• Other states have done more to better protect nursing home residents
• Among the ideas: Pass minimum staffing laws and force more financial transparency
• Michigan lawmakers seem at a standstill

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If Michigan is to hold nursing homes more accountable for the care they provide, the first step might be in looking elsewhere. 

Other states have tried reforms with varying levels of success, including New Jersey, New York, California and Minnesota.

And while none have proved perfect or easy to implement, we’re moving in the right direction,” said Katie Squires, associate state director of advocacy at AARP New Jersey, a state that has undertaken several reforms.

A Bridge review of inspection reports and citations in hundreds of nursing homes over five years paint uncovered 6,315 cases of abuse, neglect, exploitation or quality of life and care, including cases of  mold and gnats, stale odors of human waste, filth, rodents, flies, boredom and isolation.

To be sure, change isn’t easy.

Related:

• Choosing a nursing home can be tough; these tips can help
• Michigan sits on $35M fund to improve nursing homes. It’s largely unused
• Michigan cities balk at costly 911 calls to understaffed nursing homes
• Abuse, neglect common in Michigan nursing homes — and no one is coming to help
• Michigan, aging faster than most, faces big challenges as it ages. Read our series here

Since 2020 New Jersey lawmakers have been making systemic challenges to the state’s network of nursing homes. 

They were driven in large part by COVID-19, which — as in Michigan — killed thousands of nursing home residents and exposed the industry’s shortcomings.

In five years, the Garden State has: 

• Boosted wages for front lines staff,
• Established minimum staffing requirements: one certified nurse aide to every eight residents for the day shift, and one direct care staff member — nurse or nurse aide — to every 10 residents for the evening shift, for example
• Required that nursing homes use 90% of their revenues on direct care
• Expanded data reporting procedures

The 2020 package of laws also handed a 10% increase in Medicaid reimbursements — $130 million in all — to the state’s nursing homes to pay for wage increases for certificate nursing aides.

New Jersey’s is just one of more than a half-dozen efforts that Michigan could undertake to better protect residents of its some 420 nursing homes, experts told Bridge. Among those ideas:

Step 1: Establish minimum staffing

Some states have pushed for minimum staffing requirements — an effort now gaining steam after new federal staffing standards that were to go into effect this year instead collapsed.

Michigan’s minimum staffing requirements have remained unchanged since 1978. They call for patients to receive just 2.25 hours of care each day — far below the 4.1 hours a day that advocates generally considered a minimum requirement.

Step 2: Require audited reporting

Advocates in Michigan and elsewhere have long complained that nursing home finances are opaque, making it difficult to know how much is being used for care and how much, especially in for-profit facilities, is sliced off as profit.

Especially in for-profit nursing homes where shareholders must be paid, “we don’t know if they’re buying cheap hotdogs or broccoli and cauliflower and chicken soup for lunch,” said Laura De Palma, director of the Nursing Home Transparency and Accountability project at the Michigan Elder Justice Initiative, or MEJI.

In Michigan, MEJI and other consumer watchdog groups released a report in June, accusing three of the state’s for-profit nursing home chains of moving millions of dollars in profits to nursing home service companies they own called “related parties” — even as complaints about care and staffing levels increase.

The authors stopped short of accusing the chains of wrongdoing. In fact, there’s no proof that there’s financial wrongdoing among those chains or any others, De Palma said.

“It’s that we just can’t tell without the transparency,” she said.

An industry group, the Health Care Association of Michigan, dismissed the report as “unsubstantiated and purely speculative,” and one of four nursing home chains targeted in the report — Southfield-based are Ciena Healthcare, said the report was “based on conjecture and speculation.”

In 2021, California passed a law that requires more reporting by nursing homes, including information about any related parties in which the organization has an ownership or control of 5% or more. Rhode Island is trying to follow suit, as is New Jersey, where its AARP has — like Michigan advocates — questioned nursing home finances.

Step 3: Require a minimum spending level on care 

Michigan is among the states that don’t require nursing homes to spend a certain amount of revenue on care — a policy that could ensure that the bulk of Medicaid and Medicare reimbursements end up in resident living spaces rather than the boardrooms.

In contrast, New Jersey passed a law in 2020 to require nursing homes to put 90% of aggregate revenues into care. That’s known as the medical loss ratio. Those that fail to meet that minimum must give money back to the state each year. Massachusetts followed suit with a 75% medical loss ratio; New York in 2021 enacted a 70% medical loss ratio, according to a report by the Long-Term Care Community Coalition.

Step 4: Require more front lines training, pay

Michigan requires 75 hours of training — just short of two full weeks — for the vast majority of staff doing everyday care in nursing homes. That minimum has remained unchanged 18 years after the then-Institute of Medicine called for a minimum 120 hours in a report.

According to the latest research by PHI, a New York-based advocacy organization for the nation’s direct care workforce, at least 30 states require more of their nurse aides than Michigan. 

Maine, Oregon and California require twice the number of hours or more — 180, 155 and 150 hours respectively. 

Step 5: Simplify nursing home funding

Michigan is one of just two states that reimburse nursing homes for care through a complicated formula that is weighted to the costs of running the entire building, rather than focusing on the level of need of the residents according to the Michigan Elder Justice Initiative, the Lansing-based advocacy group that earlier this year called for greater transparency in nursing home finances.

In 2019, Michigan’s auditor general concluded that the long-term care cost reimbursement is “complicated, labor-intensive, ineffective and inefficient.”

The policies create a “cat-and-mouse” game between nursing homes wanting to maximize reimbursements and the state trying to contain costs,  Mike Daeschlein, a long-term care policy expert at the initiative, and formerly with the Michigan Department of Health and Human Services, previously told Bridge.

And the complicated process further tilts Michigan’s long-term care funding toward nursing home care rather than aging-in-place efforts.

He and others argue the state should simplify its payment process and — most importantly — shift the calculations to focus on the acuity of care — the complexity and cost of needs — for its residents rather than building-wide costs.

Step 6: Find ways to use fines to retrain

When nursing homes fail, they are cited and pay fines. 

It’s a punitive system that doesn’t necessarily provide the education to address the problems, said Dr. Ana Montoya, a geriatrician with an expertise in long-term care medicine.

Meanwhile, the fund — built from years of penalties paid to the US Center for Medicare and Medicaid, or CMS — continues to grow, with Michigan’s portion reaching $35 million as of Aug. 31. Nursing homes can apply for grants from that pool of funds and use the money to pay for programs that improve care. 

CMS tightly restricts the use of the funds. Grant applications are submitted to the Michigan Department of Health and Human Services, which then passes them to CMS, and some argue that the $6,000 grants are not worth the time it takes through a complicated grant application.

But Montoya believes there must be a way to use those funds to help better train staff in things like infection control or the overuse of psychotropic drugs. She and others say nursing homes can pool their grants together to tackle a specific issue such as infection control.

Step 7: Allow cameras in nursing homes

Michigan’s rules over cameras in nursing homes are murky, and laws elsewhere vary by state, according to the Nursing Home Law Center, which connects consumers to legal information. At least 20 states have laws or programs that allow families to install cameras in nursing home rooms under certain conditions, according to the Nursing Home Abuse Center, a similar website.

New Jersey lends cameras to residents who suspect loved ones are being abused, mistreated, or neglected by a health care provider. The micro-surveillance cameras can be easily hidden and are available through the N.J. Division of Consumer Affairs’ Safe Care Cam program for 30 days.

Michigan is a “one-party” state for recording, meaning just one party of the recording must approve it, leading some Michigan families over the years to use hidden cameras to record care, said Donna Mackenzie, a long-time personal injury attorney who represents nursing home residents and their loved ones. 

The resulting footage has pushed lawsuits to settlements, she said.

Ultimately, it’s up to a judge whether to allow such footage, she and others said. 

Republican State Sen. Jim Runestad of White Lake introduced a bill in June that would have given residents the option of installing a camera in their own room as long as roommates agreed. It also required the facility to post notices if an electronic monitoring device was in use. The Michigan AARP and the Michigan Long Term Care Ombudsman both supported a previous bill, but it died in committee. And a bill before that passed both the House and Senate before that, but was pocket-vetoed by Gov. Gretchen Whitmer in 2021.

The Health Care Association of Michigan, the industry group representing nursing homes, has taken no position on the current bill. 

Opponents say it’s a violation of privacy. Runestad concedes it’s “dead on arrival” and has little chance of passing.

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