Robert Smith describes his 93-year-old father as "an old-time Massachusetts guy."
That’s why Smith says his dad, James, who lives in an assisted living residence in Attleboro, doesn’t want to move a few miles across the border to a different facility in Rhode Island, even though that state lets assisted living residence nurses perform services that, so far, have only been permitted in Massachusetts on a temporary basis.
One of those services is administering insulin injections, a task the elder Smith, who is diabetic, needs help with.
“I said, 'Well, we might have to make that decision when the money’s gone.' But there it is, five minutes away. We could have resolved the problem,” Robert Smith said. “But it just doesn’t make any sense that Massachusetts doesn’t allow this.”
When his father first moved into assisted living seven years ago, he could administer his twice-daily insulin on his own.
As he aged and started to need help, his family discovered that state law didn’t let nurses in assisted living facilities provide services like insulin injections or wound care to residents. Smith said they hired outside help during the week—for upwards of $150 a day—with relatives traveling up to an hour to step in on weekends.
“What made it even more difficult was there was no guarantee that they'd be consistent, and if someone couldn't make it that morning, one of us would get a call,” he said. “We'd have to rush in to help him do it.”
Temporary pandemic measures
The arrival of the COVID pandemic brought new rules for assisted living and other residential settings. With visitors restricted, an emergency order let assisted living nurses temporarily provide health services that tended to fall to friends and loved ones.
That came as a relief to families like the Smiths, because it meant James could reliably get his insulin from a staff nurse.
That permission remains in place through March 2024. But just like takeout cocktails, remote municipal meetings and other policies adopted to solve pandemic-era problems, lawmakers will have to decide whether to keep the policy or let it lapse.
One lawmaker who wants to make the change permanent is state Rep. Smitty Pignatelli, a Lenox Democrat. He first learned about the issue when his parents were considering assisted living.
“I think it's foolish to tell a nurse who is certified to do those things that they can't do it in an assisted living center, but me, the state rep, could learn how to do it and inject my own father with the shots that he needed,” Pignatelli said.
The Massachusetts Assisted Living Association backs the bill that Pignatelli filed alongside a pair of key lawmakers: Elder Affairs Committee chairs Rep. Thomas Stanley and Sen. Patricia Jehlen. That bill would change state law to permanently allow nurses in assisted living centers to provide a limited list of services, like injections, eye drops and oxygen management.
Association president Brian Doherty said he’s seen positive results from the policy while it’s been in place.
“Because the nurse is overseeing the overall care plan for that resident, it helps that they can give them an insulin injection at the optimal time and that improves their overall health outcome,” he said.
Assisted living residences vs. nursing homes
But not all in the industry are aligned. The Massachusetts Senior Care Association, a group that represents a broad umbrella of long-term care organizations, including nursing homes and assisted living residences, has concerns with the bill, particularly around consumer protections and making sure costs for nurse-provided services are disclosed to residents.
At an April hearing on the bill, elder law attorney Kathleen Lynch Moncata asked the Elder Affairs Committee to be cautious as they consider changes.
She said that the 1994 Massachusetts law establishing assisted living residences did not envision them as medical facilities, and that they’re regulated by the Executive Office of Elder Affairs, rather than the Department of Public Health, which oversees nursing homes.
“Permitting ALRs to provide basic health services is an appealing concept, but must be accompanied by corresponding, meaningful increased oversight, and looking at this bill, the language does not provide such oversight,” she said.
Most people who testified on the bill spoke in support of it, including Smith, whose father is in the Attleboro facility. Smith said he saw his dad’s health rebound while he was getting insulin at regular times from the nurses.
And Rep. Stanley, the committee’s co-chair, wrapped up the hearing by suggesting the legislation could move forward. He said the three bills on that day's agenda were all “critical to vastly improving the continuum of care for elders.”
Bill supporters see it as an encouraging sign that the Elder Affairs Committee scheduled it for an early hearing, an indication the panel could advance it for consideration by the full Legislature sooner rather than later in the two-year session.
A total of 15 lawmakers are signed on to the House and Senate versions of the bill—a small fraction of the 200-member Legislature, but an uptick from the nine who backed last session's version. Pignatelli said he sees momentum growing as the issue becomes relevant to more families.
"People like my parents did not need to be in a nursing home, but they needed additional help," he said. "That interim, mid-level of living, like an assisted living center, would have been tremendously beneficial not only to my mom and dad, but a financial and personal relief for us as the children as they were aging to let us get back to being a family."
