Saturday, March 23, 2019

Eagle Butte
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Elderly care requires intensive preparation and attention to detail


Transitioning elders into long-term care facilities is an arduous task requiring extensive application and assessment processes.

For elders in need of care, gone are the days of simply signing an apartment lease. Even a mortgage agreement seems much less complicated and complex than the intake process required for a nursing home facility.

Medicine Wheel Village (MWV) is the first brand new nursing home facility in South Dakota on reservation land and the nineteenth of its kind in Indian country said Nursing Facility Director Deb Arbogast.

MWV is one facility with two levels of care: the assisted living care and 24-hour nursing care.

The facility opened its assisted living level of care first, Arbogast said, because they needed a place to start to provide care for elders.

MWV is a state and federally regulated facility, with funding coming predominately from Medicaid or private pay accounts.

“About 55 percent of South Dakota long-term care patients are on Medicaid,” according to South Dakota State News Watch reporter Bart Pfankuch (his article is printed in this edition of the WRE).

Newly elected SD Governor Kristi Noem, in an interview on WANX Radio, said the state administers Medicaid, a federal dollar program tied to how much providers are reimbursed for patients, and the issue for nursing home facilities in SD is that the state is not reimbursing for the full cost of care for a patient.

“So, if a big population of those patients are on Medicaid, they [nursing home facilities] are losing money every day their doors are open, or they can’t recruit nurses and aids and doctors and professionals into those communities and pay them enough to be competitive in other areas,” Noem said.

“South Dakota has one of the lowest Medicaid payment rates to nursing homes in the nation, and the state portion of aid has risen only slightly in recent years,” Pfankuch reported.

“With a daily reimbursement rate of only $131, the state’s 110 nursing homes lose about $32 a day for each Medicaid patient they house, a loss of $39 million a year statewide,” Pfankuch writes.

Arbogast explains that the $131 is an average amount per resident, and the amount increases or decreases depending on the level of care a resident needs, but this average does not pertain to the MWV because of a 638 agreement the MWV has with Indian Health Services.

“Because the Cheyenne River Sioux Tribe has entered into a 638 agreement with Indian Health Services, Medicine Wheel Village is paid a different rate, and it covers the cost of taking care of residents,” Arbogast said.

White River is the only other nursing facility in SD under a 638 agreement.

In a late evening interview in Arbogast’s office, she and Vicki Barnes, who provides social services at the facility, said the goal of MWV’s nursing home care is to promote as much independence as staff and nurses can among the elders, but still be present and prepared to provide the care each elder needs to live a quality life.   

Many people have called have their loved ones placed on a list to get into the nursing home facility at MWV, Arbogast said. The wait is long, and Arbogast said that people call regularly, wondering when they can bring their loved ones home.

The delay in opening the nursing facility level of care unit resulted because the two wings in the building marked for full care still needed the proper call system installed, and the facility’s IT system needed to be updated to meet state care and electronic health, record-keeping standards.

Now that the infrastructure is in place to open the facility, Arbogast said MWV is close to having a professional nursing staff hired to provide the 24-hour care required in the nursing home facility. Arbogast hopes that the needed RNs and LPNs will be hired soon so that the intake process for residents can begin.

Hiring appropriate and needed staff is not an easy task. Many facilities throughout the state report having a difficult time hiring and retaining nursing staff to meet patient needs, but Arbogast believes that once staff members are hired, retaining staff will not be an issue for MWV.

In its relatively short period of existence, MWV has been able to retain most of its certified and non-certified staff members, as well as its various directors.

The facility has a clean and welcoming atmosphere, containing furniture and décor reflecting Native design in warm earth tones, and offering spacious rooms with numerous windows through which natural lighting streams. 

The interior design helps to soften the presence of medical beds, lifts, rails and other aids that will be used to assist elders with varying needs.

At the same time the final pieces of the preparation are being put together, Arbogast and her staff are planning the intake process they hope to begin as soon as possible.

This intake process, per state and federal regulations, demands attention to all of a potential resident’s needs, and provides assurance that the intake facility can meet those needs.

Intake Scenario

Fictitious patient Unpa Smith resides at a facility in a place three hours from Eagle Butte. Unpa’s daughter called months ago to have Unpa placed on a wait list to transfer to MWV.

MWV administration must first have a completed MWV application on file for Unpa before any other assessments can begin.

Once the application is completed appropriately, MWV schedules several visits and observations of Unpa in his current facility to determine Unpa’s “Activities of Daily Living” (ADL), medication intake, levels of care and behavior, etc.

This observation process is called a Preadmission Screening and Resident Review, or PASRR, and requires Level I and Level II screening assessments.

Once Unpa has been assessed for level of care, MWV can determine if the appropriate nursing and other needed staff, as well as medical equipment and facility amenities, match Unpa’s needed level of care.

If MWV can meet Unpa’s needed level of care through professional and certified nursing staff and with current facility amenities, then he can move into the facility. If not, then his application would be declined, NOT because the MWV staff would not want him closer to home, but because the facility could not properly care for his needs, and if the staff cannot meet his needs, moving into MWV would be detrimental for Unpa.

While MWV is prepared to provide high levels of care for elders with a wide range of physical and cognitive needs, there are some needs they just are not yet prepared to meet, although Arbogast said that they could expand their levels of care options in the future.

However, let’s say that Unpa passes the application and assessment processes, and is able to move into MWV.

Within seven days of arriving in his new home, MWV must complete a Minimum Data Set assessment, or MDS.

The MDS must be completed by staff members after they have observed Unpa’s level of care at the facility within the first seven days of his arrival, and then again at regular intervals for the first year of care, and then quarterly thereafter.

The MDS determines the Medicaid payment a facility receives for the care of an elder, and that money is sent directly to the nursing facility.

MDS assessments are also a part of the documentation requirements that each facility maintains to show the quality and level of care elders receive throughout their stay at the facility.

The MDS is just one form of ensuring and documenting quality care. Other forms of documentation include care plans, points of care and various notations from care providers.

These forms of documentation are varied and intensive. The MDS assessment alone is 45 pages and includes everything from an elder’s personal identifying information to his or her preferred social activities, skin care conditions and bowel movement schedule.

Many people forget that their elders are moving into a newcommunity of people, and they hopefully interact regularly with these people in positive ways that make the latter years of their lives fulfilling.

To address this transition, the intake process also includes consideration for the dynamics of living communally with other elders and their full-care providers.

Once our fictional elder, Unpa, has been admitted in the facility with two or three other elders admitted about the same time, MWV provides opportunities through social activities and interactions with various staff members, nurses and neighboring elders to develop a report that makes living with these new neighbors and working with these care providers comfortable and enjoyable.

This acclimation process is much like a high school classroom with ten quiet teens. Introduce one very talkative and active person to the class, and the character and culture of the class can change. The teacher’s job is to help all of the students adjust and adapt to the new classroom dynamics, and bring out the best in everyone to positively influence the culture of the class.   

The job of the nursing home staff, with the help of the elders already residing in the facility, is to help new residents in a nursing facility adjust positively to their new home in the best possible way.

The elders, nursing and certified and non-certified staff members need time to get to know one another, and the new resident needs time to acclimate to the benefits and limitations of his or her new home.

To allow for this acclimation and adjustment period, once the facility’s first patient is cleared to move in, MWV will try to fill its remaining 28 beds by introducing new residents at regular intervals, allotting enough in-between time to give residents a chance to learn the ropes and then perhaps help others become familiar and comfortable with their new home.

A single room in the Medicine Wheel Village 400 Wing of the nursing home is pictured above. Showering facilities are located in the hallway with appropriate equipment to assist people with varying needs. Photo by Jody Rust

Above, is a hallway between a double room with a bathroom in between. Photo by Jody Rust

This sun room in one of the nursing home wings of the Medicine Wheel Village will have a wall-mounted TV and provide a place for residents to visit with each other and friends and family.

Nicole Eagle Chasing and Nicole Bear Heels work one of the nurse’s stations at the Medicine Wheel, which currently is home to 28 residents who live in rooms designated for assisted living care. The facility is preparing to transition residents from other facilities under its nursing home division, which provides 24-hour nursing care for residents unable to live independently. Photo by Jody Rust

In explaining this process, Arbogast said that, regretfully, the facility may not be capable of providing the quality of care for all potential residents, but also said that once they are able to begin accepting residents, she thinks the available beds for nursing home care will fill fast.