Medi-Cal recipient, 101, evicted from Santa Rosa assisted living facility for being unable to pay

Mabel Barnfield, like most people, probably never thought she’d live to be 101, and she clearly did not expect to be paying nearly $7,000 a month to be living in a senior residential care facility.

The expense drained her of all the money she had after selling her modest home in Santa Rosa’s Holland Heights neighborhood in 2013. By November of last year, all Barnfield could afford to give Brookdale Fountaingrove, the assisted living facility, was her monthly Social Security check of about $1,300 - it wasn’t enough.

“How do you plan for that? It’s an awful lot of money every month,” said Barnfield’s younger sister, Betty James, 90, of Santa Rosa.

On April 18, Barnfield, who suffers from dementia, was wheeled into Sonoma County eviction court on Cleveland Avenue. With her bank account drained, the former real estate agent was now receiving Medi-Cal, the state’s version of Medicaid health insurance, which the private-pay Brookdale did not accept.

Barnfield’s close friends started calling many of the 19 skilled nursing homes in Sonoma County that do accept Medi-Cal, but none would take her. During a break in her eviction proceedings, her Sonoma County Legal Aid attorney and Brookdale’s attorneys located a bed in Novato, and she was taken there the next day.

Barnfield is unique in that she’s lived longer than most people, senior advocates say. But her predicament - running out of money and relying on federal health insurance that advocates claim skilled nursing homes avoid - is one an increasing number of people will face as a large share of the population continues to age.

Crista Nelson, executive director of Senior Advocacy Services, a regional agency that runs the Sonoma County Long-Term Care Ombudsman Program, said Medi-Cal reimbursements are far lower than what skilled nursing homes get from Medicare, which covers a resident’s medical needs and also can be used for expensive physical therapy. Because of that, she said, nursing homes will try to limit the number of Medi-Cal residents they take in.

It’s a claim strongly rejected by the trade association that represents most of the skilled nursing homes in California.

Deborah Pacyna, a spokeswoman for the California Association of Health Facilities, said statewide admissions records show that 15% of residents in skilled nursing homes are on Medicare, while 73% are on Medi-Cal or Medi-Cal-managed care plans.

“It’s hard to argue that facilities are limiting access when 3 out of every ?4 patients is obtaining health care coverage through Medi-Cal,” Paycna said in an email.

Pacyna said the Bay Area, in general, is among the most affected regions in California for available skilled nursing beds because of its dense population and the lack of new nursing home construction. High real estate costs and excessive regulation by the Office of Statewide Health Planning and Development inhibits new construction, she said.

“In Sonoma County alone, there are just 1,400 beds to serve a half million people and an exploding elderly population,” Pacyna said.

According to Nelson, who runs the county’s Long-Term Care Ombudsman Program, Sonoma County is home to ?21 skilled nursing and ?169 assisted living facilities. Assisted living facilities or long-term care facilities are not covered by Medicare or Medi-Cal because they technically are not medical beds, she said.

Medicare will pay up to 100 days of care in skilled nursing facilities if a patient has a “qualifying stay” after being discharged from a hospital, she said. Of the county’s ?21 skilled nursing facilities, all but two are Medicare and Medi-Cal certified.

In total, Sonoma County has 1,463 skilled nursing beds authorized to accept Medi-Cal reimbursements. Nelson said the most common way of entering into a skilled nursing facility is by being discharged from a hospital, with Medicare covering the first 100 days. After that some patients are switched to Medi-Cal and become a financial liability for the facility, she said.

“If you have no assets or means to pay, Medi-Cal will pay that, but the Medi-Cal reimbursement is significantly lower,” she said. “They try to discharge people because Medi-Cal doesn’t pay as much.”

When Mabel Barnfield sold her home off Bennett Valley Road, she walked away with about $160,000 because she had to pay off a $250,000 loan she took out during the recession. She sold the home for about $450,000, a price that was well under market value because of deferred maintenance, said Marianne Dolan, a close friend and former real estate colleague who has been helping Barnfield and her sister, Betty James, through the eviction process.

Dolan said since last fall she tried to find a local skilled nursing facility that would take Barnfield in, but the answer was always the same. She said she was upfront about Barnfield’s Medi-Cal coverage.

“I was telling them she needed a Medi-Cal bed,” said Dolan. “They would say ‘we’re no longer accepting long-term beds,’ ‘we just filled our last bed’ or ‘we’re completely full and have no beds available.’ But they would encourage us to call back later.”

“I would said, ‘Why, because someone will probably die?’?” she said.

James, who is 90 and lives on her own in southeast Santa Rosa, was unable to care for Barnfield. With $160,000 in the bank, Barnfield entered Brookdale Fountaingrove in 2013.

Heather Hunter, a spokeswoman for Brookdale, said in an email that Barnfield “was a beloved resident” in the assisted living portion of Brookdale Fountaingrove and that staff went “above and beyond” to help her find an alternative place for her to stay once she could no longer meet her financial obligation. That included providing resources and referrals to other nursing homes, she said.

“Our staff has cared for her and wanted the best outcome for her,” Hunter said in the email. “Since this community is not Medi-Cal certified it cannot accept Medi-Cal as a form of payment. Therefore, continuing with Brookdale was not an option for Ms. Barnfield.”

But advocates say that even finding a bed in facilities that accept Medi-Cal is extremely difficult for people who, like Barnfield, have run out of money.

Paul Dunaway, director of the county’s Adult & Aging Division, said coming up with alternatives to costly institutional care is becoming increasingly important. He said the county’s population of older adults rises by about 1% each year.

Less than 10 years ago, 20% of county residents, about 102,000, were 60 and older. In 2017, those 60 and older numbered 132,000 or 26% of the population.

“We do not have the right kind of housing for these people,” he said.

Dunaway said the county’s overarching goal is enabling older residents to “age in place” instead of going into costly assisted living or skilled nursing homes. The county is trying to create more in-home and financial support services, he said.

“With that said, as much as we can keep people aging in place, there’s going to be a need for assisted living and skilled nursing facilities,” Dunaway said.

Tony Chicotel, staff attorney for California Advocates for Nursing Home Reform, said the state prioritizes institutional care over community care.

“This state pays billions of dollars on nursing home care and spends virtually nothing on assisted living care,” Chicotel said. “Medicare is where all the money is.”

Chicotel said Medicare will pay for therapy and rehabilitation services, often at a rate that exceeds the cost of care.

That, he said, in effect subsidizes other forms of care. Because Medicare pays more than Medi-Cal, skilled nursing facilities limit the number of Medi-Cal residents.

“Facilities are absolutely restricting access,” Chicotel said in an email. “I hear from people every week who are told there are no ‘long-term’ beds available when they are already in one! The facility is trying to discharge them once their Medicare runs out and is lying to the resident by saying the bed they are in is not for ‘long-term care.’”

Chicotel said the percentages cited by the California Association of Health Facilities is misleading because Medicare residents stay for an average of two weeks compared to six months for those on Medi-Cal. For that reason, Medi-Cal residents comprise only a minority of admissions.

Chicotel said data from the state Office of Statewide Health Planning and Development shows there are 111,000 long-term beds but almost 400,000 admissions over the course of a year.

“There is a lot of turnover, and that is how ultimately residents on Medicare outnumber those on Medi-Cal and how access is limited,” Chicotel said.

Barnfield moved into the Novato skilled nursing home the day after her eviction court day on April 18. James said she no longer drives and will likely have to rely on others to visit her sister.

“I can’t go as often as I did before,” James said. When she was driving, she would visit her sister once a week or more and have lunch with her.

The difficulty finding a bed for her sister befuddled her, though ultimately it came down to money, she said.

“I just didn’t know what the heck to do, I was so damn confused about everything,” she said. “I know they probably had no choice because she ran out of money. I mean what are they supposed to do?”