Wednesday, November 4, 2015
The Kaiser Family Foundation's Commission on Medicaid and the Uninsured released an issue brief on Medicaid’s Role for People with Dementia.
Almost one-half (46%) of nursing facility residents and about one in five (21%) seniors living in the community has probable or possible dementia, a syndrome characterized by a chronic, progressive decline in memory and other cognitive functions, such as communication and judgment. People with dementia often have complex medical and behavioral health needs, and many rely on family caregivers to provide assistance with self-care and other daily activities. As dementia advances, paid care may be needed. Most people with dementia have Medicare, but due to high out-of-pocket costs and lack of long-term services and supports (LTSS) coverage, low-income people with disabilities resulting from dementia may need Medicaid to fill in the coverage gaps. Medicaid plays an important role in providing LTSS and is increasingly focused on efforts to help seniors and people with disabilities remain in the community rather than reside in institutions.
Given the expected growth of the elderly population over the coming decades and barring medical breakthroughs, a larger share of Americans likely will have dementia, which has implications for Medicaid coverage, delivery system design, financing, and quality monitoring. This fact sheet describes Medicaid’s role for people with dementia who live in the community, highlighting common eligibility pathways, beneficiary characteristics, covered services, health care spending and utilization, and key policy issues.
The issue brief discusses several issues and then concludes
Improving medical care and LTSS for people with dementia is likely to remain a major public health issue as well as the focus of ongoing medical research in the coming decades as policymakers, families, and other stakeholders consider cost-effective options to meet the needs of this vulnerable and expanding population. Medicaid beneficiaries with dementia have fewer financial resources to contribute toward the cost of care and are significantly more likely to use home-based services than people without Medicaid. People with dementia will likely need paid care as their functioning declines, and in the absence of other viable public or private financing options, Medicaid will continue to be the nation’s primary payer for LTSS.
For several years, the National Continuing Care Residents' Association (NaCCRA) has hosted annual meetings in conjunction with the LeadingAge meeting, combining its own business with the opportunity for members to participate in a broad array of educational and general sessions offered under the umbrella of LeadingAge, thus providing residents with direct insights into provider-side views of the industry.
This year, the NaCCRA meetings on October 31-November 1, 2015 in Boston, offered a packed agenda of topics that attracted strong attendance by officers, board members, and representatives of more than a dozen state resident chapters (photo), as well as interested individual residents. And anyone who thinks older adults aren't tech savvy can think again, as several members were participating remotely and the sessions are recorded for later viewing through the NaCCRA website.
High on the agenda this year was finalization of a formal affiliation agreement between NaCCRA and LeadingAge.
The prospects for affiliation troubled some within NaCCRA, especially those who became active in NaCCRA precisely because of concern about the direction taken by certain owners or management of CCRCs in recent years. They saw LeadingAge as the voice of "providers" only, and perhaps even as representing "the enemy." They were worried residents might be silenced by the affiliation. Others in NaCCRA have witnessed the ever-broadening membership of LeadingAge and noted the organization's strong interest in state and federal regulation, laws and tax policies affecting senior living operations. They felt that NaCCRA needed to be inside the tent to have an effective voice in future changes that can affect residents.
Within NaCCRA, the vote in favor of affiliation lead to a change at the leadership level, with President Dan Seeger (Pennsylvania) and at least one other board member stepping down from their positions in late summer 2015.
Past President Ruth Walsh (Connecticut, center in photo below) had several weeks as Interim President. During the October 31 meeting, new officers were elected, including Rev. Bob Nicholson (Washington, below left) as incoming President, Walt Boyer (North Carolina) as President Elect, and Jack Cumming (California) as Treasurer, joining William Ratcliff as Secretary.
At the meeting the results of a recent survey of the more than 2,000 paid members of NaCCRA (including those representing affiliated state NaCCRA chapters or resident councils, thus giving NaCCRA an interest group of at least 38,000 residents) was announced. The survey provides a prioritized action list for upcoming projects. Advocating for clearer written statements of "resident rights" (matched with better understanding of resident responsibilities) came out on top of the list of objectives for the coming year
Monday, November 2, 2015
If you haven't read this yet, this is a must-read. The New York Times did an in-depth series on the use of mandatory arbitration clauses. On October 31, 2015, the Times ran the first in the series: Arbitration Everywhere, Stacking the Deck of Justice. On November 1, 2015, the next story in the series ran: In Arbitration, a 'Privatization of the Justice System'.
I recommend you read them in order. What you learn may be surprising. We have all heard about arbitration clauses in long-term care agreements. You may be surprised to learn the breadth of use of arbitration clauses.
Read the series. And assign it to your students.
Sunday, November 1, 2015
My friend Jim Pietsch at the U. of Hawaii elder law program offers this clever annual event for elder individuals to encourage the completion of advance directives. The University of Hawai'i Elder Law Program (UHELP) at the William S. Richardson School of Law held its annual "NITE" OF THE "LIVING WILL" on October 29, 2015. Here is the description of the program from their website.
During this daylight presentation of our annual Halloween event, the University of Hawai`i Elder Law Program will present a talk about medical treatment decision-making and advance care planning to include informed consent/informed refusal, individual instructions for health care, durable powers of attorney for health care, comfort care only-DNR bracelets/necklaces and Provider Orders for Life-Sustaining Treatment (POLST).
You will have the opportunity to Decide What If? you are unable to communicate your wishes for end of life care. If you still have an old “Living Will” or if you are unsure of how end-of-life decisions will be made for you, come and find out how to make an advance directive or other documents that will help make sure your wishes regarding health care decisions are honored.
The public, especially kupuna, family caregivers, service providers, students and faculty are invited. Tea and little treats will be served. Donations to cover the cost of this hydration and nutrition accepted.
This is such a creative program and kudos to Jim for all of his work!
At the opening general session for LeadingAge's 2015 Annual meeting on November 1, the results of two years of research into consumer preferences for LTC and senior housing, including consumer and provider surveys and focus groups, has culminated in a new identity for Continuing Care Retirement Communities (CCRCs). And -- drum roll, please -- the new name is Life Plan Communities.
The thinking is interesting. First, LeadingAge researchers learned that while current residents embrace the name "Continuing Care Retirement" for their communities, younger persons reject the notion of both "retirement" and "care." Thus, Life Plan Communities are viewed as playing to the "engagement" model of aging, where individuals have more control over their options, and are less likely to be passive in their response to provider-defined theories of care.
In announcing the new name, outgoing LeadingAge CEO Larry Minnix and other leaders emphasized that the change is intended to be part of a conversation, to stimulate thinking and reaction to what it means to plan for future needs. They recognize that states may or may not embrace the name change, including whether state laws will be amended to reflect the new identity for purposes of licensing and regulation.
Will a rose by any other name smell as sweet -- or, perhaps, even sweeter?
Thursday, October 29, 2015
Friends are an integral part of the fabric of our lives. Perhaps the most important time in one's life to have friends is at the end of life, according to an article in the New York Times. The article, Near the End, It's Best to be "Friended" focuses on what has become known as the "unbefriended" elders. When we think "unbefriended", we think of someone without friends or relatives. Maybe the person has outlived everyone. But the article offers that "unbefriended" has a much broader meaning: "you can also be unbefriended, even if you do have friends and family, if you are incapacitated and haven’t appointed someone you trust as a health care proxy." The article cites a study that shows an increase in the number of unbefriended elders and notes the likelihood of a continued increase since the chance of dementia increases with age.
More and more patients who lacked decision-making capacity, had no available surrogates and had not completed an advance directive,” said Martin Smith, director of clinical ethics at the Cleveland Clinic.
The kinds of unrepresented elders might change, too. In the past, many were marginalized — homeless, addicted, mentally ill, estranged. Baby boomers, with higher rates of childlessness and divorce, have smaller and more mobile families, and longer life spans. “They could live a largely mainstream life, but outlive everyone around them..."
The article notes that some states have statutes giving priority order to relatives and, in some instances, others to make health care decisions for those who haven't made a directive.
Twenty-four states and the District of Columbia have added “close friend” to that list, according to the American Bar Association Commission on Law and Aging; some states also include aunts and uncles, nieces and nephews, and adult grandchildren. A member of the clergy can serve in that role in Texas. The wider the net, the reasoning goes, the greater the likelihood of finding someone authorized to make decisions. Legalized same-sex marriages also mean fewer unrepresented gay and lesbian older adults.
This is an interesting article that provides good content for discussion with students about the importance of advance directives, and the potential for problems without them.
Tuesday, October 27, 2015
The National Center on Elder Abuse (NCEA) has a really cool fact sheet on APS. Adult Protective Services: What You Must Know, provides a concise explanation of APS, reporting, FAQs and client protections. Great information in a 2 page document! This would be a good resource for students to gain understanding of APS.
Monday, October 26, 2015
I've posted several times of late on recent articles about dementia. So here is one more, from England. Published September 21, 2015 in The Guardian, One-third of British people born in 2015 'will develop dementia' looks at the projections of dementia in England. The article opens with sobering statistics. "One in three people born this year will develop dementia, according to new figures. The Alzheimer’s Research UK charity warned of a “looming national health crisis” as the population ages." Quoting Alzheimer's Research UK which offered that age is the most significant risk factor, the article offers future predictions:
As people live longer than ever before, the numbers with dementia will rise. The latest analysis, commissioned by the charity and carried out by the Office of Health Economics, was released to mark World Alzheimer’s Day.
It showed 27% of boys born in 2015 will develop the condition in their lifetime, alongside 37% of girls. Previous research from the same team has estimated that the development of a drug that could delay the onset of dementia by five years would cut the number of cases by a third.
We know the implications on caregivers from this disease. The article offers the fiscal impact on the country:
George McNamara, head of policy at Alzheimer’s Society said: “Dementia is already the biggest health challenge this country faces. It costs the UK in excess of £26bn, which equates to £30,000 a person with dementia – more than the cost of either cancer or heart disease. Today’s stark finding should galvanise the government, and us all, into action.”
Recently I witnessed a nighttime accident on Interstate-81 in Cumberland County, Pennsylvania. There was an unmistakable "boom" signaling a rear-end collision. One truck (that appeared to be a large rental truck) had rear-ended an 18-wheeler behind me -- and I watched the faster moving rental truck continue past me on the road with heavy damage on its right side, before eventually veering to a shaky halt in the median. As far as I could tell, both drivers were alive, but at the first safe spot, I called 911.
I got off of I-81 at the next exit. I paused both for gas and to take a breath of crisp night air, before taking a back road the rest of the way home. While I was fueling, an older man in the car next to me, a car with West Virginia license plates, pointed to the I-81 overpass where traffic was crawling through more flashing lights. He asked, "Is it safe for us to get on the road to get home? We live about 75 miles from here." Frankly, I had no way to answer that with any confidence. He shook his head and said to his companion, "I think we should stay in a motel tonight."
Sunday, October 25, 2015
The October 2015 issue of Health Affairs contains an article about the impact of caring for an individual with dementia has on caregivers (family and unpaid), The abstract provides a description of the article, the Disproportionate Impact Of Dementia On Family And Unpaid Caregiving To Older Adults
The number of US adults ages sixty-five and older who are living with dementia is substantial and expected to grow, raising concerns about the demands that will be placed on family members and other unpaid caregivers. We used data from the 2011 National Health and Aging Trends Study and its companion study, the National Study of Caregiving, to investigate the role of dementia in caregiving. We found that among family and unpaid caregivers to older noninstitutionalized adults, one-third of caregivers, and 41 percent of the hours of help they provide, help people with dementia, who account for about 10 percent of older noninstitutionalized adults. Among older adults who receive help, the vast majority in both community and residential care settings other than nursing homes rely on family or unpaid caregivers (more than 90 percent and more than 80 percent, respectively), regardless of their dementia status. Caregiving is most intense, however, to older adults with dementia in community settings and from caregivers who are spouses or daughters or who live with the care recipient.
A subscription is required to access the full article.
Thursday, October 22, 2015
I was interested to learn about a new law in Illinois that allows for electronic monitoring in long term care facilities in certain cases. Protecting Our Own: The Practical Implications of Illinois’s Authorized Electronic Monitoring in Long-Term Care Facilities notes that this new law goes into effect at the beginning of 2016 and "permits nursing home residents in facilities that are licensed under certain state legislation such as the ID/DD Community Care Act or Nursing Home Care Act to use audio or video surveillance in their room at their own expense." There are criminal penalties if anyone interferes with the monitoring devices and there is some money available for those facilities unable to afford the devices.
Illinois joins 4 other states (New Mexico, Oklahoma, Texas and Washington) with electronic monitoring laws. There are other states that have guidelines for those LTC facilities who want to allow monitoring based on a desire of a resident. The article discusses the pros and cons of monitoring and offers concerns regarding quality of care.
In terms of quality of care, having cameras in the rooms may also affect the important relationships developed between facility caregivers and their residents. The staff may choose to rely on the cameras to monitor residents rather than engaging in direct communication, potentially leading to mistrust and even a greater substandard of care that such legislation was meant to combat in the first place. Residents may never truly feel comfortable without the bond usually fostered between the two parties, contributing to a negative experience.
The Illinois statute is available here. One section of the statute addresses consent to monitoring. Written consent by the resident (or the resident's guardian) is required on a specific form from the state agency. If the resident's doctor determines the resident lacks the capacity to consent, the statute provides a priority list of individuals who may provide consent. Among other things, the statute addresses monitoring when the resident has a roommate. The statute also provides for conditions to be set on monitoring. The "standard" conditions set out in the statute include no audio recording, no transmission of either video or audio, powering off the devices or blocking taping when a health care professional is caring for the resident or roommate or during bathing and dressing or during visits by certain folks such as attorney, financial planner, and ombudsman. Other restrictions beyond the statutory ones can be imposed. The statute addresses other matters, such as notice, reporting and more. Read the Illinois statute here.
Wednesday, October 21, 2015
USA Today ran an article on October 15, 2015 about the cost of long term care for individuals with dementia, especially those with Alzheimer's. The estimated price tag? Almost three quarters of a million dollars! Got $730K saved for nursing care? Dementia could cost that much notes that a person with dementia needing long term care could live for several years, needing round the clock care,the cost of that care mounts up and "leav[es] families in an emotional, financial and logistical quagmire."
This is a growing issue and one that will affect many. "Boomers are increasingly faced with supporting both their children and their parents, or at least helping to figure out how their parents can best help themselves. Senior citizens with heart disease and cancers that were once a death sentence are now living far longer."
The article discusses Medicare and Medicaid as far as coverage for long term care and the differences in Medicaid programs amongst states.
Tuesday, October 20, 2015
In the last month of life, one in two Medicare beneficiaries visits an emergency department, one in three is admitted to an intensive care unit,and one in five has inpatient surgery. But one of the most sobering facts is that no current policy or practice designed to improve care for millions of dying Americans is backed by a fraction of the evidence that the Food and Drug Administration would require to approve even a relatively innocuous drug.
The article explains why this evidence is important
The public and private sectors are now engaged in an unprecedented array of virtuous efforts to improve end-of-life care. That these efforts are generally not evidence-based is not the fault of the organizations promoting them. It is the responsibility of investigators and research sponsors to identify, develop, and rigorously test interventions so that they can offer guidance as growing political and cultural tolerance increasingly permits implementation of end-of-life care programs. Achieving evidence-based end-of-life care will require at least four key developments — which, fortunately, are now attainable.
The article discusses the four key developments and notes in conclusion "the central challenge is to avoid complacency regarding plausibly useful but non–evidence-based initiatives. Researchers, research sponsors, and large insurers, employers, and health systems can collaborate to advance knowledge about what works best for whom. And the sooner they do so, the better...."
ABA's Bifocal, an electronic journal from the ABA Commission on Law and Aging has released one of its October issue articles. Written by Charlie Sabatino in his usual bold style, we confront ten "Myths and Facts About Health Care Advance Directives," sometimes better (if confusingly) known as "living wills." To tease the article, Myth #3 is "Advance Directives are legally binding, so doctors have to follow them." You will want to read the rest of the story....
Monday, October 19, 2015
Oregon Health & Science University (OHSU) announced the forthcoming publication of a report on elders and depression and the differences when they had in-person interactions vs. virtual interactions. Research: Face-to-face socializing more powerful than phone calls, emails in guarding against depression in older adults is published in the Journal of the American Geriatrics Society (free to members). The release on the study described the findings: "Study participants who regularly met in person with family and friends were less likely to report symptoms of depression, compared with participants who emailed or spoke on the phone. The gains people derived from face-to-face socializing endured even years later."
Here are some more details about the study from the news release:
Researchers examined the frequency of in-person, telephone and written social contact, including email. Then they looked at the risk of depression symptoms two years later, adjusting for potential confounding factors including health status, how close people lived from family and preexisting depression.
The researchers found that having little face-to-face social contact nearly doubles your risk of having depression two years later. They also reported that having more or fewer phone conversations, or written or email contact, had no effect on depression.
Study participants who met up with family and friends at least three times a week had the lowest level of depressive symptoms two years later – 6.5 percent – than those who had less frequent contact. Individuals who met up just once every few months or less frequently had an 11.5 percent chance of depressive symptoms.
NAPSA and the National Council on Crime & Delinquency announce a webinar on Improving Client Mental Health to Positively Impact Abuse Resolution. The webinar is scheduled for October 20, 2015 from 2-3:30 p.m. edt.
The announcement explains the webinar
In this webinar we will discuss the implementation of mental health screening and Problem-Solving Psychotherapy (PST) into routine elder abuse services. Providing Options To Elderly Clients Together (PROTECT) is a mental health program where anxiety and depression screening and problem-solving therapy with anxiety management are integrated into elder abuse services to improve the outcomes of victims with depression and/or anxiety. The webinar will describe the methods used and the effects of the program on staff and clients.
Click here to register for the webinar.
Thursday, October 15, 2015
The Financial Insurance Regulatory Authority (FINRA) distributed a press release on October 15, 2015. FINRA Solicits Comment on Proposed Rules Addressing Financial Exploitation of Seniors announced the release of Regulatory Notice 15-37 which seeks
comment on proposed rules addressing the financial exploitation of seniors and other vulnerable adults. FINRA is proposing amendments that would require firms to make reasonable efforts to obtain the name of and contact information for a trusted contact person for a customer's account. In addition, FINRA is proposing a new rule that would permit firms to place a temporary hold on a disbursement of funds or securities when there is reasonable belief of financial exploitation, and to notify the trusted contact of the temporary hold.
The comment period closes November 30, 2015. The regulatory notice is available here.
The executive summary explains
FINRA seeks comment on proposed rules addressing the financial exploitation of seniors and other vulnerable adults. FINRA is proposing: (1) amendments to FINRA Rule 4512 (Customer Account Information) to require firms to make reasonable efforts to obtain the name of and contact information for a trusted contact person for a customer’s account; and (2) the adoption of new FINRA Rule 2165 (Financial Exploitation of Specified Adults) to permit qualified persons of firms to place temporary holds on disbursements of funds or securities from the accounts of specified customers where there is a reasonable belief of financial exploitation of these customers.
Wednesday, October 14, 2015
The Department of Justice announced a $255,000 settlement vs. a CCRC. United States Obtains $255,000 Settlement of Disability Discrimination Lawsuit Against Continuing Care Retirement Community in Lincolnshire, Illinois explains a proposed settlement (the settlement has to be approved by the court). The press release explains that this settlement resolves "allegations that the owners and managers of a continuing care retirement community known as Sedgebrook violated the Fair Housing Act by instituting policies and maintaining practices that discriminated against residents with disabilities at the facility, which is located in Lincolnshire, Illinois..."
The complaint alleges that since 2011, Sedgebrook has instituted a series of policies that prohibited, and then limited, residents’ ability to dine in the communal dining rooms of the independent living wing of the facility if they required assistance eating due to a disability. Additionally, the complaint alleges that Sedgebrook maintained a policy prohibiting residents of the independent living wing from hiring live-in caregivers and refused to grant reasonable accommodations to that policy that would have allowed Sedgebrook residents with disabilities to use and enjoy their apartments.
As part of the settlement, the CCRC "will appoint a Fair Housing Act compliance officer and will implement a new dining and events policy, a new policy applicable to residents’ private employment of caregivers, and a new reasonable accommodation policy. Additionally ... the company that manages Sedgebrook and is a named defendant in the lawsuit, will take steps to implement similar policies at the over 100 independent living and continuing care retirement communities it owns or manages across the country."
The complaint and consent order are available for download here.
I'm always playing catch-up on my "must read" list, but fortunately, others keep me on task. One such article is Florida State Medicine and Law Professor Marshall Kapp's piece, inspired in part by Hendrik Hartog's 2012 book, Someday All This Will Be Yours.
In For Love, Legacy, Or Pay: Legal and Pecuniary Aspects of Family Caregiving, published by the Springer Journals of Case Management, Professor Kapp begins with this overview and note of caution about legal planning:
Most caregiving and companionship provided by family members and friends to elder individuals in home environments occurs because of the caregiver's feelings of ethical and emotional obligation and attachment. From a legal perspective, though, it might be ill-advised for an informal caregiver to admit to such a motivation.
He advises consideration of personal service or personal service agreements, explaining:
We must reject an analytically attractive and pure, but never really socially realistic, tendency to dichotomize the caregiver experience, recognizing instead that a person may simultaneously be both a family member, with the related emotional and ethical connotations of that label, and a business employee. Morality and materiality are not incompatible. Caregiving can be both an act of love and a marketable commodity bought and sold between non-strangers.
As Professor Kapp points out, if we as a society really wanted to encourage family caregiving without all too vague promises about future inheritances, we could go beyond mere tax credits and "instead use public funds to pay family caregivers directly."
It's that time of year...CMS releasing the 2016 figures for Medicare. For some beneficiaries, the amount of their Part B premiums and deductibles is going to be a big OUCH! The New York Times ran an editorial on October 10, 2015 on how the premiums and deductibles are calculated and what it means for some beneficiaries in 2016. The Unlucky Millions Paying More for Medicare explains
Under a 1997 law, premium payments must cover 25 percent of the projected per capita costs for Part B. The premiums, which can rise and fall from year to year, are usually deducted from beneficiaries’ Social Security payments each month. A “hold harmless” provision guarantees that for most people the dollar amount of a premium increase cannot be so big that they are left with a Social Security check that is less than that of the year before. The goal is to ensure that beneficiaries, most of whom have modest incomes, don’t have less money to live on.
Since there will be no Social Security COLA for 2016 but Part B premiums are set to rise, the impact is going to hit hard a certain group of beneficiaries:
The roughly 70 percent of beneficiaries who are “held harmless” will pay the same premium as last year. That means the increased cost will have to be made up by the other 30 percent, because of the rule that premiums must cover one-quarter of Part B costs. This group includes 2.8 million new enrollees, 1.6 million people who don’t collect Social Security benefits and 3.1 million higher-income beneficiaries.
How big a hit will this group take? A pretty big one. Consider this in dollar amounts.
The Part B premium has been just under $105 a month for three years, but it is projected to reach $159 in 2016 and then drop to $120 in 2017.
Similarly, the Part B deductible, which must be paid by everyone on Medicare (no one is “held harmless”), will rise from $147 in 2015 to $223 in 2016, before falling back to $169 in 2017. This will pose a particular burden to beneficiaries just above the poverty line who aren’t eligible for assistance from Medicaid in paying deductibles.
The editorial calls for action by Congress to resolve the way premiums are determined. But for now, OUCH!