DHS rules face likely changes Long-term care eligibility key issue

AUGUSTA – A state legislative panel has voted unanimously for a bill requiring the Department of Human Services to overhaul the eligibility process that determines whether tens of thousands of Mainers get a whole range of services.

“This is really good news for a lot of older Mainers and their families, it really is,” said Brenda Gallant, the state’s long-term care ombudsman. “This affects people getting all sorts of services, both at home and nursing home residents.”

The ombudsman’s office investigates complaints and advocates on behalf of Mainers, both elderly and disabled, who receive long-term care services, such as nursing home care, residential care, assisted-living facilities, adult family care homes and home-based care.

Gallant said the current process has a “loophole” in the way nurses conduct the medical eligibility assessment that determines whether, and at what level, a person should receive taxpayer funded services.

Without the proper assessment, patients can be left an improper level of care and families can be left with increased financial burdens.

“In the case of my father-in-law, they just didn’t do the job right,” said Dena Winslow-York, an English professor at the University of Maine at Presque Isle. “They never really examined him, they just asked my mother-in-law questions and entered the answers in their computer program. I am really pleased at the committee vote.”

Winslow-York said she has battled with the state over the way the assessment process works and has been frustrated in getting answers. In testimony to the committee earlier this month, she told lawmakers of rude and insulting comments she received from the private agency the state contracts with for the assessments.

“I was just seeking information that should be available to anyone,” she said Friday in a phone interview. “And instead, I got sworn at. It’s just not right and it needs to be fixed.”

Barry Grant of Leeds said the process seems cost driven, not what is in the best interests of the individual. He said he could not get straight answers about his mother’s situation until he contacted the ombudsman’s office.

“They sat down with us the next time the nurse visited,” he said, “and believe me, it was totally different. They went out of their way to answer questions and be helpful. They need to look at the current needs and those out into the future.”

Those experiences with the process are not unique, said Gallant. She said her agency has dealt with many complaints about assessments that ignored comments of family members and other caregivers.

“They only deal with what has been documented in the records,” she said. “They are not even allowed to use their own observations as trained nurses. This lacks common sense.”

State Rep. Tom Shields, R-Auburn, agrees. A doctor and member of the Health and Human Resources committee, which voted on the bill Wednesday, is dumbfounded that nurses are not encouraged, let alone allowed, to use their training in the assessment.

“I tell you, I have trouble getting my hands around not having nurses do what nurses have been trained to do,” he said during an interview Friday. “Instead of just looking at the documents, they should look at the people. Check for sores, look under the bandage.”

He said the current process is not a bad one, but it could and should be made a better one. He said his goal in supporting the measure is to provide better care for the individuals seeking state services.

The Department of Human Services opposes the legislation. Christine Gianopoulos, director of the Bureau of Elder and Adult Services, said the measure is confusing as drafted and is not needed. She defends the current way eligibility is determined.

“The department also wants the assessment to be as comprehensive and accurate as possible,” she told the committee. “However, we don’t want the nurse, who has five calendar days in which to schedule and complete the assessment, to spend time attempting to consult with individuals simply because a rule requires it.”

In the fiscal year that ended June 30, 2000, there were 22,426 assessments conducted to determine eligibility. In nearly 90 percent of the cases, services were authorized based on the recommendation of the nurse. Gianopoulos said there have been few complaints about the process given the number of assessments completed.

“Sure, with 45 nurses out there doing these assessments, there will be some problems,” she said, “but there have not been very many. In fact, very few. But because no process can be perfect, we have an extensive appeals process to make sure everyone is treated fairly.”

There were 2,481 denials of eligibility for services and in most cases the denials were upheld on appeal, she said. The assessments cost taxpayers $3.4 million a year. That’s about 1 percent of what the state pays for nursing home care, residential care, assisted-living facilities, adult family care homes and home-based services.

Gianopoulos said that because the language of the measure is vague, she is not sure what it would cost to implement, but she is convinced it will cost more than the current system.

But Rep. Tom Kane, D-Saco, sponsor of the measure and co-chair of the committee, said he does not understand why. He said his resolve is the result of DHS not implementing the comprehensive assessment process the Legislature instructed them to create in legislation adopted by the last Legislature.

“I am convinced doing the assessments professionally, comprehensively and accurately will in the long run prove less costly,” Kane said.

The bill now awaits votes by the full House and Senate.