Within a few days, she was back in the emergency room with a blood-sugar crisis. The next month became a whirlwind of late-night dashes to the emergency room as her diabetes raged out of control.
"I'm trying so hard to take care of her," Gary Ringseth said. "But I don't have any money."
On Nov. 4, Jeri Ringseth was hospitalized at St. Joseph Medical Center after a trip to its emergency room. She recovered but has remained there ever since.
Her husband visits her daily, and he sleeps on a cot next to her bed three or four nights a week.
DSHS now says she has no business being in an adult family home. So social workers have canvassed dozens of nursing homes to find a Medicaid placement for her.
It's been three months and no luck yet. The nursing homes do not think they can meet her extraordinary needs.
To pass time, Ringseth filled out a hospital work sheet — "Sharing and Learning About Me." With a red pen she scrawled answers:
Her husband was the most important thing in life.
Favorite foods were pizza, cake and candy. Her favorite hobby — to paint and color.
If she won the lottery, she would "give it to my church."
Jeri Ringseth blames herself for being unwanted and prays for a permanent place to live.
"Please, please, please," she says. "I promise to be good."
Michael J. Berens: firstname.lastname@example.org or 206-464-2288
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