AZ--Individual

My comment addresses the question of how the increased HCBS waivers may affect states' ability to provide an institutional level of care, and other issues I believe will need to be addressed in HCBS settings. Perhaps 10-15 years ago I was contracted with our local Medicaid provider when a shift was made to increase the percentage of LTC members being served in HCBS settings rather quickly. There were 17-18 SNFs in the community at the time, and many experienced a marked drop in census at the time. Although I anticipated a proportionate drop in staffing, what I did not foresee was that at a certain point nursing and CNA coverage drops below a critical mass, and care suffers dramatically. Ultimately a couple of facilities closed, and the staffing levels floated back to baseline among the survivors. I provided services at all of these facilities, and unfortunately I can say that Darwinian principles did not apply. However, the overall quality of care also returned to baseline. The greater cautionary tale is that there is likely a similar critical mass that pertains to the number of institutional facilities within a community. I suspect it will be much more difficult to recover from having the number of facilities drop below that level than it was to recover from the staffing problems. I cautiously support the move to an HCBS model, but do think it is imperative that we not allow that to further compromise the already weak standard of care for those who require an institutional setting. A separate concern relates to expanding the woefully inadequate regulatory oversight to a dramatically larger number of care settings. The average number of health deficiencies identified in nursing home surveys across the US is currently 8, per the CMS website, 12 in the state of Arizona. Having worked in over 60 faciities in Arizona over a 10-year period I can attest tthat this dramatically underestimates the failures of these facilities, and the level of harm indicators are meaningless. The survey system is hopelessly burdened by minutiae, and the big picture has been lost. It is a very costly endeavor with minimal return, and efforts to remedy the problems generally just add another layer. It's time to scrap it and start over, over a sensible time period through proper investigation and application in progressively larger demonstration programs. Talk of the healthcare crisis in this country has largely ignored the long-term care catastrophe. History will not look kindly on how we have cared for one of our most vulnerable populations.