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The Affinity Nursing Home on North Boulevard in Baton Rouge is a one-star ranked nursing home, which is the worst ranking in the federal government's five-star rating system. Almost half of the state's nursing homes are rated one or two stars, which means they're below average or much below average.  In Louisiana, state policies favor nursing homes giving elderly and disabled people less access to at-home care programs.

The Louisiana Legislature paid lip service this summer to improving services for the elderly and physically disabled -- but it did almost nothing to actually change a system that disproportionately institutionalizes the state's most vulnerable people in nursing homes.

On Monday, the AARP Foundation released its national scorecard for elderly services, cementing Louisiana's status as one of the worst places in the nation to grow old. Overall, Louisiana ranked 40th in the nation for long-term care services, a drop from 37th from 2014, when the report was last updated. And in two of the categories that address nursing homes, Louisiana couldn't get much worse: It ranked 50th for "quality of life and quality of care," and 51st -- behind every other state plus Washington D.C. -- in how effectively people are transitioned out of nursing homes into their preferred communities. 

"If this scorecard tells us anything, it's that we're moving too slow to meet the growing demand for care needed here in Louisiana," said Andrew Muhl, a lobbyist for AARP Louisiana. "Unfortunately, older Louisianans overwhelmingly prefer living at home and want nursing home alternatives that simply aren't available to them. And as a result, they aren't getting the adequate day-to-day help they need and are entering nursing homes unnecessarily."  

Gov. John Bel Edwards' office acknowledged that improvements need to be made. But while Edwards committed on the campaign trail to fighting for opportunities for seniors to receive care at home, he provided no specifics when asked Monday about how he hopes to achieve that. 

"Improving the quality-of-life issues for Louisiana seniors is a commitment of this administration," said Shauna Sanford, press secretary for Edwards. "Realizing that there is additional work that needs to be done, this administration is dedicated to ensuring quality of care for our seniors in order for them to have the quality of life they deserve." 

The newest scorecard noted disapprovingly that Louisiana had the highest percentage of nursing-home residents receiving anti-psychotic medication. More than 21 percent of nursing home residents received the medication, compared to a national median of 16.8 percent. Michelle Alletto, deputy secretary of Louisiana Department of Health, said anti-psychotic medication has decreased 39 percent in nursing homes since 2011, as the state has worked to improve education on this issue.

Louisiana nursing homes were also among the worst -- 49th in the nation -- for high-risk residents with bed sores. Louisiana also ranked near the bottom for the proportion of new nursing-home stays that last 100 days or more, and the percentage of nursing-home residents who are hospitalized.

Notably, Louisiana also continues to score poorly -- at 42nd in the country -- for having a high percentage of nursing-home residents with relatively modest needs. The scorecard says almost 17 percent of nursing home residents are considered "low-care," meaning they don't necessarily require the 24-hour care of a nursing home. 

"Taken together, the state's rankings in these categories reflect that, despite poor care, seniors and people with disabilities are given few options outside of nursing facilities," said Kim Jones, executive director of The Advocacy Center, a New Orleans-based nonprofit which advocates for elderly and disabled people. "Until Louisiana decides to invest in home- and community-based services, as well as affordable, accessible housing, we will continue to see low rankings. We must do better." 

However, Mark Berger, executive director of the Louisiana Nursing Home Association, said federal indicators show Louisiana's nursing-home quality is improving and blamed some of the poor scores in the AARP report on the poor health of people in the state. Indeed, the AARP scorecard showed Louisiana has posted some gains in quality since 2014, but was still outpaced by other states who were also improving at a faster rate.

Berger also said the industry struggles because Louisiana nursing homes have the lowest Medicaid reimbursement rates in the nation. However, reimbursement rates paid to nursing homes are calculated based on costs. The nursing home industry is also guaranteed rate hikes at least every two years, thanks to a state law that was passed at the industry's request. 

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"I am proud of Louisiana's nursing facilities for their dedication to improving the lives of residents through quality care," Berger said in a statement, adding that 18 nursing homes in Louisiana recently received national awards. "LNHA member facilities are constantly striving to provide exceptional person-centered quality to our residents in a loving environment. We will never stop improving." 

Louisiana has a wait list of more than 30,000 people who are elderly or physically disabled who hope to receive Medicaid-funded care at their own home instead of a nursing home, a service that is both less expensive to the state and preferred by the patient, according to surveys. This summer, The Advocate reported that Louisiana overwhelmingly puts its resources in nursing homes over home- and community-based programs, offering nursing homes financial security and annual funding increases while other state services have been slashed because of budget cuts. 

"The majority of Medicaid spending still goes directly to nursing homes, which has left many older adults without options," Muhl said. "The governor and our Legislature squandered several opportunities during the recent legislative session to rebalance long term care for older adults. Now they need to accelerate their plan to implement reform measures that are desperately needed in Louisiana." 

During the most recent legislative session, Louisiana Department of Health asked for almost $50 million in state money to expand funding for home- and community-based providers. It would have funded overtime for workers, increased the hourly reimbursement rates and funded 600 new slots for the Community Choices waiver program, which have been frozen because of budget constraints in recent years.

Community Choices is the most high-demand home- and community-based program for the elderly and physically disabled. Those requests were rejected, as lawmakers battled over another year of budget cuts. 

Home- and community-based providers have faced critical challenges because their rates have been slashed year after year. As a result, salaries for workers in the industry are often close to minimum wage, and the providers can't attract a stable workforce. Since 2012, 30 percent of home- and community-based providers in Louisiana have shut down, citing budget cuts and stiffer regulations. And just in the past three months, five more closed down. 

"We can no longer make enough money billing for Medicaid services so we have decided to discontinue as a provider," said Mitch Iddins, director of New Horizons Independent Living Center in north Louisiana. "Which is unfortunate, because we are serving around 175 clients through Medicaid." 

However, Kelly Zimmerman, a spokeswoman for the Department of Health, said four other home- and community-based providers were also approved this year to open, and there are no apparent gaps in access for services. 

A few lawmakers this session also made attempts to reform nursing homes by trying to force the administration to seek bids to expand managed care to elderly and physically disabled Medicaid services. The measure was studied under the Jindal administration, and abruptly abandoned after the nursing home association objected in 2015. 

A move to managed care would mean that private insurance companies would oversee Medicaid services for the elderly and disabled population, and determine whether those patients would be better and more cost-effectively cared for in a nursing home or in their own home with supports. The state could generate more than $100 million from the move, because of a managed-care tax on the books, while reducing the state's dependency on nursing homes. 

But the measure was voted down in a House health committee meeting that was packed with nursing home owners. The measure was also introduced as a budget amendment in the House and in a Senate committee, but both were rejected. 

In the final days of the session, Baton Rouge Rep. Rick Edmonds got the House to pass a nonbinding resolution to study the issue. Alletto said the department will do its best to respond to the legislative request. 

"We are determined to escalate the dialogue around this issue in Louisiana," Edmonds said. "It is a priority, and we will press on until leadership determines it is a priority and we start seeing quality care for the elderly and disabled." 

Follow Rebekah Allen on Twitter, @rebekahallen.