Long-term planning: Albany County Executive Michael Breslin. Photo: Joe Putrock

Mr. Breslin’s Vision

As Albany County charts the course for the future of long-term care, the executive proposes a controversial direction

By Chet Hardin

Sitting at a conference table inside the Albany headquarters of 1199SEIU United Healthcare Workers East, certified nursing assistants Doris Jourdanais and Polo Ranggel are discussing their day-to-day responsibilities at Albany County Nursing Home. Ranggel is peeling and eating a Clementine. “I gotta get all the nourishment I can get when I can get it.” He just got off the 7 to 3 shift.

“We take care of the residents ’round the clock,” he says. “We take care of their daily activities. We help them with their showers, the men shaving, the women’s hair and make-up, stockings.”

“Everything you do for yourself, I do for them,” Jourdanais says. A lot of the residents have multiple sclerosis, and they need to be lifted. Many of them have Alzheimer’s or other forms of dementia. “A lot of them,” she says, “are just old.”

“If you leave them alone, they’ll never get out of a chair,” Ranggel says. “You know what that does to you? You’ll never be able to get out of a chair. You’ll never be able to stand up. We have to walk people a hundred feet several times a day. If you leave people alone, they won’t bathe. They won’t shower. They won’t brush their teeth. They won’t floss.”

Ranggel has worked at the home for eight years.

Jourdanais has worked for ACNH for 16 years.

“A lot of folks don’t know what day it is, what time it is, what year it is. They have no concept of day and night,” he adds. “Like babies.”

Some of the residents have family that will visit them, and a lot of them don’t. “The ones that do have families, they are there because the families couldn’t take care of them. We have a resident now with Alzheimer’s whose son kept her at home. He literally had to put padlocks on the door and sleep on the couch so she didn’t escape. And he couldn’t do it anymore. He almost quit his job,” Jourdanais says. “We have dementia people. We have people that will beat you up and think nothing of it.”

“You think you can take care of these people at home?” she demands. “They depend on us. We become their family, and I don’t want to see them get hurt.”

In 2006, the Berger Commission recommended decommissioning nearly 3 percent of the state’s nursing home beds, numbering 3,000. Albany County was targeted for downsizing and forced to close one of its two municipal homes, Ann Lee Home, in 2008. The residents and staff of Ann Lee merged into ACNH. The commission also charged that Albany County “rightsize” its population of nursing home beds to 250. Family members of residents in Ann Lee and ACNH saw Berger as a direct attack on the security of their loved ones and became tireless advocates. Legislators complained that the county ought to have fought back against Berger, and pledged to demolish the 35-year-old ACNH and build a modern, state-of-the-art facility.

This past June, the Albany County Legislature passed a resolution requesting that Albany County Executive Michael Breslin prepare and present to that body his plan for long-term care. Legislators, such as Majority Leader Frank Commisso, Shawn Morse, Gary Domalewicz and Brian Scavo had become impatient with the executive. The resolution noted the exhausting debate that the county has been engaged in for years: “After countless meetings and the presentation of endless alternatives,” Breslin was directed “to take all immediate and necessary steps to develop plans to overhaul the entire spectrum of long term care for the elderly in Albany County including the replacement of the nursing home.” The legislature was forcing Breslin’s hand: Are you going to get behind building a new nursing home or aren’t you?

Breslin has, in recent years, made no attempt to hide his unease with the notion of investing millions of taxpayer dollars—state, federal or otherwise—into the bricks and mortar of institutional long-term care. What he has learned from years of study, he says, was that the health-care industry is slowly trending away from institutionalized care in favor of more cost-effective and flexible home and community-based services.

So in September last year, when Breslin presented his plan to the legislature as requested, it shouldn’t have been too surprising that his vision for long-term care included shuttering ACNH and shelving discussions to build a modern facility.

“Rather than building a new nursing home,” his plan reads, “Albany County can and should use this once-in-a-lifetime opportunity to change the direction of all of long-term care in Albany County and be a model for many other areas of New York State. While significantly reducing what would otherwise be very large property tax increases, Albany County can provide for new opportunities especially for patients needing care in the future, opportunities that current patients never had.”

It’s almost unthinkable to Jourdanais and Ranggel—and to the union that represents them—that Breslin would want to get out of the municipal nursing home business. They say that it’s a reprehensible position, cruelly out of touch. These people who depend on the home are frail, vulnerable, with nowhere else that they can go. They are veterans, firemen, nurses, mothers and fathers. Their families tried to keep them at home. When that got too difficult, they tried to place them in a half-dozen private nursing facilities. Nothing worked. No one would take them. Albany County Nursing Home has been, for so many families, solace at the end of an exhausting and traumatic struggle.

Breslin, Ranggel says, is only concerned with the dollars and the cents. That’s just the way some people spend their entire lives, he says, “thinking about the numbers” and not the people.

“I don’t have faith in Mr. Breslin, anymore. And a lot of them don’t,” Jourdanais says of her residents. “When he comes in the building, they won’t give him the time of day. They will walk away from him. They won’t shake his hand. I have nothing to say to the man.”

Put simply, Breslin’s plan for long-term care calls for the further investment of county resources into home and community-based services, with the stated goal of keeping people out of nursing homes for as long as possible. And, the plan reads, if the time comes that a 24-hour medical facility is needed for a Medicaid-sponsored county resident, then the county will place that resident into one of the private nursing homes in the area.

If you ask Breslin to explain, he will—in detail.

The plan hinges on a trend widely recognized in the medical community: the demand for nursing homes is on a steady decrease. From 2002 to 2008, the number of Medicaid-assisted Albany County citizens living in nursing homes fell by 12 percent. Since 1983, as the Berger Commission reported, the state has lost to closure 63 nursing homes.

“It’s counter-intuitive to so many people, because they say, ‘My God, we are getting older, we must need more nursing homes,’ ” Breslin says. “Well, we might be getting older, but we are also getting healthier. Not too long ago, the average age of people going into nursing homes was 65. Now, it is almost 85.”

When ACNH was first built in the 1970s, it was a place where people lived out the last years of their lives, he says. Now, the home is used to great extent as a location for post-hospitalization rehabilitation, where a patient might stay for a few months before being restored back into the community.

“Over the course of years it became clear that we had a situation in the county where the default position was still just put a person in a nursing home,” Breslin says, “and we weren’t focusing on those things that allow people to make other choices.”

The county, along with the state, began to invest in alternatives. In 2007, the county established the Long Term Care Council, some 35 people with connections in the community through nursing homes and hospitals, among retirees and with unions.

The county eliminated the waiting list for the Expanded In-home Services for the Elderly Program in 2007, and has seen the number of residents using that service grow by 158 percent. As well, there has been a significant increase in the number of people using other programs, including home-health nursing, meal delivery services, the Long-Term Home Health Care Program, the Personal Emergency Response System, the Adult Day Health Program.

According to the executive’s office, “The total number of Medicaid clients receiving any home care services grew from 3,962 to 4,494.”

The lesson that Breslin says that he has learned is that the more you invest in those resources in the community, the more they will be utilized. And by providing flexible assistance to help those people struggling with age or advancing illness stay in their communities, the less you will need nursing home beds.

Proof of this can be found in the experiences of Vermont and Oregon.

Oregon allots 54 percent of its Medicaid spending to home and community-based services. Between 1999 and 2004, that state saw a 12 percent decrease in the number of people in nursing home care while the number of people using HCBS increased by more than 14 percent. Likewise in Vermont, as that state increased its investment in HCBS, it saw a similar decrease in demand for nursing home beds.

“You’d be amazed,” says Rick Iannello, a former nursing home administrator and the director of the Albany Guardian Society, “by how well somebody can be cared for by a family member or a spouse if you give that spouse just a little support. That person can do a great job for a long period of time.” Iannello has worked in the field of aging issues for decades, and says that he has found that by providing “little pieces of service packages to people living in senior housing or in the community, you can keep a person independent for a long time, much longer now than you could in the past.” Sometimes this is a very simple amount of service, such as food delivery; sometimes it’s just a $100 set of assist rails installed in the bath. In other situations, it’s providing respite services for the families who are caring for their loved ones.

And while it’s arguably more humane to help keep people in the community for as long as possible, the executive says, it’s definitely more fiscally sensible.

“Today, it is very clear how much more expensive it is for the county to offer services by way of a nursing home,” Breslin says. In 2008, the subsidy to operate the nursing home, the taxpayer dollars that went in above and beyond the Medicaid reimbursements, was $18 million, “for between 200 to 250 people.” His office is predicting that number to continue to balloon, reaching 30 percent of the property tax levy.

Breslin believes that, by introducing new programs and by better coordinating the current hodge-podge of resources, the county will be able to save money while extending services.

Waiting for the ax to drop: disability-rights activist Michael Volkman. Photo: Joe Putrock

Look at Assisted Living Program beds, Breslin says. These are a form of interim care for people who can no longer live at home, but don’t require the 24-hour medical care provided by a nursing home. “It’s dramatically less expensive to have an assisted-living bed compared to a skilled nursing home bed.”

Legislator Lucille McKnight is a member of the Long Term Care Council and a supporter of Breslin’s vision. She has chaired the Social Services Committee for much of her legislative career. “I have seen how the concept of case management of long-term care could work marvelously in this county,” she says. “In fact, it works right now. It’s in place, some of it for decades. I have tried to stress to my colleagues on the legislature, who don’t understand the theory and methodology in social service language to think about it, read about it, come to the meetings and hear it discussed.”

McKnight says that most of her colleagues on the legislature, though, aren’t listening. “They have shut down. All they want to hear is: ‘Go build a building!’ ”

‘You know the old fable about the axe in the ceiling?” asks Michael Volkman. “A guy is about to get married. He comes into his fiancé’s house. ‘Where is everybody?’ He hears crying from the basement. He goes down, and the whole family is down there crying. ‘What’s wrong?’ The fiancé points up, ‘There’s an axe in the ceiling! What if we have a child and he comes down here and the axe falls down and kills him?’”

He pauses, and lets the absurdity of that situation resonate.

Volkman, a 40-something Yonkers native, has spinal muscular atrophy, a medical condition that permanently disconnects the nerves that carry signals from the brain to the muscles, he explains, “one by one at random intervals without warning. Functional capability is lost gradually over time, and must be replaced with technology and personal assistance. I walked with the aid of crutches until I was 6 years old. I have used a wheelchair for all my mobility needs since May of 1972. For seven years my chair was acoustic. I went electric on December 4, 1978. Unlike Bob Dylan, I was not booed off stage.”

A disability-rights activist, the first time Volkman went to a protest at the Capitol was in 1991. He was 26. Among other things, he was advocating for the statewide implementation of consumer-directed health care, a model that was created in the 1970s in New York City.

In 1992, the state launched a three-year pilot program for consumer-directed care in Syracuse, he remembers. “We wanted to try to get it expanded in ’95, and at the 11th hour, with the budget late, we were surprised. It was a separate bill originally, and it got thrown into the budget. It defined this new category of service, made it statewide, and it also included the requirements that all counties’ social-services agencies offer it, pay for it and notify consumers that it exists.”

At the time, Volkman was working at the Capital District Center for Independence. “Albany in particular was very stubborn. The director of adult services didn’t believe in the program. Didn’t think anybody was capable of being self-directing. I heard him say that he knew maybe five people that were capable of being self-directing. When I heard this, I was like, ‘I can name 10 people without thinking about it.’ There were dozens, probably hundreds more.”

Since implementation, consumer-directed care has helped thousands of people like Volkman live in the community of their choice. As of 2009, there were 167 people living in Albany County who utilized the care method. In many ways, it is just like typical home care that you might get from an agency, he says, except that he, as the consumer, is responsible for hiring, recruiting and training his aides.

Volkman lives on his own in a private apartment in Center Square that is neither owned nor operated by the government. His rent is subsidized and his health care costs are covered by Medicare and Medicaid. He employs three round-the-clock personal assistants, he says, plus a part-timer and one reserve. “They handle all my daily tasks, including getting out of bed in the morning, preparing breakfast and helping me eat it, assisting with toileting, assisting with showering, getting dressed, preparing lunch and helping me eat it, keeping my apartment clean and presentable, assisting with medications, shopping, preparing dinner and helping me eat it, and laundry. They help me with all the various odds and ends around the house. One stays overnight to help me turn, and to be there in case there is an emergency and I need to evacuate the building. They accompany me when I go out anywhere. They run errands. One of them comes with me on those occasions when I need to travel for business or vacation.”

He makes it down to the city about once a year to visit his family and take in Yankees games with his brother.

Volkman is vehemently opposed to the construction of a new municipal nursing home. As he puts it, “The issue is, do we want to go backwards and maintain the industrial 20th-Century model of nursing homes, or do we want to move forward and give people service that they actually want and can be able to use? Services, which by the way, happen to cost a lot less.”

Just like an airline wants to fill every seat on a flight, Volkman points out, to remain financially tenable a nursing home must work to fill every bed.

“These nursing homes have very high operating costs. If they build a new nursing home, they are going to have to justify the expense. Now, if there is a person who can benefit from in-home community-based services, there is going to be so much pressure to fill that nursing home, how many people are going to be steered into it when they could benefit and could live well independently? What you are going to see with that new nursing home, it is going to suck away funding from what could be put toward the other line items for community services.”

Volkman cites the Olmstead decision, the 1999 Supreme Court ruling that states that it is a violation of civil rights to institutionalize a consumer when that person could be treated in the community. “So all this grandstanding with the Legislature, with all of their promises with the nursing home, they are actually turning the clock back on disability rights. And they may risk putting Albany out of compliance with Olmstead.”

The core of Volkman’s advocacy for decades has been aimed at educating politicians to the benefits of home-based and community long-term-care models. But it is difficult. For most people, it is too complex. The easier solution, the default position as Breslin put it, is to just rely on institutionalization—to continue crying over the axe in the ceiling.

“We go to the government every year and tell them what we need, and they just don’t listen. We are saying, ‘Get us out of these nursing homes; put the money into long-term community-based services,’ ” he says. “We are giving the county the answer. We have been giving everybody these answers for the last 25 years. But the loudest voices are the ones coming from the people working in the nursing home. Those are union laborers, and they are using the union clout, and the unions have a lot of clout with elected officials.”

Critics of Breslin’s plan argue that it’s unrealistic. They argue that private nursing homes will balk at accepting the Medicaid-dependent county residents who are too difficult to deal with, such as Alzheimer’s patients. They argue that even currently there are Albany County residents who are sent out of county and out of state to receive nursing home care and if the county closes ACNH, those numbers will increase. They say that the only way to ensure the welfare of the county’s most vulnerable citizens is for the county to provide its own nursing home.

The Albany County Legislature’s Special Nursing Home Facilities Committee started to explore the county’s long-term options, and commissioned architectural renderings of a long-term care park, intended for the Heritage Park site near the airport. These renderings are the legislature’s answer to Breslin’s proposal.

United Healthcare Workers East are fans of the committee’s architectural drawings and have posted them on the wall of the union’s large conference room. As one organizer put it, “That’s a plan. What Mr. Breslin offers, that’s just a vision.”

The committee’s chair, Legislator Gary Domalewicz, says that the park will offer “a nursing home, residential health-care facilities with rehabilitation and assisted-living and nursing facilities all on one campus, so that we could take care of all of your needs right there. It will be a state-of-the-art facility, and after we build it right, I believe we will be back to having a waiting list in Albany County.”

Domalewicz says that 95 percent of the cost of the construction will be paid for by a combination of federal and state money, and estimates that it will be a $40 to $50 million project. “Albany County’s portion will probably be $3 to $4 million.”

“The only way you can ensure your grandmother, who has dementia and is from Albany, will have someplace to go is by building an Albany County nursing home,” Domalewicz says. “No one else will take her within a 50-mile radius.”

The issue surrounding the placement of residents in nursing homes outside Albany County is a complicated one. For one thing, Breslin counters, the county has no say where nursing home patients are sent. That is a state decision. Currently, about 25 percent of the people in ACNH are not Albany County residents.

Further, Albany County patients are sent to other states and counties for a number of reasons: They have highly specialized medical needs; they have violent behavioral issues; and by choice. Plus, he argues, no matter what size of nursing home the county builds or maintains there will always be people who cannot be placed in Albany County.

Rick Iannello agrees with the executive’s assessment.

“I tend to believe that moving a person out of state does occur and has occurred for a long time—that is not a new phenomenon—because none of the facilities are well-equipped to deal with someone who has severe or violent behavioral type problems,” he says, adding that there are a handful of patients who need medical care that is easiest to provide in specialized regional facilities.

As for working with the private homes, Breslin says, the way to incentivize that relationship is for the county to pay a premium for the residents who have been historically “hard to place,” people who suffer from Alzheimer’s and other forms of dementia.

His critics argue that private nursing homes don’t want to deal with the hassle of dementia sufferers, but Breslin argues that it has more to do with Medicaid reimbursement rates. These rates are set based on medical need. If a patient only suffers from Alzheimer’s and no other medical condition, Medicaid reimburses their stay at the same rate as someone who doesn’t have Alzheimer’s. Here, Breslin says, the county would step in with a premium payment above the Medicaid rate.

This is a proposal that the private homes have expressed interest in, the executive says, with one suggesting that it might build a new wing in order to absorb the new consumers.

“This is not part of a campaign to do anything but give the people of this county the best possible resources at the best possible cost,” Breslin says. “I probably should have folded the tent a couple years ago and said, ‘Sure, go ahead, go build the thing.’ But then there would be a significant number of people who wouldn’t have those choices. And I realize now how much more expensive that would be. And in both ways, I can’t in good conscience say that I agree with building a nursing home.”

Despite Breslin’s dogmatic vision, he still has a county to run. During the heated budget negotiations at the end of 2009, he acquiesced and offered a compromise to the legislature. He would support building a nursing home of 150 beds if the legislature would support his efforts to establish 100 ALP beds in the county—that, and layoff 74 union-represented workers at the nursing home.

The legislature balked, and passed their budget without compromise.

Domalewicz saw that as a critical win. “The county executive agreed with us on what we have said all along, that we need a new nursing home for the seniors of Albany County. And now we’ll be moving forward with that process very shortly.”

chardin@metroland.net

To read Breslin’s proposal for long-term care, visit the Albany County Web site. For more information on long-term care in Albany County, call NY-Connects at 447-7177.