Rose Belanger, a resident of Elmhurst Extended Care, will leave the nursing home as a result of new Medicaid rules.

The Providence Journal / Bob Thayer

PROVIDENCE –– Rose Belanger is a fighter, a 79-year-old spitfire raised in the Italian neighborhoods of Federal Hill.

She reluctantly became a nursing home resident in January, hobbled by her second serious fall in two years.

“They said I’d be wheelchair-bound. I fooled them,” she said with a defiant grin this week, sitting in what has been her home for the last six months, Elmhurst Extended Care.

Now, Belanger is fighting to go home.

It doesn’t matter that she has poor hearing, kidney disease, and needs to use a walker. Backed by the Carcieri administration’s push to rebalance Rhode Island’s long-term care system, Belanger –– and dozens more nursing home residents –– plan to leave costly medical institutions voluntarily in the coming months.

“I’d rather live in the apartment. I’ve never lived in a facility like this. Not that this isn’t a good place. But … ,” she said, shaking her head. “Not for me.”

Under the new system –– made possible by an unprecedented five-year agreement with the federal government known as the “global Medicaid waiver” –– hundreds of seniors will be encouraged to leave or be diverted from costly institutions based on stricter eligibility standards that took effect July 1.

Belanger is among the first wave of seniors who carry on their shoulders the hopes of state policymakers and budget officials.

The state budget for the fiscal year that began July 1 projects $27 million in savings directly related to “authority provided under the global waiver,” according to the Department of Human Services. To meet those projections, the state must “divert or transition” 50 seniors each month –– a 20 percent reduction from the 250 who entered a nursing home each month over the last year –– away from nursing homes, according to DHS.

Regulations affecting disabled residents and children in long-term placements are expected to follow in the near future.

Industry officials acknowledge that the new system will have dramatic implications for some of the state’s 92 nursing homes that currently offer a total of 9,281 beds.

“There will be some collapsing of the nursing homes,” said Elmhurst Extended Care vice president and administrator Richard Gamache, adding that the stronger homes, such as his, would survive. “Maybe I’m a little naive, but I’m not fearful of the global waiver.”

Belanger doesn’t involve herself with the political or financial implications of the Medicaid overhaul.

She’s simply grateful the new system allows her to use Medicaid dollars to pay for visiting nurses, minor home modifications, and adult daycare. With those supports, she plans to move into a private apartment with her longtime boyfriend in the next “month or two.”

“I’m excited about picking out the curtains,” she said. “I’m a typical girl.”

But Belanger’s path to independent living will not be an easy one.

Five months shy of her 80th birthday, she has numerous health problems. Her grown daughters work full time and cannot provide regular care for their ailing mother. And questions remain about the availability of services for the exodus of frail senior citizens moving into the community.

While administration officials play down capacity concerns, the state last week issued a comprehensive survey trying to gauge the situation.

“The state is sponsoring an independent survey to assess the capacity of on-the-ground providers in the state to meet both the current and future demand for long-term supports and services as the population ages and the state looks to restructure the long-term care system to better meet the needs of Rhode Islanders,” wrote Gary Alexander, secretary of the Executive Office of Health and Human Services, in a letter to medical providers dated July 1, the same day the new nursing home standards took effect.

And there is a question of what would happen to people like Belanger, who leave, but later wish to return.

They would not be guaranteed nursing home re-admission, based on legislation approved by the General Assembly late last month. Instead, along with all prospective nursing home residents, they would be subject to tighter standards guaranteeing admission only to those who, for example, “require extensive assistance or total dependence” with at least one “activity of daily living,” such as toilet use, eating, bed mobility and at least “limited assistance” with another activity.

The state has hired three nurses to supplement three existing nurses who will determine the “appropriate level of care” under the new rules, according to the DHS. Decisions may be appealed.

Those denied nursing home-level care would qualify for out-patient services, such as visiting nurses or adult daycare, but only if they are available. Waiting lists are possible.

“It’s a real disincentive for people who would want to try to make it out in the community,” said William Flynn, executive director of the Senior Agenda Coalition. He notes that the legislation allows an exception for “failed placements,” but fails to define the term.

The state is currently paying $550,000 for a private contractor, the Alliance for Better Long Term Care, to move nursing home residents like Belanger into the community.

“We tell them right at the getup that we want to be careful because the system may be that once you get into the community you may not be able to get back in,” said the contractor’s executive director, Kathleen Heren. “That’s why we’re very careful about those who we’re sending out. We’re not sending people out we know who would fail.”

But a pamphlet left behind by the Alliance at Elmhurst, entitled, “Now You Have a Choice,” does not include Heren’s warning: “If you decide you want to return to a nursing home or your circumstances change, assistance will be available,” it reads.

The optimistic Belanger said she’s not worried about moving back to a nursing home.

But her social worker, Adele Paradis, said it may not be that simple. To succeed, Belanger may require as many as three two-hour visits each day from certified nursing assistants, according to Paradis. And it’s unclear if the state would approve the service or if the health-care workers are available.

“I’m going to do all right,” Belanger said, flashing her fists like a prize fighter. “I have the fight.”

R.I. nursing homes

92: Nursing homes in Rhode Island

9,281: Nursing home beds

6,360: Medicaid-funded residents*

50: Medicaid-funded residents state hopes to divert each month

*As of March 2009

speoples@projo.com