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Despite offerings, reporter finds nursing home beds and funds still lacking Date: 05/04/16

Rick Jurgens

By Rick Jurgens

About a year ago, with the support of an AHCJ Health Care Performance Fellowship, supported by the Commonwealth Fund, I began working on stories comparing health care for low-income people in New Hampshire and Vermont.

When I wrote about the experiences of seniors and others in nursing homes, I found voices, anecdotes and other narrative material by using Google Forms as an online tool, using an approach developed and shared by AHCJ members from ProPublica and Sarah Kliff of Vox, another HCP fellow.

But the road took a few twists and turns.

I began thinking that a comparison of Vermont and New Hampshire would be interesting because those states have similar populations and economies but noticeably different political cultures. I assumed the comparison would be doable because both states are small and geographically compact. I thought I could examine experiences in the “medical system” of Medicaid recipients and the uninsured.

But I soon realized the volume of work entailed in doing a broad comparison would be unmanageable.

In the end, I produced two packages comparing mental health care and nursing home care in the two states.

In my reporting on nursing homes, I traveled some well-worn roads. I found comprehensive information in a database maintained by the Centers for Medicare and Medicaid Services. My printer overheated grinding out federal and state reports and studies on the industry as well as a few earlier newspaper takeouts and some nonprofit tax returns and company reports to investors. I knocked on the doors of owners, managers and front-line caregivers; administrators, regulators and policymakers; trade associations; and social service agencies.

I found that nursing home care has some characteristics of a transparent market. The location, capacity, quality and ownership of most homes show up in the CMS database. A bulk of the revenue comes through Medicaid programs, and that Vermont and New Hampshire regularly publish reimbursement rates. A nationwide framework of regulation exists.

But I discovered that, even in these two small states, rapid and sometimes disjointed evolution was underway in nursing home care. Ownership was changing hands. Home health care and community services were being promoted as an alternative to residential services. And in New Hampshire and other states managed care organizations (aka insurance companies) were being brought in to oversee distribution of funding and provision of services.

A word about Medicaid: If you don’t know what the last sentence in the previous paragraph means, don’t worry. Nobody that I could find did either. And the transition to managed care is just one aspect of Medicaid that is opaque and dizzyingly complex. Yet in nursing home care – as in many areas of the social safety net – Medicaid funding plays a critical role that can be excruciatingly difficult to describe.

All along, I knew a critical ingredient in my reporting would be my ability to gather and incorporate into my overall narrative the stories of patients and their families.

As a health care reporter I have come to appreciate some special challenges of assembling narrative. Often, people view their health and experiences with health care providers as private matters. Further, stigma is attached to some diseases and treatments. And even when people put aside privacy and stigma concerns, the inaptly named Health Insurance Portability and Accountability Act limits access to records and providers’ perspectives.

That’s where Google Forms came in. Taking advantage of the traffic generated by a news story about a pending purchase of several Vermont nursing homes by a company that was already the largest owner in New Hampshire, we invited visitors to our website to complete an online questionnaire describing their own or family members’ or friends’ experiences as current and former nursing home patients.

We created the questionnaire and a spreadsheet to gather comments and information using Google Forms. You can find the end product here.

Some submitters did not supply contact information or respond to my follow-up calls and emails. In a majority of cases, I conducted telephone interviews. When possible, I tried to sit down with subjects and record interviews. Although more time-consuming, especially when counting transcription time, I think a chance to size up a subject in person, pay attention to their body language, observe their home or work setting, exchange ideas and carefully parse their transcribed words makes in-person recorded interviews the gold standard for me.Fortunately, our responders included one family member and one former patient (a retired nurse) whose experiences and voices were clear and included enough detail, emotion and detached self-awareness to carry a heavy narrative load.

That said, I tried to weigh all of the responses – including some in which anger drowned out detail and others where it seemed the commenter might have been aiming to influence our reporting with a slanted or fabricated comment.

In the end, I believe the accessibility of my story was enhanced by whatever success I had weaving their stories into my overarching story. 

Rick Jurgens covers health care for the Valley News, a daily newspaper in West Lebanon, N.H. Previously, he was a staff reporter for the Contra Costa Times in Walnut Creek, Calif., and Dow Jones Newswires and wrote stories for the Center for Investigative Reporting, Christian Science MonitorWall Street JournalNieman Reports,, San Francisco Business Times and California Current. He also worked as an investigative reporter for the National Consumer Law Center.