Can a First-Rate Nursing Home Survive?

Sermon delivered February 18, 2005, by Rabbi Barry H. Block

Next month, God willing, my family will travel to New Orleans to celebrate the 100th birthday of my grandmother’s sister, my Aunt Polly. Aunt Polly almost reminds me of Moses. When Moses died at the age of 120, the Torah tells us that “his eyes were undimmed and his vigor unabated.” Even Aunt Polly has trouble hearing. For the last year or so, she hasn’t walked very well, but that’s only because, shortly before her 99th birthday, she was doing Tai Chi, and the lady next to her fell, knocking her over, and breaking her femur.

Sadly, most older people are not as vigorous as either Moses or Aunt Polly. We do have a couple of centenarians in our congregation, one of whom still lives in her own apartment. Other members in their 90s remain quite active. And yet, the majority of elders require significant assistance. Many can no longer live in their own homes.

I have heard many people proclaim that they hope never to end up in a nursing home. Surely, we would all like to retain our independence to the very end. Nevertheless, time and again, I have been with members, as they made painful decisions about giving up their cars, giving up their homes, and entering Golden Manor and other senior care facilities.

Many people find new life in retirement living. Particularly in independent living environments, where folks have their own apartments, everyone is mentally competent, and meals are served, seniors make new friends, enjoy increased activity, and find new meaning in life.

Even in a nursing home, many people are rejuvenated. I have seen countless individuals enter Golden Manor quite ill, and then go on to enjoy months or years of relative good health, surrounded by their family and friends. There is great strength in the community that regularly pops into Golden Manor, folks of every generation coming to see their own relatives, but greeting all the other residents they have known over the years, or whose acquaintances they have been pleased to make right there at the nursing home.

My own grandmother, of blessed memory, Aunt Polly’s younger sister, lived the last six months of her life at Golden Manor, until she died last May in her 97th year. She was among those who had said that she wouldn’t want to enter a nursing home unless she didn’t know where she was. Thankfully, she never reached that ultimate point of mental decline until her final week. And yet, the truth be told, she was better off in Golden Manor than she had been in her own apartment, with wonderful round-the-clock caregivers. For many seniors, the nursing home can provide greater independence, more to do, and a social life they would not otherwise enjoy in their ever-shrinking world. Together with my family, I am eternally grateful to Golden Manor, to VITAS Hospice, to Porter Loring Mortuary, and to Rabbi Stahl, all of which made the last months of my grandmother’s life, and her death, a meaningful journey.

As much as we all know that nursing homes are needed, many of us shy away from visiting them, at all costs. Perhaps we fear that we are looking into a future that we would rather not see. We don’t want to think about how where and how our lives might end. Perhaps we are repulsed, or too deeply saddened, by the sights of men and women, once vital members of our community, who can no longer care for themselves, who may not even know their own family. We wonder how the more ambulatory and aware residents can endure life among those who are less highly functioning.

The Bible seems to be almost totally ignorant of infirm elderly folks. We have characters like Abraham, living to age 175; and Sarah, bearing her first child at 90. Only about five biblical verses offer descriptions of old age, as we know it. In the holiness code, we are commanded: “Rise before the hoary head; honor the face of the old man.” The voice of the infirm elderly person comes through only in Psalm 71: “Cast me not off in time of old age; when my strength fails, forsake me not.” Even here, the plea emanates from a younger person, praying that he won’t be alone in later years.

Explaining the relative paucity of biblical material on aging may be easy: Most people, in ancient days, died before they reached what we would call old age. With advances in sanitation, public health, and medical care, people are living longer today than ever. We have to concern ourselves with how our society treats the infirm elderly who can’t afford their own care, more than our ancestors did. The reason is cause for celebration: Life! Men and women are living longer, with quality of life and with dignity, even if less actively and in need of greater care.

Having visited a wide variety of nursing homes and other senior care facilities, I have seen a broad range. Admittedly, I probably haven’t seen the worst. People who can afford their own care, or whose families are able and willing to pay for it, may receive the finest possible attention. I might single out the Forum, because of the continuity of care that facility offers, including independent living, assisted living, full nursing care, and an Alzheimer’s unit. A person can move into the Forum in excellent health, but being realistic, knowing that, if health declines, care will be available in the same facility. The Madison and Arden Courts are examples of more limited facilities that are equally excellent, in my experience.

The truth be told, though, no nursing home I have ever visited is finer than Golden Manor. Our Jewish Home for the Aged is a Medicaid facility. In other words, anybody can live at Golden Manor. You may be surprised to know that fully three-quarters of Golden Manor’s beds are designated for Medicaid patients, meaning those whose financial assets are exhausted, who can no longer pay for their own care, and whose family members either cannot or do not pay. You may be even more surprised to learn that more than half of Golden Manor’s Jewish residents are on Medicaid.

We are blessed to live in a country that has not cast aside its elderly. Medicaid does pay for nursing home care for the indigent And yet, the truth be told, Medicaid, as it is today, is a woefully inadequate program to sustain a first-rate nursing home like Golden Manor. Medicaid pays Golden Manor $80 to $120 per day, for each indigent patient. That low reimbursement rate has been reduced by three per cent, several times in recent years, and is threatened with yet another reduction in the current session of the Texas Legislature. Golden Manor spends, on average, $155 per day on each patient, whether that patient is paying privately or is funded by Medicaid. Golden Manor treats all its patients the same, not distinguishing between them, except on the necessary government forms. We would have it no other way. As a result, Golden Manor spends about one million dollars providing charity care each year. About a quarter of that amount is generously provided by an allocation from the Jewish Federation of San Antonio, yet another reason to respond generously when the Federation comes calling this year. Patients who pay privately are not subsidizing Medicaid patients, to any meaningful degree. Though Golden Manor has a few other sources of income, the real result of its situation is that Golden Manor operates at a significant deficit. The answer to the question that forms the title of tonight’s sermon, “Can a first-rate nursing home survive?,” is, in short, “no.” If the nursing home is a Medicaid provider, and if it is not allied with an assisted living facility and an independent living resident, that nursing home will eventually be bankrupt, either morally or financially.

Golden Manor will never be spiritually bankrupt, and not only because of the religious services provided by Mark Forman, Golden Manor’s Director; by Temple Beth-El, and by Temple Chai, our community’s new Reform congregation. Because of the legacy of its founders, because of the commitment of its Board and Past Presidents, because of the determination of its Executive Director, and because of the partnership of the Jewish Federation, Golden Manor will sooner close its doors than it will provide substandard care as a Jewish nursing home.

I have seen other places. Not all are bad. Indeed, Morningside Ministries, whose President happens to be my cousin, offers nursing care that is every bit as good as that of Golden Manor. Morningside Ministries, though a Medicaid provider, is in less dire straits, thanks to a vision, put into action long before its time, including retirement apartments, assisted living and Alzheimer’s care.

Sadly, though, I must tell you that many other Medicaid nursing homes that I have visited are sub-standard. They smell of urine. The rooms are small and cramped. With two in a room, each resident has no privacy and only a few feet of personal space around the bed. Even employees who care are too overworked to provide adequate attention to the residents.

Golden Manor, then, is the gold standard for stand-alone Medicaid nursing homes. It will not survive as it is. Therefore, all of us must step forward when the time comes to build Golden Manor’s new campus, with a full continuity of care. And yet, as Americans, and as Texans, we must turn our eyes not only to our Jewish nursing home, but also to the substandard Medicaid facilities in which hundreds of thousands of our society’s elderly are warehoused. The profit motive may be partially at fault, but when we see those poor conditions, we are compelled to acknowledge: This is what $80 per day will buy.

Rabbi Nahman of Bratzlav taught: “Gauge a country’s prosperity by its treatment of the aged.” In 2005, the United States of America, and Texas in particular, cannot be judged favorably on this moral scale.

The Trustees of Temple Beth-El and the Community Relations Council of the Jewish Federation of San Antonio have spoken clearly: We must protect and enhance Medicaid reimbursements to all nursing homes in the State of Texas. Let each of us speak out to our representatives in Austin, in session at this hour: We will be judged by the treatment of the poorest and most defenseless among us. Let us not cast off our seniors at their hour of need. Caring for those who cannot care for themselves is a mitzvah; it is a great and very real moral value.