Connecticut, like every state trying to reduce health care spending, is looking closely at how it cares for people with chronic conditions. Gov. Dannel Malloy has promised to move more than 5,000 poor and disabled patients out of nursing homes in five years. But the Democratic governor says there's an expensive obstacle in the way -- Connecticut law says nurses have to give medications to people in the Medicaid system living at home, and that costs a lot of money.
Jane Counter is one of those nurses. On a recent weekday near Hartford, Counter began her day at 5:45 and she had already seen a dozen patients before 9 a.m. when the psychiatric nurse arrives at the condo apartment building of Frank. (We are identifying him by first name only to protect his privacy).
Counter, dressed in scrubs and carrying a locked box of medications, greets Frank at his door. He is just waking up as she begins to go through his extensive series of daily medications. But she says she's doing a lot more than delivering pills. She's assessing Frank -- asking about his blood sugar, his diet, his sleep medications, and about any bruising or bleeding that could give her pause. She's not technically paid to assess him, but she does, because it's what nurses do.
"And it's helpful because we build a rapport and, and that, over time, they become more comfortable with us and will report more symptoms to us, which is really important for us to know,” says Counter. “It affects their plan of care, their medication regimen, and it's important information that we can give back to their providers."
But now the state of Connecticut is asking the question: Could someone other than a nurse do that same job, or part of it, for less money?
Connecticut officials say the state spends far too much money for nurses to give prescription drugs to Medicaid patients living at home. Anne Foley is the governor’s undersecretary for policy and planning. She says the high cost also means some patients don't have the option of leaving an institution.
"The cost of medication administration is a significant barrier to getting people out of nursing homes and keeping people out of nursing homes," Foley says.
Last fiscal year, the state spent $128.28 million to have nurses administer medication to about 8,500 Medicaid clients, averaging $54 per visit, according to The Connecticut Mirror, a nonprofit news site similar to KHN.
"There are a few states that allow home health aides to do almost nothing in terms of medication administration, and Connecticut is one of them," according to Howard Gleckman, an author and resident fellow at the Urban Institute, who studies elder care.
Connecticut is thinking of changing its approach and letting non-nurses administer drugs.
The state legislature is now considering a plan to allow trained home care aides -- who now cost half what nurses do -- to administer medications while working under a nurse's supervision. Foley says that and other changes could eventually save the state millions. And nurses like Counter would still go out to assess the health and safety of their clients – but they would clock less time traveling between patients.
"It just means that they're not going two times a day, every day, three times a day, every day, to [give medications]," Foley says
But what makes sense to Foley makes for a complicated problem for Tracy Wodatch. She's a vice president with the Connecticut Association for Home Care & Hospice. Her organization is working with the governor on his bill.
Wodatch says there are serious concerns on the minds of nurses and the agencies that hire them -- from affordability to liability to figuring out which patients are best suited for the change.
She described the kind of patients who would benefit from still seeing a nurse every day: "One that has changes on a daily basis, one that may have outbursts, may have significant mood swings on any given day, not be safe with a home care aide who's trained just in giving medications and not really recognizing symptoms, side effects, interventions that could be put in place to avoid further problems."
Still, Gleckman says there's some logic in giving home health aides more responsibility. Nurses have more important things to do than hand out pills. And home health aides are on the front line.
"So in fact, if something changes with the patient -- she's not eating at much as she was, she's having incontinence problems, it's much more likely that a home health aide will notice that than a nurse who spends five minutes in the house,” Gleckman says. “This does require some training, but a well-trained aide can absolutely do this."
Plus, Gleckman says the limited research done on the issue suggests that the outcomes for patients are at least as good.
Now, it’s up to the state’s legislature.
This article was produced by Kaiser Health News with support from The SCAN Foundation.