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Labors of Love

Labors of Love: Nursing Homes and the Structures of Care Work

Jason Rodriquez
Copyright Date: 2014
Published by: NYU Press
Pages: 256
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  • Book Info
    Labors of Love
    Book Description:

    Every day for the next twenty years, more than 10,000 people in the United States will turn 65. With life expectancies increasing as well, many of these Americans will eventually require round-the-clock attention-and we have only begun to prepare for the challenge of caring for them. InLabors of Love, Jason Rodriquez examines the world of the fast-growing elder care industry, providing a nuanced and balanced portrait of the day-to-day lives of the people and organizations that devote their time to supporting America's aging population.

    Through extensive ethnographic research, interviews with staff and management, and analysis of internal documents, Rodriquez explores the inner workings of two different nursing homes-one for-profit and one non-profit-to understand the connections among the administrative regulations, the professional requirements, and the type of care provided in both types of facilities. He reveals a variety of challenges that nursing home care workers face day to day: battles over the budget; the administrative hurdles of Medicaid and Medicare; the employees' struggle to balance financial stability and compassionate care for residents. Yet, Rodriquez argues, nursing home workers give meaning and dignity to their work by building emotional attachments to residents and their care. An unprecedented study,Labors of Lovebrings new insight into the underlying structures of a crucial and expanding sector of the American health care system.

    eISBN: 978-1-4798-0956-1
    Subjects: Anthropology, Health Sciences, Sociology

Table of Contents

  1. Front Matter
    (pp. i-vi)
  2. Table of Contents
    (pp. vii-viii)
    (pp. ix-x)
  4. Introduction: Locating Nursing Home Care Work
    (pp. 1-20)

    “Jason is helping me out, so he can hear all of this,” said Andy Fischer, the administrator of Rolling Hills Extended Care and Rehabilitation Center, a nonprofit and secular nursing home. Eli, a sick old man with shaggy white hair and thick glasses, pedaled his wheelchair until he came to a standstill in Andy’s doorway. Eli looked tired and somewhat disheveled, wearing an oversized red-and-black flannel shirt, gray cotton shorts, white socks pulled up toward his knees, and an old pair of loafers. His right arm was held in a sling that looked uncomfortable. Andy leaned forward in his office...

  5. 1 Making the Most of Medicaid
    (pp. 21-36)

    Victoria burst through Andy’s door and presented him, triumphantly, with a document full of names and numbers. As the Medicaid reimbursement coordinator for Rolling Hills, she had just completed her estimation of the reimbursement rate for all residents on Medicaid. She pointed out that the overall average reimbursement they would get from Medicaid went up, and, if her estimates were approved by the Medicaid auditors who would visit Rolling Hills in a few weeks, the nursing home was poised to increase the flow of revenue from Medicaid. Victoria was proud, indicating that her job was not simply to collect and...

  6. 2 Staging the Inspections
    (pp. 37-56)

    I sat on the floor of the financial office at Rolling Hills as the managers filed in for a hastily scheduled meeting. Just a few hours earlier, inspectors from the Department of Public Health had arrived, unannounced, to conduct their annual health and safety inspection. The mood felt tense; the managers spent months preparing for this moment that had finally arrived. Andy, the administrator, was quietly optimistic that the inspection would go well. But he was also nervous that the inspectors might find something that would cause them to widen the scope of the survey. Andy may have taken his...

  7. 3 Documenting Conflict
    (pp. 57-76)

    Nursing home managers are subject to significant constraints and pressures from the financial and regulatory structure to treat care as a sequence of reimbursable acts. In a system that essentially does not provide enough resources, the managers do what they can to squeeze every dollar out of Medicaid without crossing the fraud line, and they maintain regulatory compliance with performative measures that leave systemic understaffing and work overload in place. The managers are themselves subject to these demands in order to keep the nursing homes financially afloat, but they are torn and struggle to reconcile the tensions inherent in this...

  8. 4 The Costs of Doing Business
    (pp. 77-100)

    The first three chapters of this book have shown how a range of structural constraints shapes the character of nursing home care work. Medicaid reimbursement and state audits, the health and safety inspections, and the hierarchical battles around the documentation of care exacted an emotional toll, pulling workers in different directions internally and organizationally. Internally, staff members were conflicted about making residents into the embodiment of reimbursable activities. They did what they had to do, but they did not feel good about it. Organizationally, the hierarchy of authority generated animosity and distrust. Managers and floor staff seemed to work in...

  9. 5 Feeding Residents on a Starving Budget
    (pp. 101-114)

    Given the reimbursement system of nursing home care, no nursing home can take a first-come, first-served approach to admissions without jeopardizing revenues. Andy learned this lesson the hard way. He was terminated because of the revenue crisis that developed at Rolling Hills. He ran the nursing home according to principles that were out of sync with what the reimbursement system recognized as care. Although it is hard to ignore that Andy could have managed the budget better, despite his virtues in other areas, the problem he faced is a problem more generally in the nursing home care industry. Residents need...

  10. 6 The Uses of Emotions
    (pp. 115-138)

    Nursing home care workers often felt a sense of frustration and resentment toward the reimbursement and regulatory systems.¹ But beyond how they felt, the actions, interactions, and underlying assumptions that guided their behavior suggested that they were constrained by these systems, nudged into doing care work that seemed to serve the needs of those systems more than the residents. Managers and floor staff faced those pressures and constraints, but given the hierarchical structure of the workplaces, they faced them differently. The managers had to be concerned with the documentation, and those concerns forced them into behaviors like pushing documentation to...

  11. 7 Making Sense of Death and Abuse at Work
    (pp. 139-154)

    “I had a resident, Priscilla, who everyone thought was very precious,” Heather explained.¹ Priscilla was on death’s doorstep and had suffered for years with the symptoms of advanced dementia. Priscilla’s advance directives were not on file, a common problem among the elderly at the end of life.² Faced with wrenching end-of-life decisions, her children fought bitterly over how to proceed. Heather dealt often with these issues, although not quite as complex as this particular case. She held individual meetings with the adult children and stressed the need to focus on “what would your mom want?” Eventually one of the children...

  12. 8 Connecting Quality of Life and Quality of Work
    (pp. 155-168)

    As workplaces, nursing homes offer few rewards. The pay and prestige are low, the prospects of career advancement are slim, and the decline and death of the customers are routinized into the fabric of care. Nursing home care workers, even the managers, have very little autonomy over their work routines and often find themselves doing care work tasks in ways that satisfy the demands of their organizations instead of meeting the needs of their residents. The payment and regulatory structures that shape the character of the nursing home industry perpetuate the difficulties that workers face on the job. Faced with...

  13. APPENDIX: From the Poorhouse to the Skilled Nursing Facility
    (pp. 169-174)
  14. NOTES
    (pp. 175-184)
    (pp. 185-196)
  16. INDEX
    (pp. 197-206)
    (pp. 207-207)