By Maggie Lee / Staff

For all of her 63 years, Jill has lived with her mother Barbara.  Their latest address is the Dogwood Forest personal care home in Alpharetta.  But now the Georgia Department of Community Health says Jill has to move away from mom, her friends and her social life -- because of a haphazard piece of Georgia law on long-term care.

"They enjoy each other's company and Barbara is still able to mother Jill as she has always done," according to Michelle Minor, whose company manages Dogwood. "But DCH is now saying Jill is not appropriate for a personal care home because she is unable to propel her wheelchair on her own."

Jill's condition hasn't changed between last year and this year. She has cerebral palsy, a disorder that affects a person's ability to move and maintain balance and posture -- and it's not progressive. What has changed is the DCH's interpretation of her case.

In Georgia, there are two major kinds of long-term living arrangements for seniors who require a hand.

The first is what many people call assisted living -- in Georgia Code parlance, a "personal care home".  Staff makes meals and help residents with day-to-day things like bathing, tooth-brushing and dressing.

Nursing homes, on the other hand, provide more intensive services to residents who, because of their mental or physical condition, require services generally only available from skilled staff. 

 
But there's a grey area in the middle of the continuum.  Nursing homes can "administer" medicine, but personal care homes can't.  But does "administer" mean counting out pills?  Does it mean prompting someone to count their own pills?

Or, take a B-12 shot. It hardly takes a nurse to administer one. But if a person develops tremors from Parkinson's disease and can't administer their own shot anymore, Georgia Code suddenly considers them too acute to stay in a personal care home. Though realistically, they're probably not acute enough to need the 24-hour skilled care of a nursing home.

But walking is the biggest trip-up.  Personal care homes are only for people who can move under their own power, like to the fire exit.  Become non-ambulatory and you need more care.  Or do you?

AMBULATORY PROBLEM

It's been legal for Jill to live at Dogwood with friends or staff pushing her wheelchair because her home won a DCH waiver for her.

To do it, Dogwood had to submit plans to DCH showing that not only could they care for Jill's elevated needs, but that they could do it while still taking care of other residents.  DCH liked the plan and gave her a pass to live there, in a ground-floor room yards from a fire exit, until Jul. 2010. 

When Minor's company, Trinity Lifestyles Management, took over Dogwood in Oct. 2009, they had to reapply for the waiver under their own name.  The staff stayed the same, the building stayed the same, Jill stayed the same -- but in a letter that didn't go into details, DCH rejected the waiver.

The DCH does not keep track of how many waiver requests it receives or grants annually. 

In the meantime, because Jill is not yet a senior citizen, it's not likely that she would qualify for a nursing home bed, if she could even find one.

There is only one nursing home in Fulton County above I-285; it's a Medicare/Medicaid home in Roswell.  There's another in Roswell just over the Cobb County line.  According to 2008 U.S. Census bureau estimates, that's against an over-80 north Fulton population of about 5,000.    

HOMELESS SENIORS

Deltra Clark at Dogwood in Fayetteville is trying to appeal a waiver rejection for one of her residents.

Emma -- not her real name -- has dementia, said Clark, but added:  "I don't think she would flourish" in a nursing home since she's used to the routine and people in Fayetteville.

Besides that, the nearest long-term bed in a nursing home is 20 miles away in Newnan – if Carter can even get that slot.

"The nursing homes are fighting us," Clark declared, "but they know they don't have any beds."

"I call it being homeless," she said.  "Somebody's got to do something for our seniors."

LITIGATION

Minor said her company is fighting to keep Emma in Fayetteville.  After a rejection, the next step is talks between personal care home management and the DCH.  If that fails, the case can be carried to an administrative law judge. Trinity's legal tab, according to Minor, has already come to $30,000 for Emma. 

"We think it's the right thing to do and we want to set a precedent," said Minor. 

ENTER HB 850: MARTIN TO THE RESCUE

State Rep. Chuck Martin (R-Alpharetta) filed a bill this year that was aiming to bridge the gap with a new legal entity: the assisted living community. 

There, more-trained staff would be allowed to help with what the bill calls supplemental care -- things like administering medication and managing catheters. And the doors would be open to non-ambulatory residents.

That would match existing code in Florida, North Carolina, Virginia and Tennessee.

Both the AARP and The Georgia Council on Aging support Martin's bill in part because it discourages the phenomenon of "aging to the mean."  Nursing homes tend to be a little more sedate than personal care homes and residents have a higher median age. Moving to one can drag down someone who accustomed to the liveliness and sociability of a personal care home. 

"Honestly," said Martin, "I think everybody got what they wanted from the bill from an advocate standpoint."

Except, that is, nursing homes. 

NO WAY, SAYS GHCA

The Georgia Health Care Association, a lobby that represents 95 percent of Georgia's nursing homes, fought the bill. 

"Many times you have well-intended pieces of legislation," said GHCA President Jon Howell, "But when it passes it needs fixing."

He'd like to see more oversight of the pharmaceutical aspects of the bill, for example.

Overall, "We want to make sure that people are being served in the most appropriate environment," complete with thorough clinical checks.

He thinks some supporters of the bill simply don't want to see institutional long-term care at all. 

Existing code is best, Howell opined, because the waiver system allows personal care homes to be flexible. But at the same time it keeps a close eye on borderline residents. 

Martin rejected those arguments and said the GHCA is not acting in good faith. 

"Since 1994, they've stopped opportunities for our own seniors to make their own decisions," said Martin, referring to previous, similar bills.  

Besides that, Minor added that "it's in the last year we've had the problems getting waivers."

WHO PAYS THE BILLS?

Medicaid reimburses nursing homes on a sliding scale that depends on the residents' conditions.  If more residents are on the low-acuity end of the scale, Medicaid pays less per patient than a home full of high-acuity people. 

In that respect, nursing home reimbursements are connected to the level of care they provide.

But on the other hand, private payers -- estimated to be about a quarter of the nursing home population -- are billed a flat rate just like a hotel, no matter their condition. 

"It continues to be a situation where money trumps what's right," Martin concluded.

HURRY UP AND WAIT-- UNTIL NEXT YEAR

Martin's bill made it out of committee -- with bipartisan support, he pointed out -- but like many bills, it failed to make it onto the floor debate schedule before the annual new legislation deadline. 

But "I'm confident we can pass this thing through next year," he said, pledging to re-file. 

Right now, Jill is still at home in Dogwood while Trinity appeals her rejection. If they're forced to oust her, Jill has no place to go save her sister's house. It'll be a loving environment, but completely empty of professional care, and a long way from the mom and friends Jill now enjoys every day. 

"I've never been as personally committed to any bill as seeing this one through," the veteran Alpharetta legislator said.

All resident names have been changed to protect privacy.

Contact: mlee@beaconcast.com