Hacker News Reader

The biggest sign something is broken is when someone writes: "Thankfully, my mother died before the acquisition, and my father died last week, only a few months after the acquisition, so I don't have to deal with this any more."

Depressing to read. I'm not sure on which side.

To be fair, my mother had cancer and my father had Parkinson's, and that was a much bigger factor in their ultimate quality of life than any deficiencies in the retirement home they found themselves in. So I don't mean "thankfully" in the sense that "thankfully they died prematurely so they didn't have to suffer under their home's new management", I mean it, "Thankfully the natural course of their lives timed their deaths so that they were minimally affected by the new management."

But yeah, it kinda sucks, and not just for the residents who are still there. It sucks for the rank-and-file staff as well, most of whom still really care about their clients, but who now have to answer to people who absolutely do not care about anything other than money.

I got what you were saying. I read it the same way. I’m sorry for your loss.

No one leaves this planet alive, and the best you can hope for is that the majority of your time is spent relatively healthy and independent.

I didn't read that as saying anything about your character; it's an understandable way to react. It is an indictment of the system that people have to feel that way when it really shouldn't have to feel that way.

> I didn't read that as saying anything about your character

I didn't take it that way, I just wanted to make sure there was no misunderstanding. This is an emotionally charged topic.

I think most of us read it the way you meant it. Sorry for your loss.

The concern you raise is front and center for me, because my mother is 87 and we’ve been looking for a place. All the options are terrible, without considering PE.

Where I live Medicare and Medicaid want people to live (and die) in their own homes. They send out nurses and nurse practitioners to you. That is what I want. After some research I realized the provider that I want which is UTSW in Dallas has a geographical radius that they serve. I am planning to eventually move to be within that radius.

https://utswmed.org/medblog/geriatrics-cove-team-makes-house...

That was my parents' original plan. But they were in denial about how much preparation would be needed to make that happen. They lived in a split-level house and my father had severe osteoarthritis in his knees. It's actually a miracle that he didn't fall and break his neck going up and down the stairs. But one day he fell in the shower and could not get back up, and that was the beginning of the end.

That’s totally doable and encouraged, as it’s by far more cost effective.

But you really, really need a support system of willing people who care about you, and are savvy enough to effectively advocate for you when you lose that ability. Independent home care works well when you need help, not constant care.

Our family worked with this for 6 years with my bad post stroke and for about a year with my mom and cancer. My siblings were all on board and my mom was uniquely positioned - she was a regulator at the state level who was adept with the rules (and had in fact wrote many!).

Even so, as things progressed it was hard. My mom was devoted to my dad, and filled every gap. We depended on hired help for mom, and despite the financial resources it was difficult to get staff.

Family and friends are key.

This is going to sound a bit wild, and only viable under 70 or so, but I've met a lot of 55-70 expats in walkable southeast asian cities. There's obviously varying circumstances so do the research, but you can almost get adopted by your landlord family, where you're getting home cooked meals, rides, doors held open, etc. This part of the world is so family oriented, it just comes naturally to many of them.

Makes sense. If you travel regularly, you can see that in relative terms, the standard of living in the US has declined relative to many places.

It's a nice idea, though I hope I'm humble enough to vacate my house for a younger family that will make the most use of it. By which time I hope to be in a manageable apartment, or perhaps a group home where I can pass the time with others at a similar stage in life.

For some (like one of my family members), circumstances are such that they need more social attention than the family/medical system can provide. That's one of the reasons we are considering.

>Where I live Medicare and Medicaid want people to live (and die) in their own homes. They send out nurses and nurse practitioners to you.

In NY State at least that's turned into a cashgrab too. One they are having trouble reforming.

As a (former) paramedic, PE-run SNFs (skilled nursing facilities) are an absolute evil that absolutely kills people. I do want to be clear before any of the following that while there is a truth that many of the nursing staff at these facilities are often the lower quality tier of nursing care, they often care greatly for their patients/residents.

Staffing/flooring ratios? Laughable correlation to reality. Many a time? A single LPN "supervising" a floor of CNAs. Doctor consultation? The CNA oftentimes leaves a voicemail for the physician to review and care decisions are made without the physician talking to either the patient or a nurse (I'm not sure how this isn't malpractice, and I'm not convinced it's not). Facility "policy", often hidden behind "insurance requirements" have the facility overburdening the local EMS system because "we are required to call 911 for anything larger than a bandaid", and we can find ourselves doing anything from the most basic wound care to pointing out to a sleep-deprived CNA "you know your patient appears to have had a stroke sometime recently, right?". EMS arrives and often gets woefully incomplete or inaccurate history information (often for patients who are unable to be reliable historians themselves).

There is, however, ALWAYS money for the colorful glossy brochures/books at the front desk, or the big shiny billboard or TV ad that talks about "mom being in good hands with round the clock nursing care!" (and of course, a facility fee per month that would make you feel like she has her own personal RN and on-call MD 24/7").

Also a former medic, the best care homes I ever went to were the Jewish Home for the Aged. They were so much nicer and the patients there never had decubitus ulcers or staph infection in skin folds from not being cleaned.

The worst place I ever saw was Atherton Long Care which supposedly is fancy and expensive but they had neglected an old lady so poorly I actually reported them to CDPH and the ombudsman. She had full on necrotized tissue under both her breasts and a rotted unchanged g-tube that you could smell all the way down the hallway to the nursing station it was so sad. John George Psych hospital and Cordilleras MHRC are both also very sad hellholes. Patients sleeping laying on the floor in the hallways with a blanket because the rooms are full etc. We had a lady who purposely stabbed herself in the eye so she could go to the ER to get out of Cordilleras because it was so awful.

What I found if you ever need to place your loved on in a care home is the sniff test is the best assessment of how well it's run and if the patients are cared for. If patients are cleaned regularly and not left to sit in their own diapers it really shows there is enough staff ratio and attention given to the patients. Go on a random evening or day and at different times. Food quality is also a good indicator - eat lunch with your parents there. Would you eat this yourself voluntarily? If yes, it's probably a good place not run on a shoestring budget.

Also - hn readers - if your mom is in a care home please always check under her breasts to ensure she is clean and dry there every time you visit. Far far too many old ladies get candida and bacterial infections under their breasts that are never cleaned or taken care of because it's embarrassing to check or clean and dry so then it just gets wet and rots and is painful, sad and gross and can lead to even worse things like cellulitis or an abscess.

> There is, however, ALWAYS money for the colorful glossy brochures

OMG, so much this! One of the things that happened after the acquisition is that they changed the phones to play a marketing pitch whenever you were on hold. (They even did this on the resident's phones!) One of the things the pitch said was that the place featured "chef-inspired meals" which was about as disconnected as you could possibly get from what I knew first-hand to be reality. It was one of the most bald-faced lies I have ever heard in my life, and it really steamed my clams because I knew there was nothing I could do about it.

Aren’t these kind of borderline fraudulent business practices the sort of thing state attorney generals are supposed to investigate?

The people that perform these acts to the elderly should be tortured to death. You may think "wow thats some hyperbole right there!" but active torture is effectively what they're engaged in against the people in their care.

So let's give them an eye for an eye.

The way you nonchalantly mentioned your dad died last week caught me off guard -- my condolences!

Thank you. But he was two months shy of his 90th birthday and, except for struggles with osteoarthritis and Parkinson's, he had a good run. I'm sad that he's gone, but it's not like it took anyone by surprise. And I'm glad that his suffering, which towards the end was not insignificant (though he was very stoic about it), is over.

The last week has actually been pretty (ahem) interesting in a lot of ways. I should probably write a blog post about it.

> Fortunately, the place turned out to be run by people who mostly cared about their clients and so my parents' lives were basically OK, except that the food sucked (which AFAICT is par for the course at retirement homes).

My dad unfortunately never made it to a retirement home (cancer onset when he just turned 70), but in his one week hospice stay, he couldn’t help but complain about the food.

Sorry for your loss.

I'm sorry about your parent's death, and sorry you guys were forced into this circumstance in the first place. Venture capital is one of the biggest stains on the concept of free market enterprise. I don't offer any solutions.

I’m sure the new owners are scummy, but the fundamental problem isn’t scummy people. There’s lots of markets that are okay-ish notwithstanding scummy people. Even those with natural lock in effects.

The fundamental problem is it is at the intersection of two out of the three areas of the economy that have had insane cost growth over the last 30 years—-housing and healthcare (the third is education.) For the first one we know roughly what we need to do but won’t. For the second we don’t even have that.

> housing and healthcare (the third is education.) For the first one we know roughly what we need to do but won’t. For the second we don’t even have that.

Healthcare costs increasing is of very little concern to nursing facility ownership. Almost none of that is borne by the facility itself. They'll often hire skeletal crews of CNAs and LPNs (I was a paramedic, rare was it to see a facility in our area that even had an RN, and if they were, they were the DON, Director of Nursing, and had no direct hand in patient care). The facilities would contract with a physician service who oftentimes would not even speak to the patient, let alone -see- them.

And every, every single interaction with actual care provision was fully billed to the patient/resident's insurance. Anything that is not a profit making center for facility ownership is ruthlessly subcontracted out. A solid portion of the SNFs in my county will openly call 911 for anything beyond the most absolute basic first aid, even when their employees are ostensibly better educated/trained than the EMTs who might be responding.

Healthcare costs in the US are an abomination, but that's not the issue here, or not directly.

It’s worse than that — not only are the subcontracted entities often affiliated with the owners, but when your EMTs transport a resident, the SNF “holds their spot” (ie invoices the government) for 30 days.

It’s in their interest to dump the resident on the hospital and get paid for services not rendered. Also, as residents decline they need more care, are often on Medicaid (lower reimbursement), each time they go to the hospital there is a probability they they won’t come back, and will be replaced by a Medicare patient (Medicare pays for ~90 days) at a higher rate, and perhaps higher margin services like PT/OT.

It’s an evil system. Most of the people who died in NYC during early phases of COVID did because of intense lobbying to send them back to the SNF.

The other fundamental problem is the demographic profile in most developed countries. We have aging populations, and proportionally fewer young people to care for them. I'll bet most HN users wouldn't want to work at a retirement home or assisted living facility even if it paid well. My father spent his final years in such a facility and dealing with him was quite difficult for the staff there. This will inevitably cause higher costs and lower quality.

The other other fundamental problem is that dealing with elderly people often is difficult and unpleasant and what can you really expect from people who aren't related to them? Daycares and preschools are often very loving places because babies are cute and trigger people's nurturing instincts but that's not true of the elderly.

In some parts of the facility, workers are recognized by older folks who are aging with poise. That connection looks mutual.

In other parts, memory care, you are never recognized by the patients. Prepare for combative, confused ill people; your job depends on not treating them like animals.

I see adult children visiting their parent, who doesn't recognize them, and wouldn’t understand that $115,000/year isn’t entirely paid by the state.

Yet daycare costs are also exploding. In both cases it’s not primarily about wages going to the direct care workers—-though steep minimum wage increases are a factor in some jurisdictions.

That's not the fundamental problem.

The fundamental problem is that we have ceased demanding that our government produce reasonable outcomes.

The reasons for that are many, but it's a core sign of how far we've fallen that there's even a discussion or argument about this obvious fact. We are in charge. We can just ban private equity companies from doing this you know.

There didn't used to be ambiguity about the point of having a society and having that society governed by the people and having those people's representatives solve problems like this.

That ambiguity was created on purpose, for money, by specific people. Not coincidentally, they're the same people making the profits in this story.

> We can just ban private equity companies from doing this you know.

Ideologues love to identify some small group of bad guys that if we only rein in everything will be great.

It’s private equity! It’s health insurance executives! It’s trial lawyers! It’s CNN!

The actual truth is far worse. It’s 100 million homeowners, it’s 20 million healthcare workers, it’s an entire generation too online, etc.

There’s no magic bullets. Propagating the idea that there are is how we end up with garbage legislation and regulations that don’t improve anything.

What people need to start respecting and demanding from their government is competence. The ideologues of every stripe need to go sit in a corner for a decade or three while we build back up working institutions.

it's private equity.

We have more private equity funds than McDonalds, looking to do this kind of extraction everywhere, because we have huge wealth inequality and therefor those at the top needing to park more money in more places. Then end goal is modern feudalism, with the top owning everything and extracting more and more from every single transaction/event in a person's life.

We can't fix competence when we have one political party working to make the government incompetent so that they can leverage that to tear down government. They have internal politicides such as 'starve the beast', all with the goal to make American government unable to function.

No it really isn’t. That’s just the latest in a long line of boogeymen. The prior ones being banned somehow didn’t lead to paradise on earth. California is the world champion and banning boogeymen. How’s that going for them?

And it’s not just one party that’s working to make the government incompetent. Both are. One for the reasons you cite, the other because it is beholden to public employees that want more money and less work. Just visit nyc or Chicago to see how that goes.

> We can just ban private equity companies from doing this you know.

From doing what exactly? Do you think small businesses are any better about cutting corners for profit? They're often worse because they have worse economies of scale and face more cost pressure.

We have done quite the opposite. We have insisted that the government allow, and even encourage, unreasonable outcomes, so long as they benefit the right people at the cost of... well, if you have to ask, it's you.

What was the standard of care that the government used to provide for elderly nursing in the good old days?

It seems like you are remembering a history that never existed

> There’s lots of markets that are okay-ish notwithstanding scummy people.

It is not at all clear to me that there are "lots" of such markets, but that is neither here nor there. A prerequisite for an okay-ish market is that buyers need to be able to choose not to buy, and when you have literal limited mobility it becomes very difficult to walk away from your housing and care provider, either literally or figuratively.

Scummy people are like flies to shit - they thrive in the chaos.

People buying up nursing homes are using tactics like what you’d see in the movie Goodfellas. They’ll structure the buy so that they are assuming the license to operate while “renting” the facility from an affiliated entity, cut opex, fraudulently bill Medicare and Medicaid for rehab, and exit through bankruptcy of the operating entity.

I am very sorry for your loss.