Connecticut, like every state trying to reduce health care spending, is looking closely at how it cares for people with chronic conditions.
Gov. Dannel Malloy has promised to move more than 5,000 poor and disabled patients out of nursing homes in five years.
But the Democratic governor says there's an expensive obstacle in the way. Connecticut law says nurses have to give medications to people in the Medicaid system living at home, and that costs a lot of money.
Jane Counter is one of those nurses. On a recent weekday near Hartford, Counter had already seen a dozen patients before 9 a.m.
The psychiatric nurse arrives at the apartment of Frank. (We are identifying him by first name only to protect his privacy).
Counter gives Frank his extensive series of daily medications. But she says she's doing a lot more than delivering pills from a lock box. She's assessing Frank asking about his blood sugar, his diet, his sleep medications and about any bruising or bleeding that could give her pause.
She's not technically paid to assess him, but she does, because it's what nurses do. "And it's helpful because we build a rapport and, and that, over time, they become more comfortable with us and will report more symptoms to us, which is really important for us to know," Counter says.
But now the state of Connecticut is asking the question: Could someone other than a nurse do that same job, or part of it, for less money?
"The cost of medication administration is a significant barrier to getting people out of nursing homes and keeping people out of nursing homes," says Anne Foley, the governor's undersecretary for policy and planning.
So Connecticut is thinking of changing its approach and letting non-nurses administer drugs. "There are a few states that allow home health aides to do almost nothing in terms of medication administration, and Connecticut is one of them," says Howard Gleckman, a resident fellow at the Urban Institute who studies elder care.
The state legislature is now considering a plan to allow trained home care aides who now cost half what nurses do to administer medications while working under a nurse's supervision. Foley says that and other changes could eventually save the state millions.
Nurses like Counter would still go out to assess the health and safety of their clients, but they would clock less time traveling between patients. "It just means that they're not going two times a day, every day, three times a day, every day, to [give medications]," Foley says
The Urban Institute's Gleckman says there's some logic in giving home health aides more responsibility. Nurses have more important things to do than hand out pills.
And home health aides are on the front line. "So, in fact, if something changes with the patient she's not eating at much as she was, she's having incontinence problems it's much more likely that a home health aide will notice that than a nurse who spends five minutes in the house," Gleckman says. "This does require some training, but a well-trained aide can absolutely do this."
Now, it's up to the state's legislature, which is holding a hearing on the governor's proposal Tuesday.