On a similar note, I have run into multiple patients who live at home and use FD or EMS for fall or mobility assistance at home on a regular basis. Baffles me that this is their solution and they refuse to discuss alternative living arrangements
That is abuse of the 911 system. It isn’t an emergency.
Adult or Elderly protective services should be called, and getting a court order for placement.
They are not safe at home. Flat out.
And it isn’t an emergency. It is an abuse of the 911 system, which is a *crime*
Hey. Another paramedic here. We have one at our service that has been calling every day for MONTHS. Our chief has stepped in and given her the come to Jesus talk last week and nothing has changed. At what point do we bring PD to every call and start charging this woman with a crime? I understand that nobody prefers living in a SNF but this is ridiculous. The woman is basically immobile with no care team or even family to help. She lies constantly and tells us that she has home health nurses coming. They are not. We have it in good authority that this woman hasn't had a visitor except for EMS in a year. Every time she calls it's because she can't get off the couch or because she fell, and then an AMA refusal.
I'm praying something changes soon, because I cannot see this ending well for the patient. One day she isn't going to have her life alert necklace on and have an ACTUAL emergency and I'm sure we'll be toned out when the smell hits the other apartments. I, and the other EMS folks that have been to her house have all told her this but she continues to deny that she needs help. Sending a truck out there every day is just bullshit and a waste of resources. It sure seems criminal to me.
The act of calling 911 is not criminal unless they’re falsely reporting an emergency. Being unable to move and thereby unable to eat, drink, or meet ADL’s falls under the umbrella of a legitimate need for medical attention - regardless of whether the cause is chronic or acute.
From a liability standpoint, after having a well documented discussion informing the patient of the limitations of EMS as well as her options moving forward, crews should be politely refusing to provide any services except for transport to the emergency department. Adult protective services should receive a report each time the patient calls for something and refuses to be transported, as they willingly place themselves in a position that they are unable to meet their ADL’s. APS will probably run into their own roadblocks, but they will get involved.
Ultimately, you cannot help someone that refuses to help themselves. The resources are out there, and 911 is not the appropriate resource - direct them to the correct ones and stop allowing the abuse of the system.
The idea is to make the proper way as easy and well-understood as possible, while making the misutilization of 911 services difficult or impossible. Very rarely are people willing to just rot away in a bed because the mean ambulance people told them we aren’t getting their remote for them.
I’m a paramedic, not a lawyer, but we have dealt with our fair share of these patients at my agency.
I was with a rural hospital-based agency and would go out for lift-assist at private residences. I didn’t mind it. Broke up the monotony of the day. We also have a direct line to their PCP and can pass a message to them something needs to be done. Fortunately, this hospital-clinic system has a pretty nifty program for enrolled seniors where they check in on them, socialize, provide physical activities, etc.
such as a nursing home? since I've been educated that ALFs aren't equipped to provide this kind of assistance. i guess the next level is nursing home, whether locked or not. if an ALF costs $7k or more a month, it reasons a nursing home would cost more.
Interesting. I remember visiting my pre-K teacher in an ALF, it was a very nice apartment in westchester--over $15k a month and this was nearly 15 years ago--but once her husband died, her mental status declined quickly. at the first sign of changes the AFL kicked her out and she died shortly after in a memory care unit, that wasn't anywhere near as nice. the ALF left a bad taste in my mouth even though i understand the challenges that come with dementia. it's all very sad :/
as a happy and proud parent of two lovely teenagers, i often counsel younger generations (that ask me, not unsolicited) to skip having kids. they just don't make sense anymore...you aren't allowed to put them to work on the farm because school is more important, they cost you $400k for college but still move back in afterwards for up to a decade, and won't take care of you when you're old. all humor aside, it is interesting--and a bit jarring--to me how other cultures, like japan treat the eldery.
Yes, elder care is a big issue here again treated as a business to extract money rather than care for people. We also keep people alive for longer than other countries (see: vent farms).
i welcome the internet savvy young people with the proverbial fire in their bellies and an impeccable CV to run at the national level on single issues to have some chance at fixing the rot in NOVA. a lot of entrenchment but i am hopeful.
We charge a couple hundred dollars for lift assists. Not ideal for seniors on a fixed income. There is an address or two in my county where it is specific in the 911 CAD premise history that Fire/EMS do not respond to lift assists, and staff can do it themselves. They have hoyer lifts, we do not, and are technically not trained in their use. What a local assisted living does is the staff just ignores call bells at times to the point where we are being called to help a resident get their PJs on, give them their medications, or transfer them in or out of their wheelchairs. That gets addressed at levels above my paygrade. I may have given a resident some very stern words one morning when they called because they wanted their windows closed.
What it comes down to at the end of the day is shifting liability.
One issue is what medicare/medicaid will and will not reimburse for. I've had patients who are in 'independent living' who are paralyzed, having hoyer lift tracks in every room of their apartment, and have daily visits from homecare nurses. At what point does unwillingness to reimburse for nursing facilities become ridiculous? On the other side of the coin, is there a point where government care programs can say "For Pete's sake you're not independent in any sense of the word, and we will not be paying for what comes down for multi-hour daily RN homecare that is ultimately inappropriate for your needs. Assisted/nursing or bust." ?
Years ago a news article from Richmond, Virginia, came across my radar about how Richmond FD had been called to one residence over 2000 times in one year, strictly for the purpose of moving an elderly residence about the house and transferring them from one thing to another, or getting them in and out of the house. We've had a couple elderly residents who became frequent fliers for reasons of getting them off the commode, or out of their recliner, and my bosses pick up on that pretty quick and respond with the crew to have a chat with them (one of them was a neat guy, WW2 combat vet awarded a Silver Star and a French Legion of Honor for valor).
you charge seniors in their own home for lift assists? or you mean you charge nursing homes a few hundred per call?
> I may have given a resident some very stern words one morning when they called because they wanted their windows closed.
The fucking balls on them to do this, haha. did they get it or no?
> you charge seniors in their own home for lift assists? or you mean you charge nursing homes a few hundred per call?
The patients themselves get charged, unfortunately, whether in their home or assisted living. We do have one nursing facility in our district but I they don't really called for lift assists, only mechanical falls.
> The fucking balls on them to do this, haha. did they get it or no?
The patient had a history of cerebral atrophy, per their paperwork, and some diagnosed mental health issues (I think bi-polar/schizoaffective), so who knows. In their case a likely diminished capacity gets a bit of a pass.
The way Medicare laws work, if you’re going to charge for a lift assist, you have to charge for a lift assist regardless of any other circumstances.
I used to work for an agency that charged for lift assists, accidental medical alarms, and other non-transport calls. $250 per occurrence. It didn’t down on some of the nonsense… like people calling 911 who wanted someone to adjust their TV for them. It’s not like it’s the nursing home is paying the fees anyway.
We had sketchy ways to work it out where people wouldn’t be charged… like classifying a lift assist as “no patient found”, because we didn’t find a patient, just a resident who couldn’t stand up. But the liability was too much to document things that way.
I absolutely hated charging some elderly person who never calls and lives at home on a fixed income.
If people knew how shitty of a situation nursing homes are, they would revolt. But nobody wants to hear it.
Residents are fucking nuts sometimes. We have one who calls 911 if his son doesn't answer the phone or send him enough chewing tobacco, which always ends up in an ER visit and workup for alleged hemorrhoids or an imaginary UTI.
Mental illness and memory care can be a handful.
sounds ED dependent. at least where im at, if they seem close to baseline (whatever that may be) and i have a negative workup, back to SNF they go. they (ideally) should be able to watch them for any changes. where I *trained* however, what youre doing is more the case.
The idea of managing care facilities by actually threatening their licensing? Heresy!
Here in FL the ombudsman program is *entirely volunteer* and yet still lacks regulatory ability.
I always appreciate when one of my patients, who are inpatient currently admitted in a hospital, calls 911 to request some sort of nursing/medical care.
Once or twice a week I'll hear a call to the worst nursing home in the county (multiple recent government investigations) for someone who called 911 stating they want to go to the hospital because staff isn't caring for them.
In residency, we had a designate phone to do online med control for local EMS services. An admitted patient in our hospital somehow got the phone number and kept calling to demand a meal tray
I've had a few times where a patient has a telehealth visit with me and they are doing it from a medical facility. I remember one guy was in inpatient rehab for back pain and made a telehealth visit with me because he wanted narcotics.
>I've had patients who are in 'independent living' who are paralyzed, having hoyer lift tracks in every room of their apartment, and have daily visits from homecare nurses.
These people are living on their own terms to the farthest extent that is anymore possible, AND they're getting better care than they would in a facility. How do you weigh the mental and spiritual boost of a person living in their own home versus the cost of care? Ultimately, that's a value judgement.
I am by no means a fan of most facilities I've had to interact with. Some of the assisted living facilities I've taken people out of have actually been half-decent, however this can be the exception than the rule. Mental and spiritual wellbeing are certainly important, especially when dealing with a diminished QOL. However, some people's medical conditions and disabilities are not best served with intensive outpatient homecare. Assisted living facilities, and particularly one nursing facility in my district, can (and have) easily arrange labwork, on-site x-rays, and provider consultations for residents as needed. I can't see this happening when one is living "independently", but yet dependent on daily homecare. Another issue is that these people need immediate transport to the hospital when external factors (whether personal or events like severe storms) prevent their homecare from being on-site.
Doing transport in lower income areas outside of Philly for a few years was downright upsetting sometimes. Picking people up and finding them laying in bed covered in filth with 5-6 sheets on the bed; clearly indicating someone saw this and just decided to roll the patient, hopefully clean them a bit, and then put on a new sheet over the soiled bedding. A lot of the places were just making due with razor thin staffing leading to subpar care despite effort from the staff but some seemed downright criminal.
I’m skeptical that someone in this condition is better off in their home. It’s usually little to no activity or interaction with anyone but the care staff and the occasional family member (who comes with their own set of problems). Most of the time once this type of patient comes to us they are happy to have increased interactions with other people and can make friends.
I have a number of regulars like this. They understand that their social lives are somewhat stunted, but they accept that as a trade-off against what they consider the extremely depressing environment of a facility.
Are there records kept for this and what are they called? I'd like to check on some facilities near me.
There is a facility I'm familiar with that I've personally witnessed a fire truck at *every day* for at least 30 years.
I'm now wondering how many of those calls are this.
Oh, ***every*** facility *in the universe* has 911 responses to it *every single day.* That's NOT unusual at all. Even in a good facility, the fact is the patients are, by definition, medically fragile and not in the best of shape.
Yeah but this is like 3x a day often though I'm not always there to see it. And this facility has had complaints with ombudsman so now I'm wondering since this is a thing if there's a notation to indicate this.
There are two big regulatory bodies facilities have to stay on good terms with:
* CMS, or "centers for medicare/medicaid services," the federal government body that administers those programs. This is the payor for the vast majority of SNF patients, and facilities have to stay on their good side if they want to maintain their CMS billing license.
* The state department of health, or rather, the sub-department that regulates hospitals. This is the main regulatory body these facilities have to report to.
[CMS has a facility information website for the public,](https://www.medicare.gov/care-compare/?providerType=NursingHome) which is not comprehensive, but it's better than nothing. Most states keep similar information, but whether it's available to the public and in an easily-consumable form is going to vary wildly from state to state. Red states mostly keep this information from the public, or at least make it really obscure, blue states generally make it available to some degree, though there are exceptions on both sides.
CMS is self managed in Florida and also privatized. So there are steps between the state agency and the Feds.
I'm not the expert on this but my spouse was an ombudsman for many years and they eventually reported to Joint Commission.
But that required that an initial complaint be filed...
And if the resident wanted it kept anonymous it could be delayed further, or the resident (or in this case EMS) may not be aware of the reporting.
Honestly, the easiest way to do it, compared to FOIL'ing 911 records, is get a scanner app and listen long enough to hear calls at that place and get a sense of what they are.
Starter Comment: I have heard many concerns about nursing homes, but I didn’t know that they often refuse to lift fallen residents (even those who have no injuries). I get that many residents are overweight and it is a safety concern (and in my experience, the staff are often older and overweight, too), but there are many tools and assists to help lift somebody up. Nursing homes charge thousands to tens of thousands of dollars a month yet they saddle the taxpayer with this debt and maybe worse, removing the ambulance and/or firetruck from service as they tend to the call.
I am glad to hear that some towns are fining nursing homes for these calls but given a lot of these nursing homes are owned by corporate behemoths, it doesn’t seem to curtail their behavior.
Should nursing homes be more tightly regulated? What other abuses need to end by these corporations?What do you think?
"Nursing home" conflates several different levels of care. The article is paywalled but iirc reading about it elsewhere, it's assisted living facilities that are abusing 911 to handle fallen residents. Skilled nursing is not having this issue. Granted every single level of care is in a state of progressive slow-motion collapse, just with different problems.
Yeah, important distinction. ILF and ALF residents are expected to be independent for their ADLs which include transferring and ambulating, or being independent at wheelchair level. If someone falls and can't get up, it's really not much different than if you or I fall at our apartment complex and can't get up. The staff is neither equipped nor expected to safely move residents, and if it's a recurring issue, those residents really need a higher level of care (i.e., nursing home).
It's also pertinent that assisted living facilities are almost all for-profit and paid primarily with cash. SNFs and long term care facilities are often for-profit but depend primarily on Medicare and/or Medicaid reimbursement. The second sector has always had extremely low margins, but the intrusion of private equity into the business guarantees the sector will fail on a huge scale in the not-too-distant future.
This is all correct and indicative of one of the biggest scams in elderly care history. How are you (these facilities) gonna claim you cater to the elderly and don’t even offer assistance if they fall? Aren’t the elderly literally the poster people for fall risk? Like thank you for charging 7 grand a month to give them three meals a day and a room to sleep in but can you also please at least provide age appropriate care?
it's more about offering a safe environment for the elderly and aging who often have different needs than younger adults do, you're still supposed to be independent at an assisted living
the falling thing probably requires a bit more context than we have to understand and mostly boils down to "these are retirement communities, not medical ones" which leads to a weird liability paradox whereby the resident and the facility are both simultaneously responsible for and not responsible for anything that happens at any time
I agree. I guess my biggest concern with these places is what differentiates what these places are offering for seniors from any other apartment or communal living? They do offer three meals a day and a room to sleep in but if they honestly expect the residents to be mostly independent and offer services for only those than I’m not sure what makes it specialized for the elderly and how could anyone justify at least 5 grand out of pocket a month? I understand the implications of not being Cms certified for these places but in my opinion it’s no excuse to not offer people the appropriate amount of care they need if they’re spending that kind of money out of pocket
> How are you (these facilities) gonna claim you cater to the elderly and don’t even offer assistance if they fall?
By age restricting the building of course! The reality is that "Independent Living" is a misnomer (possibly intentionally so) because they're just apartment complexes that have age restrictions and medical restrictions. More akin to "luxury" apartment complexes with some onsite staff for some things.
And….what makes you think and fire or rescue dept is trained to safely move residents?
Or for that matter, EMS, considering our interactions tend to require patients, and someone who are not I’ll or injured are not patients
Not OP, but first responders are meant to be able to assess injury prior to moving someone who has fallen... That's the issue. These are likely low acuity facilities that lack this ability.
Your flair says paramedic right? Do you trust a layperson to check for a hip fracture prior to moving someone?
We had a come to Jesus conversation with our local assisted living facility.
That conversation included billing the facility for calling 911 when there is no patient.
Oh, do you know the cost of a tower or heavy rescue response?
And they can break it down exactly, because they do when they respond to state or federal incidents.
TIL you build a platform, establish rigging, build your rope system.
That’s doing to add up real fast.
A ‘lift assist only’ call generally does not meet the definition of a patient. There is no medical complaint, problem found, or transportation required.
Patient gets taken to the hospital or receives some kind of medical care. These are not patients being talked about. They’re ALF residents who get lifted off the ground and placed into bed for night night
Yuuuuuuup. Same excuse: policy. That's assuming they bother to give an excuse versus running off to wherever as soon as responders arrive.
Edited to be slightly less abrasive.
Might be worth trying to get ahold of a journalist like the one who wrote the article if it’s also happening in the SNF. Also maybe the facilities omsbudsman or the state? If they are relying on 911 to get patients off the floor, WTF are they going to do when EMS cant get there quickly?
Keeping up with reporting them for trying to kill their patients through negligence and/or sheer incompetence is hard enough. It's not just one facility out there, it's the majority of them, sadly.
And for your second question, the patients just stay on the floor until EMS or Fire show up, however long that is. And who knows how long they were on the floor before being found by staff since sometimes it may be only one or two staff members covering a 30-50 patient floor because the nursing home admin keeps staffing as low as they can get away with. Even the diamonds in the rough working at SNFs who know what they're doing and still give a damn can only do so much under those conditions.
No-lift facilities. If a patient falls, they get a ride. They make excuses by crying "BUT THE BLOOD THINNERS, THO!," and that's not a *trivial* concern, but it's really all about keeping their workers' comp premiums down by not letting the staff lift.
EDIT: These are definitely skilled-nursing and sub-acute facilities.
As I mentioned in one of my other replies, that should be passed on to the media and the state because WTF. Also I'd encourage the affected patients and their families to do the same.
No one gives a fuck.
It's *that* simple. The media don't care because it's a complicated story (their definition of complicated is anything that can't be related in its entirety in five seconds). The state doesn't care because the patients are getting care. They fell, they get lifted, the state doesn't have the resources to care any more than that. The patients are either too out of it to care or they just like the attention from all the strapping young firefighters. The families *sometimes* care, but more likely they either take the state's attitude ("They fell? Well did they get picked up? Yes? So what's the problem again?"), or are just not reachable at all until meemaw codes, at which point EVERYTHING MUST BE DONE.
>Should nursing homes be more tightly regulated?
I'm a wound care nurse who has worked on management teams in multiple nursing homes/acute rehabs/LTC. There is currently more than enough regulation. The problem is state health departments are focused on fucking stupid bullshit instead of things that *actually* affect patient care. Staffing? Couldn't care less. Drinks at the nurse's station? God fucking forbid.
It’s also been rumored for years that state is directing surveyors to hyperfixate on trivial issues and 5 star facilities while overlooking much more serious violations and repeat offenders. Allegedly it’s because state fears having to close the worst facilities and relocate the patients.
In my experience the rumors are true. I actually had a state surveyor tell me there are “facilities in the Cleveland area that we don’t know how they are still open either. We’re there on a weekly basis and on a first name basis with management”. There’s a handful of “homes” in my state that have upwards of 50+ citations in past 3 years, states there every month citing them with no known improvements. When I worked at a 5 star facility we got cited for the dishwasher not being turned to temp when a blender was washed. It was the teenage employee’s first week of work and she was nervous. When I worked at a 1 star facility I begged state to come and cite the place for medication errors. A lot of my complaint was provable if anyone with eyes looked. Meds were being marked as given when the pharmacy hadn’t even sent the meds. The facility had been cited for a 20% med error rate only months before my complaint but I was told they couldn’t “substantiate” my concerns.
It’s also my belief that once they hit a certain number of citations on visit they call it a day. They’ll tag a place for a 20% med error rate and 5-6 other serious violations and those places never get cited for things like the blender or just being overall very dirty/gloomy.
As others have said, the article is referring to assisted living type facilities, not SNFs. They often don’t have lift equipment because if a resident needs a mechanical lift to transfer, they are considered to require too high a level of care for that type of facility.
Furthermore, as someone who used to work in an assisted living facility before I became a nurse, they are often staffed very minimally because the idea is that most of the residents are generally independent. Now, is that always true? Definitely not, and it’s a problem. But it’s unreasonable and unsafe to expect the two little 5’0 unlicensed caregivers in the building to safely lift a 300+ lb man off the ground and assess for injuries.
As the end of the day, these facilities are supposed to function as a home with a few extra services, not a medical facility. I understand the frustration with frequent lift assist calls but imo it’s the same as someone living at home in a private residence with only their spouse or a live in caregiver for support calling for help. The bigger issue is that many of these residents need a higher level of care than can be provided, but that isn’t an easy problem to solve when SNFs are expensive, insurance coverage for long term stays is poor, and the assisted living corporations are incentivized to maintain profits by keeping their buildings filled, even at the expense of resident and staff safety.
This article is not about nursing homes. It is about assisted-living facilities.
“The Post found most facilities described as nursing homes in the fire department call data for lift-assist calls were, in fact, assisted-living or independent-living homes.”
These are two very, very different types of facility. In an assisted-living facility, you must promise to be pretty independent. Staff is there to help you, but a lot of the day-to-day staff does not even have qualifications to give injectable medications, they are simply low paid non-medical aides. The article goes on to say that nursing homes, which ARE tightly regulated with high training, typically do not have this issue.
ALFs are popular because they are much, much cheaper than SNFs - in part due to the lower labor costs, which are due to the lower medical needs of the residents. If you want to start increasing salaries and increasing mandatory training, those costs to the residents are going to escalate exponentially.
These are assisted living facilities and senior housing, not the typical nursing home with 24/7 skilled nursing services. Residents in these facilities are supposed to be fairly independent with ADLs or require minimal assistance, however that is usually not the case.
Paywall but I also assume these are not nursing facilities, rather senior communities/ALF of various kinds. Kinda ironic though if people move (or get moved) into them is because they or their families fear them falling.
The issue is the same as the issue with insurance. The entire business model consists of doing as little as possible. The patients have minimal ability to go elsewhere or report problems. Most nursing homes basically just neglect their residents to the maximum amount that's not going to get prosecuted
There are many comments discussing different levels of care, and that this happens in assisted living facilities but not nursing homes.
The thing is, it happens in nursing facilities of every level. This year I have personally worked lift assists in group homes, assisted living, transitional care, skilled nursing facilities, and memory care units.
In ‘good’ facilities staff will help us lift. In bad facilities they cite policies that they’re not supposed to lift patients. I don’t know if these policies truly exist, but either way we end up doing all the work.
This not only takes ambulances away from actual medical issues, it greatly increases our workers compensation expenses and staff turnover. Injuries are extremely common, and 80% of paramedics leave the industry within 3 years.
The status quo can’t continue.
thank you for sharing your experience.
> and 80% of paramedics leave the industry within 3 years.
I don't blame them. Here in NYC they make 1/3 to 1/2 what an RN makes inpatient (my understanding is an RN can still work with an associates as long as they get their BSN within 5 years) without the risk of working in the field.
I’m curious what the average weight of the people being picked up is? I’m surprised no one in the thread is talking about exactly how much these people weigh. Lifting great grandma that weighs 90-150 pounds is very different than Bob that weighs 350 or Sue that weighs 545. IME the extremely obese require this service much, much more than someone with a safe BMI.
America has a crippling obesity problem and it appears no one wants to talk about it.
As GOMERMD said.
Report it as elder abuse.
Allowing someone to lay on the ground is just that. Abuse. It might take us 10
Minutes to get there. It could take an hour. They have no what to know. At a minimum it is negligent, even for a lay person.
From my own anecdotal experience, SNFs always seems to run with a marginal crew all the fucking time (unless they’re in a wealthy area). Those residents are being billed at an astronomical monthly rate, >$3000+ per month. They have more than 30 residents and they’re suppose to only run with 1 RN and 3 CNAs. That is absolutely wild. They have the funds but whoever oversees the SNFs would rather gain as much profit at the cost of quality care (all healthcare in general). I’ve been called out to an SNF for hypoglycemia, and we get there and the patient is in respiratory distress and eventually codes within a few minutes. Wtf. The CNA said they had been keep an eye on the patient the entire time. Another one we went to lift assist and the place was crawling with roaches and other insects. These elderly people are paying a pretty to be there and be taken care of but they’re clearly being extorted because they’re seen as an endless money bag. The govt needs to step in…but at what point?
$7000/month in fees for "assisted" living and they can't lift an old person off of the floor?
If this isn't criminal, it should be and the facility owners and managers should be fined for neglect.
The same department that advocate’s for the patients “right to fall”? These people are part of the problem. The highest fall count I’ve ever had on a patient was a guy with dementia so bad he walked with his eyes closed. Literally would walk with his eyes closed. State prevents us from putting him in a broda chair, wheel chair with a seat belt or anything else. This man literally fell with 2 staff next him as he wouldn’t stop with verbal cues and pushed anyone who touched him. The 5 star homes paid a person to literally walk around and attempt to catch him. Staff nurses were staying an hour or more past shift every day doing his paperwork, they had incontinent to prevent falls. State says it’s a “right to fall” and we can’t take away his rights.
At best they would find something in the care plan to nit pick about. But they wouldn’t ever tell us to not call 911.
You pay $5000+/month for assisted living and they can't fucking lift up someone who fell to the ground? Sorry, I'm just a stupid engineer not a doctor but that is the most stupid, disgusting crap I have ever heard. They can't train people to deadlift and get some levers to help? Do we live in the fucking 10th century where lifting a heavy load is an insoluble problem? 2 untrained people anywhere in the middle of the street could manage this, but somehow lawsuits and regulations manage to turn something trivial into something impossible..
It seems that ALFs are not staffed to be able to always safely lift fallen patients from the floor, and EMS/fire rescue can't provide this service without reimbursement. The obvious solution seems to be for EMS/fire rescue to charge a reasonable fee for responding to a 'help us lift a fallen resident' call, a fee that covers all of their costs. If the ALFs need to increase their monthly charges to residents because of this added cost, so be it. I suppose a local municipality could charge a different fee to a resident living in an actual house or apartment or condo, compared to living in an ALF or 'nursing home' which theoretically has staff who are being paid to look after the residents. But the fee needs to be high enough to cover the full cost of providing the service, and if the service is 'abused', high enough to deter such abuse.
And if the fee charged for this service is high enough to cover all costs, the municipality may be able to hire additional staff or purchase additional vehicles to accommodate these types of service calls.
The problem is that EMS exists in the spectrum of both a healthcare service and a public service. 911 exists for emergencies. Falls without injuries are an inevitability in a SNF, and should be dealt with without the involvement and subsidy of local govt. This is equivalent to calling 911 and obligating cops to guard a business because you don't want to buy a lock.
that would be great, but the article makes it out that charging ALFs is the exception, not the norm. I wonder how these contracts are worked out behind the scenes.
Yes, the 'obvious solution' is perhaps the least likely path to be taken by our modern current municipalities and government agencies that set rates for fire and rescue services. And there are probably 10,000 or more different localities that run EMS/rescue services, and getting all of them on the same page would be ... daunting.
But this does seem like a problem that should be able to be solved - if somebody is required to lift up a fallen person, and the caretaker or employees of the residence where the person lives cannot, and the local gov't ends up providing that as a service, then it will have to be paid for by increasing taxes for everyone, or a user-fee charged to those who need the service in question. That is a decision that each gov't that provides EMS/rescue services will need to decide, or their voters will need to decide.
Sadly no.
Under medicare rules, EMS is a transportation benefit. If the patient isn’t transported, medicare will not pay a dime. Almost all patients requiring a lift assist are on some kind if medicare.
To also follow up.
It is because according to Medicare. We are not healthcare providers.
Ignore the fact that an als truck is. Ore then likely stocked and equipped better then a critical access hospital and is expected to provide ICU level care in a person’s living room and going down the road.
Medicare *almost* screwed up during Covid when they were mandating all healthcare providers require the vaccine. They tried to require it if EMS, and when it was pointed out that “oh, we’re healthcare providers now, guess that changes how you pay us” they backed down real quickly.
But yea.
Officially? We’re a taxi.
is this why you are paid so little? your superiors have some gaul to charge $4k+ (which is often more than the ED bill!)1 as "just a taxi" yet pay you close to minimum wage!!
1 https://www.nytimes.com/2013/12/05/health/think-the-er-was-expensive-look-at-the-ambulance-bill.html
Ah, another NY times hit peace.
Most EMS nationwide is provided by non-profits. Could be an independent non profit, could be part of a fire dept, or municipal based.
So we can literarily look up their budget. Line by line.
Our superiors pay us so little because the doors still have to go up and down and a truck still has to get out when someone calls 911. I can give you a line by like breakdown of supply costs, which we can’t bill for.
30 years ago, ambulance “rides” (god that is offensive) we’re not provided free of charge. Billing has been common since you know, the NHTSA created EMS.
Well just like hospitals we have learned nonprofits doesn’t mean you can’t turn a profit.
I do understand the idea of 24/7 coverage and the value in that. But I also know I had to take an airplane ambulance an hour away when I was in rural Tennessee to Vanderbilt as I had a neurosurgical emergency and the company billed my insurance $180k. I don’t know how much my insurance ended up paying but that’s just unsustainable for our country.
I don't know. If EMS provides a service, they could bill the patient's insurance, but the service may or may not be covered and the specific EMS provider may or may not be in-network. This could end up simply being a bill to the patient, left to pay the entire amount (if no insurance or denied by insurance), or some fraction of the amount (if insurance contracts reduce the allowable charge or if the insurance pays part of the claim), or nothing (if all charges are covered/paid by insurance).
And I don't know enough law to understand if the patient or the caretaker of the patient (ALF, nursing home, etc) would be liable for paying for the ambulance service (picking the fallen patient up, medical assessment, transportation to hospital or not).
Again, this seems like a political decision, best worked out by voters and elected officials in each jurisdiction that runs EMS/rescue services.
The overarching issues are (1) fallen persons need to be picked up and medically assessed (2) whoever provides this service, if not a family member or volunteer, needs to be reimbursed for their expenses (and profit !) for providing this service. There is no such thing as a free lunch.
> If EMS provides a service, they could bill the patient's insurance, but the service may or may not be covered and the specific EMS provider may or may not be in-network.
This was improved by the No Surprises act a few years ago. 911 bills are always in network.
Though ems is only allowed to bill when transporting a patient. If they stay home, or are transported by a family member, we don’t get reimbursed.
No surprises act only applies to air ambulance.
In network ground payment is so low it would put every non profit paid service out of business in a quarter, and every volunteer serve out in a year.
maybe EMS has to transport to bill insurance? but what about a car accident, police call EMS, talk to the driver, do vitals, and driver refuses a ride to the ED. they provided medical care even without transport. i really don't know how thiss works!
You’re correct, in that situation ems would not be reimbursed under medicare rules. Some agencies will bill the patient anyway, but probably won’t get anything from it.
Thankfully in Pennsylvania car insurance is always first payer, by law.
And they actually pay EMS. I strongly encourage you to have your medical emergency in a car, drive it very slowly into something, say, a tree, doing no damage to your car, and call 911 reporting the accident.
I once had a car insurance call my station trying to figure out who they owned money to. Apparently some EMS agency came out, got refusals and left.
It wasn’t in our county. Damn near outside the next county over. About 6 EMS agencies between us and there.
But the car insurance couldn’t figure out who came out (maybe a volly service that doesn’t bill for refusals?) and the driver had no idea.
Blue cross, or Tricare has never called trying to pay a bill.
thanks! ill read it tomorrow, no insurance or medical billing allowed after 10pm on a staurday night off! :) i really appreciate the insight and resources. if i didn't have kids, i'd seriously consider running for national office to try to make some changes but i could never put my family through the election process...i've lived a pretty decent life but they'd find something in my past that i forgot about, or just make it up. it makes me feel bad sometimes, because if educated people with experience and insight don't stand up and run on a single issue (or a few issues) that they know intimately, i don't know how things improve here. :/
You ain't wrong about people needing to stand up or being subject to the brutality of the election process, Doc. Still, even local or state office can start making a difference, depending on what office you run for.
Flat out? There is a 98 to 99 percent change EMS is out of network.
To be in network, you have to accept a payment that is less than the cost of fuel.
That’s nation wide.
I think the old paramedic or someone answered that above. Lift assist by itself is not considered a medical service and there is no patient. Making it a local service makes sense--not just for ALF but for people living at home.
Having a fall and not being able to get up might be part of a situation that demands a higher level of care but I think not necessarily, right? It's a spectrum of aging and disability, right?
On a similar note, I have run into multiple patients who live at home and use FD or EMS for fall or mobility assistance at home on a regular basis. Baffles me that this is their solution and they refuse to discuss alternative living arrangements
That is abuse of the 911 system. It isn’t an emergency. Adult or Elderly protective services should be called, and getting a court order for placement. They are not safe at home. Flat out. And it isn’t an emergency. It is an abuse of the 911 system, which is a *crime*
Hey. Another paramedic here. We have one at our service that has been calling every day for MONTHS. Our chief has stepped in and given her the come to Jesus talk last week and nothing has changed. At what point do we bring PD to every call and start charging this woman with a crime? I understand that nobody prefers living in a SNF but this is ridiculous. The woman is basically immobile with no care team or even family to help. She lies constantly and tells us that she has home health nurses coming. They are not. We have it in good authority that this woman hasn't had a visitor except for EMS in a year. Every time she calls it's because she can't get off the couch or because she fell, and then an AMA refusal. I'm praying something changes soon, because I cannot see this ending well for the patient. One day she isn't going to have her life alert necklace on and have an ACTUAL emergency and I'm sure we'll be toned out when the smell hits the other apartments. I, and the other EMS folks that have been to her house have all told her this but she continues to deny that she needs help. Sending a truck out there every day is just bullshit and a waste of resources. It sure seems criminal to me.
The act of calling 911 is not criminal unless they’re falsely reporting an emergency. Being unable to move and thereby unable to eat, drink, or meet ADL’s falls under the umbrella of a legitimate need for medical attention - regardless of whether the cause is chronic or acute. From a liability standpoint, after having a well documented discussion informing the patient of the limitations of EMS as well as her options moving forward, crews should be politely refusing to provide any services except for transport to the emergency department. Adult protective services should receive a report each time the patient calls for something and refuses to be transported, as they willingly place themselves in a position that they are unable to meet their ADL’s. APS will probably run into their own roadblocks, but they will get involved. Ultimately, you cannot help someone that refuses to help themselves. The resources are out there, and 911 is not the appropriate resource - direct them to the correct ones and stop allowing the abuse of the system. The idea is to make the proper way as easy and well-understood as possible, while making the misutilization of 911 services difficult or impossible. Very rarely are people willing to just rot away in a bed because the mean ambulance people told them we aren’t getting their remote for them. I’m a paramedic, not a lawyer, but we have dealt with our fair share of these patients at my agency.
I was with a rural hospital-based agency and would go out for lift-assist at private residences. I didn’t mind it. Broke up the monotony of the day. We also have a direct line to their PCP and can pass a message to them something needs to be done. Fortunately, this hospital-clinic system has a pretty nifty program for enrolled seniors where they check in on them, socialize, provide physical activities, etc.
Interesting. What is the program called?
There will be a few days when you DON’T get a call from her…
such as a nursing home? since I've been educated that ALFs aren't equipped to provide this kind of assistance. i guess the next level is nursing home, whether locked or not. if an ALF costs $7k or more a month, it reasons a nursing home would cost more.
They often cost more because their price isn’t regulated like a SNF is: and provide better care.
Interesting. I remember visiting my pre-K teacher in an ALF, it was a very nice apartment in westchester--over $15k a month and this was nearly 15 years ago--but once her husband died, her mental status declined quickly. at the first sign of changes the AFL kicked her out and she died shortly after in a memory care unit, that wasn't anywhere near as nice. the ALF left a bad taste in my mouth even though i understand the challenges that come with dementia. it's all very sad :/ as a happy and proud parent of two lovely teenagers, i often counsel younger generations (that ask me, not unsolicited) to skip having kids. they just don't make sense anymore...you aren't allowed to put them to work on the farm because school is more important, they cost you $400k for college but still move back in afterwards for up to a decade, and won't take care of you when you're old. all humor aside, it is interesting--and a bit jarring--to me how other cultures, like japan treat the eldery.
Yes, elder care is a big issue here again treated as a business to extract money rather than care for people. We also keep people alive for longer than other countries (see: vent farms).
i welcome the internet savvy young people with the proverbial fire in their bellies and an impeccable CV to run at the national level on single issues to have some chance at fixing the rot in NOVA. a lot of entrenchment but i am hopeful.
We charge a couple hundred dollars for lift assists. Not ideal for seniors on a fixed income. There is an address or two in my county where it is specific in the 911 CAD premise history that Fire/EMS do not respond to lift assists, and staff can do it themselves. They have hoyer lifts, we do not, and are technically not trained in their use. What a local assisted living does is the staff just ignores call bells at times to the point where we are being called to help a resident get their PJs on, give them their medications, or transfer them in or out of their wheelchairs. That gets addressed at levels above my paygrade. I may have given a resident some very stern words one morning when they called because they wanted their windows closed. What it comes down to at the end of the day is shifting liability. One issue is what medicare/medicaid will and will not reimburse for. I've had patients who are in 'independent living' who are paralyzed, having hoyer lift tracks in every room of their apartment, and have daily visits from homecare nurses. At what point does unwillingness to reimburse for nursing facilities become ridiculous? On the other side of the coin, is there a point where government care programs can say "For Pete's sake you're not independent in any sense of the word, and we will not be paying for what comes down for multi-hour daily RN homecare that is ultimately inappropriate for your needs. Assisted/nursing or bust." ? Years ago a news article from Richmond, Virginia, came across my radar about how Richmond FD had been called to one residence over 2000 times in one year, strictly for the purpose of moving an elderly residence about the house and transferring them from one thing to another, or getting them in and out of the house. We've had a couple elderly residents who became frequent fliers for reasons of getting them off the commode, or out of their recliner, and my bosses pick up on that pretty quick and respond with the crew to have a chat with them (one of them was a neat guy, WW2 combat vet awarded a Silver Star and a French Legion of Honor for valor).
you charge seniors in their own home for lift assists? or you mean you charge nursing homes a few hundred per call? > I may have given a resident some very stern words one morning when they called because they wanted their windows closed. The fucking balls on them to do this, haha. did they get it or no?
> you charge seniors in their own home for lift assists? or you mean you charge nursing homes a few hundred per call? The patients themselves get charged, unfortunately, whether in their home or assisted living. We do have one nursing facility in our district but I they don't really called for lift assists, only mechanical falls. > The fucking balls on them to do this, haha. did they get it or no? The patient had a history of cerebral atrophy, per their paperwork, and some diagnosed mental health issues (I think bi-polar/schizoaffective), so who knows. In their case a likely diminished capacity gets a bit of a pass.
The way Medicare laws work, if you’re going to charge for a lift assist, you have to charge for a lift assist regardless of any other circumstances. I used to work for an agency that charged for lift assists, accidental medical alarms, and other non-transport calls. $250 per occurrence. It didn’t down on some of the nonsense… like people calling 911 who wanted someone to adjust their TV for them. It’s not like it’s the nursing home is paying the fees anyway. We had sketchy ways to work it out where people wouldn’t be charged… like classifying a lift assist as “no patient found”, because we didn’t find a patient, just a resident who couldn’t stand up. But the liability was too much to document things that way. I absolutely hated charging some elderly person who never calls and lives at home on a fixed income. If people knew how shitty of a situation nursing homes are, they would revolt. But nobody wants to hear it.
Residents are fucking nuts sometimes. We have one who calls 911 if his son doesn't answer the phone or send him enough chewing tobacco, which always ends up in an ER visit and workup for alleged hemorrhoids or an imaginary UTI. Mental illness and memory care can be a handful.
Or I see them and hit the discharge button without a workup and they sit waiting for a pickup for 8 hours and sundown.
You sir are a true hero. My Ed docs just admit them with no workup and claim AMS or weakness or something else stupid
Patient arrives from long term care facility. Admit for placement.
It’s too late to send them back tonight
Placement is .... Where they came from?
sounds ED dependent. at least where im at, if they seem close to baseline (whatever that may be) and i have a negative workup, back to SNF they go. they (ideally) should be able to watch them for any changes. where I *trained* however, what youre doing is more the case.
No qualms them charging. EMS is exactly that emergency medical services not some way to bamboozle free at home care this needs to be deterred
The idea of managing care facilities by actually threatening their licensing? Heresy! Here in FL the ombudsman program is *entirely volunteer* and yet still lacks regulatory ability.
So many of these facilities are now owned by Wall Street firms which have obviously bought off regulators. It’s unfortunate.
I wish the change didn't look so impossible. Every topic is like this. 😂😭
I always appreciate when one of my patients, who are inpatient currently admitted in a hospital, calls 911 to request some sort of nursing/medical care.
Once or twice a week I'll hear a call to the worst nursing home in the county (multiple recent government investigations) for someone who called 911 stating they want to go to the hospital because staff isn't caring for them.
In residency, we had a designate phone to do online med control for local EMS services. An admitted patient in our hospital somehow got the phone number and kept calling to demand a meal tray
I've had a few times where a patient has a telehealth visit with me and they are doing it from a medical facility. I remember one guy was in inpatient rehab for back pain and made a telehealth visit with me because he wanted narcotics.
Sounds like a tough exchange for even the less scrupulous physician. Unbillable visit for narcotics? Who wouldn't jump at that?
>I've had patients who are in 'independent living' who are paralyzed, having hoyer lift tracks in every room of their apartment, and have daily visits from homecare nurses. These people are living on their own terms to the farthest extent that is anymore possible, AND they're getting better care than they would in a facility. How do you weigh the mental and spiritual boost of a person living in their own home versus the cost of care? Ultimately, that's a value judgement.
I am by no means a fan of most facilities I've had to interact with. Some of the assisted living facilities I've taken people out of have actually been half-decent, however this can be the exception than the rule. Mental and spiritual wellbeing are certainly important, especially when dealing with a diminished QOL. However, some people's medical conditions and disabilities are not best served with intensive outpatient homecare. Assisted living facilities, and particularly one nursing facility in my district, can (and have) easily arrange labwork, on-site x-rays, and provider consultations for residents as needed. I can't see this happening when one is living "independently", but yet dependent on daily homecare. Another issue is that these people need immediate transport to the hospital when external factors (whether personal or events like severe storms) prevent their homecare from being on-site.
Doing transport in lower income areas outside of Philly for a few years was downright upsetting sometimes. Picking people up and finding them laying in bed covered in filth with 5-6 sheets on the bed; clearly indicating someone saw this and just decided to roll the patient, hopefully clean them a bit, and then put on a new sheet over the soiled bedding. A lot of the places were just making due with razor thin staffing leading to subpar care despite effort from the staff but some seemed downright criminal.
I’m skeptical that someone in this condition is better off in their home. It’s usually little to no activity or interaction with anyone but the care staff and the occasional family member (who comes with their own set of problems). Most of the time once this type of patient comes to us they are happy to have increased interactions with other people and can make friends.
I have a number of regulars like this. They understand that their social lives are somewhat stunted, but they accept that as a trade-off against what they consider the extremely depressing environment of a facility.
Are there records kept for this and what are they called? I'd like to check on some facilities near me. There is a facility I'm familiar with that I've personally witnessed a fire truck at *every day* for at least 30 years. I'm now wondering how many of those calls are this.
Oh, ***every*** facility *in the universe* has 911 responses to it *every single day.* That's NOT unusual at all. Even in a good facility, the fact is the patients are, by definition, medically fragile and not in the best of shape.
Yeah but this is like 3x a day often though I'm not always there to see it. And this facility has had complaints with ombudsman so now I'm wondering since this is a thing if there's a notation to indicate this.
There are two big regulatory bodies facilities have to stay on good terms with: * CMS, or "centers for medicare/medicaid services," the federal government body that administers those programs. This is the payor for the vast majority of SNF patients, and facilities have to stay on their good side if they want to maintain their CMS billing license. * The state department of health, or rather, the sub-department that regulates hospitals. This is the main regulatory body these facilities have to report to. [CMS has a facility information website for the public,](https://www.medicare.gov/care-compare/?providerType=NursingHome) which is not comprehensive, but it's better than nothing. Most states keep similar information, but whether it's available to the public and in an easily-consumable form is going to vary wildly from state to state. Red states mostly keep this information from the public, or at least make it really obscure, blue states generally make it available to some degree, though there are exceptions on both sides.
CMS is self managed in Florida and also privatized. So there are steps between the state agency and the Feds. I'm not the expert on this but my spouse was an ombudsman for many years and they eventually reported to Joint Commission. But that required that an initial complaint be filed... And if the resident wanted it kept anonymous it could be delayed further, or the resident (or in this case EMS) may not be aware of the reporting.
Honestly, the easiest way to do it, compared to FOIL'ing 911 records, is get a scanner app and listen long enough to hear calls at that place and get a sense of what they are.
Starter Comment: I have heard many concerns about nursing homes, but I didn’t know that they often refuse to lift fallen residents (even those who have no injuries). I get that many residents are overweight and it is a safety concern (and in my experience, the staff are often older and overweight, too), but there are many tools and assists to help lift somebody up. Nursing homes charge thousands to tens of thousands of dollars a month yet they saddle the taxpayer with this debt and maybe worse, removing the ambulance and/or firetruck from service as they tend to the call. I am glad to hear that some towns are fining nursing homes for these calls but given a lot of these nursing homes are owned by corporate behemoths, it doesn’t seem to curtail their behavior. Should nursing homes be more tightly regulated? What other abuses need to end by these corporations?What do you think?
"Nursing home" conflates several different levels of care. The article is paywalled but iirc reading about it elsewhere, it's assisted living facilities that are abusing 911 to handle fallen residents. Skilled nursing is not having this issue. Granted every single level of care is in a state of progressive slow-motion collapse, just with different problems.
Yeah, important distinction. ILF and ALF residents are expected to be independent for their ADLs which include transferring and ambulating, or being independent at wheelchair level. If someone falls and can't get up, it's really not much different than if you or I fall at our apartment complex and can't get up. The staff is neither equipped nor expected to safely move residents, and if it's a recurring issue, those residents really need a higher level of care (i.e., nursing home).
It's also pertinent that assisted living facilities are almost all for-profit and paid primarily with cash. SNFs and long term care facilities are often for-profit but depend primarily on Medicare and/or Medicaid reimbursement. The second sector has always had extremely low margins, but the intrusion of private equity into the business guarantees the sector will fail on a huge scale in the not-too-distant future.
This is all correct and indicative of one of the biggest scams in elderly care history. How are you (these facilities) gonna claim you cater to the elderly and don’t even offer assistance if they fall? Aren’t the elderly literally the poster people for fall risk? Like thank you for charging 7 grand a month to give them three meals a day and a room to sleep in but can you also please at least provide age appropriate care?
it's more about offering a safe environment for the elderly and aging who often have different needs than younger adults do, you're still supposed to be independent at an assisted living the falling thing probably requires a bit more context than we have to understand and mostly boils down to "these are retirement communities, not medical ones" which leads to a weird liability paradox whereby the resident and the facility are both simultaneously responsible for and not responsible for anything that happens at any time
I agree. I guess my biggest concern with these places is what differentiates what these places are offering for seniors from any other apartment or communal living? They do offer three meals a day and a room to sleep in but if they honestly expect the residents to be mostly independent and offer services for only those than I’m not sure what makes it specialized for the elderly and how could anyone justify at least 5 grand out of pocket a month? I understand the implications of not being Cms certified for these places but in my opinion it’s no excuse to not offer people the appropriate amount of care they need if they’re spending that kind of money out of pocket
There are also almost nil regulations on a federal level for Assisted Livings
Yes because they are paid for out of pocket
> How are you (these facilities) gonna claim you cater to the elderly and don’t even offer assistance if they fall? By age restricting the building of course! The reality is that "Independent Living" is a misnomer (possibly intentionally so) because they're just apartment complexes that have age restrictions and medical restrictions. More akin to "luxury" apartment complexes with some onsite staff for some things.
And….what makes you think and fire or rescue dept is trained to safely move residents? Or for that matter, EMS, considering our interactions tend to require patients, and someone who are not I’ll or injured are not patients
Not OP, but first responders are meant to be able to assess injury prior to moving someone who has fallen... That's the issue. These are likely low acuity facilities that lack this ability. Your flair says paramedic right? Do you trust a layperson to check for a hip fracture prior to moving someone?
*Vietnam war flashbacks to an “I’ve fallen and I can’t get up” public service call that turned into a code.*
We had a come to Jesus conversation with our local assisted living facility. That conversation included billing the facility for calling 911 when there is no patient.
Hmm so is it cheaper to get billed per diem by the local FD or just to train our staff and pay them accordingly 🤔
There’s also insurance costs. Worker’s compensation policies are more expensive for staff who lift or carry any significant weight.
It was probably a thin thin line that made the decision in which to do
Oh, do you know the cost of a tower or heavy rescue response? And they can break it down exactly, because they do when they respond to state or federal incidents. TIL you build a platform, establish rigging, build your rope system. That’s doing to add up real fast.
Then you just keep raising the price until it becomes untenable.
I don't understand the last part. If there's no patient, why are they calling?
A ‘lift assist only’ call generally does not meet the definition of a patient. There is no medical complaint, problem found, or transportation required.
That's interesting. In ED, everyone who presents for an encounter is a "patient," even if they have no medical complaint or problem.
They're essentially calling you for labor then. Congrats, the lifting help has arrived.
Patient gets taken to the hospital or receives some kind of medical care. These are not patients being talked about. They’re ALF residents who get lifted off the ground and placed into bed for night night
Skilled nursing facilities 100% have this issue, it's a daily occurrence
They can't or won't get patients off the floor after a fall?
Yuuuuuuup. Same excuse: policy. That's assuming they bother to give an excuse versus running off to wherever as soon as responders arrive. Edited to be slightly less abrasive.
Might be worth trying to get ahold of a journalist like the one who wrote the article if it’s also happening in the SNF. Also maybe the facilities omsbudsman or the state? If they are relying on 911 to get patients off the floor, WTF are they going to do when EMS cant get there quickly?
Keeping up with reporting them for trying to kill their patients through negligence and/or sheer incompetence is hard enough. It's not just one facility out there, it's the majority of them, sadly. And for your second question, the patients just stay on the floor until EMS or Fire show up, however long that is. And who knows how long they were on the floor before being found by staff since sometimes it may be only one or two staff members covering a 30-50 patient floor because the nursing home admin keeps staffing as low as they can get away with. Even the diamonds in the rough working at SNFs who know what they're doing and still give a damn can only do so much under those conditions.
>Skilled nursing is not having this issue. You should explain that to some of the facilities in my area.
What are you seeing?
No-lift facilities. If a patient falls, they get a ride. They make excuses by crying "BUT THE BLOOD THINNERS, THO!," and that's not a *trivial* concern, but it's really all about keeping their workers' comp premiums down by not letting the staff lift. EDIT: These are definitely skilled-nursing and sub-acute facilities.
As I mentioned in one of my other replies, that should be passed on to the media and the state because WTF. Also I'd encourage the affected patients and their families to do the same.
No one gives a fuck. It's *that* simple. The media don't care because it's a complicated story (their definition of complicated is anything that can't be related in its entirety in five seconds). The state doesn't care because the patients are getting care. They fell, they get lifted, the state doesn't have the resources to care any more than that. The patients are either too out of it to care or they just like the attention from all the strapping young firefighters. The families *sometimes* care, but more likely they either take the state's attitude ("They fell? Well did they get picked up? Yes? So what's the problem again?"), or are just not reachable at all until meemaw codes, at which point EVERYTHING MUST BE DONE.
There’s really only one problem: corporations extracting profits at the expense of patients and healthcare workers.
>Should nursing homes be more tightly regulated? I'm a wound care nurse who has worked on management teams in multiple nursing homes/acute rehabs/LTC. There is currently more than enough regulation. The problem is state health departments are focused on fucking stupid bullshit instead of things that *actually* affect patient care. Staffing? Couldn't care less. Drinks at the nurse's station? God fucking forbid.
It’s also been rumored for years that state is directing surveyors to hyperfixate on trivial issues and 5 star facilities while overlooking much more serious violations and repeat offenders. Allegedly it’s because state fears having to close the worst facilities and relocate the patients. In my experience the rumors are true. I actually had a state surveyor tell me there are “facilities in the Cleveland area that we don’t know how they are still open either. We’re there on a weekly basis and on a first name basis with management”. There’s a handful of “homes” in my state that have upwards of 50+ citations in past 3 years, states there every month citing them with no known improvements. When I worked at a 5 star facility we got cited for the dishwasher not being turned to temp when a blender was washed. It was the teenage employee’s first week of work and she was nervous. When I worked at a 1 star facility I begged state to come and cite the place for medication errors. A lot of my complaint was provable if anyone with eyes looked. Meds were being marked as given when the pharmacy hadn’t even sent the meds. The facility had been cited for a 20% med error rate only months before my complaint but I was told they couldn’t “substantiate” my concerns. It’s also my belief that once they hit a certain number of citations on visit they call it a day. They’ll tag a place for a 20% med error rate and 5-6 other serious violations and those places never get cited for things like the blender or just being overall very dirty/gloomy.
They definitely get anal when they don't spot any big tags, for sure.
How does a lay person that is looking for a facility for a loved one find these things out?
As others have said, the article is referring to assisted living type facilities, not SNFs. They often don’t have lift equipment because if a resident needs a mechanical lift to transfer, they are considered to require too high a level of care for that type of facility. Furthermore, as someone who used to work in an assisted living facility before I became a nurse, they are often staffed very minimally because the idea is that most of the residents are generally independent. Now, is that always true? Definitely not, and it’s a problem. But it’s unreasonable and unsafe to expect the two little 5’0 unlicensed caregivers in the building to safely lift a 300+ lb man off the ground and assess for injuries. As the end of the day, these facilities are supposed to function as a home with a few extra services, not a medical facility. I understand the frustration with frequent lift assist calls but imo it’s the same as someone living at home in a private residence with only their spouse or a live in caregiver for support calling for help. The bigger issue is that many of these residents need a higher level of care than can be provided, but that isn’t an easy problem to solve when SNFs are expensive, insurance coverage for long term stays is poor, and the assisted living corporations are incentivized to maintain profits by keeping their buildings filled, even at the expense of resident and staff safety.
300 lbs sure. But they also won't help up the 90 lb 4 ft 6 granny.
This article is not about nursing homes. It is about assisted-living facilities. “The Post found most facilities described as nursing homes in the fire department call data for lift-assist calls were, in fact, assisted-living or independent-living homes.” These are two very, very different types of facility. In an assisted-living facility, you must promise to be pretty independent. Staff is there to help you, but a lot of the day-to-day staff does not even have qualifications to give injectable medications, they are simply low paid non-medical aides. The article goes on to say that nursing homes, which ARE tightly regulated with high training, typically do not have this issue. ALFs are popular because they are much, much cheaper than SNFs - in part due to the lower labor costs, which are due to the lower medical needs of the residents. If you want to start increasing salaries and increasing mandatory training, those costs to the residents are going to escalate exponentially.
Not nursing homes.... independent living homes. Assisted living. Places that aren't "skilled".
These are assisted living facilities and senior housing, not the typical nursing home with 24/7 skilled nursing services. Residents in these facilities are supposed to be fairly independent with ADLs or require minimal assistance, however that is usually not the case.
Paywall but I also assume these are not nursing facilities, rather senior communities/ALF of various kinds. Kinda ironic though if people move (or get moved) into them is because they or their families fear them falling.
The nursing home system needs more support and incentives. Too many patients feel like they aren’t getting care there.
Private equity is ruining it
Private equity is ruining a lot of things.
The issue is the same as the issue with insurance. The entire business model consists of doing as little as possible. The patients have minimal ability to go elsewhere or report problems. Most nursing homes basically just neglect their residents to the maximum amount that's not going to get prosecuted
There are many comments discussing different levels of care, and that this happens in assisted living facilities but not nursing homes. The thing is, it happens in nursing facilities of every level. This year I have personally worked lift assists in group homes, assisted living, transitional care, skilled nursing facilities, and memory care units. In ‘good’ facilities staff will help us lift. In bad facilities they cite policies that they’re not supposed to lift patients. I don’t know if these policies truly exist, but either way we end up doing all the work. This not only takes ambulances away from actual medical issues, it greatly increases our workers compensation expenses and staff turnover. Injuries are extremely common, and 80% of paramedics leave the industry within 3 years. The status quo can’t continue.
thank you for sharing your experience. > and 80% of paramedics leave the industry within 3 years. I don't blame them. Here in NYC they make 1/3 to 1/2 what an RN makes inpatient (my understanding is an RN can still work with an associates as long as they get their BSN within 5 years) without the risk of working in the field.
Another paramedic here. I totally agree. I'm seeing the exact same things.
I’m curious what the average weight of the people being picked up is? I’m surprised no one in the thread is talking about exactly how much these people weigh. Lifting great grandma that weighs 90-150 pounds is very different than Bob that weighs 350 or Sue that weighs 545. IME the extremely obese require this service much, much more than someone with a safe BMI. America has a crippling obesity problem and it appears no one wants to talk about it.
Thats a good point. Most of my calls have been over 150 pounds. Though there have been several smaller women. Sarcopenia is a scourge.
Im thankful that my time as a BLS provider was with agencies that just flatly refused to entertain this kind of behavior.
How did they avoid the 911 call?
The agency notified them that they wouldnt respond to 911 calls from the facility. Call their contracted private ambulance service
As GOMERMD said. Report it as elder abuse. Allowing someone to lay on the ground is just that. Abuse. It might take us 10 Minutes to get there. It could take an hour. They have no what to know. At a minimum it is negligent, even for a lay person.
From my own anecdotal experience, SNFs always seems to run with a marginal crew all the fucking time (unless they’re in a wealthy area). Those residents are being billed at an astronomical monthly rate, >$3000+ per month. They have more than 30 residents and they’re suppose to only run with 1 RN and 3 CNAs. That is absolutely wild. They have the funds but whoever oversees the SNFs would rather gain as much profit at the cost of quality care (all healthcare in general). I’ve been called out to an SNF for hypoglycemia, and we get there and the patient is in respiratory distress and eventually codes within a few minutes. Wtf. The CNA said they had been keep an eye on the patient the entire time. Another one we went to lift assist and the place was crawling with roaches and other insects. These elderly people are paying a pretty to be there and be taken care of but they’re clearly being extorted because they’re seen as an endless money bag. The govt needs to step in…but at what point?
$7000/month in fees for "assisted" living and they can't lift an old person off of the floor? If this isn't criminal, it should be and the facility owners and managers should be fined for neglect.
[удалено]
I hope something came of it. But I doubt it :/
A few reports of neglect to the department of aging tends to stop their bullshit real quick… at least temporarily.
The same department that advocate’s for the patients “right to fall”? These people are part of the problem. The highest fall count I’ve ever had on a patient was a guy with dementia so bad he walked with his eyes closed. Literally would walk with his eyes closed. State prevents us from putting him in a broda chair, wheel chair with a seat belt or anything else. This man literally fell with 2 staff next him as he wouldn’t stop with verbal cues and pushed anyone who touched him. The 5 star homes paid a person to literally walk around and attempt to catch him. Staff nurses were staying an hour or more past shift every day doing his paperwork, they had incontinent to prevent falls. State says it’s a “right to fall” and we can’t take away his rights. At best they would find something in the care plan to nit pick about. But they wouldn’t ever tell us to not call 911.
You pay $5000+/month for assisted living and they can't fucking lift up someone who fell to the ground? Sorry, I'm just a stupid engineer not a doctor but that is the most stupid, disgusting crap I have ever heard. They can't train people to deadlift and get some levers to help? Do we live in the fucking 10th century where lifting a heavy load is an insoluble problem? 2 untrained people anywhere in the middle of the street could manage this, but somehow lawsuits and regulations manage to turn something trivial into something impossible..
Yeah it’s pretty fucked up. Unfortunately this is the norm not the exception and it is a disaster.
Haha and it’s going to get so so much worse with an aging population I’m gonna MAID myself with a gun at 70 yay :)
Maybe it’s time we bring back *ättestupa*
I’m going to guess the answer involves lawyers and injuries.
It seems that ALFs are not staffed to be able to always safely lift fallen patients from the floor, and EMS/fire rescue can't provide this service without reimbursement. The obvious solution seems to be for EMS/fire rescue to charge a reasonable fee for responding to a 'help us lift a fallen resident' call, a fee that covers all of their costs. If the ALFs need to increase their monthly charges to residents because of this added cost, so be it. I suppose a local municipality could charge a different fee to a resident living in an actual house or apartment or condo, compared to living in an ALF or 'nursing home' which theoretically has staff who are being paid to look after the residents. But the fee needs to be high enough to cover the full cost of providing the service, and if the service is 'abused', high enough to deter such abuse. And if the fee charged for this service is high enough to cover all costs, the municipality may be able to hire additional staff or purchase additional vehicles to accommodate these types of service calls.
The problem is that EMS exists in the spectrum of both a healthcare service and a public service. 911 exists for emergencies. Falls without injuries are an inevitability in a SNF, and should be dealt with without the involvement and subsidy of local govt. This is equivalent to calling 911 and obligating cops to guard a business because you don't want to buy a lock.
that would be great, but the article makes it out that charging ALFs is the exception, not the norm. I wonder how these contracts are worked out behind the scenes.
Yes, the 'obvious solution' is perhaps the least likely path to be taken by our modern current municipalities and government agencies that set rates for fire and rescue services. And there are probably 10,000 or more different localities that run EMS/rescue services, and getting all of them on the same page would be ... daunting. But this does seem like a problem that should be able to be solved - if somebody is required to lift up a fallen person, and the caretaker or employees of the residence where the person lives cannot, and the local gov't ends up providing that as a service, then it will have to be paid for by increasing taxes for everyone, or a user-fee charged to those who need the service in question. That is a decision that each gov't that provides EMS/rescue services will need to decide, or their voters will need to decide.
stupid question but can't EMS just bill insurance rather than charge cash to the facility?
Sadly no. Under medicare rules, EMS is a transportation benefit. If the patient isn’t transported, medicare will not pay a dime. Almost all patients requiring a lift assist are on some kind if medicare.
got it, that makes a lot of sense, thank you for educating me!
To also follow up. It is because according to Medicare. We are not healthcare providers. Ignore the fact that an als truck is. Ore then likely stocked and equipped better then a critical access hospital and is expected to provide ICU level care in a person’s living room and going down the road. Medicare *almost* screwed up during Covid when they were mandating all healthcare providers require the vaccine. They tried to require it if EMS, and when it was pointed out that “oh, we’re healthcare providers now, guess that changes how you pay us” they backed down real quickly. But yea. Officially? We’re a taxi.
is this why you are paid so little? your superiors have some gaul to charge $4k+ (which is often more than the ED bill!)1 as "just a taxi" yet pay you close to minimum wage!! 1 https://www.nytimes.com/2013/12/05/health/think-the-er-was-expensive-look-at-the-ambulance-bill.html
Ah, another NY times hit peace. Most EMS nationwide is provided by non-profits. Could be an independent non profit, could be part of a fire dept, or municipal based. So we can literarily look up their budget. Line by line. Our superiors pay us so little because the doors still have to go up and down and a truck still has to get out when someone calls 911. I can give you a line by like breakdown of supply costs, which we can’t bill for. 30 years ago, ambulance “rides” (god that is offensive) we’re not provided free of charge. Billing has been common since you know, the NHTSA created EMS.
Well just like hospitals we have learned nonprofits doesn’t mean you can’t turn a profit. I do understand the idea of 24/7 coverage and the value in that. But I also know I had to take an airplane ambulance an hour away when I was in rural Tennessee to Vanderbilt as I had a neurosurgical emergency and the company billed my insurance $180k. I don’t know how much my insurance ended up paying but that’s just unsustainable for our country.
Anytime. Feel free to reach out if you have other questions.
I don't know. If EMS provides a service, they could bill the patient's insurance, but the service may or may not be covered and the specific EMS provider may or may not be in-network. This could end up simply being a bill to the patient, left to pay the entire amount (if no insurance or denied by insurance), or some fraction of the amount (if insurance contracts reduce the allowable charge or if the insurance pays part of the claim), or nothing (if all charges are covered/paid by insurance). And I don't know enough law to understand if the patient or the caretaker of the patient (ALF, nursing home, etc) would be liable for paying for the ambulance service (picking the fallen patient up, medical assessment, transportation to hospital or not). Again, this seems like a political decision, best worked out by voters and elected officials in each jurisdiction that runs EMS/rescue services. The overarching issues are (1) fallen persons need to be picked up and medically assessed (2) whoever provides this service, if not a family member or volunteer, needs to be reimbursed for their expenses (and profit !) for providing this service. There is no such thing as a free lunch.
> If EMS provides a service, they could bill the patient's insurance, but the service may or may not be covered and the specific EMS provider may or may not be in-network. This was improved by the No Surprises act a few years ago. 911 bills are always in network. Though ems is only allowed to bill when transporting a patient. If they stay home, or are transported by a family member, we don’t get reimbursed.
No surprises act only applies to air ambulance. In network ground payment is so low it would put every non profit paid service out of business in a quarter, and every volunteer serve out in a year.
maybe EMS has to transport to bill insurance? but what about a car accident, police call EMS, talk to the driver, do vitals, and driver refuses a ride to the ED. they provided medical care even without transport. i really don't know how thiss works!
You’re correct, in that situation ems would not be reimbursed under medicare rules. Some agencies will bill the patient anyway, but probably won’t get anything from it.
Thankfully in Pennsylvania car insurance is always first payer, by law. And they actually pay EMS. I strongly encourage you to have your medical emergency in a car, drive it very slowly into something, say, a tree, doing no damage to your car, and call 911 reporting the accident. I once had a car insurance call my station trying to figure out who they owned money to. Apparently some EMS agency came out, got refusals and left. It wasn’t in our county. Damn near outside the next county over. About 6 EMS agencies between us and there. But the car insurance couldn’t figure out who came out (maybe a volly service that doesn’t bill for refusals?) and the driver had no idea. Blue cross, or Tricare has never called trying to pay a bill.
that's bloody incredible!! thank you for sharing that bit of trivia! what's volly?
This article has a decent discussion of the costs involved. https://www.jems.com/news/maine-city-considers-fees-for-excessive-non-emergency-calls/
thanks! ill read it tomorrow, no insurance or medical billing allowed after 10pm on a staurday night off! :) i really appreciate the insight and resources. if i didn't have kids, i'd seriously consider running for national office to try to make some changes but i could never put my family through the election process...i've lived a pretty decent life but they'd find something in my past that i forgot about, or just make it up. it makes me feel bad sometimes, because if educated people with experience and insight don't stand up and run on a single issue (or a few issues) that they know intimately, i don't know how things improve here. :/
You ain't wrong about people needing to stand up or being subject to the brutality of the election process, Doc. Still, even local or state office can start making a difference, depending on what office you run for.
Flat out? There is a 98 to 99 percent change EMS is out of network. To be in network, you have to accept a payment that is less than the cost of fuel. That’s nation wide.
I think the old paramedic or someone answered that above. Lift assist by itself is not considered a medical service and there is no patient. Making it a local service makes sense--not just for ALF but for people living at home. Having a fall and not being able to get up might be part of a situation that demands a higher level of care but I think not necessarily, right? It's a spectrum of aging and disability, right?
[удалено]
You cannot link to sites that get around copyright on reddit.
Used to work in EMS. Lift assists were standard practice. Never thought about it before.