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Dr. Fazeli advocates for the elderly & the geriatric providers who care for them.

Our Past Advocacy Work

Addressing the root cause of rural nursing homes shut downs

Dependence of smaller nursing homes on Short Stay SNF Admissions 

  • Rural Nursing Homes are very dependent on the few short stay skilled rehab admissions they get from hospitals every month. These few admissions provide a desperately needed Medicare and private insurance payments that can make or break a facility. Most long  term care residents are on medicaid and those payments alone are not enough for a nursing home to pay their operating cost.

Once the SNF beds are gone the community also loses the LTC (long term care) nursing beds

  • Starved of SNF referrals, rural facilities are forced to shut the SNF unit down and use them as LTC beds,  but finances eventually force the shutdown of the nursing home all together. 
  • The elderly in that community who need nursing placement would have to find a facility far from home and away from family and friends. 
  • The state is always looking for ways to help the smaller rural nursing homes, but the costly, yet minor, state budget adjustments are insufficient to offset the loss of Medicare payments from the SNF short stay patients.

Why aren't smaller Nursing Homes able to get 2-3 SNF admission a month to remain open?

  • With the advent of ACOs  (Accountable Care Organizations) major hospitals developed a preferred or sometimes a closed network of providers that includes home health care and skilled rehab nursing facilities (SNF). When a rural patient arrives to an urban hospital for a short stay, that patient is not necessarily returned to a rural facility close to home for post acute care or rehab, and is instead referred to an affiliated SNF in the city. 
  • To affiliated urban facilities these few rural admissions are a drop in the bucket, but the loss of these few SNF referrals is catastrophic for the rural facilities. 
  • The benefit to the ACO and the hospital is likely negligible too, but the system is designed by default to always keep the patients in the network .  The big elephant in the room is that had these rural patients been given a clear choice of being close to home or staying in the city for rehab, many would chose the rural facility closest to home and the rural nursing homes would not go under. ​This is the area we targeted for advocacy-See below (What did Maine Geriatrics do about it?)

It is worth noting that the ACO system of mini-monopolies to control cost for medicare have not delivered on their promise of cost saving and yet we continue on the same path undeterred.

Even Successful Medicare ACOs lose money

Report: ACOs Lose Money First 3 Years

The Economics of Medicare Accountable Care Organizations

  • One can easily argue that the most controversial element of the ACA is the unintended negative impact on patient choice and the disadvantaging of small independent facilities and providers. Expanding medicaid or covering the uninsured are not controversial in the mind of many providers, this issue is; yet there is very little appetite on part of decision makers to change course or at least pause to reassess the damage. 

What did Maine Geriatrics do about it?

In 2013, Dr. Fazeli with the help of the Maine Medical Directors Association, and a volunteer lobbyist, drafted a bill to fix this issue by simply demanding that patients be given a clear choice of service providers upon discharge from the hospital. 

  • This bill was signed into law by governor Lapage on June 10, 2013. The state went through its rule-making without involving the advocates for the bill, and to this date there has been no training of surveyors on the issue. 
  • Subsequently,  this law has not been used by the state to cite any hospital or facility for not giving clear choice to patients during and after the hospital discharge process. 
  • Unfortunately, a few more rural nursing homes closed permanently since this law was passed.

More details on the fight to get this law passed

Update: April 05, 2013

Various stakeholders have held a meeting on LD 447 and agreed to language changes. The bill was then amended to meet everyone's approval. 

Update: March 12, 2013

The Maine Joint Committee of Health and Human Services voted from March 12, 2013 until April 2, 2013 to table LD 447. Stakeholders were also asked to discuss the bill's goals and language. 

Update: March 11, 2013

The State of Maine is considering a bill to improve patient choice and more transparency in hospital regal practices.  

LD-447 is supported by the Maine Medical Directors Association (MMDA) as it also improves the health care business environment for new physicians interested in geriatric and nursing home medicine. The bill also strengthens existing Maine regulations regarding the role of medical directors in facilities owned by nursing home corporations.

The opponents of the bill, primarily the Maine Hospital Association (MHA), opposed the bill based on resulting "administrative burden" and the fact that Maine has existing laws on the issue.

The MaineMDA conducted a survey of Maine nursing facilities to get their perspective on how big the hospital referral issue is and how much of a burden the provisions in the bill would cause. The survey was sent to 107 Maine facilities on Thursday afternoon, March 7, 2013. Below is the survey result. 

We surveyed Nursing homes about this issue and here is what we got!

Below are the anonymous comments from the facilities:

  1. "I believe one hospital (hospital name removed) in our area fills their affiliated skilled facility first. I am almost always told when they refer to me that (facility name removed) or (facility name removed) were the patient's first choice. Often when I take a referral from them, the hospital will send the patient to one of these facilities at the last minute even though the referral was already made to and accepted by us. When I follow up for patient arrival, I am always told that the patient is going to one of the other facilities aforementioned. (facility name removed) is the hospital's affiliated facility and (facility name removed) appears to be the second preferred.”
  2. "Some hospitals have admission staff who affords them immediate access to who is ready for discharge. They also allow them to accept this patient or not before any discussion ensues with patient regarding other opportunities!"
  3. "Our Social Worker/Admission Coordinator has established strong, professional relationships with the Hospital Discharge Planners. We're successful in filling empty beds within a matter of days. The facility is highly regarded with a stellar reputation for providing quality care."
  4. "With the new EPIC software, we are finding that medical information on referrals/admits to be difficult to pull together, often missing crucial pieces of data. As an example, since the change to EPIC, we are missing social security numbers and orders are difficult to read. Overall, admissions from most area hospitals keep coming later and later in the day, impacting the SNF's ability to ascertain meds, therapy minutes, etc. This does not seem to be fair to the patients, who often arrive at SNF in the evening, when they are overtired, under medicated, hungry, etc."
  5. "Question no. 9 is difficult to answer. Yes, I'd be willing, No, it isn't a burden."
  6. "There is a great need to offer patients a wide variety of choices, not just funnel them into the hospital owned by SNF/NF/AL."
  7. “The majority of our local physicians will only take patients who are already established with them prior to hospitalization. We have one who will accept new patients. This is a tremendous challenge for us. The type of patient sent to us is often extremely challenging; when they come from out of our area, they do not want to stay away from their family and friends, they want to be in their home area.
  8. They are often enduring behavioral challenges and sometimes without appropriate information and once they arrive, we have no resources to consider a readmission.” 

Anything we can do now to save rural nursing homes from closing?

Call and ask the governor to apply the law!

If you would like to share your thoughts on why LD 447 was passed but never enforced you can contact the office of the governor here or the Joint Standing Committee on Health and Human Services by clicking here or contact: 

Committee on Health and Human Services

c/o Legislative Information

100 State House Station

Augusta, ME 04333 

Committee Clerk: Ben Frech

Phone: (207) 287-1317

2013 MaineCare Budget Cuts & LTC Bed Hold Issue​

March 28, 2013

Under the new budget cut proposal this would happen when nursing home residents are admitted to the hospital for more than four days in a year?

  • The facility is no longer paid by MaineCare to keep the bed open.
  • You or your loved one could get evicted and have no bed to return to unless one opens up in time.          

As some of you may know, the MaineCare budget is cutting the 10-day bed hold in two stages. The first stage took effect on March 26, 2013, which cut the bed hold from 10 days per incident to 4 days per year. The second phase of this cut will come on July 1, 2013 and it is proposed that the MaineCare coverage for bed hold must be cut completely.

MaineCare patients residing in nursing homes get their room and board paid for by MaineCare. Most patients in nursing homes become MaineCare recipients sooner or later if they live long enough.

Unintended Consequences:

  • Patients are literally evicted from their home (the nursing home) when they exceed the four days per year hospitalization; if the budget plans go forward, they can be evicted the day following their admission to the hospital.
  • Most smaller and rural facilities don't have the capacity or financial cushion to eat the cost and keep the beds open. It can cost thousands of dollars each month to keep beds open for hospitalized patients to return to as facilities can easily allow patients from the waiting list to move in and take their place.
  • With more than half of the nursing home patients having dementia (based on the most conservative estimates), an increase in such evictions and change of living environment would have well-known detrimental effects on these patients health, as they would have a harder time adjusting to a new environment and new.
  • Last but not least, facilities can use this as a way to get rid of some harder to care for patients.

  • The budget cut also removed 1/3 of the ombudsman budget which was later made up for other parts of the budget. While this leaves the ombudsman budget neutral, it does pave the way for future cuts in their budget.   

What can you do to help stop this? (Thanks to eldercare advocates around the state of Maine the issue was resolved and cuts were reversed)

  1. Attend the Appropriations and Financial Affairs Committee Public Hearing on Thurs. April 4, 2013, 1:00 pm at the State House located at 5 State House Station, Augusta, ME 04333.
  2. Call the Committee on Appropriations and Financial Affairs to express your opposition to this budget cut at (207) 287-1316. 
  3. If you are not able to give oral testimony on behalf of a loved one, you can email your comments to Holly Mullen, Committee Clerk at
  4. Call your local Representatives in the State House and Senate:
State House: (207) 287-1400
Maine Senate Republicans: (207) 287-1505
Maine Senate Democrats: (207) 287-1515
Senator Richard Woodbury, Independent: (207) 846-3056

Please read Dr. Fazeli's testimony to the Appropriations Committee and Health and Human Services Committee on this issue.

Please feel free to contact us with any questions

Office #: 207-780-6565  or  Email us

Office Address: 22 West Cole Road, Biddeford, ME 04005

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