Veterans Affairs

shows the front of a building with several flags on poles, the American flag is at half staff, as there are dead COVID patients within. A sign in front of the building reads, "Heroes work here"

Coronavirus deaths bring attention to privatized state veterans homes

July 31, 2020 by Thomas Goldsmith

Coronavirus deaths bring attention to privatized state veterans homes - North Carolina Health News

As COVID-19 outbreaks moved through North Carolina this year, nursing home residents quickly numbered high among those who became infected. Among that population, 36 North Carolina residents of military service died of the novel coronavirus in state-owned veterans nursing homes managed by a Georgia conglomerate, PruittHealth.

By Thomas Goldsmith and Riley Davis

With the federal government footing much of the operations bill, state veterans homes have existed since the Civil War, first to care for homeless survivors of war and those with disabilities. A second wave of soldier’s homes came after World War I.

“Prior to World War I, programs for veterans centered on pensions and ‘soldiers homes,’ where the aged and disabled could live,” historian Bernard D. Rostker wrote in a 2013 Rand Corporation research report. “After World War I, rehabilitation became an important third element of veteran care.”

The focus of the state-owned nursing homes has changed as the nature of wars has transformed. Preference for spots in North Carolina’s homes generally goes to veterans with service-related disabilities, such as exposure to Agent Orange in Vietnam, exposure to radiation at Nagasaki and Hiroshima, or conditions related to their Gulf War environmental exposure.

North Carolina’s COVID-19 outbreaks brought the state’s first virus-linked death on March 24, to a Cabarrus County man, and soon started taking an exceptional toll in long-term care facilities.

Of 1,903 COVID-related deaths in the state by July 30, at least 797 have been of people who lived in nursing homes. According to state and corporate records, 36 of North Carolina’s military veterans have died from COVD-19 in nursing homes that are owned by the state, but for more than two decades have been under the contract management of a privately owned health care conglomerate.

State records show that the state of North Carolina agreed in 2014 to pay Georgia-based PruittHealth an estimated $207 million in the past five years to run the state’s veterans nursing homes. The company had received many millions more in commissions during the preceding 17 years.

If the current contract wins a second extension in December, Pruitt will take over the management of two new state veterans nursing homes, already announced for Raleigh and Kernersville.

Dr. Philip Sloane, a geriatrician and distinguished professor of family medicine at UNC Chapel Hill, speaking generally, said COVID-19 overwhelmed nursing homes and other health care facilities because it was indeed novel and came on so fast.

“When COVID gets into a facility, it gets into it,” he said. “And that’s the problem, especially early on when we just knew nothing and nursing homes were so ignored by all the responses to COVID.”

Related story: Read the other parts of this series: Thirty-six veterans die of COVID-19 in NC state veterans nursing homes that a private company has run for 22 years

Cooper, national leaders respond to ravaged veterans nursing homes, look ahead for solutions

Public health officials concentrated on getting ventilators and other hardware, but didn’t initially focus on making sure that nursing homes had personal protective equipment or PPE, Sloane said.

“Nobody said that and then they were stuck,” he said.”Then when you got somebody that you think had COVID, if they had to get the health department to do the test, the test would come back in five days, or six days. We really flubbed it for months, as a society.”

Show me the money

North Carolina’s Veterans Nursing Homes have been managed for 22 years by the Georgia-based PruittHealth company, which takes a commission exceeding $3.5 million annually from the stream of Veteran Administration, Medicare, Medicaid and other funding designated to operate the state veterans nursing homes.

The amount of Pruitt’s commission has importance because for-profit, long-term-care ownership and management chains have the potential to put concern for profit above residents’ safety, said Suzanne Gordon, an assistant adjunct professor at the University of California-San Francisco School of Nursing and a widely published authority on long-term care.

“It’s the perfect storm when you have a pandemic like COVID-19,” she said in a phone interview. “You have poor staffing, you have poor pay so that nursing home workers have to work in multiple different facilities and they take the infection from one facility to another. You have an incredibly vulnerable population.

“You have low staffing and low training.”

Pruitt privatizes management

PruittHealth, founded in 1969, first managed a facility of this type in 1996, when the company won a contract to run the Georgia War Veterans Home in Milledgeville. A story in the Atlanta Constitution describing the deal noted that the Georgia State Employees Union sued Pruitt in an unsuccessful move to halt the takeover. The newspaper also cited past problems with Pruitt’s supervision of other Georgia nursing homes during the 1990s.

By 1998 Pruitt had successfully bid for management of the North Carolina homes. Since then, the company has retained the contract for five terms in a process that garnered little media or public attention. The company manages the four North Carolina state veterans nursing homes — comprising 100 beds in Black Mountain,150 beds in Fayetteville, a 100-bed center in Kinston, and 99 beds in Salisbury.

shows people in military uniforms talking to an aging veteran who's in a wheelchair, they're all smiling and laughing. — Before the days of COVID-19, local service groups would frequently visit the veterans homes. In this photo from Dec. 2016, Chief Master Sgt. Shane Wagner (left), 4th Fighter Wing command chief, and Col. Christopher Sage (center), 4th FW commander, laugh with Eugene Shaw, U.S. Army veteran and resident of the State Veterans Home in Kinston. More than 45 volunteers visited with over 90 veterans and passed out goody bags and holidays cards. Photo credit: U.S. Air Force/ Airman Shawna L. Keyes

The only bidder beside Pruitt for the most recent North Carolina contract was the for-profit, Minnesota-based Health Dimensions Group, which failed to complete the second portion of a two-bid process. The company manages a Wisconsin state veterans home in Chippewa Falls, which has had no COVID-19 cases, according to a CMS database.

The Health Dimensions 2014 bid for the work provided by the North Carolina Department of Military and Veterans Affairs lacks a crucial detail — the percentage of revenue that the company would receive to oversee the homes. Health Dimensions officials did not respond to a request for additional information.

Today, PruittHealth manages the state veterans nursing homes under a one-year extension of the 2015 document it signed in 2015. Anna Amirkhanyan, an American University professor who studies long-term care, was an author of a paper that compared public, nonprofit and for-profit nursing home care.

“Consistent with … the ample empirical research on nursing home quality, we found that for-profit nursing homes have significantly lower care quality compared to public and nonprofit nursing homes,” Amirkhanyan and colleagues wrote in 2018 in the academic Journal of Public Administration Research And Theory.

PruittHealth company has championed openness about its COVID-19 caseloads and announced that a resident of one of its Georgia nursing homes was presumed to have the disease on March 19.

On April 1, the company announced an Alert Code Red, or high-level warning, for its PruittHealth-owned and -operated Carolina Point nursing home in Chapel Hill, managed and owned by the company, but not a veterans center.

An Alert Code Red means only essential staff will come to work and that no new admission will be allowed. In addition, specific, higher levels of infection control including more frequent cleaning and “postponing communal activities, ceasing visitation, and screening staff and patients daily.” The early outbreak at Carolina Point eventually resulted in the COVID cases among 20 staff and 89 patients, with the deaths of 20 patients.

First of 36 veterans dies

The first death of a veteran in a COVID-related case came at the Kinston state veterans nursing home on April 21, of Benjamin Vincent Askew, 94, of Kinston, who served during World War II as a radio operator on a PV1 bomber in the Aleutian Islands.

Pruitt sent a statement to the Neuse News about the April 21 death: “We are saddened to share that a veteran at North Carolina State Veterans Home – Kinston passed away Tuesday, April 21 after testing presumptive positive for COVID-19. The veteran’s family has been informed, and out of respect for the situation, we will not be commenting further.”

One of Askew’s daughters, Jo Teague, 69, of Raleigh, said in a phone interview that Askew had developed a fever the last few weeks of his life, leading up to his death April 21.

“It would come and go, come and go, and then he had a urinary tract infection, I believe,” she said. “Two or three days before he died, they did some blood work and tests. They found out that he had COVID. But we don’t think that’s what killed him.”

Teague, a substance abuse counselor, said she was not aware of the private management of the Kinston veterans nursing home. However, both she and sister Ann Kohler, 74, of Virginia, seemed somewhat unclear about the complex web of relationships between the federal Department of Veterans Affairs, the local VA Hospital, the state-owned nursing home, the management company out of Georgia, and ancillary functions such as a hospice service.

“I really don’t know anything about that. I just know that dad’s facility was very, very kind and helpful, and professional,” Teague said.

‘You never think there’s enough’

The sisters expressed general positive feelings about the way the Kinston center was run by Pruitt, accepting as a given that health care facilities operate with too few employees.

“It’s like everywhere,” Kohler said. “You never think there’s enough help — especially at night and on the weekends. And experiencing a lack of communication sometimes between shifts.

“There are always money restrictions. And so there’s only so many people that you can have on the floor on the weekends and at night,” she said.

“I mean people can’t work seven days a week, 24 hours a day.”

In fact, for-profit providers like Pruitt must constantly deal with the tension between personnel expenses and winding up in the black. Staffing up requires more salaries and/or overtime, which can put a dent in profits.

“Staffing is a widespread problem in long-term care,” said Lauren Zingraff, executive director of the non-profit Friends of Residents in Long Term Care. “COVID-19 shone a very bright spotlight on how severe the staffing shortage problem is.”

Part of the problem, Zingraff added, is that long-term care staff are generally not paid a liveable wage.

“They have no health benefits, they have no benefits of any kind,” she said. “If they’re sick and they don’t come to work they don’t get paid.”

shows a group of people, many of them dressed in military uniforms, gathered around a pallet of boxes in the hallway of a building. — Before the days of COVID-19, local service groups would frequently visit the veterans homes. In this photo from Dec. 2016, members of Seymour Johnson Air Force Base, North Carolina, the Goldsboro Elks Lodge #139, and the local Wayne County community receive instructions before visiting with the residents of the N.C. Veterans Home, Dec. 24, 2016, in Kinston, North Carolina. More than 45 people volunteered to pass out goody bags and holiday cards to the veterans. Photo credit: U.S. Air Force/ Airman Shawna L. Keyes

‘No major issues … exist’

In 2015 the North Carolina Department of Administration delved into the contract relationship between state government and PruittHealth through the questioning of an unidentified Department of Veterans Affairs official that appears in a nine-page state report related to the deal. Among the exchanges:

C. Has the State ever performed formal background checks on the Management Company and its principles? Please note that CPA firms are required to perform due diligence checks to accept new engagements?

ANSWER: The State has not performed any “Background Checks” on the Management Company. Pruitt Health is a large HealthCare Provider and is required by Banking Institutions to have annual CPA reviews and Statements issued. The CPA firm is nationally recognized and will produce Statements.

E. How long has Management Company performed a contract for the State of North Carolina?

ANSWER: First contract was awarded in 1998 and every five year, the Management Company had to “bid” the contract for rendering services.

F. Any issues with the Management Company?

ANSWER: Normal business relationship exists with Management Company, minor problems do occur which is to be expected. No major issues have developed and none exist.

Role of private management questioned

Some nursing homes and other long-term care facilities tend only to attract attention for their failings. These centers encountered the problems they are facing now, in part, because of their complicated funding and reporting structures, a Duke expert said.

“There’s this mixture of federal, state, county regulation and oversight, the reporting up the chain is very different,“ said Nathan Boucher, a professor in the Sanford School of Public Policy at Duke University and a research scientist at the Durham VA. “And that piecemeal, that patchwork, that mixed oversight of various things, it creates a problem.”

The veterans nursing homes run by Pruitt mostly score well on rankings by the Centers for Medicare and Medicaid Services, especially in the category of staffing, an element seen as crucial to care.

In its 2014 bid to retain its North Carolina contract, the company cited its “many deficiency-free licensure and certification surveys” among all its facilities.

As another recommendation, company CEO Neil L. Pruitt cited 70 awards to his facilities during a three-year period from the American Health Care Association. Known as AHCA, the industry group in 2013 named Neil Pruitt Jr. to the position of chair of its board of governors.

Pruitt, his father, and his wife Mebane have donated $138,076 to political action committees of the AHCA starting in 1987. Overall, CEO Neil L. Pruitt Jr. has made bipartisan donations of almost $1 million to candidates, political parties and PACs. In 2013, Sen. Mitch McConnell (R-Ky.) named Pruitt to the federal Commission on Long-Term Care.

“I’ve seen firsthand how post-acute care has evolved through the years and become a vital partner in the long term care continuum,” Pruitt said in a statement. “But we’ve never lost sight that it all hinges on quality.”

Problems before COVID-19

However, the federal Centers for Medicare and Medicaid Services recorded 47 health deficiencies between 2017 and 2019 at the Pruitt-run North Carolina veterans nursing homes.

Despite a relatively clean record, there have been significant deficiencies in Pruitt’s administration of veterans homes in North Carolina. A new report from the state Department of Health and Human Services says that the Pruitt-run veterans nursing home in Salisbury allowed dozens of relatives of ailing veterans to make drive-up car visits for 10 days in June. The visits came during a high-level alert at the home and despite federal and state bans on such visits.

This deficiency certification is an element that could be considered before December when Pruitt seeks its second renewal of its $207 million contract of 2015.

The deficiencies listed below happened eight years ago, well into Pruitt’s management of the veterans homes. They had been public record for two years when the state last asked for bids on the veterans nursing home management contract.

For example, a 2012 state report cited Pruitt’s Salisbury deficiencies for failures to:

Keep pressure sores from getting worse
Keep the medication error rate at 5 percent or less
Secure catheters for two residents
Throw away out-of-date meds
Post results of DHHS survey results
Provide proper dental care for a resident with only 12 teeth, one broken
Make sure two special locked doors open as mandated when a fire alarm sounds

Most of the recorded deficiencies were at lower levels, but Kinston recorded a high level (J-level) deficiency, indicating potential immediate jeopardy to a resident, with a note of past noncompliance.

Salisbury also had a J-level deficiency, under which it was told to make sure the facility was free of accident hazards.

The veterans nursing home, CMS said, should “protect each resident from all types of abuse including mental, sexual abuse, physical punishment and neglect by anybody.”

Most recent pre-COVID deficiencies in NC’s state veterans nursing homes

Only the most recent inspections by the state Department and Health and Human Services into the Pruitt-run homes do not cover the period in which COVID-19 infected residents of three of them.

A 2018 health inspection of the Salisbury home resulted in a finding of immediate jeopardy in the case of a resident who “eloped” or wandered away from the home. An unidentified police officer told inspectors that he had gotten a radio call about a missing veteran.

“Campus Police further revealed that he drove near the building and observed Resident # 6 immediately,” the state report said: “He reported [that] the nurse was coming up on him (Resident # 6). As soon as I shined my lights (sic), Campus Police further revealed that Resident #6 was sitting right across from the helicopter pad in front of Building 10 (the facility) in his wheelchair.”

Another inspection found that the Salisbury home had failed in 2019 to carry out the physician-ordered blood tests for two of six residents with cognitive disorders, one of whom went two weeks without testing for anti-coagulant status. Other residents failed to receive nutritional supplements as ordered, inspectors said.

Riley Davis provided assistance via the the NC News Intern Corps, a program of the NC Local News Workshop, funded by the North Carolina Local News Lab Fund and housed at Elon University’s School of Communications.

Shows a brick wall with the title, "North Carolina State Veterans Home" and brass plaques on the wall from each of the branches of the U.S. military

Thirty-six veterans die of COVID-19 in NC state veterans nursing homes that a private company has run for 22 years

July 30, 2020 by Thomas Goldsmith

Thirty-six veterans die of COVID-19 in NC state veterans nursing homes that a private company has run for 22 years - North Carolina Health News

Since April 21, 36 North Carolina military veterans have died of COVID in state veterans nursing homes managed by the Georgia-based PruittHealth corporation, whose five-year, $207 million contract is up for a second extension in December. In July, state inspectors report, the state veterans home in Salisbury allowed dozens of drive-up visits by relatives, less than three weeks after the center’s 15th resident death from COVID-19.

By Thomas Goldsmith and Riley Davis

North Carolina’s state-owned veterans nursing homes became the place where 36 ailing men caught COVID-19, then died, after surviving tours in places such as Pearl Harbor and Korea, according to federal records.

According to the Centers for Medicare and Medicaid Services, the death totals mean North Carolina ranks third nationally in COVID-related deaths in state veterans nursing homes.

The Georgia conglomerate PruittHealth has run North Carolina’s four veterans nursing homes for 22 years, under a contract which has had little public attention and pays Pruitt 9.25 percent of annual state funding of about $38 million, a cost projected to rise to $47 million in 2021.

Pruitt has chalked up mid- to top-ranked reviews from CMS but has also gotten the federal oversight agency’s attention with citations for dozens of deficiencies. Most recently, for 10 days in June, the PruittHealth managed nursing home for veterans in Salisbury allowed dozens of relatives to make drive-up visits to residents, according to state records.

The visits came despite multiple recent COVID-19 deaths in that facility and in two equivalent veterans homes also run by PruittHealth.

The visitation was in contravention of federal and state instructions banning the contact, state inspectors reported.

Fifteen residents had already died of COVID-19 in the Salisbury skilled nursing facility. The inspection and citation at the Salisbury center came after a total of 36 veterans had died of COVID-19 at three of North Carolina’s four state-owned veterans nursing homes managed by PruittHealth.

Anna Amirkhanyan, an associate professor of public administration and policy at American University, and an expert in nursing home care and public-private collaborations, noted the perilous circumstances of nursing home residents, including those with neurocognitive orders such as Alzheimer’s disease.

“Even one death is one too many in the context of nursing home care, particularly because this is a vulnerable population,” Amirkhanyan said in a phone interview. “These are our American elderly, and they often lack the ability to complain.

“Not all of them are able to switch their residence promptly if they’re not happy with care and many of them are not even able to differentiate between good and bad.”

Pending any further investigations or post mortem, it’s not possible to know what responsibility Pruitt may hold for the COVID-19 deaths among what are now 342 men in North Carolina’s four veterans nursing centers. The numbers of dead are higher than those in veterans nursing homes in neighboring states according to a database maintained by the federal Centers for Medicare and Medicaid Services.

Read the rest of this series: Coronavirus deaths bring attention to privatized state veterans homes
Cooper, national leaders respond to ravaged veterans nursing homes, look ahead for solutions

Pruitt’s communications department said they would not discuss any details of the deaths because of their respect for residents’ privacy.

“We offer our sincerest condolences to the veterans’ families and loved ones during this difficult time,” a representative of Pruitt’s communications staff said in a statement.

An NCHN analysis of Centers for Medicare and Medicaid Services data shows that no veterans have died of COVID-19 in state-run nursing homes dedicated for their use in neighboring states of Virginia, Tennessee and South Carolina.

An outdoor seating area at the Veterans Home in Salisbury. Image courtesy:
NC Governor’s Working Group on Veterans, Service Members and their Families

A July 9 state Department of Health and Human and Services inspection report faults the State Veterans Nursing Home in Salisbury for failing to have a plan for controlling and preventing infection, as required under state law.

According to that report, Salisbury staff members scheduled between four and six visits for residents each weekday during a period when countless North Carolina families were turned down when they asked for more time with their relatives in nursing homes across the state.

Bringing ‘peace to residents’

“The Director of Nursing stated visitation was started as it was the only way to bring peace to the residents and they had not broken any codes,” the inspectors wrote of the visits. “The administrator noted that they had stopped the family visitation effective 06/18/20.”

That was the day state inspectors talked to staff and walked through the facility.

The core citation alleges failure by the nursing home to create and run an effective infection control and prevention program, meant to “help prevent the development and transmission of communicable diseases and infections.”

PruittHealth offered a bristling rebuttal of the charges.

“The suggestion that there was no plan for infection control and prevention in place at North Carolina State Veterans Home – Salisbury is categorically false,” a statement from the PruittHealth communications staff said in part in an email to NCHN.

“As part of our Commitment to Caring, we recognize the importance of addressing veterans’ emotional well-being and mental health needs resulting from months of separation from loved ones.”

Of the three dozen North Carolina military men lost to COVID-19 in PruittHealth-run nursing homes, 20 died after contracting the disease in the State Veterans Nursing Home in Fayetteville, 15 in the State Veterans Nursing Home in Salisbury and one at the State Veterans Nursing Home in Kinston. That’s according to the most recent data from the federal Centers for Disease Prevention and Control.

The dataset shows an additional 12 veterans have died of COVID-19 in the Georgia Soldiers Home in Milledgeville, Ga., a skilled nursing facility that Pruitt also manages.

According to CMS data, COVID-19 has broken out at more than 55 of the country’s 130-plus state veterans nursing homes.

For its management role, Pruitt receives 9.25 percent of each facility’s revenue. The $1.2 billion company won the contract for the first time in 1998 and has received a cut of the taxpayer-funded revenue since. Pruitt now works under a one-year extension of a five-year contract signed in 2014, with four more potential one-year extensions.

Representatives of PruittHealth would not answer questions from NCHN about the percentage of revenues the company receives from North Carolina.

Is a 9.25 percent commission fee fair?

“Nine percent is awfully high,” said Dr. Philip Sloane, a geriatrician and distinguished professor of family medicine at the University of North Carolina-Chapel Hill. “My understanding of it is in the more like the four to five percent range.

“The thing is, they can tolerate a low percentage because they basically have a captive population that’s supposedly relatively guaranteed.”

A short survey of people with knowledge of the industry found some who believed the Pruitt commission is high, but others such as Jeff Horton, the executive director of the North Carolina Senior Living Association and a former state official, thought the share is warranted given regulatory burdens and other factors.

Before and since the onset of the pandemic, state and federal officials, advocates for older people, academics and family members have raised questions about the operation of several of the more than 130 such centers across the country, including some with privatized management.

The arrangement between PruittHealth and the state Division of Military and Veterans Affairs dates to 1998, but has received little attention beyond a small circle of industry and government leaders.

Drive-in visitors, but how close?

As many as four or five sets of relatives visited residents at the Salisbury nursing home each weekday from June 8 to June 18. The relatives remained in their cars and the ailing veterans in wheelchairs at what several staffers told DHHS was always within an appropriate social distance. But a DHHS interview with one of the center’s activity staffers told a different story.

“She noted the visits were done at the main entrance,” the DHHS inspection report says. Interviewees in DHHS inspection reports remain anonymous. “She said they would roll the resident outside almost to the car door so they could see their family and speak with them from a distance.”

PruittHealth’s communications team strongly denied any wrongdoing at the Salisbury nursing home in an emailed statement.

“When the clinical leadership team developed an idea to help improve veterans’ quality of life with a few, socially-distanced visits in which family members wore masks and stayed in their cars while speaking with their loved ones – also in masks – at the entrance of the building, we sought and obtained approval from epidemiologists at the VA before proceeding,” the statement said. “The visits in no way contributed to the spread of COVID-19 in the center.”

Federal Veterans Affairs spokeswoman Megan Heup painted the exchange between PruittHealth and the VA differently.

“As part of VA’s Fourth Mission, and through an official tasking from the Federal Emergency Management Agency (FEMA), VA simply conveyed CDC guidance that appropriately socially distanced outdoor events utilizing proper PPE would not contribute to COVID spread,” Heup wrote in an email.

The DHHS COVID Dashboard site lists both the Salisbury and Fayetteville veterans nursing homes as having ongoing outbreaks as of Tuesday.

Two more vets’ homes on the way

The decision by Pruitt to allow visits came among growing discontent about strict limits on nursing home visits that countless frail elderly people died without being able to spend their last minutes with loved ones. Bill Lamb, a long-time advocate for older people and former head of Friends of Residents of Long-Term Care, said PruittHealth likely had good intentions when it started the process that ended with a citation.

“There’s very heavy pressure from families, so you are seeing responses from some facilities, trying to stay as close to the line as they can,” Lamb said.

“My own orientation is that I worry when we privatize the public interest, going to the private market for things like prisons.”

For more than two decades, Pruitt has managed North Carolina’s state veterans nursing homes after submitting bids and signing a series of contracts. However, details of the early years of the arrangement remain murky because the state Department of Administration has been unable to provide any records earlier than 2014. NC Health News first requested them June 4 and submitted a formal public records request on June 17.

The state contract signed in 2014 projected that PruittHealth would be paid $207 million from 2014 to 2019 to run the veterans nursing homes. More than $19 million of that revenue became Pruitt’s 9.25 percent commission.

PruittHealth CEO Neil Pruitt attempted, but failed, to increase the fee to 9.75 percent just before the 2014 contract signing, according to a Department of Administration document.

This privatized management arrangement got an extension this year, according to state officials. The deal will be up for renewal in December. The future management of planned veterans nursing homes in Raleigh and Kernersville is already written into the deal.

‘Does not constitute an admission’

The Salisbury car visits to veterans came when state and CDC guidelines had prohibited it and when Pruitt had announced that the facility had reached Code Red Alert, its highest level of warning.

As part of the DHHS deficiency process, Pruitt officials were obliged to respond to the report, but admitted no fault and described its required plan of correction as a “written allegation of compliance.”

The response continued: “Preparation and submission of the plan of correction does not constitute an admission or agreement by the provider of the truths of the conclusions alleged or the corrections of the conclusions set forth on the statement of deficiencies. The plan of correction is prepared and submitted solely because of requirements under state and federal law.”

Between Salisbury and Fayetteville, the PruittHealth-run veterans homes have reported132 cases of COVID-19, according to state DHHS. Six of the company’s other non-veterans facilities in North Carolina have had deaths, including a large outbreak of more than 80 patients at PruittHealth-Carolina Point in Orange County, with 20 COVID-related deaths among them.

Where sick veterans go

The most recent budget document from the NC Office of State Management and Budget projects that the state will spend $47.58 million in 2021 in support of the state veterans nursing homes. PruittHealth would earn $4.4 million in annual profit based on their contracted commission rate.

PruittHealth communications staff declined to comment on the deaths or the company’s contract.

“The health and safety of our veterans and staff are top priorities at PruittHealth,” one statement said. “We consider it an honor and a privilege to serve those who have given so much of themselves for our freedom and our country. As such, we are deeply saddened by the veterans lost to COVID-19.”

Among more than 130 state veterans nursing homes across the United States, North Carolina’s death total in such facilities is outranked only by single, similar homes in New Jersey with 79, Maryland with 56 and another in Massachusetts with multiple deaths.

“Most veterans are vulnerable because most of them have underlying health conditions, and that if you have any underlying health conditions with COVID-19 you’re at much greater risk for hospitalization and death,” said Suzanne Gordon, an adjunct professor at the University of California-San Francisco School of Nursing and an authority on long-term care.

Questions from the top

Two U.S. senators asked in May for the General Accounting Office to look into the Department of Veterans Affairs’ oversight of the nation’s state-owned nursing homes following a COVID-19 outbreak that killed 76 people at a Massachusetts veterans nursing home.

Subsequently, family members and media accounts have described actions by the nursing homes that the kin found troubling and made public the names of a few of those who died after contracting COVID-19.

Master Sergeant Harold Lee Brigman, Sr., 85, died in May after living in the Fayetteville state veterans nursing home since 2017. He was among 20 veterans who died after contracting COVID-19 there, according to state records. Photo courtesy Jennifer Brigman

Among that group was retired Master Sergeant Harold Lee Brigman, Sr., 85, who had lived in the Fayetteville state veterans nursing home since 2017. He died May 23, 10 days after Pruitt announced a high-level Code Red Alert warning status for COVID-19 at the center.

Brigman loved his family and would go above and beyond for those in need, one of his daughters, Jennifer Brigman, said in a phone interview. He once drove halfway across the country without stopping to help her out of a dangerous domestic situation, she remembered.

His philosophy was “never to leave wounded,” meaning you should always go back for those injured in battle, she added.

‘They should have been more careful’

Brigman said that communicating with her father in his nursing facility was often difficult. They faced a large cell phone theft problem, and the phone she bought him disappeared the first day she gave it to him. The family wasn’t allowed in the hospital where Harold Brigman was admitted and eventually died.

Doris Brigman offers a kiss to Retired Master Sergeant Harold Lee Brigman, Sr., 85, in the NC State Veterans Nursing Home in Fayetteville. He died of COVID-19 in May in the NC State Veterans Home in Fayetteville, where 19 of his fellow residents also died after contracting the disease. Harold Brigman served for years as a police detective following his military service. Photo courtesy: Jennifer Brigman

“We would have never let him die alone,” Jennifer Brigman said.

Brigman praised two Pruitt employees for assisting her family in finding the paperwork needed to hold her father’s funeral with full military honors. But she also faulted some of the company’s care during the outbreak.

“I think that they should have been more careful,” Brigman said. “They’ve admitted that it was one of their personnel who brought the virus in.”

Another who died during the outbreak was Navy veteran Van Thomas Kluttz, who survived Pearl Harbor, contracted COVID-19 in the state veterans home in Salisbury, and died at age 95. His death came a day after a related trip to an emergency department, his granddaughter, Sally Nifong, told Charlotte television station WBTV.

“Had I known that he was going to be even exposed to it, I wouldn’t have brought him out,” Nifong told WBTV. “I would have brought him home with me, had I known. I thought he would have been safer there.”

Elected officials respond

State Rep. Grier Martin (D-Raleigh), who served in Afghanistan and continues in the U.S. Army Reserve, said his fellow veterans in nursing homes deserve the best possible treatment.

“It’s a tragedy all the lives we’ve lost and certainly my hope would be for any of my fellow veterans that they be able to enjoy the retirement and the care that they’ve earned, that our state and the federal government work hard to provide them,” Martin said in a phone interview.

At the federal level, U.S. Rep. David Price (D-NC) also said the country’s veterans deserve the best care.

“The deaths and COVID-19 spread at congregate care facilities, including state veterans homes, are alarming,” Price said in a statement.

U.S. Rep. Richard Hudson (R-NC), whose district includes Fayetteville, did not respond to a request for an interview.

Meanwhile, CMS appears to have started inspecting nursing homes specifically to uncover how COVID-19 spread to thousands of residents.

Recent information about COVID-19 spread in Long Term Care Facilities (LTCF) shows about half of residents testing positive for COVID-19 are not symptomatic. Spread of the virus could have been occurring undetected long before a positive test is reported, inspectors said in a report on the Southeastern Pennsylvania Veterans’ Center in Spring City, Pa.

The cost of care

Georgia-based PruittHealth has managed the publicly financed State Veterans Nursing Home since 1998. Here are totals of recent amounts paid to the company, part of these payments became profit for Pruitt:

In 2019 PruittHealth Veteran Services received $41,456,079.

In 2018 PruittHealth Veteran Services 2018 received $40,324,205, including $8,262 for equipment.

In 2017 PruittHealth Veteran Services received $38,466,256.

In 2016 PruittHealth Veteran Services 2016 received $41,810,166 in two contracts for $32,149,943 and $9,660,972)

a man stands at a podium with a number of grim faced advocates for Medicaid expansion standing behind him

Legislative mini-session produces little movement on health care issues, despite new call for Medicaid expansion

January 16, 2020 by Rose Hoban

Legislative mini-session produces little movement on health care issues, despite new call for Medicaid expansion - North Carolina Health News

An unlikely coalition of business people, law enforcement and local officials - all conservative - came together Wednesday to criticize the legislature for missing the opportunity to act on Medicaid.

By Rose Hoban

By the time he reached Raleigh after six hours of driving, Dale Wiggins was angry that the lawmakers he was coming to see had already skipped town.

Wiggins, the chair of the Graham County Board of Commissioners, came to Raleigh Tuesday to speak to legislators about enacting Medicaid expansion. But by the time he and several other officials from their rural far western county made it to the capitol, lawmakers who had come to the General Assembly for a “mini-session” had wrapped up their work after only a few hours, and left. They won’t be back until late April.

That frustrated Wiggins, a Republican, who wanted to tell his party leaders about the needs of his constituents in a county where wages are low and rates of uninsurance are high.

“That tells me that their priorities are not ‘we the people,’” he said during a press conference held Wednesday morning to encourage lawmakers to expand Medicaid, the state and federal funded health care program that currently provides coverage to almost 2.2 million North Carolinians.

Under the Affordable Care Act, North Carolina is eligible to expand Medicaid to include as many as a half-million low-income workers who make too much to qualify for the program now, but too little to qualify for health insurance subsidies on the online health insurance marketplace. North Carolina is one of only 13 states not moving to add those extra people to the program.

“The Affordable Care Act, a lot of people were unhappy with that and maybe there’s a better option out there somewhere, but it’s what we’ve got,” said Wiggins, who identified as a Republican as soon as he got up to speak. “We have to work with it and try to take care of the people that really need it.”

Wiggins was part of a group of business leaders, law enforcement and county officials, all of whom identified themselves as conservative or Republican. They were gathered by the Care4Carolina coalition, an advocacy organization that’s been pressing for Medicaid expansion for several years.

But lawmakers weren’t there to hear from them.

Lawmakers came, did little, left

Tuesday’s mini-session was contrived in the fall, when lawmakers wrapped up what had become an increasingly contentious 2019 work session. The resolution adjourning the session to November (and a subsequent one adjourning until January) included a reference giving advocates the impression lawmakers would take up health care access issues once they gathered again.

But by the time legislators arrived in town Tuesday, it was clear their activities would be tightly focused. In the end, the House moved on only two bills: one to adjust tax deductions on medical expenses and another to add to scholarship funding for children of veterans. Then the state House quickly moved to adjourn.

a man in a suit and tie gestures as he speaks to people holding microphones. He has staunchly opposed Medicaid expansion — Senate majority leader Phil Berger (R-Eden) told reporters on Tuesday that none of the Republicans in his chamber would be willing to vote for a Medicaid expansion bill. Photo credit: Rose Hoban

The Senate took action only on two overrides of gubernatorial vetoes while sending the House’s tax deduction bill to committee. Then the chamber adjourned without attempting an override of the state budget bill, which has been held up since June.

Senate leader Phil Berger (R-Eden) expressed his frustration at a morning press conference.

“We could have seen a negotiated compromise resolution of the entire budget, but Gov. Cooper refused to sign any budget including his own unless Medicaid expansion was included,” he told reporters. “Senate Democrats and Gov. Cooper have blocked teacher pay raises, blocked billions, billions for new schools and blocked Medicaid transformation, among other things.”

Berger also insinuated that when lawmakers return in the spring for the traditional “short session” that there would be no changes in the budget stalemate.

He criticized Democrats for not standing up to Gov. Cooper, who is also a Democrat.

“I actually commend Sen. Ben Clark (D-Raeford), who at least was willing to say publicly what Democrats have been saying privately … ‘Until we sit down and negotiate Medicaid expansion, I see no reason to vote to override the veto’,” Berger said. “So it’s clear that Medicaid expansion is the thing that is holding up the budget.”

a man standing at a podium raises his hands and shoulders in a shrug as he speaks to someone off camera. — Senate minority leader Dan Blue (D-Raleigh) told reporters he doesn’t know what it will take to reach compromise over Medicaid expansion, teacher pay and other contentious issues in the legislature during a press conference Tuesday morning at the General Assembly. Photo credit: Rose Hoban

For their part, senate Democrats decried their senate colleagues’ inability to forge any compromise, focusing their ire on pay raises for teachers and school staffers that they deemed were too low. They voted to sustain Cooper’s veto of a teacher raise bill, as well as a veto of a 25-page regulatory “reform” omnibus bill.

With those statements, the two parties seemingly put their chips down on what will likely be the talking points for the fall election.

Failure to compromise frustrates

The advocates gathered on Wednesday morning seemed to put their weight behind the idea of coming to agreement on Medicaid expansion.

“The stress levels of parents with autism are comparable to that of combat soldiers. Unfortunately, caring for children with special needs is not a job that comes with health insurance,” said Rachel Radford, a Goldsboro parent of two children on the autism spectrum. “Our current legislature does not seem to appreciate the value we as parents have for our children because of the lack of swiftness to pass Medicaid expansion.”

She decried the tit-for-tat and political spin that often passes for dialogue between the two political parties on Twitter and Facebook.

“You all need to get off social media blame games and pass our budget,” she said.

Alamance County Sheriff Terry Johnson, a conservative stalwart, made his plea for expansion, explaining that he sees the result of untreated mental health problems in his county jail.

“Our staff has saved eight people trying to commit suicide in our detention facility and if you will go back and do the history on some of these people, you will find that issue started in childhood and continued to escalate all the way up until they violated the law,” said Johnson, who noted that one person had actually died by suicide in the jail.

a man stands at a podium gesturing. he's wearing a sheriff's star on his jacket, and is an unlikely support of Medicaid expansion — Alamance County sheriff Terry Johnson told advocates and reporters on Wednesday morning that he ran the county’s largest mental health facility in his jail as he made the case for Medicaid expansion. “We can pay now or we can pay later,” he said about the policy. “And we are paying later with human life and people’s lives being destroyed.”

“What has happened to America? What has happened to our politicians? What has happened to their thought of ‘We the people’?,” Johnson asked. [Politicians are] worried about their reelection, they’re worried about, you know, their party.”

‘Lives on the line’

The meeting came during a fortnight where several new studies pointed to the benefits of Medicaid expansion. A study in the journal Health Affairs found worsening individual health outcomes in the 14 states that have not expanded Medicaid when compared to states that have expanded. North Carolina ranked number two in declining health among non-expansion states.

And a study released this morning by the Commonwealth Fund found that all races have made significant gains in health care coverage in the wake of passage of the Affordable Care Act, but North Carolina has a higher rate of uninsurance (15.7 percent) than the national average (12.4 percent). Those researchers also found that blacks in Medicaid expansion states have higher rates of health insurance than whites in states that have resisted expanding.

McDowell County Chamber of Commerce chair Steve Bush pointed out that many veterans coming back from Iraq and Afghanistan are ineligible for TRICARE or Veterans Affairs health care and lack health insurance.

“[They] are putting their lives on the line, they are risking everything to protect us to come home to a country that does not serve them to protect them in their health,” he said.

His chamber is one of 17 around the state that has endorsed Medicaid expansion.

Mostly, the business leaders in the room worked to make a case that not having access to coverage for low wage workers, and workers in the state’s 870,000 small businesses hurts the economy, hoping that argument might carry weight with politicians.

“We’re made up primarily of small businesses, those small businesses can’t pay their waiters and their dishwashers and their chefs, health insurance,” said Tom Kies, chair of the Carteret County Chamber of Commerce. He said many workers in the tourism-heavy coastal region often work two or three jobs to earn enough money to survive and often come to work sick.

“It’s been said that in Carteret County, a Democrat can’t get elected to dog catcher, it’s a very Republican market,” he said. “However, we have a number of issues that have become bipartisan.”

One of them, he said, is Medicaid expansion.

a bearded man smiles at the camera. He says he's looking to see Medicaid expansion in NC — Carteret County Chamber of Commerce chair Tom Kies said he was unsure what would happen when he brought a measure supporting Medicaid expansion to the chamber for a vote. He got a surprise when the vote was unanimously in support. Photo credit: Rose Hoban

How we reported this story:

Talked to multiple, bipartisan sources before and after events.
Attended three press conferences, attended/ listened to legislative hearings.
Reporter has followed this topic for multiple years.
Consulted academic research.
Interviewed lawmakers and others in addition to press events.

shows three empty hyperbaric oxygen treatment chambers, they look like large tubes that you can lay down in.

A new treatment could benefit vets with PTSD and brain injury, lawmakers want insurers to reimburse for it

July 9, 2019 by Emily Davis

A new treatment could benefit vets with PTSD and brain injury, lawmakers want insurers to reimburse for it - North Carolina Health News

Hyperbaric therapy forces more oxygen into damaged cells. Even as the evidence remains mixed, the NCGA is poised to make the treatment easier to get.

By Emily Davis

Veterans who have had brain injuries or are struggling with the effects of trauma may soon have a new treatment option if a new bill making its way through the legislature eventually becomes law.

On Tuesday, a Senate Health Care ommittee greenlighted House Bill 50, the North Carolina Veterans Traumatic Brain Injury and Post-Traumatic Stress Disorder Treatment and Recovery Act which would allow medical professionals to prescribe hyperbaric oxygen therapy, or HBOT, to North Carolina veterans who have had traumatic brain injuries and/or have post-traumatic stress disorder.

Jim Hooker, a Navy veteran, has been advocating for hyperbaric chamber treatment for veterans for several years. Patients sit in chambers where the atmospheric pressure is pumped up, pushing a patient’s blood, and the oxygen that blood cells carry, into vessels where the blood doesn’t always reach.

Cells require more oxygen to repair themselves. The increased pressure maximizes tissue oxygenation and stimulates wound repair.

According to Sen. Jim Perry (R-Lenoir), a bill supporter, “It’s like fertilizer for the healing process.”

The bill has been in the works for two years, since Hooker began talking with Rep. Greg Murphy (R-Greenville), a physician, about the treatment. There are questions around how well it works as well as how the treatment would be paid for.

“We have a great number of veterans here and Marines and Army veterans who live and need this therapy in the state,” Hooker said. “And it’s going to be a great accomplishment for the state, the governor to have this bill passed here.”

According to UNC Chapel Hill’s Carolina Population Center, there were over 656,000 veterans living in the state in 2017, and they make up a higher percentage of the adult population than the national average.

Jury still out

TBI and PTSD are neurocognitive disorders that can benefit from the reparative treatment offered with HBOT, Hooker argued.

“I’ve had the honor to work with veterans who have suffered major combat injuries, many of whom have suffered PTSD and TBI as a result of losing limbs among other things, and this therapy is a therapy that works,” Hooker said. “The word of mouth is eventually going to overwhelm this if nothing else does because it works, it just really works. I mean these guys, they get their lives back.”

shows a man laying in a hyperbaric oxygen therapy chamber. Another man in military fatigues stands outside the chamber, talking on the telephone. — The military uses hyperbaric oxygen chambers often for treating things such as wounds, as in this photo taken at the Southwest General Hospital Hyperbaric Wound Care Center, in San Antonio. Photo credit: US Air Force/ Staff Sgt. Jason Huddleston

But the research is not completely clear if or how HBOT might help people with TBI or PTSD.

Some studies have shown that the treatment is definitely effective at creating cognitive and quality of life improvements in TBI and PTSD patients. These studies back up reports from individual veterans who say they’ve experienced some degree of healing from HBOT.

“The reality is that oxygen therapy and all of the studies that have been conducted have shown an improvement, in many cases significant improvements in the condition of patients that receive the therapy, in particular, those veterans who have suffered TBI and PTSD,” Hooker said.

Other research claims any benefits are the result of a placebo effect,, something Hooker acknowledged in an article in the NC Medical Journal.

“The use of hyperbaric oxygen therapy is controversial, but there is some scientific evidence that it can lead to improvements in neuroplasticity, with concomitant improvement in body and motor function, cognition, and emotional system responses.” he wrote.

One of many possible treatments

Murphy worked on the bill in the House of Representatives, which passed it in April, while Sens. Don Davis (D-Goldsboro) and Jim Perry (R-Lenoir) gave it support in the senate.

shows a woman receiving hyperbaric oxygen therapy via a helmet — Patients can also receive treatment using small apparatus, as in the photo taken at the new Undersea & Hyperbaric Medicine Clinic at Brooke Army Medical Center June 2017. If the patient is not comfortable with the hood, they can also wear a mask to receive their treatment. Photo credit: Robert Shields/ U.S. Air Force

In the Senate Health Care Committee last week, Sen. Gladys Robinson (D-Greensboro) spoke up in strong support of the bill. In addition to her long-time work with veterans in Guilford County, Robinson’s late brother was a Marine for over 30 years, served in the Vietnam and Korean Wars, and suffered from PTSD.

Robinson said she was perplexed as to why the state had not already made this treatment available for veterans.

“We seem to be behind in terms of some of the medical treatments, like telemedicine and telehealth,” Robinson said. “I don’t know why we are so delayed in implementing health care treatments or medical treatments for special populations, but this is important, this is important for the health of veterans.”

According to Perry, quirks in the law caused the gap in treatment, and this act ensures that veterans are not denied this treatment option. HBOT treatment is available to patients in hospitals and private facilities around the state but is currently not authorized to be prescribed in Veterans Administration and Department of Defense facilities.

“What we’ve seen is increasingly other states have taken interest in HBOT, and I think it’s long time past due for North Carolina to take interest in this,” Davis said.

In addition to North Carolina, there are at least six states that have now passed a law authorizing this therapy for veterans: Oklahoma, Indiana, Arizona, Kentucky, Texas, and as of two weeks ago, Florida.

Public and private dollars

As of now, HBOT for these conditions is often not covered by insurance, according to Murphy, so users often end up paying out of pocket or with the support of a donor group. A separate bill creating a state Hyperbaric Oxygen Therapy Fund is currently in the works, which would establish a special fund within the Department of Military and Veterans Affairs (DMVA) to provide financial assistance to veterans for hyperbaric oxygen therapy. Sens. Davis, Perry and Joyce Krawiec (R-Kernersville) are the primary sponsors.

Davis said that there are still conversations being had around that bill.

“Right now you see DMVA, but we’re actually in the process of weighing where’s the best fit for it, maybe DHHS [Department of Health and Human Services],” said Davis, who served in the Air Force.

The fund would receive appropriations made by the General Assembly along with donations, gifts and earned revenue. As Perry explained, it allows HBOT for veterans to be funded by private donors, not just by state dollars.

“So now those veterans who may not have insurance, may not be able to cover the cost could actually come in and participate with some HBOT treatments,” Davis said.

Today, the bill heads to the Senate floor for final approval by that chamber, after which, it will head to Gov. Roy Cooper’s desk for his signature.

Middle aged white man with beard and a ball cap does running plank in a gym with his service boxer dog in front of him

A Veteran and His Dog: A Story of Mental Health Recovery

November 12, 2018 by Taylor Knopf

A Veteran and His Dog: A Story of Mental Health Recovery - North Carolina Health News

Quinn, a 4-year-old boxer goes everywhere with Billy DeWalt, keeping him safe, providing him with alerts, acting as a companion and helping him with PTSD.

By Taylor Knopf

On Saturday mornings, Billy DeWalt stretches for a workout class at Neuse River Crossfit while his dog, Quinn, sits patiently watching. There are other adaptive athletes in the room.

A one-armed athlete works out his remaining shoulder. Meanwhile, a woman with nerve damage lifts weights, despite arm and leg braces.

“Everybody should be able to have their own health. That shouldn’t be a special thing that only certain people can have,” said John Prescott, the gym owner. “Everyone should have it.”

Prescott said adaptive athletes like DeWalt started coming about four years ago and the group has grown organically.

Dogs such as Billy DeWalt’s boxer, Quinn, can provide services such as seizure alerts, diabetes alerts, assistance moving around and other functions, while also being a companion. Video credit: Taylor Knopf

It’s a place DeWalt feels at ease. And it’s a place that’s welcoming of everyone, including Quinn.

She is a 4-year-old boxer who sports a service vest with pink ribbons and pink or purple painted toenails. She goes everywhere with DeWalt, in the car, to the office, to his kids’ school and on planes.

DeWalt is an Army veteran and Quinn is trained to help him cope with Traumatic Brain Injury (TBI), Post Traumatic Stress Disorder (PTSD) and anxiety.

Quinn will alert DeWalt before a seizure. He said this is especially helpful to him in the car because it allows him a little less than a minute to pull to the side of the road before the seizure happens.

The injury to his brain causes DeWalt to have petit mal seizures, which are not obvious since they have no tremors or thrashing. Nonetheless, they are dangerous because he basically freezes for up to 30 seconds, his attention redirected. Quinn is trained to find somebody if he ever experiences a larger episode or act as a pillow for his head in the event that he falls down.

Quinn calms DeWalt when he’s feeling anxious. She walks ahead of him — know as “big guy” on Quinn’s Instagram account — so he won’t be surprised by anything around the corner. She will also wake him from PTSD-induced dreams.

But obtaining a service dog isn’t easy or cheap. DeWalt said the cost of an animal, in addition to training and insurance, runs anywhere from $40,000 to $60,000. And the Department of Veterans Affairs doesn’t cover it. He’s working with organizations such as K9s Serving Vets to help more veterans acquire a service dog.

For DeWalt, Quinn represents a new phase in his life, one where he’s open about his limitations as he’s become an advocate for mental health and veterans.

DeWalt didn’t always know how to handle his mental health issues. And when his time in the military was cut short due to his TBI and seizures, it was hard to let go of that life.

He’s a survivor of two suicide attempts.

Dream cut short

DeWalt was an Army paratrooper stationed at Fort Bragg with the 82nd Airborne and then in Germany with the 1st Infantry Division. It wasn’t until he was on deployment to Turkey in the early 2000s when a physician assistant discovered his seizures.

DeWalt said he trained really hard and sustained a few concussions which created scar tissue on his right frontal lobe.

He’d had his sights set on the U.S Army Special Forces. Growing up, DeWalt said he and the other kids would play “army” all the time. His dad was in the military and DeWalt signed up before he even turned 18.

Group of people in a parking lot stretching and working out together. In the center is a middle aged white man with his service dog, a boxer breed. — Veteran Billy DeWalt and his service dog, Quinn, work out with their Neuse River Crossfit class. Photo credit: Taylor Knopf

“There was a lot of stigma around mental health in the military when I was in,” he said. “Any chink in your armor disqualifies you [from Special Forces.] For that reason, I ignored a lot of things I should have paid attention to.”

While the rest of his troop readied for deployment, he was sent back to get his seizures checked out. He was medically discharged in 2004, which he said was “kind of hard.”

“I had been training to go to war and right before we hit the start line, I got pulled out,” he said. “That was hard to deal with.”

He said many of his fellow soldiers turned to drugs or alcohol in tough times, but he had four kids to prioritize.

“During the second hospitalization, I made peace with my regrets and have tried to find my purpose since then,” he said of his second suicide attempt. “I can’t think my purpose is solely going to work and paying bills.

“At this point, I’m just trying to stay healthy. There’s a reason for being here,” DeWalt continued.

So he’s turned his attention to helping other veterans. He’s invested a lot of his time in volunteering, telling his stories, and educating others about disabilities. For example, he’s on the board of the local military veterans resource coalition and does a lot of fundraising and races with them.

Invisible disabilities

DeWalt is over 6 feet tall, with black hair, a beard and multiple tattoos. He just looks strong.

It’s not hard to see why DeWalt says many doubt his disability or take his issues less seriously.

“Sometimes invisible disabilities are hard,” he said.

And people, including past employers, have a hard time understanding that he needs Quinn around all the time.

Middle aged white man with beard kneels and wipes the sweat from his face in a gym with ropes and weights in the background while his dog stands in front of him. — Veteran Billy DeWalt needs Quinn with him day and night. She alerts him before seizures and helps with his anxiety and P.T.S.D. Here, she joins him for his Saturday CrossFit workout. Photo credit: Taylor Knopf

Now, DeWalt is an IT project manager for a software development company, and he says his employer “meets the golden standard for dealing with people with disabilities.”

When he got the job, he said the human resource staff called to ask what other employees should know about Quinn before he even started.

“It was nice to work somewhere where they didn’t treat me like I wasn’t broken from day one,” he said.

But DeWalt said he’s found that many institutions don’t have comprehensive policies for service animals. He’s had trouble at his son’s school, which has a policy for students or employees with service dogs, but not parents.

“I thought the one place I won’t have to worry about her is a health care facility,” he said. “But it was one of my worst experiences.”

When picking up his wife from a surgery, the hospital would not let him in with Quinn to pick up the discharge papers. They had a policy for a patient with a service dog, but not a caretaker.

map showing the status of states and their licensure of nurse practitioners. North Carolina falls into one of the red states.

More Nurse Practitioners Now Pursue Residency Programs

July 6, 2018 by Kaiser Health News

More Nurse Practitioners Now Pursue Residency Programs - North Carolina Health News

The year-long residencies give newly graduated nurse practitioners extra time with complicated patients and extra time to hone their skills after completing academic training.

By Michelle Andrews

Kaiser Health News

The patient at the clinic was in his 40s and had lost both his legs to Type 1 diabetes. He had mental health and substance abuse problems and was taking large amounts of opioids to manage pain. He was assigned to Nichole Mitchell, who in 2014 was a newly minted nurse practitioner in her first week of a one-year postgraduate residency program at the Community Health Center clinic in Middletown, Conn.

In a regular clinical appointment, “I would have been given 20 minutes with him, and would have been without the support or knowledge of how to treat pain or Type 1 diabetes,” she said.

Shows a woman holding a smiling little baby. — Nichole Mitchell, a nurse practitioner, holds her daughter, June. Mitchell says a residency program helped her develop a specialty in caring for patients with HIV and hepatitis C, as well as transgender care. (Courtesy of Nichole Mitchell)

But her residency program gives the nurse practitioners extra time to assess patients, allowing her to come up with a plan for the man’s care, she said, with a doctor at her side to whom she could put all her questions.

A few years later, Mitchell is still at that clinic and now mentors nurse practitioner residents. She has developed a specialty in caring for patients with HIV and hepatitis C, as well as transgender health care.

The residency program “gives you the space to explore things you’re interested in in family practice,” Mitchell said. “There’s no way I could have gotten that training without the residency.”

Mitchell is part of a growing cadre of nurse practitioners — typically, registered nurses who have completed a master’s degree in nursing — who tack on up to a year of clinical and other training, often in primary care.

Residencies may be at federally qualified health centers, Veterans Affairs medical centers or private practices and hospital systems. Patients run the gamut, but many are low-income and have complicated needs.

Proponents say the programs help prepare new nurse practitioners to deal with the growing number of patients with complex health issues. But detractors say that a standard training program already provides adequate preparation to handle patients with serious health care needs. Nurse practitioners who choose not to do a residency, as the vast majority of the 23,000 who graduate each year do not, are well qualified to provide good patient care, they say.

As many communities, especially rural ones, struggle to attract medical providers, it’s increasingly likely that patients will see a nurse practitioner rather than a medical doctor when they need care. In 2016, nurse practitioners made up a quarter of primary care providers in rural areas and 23 percent in non-rural areas, up from 17.6 and 15.9 percent, respectively, in 2008, according to a study in the June issue of Health Affairs.

Depending on the state, they may practice independently of physicians or with varying degrees of oversight. Research has shown that nurse practitioners generally provide care that’s comparable to that of doctors in terms of quality, safety and effectiveness.

But their training differs. Unlike the three-year residency programs that doctors must generally complete after medical school in order to practice medicine, nurse practitioner residency programs, sometimes called fellowships, are completely voluntary. Like medical school residents, though, the nurse practitioner residents work for a fraction of what they would make at a regular job, typically about half to three-quarters of a normal salary.

Advocates say it’s worth it.

“It’s a very difficult transition to go from excellent nurse practitioner training to full scope-of-practice provider,” said Margaret Flinter, a nurse practitioner who is senior vice president and clinical director of Community Health Center, a network of community health centers in Connecticut.

“My experience was that too often, too many junior NPs found it a difficult transition, and we lost people, maybe forever, based on the intensity and readiness for seeing people” at our centers.

Flinter started the first nurse practitioner residency program in 2007. There are now more than 50 postgraduate primary care residency programs nationwide, she said. Mentored clinical training is a key part of the programs, but they typically also include formal lectures and clinical rotations in other specialties.

Not everyone is as gung-ho about the need for nurse practitioner residency programs, though.

Additional Thanks

Categories

Veterans Affairs

Coronavirus deaths bring attention to privatized state veterans homes - North Carolina Health News

By Thomas Goldsmith and Riley Davis

Show me the money

Pruitt privatizes management

First of 36 veterans dies

‘You never think there’s enough’

‘No major issues … exist’

Role of private management questioned

Problems before COVID-19

Thirty-six veterans die of COVID-19 in NC state veterans nursing homes that a private company has run for 22 years - North Carolina Health News

By Thomas Goldsmith and Riley Davis

Bringing ‘peace to residents’

Is a 9.25 percent commission fee fair?

Drive-in visitors, but how close?

Two more vets’ homes on the way

‘Does not constitute an admission’

Where sick veterans go

Questions from the top

‘They should have been more careful’

Elected officials respond

Legislative mini-session produces little movement on health care issues, despite new call for Medicaid expansion - North Carolina Health News

By Rose Hoban

Lawmakers came, did little, left

Failure to compromise frustrates

‘Lives on the line’

A new treatment could benefit vets with PTSD and brain injury, lawmakers want insurers to reimburse for it - North Carolina Health News

By Emily Davis

Jury still out

One of many possible treatments

Public and private dollars

A Veteran and His Dog: A Story of Mental Health Recovery - North Carolina Health News

By Taylor Knopf

Dream cut short

Invisible disabilities

More Nurse Practitioners Now Pursue Residency Programs - North Carolina Health News

By Michelle Andrews