Our homes: Where health care is really hurting

Sporting flashy red shoes and a radiant smile, Trudy Nesvig was waiting expectantly for her home-health aide to arrive on a recent fall afternoon in Gaylord, Minn.

Frail but perceptive and well past her 80s, Nesvig understands the importance of quality medical attention and her regular therapeutic walk: "It's what keeps me alive," she said as she and the aide set off down her tree-lined driveway near Titlow Lake.

Patients like Nesvig are justifiably proud of Minnesota's reputation for excellent health care. The state's hospitals, clinics and nursing homes consistently rank among the best in the nation in federal quality ratings.

But when it comes to home-health care -- the kind Nesvig was getting that day in Gaylord -- the picture is surprisingly bleak.

On quality measures compiled by the federal government, Minnesota's 202 Medicare-certified home health care agencies appear to be among the worst in the nation. On 30 measures of care quality, Minnesota ranks 48th among the 50 states and the District of Columbia. Only Vermont, Texas and Wyoming fare worse.

For more than 50,000 Medicare and Medicaid patients, many of them frail and living alone, home health care is a critical but hidden component of Minnesota's health care system. Its role will grow even more critical in the next decade with the rapid growth of Minnesota's elderly population, many of whom want to stay in their own homes even as they grow increasingly infirm.

"We tell ourselves, 'This is Minnesota, for goodness sake. We shouldn't rank so low,'" said Jennifer Lundblad, CEO of Stratis Health in Bloomington, a nonprofit firm under federal contract to improve health care quality in the state. "I don't think our home health care is as bad as the quality measures would indicate," she said. "But we've studied them and trained on home health quality, and we still agonize over this. The scores are the scores, but we can't explain them."

Home care lapses seldom draw public attention, but they can lead to tragic results, as in the case of a quadriplegic Twin Cities man who died last year after being left in a shower so hot that it gave him severe burns. In New York State, Attorney General Andrew Cuomo has launched a major investigation of the industry. He recently won an indictment against the president of a home health agency for allegedly employing 1,000 aides who lacked proper training and credentials.

'We're concerned'

State officials have known for some time that Minnesota home health care ranked well below the national average, but not how low until the Star Tribune compiled the numbers last month. Nearby states fared better: South Dakota ranked 7th, Wisconsin 21st, North Dakota 29th and Iowa 31st.

"Worried? Well, we're concerned," said Loren Colman, assistant commissioner at the Department of Human Services, which buys home health care for about 25,000 low-income patients with chronic conditions who are on Medicaid. That represents about one-fourth of all Minnesotans who get home health care. "At a time when we're encouraging people to use home- and community-based services instead of institutional care, we're very interested in figuring this out."

Legislators, too, are curious.

The scores, which reflect the percentage of patients who get better at walking, bathing, taking medications and other measures of well-being, are reported by each agency for every Medicare and Medicaid patient, then adjusted so that agencies aren't penalized for taking on clients who are especially ill or frail.

Among 160 Minnesota agencies with enough data to be listed on a website that allows consumers to compare quality scores, (www.medicare.gov) just 18 exceed the national average.

In general, the highest-ranked agencies are operated by hospitals or medical systems, followed by those in nursing homes. County-owned and privately owned agencies typically fall at the bottom.

The quality scores, updated several times a year, are used primarily to show agencies where they should improve, according to officials at the federal Centers for Medicare and Medicaid Services. It reports how states compare on each measure, though not on total scores.

Other sectors rank high

Authorities familiar with the mystery have offered several theories: Perhaps Minnesota has too many small home health agencies without the depth to give comprehensive care and report results accurately. Or managed care insurance plans here might be cutting off home health services more quickly than in other states, causing lower scores. It can't be that Minnesotans are sicker, since the scores are adjusted for that.

But Robert Fazzi of Boston, a nationally known consultant, said in an interview that "those possible explanations don't seem to stand up." He was so intrigued by Minnesota's low rank that he put two staff members to work on the issue for two days.

"Bottom line, we don't know," he reported a few days later. "We can't see that it's managed care cutting off care too early, or too many small agencies, like in Texas. Given Minnesota's reputation, I don't get it."

Lacking a good explanation, Fazzi and other experts urge clients and their families to compare home health agencies on the Medicare website. It lists scores for up to 12 of the 30 quality measures.

"Most people can't tell by watching whether you're getting good care," he said. "The scores at least give you a clue about what questions to ask before you sign up."

By those scores, a client might conclude that Sibley Medical Center Home Care in Arlington, Minn. -- the agency that serves Trudy Nesvig in Gaylord -- is one of the state's best.

So small that it is scored on only 10 of the 12 major quality measures, Sibley Medical Center Home Care still earns an overall score of 825 points -- compared with a state average of 695 and a national average of 777 -- and places fifth-best in Minnesota.

Describing their agency, Sibley officials spelled out some traits that seem to be associated with higher-ranked agencies.

"Because we're small, we really do get to know our clients," said Rhonda Matz, administrator of both Sibley Medical Center and its attached home health agency. "And because we're connected to the hospital, we can consult with medical specialists pretty much when we need to." Matz also cited the low turnover and frequent training of her five-member staff.

Still, after learning how her agency compares, Matz said, "I'd never say we're best. There's more to quality than just the numbers. It depends on how well the help that's provided fits your individual need."

"We are pretty big, but we try very, very hard to keep the care for our clients very personal," said David Olshansky, whose first job in America in 1992 was cleaning buildings. "So we have nurses and aides who live all over the metro area, and we try to have them serve people who live nearby."

Much further down the list is Presbyterian Homes Home Care in Roseville, with a score of 599.

"The joke we say to explain the state's lower scores is that Minnesota [agencies] tell the truth," said Beckie Conway, director of clinical operations for Presbyterian Homes.

"We think we are giving good care as we serve all 21 of our [assisted-living] facilities in the Twin Cities, plus maybe 150 people in the community," she said. "But most of our scores don't reflect that, and we don't know why."

Conway said she trains her home health staff to improve care, not to improve the scores -- "but I don't know anyplace that coaches workers to twist patient assessments so their scores will look good."

Though they express concern about Minnesota's ranking, officials at Stratis and the state agencies note that the gap between the best state and the worst -- 2,195 to 1,963 -- is not wide, and that state inspections and consumer complaints in Minnesota do not reveal major problems.

"Granted, I wish we had resources to [inspect] agencies more often," said Darcy Miner, who oversees health care inspections at the Health Department. Her agency inspects nursing homes yearly but sees home health agencies only about once every three years. "But we're not seeing big red flags. That's what makes the quality numbers so mystifying."

Minnesota has charged a half-dozen home health agencies with fraud after they billed the Medicare and Medicaid programs for care they didn't provide and sometimes with neglecting or harming their patients, including the quadriplegic man who was burned in the shower, said Attorney General Lori Swanson. In that case, the owner of Mayfair Home Health Services of St. Louis Park allegedly overcharged Medicaid more than $100,000 and was charged with neglect and fraud and criminal neglect.

"We have some concerns about home health agencies and we may ask the Legislature next session to tighten some regulations," she said. She offered no specifics.

Though unable to explain Minnesota's low marks, other state officials said they are seeking ways to help consumers choose home health agencies that provide good care.

"If we can't explain these [federal] quality measures, we have to find something that we can explain, something we know can help consumers," Miner said.

"In home health care, there are fewer sets of eyes watching than if you were in a hospital or nursing home," she said. "We've got to find a better way to assure people that, when they're most vulnerable, the care they get will be the care they need."

Warren Wolfe • 612-673-7253