North East-based mostly treatment company Hark Team Holdings has reported it is trying to find to go on to expand through acquisitions as it capitalises on fragmentation in the Uk care sector. Above the last yr, acquisitions have helped the enterprise to treble in dimensions.
In the previous 12 months, the company has acquired the small business and belongings of Sunderland treatment house Cedar Dwelling, as properly as the entire issued share money of Thorncliffe Care Minimal, which operates the Thorncliffe Property treatment house in Sunderland (pictured higher than).
Hark Group labored with Mincoff Solicitors and accountancy and company advisory Azets on the discounts, with funding furnished by Allica Financial institution. The group’s leadership suggests it is aiming to function with both of those Mincoff and Azets on long term M&A specials.
Hardip Kang, director and owner of the Hark Group, who established the enterprise with his spouse Rupinder Kang, commented: “Our growth and advancement this past yr was significantly assisted with the know-how, knowledge and eye for depth from Chris Hughes and all the team at Mincoffs.”
“It is really the type of reassurance a rising organization needs when seeking to realize their expansion targets. Lee Humble and the workforce at Azets offered me with the economic tips and aid to speed up the momentum desired to get the offer more than the line. I look forward to doing the job with equally all over again for any doable upcoming acquisitions.”
Mincoff Solicitors Corporate Spouse Chris Hughes mentioned: “It has been great to perform intently with the two Hardip and the workforce at Hark and with Lee and the crew at Azets to provide Hark Group Holding’s vision for the North East care sector.”
“Thorncliffe Household and Cedar Property Treatment Residence are amazing additions to Hark’s portfolio and it has been a enjoyment to assist the group in acquiring these two business enterprise, so it can keep on to present essential, leading quality, treatment across the location.”
Azets Corporate Finance Partner Lee Humble extra: “It has been a pleasure to do the job with these kinds of a strong crew with a compelling development eyesight. I am enthusiastic to see what the potential retains for the Group, and we are delighted to be portion of their journey.”
Fragmentation and a large number of owner exits because the COVID-19 pandemic have driven a growth in dealmaking in the care sector and Lee Humble noticed: “The sector is incredibly energetic at current, and we are usually eager to support aid transactions for enterprises like Hark.”
Additional than ever, Connecticut inhabitants are looking to age at residence. Can the condition hold up with a growing home wellness treatment market that has been unregulated so considerably?
WSHU’s Ebong Udoma spoke with CT Mirror’s Dave Altimari to talk about the post he wrote with Jenna Carlesso, “Home treatment suppliers: A developing but unregulated field,” as part of the collaborative podcast Very long Tale Shorter.
You can browse their story here.
Episode Transcript
WSHU: We’ve viewed a shift away from nursing homes or lengthy-phrase treatment facilities as extra individuals choose to age at dwelling. But you say there may be a difficulty, mainly because residence care companies are not properly supervised by the condition. And you give the instance in your post about 92-year-outdated Ruth Hughes of Farmington who was ripped off by mom and daughter group property treatment suppliers Cynthia Williams and Sharonda Williams, could you convey to us a little bit a lot more about them and this certain instance in this article?
DA: Sure. So the dwelling companion agency industry is the only point in healthcare that is not overseen by the Office of Community Wellbeing. It is the Department of Client Defense at the moment that is dependable for investigating them. And there’s quite minimal that is finished to track who’s functioning for these providers. The firms are meant to do track record checks, but they do not have to offer them to the condition. In the scenario you are referencing, what happened was, I did a Freedom of Facts request to get three many years truly worth of DCP investigations. And there had been over a 50 {1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} a dozen of them in which a personal treatment aide stole the cash from the customer.
In the situation that you’re referring to, Ruth was in an assisted residing facility. She experienced employed a corporation to have an aide arrive and remain with her a several hrs a working day. And about a thirty day period immediately after the human being had started off performing there, her conservator got a phone from the lender inquiring about $27,000 worthy of of checks that experienced been prepared off Ruth’s checkbook. The conservator right away understood that that wasn’t the variety of funds that Ruth would be investing and went to the Farmington law enforcement to do an investigation and they determined that the PCA, her title was Cynthia Williams, was mainly writing checks to purchase furnishings for her condominium and experienced invested just about $27,000 producing all these checks. When the police started investigating, they realized there was a next consumer that she was also thieving from. They inevitably arrested the two the mom and daughter on larceny fees. And each of them ended up pleading responsible in Harford court docket.
WSHU: But which is just one case in point. And it’s not just fraud we’re chatting about here. You have a different instance of an 86-calendar year-previous shopper in Waterbury whose dwelling treatment assistant ended up overdosing in his condominium. And he was by himself.
DA: That was a South Windsor case. The Waterbury scenario was the just one in which when the guy died, he was 89 decades aged, the PCA refused to allow the household into the apartment saying that they experienced a relationship and had to get the law enforcement associated and DCP and it took six-8 weeks for them to even get access to the father’s stuff.
The scenario you are referring to occurred in South Windsor. A gentleman struggling from dementia, usually him and his PCA would choose a bus to a senior middle. So the bus driver understood who he was and realized we usually experienced a PCA with him. So when he confirmed up a single early morning with out his PCA, they essentially did not allow him on the bus and left him on the aspect of the road. The male had no thought of how to get home. He was described lacking to the law enforcement. They sooner or later observed him about an hour following he experienced been reported missing. And when they introduced him back again to the home, they observed that his PCA had overdosed on heroin and died in the household. And the man had just walked out and walked to the bus station and then experienced walked around the community. Thankfully the police found him comparatively rapidly.
WSHU: So what is been done about this? I imply, is the state accomplishing a little something, are lawmakers seeking into this?
DA: Indeed, in fact. As we have been reporting on this series, the legislature formed a Home Companion Job Drive to consider a look at what DCP was doing, what was the oversight, and what could be performed in different ways. And they have a invoice that’s handed out of committee that would transfer the duty of overseeing these services from DCP to DPH.
WSHU: The sensation is that DCP is much too lenient, or DCP does not have the capacity to properly regulate this industry? That it is improved carried out by the Section of General public Health?
DA: DCP does not have the manpower, the selection of property companion businesses has gone from 300 to 900 in just a few a long time. DCPS investigative unit is down to like a few persons, one supervisor and two investigators, so they just really do not bodily have the bodies to do investigations. The kinds they do are inclined to emphasis more on factors like firms that mis-promote their products and services, and assert that they can do health care processes like clean up wounds or modify IVs, when they are genuinely not intended to do that kind of things. They emphasis additional on that than they do on who’s doing the job in these spots.
And DCP does have a tendency to generally situation reasonably compact fines when they do come across a firm has done a little something incorrect. And their argument there is that as opposed to with nursing residences, where DPH can place a receiver in and can get over a nursing residence. DCP simply cannot do that. So if they shut down a home companion agency because someone was stealing from a customer, they would shut the full agency down. All the men and women who are getting expert services by that agency are going to be left in the lurch.
WSHU: But do you also say listed here that the Office of Public Wellness is saying that they’re not ready to choose this on appropriate away.
DA: They also are down a whole lot of folks who’ve retired. their unit that investigates nursing households would likely be the unit that would acquire this about. And I believe what the general public wellbeing commissioner informed the committee and I’m absolutely sure what she will notify the full legislature is that if you want us to do that, we’re likely to require a substantial boost in funding so that we can seek the services of investigators exclusively to offer with this kind of agency.
WSHU: I noticed anything you described in the post, about a billion bucks is necessary to spend on regulating this market in the in the vicinity of potential?
DA: Three matters heading on. Number a single, the point out is by now putting additional cash into household health care, they have sped up a system that had now started out ahead of COVID. And the greater part, ultimately, about 75{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} of Medicaid cash that the condition gets will likely go to dwelling health and fitness treatment rather than nursing houses. The other problem is just like nursing households and hospitals, household wellness treatment organizations are getting a challenging time finding staff. It is not a great paying out career. It’s not simple function. And so that’s a big difficulty. So we’d have more people seeking for residence wellbeing care, much less folks performing in the industry. How do you tackle that? Chatting about needing to maximize salaries potentially or come up with much better advantages or improved spend deals to get people today into the subject?
WSHU: A great deal of particular treatment aides have joined a union, SEIU 1199. Would that help, the point that it is been unionized now, would that enable in seeking to control this market?
DA: A person of the difficulties with the whole agency is it is a really confusing issue to navigate. The PCA’s you’re referring to as members of the union, they actually are licensed by the Office of General public Wellbeing presently, so they can deliver a larger stage of care than what the property companions can. The home companions are an individual who is heading to arrive about, prepare dinner your meals, clean your dresses, and do your banking for you. They’re not caring for your wounds. So that is a various degree, the PCAs that are unionized are compensated more than home companion agencies. The trouble with the PCA is that there’s once more, there is not sufficient of them and the procedure that the point out has set up, it is incredibly tricky to discover. It is generally a paper booklet that they set out that has names of PCAs and the listing is previous. The point out desires to do a far better job of acquiring online sites. And proper now, they really do not have that and it’s a pretty difficult discipline to navigate.
WSHU: Something interesting in your posting, a few of several years back, Senator Saud Anwar tried to put ahead legislation that would have demanded a drug test for home companions, but there was a large amount of pushback from the house companion companies. What was the purpose for that?
DA: That was following the South Windsor case exactly where the aide overdosed in the household, there have been a few points that they were being proposing there. The one that did get handed was a necessity that a federal qualifications check out be carried out on each and every staff that an HCA hires, the trouble there is that the state nonetheless does not call for the businesses to switch that in excess of to the condition. So DCP has no strategy who is working at any of these areas, and no matter if they’ve experienced a appropriate background check out performed.
What you are referring to is right after the aid overdosed in the South Windsor scenario, they wished to move laws to make it a need to move a drug test and get a work. And the pushback on that was the value of the tests. HCA didn’t want to decide up the price of owning to pay out for drug tests for all people that they hired. And in the end, that did not make it into the bill.
WSHU: So is the condition likely to be able to grapple with this, as you know, you say listed here, the projections are that by 2040, there’ll be a 30{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} improve in the selection of men and women who are choosing to age at property, who will want this care. So it’s a growing population. It’s a increasing need to have. And we feel to be quite much driving where by we have to have to be as considerably as regulating that sector.
DA: I consider we’re very considerably guiding on regulating it, but also on funding healthcare, in general, but in certain aged care services. And which is a issue the legislature is, I feel, this session for the to start with time is genuinely wrestling with. I’m curious to see what receives passed this session, what type of funding comes with some of these payments that are at this time getting mentioned. Mainly because that is ultimately going to say, what comes about in this article.
How significantly money is the condition prepared to set into what is likely to be a growing trouble? The range that you ended up speaking about, the projections are quicker than even the state originally projected with this and where by this. I feel Connecticut is the sixth oldest point out in the nation proper now, and receiving older. So this is a challenge that is only gonna get even worse until it will get dealt with. And I consider we’ll see how it performs out. But I believe this is the to start with time I do feel the legislature sees that this is a major problem likely forward, and appears keen to maybe set additional income into it.
When the bank manager called Irene Loretto and told her that her 92-year-old friend Ruth Hughes, who suffered from dementia and lived in a Farmington assisted living facility, tried to cash $27,000 worth of checks andbought a $3,000 bedroom set, she knew something was amiss.
Loretto, who had been granted power of attorney for her friend, immediately called Farmington police because she knew Hughes would not have spent that much money.
During a seven-month investigation, Farmington police discovered that Hughes’ home care aide had not only stolen her identity but also that of another client living at a nursing home in Farmington and had cashed at least 20 ofher clients’ checks, totaling nearly $40,000, according to police reports.
They charged a mother-daughter team of Cynthia Williams and Sharonda Williamswith first-degree larceny and forgery, among other charges, according to court documents and news reports. Both women eventually pleaded guilty in Hartford Superior Court and received suspended jail sentences.
Loretto was shocked to learn from Farmington police that Cynthia Williams had a previous conviction for fourth-degree larceny in 2017 after an arrestby Hartford police.She called Williams’ employer, Brightstar Care, and asked why they had hired someone with a criminal record to work with older adults and people with disabilities. Brightstar did not respond to several requests for comment from the CT Mirror.
“I asked them, ‘Didn’t you check her background at all before assigning her to work with a 92-year-old woman?’” Loretto said. “They told me they did and didn’t find anything. Well, they didn’t look too hard. It was my mistake to assume that they checked people out.”
Cases like Hughes’ are an example of the challenges policymakers face as they attempt to “right size” the state’s elder care services by pivoting from long-term care facilities to expanding options for people to receive care at home.By 2040, state leaders expect a nearly 30{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} increase in the number of long-term care residents on Medicaid who remain in their homes, and they’ve committed more than $1 billion annually to that cause.
The shift has exposed a home care industry that operates with little oversight, is hard for consumers to navigate, and has a dire shortage of chronically underpaid workers.
One element of the sprawling home care industry is homemaker companion agencies (HCAs), which are overseen by the state Department of Consumer Protection. Unlike nursing home employees and home health aides, who must be licensed by the state Department of Public Health, there is no licensing process for HCA workers. Instead, homemaker companion agencies must register annually with DCP.
Managers at the companies are required to conduct criminal background checks on prospective employees but aren’t required to share that information with DCP, which does not track who works at the more than 900 HCAs registered with the state.
The result is an industry that some elder care experts refer to as the “wild west,” because there is little oversight, unlike long-term care facilities, which are heavily regulated by the state Department of Public Health.
The CT Mirror reviewed more than 75 complaints against homemaker companion agencies filed with the consumer protection department between 2018 and 2020 and discovered at least half a dozen cases in which HCA employees were arrested for allegedly stealing from their clients, more than a dozen findings by DCP investigators of agencies that routinely mis-advertised the services they provided, and seven complaints of clients being left alone for hours at a time.
The complaints against the companion agencies are varied and troubling.
There’s the 2019 Shelton case where apersonal care aidewas accused of stealing more than $20,000 from her 83-year-old client. There’s the Waterbury family who couldn’t get their father’s aide to leave after he died inMarch 2018 because she claimed she had been in a relationship with the 88-year-old stroke victim. There’s the East Hartford man with dementia who tried to board a bus while wandering the neighborhood after his live-in aide overdosed on heroin. And there’s the Cromwell woman who realized her aide had rented and furnished an apartment using her stolen checkbook.
The Mirror’s review of the DCP investigations found that many either led to small fines of less than $5,000 or an employee being fired.
DCP spokeswoman Kaitlyn Krasselt acknowledged that the agency has never denied a homemaker companion business’s registration and has never revoked a business’s registration following an investigation.
“It’s not the goal to close them down,” Krasselt said. “It is to bring them into compliance so that families aren’t left without the care that they rely on.”
She said state statutes don’t allow DCP to take over a company like DPH can do with a nursing home by placing it in receivership.
Sen. Patricia Billie Miller said DCP is too lenient on the agencies.
Senator Pat Billie Miller thanks Rep. Robyn Porter, D-New Haven, after being sworn in as the new state Senator for the 27th District representing parts of Stamford and Darien. Yehyun Kim / ctmirror.org
“The way it stands now, you can basically get a certificate … and I think there are potentially bad actors out there that would harm our seniors or take advantage of our older adults,” said Miller, a Democrat from Stamford.
“This is an industry that needs to be looked at a lot more closely, because we’re an aging population. I think there needs to be some policies and regulations in place to protect them,” she said.
Kicked to the curb
The voice mail message left on the morning of June 12, 2019,stunned Alma Hernandez.
Her 86-year-old father, who has dementia, tried to get on a bus in South Windsor without his caregiver and was escorted off because he didn’t have a ticket, the bus company representative said. Hernandez said her father and his home care aide rode the bus to go to a community center several times a week, so the drivers were familiar with him and knew he shouldn’t travel alone.
“They left him alone on the sidewalk, so where was he? And where was his live-in aide that was supposed to be with him?” Hernandez said.
She called the police, who soon found her father wandering around the neighborhood. When police took him home, they discovered his aide comatose in the apartment. Hernandez said the aide died on the way to the hospital of a suspected overdose and that police found drugs in the apartment.
Police told her thehome care aide had previous drug convictions, Hernandez said, so she called Companions Forever to ask why they hadn’t drug-tested their employee, given his history. Hernandez said in her complaint to DCP that Companions Forever told her they weren’t required to perform drug tests and that they had no knowledge of their employee’s previous drug charges. Companions Forever did not respond to requests for comment from the CT Mirror.
“I wonder how many people assume that they require people to get drug tested before they put them with their loved ones or don’t know what type of background check, if any, they even do,” Hernandez said.
So Hernandez decided to act.
She contacted state Sen. Saud Anwar, D-South Windsor, and asked him to sponsor legislation that would require homemaker companion agencies to test prospective employees for drugs. She also asked him to submit a bill making bus drivers mandatory reporters if they see abuse or neglect.
“My father got on that bus every day to go to the senior center, and he always had his aide with him, so they knew him and should have realized something wasn’t right that he was by himself and not kicked him to the curb,” she said.
The mandatory reporter bill passedin 2021, butdrug testing legislation died after the HCAs told lawmakers it would be too expensive, given their high employee turnover. They also objected to legislation that would have required them to pay for an FBI background check for every employee, arguing it wasn’t cost effective, but legislators passed it anyway.
The updated law included a requirement that HCAs perform national background checks and “recommended” they hire an outside company that specializes in doing them. Previously, DCP did not place parameters on what type of background search agencies did.
DCP officials acknowledged they have no idea whether the HCAs are actually performing the background checks unless they get a complaint or randomly audit the company.
Massive growth
During that same legislative session, lawmakers — recognizing the oversight problems in the rapidly growing homemaker companion sector — established a task force to study and recommend long-term solutions.
Miller, a former co-chair of the Aging Committee, helped pass legislation establishing the Homemaker Companion Task Force that began meeting last September.
The task force recently submitted a 26-page report to the Aging Committee, which used it as the basis of a bill that went to a public hearing in February and drew more than 40 comments, nearly all of which were favorable.
The task force’s most significant recommendation — transferring oversight of HCAs from consumer protection to the public health department by July 1, 2024 — was adopted and approved by the Aging Committee despite concerns raised by officials from both agencies.
The bill also requires the DCP commissioner to revoke a certificate of registration if an agency violates certain provisions three times in one calendar year, to create a guide that details how to file a complaint against a homemaker-companion agency, and to develop a plan to implement mandatory training standards for agency employees.
But in written testimony submitted for the public hearing, DPH Commissioner Manisha Juthani said her agency would need more time before assuming oversight of the HCAs. The commissioner requested an extra year for the takeover and said DPH’s approach to regulating the HCAs would be different from consumer protection’s.
Public Health Commissioner Manisha Juthani. Juthani, MD, an associate professor of medicine at Yale School of Medicine and of epidemiology at Yale School of Public Health. Yehyun Kim / ctmirror.org
“A significant information transfer between DCP and DPH would be required to fully understand the scope of the registration and monitoring process already in place,” Juthani wrote. “Additionally, given the differences in responsibility and subject matter expertise at DCP and DPH, the process that DPH would use to regulate and monitor the Homemaker Companion Agencies would be different from what DCP currently monitors. While DCP’s focus lies more in monitoring business practices, DPH would focus on the health and safety of the services provided by Homemaker Companion Agencies.”
One of the task force members was Leslie O’Brien, a legislative liaison for the consumer protection department, who acknowledged the growing homemaker companion industry is overwhelming the department.
“We’re really struggling at DCP to figure out how to manage the massive growth in this industry with what the statutory constraints are, while recognizing that the most important thing is protecting consumers and ensuring public health and safety,” O’Brien said during a presentation to the Homemaker Task Force.
This is an industry that needs to be looked at a lot more closely, because we’re an aging population. I think there needs to be some policies and regulations in place to protect them.
Sen. Patricia Billie Miller
“The confusion about thedifferent spectrum of services provided under the home care umbrella is a huge issue,” she added. “It’s confusing for people who work for the state, so think about how confusing it is for consumers. So I think the real challenge as a state is: Does it make sense the way this is all happening right now, all chopped up, among state agencies?”
Several HCA owners testified in favor of the bill, particularly the need for more training and transparency by all HCAs.
“The demand for in-home care has never been greater. Not only is their home where they want this care to occur, but this is the most cost-efficient setting,” said Guy Tomasso, owner of Lifetime Care in Guilford.
“This bill will ensure that all registered homemaker companion agencies will be held to the same standards,” he said. “As providers of this care, we must be accountable to those who have placed their trust [in us] and have peace of mind.”
Tomasso specifically mentioned mandated training programs and several important upgrades, such as “person centered care plans.”
Task force co-chairwoman Anne Foley was a state employee 15 years ago when the original language for registration for HCAs was established, she said.
“We didn’t have any kind of oversight at all over homemaker companion agencies, and we decided that we needed some kind of structure in order to protect the consumers and clients of these services,” Foley said.
“But, clearly, 15 years is a long time, and things have changed demographically, things have changed structurally, and I think it’s just really the right time to relook at the entire system,” she added.
The biggest change is the sheer number of HCAs, which have tripled, while the size of the DCP unit that handles complaints and conducts audits has shrunk, according to DCP officials.
Over the last 10 years, the number of HCAs has grown from 308 to 903, and “we’re still dealing with minimal staffing and in statutory and regulatory frameworks that are much different from when this started,” Foley added.
Home care options vary
With the state placing more money and emphasis on keeping people out of nursing homes, there are several options available for aging in place, according to Tracy Wodatch, the president of the Connecticut Association for Healthcare at Home.
The highest level of care would be by a licensed home health care professional. Wodatch said this is someone who has the ability to administer medications, including shots if necessary, and would be needed by anyone with long-term health concerns. Consumers must have an order from a health care provider to access these services.
The field includes everyone from registered nurses to physical therapists to speech therapists. They are licensed by the Department of Public Health and must follow strict regulations, Wodatch said.
Tracy Wodatch Arielle Levin Becker / CTMirror.org
“The other level of care is what we would call long-term services and supports,” she said. “Somebody doesn’t really have a medical diagnosis, maybe they have some dementia, they can’t live alone, but they’re certainly able to get up and about, they might not remember to take their medications, they might not remember to take a shower or eat. So they really need a support system in there to help them with a structured day.”
At this level, she said, residents on state Medicaid waivers can hire a personal care aide, or PCA, to help them with daily tasks.
Many PCAs are represented by SEIU 1199 New England. Their numbers have grown from fewer than 6,000 in 2012 to about 11,000 now.
The PCAs are listed in a binder of printed pages created by the contractor hired by the state Department of Social Services to handle payroll, but the information that is available is often outdated, and there is no searchable online database.
“A lot of it is through word of mouth. I’ve seen people posting for PCAs on grocery store bulletin boards. I’ve heard of people posting for them on Craigslist. It’s all over the map,” said Diedre Murch, home care director with SEIU 1199 New England, the state’s largest health care workers union, which represents many of the PCAs.
PCAs are not licensed by the state, and while they are not authorized to dispense medications or provide medical services, such as wound care, many end up doing just that, Murch said.
“We often think of home care as kind of like the wild, wild west,” Murch said. “There’s a lot of gray area in home care. Technically they’re not doing medical tasks, but it’s not uncommon to have a PCA talk about removing suctioning tubes.”
“There are certainly a pretty large number of caregivers who provide some pretty advanced care to people with very complex medical needs,” she added.
We often think of home care as kind of like the wild, wild west.
Diedre Murch, SEIU 1199 New England
The third level of care is what Wodatch refers to as “agency-based, long-term services and supports.” Those are usually provided by a homemaker companion agency, she said.
All homemaker companion agencies must be registered with DCP, but their workers are not licensed by the state.
Just over one-third of the HCAs participate in a state-funded Medicaid waiver program called the Connecticut Home Care Program for Elders. Those agencies are subject to some additional quality checks and audits from a fiscal intermediary hired by the state.
The different state agencies involved, varying licensing requirements and a dearth of accurate information make the system difficult to navigate, advocates say, especially for consumers facing family emergencies.
“A lot of people come into needing home care services at a moment of crisis in their life and find it really confusing to understand. If there’s a problem, do I call DPH? Do I call DCP? And it feels very unclear,” AARP Executive Director Anna Doroghazi said.
Anna Doroghazi, policy and advocacy director for the AARP in Connecticut, far right, talks to Antonio Matta, architect at Goodwin University. Doroghazi said there aren’t enough workers in the home health agencies compared to the demand. “We know that the need for it is going to grow and grow as we have an aging population,” she said. Yehyun Kim / ctmirror.org
“It’s a very, very disjointed consumer experience,” Doroghazi said. “I get a lot of very upset, very surprised calls from consumers who are saying, ‘I didn’t realize there were different standards for background checks between my homemaker companion and my personal care aide like, why, why is this happening? How do I fix this?’”
‘Keeping my father hostage’
Constantine Milonas was frustrated having to deal with multiple agencies when he discovered his father’s personal care aide had moved into his apartment and wouldn’t leave.
Milonas said he was stunned when he walked into the emergency room at St. Mary’s Hospital in March of 2018 to see the woman who had been hired as his father’s PCA telling doctors they were married.
“I was shocked when the doctor told me that ‘Ms. Milonas’ had informed them she was in a romantic relationship with my father, so they should inform her of all medical decisions,” he said.
Her name was Kelly Jennine Peters, and she had been hired through a company called Quality Home Care to be a personal care aide for 79-year-old James Milonas, who had suffered a stroke a few years before.
James Milonas died a few weeks after he was brought to St. Mary’s, but the family’s troubles with Peters were far from over, according to the complaint the family’s attorney filed with the state. The aide refused to allow them into the apartment or turn over the keys, the attorney wrote, and said she had moved in when they became a couple.
We don’t know what happened to this woman who took over this man’s house, but neither does the state, and she could be doing it all over again elsewhere and they wouldn’t know.
attorney Mary Alice Loughlin
Milonas said he tried multiple times to gain entry to his father’s apartment and get the keys back but was unsuccessful. He then hired attorney Mary Alice Loughlin, and she filed complaints with the HCA, state Office of Elderly Protective Services and, finally, DCP.
“There was nothing I could do. I had the power of attorney for my father, and I couldn’t even get into his apartment, and I couldn’t get anybody to help me out,” Milonas said.
Eventually, Loughlin, with the assistance of Waterbury police, did get the family into the apartment and removed some of the father’s possessions.
DCP opened an investigation in the spring of 2018 and found that the agency fired Peters before the state could fully investigate.
Quality Home Care could not be reached for comment. But the DCP investigative file contains a letter thatQuality Home Care President Miguel Rosado wrote to Peters informing her that she “was no longer employed by Quality Home Care effective immediately.”
“As you know, you never have been and are not now authorized to occupy the residence of James Milonas,” Rosado wrote. “You were not assigned to any oversight position and have never been entitled to occupy the residence.”
Rosado ended the letter warning Peters “she was not permitted by the Milonas family from attending the wake, funeral of graveside service.”
Peters could not be reached for comment.
When DCP finished its investigation in October 2019, the company was ordered touse specific language in employee contracts having them certify they don’t have criminal records.
“The state doesn’t have the resources to adequately inspect, oversee and police the home care field,” said Loughlin, the family’s attorney. “We don’t know what happened to this woman who took over this man’s house, but neither does the state, and she could be doing it all over again elsewhere and they wouldn’t know.”
Growing problem
DCP Deputy Commissioner Pamela Brown, who oversees the agency’s investigative units, said in an interview with the CT Mirror that the agency randomly audits about two HCAs a month. The department has one supervisor and two investigators dedicated to investigating complaints against HCAs.
Brown said in 2019 there were 81 complaints filed with DCP; the number rose to 120 in 2020 and fell back to 73 in 2021, with 64 complaints in 2022.
A review of these complaints shows that many are either billing issues, false advertising allegations against a company, or accusations that apersonal care aide has left someone home alone.
“Advertising is one of our larger issues, where as someone may say they offer home health services when they’re actually a homemaker companion, or they claim they offer a higher level of service for dementia care or Alzheimer’s care when their staff hasn’t been trained in those areas,” Brown said.
Complaints of fraud or abuse are passed onto law enforcement agencies or, in cases of just fraud, to the banks involved. Given the number of complaints compared to the number of staff, the agency has no choice but to pass on many investigations.
“We can always use more staff there. I mean, this is a growing issue,” Brown said. “Investigating these complaints is going to take time, especially when you are dealing with someone’s finances.”
She acknowledged the state relies on the agencies to police themselves because the state just doesn’t have the manpower to do so.
“There are over 900 home companion agencies registered in Connecticut right now. Some of these individuals are working in someone’s home either 24 hours a day, or 12 hours a day, and I believe if we had more supervision site visits from these agencies themselves, that would prevent a lot of the problems,” Brown said.
Brown also testified before the task force and emphasized the department’s concern that many HCAs are falsely advertising services they cannot provide.
‘I figured, what the heck’
Regina Stankaitis, 69, knew she was going to need some assistance at her Cromwell home after surgery and decided to contact “Care Giving by Kathy” — the homemaker companion agency recommended by her doctor’s secretary.
But Sally Douglas lasted barely a week as her aide before Stankaitis, feeling threatened by her new aide, asked her to leave. It wasn’t until about a month later, when her bank contacted her about a $4,000 check for a paint job at an apartment in Rocky Hill, that she realized something was wrong. Police later determined Douglas was living in the apartment.
She went to her bureau and discovered that the checkbook she kept hidden in her underwear drawer was missing. She called her sister, andthey filed a complaint with the Cromwell police.
“I figured if someone from the doctor’s office was recommending them, then I figured what the heck, they must be OK,” Stankaitis said. “But boy, was I wrong.”
The police investigation showed that Douglas, who only worked for the agency for one week, also had used Stankaitis’ credit card to purchase about $2,300 worth of furniture for the Rocky Hill apartment. Police also discovered thatDouglas had a previous criminal record that included assault, criminal trespassing and threatening, and had been charged with third-degree larceny only a few months before she became Stankaitis’ personal care aide.
Care Giver by Kathy Business Manager Ciara Lundell said she couldn’t discuss an employee but noted, “Sally Douglas was only an employee here from Aug. 10 to Aug. 18th.”
Police charged Douglas in March 2022 with third-degree larceny and second-degree identity theft. Her case is still pending in Middlesex Superior Court, and Stankaitis has attended all 14 court dates, with the next onescheduled for May 4. Attempts to reach Douglas’ attorney, Richard Silverstein of New Haven, were unsuccessful.
“I want to see this through and make sure she is held accountable so she can’t do this to anyone else,” Stankaitis said.
Yehyun Kim / ctmirror.org
“CT’s Elder Care Reckoning” is a four-part series about Connecticut’s aging population and the challenges in finding ways to care for people.
Want to share what you know? Send your tips to Jenna Carlesso at jcarlesso@ctmirror.org or Dave Altimari at daltimari@ctmirror.org.
PROJECT CREDITS
Reporting: Dave Altimari, Jenna Carlesso Photography: Yehyun Kim Data visualization: Katy Golvala Editing: Elizabeth Hamilton, Stephen Busemeyer, Keila Torres Ocasio Social media: Gabby DeBenedictis, Nicole McIsaac Web development: Kyle Constable
Ebony Ross-Peel, of Waterbury, wasn’t paid for two months for two weeks of her work as a personal care aide. It led her to be evicted and lose her car because she couldn’t pay for her car insurance. “They want quality of life from us for their clients. That’s what I want,” she said. “But where’s my quality of life?” Yehyun Kim / ctmirror.org
Editor’s Note: This is the first report in a four-part series about Connecticut’s aging population and the challenges in finding ways to care for people.
This week: The country’s aging population is expected to more than double. Connecticut’s network of supports is struggling.
Next week: Nursing homes face a reckoning as they deal with fewer residents, a change in pay and plans to ‘right size’ the industry.
Upcoming: As more people choose home and community options over institutional care, will access to services be equal for all?
Upcoming: More people are aging in place. But the state’s home care industry operates with little oversight.
Connecticut’s elder care system is at a precipice.
Nursing homes, for decades the final destination for many older adults and people with disabilities, are being squeezed at both ends as state officials increase oversight of the industry while funneling millions intoprograms that aim to keep residents in their homes and communities.
The state’s aging nursing facilities, beset by staffing problems, outdated infrastructure and dwindling financial support, are facing an identity crisis. Occupancy, which plunged steeply during the pandemic, has yet to fully recover. Complaints about the quality of care in some homes are escalating, as arequestions about how owners spend taxpayer money.Connecticut policymakers no longer envision nursing homes as the primary option for elder care but as a recourse only for those with medical needs that can’t be managed at home.
At the same time, the state’s lofty goals for boosting the number of people aging at home have hit roadblocks.
Connecticut launched a vast network of programs in recent decades designed to prevent unneeded nursing home admissions and increase the flow of people from facilities back to the community. State officials use terms such as “right-sizing” and “rebalancing” when contemplating the future of long-term care, with the objective of reducing the number of nursing homes.
By 2040, state leaders expect a nearly 30{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} increase in the number of long-term care residents on Medicaid who remain in their homes, and they’ve committed more than $1 billion annually to that cause.
But a year-long review by The Connecticut Mirror that encompassed interviews with state officials, elder care advocates, legislators, nursing home leaders and union representatives has found the intricate web of resources supporting those ambitions is fraying.
Private agencies and the state are struggling to recruit enough workers to care for this expanding population. Residents complain of difficulty navigating a convoluted home care system that operates with little oversight. A dearth of affordable housing and a lengthy process for accessing Medicaid are undercutting efforts. And Connecticut lacks a streamlined process for hospital discharges to the community, as it has with nursing homes.
The stakes are extraordinarily high. The nation’s 85-and-older population is expected to more than double by 2040. And Connecticut shoulders a disproportionate number of older adults. The state ranks 4th-highest nationally for its share of people in that age group.
“We’re in a care crisis, a housing crisis and a nursing home crisis. We’re at a dire point now,” said Rep. Michelle Cook, D-Torrington, a member of the legislature’s Human Services Committee. “There is a rapidly aging community. A vital part of our state’s future is how we navigate this.
“We have a moral and ethical obligation to take care of people.”
“I don’t think enough people are paying attention to this,” said Sen. Cathy Osten, D-Sprague, co-chair of the Appropriations Committee and an influential member of the Nursing Home and Assisted Living Oversight Working Group. “The things we pay attention to concern the next generation, what we are doing for children, and we certainly should do things for children. But we need to put as much into services for seniors as we are putting into services for young people.”
Advocates, lawmakers and elder care experts say there is an urgent need for better strategies to attract and retain a workforce that will aid Connecticut’s aging and disabled population, to ease the cumbersome process of navigating the home care system, to speed up Medicaid enrollment, and to address peripheral problems like housing that have an outsized impact on how and where people age.
“We need to address this in a big way, or we’re not going to have the workers and the physical infrastructure to care for an older population,” said Anna Doroghazi, associate state director of advocacy and outreach for the AARP in Connecticut. “We can’t just react to what the need is now.”
“We have to meet the immediate need but also to anticipate what that’s going to be years from now, when we will have more people over the age of 60 than under 18,” she said. “We’ve never had that. We don’t know what that world looks like. But we do know that it’s on its way and we have to rethink a lot of things.”
Anna Doroghazi, right, policy and advocacy director for the AARP, and Heidi Carlson, a grant officer at Goodwin University, try out exercise equipment during a tour of South Meadows River Trail that AARP funded to make the trail more accessible. Doroghazi said better coordination is necessary to make information accessible for people who need it. “There are three different state agencies involved with regulating different pieces of home care, and they don’t really talk to each other,” she said. “So when people want information, they’re not sure where to go.” Yehyun Kim / ctmirror.org
Problems mount in nursing homes
For decades, the bulk of the state’s long-term care spending went toward institutional settings like nursing homes. But just before the pandemic began, that trend shifted considerably.
In 2018, for the first time ever, the state spent more Medicaid funds on home and community-based services than on institutional care, 53{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} to 47{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b}, state data show. By 2022, it had spent 58{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} of its Medicaid long-term care money on home services, versus 42{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} for nursing homes and other facilities.
Although the spread of COVID accelerated that swing, a migration from institutionalized care to home services had been underway for years. In 2009, 65{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} of the state’s long-term care Medicaid expenditures went to nursing homes. By 2017, that number had dropped to 50{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b}.
Nursing home occupancy fell steeply during the early months of the pandemic. Hovering around 88{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} statewide before the first reported case of COVID, it plunged to 71{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} by July 2020.
As of February 2023, it had climbed to 83{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} but still hadn’t reached pre-pandemic levels.
Facility operators have sought $193 million more from the state to sustain struggling buildings. State officials balked at the request, and lawmakers raised questions about how several infusions of money during the pandemic were spent.
“We’re concerned about quality,” said Matthew Barrett, president and CEO of the Connecticut Association of Health Care Facilities. “As we move to the other side of the pandemic, especially as it relates to high Medicaid facilities and serving low-income communities, there is evidence that they continue to be under-resourced, and without proper focus and attention, we’ll continue to see slippage.”
People send me pictures and videos of their loved ones in nursing homes with their bed sores and whatnot. It’s horrific.
Rep. Jane Garibay, D-Windsor, co-chair of the Aging Committee
Nursing home owners say they are having extraordinary difficulty recruiting and retaining workers, and many facilities are understaffed. From February 2020 to December 2022, the nursing home industry lost 210,000 jobs nationally, and staffing tumbled to levels not seen since 1994, officials with the American Health Care Association and National Center for Assisted Living said.
And in recent years, complaints about care in nursing homes have increased. In 2017, the Office of the State’s Long-Term Care Ombudsman logged 3,090 grievances from nursing home residents and their loved ones. Last year, it received 4,278.
Complaints range from lack of access to care, typically from understaffing, to meals arriving late and cold, problems with heating and air conditioning, trash piling up and residents missing daily activities.
During the last quarter, the health department issued four “immediate jeopardy” findings in Connecticut. In general, there has been an increase in those orders, at least partially due to staffing issues in nursing homes, Barbara Cass, chief of the department’s health care quality and safety branch, said at a public meetingrecently.
The findings indicate that violations in a nursing home caused or were likely to cause serious harm or death to a resident.
The problems have stirred debate at the Capitol.
“People send me pictures and videos of their loved ones in nursing homes with their bed sores and whatnot. It’s horrific,” said Rep. Jane Garibay, a Democrat from Windsor who is co-chair of the Aging Committee. “Here we are discussing if we can afford to put in air conditioning for seniors when the majority of our animal shelters have air conditioning. We have to change the way we think.
“When someone says, ‘I went to see my father. He got up in the morning, and they didn’t answer his bell so they could assist him to the bathroom. After three hours, he went in his bed and they served him lunch in that state without cleaning him,’ people will say, ‘Oh, that’s awful.’ But there’s just not the outrage. I get outraged.”
Lawmakers have introduced bills during the 2023 legislative session to raise the mandatory minimum staffing hours in nursing homes, to require more transparency in how facility operators spend state money, to mandate that owners provide air conditioning in resident rooms, and to prompt broader disclosures about private equity investment in long-term care, among other proposals.
State officials are also trying to “right size” the nursing home industry by scaling back the number of beds — and, eventually, facilities — to align with current demand. Lawmakers are weighing a measure that would slash funding for buildings whose occupancy drops below 90{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} over a 12-month period.
“Essentially, we no longer want to pay for excess beds,” Andrea Barton-Reeves, the state’s social services commissioner, said at a public hearing in February.
A push for home care, a lack of direction
Home care services are ideal for both residents and the state. Most people prefer to age at home, and it costs less for the state to fund a Medicaid recipient in home care than in a nursing home.
But difficulty navigating the system has left many people feeling lost. For people already at home, the confusion can cause delays in getting care. For those in nursing homes who want to move back to the community, it can mean extra time sitting in institutional settings waiting for services to line up.
One issue is the absence of an updated home care worker registry. People on the state’s Medicaid program seeking care at home receive a binder with printed pages containing the names and contact information of potential employees.
But several residents have said the paper registry, produced by the state’s payroll agency, does not have up-to-date information for employees. Some people reported spending weeks calling candidates, only to be told they no longer work in the field, they could not take on additional clients, they did not live within a reasonable commuting distance or, in cases of people with special needs, they did not have the right skills.
Workers have complained about providing updated contact information but never seeing it reflected in the registry.
“There is a paper list. The reports we tend to hear about it are that it’s not up to date and it often does not reflect who’s actually looking for work,” said Diedre Murch, home care director with SEIU 1199 New England, the state’s largest health care workers union. “I’ve heard consumers talk about having to go through dozens of workers just to find someone who’s looking for another client. People tell me they live in Stamford and get names of employees from Manchester.
“Some of the workers say, ‘Oh my God, I’ve given my updated contact information 40 times and they still have my bad phone number on the directory.’ I hear a whole constellation of problems.”
Alan Coker, left, and his personal care aide, Jackie Katibian, leave after grocery shopping. Coker had several strokes and back surgery and receives help from two personal care aides for daily tasks. Yehyun Kim / ctmirror.org
Coker watches a comedy show that he loves. “We have happy lives now,” he said. He is happy that he can take a walk, meet his family and go grocery shopping whenever he wants to, which wasn’t possible at a nursing home. Yehyun Kim / ctmirror.org
Coker’s to-do list hangs on the wall. He is passionate about Bible education and joined an online school to enhance his teaching skills. Coker thinks he wouldn’t have been able to do that at a nursing home. Yehyun Kim / ctmirror.org
Jackie Katibian, one of Alan Coker’s personal care aides, cleans his house, does the laundry and drives him to doctor’s appointments. “If I don’t have PCAs, I can’t stay home. That’s part of the condition for me to be on my own,” Coker said. Yehyun Kim / ctmirror.org
Katibian, right, takes a short break after cleaning the bathroom. It took a lot of effort for Coker to hire personal care aides after staying at a nursing home for 10 months. “They just gave me a notebook and said you got to hire somebody … I really didn’t know what I was doing,” Coker said. “I would have appreciated if I had some guidance and some hands-on assistance.” Yehyun Kim / ctmirror.org
Coker’s house is covered with photos of his loved ones, including social workers who helped him leave a nursing home and live independently with assistance. “There’s no reason to stay in a nursing home when you can get back on your feet,” Coker said. “If you put somebody in, you’re going to put me in a nursing home to die.” Yehyun Kim / ctmirror.org
After receiving care in a nursing home for 10 months, Alan Coker, 65, wanted to transition back to a home. Through a state program called Money Follows the Person, Coker set out to hire aides who could help him prepare meals, clean, run errands and shuttle him to doctor appointments.
But the process proved difficult. During an initial visit with an employee from the state’s payroll company, Coker said he was able to ask questions, but the answers weren’t especially helpful in picking a home care aide. After calling several candidates and conducting interviews, Coker spent more than a month in the nursing home waiting for paperwork to be processed.
“I was getting worried because I couldn’t leave the nursing home until I was able to find somebody,” said Coker, who lives in Manchester.
He wishes he had received more guidance and information about the system up front.
“I was given a notebook and told a checklist of employment information and questions you can ask — ‘You can ask for references, you can do this, you can do that.’ But there was no help from there,” Coker said. “Mistakes could be prevented or done away with if there was more initial assistance given. They’re basically throwing the consumer and the new personal care aides right into the fire.”
Mairead Painter, the state’s long-term care ombudsman, and others have recommended developing an electronic database with worker information that can be updated regularly.
“It is so antiquated, the way it’s done,” she said. “It needs to be electronic. There needs to be a database where someone can click and see — ‘I’m still working’ or ‘I’m not working,’ instead of literally this thing of paper. Everything should be computerized.”
Officials at the social services department said they plan to issue a request for proposals to hire a company that could develop an electronic database, though they did not give a target date for when the request would be issued or when the project would be completed. It would be funded with state and federal money.
The revolving door of home care workers is hard on some people and disrupts continuity of care. And trouble navigating the system means residents are going through a burdensome hiring process repeatedly.
Sharon Thorstenson, of Southington, gets her hair colored by her niece Megan Murphy. It was the first time getting her hair cut since 2017, having stayed home most of the time during the pandemic partially because of her compromised immune system. Yehyun Kim / ctmirror.org
Sharon Thorstenson, second from right, spends time with her relatives at their home after not having seen them for a long time. Yehyun Kim / ctmirror.org
Sharon Thorstenson, 58, began needing care in 2017 after a tick bite left her with a disability. She made a volley of calls to potential workers before landing a person who was right for her.
“Initially, I want to say I probably made 30 phone calls,” said Thorstenson, a Southington resident.
“It was very challenging, because there was so much thrown at you. And they really didn’t walk you through the program. You pretty much were given a binder with legal forms and things like that. There were so many things, and I wish there was more guidance from the agencies so it wasn’t so time-consuming and frustrating.”
To make matters worse, problems with compensation from the payroll agency and other issues meant workers kept quitting. From 2017 to 2021, her first years of home care, Thorstenson estimates she hired 28 different aides. Aside from disrupting her care, the exits were painful because she formed relationships with workers, only to have them leave over and over again.
“It breaks my heart,” Thorstenson said. “It’s kind of like grieving, because you’re losing somebody.”
‘Massive need’ for increased workforce
Home care is a fast-growing field in Connecticut. In 2011, there were nearly 21,000 home health and personal care aides working in the state. By 2021, there were about 38,000.
But the industry experiences staggering turnover, and the population it serves is expected to grow substantially. That has raised alarms for officials in the long-term care sector.
Turnover is 30{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} to 50{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} a year in the 11,000-member unionized workforce of personal care aides that serves residents on Medicaid. Low wages, problems getting paid on time and, until recently, a lack of paid time off have hampered efforts to keep workers in the industry.
Even at private sector agencies where benefits are better, some employers report an annual turnover of 50{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} or more.
“The biggest challenge — and it’s getting worse — is workforce availability,” said Julie Robison, professor of medicine at the UConn Center on Aging. “There is a massive need for an increased workforce in institutional settings but even more so in the community. You have lots of demand, and you have organizers who are willing to help set up plans for people. But just getting the day-to-day workers on the ground has been extremely challenging.
“The wages are low, the benefits are spotty, and it’s really hard work. Some people are just made for it and are so good at it. They should have a living wage.”
“It’s a real struggle,” added Painter. “We have many, many more older adults and individuals who may have care needs than we do the population of people who want to do that work.”
This is still not a living wage in Connecticut.
Diedre Murch, home care director with SEIU 1199 New England
Until recently, the personal care aides represented by 1199 SEIU in Connecticut made an average salary of $16.25 per hour, or $33,800 annually. After more than a year of rallies and bargaining, the union reached a new agreement with the state that raised pay to $17.75 an hour in 2022. For many members, it increased again to $18.25 this year.
“Our members are excited about the raises, but it’s clear this is still not a living wage in Connecticut,” said Murch, the 1199 home care director. “A living wage is north of $20 an hour. Even at $17.75, if you work full time, you’re making $36,000 a year. So it’s still a real struggle.”
In a 2022 union survey, roughly one-thirdof the personal care aides reported being behind on their rent or mortgage payments during the last year. Forty-two percent said they had paid late fees or were referred to a collection agency for unpaid bills, andmore than one in five received a shutoff notice for utilities or had their utilities turned off during the past year.
Thirty-seven percent of the aides said they rely on food stamps, and a thirdcould not afford groceries or did not have enough food to feed their families over the last year. Seventy-two percent reported using some form of state assistance.
Halfof the PCAs reported taking unpaid days off during the last six months due to illness or quarantine. For years, the workers did not have regular paid time off (federal programs during the pandemic provided some relief, as did the recently enacted paid leave law). Under the terms of the new union contract, full-time aides were granted five paid days off, though union leaders say that benefit is on hold until the state hires a new payroll agent.
“There’s still a long way to go,” said Murch. “It’s not like illness neatly confines itself to five days a year.”
Aside from low wages and scant benefits, many personal care aides have complained about late payment or non-payment from an agency hired by the state to manage payroll. The unreliability of the agency, Allied Community Resources, to pay employees promptly has caused some workers to leave the industry, union officials and employees said.
For those living paycheck to paycheck, the consequences are worse. Some workers have been evicted from their homes or faced the threat of eviction.
Ross-Peel calls a state office to reinstate her food stamps. She raises a 2-year-old son as a single mom and sometimes has had to choose between buying diapers or clothes. Yehyun Kim / ctmirror.org
Ebony Ross-Peel, 27, took on a new home care client in July 2022, her only one at the time. After two weeks of work, Ross-Peel had not received payment.
She and union leaders sent urgent pleas to the state and its payroll agent about the missed compensation. Confusion over paperwork was blamed for the problem.
But the late paycheck caused Ross-Peel, who has a 2-year-old son, to be evicted from her home.
In an email she sent to union leaders and the state on Aug. 18, Ross-Peel pressed for answers.
“So am I going to be receiving payment today or tomorrow? Because I had to let my son stay with my mom last night and sleep in my car,” she wrote. “I just need to know what I am doing tonight.”
“I shouldn’t have to go through this amount of stress over not getting paid for work,” she said in an August interview. “I just don’t understand it. I have never been through something like this in my life.”
Ross-Peel eventually was paid, but she left the field not long after.
“I most certainly do not want to work in home care anymore,” she said. “You give so much and you get so little out of it.”
Murch said many aides have complained about nonpayment or late payment. In 2022, the union received 1,653 grievances against Allied from personal care aides over payment problems. It has received 622 so far this year, she said.
She remembered one worker who went as long as 12 weeks without compensation.
“I can’t even talk about this without getting emotional,” Murch said. “I have been texting with a worker who is being evicted because Allied didn’t process her new hire paperwork. … I wish I didn’t hear these stories ever, but I wish I didn’t hear them every single week.”
Don Waddell, executive director of Allied, said all kinds of issues can cause problems with payment. For example, he said, if a client is discharged home from the hospital and begins receiving services, the company can’t pay a worker until it knows the client’s discharge date.
“We have rules and rules that we have to check before we actually make the payment,” he said. “We just can’t pay anything that comes to our office.”
In a joint statement, Waddell and Allied CEO Leigh Gallivan Mahoney added: “Our staff work extremely hard to clear up issues with employers and providers and are dedicated to processing the payroll … as quickly as possible,” they said. “We know how critical it is for them to receive their pay every week.
“We have also introduced multiple ways for employers and their providers to report payment issues, all to streamline the problem-solving necessary for managing such a complex system. One of these areas is our website, which has an integrated problem-resolution form and online chat.”
State officials said they are aware of the payroll problems and put out a request for proposals to hire a new company to manage payments.
“The RFP process has concluded, and the state is in active contract negotiations with the selected vendor,” said Jalmar De Dios, a spokesman for the Department of Social Services. “The contract, which will include specific service level agreements, will start when negotiations are complete.”
State officials did not provide an estimate for when the new company would begin work.
“The goal [with the new vendor] is 100{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} payment on time, which we don’t have right now for a lot of different reasons,” said Dawn Lambert, co-leader of the Community Options Unit at the social services department. “There is a history of corrective action with Allied. We are aware of some performance targets not being met and have put in place corrective action over the years.”
But that hasn’t stopped the issue from recurring, even recently.
Union leaders said that even when a new company takes over, the state should provide better oversight to ensure payroll problems don’t keep happening.
“Sadly, the state has been slow on this,” said Pedro Zayas, a spokesman for 1199 SEIU. “Hopefully, the new payroll agency will make good for these members. We don’t expect perfect payroll, we know it’s thousands of workers, but we need good customer service.”
Challenges abound
Aside from an unwieldy system and cratering workforce, the state faces other barriers as it tries to encourage more people to age at home.
Lengthy wait times for accessing Medicaid, the lack of a streamlined process for hospital discharges to the community and challenges with housing also pose obstacles.
Medicaid, the primary funder of long-term care services, has a long approval process, sometimes as many as 90 days for verifying eligibility, state officials said. For people who need elder care urgently, the system can unintentionally steer them toward nursing homes.
“Nursing homes will typically admit an individual pending Medicaid eligibility determination because they are generally able to bear the cost of providing services until they are eventually paid, or even to withstand a total loss if they are never paid,” officials with the AARP noted in a 2021 report. “In contrast, agencies that provide home and community-based care typically cannot afford to start services without the certainty of being paid right away.”
“The time period between applying and final approval of Medicaid eligibility can be particularly perilous and stressful for individuals who urgently need long term services but have limited resources,” the authors wrote. “To avoid a nursing home admission, they must either rely on family caregivers or privately pay for home-based services, all the while navigating a complex, fragmented system of providers.”
Advocates have urged the state to consider “presumptive eligibility” as a way to help more people avoid institutionalized care.
I most certainly do not want to work in home care anymore. You give so much and you get so little out of it.
Ebony Ross-Peel
Under the program, case managers and social workers can use screening tools and basic financial information to determine if a person is qualified for Medicaid and temporarily provide services, the AARP noted.
“To say, ‘Go sort it out for 90 days at home while we do the paperwork’ — some people can’t go 90 days without services. If they can, it might be because they have a friend or daughter or son who can take on a lot of that care, which also comes at a cost,” said Doroghazi, the AARP advocacy director. “There’s a big ripple effect, so presumptive eligibility is something that would be helpful.”
At least seven states already offer it. Five of them — Michigan, Washington, Ohio, Vermont and Rhode Island — adopted policies that allow for presumptive eligibility. Two states, California and Indiana, are offering it under a temporary Medicaid amendment.
In Connecticut, lawmakers introduced a bill in 2021 that would have established a presumptive eligibility program for certain home care applicants, but the measure never made it out of the Human Services Committee.
The program poses a risk. If a person ultimately is found ineligible for Medicaid, the financial burden of the services falls on the state or is shared with home care providers.
“It’s really about underwriting it upfront,” said Lambert at the social services department. “We’re going to assume that you’re going to qualify, and we’re going to pay your claims as if you qualify. And then we’re going to go through the [eligibility] process.
“If we’re right, we’ll go back and claim all of that money appropriately to Medicaid. But if the state’s not right, it’s going to continue to fund that, which could be expensive.”
Despite that, advocates say the state should consider the potential savings in averting unnecessary nursing home care.
“On average, states can provide care for approximately three individuals at home for the cost of one in a nursing home,” AARP officials wrote in the 2021 report. “Washington state officials determined that each client in their ‘fast-track’ presumptive eligibility program saves Medicaid an average of $1,964 a month by helping individuals access community services instead of institutional care.”
Affordable housing is critical, and we don’t have it. We cannot get people out [of institutions] because they can’t live in their community of origin. It’s so expensive.
Mairead Painter, long-term care ombudsman
As Connecticut tries to keep more older residents at home, it also must explore better options for hospital discharges to the community, advocates say.
The hospital discharge process often shuffles older adults and people with disabilities to nursing homes because those facilities already have the infrastructure to care for them and can ensure a smooth transition.
“Ownership structures, in some cases, lend themselves to going from hospitals to nursing homes because they have the same management. A big health care system might have its own rehab center and nursing homes,” Doroghazi said. “It’s an easier lift for case managers and care planners.”
The Connecticut Hospital Association acknowledged that hospital discharges to the community are rife with challenges but said patient releases of any kind can be difficult.
“A lack of available home care services, due to the present health care workforce shortage, is impacting the staffing of home and community-based care programs and agencies, and delays in securing the necessary durable medical equipment to meet needs … can create further challenges,” said Nicole Rall, a spokesperson for the organization.
Residents who would prefer to be discharged to the community might not know they have that as an option, Doroghazi said. And hospital discharges to the home can be more difficult because there is no streamlined process for accessing community support systems. Low-income residents who need care immediately after their hospital stay may be steered toward a nursing home, because those facilities can accept people while they are waiting to be approved for Medicaid.
But discharging people to nursing homes increases their risk of remaining there. Data show nearly two-thirdsof all Medicaid participants who enter nursing facilities are still there after six months, according to a state study of long-term care needs.
“Thus, for vulnerable populations, entry into a nursing facility can often lead to permanent institutionalization and loss of community ties and individual freedom of choice,” the report’s authors wrote.
Transitions from nursing homes back to the community are also complicated by a lack of affordable housing.
If a Medicaid recipient is looking for an apartment, it must be within the state’s maximum allowable rent, which varies depending on the town of residence and the number of bedrooms. It also must suit the person’s needs; someone who relies on a wheelchair must have a wheelchair-accessible unit.
Finding safe, affordable housing has proven difficult for many aging residents and people with disabilities.
“Affordable housing is critical, and we don’t have it,” said Painter, the long-term care ombudsman. “We cannot get people out [of institutions] because they can’t live in their community of origin. It’s so expensive.
“If you want to live in your community of origin and you live anywhere [in Fairfield County], for example, you really can’t find housing for most people unless you’re going to put them in horrible housing.”
The state study also cites affordable housing as a key impediment to home-based care.
“Finding adequate housing can be more challenging than developing the array of services needed to assist consumers,” its authors noted.
Weighing solutions
State officials say they are working on solutions to help ease the migration from nursing homes to home care.
For people seeking long-term care, they have launched a website, myplacect.org, with information about the process and what services are available.
Organizers say they plan to add podcasts and other elements to the site “to reach a broad range of audiences.” But advocates contend that the website still has a low profile, and a state study recommends increasing its readership.
The state also plans to build an electronic registry of home care workers that will be updated regularly.
“An RFP has been drafted and is near finalization and will then move through the final approval processes before issuance,” De Dios, the social services department spokesman, said.
In the meantime, the state Department of Developmental Services will put some worker contact information on its website to help connect people in its programs with personal care aides.
Painter has suggested the addition of a mobile app where consumers can search for prospective home health aides on their phones.
In the coming months, state employees will begin testing screening tools that could be used in a presumptive eligibility program, though no funding is lined up to launch the initiative.
“We have screening tools, we have an interview tool, and we’ve done training on them,” Lambert said. “We’ve worked with other states on the development of those tools.”
But to offer presumptive eligibility, Connecticut will need to set aside money to fund care for people awaiting Medicaid approval. Officials at the social services department said they did not know of any immediate plans to do that.
“It would have to be money appropriated by the state, because the state would be at risk,” Lambert said. “I’m hopeful of continuing the discussion.”
The study on long-term care lays out recommendations to prepare for the ballooning aging population.
To expand the home care workforce, it suggests recruiting employees who have left the nursing home industry. It also recommends boosting the profile of myplacect.org, increasing the number of physicians’ offices, hospitals and other locations that provide information on long-term care options, and creating an educational campaign for hospital social workers and discharge planners to improve awareness of home care services.
“Given the aging demographic, there is an urgent need for systemic reform,” the authors wrote.
The state’s health czar agrees.
“The country as a whole is undergoing a shift in demographics,” said Deidre Gifford, senior adviser to the governor on health and human services and executive director of the state Office of Health Strategy. “The population of the country is aging, and people are wanting to age in place. We need to adapt our health care system to align with those changing demographics.”
Legislators say that in the coming years, a wide-ranging bill or set of proposals is needed to address these issues in a broader way.
“The plan is not there,” said Garibay, co-chair of the Aging Committee. “We see the problem coming, but right now we’re just trying to plug the dike with patches. We need to have an overall plan, and we have to work together.”
CT Mirror staff writer Katy Golvala contributed to this story.
CVS Health Corporation (CVS) has emerged as a pioneer in the pharmaceutical industry in the 21st century.
With roughly 85{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} of Americans living within five miles of a CVS pharmacy, the company is the most profitable retail pharmacy in the U.S. While Rite Aid has a net worth of roughly $200 million and Walgreens is worth $30.52 billion, CVS’s net worth is a whopping $104.57 billion as of March 3, 2023.
CVS came to dominate the retail pharmacy industry and beyond through ever-expanding operations fueled by acquisitions, mergers, and partnerships:
The first wave of acquisitions
The Consumer Value Store first began in 1963 as a health and beauty retailer in Lowell, Massachusetts, before changing its name to CVS in 1964.
Pharmacies within CVS stores were introduced later in 1967, and two years later the company was sold to Melville Corporation.
By 1988, the chain grew to 750 stores with sales reaching roughly $1.2 billion. But it wasn’t until 1994 that CVS’s health care and pharmaceuticals became the primary sources of revenue.
That’s when CVS introduced PharmaCare, a pharmacy benefit management company (PBM), which serves as the middleman between insurance companies and pharmaceutical manufacturers.
Subsequently, as the internet boom swept across the country, CVS capitalized on the opportunity by acquiring Soma.com for $30 million. Soma was one of the first big digital drugstore startups, and the acquisition helped put CVS on the map digitally, giving the company leverage to launch its own website.
“The Internet is a logical extension of our business strategy of making life easier for our customers,” CEO Tom Ryan said at the time.
PBM domination
Fast forward to 2006, CVS acquired Caremark, a PBM, and merged the company’s operations with PharmaCare. This eventually became CVS Caremark, which is now one of the three biggest PBMs in the prescription drug market that dominate market share. As of 2022, CVS Caremark led the way with 34{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} market share while Express Scripts accounted for 24{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} and Optum Rx accounted for 21{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b}.
The Caremark deal was unique in that health insurers, rather than pharmaceutical retailers, are typically the ones who buy PBMs through a strategy known as vertical integration — that is, when a company acquires another company in the supply chain or industry and uses it to its advantage.
Also in 2006, CVS acquired MinuteClinic for $170 million. The company’s annual revenue that year stood at $44 billion, with 70{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} coming from pharmacy sales alone. The business buoyed CVS during the Great Financial Crisis, and the company’s stock continued to outperform the broader S&P 500 for years to come.
At the same time, CVS’s dominance in the PBM space correlated with the demise of smaller, independent pharmacies through buyouts and bankruptcies.
As “middlemen,” PBMs have the ability to influence or negotiate drug prices by working with pharmacies, health insurers, patients, manufacturers, and in some cases, the government.
This led to controversy due to the lack of price transparency and fee practices. The lack of price transparency raised alarms at the Federal Trade Commission (FTC), which intervened to investigate CVS Caremark and five other PBMs in June 2022.
The ongoing investigation, according to an FTC report, is intended to look into how PBMs steer insurance networks to their own pharmacies, move drug price tiers, manage rebate contracts with manufacturers, and overall how they make the pharmaceutical supply chain more favorable to them.
“Although many people have never heard of pharmacy benefit managers, these powerful middlemen have enormous influence over the U.S. prescription drug system,” FTC Chair Lina Khan said in a statement at the time. “This study will shine a light on these companies’ practices and their impact on pharmacies, payers, doctors, and patients.”
As CVS became one of the main leaders in both the retail pharmacy and PBM space, the company elected to venture even further into the health care industry.
In August 2018, the CVS MinuteClinic launched online services that could be accessed 24 hours a day, which increased market access and revenue for CVS. Virtual visits began at $59, along with an option of insurance coverage. A few months later, CVS officially acquired health insurance company Aetna.
“CVS Pharmacy is evolving from not just a store that happens to have a pharmacy and products into more of a health care destination,” then-CVS CEO Larry Merlo said about the deal.
“The possibilities are incredible,” SCAN Health Plan CEO Sachin Jain told Yahoo Finance Live recently (video above) when asked about CVS being more of than a pharmacy. “You have a company that owns an insurance arm. You also have a company that now owns a clinical care delivery arm as well as a retail pharmacy. And so, if you can make the pieces work together, it’ll be great.”
A woman walks past a CVS Pharmacy in Washington, DC, on November 2, 2022. (Photo by BRENDAN SMIALOWSKI/AFP via Getty Images)
Despite antitrust concerns over reduced competition in the market, the CVS-Aetna merger ultimately received the green light from the Department of Justice in September 2019.
The American Medical Association (AMA) opposed the arrangement, which entailed Aetna sending their patients directly to CVS, arguing that the “benefits were speculative, [and] it will likely have anti-competitive impacts in the PDP, health insurance, retail pharmacy, specialty pharmacy, and pharmacy benefit management markets.” AMA also argued that it would raise health insurance premiums.
And with Amazon’s recent $3.9 billion acquisition of One Medical, a primary care organization, retail’s push into health care continues apace.
“These are potentially industry-transforming deals,” Jain said. “I think people have longe hoped that retail plus health care could equal a better experience for patients. The cautionary tale is really about the very different cultures of retail and clinical service entities. And I think these deals could end up being highly transformative for health care, or they could go down as potentially the worst deals in the history of the health care industry.”
When the coronavirus pandemic swept through the U.S. in 2020, all of CVS’s assets were put to the test.
In November 2021, CVS announced its plans to close 900 stores over a span of three years as the prospect of “a CVS next door” was replaced by Amazon (AMZN) goods at the doorstep.
Nevertheless, revenue remained steady for the company, enabling more acquisitions and partnerships.
CVS acquired Signify Health (SGFY) for $8 billion in 2022 and is in agreement to acquire Oak Street Health (OSH) for $10 billion at some point in 2023. Oak Street Health is a health care provider for older adults and promote their economics on “value-based care.”
“These moves demonstrate the continued push by many high-profile pharmacies into fast-growing health care markets such as senior care, primary care, and home health,” Scott Dunn, lead health care analyst at CB Insights, told Yahoo Finance.
At the same time, some experts wonder whether retail’s reach into health care could go too far.
“I’ve just been around the block enough to know that oftentimes publicly-traded entities don’t necessarily understand clinical culture,” Jain said about the recent moves by Amazon and CVS. “They’re making decisions for the short term. And when you’re making decisions to hit a quarterly earnings target, you aren’t necessarily doing the things that you need to do to improve people’s health over the long term.”
Anjalee Khemlani contributed to this report.
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Tanya is a data reporter for Yahoo Finance. Follow her on Twitter. @tanyakaushal00.
For 55 many years, Nancy Dusckas lived over her family’s funeral dwelling.
She remembers sliding down the staircase railing and playing hide-and-seek out in the casket showroom with her sister at Dusckas Funeral Home’s flagship area, 2607 Buffalo Highway.
From running the vacuums to typing obituaries, Dusckas said she grew up finding out the ins and outs of running a funeral house from her father, Constantine “Gus” Dusckas, who started out the company in 1946.
“Simply because my father was so perfectly respected and worked properly with the group in the items he made available and going above and outside of, I simply cannot reduce again on that stuff,” mentioned Dusckas, who’s been the funeral director of Dusckas Funeral Household for far more than 40 several years.
Dusckas has uncovered to adapt to various lengthy-phrase shifts in an evolving funeral property industry.
Furnishing shorter, meaningful memorial services experiences
Dusckas remembers when a family’s visitation and funeral service typically took two total days.
“When we lived higher than the funeral property, my mom would check out and get us out of the developing, or my dad would place us on a coach to stop by some family,” she explained. “I can remember we as little ones would sit on the couch by the window and look at out the doorway till we observed the funeral procession pulling absent, and then we’d start leaping and shouting because we had been allowed to make sounds once again.”
Funeral services and calling hrs now are generally contained to one particular working day, Dusckas stated.
“I imagine some of it has to do with the young children of the relatives coming from out of town, so by the time they arrive again, we have all the things set and they’re not sitting right here for two times,” Dusckas mentioned. “Additionally, the younger technology, we’re lucky to get them by the door to have a visitation, they are so fast paced.”
Acquiring shorter companies won’t necessarily suggest less time is expended creating them unique, said Peter Burton, president of Burton Funeral Dwelling.
“‘People want pleasant spots,” he claimed. “They want to be taken care of, they want to arrive into the Ritz-Carlton and have a stunning funeral residence and knowledge.”
Burton, a fifth-era funeral director, remembers when funerals ended up conducted in residences with several home windows and only specific, traditional expert services. But now, people are hunting for outstanding encounters.
“They want it to be a celebration and sometimes funeral houses do not notice they have to provide that,” Burton claimed. “Funeral houses a long time back were dim or darkly lit, but now they’re much more uplifting and extra open. They’re not in a official-variety location.”
Providers have come to be far more about a celebration of daily life in a much more personable way, Burton explained. Households are looking for distinctive methods to conclude companies with matters like balloon, dove and butterfly releases.
“These points my father did not actually do much too substantially, we’re carrying out all the time now since individuals want an knowledge and they want to feel portion of the cherished a single and celebrate this full point, not just have a priest appear in and read through 5 or six prayers and then depart,” he said.
Burton Funeral Property also commenced providing a grief assist team much more than 5 decades ago.
“In hospitality, we have to do a lot more than just choose treatment of the deceased like they did in the 1900s,” Burton said. “We have to consider treatment of the folks far more if you want them to occur to you the up coming time. Today, you seriously have to exceed their anticipations.”
Cremation fees on the increase
As memorial companies evolve, so does the method in which the stays are taken care of.
One extended-long lasting modify funeral households nationwide saw from the COVID-19 pandemic was an boost in cremations. The cremation level in all 50 states and Washington, D.C. is predicted to exceed 50{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} by 2035, in accordance to the Nationwide Funeral Administrators Association.
Burton mentioned 70{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} of the men and women his funeral residences just take care of are cremated, when compared to when he commenced in the 1980s, when nearly everybody acquired a common burial.
“It is just a tiny significantly less pricey and people today are more transient now,” he reported. “When you were born and lifted in Erie and by no means still left, your mother and father have been born in Erie and you’d go and stop by them, and now it’s really hard for children to go out and stop by the cemeteries currently, so it’s grow to be fewer of a preferred alternative.”
For Dusckas, half of all her tendencies are cremations. She began to see this greater curiosity in cremations practically a decade in the past.
“I understood cremations ended up shifting when I experienced a really strong religion-based mostly pair occur to me ― and usually, older era church-centered men and women would always bury ― and that was the very first just one I don’t forget coming to me and declaring, ‘When I die, I want a cremation,'” Dusckas mentioned. “I was stunned, but from that place, I began to see a generational shift.”
Dusckas believes cremations have turn out to be a much more well-liked possibility not just since of the typically lower value but mainly because people today are trying to keep the natural environment in head as properly.
“The major explanation, I think, is people today just want to continue to keep lifetime easy,” she said. “I feel men and women just really don’t want to waste the place on Earth, they want to keep it clean and neat. Why tie up Mother Earth for a burial-sort point?”
Producing do with the funeral administrators she has
The enhanced wish for cremations has also eased the challenge of locating personnel, Dusckas reported.
The employment price for funeral company personnel is anticipated to develop by 4{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} from 2020 to 2030, hence many companies foresee employing eligible personnel to be a future obstacle, according to the NFDA.
That is enabled Dusckas to make do with the team she has.
“With cremation, we’re not embalming as much, we’re not operating the funerals as substantially, so you do not have as substantially personnel as you’d need to have for those people distinct form of funerals,” she reported.
But filling people gaps even now proves to be an problem for Dusckas that impacts how she and her personnel method the career.
“With restricted workers, if you have two funerals heading on and funeral directors out managing these, you even now need to have an additional capable to see a relatives in the morning if a death comes in at night time,” Dusckas explained. “So, that is a single of our staffing troubles: getting a director totally free in the mornings so we can hit that noon deadline with the newspaper.”
Dusckas reported most of the funeral directors she’s employed came searching for a work, but that isn’t going to mean she has not been hoping to fill the openings herself.
“I’ve had a few funeral directors who have retired, so striving to replace them has not been uncomplicated,” she explained. “There is a technology of little ones in mortuary university, but you’re attempting to obtain the proper temperament of a particular person who has a compassionate coronary heart, really sharp, superior at facts, and we haven’t still discovered an additional individual to fill in the gaps yet.”
Because of that, Dusckas Funeral Residence personnel will from time to time consider on further hrs in purchase to services families to the fullest, but Dusckas reported they don’t mind.
“I’ve asked them if they want me to force to find someone to fill in the gap, but they never thoughts stepping in when I just cannot do it, so they’re very keen to assist,” she mentioned. “They’re quite fully commited funeral administrators who’ve grown up on old-school ways.”
Dusckas said she’s been lucky to have a team that shares her dedication to the enterprise.
“To me, acquiring one a lot more funeral director accredited and experienced perfectly is what the top target is to have a 100{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} smooth circulation, but we purpose nicely with what we have and they step up as need to have be,” she stated.
