Tuesday, October 9, 2007

Honor Thy Mother, And Thy Father...

...And Grandma, And Grandpa Too...

Recently, I called for everyone to tend to their health around here in a post entitled, “We Must Take Care Of Ourselves”. In that post I spoke of my Mother-in-Law, who was in a nursing home for a short-term basis after a TIA, a fall (thankfully breaking nothing), and subsequent incapacitating dizziness. Well, thank God, fate, or whoever, but she has mended enough to come home. Albeit with a walker for ventures outside, where dizziness, hard-pavement, and brittle, elderly bones need all the help they can get.

We got her back last week, spending the better part of a day filling out forms, collecting all the bags of way-too-many-extra-clothes-we-brought-for her, having this doctor and that doctor visiting her to make sure she was on the ball mentally, and clear on all the wonderful new medications she'd been put on.

Her discharging physician mused off-handedly as he checked her out, “So, Ms. _______, I see you've been prescribed a couple of new medicines.”

“A couple?”, she half snapped, “Foooey! S'more like ten! A dozen! My daughter's gonna have to make me a chart! Sheeesh!’

“Well”, he monotoned, “I just want to know if you're clear on what you'll be—”

“I've gotta take “blah-blah” for my blood pressure every morning, along with my salt pill, and I have to take “blah-blah” three times daily to stop the vertigo, ”, she whined, rattling off medicine after medicine by “ex”-ending name after “ex”-ending name.

“I take the “blah-blah” before I go to sleep for my cholesterol, and then one day a week—the nurse said Friday—I should take the “blah-blah” for the osteoporosis...and I have to sit up for 30 minutes after taking it? Right?”

“Yes, that sounds about right, ma'am.”

“Ah! Foooey!”

It was a long day there, getting her out...and in its being the longest stretch of time (about four-and-a-half hours) I'd spent there in one pop, the things that so unnerved me in my previous, briefer visits really got to me this time. I've been in many nursing homes before. Too many for my taste. And this one is by far the best I'd ever visited. The level of care was impeccable, the personnel was supremely professional, and the surroundings themselves were aesthetically pleasing.

But...it was a nursing home. And by nature, such a place is where you find those of us at that stage of life where there is far more wick than candle left. My Mother-in-Law was the spryest person I'd seen there—practically a Jesse Owens among near statues. And those “statues”—those older people who were in bad shape shook me to the core. I saw so many of them on that long day that it still haunts me. I wrote the following about one of my visits earlier—imagine it being about seven times more intense on Mom-in-Law's getaway day:

There is the smell of the place. Of old skin. And sickness. Liniments and medicines, rubber gloves and tubing. Alcohol, urine and tears.

And there are the sights. Of wizened people sitting out front in the blinding sun, blinking at the light while struggling to move their wheelchairs to shade. There was the woman who was quite literally gray of skin, slumped in her wheelchair. Her chest seemed not to move. I watched he for a long minute, fearfully. And then, a loud truck rumbled past, and she slowly opened a rheumy eye and shrugged, signaling life—as it were.

Then in the building, there were worse sights. The people lying in beds with mouths gapped open, eyes ceiling-locked. The old man sitting in the dining room leaned against the window, quietly whimpering like a wounded dog. And the woman...the woman curled on the bed in a corner of the dining hall, contracted in a fetal ball and quivering, with knees to chin, as an attendant held a spoonful of pureéd something to her mouth, cajoling her to eat. She did not.

Mom is fine. Getting better every day. But the place messes with her head. Sparks those thoughts of mortality, which echoes in her talk. She hates the place. You can hear it in her voice, the desperation. The anxiety. Again, the mortality.

Which messes with me, too. It's clichéd, but all I could hear as I slowly walked the halls there, was Roger Daltrey fairly screeching “Hope I die before I get old!”

The place, good as it was—was a gut-kick-and-a-half. I was happy to leave that afternoon...but no one was as happy as Mom riding in that spacious ambulette.

“Good-bye!”, she fairly yelled as we pulled off. “I don't wanna see that place again until I'm so messed up that it doesn't matter! Fooey!”

“Fooey”, indeed.

During her five weeks away, the wife and I tidied up, watering plants and so on. And we kept her voluminous Sunday Timeses for her. She practically dove into them, nearly inhaling the Arts sections that had accumulated. And as she busied herself with those, and sipped at her freshly made Café Bustelo, I pored over the big main sections I'd missed recently. Where I stumbled across this:

Habana Health Care Center, a 150-bed nursing home in Tampa, Fla., was struggling when a group of large private investment firms purchased it and 48 other nursing homes in 2002. The facility’s managers quickly cut costs. Within months, the number of clinical registered nurses at the home was half what it had been a year earlier, records collected by the Centers for Medicare and Medicaid Services indicate. Budgets for nursing supplies, resident activities and other services also fell, according to Florida’s Agency for Health Care Administration. The investors and operators were soon earning millions of dollars a year from their 49 homes. Residents fared less well. Over three years, 15 at Habana died from what their families contend was negligent care in lawsuits filed in state court. Regulators repeatedly warned the home that staff levels were below mandatory minimums. When regulators visited, they found malfunctioning fire doors, unhygienic kitchens and a resident using a leg brace that was broken.

“They’ve created a hellhole,” said Vivian Hewitt, who sued Habana in 2004 when her mother died after a large bedsore became infected by feces.

Habana is one of thousands of nursing homes across the nation that large Wall Street investment companies have bought or agreed to acquire in recent years. Those investors include prominent private equity firms like Warburg Pincus and the Carlyle Group, better known for buying companies like Dunkin’ Donuts. As such investors have acquired nursing homes, they have often reduced costs, increased profits and quickly resold facilities for significant gains. But by many regulatory benchmarks, residents at those nursing homes are worse off, on average, than they were under previous owners, according to an analysis by The New York Times of data collected by government agencies from 2000 to 2006. The Times analysis shows that, as at Habana, managers at many other nursing homes acquired by large private investors have cut expenses and staff, sometimes below minimum legal requirements. Regulators say residents at these homes have suffered. At facilities owned by private investment firms, residents on average have fared more poorly than occupants of other homes in common problems like depression, loss of mobility and loss of ability to dress and bathe themselves, according to data collected by the Centers for Medicare and Medicaid Services. The typical nursing home acquired by a large investment company before 2006 scored worse than national rates in 12 of 14 indicators that regulators use to track ailments of long-term residents. Those ailments include bedsores and easily preventable infections, as well as the need to be restrained. Before they were acquired by private investors, many of those homes scored at or above national averages in similar measurements.

In the past, residents’ families often responded to such declines in care by suing, and regulators levied heavy fines against nursing home chains where understaffing led to lapses in care. But private investment companies have made it very difficult for plaintiffs to succeed in court and for regulators to levy chainwide fines by creating complex corporate structures that obscure who controls their nursing homes. By contrast, publicly owned nursing home chains are essentially required to disclose who controls their facilities in securities filings and other regulatory documents.

The Byzantine structures established at homes owned by private investment firms also make it harder for regulators to know if one company is responsible for multiple centers. And the structures help managers bypass rules that require them to report when they, in effect, pay themselves from programs like Medicare and Medicaid. Investors in these homes say such structures are common in other businesses and have helped them revive an industry that was on the brink of widespread bankruptcy.

“Lawyers were convincing nursing home residents to sue over almost anything,” said Arnold M. Whitman, a principal with the fund that bought Habana in 2002, Formation Properties I. Homes were closing because of ballooning litigation costs, he said. So investors like Mr. Whitman created corporate structures that insulated them from costly lawsuits, according to his company.

“We should be recognized for supporting this industry when almost everyone else was running away,” Mr. Whitman said in an interview.

Some families of residents say those structures unjustly protect investors who profit while care declines. When Mrs. Hewitt sued Habana over her mother’s death, for example, she found that its owners and managers had spread control of Habana among 15 companies and five layers of firms.

As a result, Mrs. Hewitt’s lawyer, like many others confronting privately owned homes, has been unable to establish definitively who was responsible for her mother’s care.

I sat there and looked at my Mother-in-Law, enjoying a sandwich, sipping coffee, and now, entertaining the fellow tenants from her floor who'd missed her while she was away, and I looked back down at the article, which featured a photo of the above noted woman who died at that Habana nursing home—Ms. Alice Garcia.

She was damn near a dead-ringer (pardon the phrase) for my Mother-in-Law. And I thought again about those patients I saw ever day when I visited her.

There is the smell of the place. Of old skin. And sickness. Liniments and medicines, rubber gloves and tubing. Alcohol, urine and tears.

Then in the building, there were worse sights. The people lying in beds with mouths gapped open, eyes ceiling-locked. The old man sitting in the dining room leaned against the window, quietly whimpering like a wounded dog. And the woman...the woman curled on the bed in a corner of the dining hall, contracted in a fetal ball and quivering, with knees to chin, as an attendant held a spoonful of pureéd something to her mouth, cajoling her to eat. She did not.

There but for the grace of God went she.

Let me extend my plea from that previous post, from “We Must Take Care Of Ourselves”, to “We Must Take Care Of Ourselves And Our Families”.

I strongly urge you to read that entire article from The Times. It's lengthy, but if you have older relatives, or friends and acquiantances with older relatives who are in a state where they are needing of nursing home care, this article is an eye-opener that you must share, and if it affects you directly, use it as a guidepost for an action (pro-active action) plan for the aged you care about. What often happens is that our elderly can be seemingly fine one day, and then with one “spell” or fateful moment find themselves in the position of needing nursing home care. And oftentimes it'll be long-term nursing care like the (mostly) women required at the home my Mom-in-Law happily left behind that day.

Those Google skills you use so deftly sussing out the provenance of this or that insignificant thing, can and should be put to use in digging about for clues to the corporate structure of these homes we trust our mothers, dads, and grandparents to every day. We've seen the jokey examples of the dark side of these places in movies like “Happy Gilmore” where Ben Stiller was the sadistic, elder-hating supervisor, who sweat-shopped the clients, threatening them with violence and so on. Jokey as that was, it's still a better thing damn near than the awfulness described in The Times article. At least Stiller kept his charges well enough to work. The poor souls in the Habana article have every possible corner cut around them, close, close, ever closer, until they seem to just bleed life itself.

It's a scandal. One that too few of us are willing to deal with, because of the initial guilt involved in turning an elder over to one of these facilities in the first place. I can understand that. It's human nature. But we have to get over that silly defense mechanism, and effect the due diligence for our loved ones. Dig around—find out about these places—are there unfavorable, past news reports about a facility you're considering? Go in, get a brochure—if you should find that it's one of the corporatized variety, spend a night or two on the computer diggin' 'round the financials. Make a call or two based on what you discover. If it means being a little duplicitous to get those who answer the phone to give you the info you need, so be it. Tape the calls—document who you spoke to—find out what hospital they're affiliated with—ask doctors involved in geriatric care at nearby hospitals about anyplace you consider seriously. Better yet—ask nurses, as they're even more inclined to give you the straight dope without conflicts of interest insofar as “steering” outgoing patients to places for any potential profit (this sadly does happen with some overly self-interested physicians every now and then).

But moreover, this is an issue for a smart, thoughtful, enterprising Senator, Representative, or even Presidential candidate to take up—the care of our elderly and elderly to be—namely, us. It affects everyone I know! Most of my friends are within just a couple of years of me age-wise, and for us all—parent after parent, grandparent after grandparent, every one of them is living this reality out loud. The same chase for the dollar over all and the hyper-corporatiziation of a business that is at its very core based on tender loving care has damaged the nation's funeral industry as well (how freakishly ironic), with the mass purchasing of many one-time local, family-run funeral homes. That financial “one-two” at the end—first at the nursing home, then at the funeral home is flat-out criminal. End of discussion.

This is your blood we're talking about here—folks who taught us how to walk, how to talk, fed us, clothed us—yes...and wiped our asses. And we're talking about ourselves, too—at least in thirty or forty years, so it's only logical to do what we can do make certain that the infrastructure is in place for the care that like it or not, a large number of us is going to need when the body “fails” in the ways it does when one gets...old.

It's also a moral obligation. I'm not some damn holy roller, but in the text of the holy books for virtually all of the major faiths, there are words to the effect of the tried and true,“Honor thy mother and thy father.”

In Islam—Excerpt from the Qur'an (oh yes, that mean old, crazy Qur'an everyone hates so much): “And We have enjoined on man (to be good) to his parents: in travail upon travail did his mother bear him, and in years twain was his weaning: (hear the command), "Show gratitude to Me and to thy parents: to Me is (thy final) Goal. (Qur'an 031.014)

In Christianity—From Martin Luther's Small Catechism: “We must respect and love God, so that we will neither look down on our parents or superiors nor irritate them, but will honor them, serve them, obey them, love them, and value them.”

In Judaisim—From The Torah:“Honor your father and your mother, that you may long endure on the land that the Lord your God is assigning to you. (Tanakh, Torah, Exodus 20:12)

In Hinduism—From The Laws of Manu: “The father [is] the physical form of the Lord of Creatures, the mother the physical form of the earth... The trouble that a mother and father endure in giving birth to human beings cannot be redeemed even in a hundred years. He should constantly do what pleases the two of them....”(The Laws of Manu, 2:226)

And if you're not down with a faith, just go with “Hey, common sense says that perhaps if I help to set up a structure to take care of older folks in decent surroundings and some level of respect now, that'll go a long way towards that system being there when I get to be that age too.

We're glad to have Mom home. And after her coterie of visitors left, and we did a bunch of laundry and shopping for her, dusk fell. It was a quiet West Side night. The hardhats were done for the day wrecking the neighborhood's ears with their mechanized din. The only sounds were an occasional car horn and the soft rustling of wind through the trees in the courtyard. I sat exhausted in a kitchen chair, nursing a lemon-ed ice water and staring out the window at a twinkling Hell's Kitchen just a few blocks south.

I heard my wife aks her Mom about her statement on the nursing home earlier in the day—“I don't wanna see that place again until I'm so messed up that it doesn't matter!

“Why would you say that, Mama?” she asked. “Right in front of everybody?”

“Listen,” she replied. “I'm being realistic. That place was pretty good—compared to a lot of the other places I've seen. Where they had your Aunt D____? I swear, they were just about hurrying her along. They didn't care about her! It's like they wanted the bed, and the gold fillings inside her mouth! But they put on a good show when they brought her there...holding her hands, reading to her...and as soon as you turn your head, Fooey!—they're handling you like...when you go to the post office, and give them a package you wrapped all nice, and you put all the bubble stuff in? And as soon as it's across the counter in their hands—BOOM! They just toss it in those bins? Like it was nothing? That's how they do you in those homes. My place was good. But I know it could be bad tomorrow. There's a lotta money involved. Remember that old lady across from me who never talked? I heard her kids talking about how much they were paying every week for her there. $1400 a week! That's a lotta money! And she was there when I got there, and she's gonna be there awhile longer—maybe till the end. That's a lotta money. Those places taake advantage of that. Not my place—but places. And maybe someday my place too, 'cause it's how you say...tempting. It's too tempting.

“So.” she said. “When I have to go back there in a few years (she's 86 years old), just make sure it's when I don't even know what's going on anymore. You can't be there all the time. It would just be me. So, if they're gonna treat me like “a package”, I'd rather be like where I don't even know about it. Don't wanna know it's happening. You get me? Cause maaaaannn, if they ever treated me like they treated your Aunt D____, and I could halfway get outta that bed? Fooey! I'd be right out that window. I'd rather jump!”

“Mom!”, my wife scolded.

“I'm serious. No way, man. That's no way to live. Fooey!”

No way to live.