Senior care home operators all over Oregon are increasingly calling on emergency responders to handle routine tasks. A resident needs a bandage changed? An IV line inserted? A catheter replaced? A prescription refilled? Call 911.
And that won’t end anytime soon, despite the protests of some fire department officials. In a sweeping victory over the summer, the industry secured a new state law that prohibits cities or fire districts from doing much of anything about it, at least for the next few years.
But across the state, firefighters, ambulance crews and hospital emergency room staff say they’re being taken advantage of, and potentially taken out of action when a real disaster strikes.
“We are subsidizing their operations,” said Ryan Gillespie, division chief of emergency operations at Portland Fire & Rescue. “These are private businesses. They should be providing that service.”
The senior care calls are increasing just as local paramedics are already straining to deal with the pandemic and an exploding number of people seriously ill with other problems. Hospital ERs are jammed to capacity, forcing ambulance crews to look elsewhere.
“Our crews have never been busier,” said Steve Boughey, emergency services division chief at Tualatin Fire & Rescue. “The ERs are filling up. These calls from the senior living facilities just contribute to the overcrowding.”
Clackamas Fire District #1, another of the state’s largest fire departments, answered 2,110 calls to senior care centers in 2020, about 13% of the total. Josh Santos, Clackamas division chief of medical services, said the department has met repeatedly with assisted living managers to try to reduce the number. But the message never sticks, he said, in part because turnover in the assisted living operations is so high.
Phil Bentley, president and CEO of the Oregon Health Care Association, a care homes industry group, said senior care operators are only concerned with the safety of their residents. And, he said, it shouldn’t surprise anyone that senior care centers make a disproportionate number of 911 calls: “Of course they do. The residents are 80-90 years old.”
“The last thing I think anyone wants is a system that discourages a 911 call when a senior needs help,” he said.
Bentley also conceded that there must be a smarter, more efficient way. The newly passed state law creates a board to find that alternative. The bill, originally drafted by OHCA, specifies that a majority of the board members must be from the senior care industry or its allies.
But critics say the industry’s reliance on publicly funded emergency medical responders is about profit margins more than protecting residents.
“It’s just part of the business model,” said Fred Steele, Oregon’s long-term care ombudsman. “They don’t want to have to pay for the staff on hand to handle the basic needs.”
OHCA is a sophisticated operator in the Oregon Capitol, known for its deep pockets and encyclopedic knowledge of Medicaid, a key funder of senior care facilities. Bentley for years worked as Senate President Peter Courtney’s top lieutenant. He is married to Gina Zejdlik, Gov. Kate Brown’s chief of staff.
The political clash has taken place largely under the radar. The whole issue has been overshadowed by the pandemic, which poses an existential threat to the senior care industry. OHCA’s ability to drive public policy in this case is all the more impressive as it was a back-burner issue.
Power play
McMinnville Fire Chief Rich Leipfert thought he had seen it all. Local senior care centers routinely called his department for help with what he considered routine medical tasks. But refilling a prescription?
As Leipfert tells it, a center’s employees had forgotten about the needed refill and explained to McMinnville dispatchers that the pharmacy was now closed. The assisted living center’s solution: Call 911 and get their resident transported by ambulance to the nearest hospital, where the needed medicine would be in ample supply.
Leipfert and Jeff Towery, McMinnville city manager, decided enough was enough. There were 15 senior care centers in the city limits, housing about 3% of the city’s population. Yet, they were placing about 38% of the 911 calls, most of them nonemergency situations.
They determined those calls were costing the city $750,000 a year.
They devised a new care home licensing system that would help defray the costs of the emergency calls. The new ordinance also allowed the city to levy fines against facilities deemed to be making frivolous or excessive emergency calls.
The same dynamic was unfolding all over the state as fire departments began demanding some compensation for their time.
In January 2018, Clackamas Fire District #1 adopted a “nonemergency facility response fee” to levy against senior care centers that repeatedly requested assistance for routine tasks.
Portland Fire & Rescue tackled the issue in 2019. It was getting 350-400 calls a year just for so-called “lift-assists.” As the name implies, lift-assists involve picking up a care home resident who has tripped or fallen. It is among the most common reasons senior living centers make 911 calls.
“These were not cases where a resident took a serious fall,” said Gillespie, the Portland Fire division chief of operations. “These were more like noninjury cases of a senior falling out of bed or tripping.”
Gillespie wanted to bill $500 every time his crews were called out for a nonemergency lift-assist. Jim Carlson, Bentley’s predecessor as head of OHCA, intervened. He conceded the lift-assists have become a problem but he convinced Gillespie and the Portland City Council to adopt a graduated system of fines rather than the flat $500.
When McMinnville lined up to do something similar, the industry vowed to stop it. Leipfert and Towery had no idea what was in store.
Feelings ran hot from the beginning. Negotiations were a nonstarter. Instead, the industry group hit the bricks of the Yamhill County wine town. The group hired signature gatherers and circulated a petition to repeal the care home ordinance that the city council had passed the year before. OHCA crafted an initiative that would amend the city charter not only to repeal the ordinance but also to forbid the city from ever trying a similar move in the future.
The group lobbied local leaders and convinced the McMinnville Chamber of Commerce to come out against what it called the “unfair senior tax.”
OHCA spent $160,000 on the campaign, a huge amount of money for a small-town election.
Towery said the city was precluded by law from putting any money into the campaign.
“I’ve never seen a private-sector group come in and pre-empt the authority of a city government like that,” said Scott Winkels, lobbyist for the League of Oregon Cities.
The city got greedy, Bentley now says. Under its system, it could charge $1,500 fines. The licensing fees could reach $200 per bed.
“They were trying to print money for their budget,” Bentley said. “It was about raising revenue to fill a budget hole.”
Tragedy in Seattle
Oregon officials say their nightmare scenario unfolded 11 years ago in Seattle.
The city’s trendy Fremont neighborhood, known for its quality craft brewers, is home to the Seattle Fire Department’s Station 9. On a June night in 2010, Station 9′s crew got the summons from dispatch. A resident of an assisted living center needed some routine medical assistance.
Seattle dispatch classified it as “aid response code yellow” — a non-life-threatening situation that doesn’t require a response with lights and sirens. Firefighters were familiar with the place. Fire department records show the department was called to the assisted living center 133 times the year before.
Twenty minutes later, a fast-moving fire broke out at a nearby townhouse, trapping several members of an extended family of Ethiopian immigrants.
The townhouse was just three-tenths of a mile from Station 9 — about eight minutes away. Its crews should have been among the first at the scene. But they were busy attending to the code-yellow issue at the assisted living center, and the next engine on the scene — an older reserve truck — suffered an equipment malfunction.
Five people, including three children, died in the townhouse fire.
Dacia Grayber, a career firefighter and paramedic, is well aware of the Seattle disaster. It has become a cautionary tale about the risks of the growing assisted living burden.
Grayber works for Tualatin Valley Fire & Rescue, which is feeling the squeeze from the mounting number of assisted living calls. She is also a state legislator representing Southwest Portland. Last winter, she got a call from Rachel Prusak, one of her Democratic allies in the Oregon House, who said she had a bill on this very issue.
Prusak asked Grayber if she might be willing to serve as primary sponsor. One more thing, Prusak added: The measure had come from OHCA.
Grayber gulped. All she could think of was that awful night in Seattle.
But the more she read, the better she liked it. House Bill 2397 would create a task force to devise ways to improve the current system. The panel’s job would be formidable — ensure emergency medical services are available to the growing populations of frail elderly in a way that is efficient and appropriate for paramedics. And it needs to reduce costs as well.
“I really wanted assurances,” Grayber said. “I needed to know that everyone had skin in the game. I really want to see innovation.”
The bill also contained a bombshell. It would prohibit any attempt by local government to regulate or impose fees on senior care facilities. Portland’s lift-assist penalty will live on — the bill carved out lift-assists as a separate category that could be billed to the care homes. But otherwise, it would require every city and fire department in the state to continue to answer the senior care industry’s calls, no matter how minor, regardless of volume.
Grayber points out that the bill sunsets in 2027, which she views as some protection for cities and fire districts like hers.
Not a single fire department opposed the bill. The Oregon Department of Human Resources, which regulates the senior care industry, did not offer any testimony. The only opponents were the city of McMinnville and the League of Oregon Cities.
The measure was approved by the Legislature with just three no votes. Brown signed it into law on July 27.
Bentley vows to find a workable solution, even as he said the whole issue was overblown.
“There clearly are a percentage of calls to 911 that should be handled differently,” he said, “but I’d be surprised if it’s more than 10-15% of the total.”
OHCA is a prodigious donor to Oregon lawmakers. It contributed $3,500 to Grayber’s campaign and $14,000 to Prusak’s over the years, as well as $150,000 since 2018 to Brown.
Prusak bristled at the implication that there was a link between OHCA’s money and her sponsorship of its emergency services bill. “The way I have survived in this place is to not focus on that,” she said of the OHCA money. “I just try to focus on the well-being of seniors.”
Steele, the industry ombudsman, said the industry’s reliance on local fire department paramedics raises important questions about the adequacy of their services. Under Oregon administrative rules, assisted living centers and long-term care facilities “must have qualified awake direct care staff, sufficient in number to meet the 24-hour scheduled and unscheduled needs of each resident.”
The rules go on to say the facilities “must assure an adequate number of nursing hours relevant to census and acuity of the resident population.”
The position of state regulators on this topic is unclear. The Aging and People with Disabilities division of the Oregon Department of Human Services, the unit charged with protecting the elderly customers of the assisted living industry, has been almost entirely absent from the debate.
A division spokeswoman confirmed that no one in the agency is monitoring the issue of emergency calls. The one time the division has engaged with an emergency responder came when the division “facilitated” a meeting between OHCA and Tualatin Valley Fire & Rescue about five years ago.
The new law will force the division to be involved through funding and staffing the effort to devise alternatives.
Officials at the division declined requests for interviews.
Firefighters and paramedics, meanwhile, will continue to answer the nonemergency calls. With these facilities charging thousands of dollars a month, you’d think they could afford some qualified medical personnel, said Merrill Gonterman, assistant fire chief in Roseburg.
“The people in these facilities are paying big money and expect someone to help,” Gonterman said. “And they call us. The workers there, they tell us, ‘Hey, I don’t want to try to lift them. I might hurt my back. Then we have a workplace injury.’ And we say, ‘Yeah, what about us?’”
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