Home care law lessens skill set

At a time when Hawaii’s senior population is surging, the state has watered down the main qualification for secondary caregivers at hundreds of adult foster homes, senior advocates say.

The move has been hailed by the industry as critical to the economic health of foster homes but has been panned by senior advocates as a blow to the quality of care in those homes.

Gov. Neil Abercrombie signed a bill last week allowing substitute caregivers who provide less than five hours of care daily or 28 hours weekly to be nurse aides, rather than certified nurse aides, in homes authorized to have three clients.

The state previously required such substitute caregivers, regardless of the hours worked, to be at least CNAs, who must pass a state-approved exam every two years showing continued mastery of certain skills. Nurse aides do not have to take the 24-hour exams, but receive the same basic training as their certified counterparts.

The lesser qualifications apply only to foster homes with three clients, the maximum that can be accepted in such facilities. More than a third of the nearly 1,100 foster homes in Hawaii are certified to take in three clients, but that number is expected to grow now that the bill has been signed by the governor, industry representatives say.

Even though the new law’s changes expire in June 2013, giving the state time to study the effects before determining whether to make the changes permanent, senior advocates and others say any lessening of qualifications is worrisome.

"More is better. Less is not good," said Nancy Manali-Leonardo, a registered nurse who used to help evaluate foster homes for recertification. "It decreases the quality of care for patients."

Care home operators and industry advocates contend quality will not be affected because nurse aides learn the same skills as their certified counterparts — they just haven’t passed the state exam.

"It’s not a problem," said Thelma D. Ortal, a Waipahu foster home operator and president of the Adult Foster Homecare Association of Hawaii. "In applying skills that we’ve learned, there’s no difference."

Supporters of the new law also say that nurse aides undergo yearly skill checks from case managers — usually nurses — assigned to oversee care for foster home residents.

Proponents likewise note that some standards — added to the original bill to address various concerns — have been increased under the new law. The substitute caregivers must have one year of experience in a homelike care setting, whereas no such experience was required previously. A continuing-education requirement was increased to 12 hours a year, compared with eight previously. And the minimum age for substitute caregivers was boosted to 21 from 18.

The bill also was amended to include the cap on the number of hours a nurse aide can provide care while the primary caregiver is away from the home.

Still, senior advocates say they worry about any lessening of caregiving qualifications in foster homes because such facilities will become more critical in the years ahead as the state struggles to meet the demands of a rapidly growing elder population.

Foster homes, formally called Community Care Foster Family Homes, are licensed to be able to accommodate residents whose conditions are comparable to those in nursing homes. Generally, the residents are more frail and their medical needs more demanding than those living in standard care homes.

As the state and federal governments have placed greater emphasis on noninstitutional, neighborhood-based care facilities, the number of foster homes in Hawaii has grown dramatically over the past decade, while the number of nursing home beds has remained relatively flat.

Because many foster home owners, who generally are listed as the primary caregivers, hold jobs outside their homes, much of the caregiving falls to the substitutes — another argument against weakening qualifications, the bill’s opponents said.

"When you lower the quality of care, when you lower the level of professionalism, you certainly increase the potential for problems," John McDermott, the state’s long-term care ombudsman, said in an interview.

Samuel Moku, director of the city’s Department of Community Services, told legislators in written testimony that having a third client "at the nursing facility level of care significantly increases the degree of supervision and care required of the caregiver."

Tony Lenzer, a legislative committee member for the Policy Advisory Board for Elder Affairs, a state advisory group to the Executive Office on Aging, acknowledged that improvements were made to the original measure, which was introduced by state Rep. John Mizuno and others.

"There are things to be said for the bill," Lenzer said, "but there still are concerns that I think are serious."

HB 739 sailed through the Legislature this year despite opposition from the advisory group, McDermott, Moku’s city agency and the state Department of Human Services, which regulates foster homes. Boosted by a concerted lobbying effort from the industry, with dozens of foster home owners submitting identical or nearly identical testimony, the measure passed the House 40-9 and the Senate 25-0.

As has been the pattern in recent years, the influence of foster home and care home interests — predominantly Filipino groups because the vast majority of such homes are operated by Filipinos — won the day over seniors advocates at the Legislature. The Filipino Chamber of Commerce of Hawaii made passage of the bill its No. 1 priority in the session.

Ron Menor, a former state senator and chairman of the National Federation of Filipino American Associations Region XII, which includes Hawaii, told legislators in written testimony that requiring substitute caregivers to be CNAs was cost-prohibitive.

"It would drive many foster care operators out of business at a time when a rapidly growing elderly population in Hawaii (is) in dire need of their services," he wrote.

Proponents also said that some nurse aides, though as qualified from a skills perspective as CNAs, have been unable to become certified because they have difficulty with English.

"Given many caregivers do not speak English as their first language, I believe the language barrier is significant for them not pursuing the CNA title," Lourdes Vergara Marcelo, chief executive officer of Lou’s Quality Home Health Services, said in written testimony.

Ortal, the Adult Foster Homecare Association of Hawaii president, said the language barrier doesn’t get in the way of providing quality care to residents, even if the residents don’t speak Filipino.

Another argument raised by the bill’s supporters was the disparity between requirements for substitute caregivers at foster homes and those at what are called expanded care homes, which also can accept nursing-home-level cases.

Whereas the substitute caregivers at three-client foster homes were required under the old law to be CNAs, the substitutes at the expanded care homes, which are regulated by the Department of Health, don’t even have to be nurse aides. They need only to be trained in cardiopulmonary resuscitation, according to DHS.

Despite the Department of Human Services’ opposition to the bill, the agency recognized that the measure had substantial support at the Legislature and likely was to pass in some form, "so the best option was to do everything we could to make it the best bill possible," according to DHS spokesman Joe Perez. With the amendments that were made, the department believes adequate safeguards remain in place, Perez said.

At the same time, DHS Director Patricia McManaman is open to starting discussions about how to make requirements for care facilities more consistent while continuing to protect residents, Perez said.

In a bill-signing ceremony before an upbeat crowd of foster home representatives, Abercrombie told them last week that the next two years will provide the state with information to determine what to do after the measure’s so-called sunset.

"We need to figure out over the next couple of years where we are succeeding, where we are failing," Abercrombie said. "You’re the pioneers in this. You’ll set the standards, the benchmark."