Wednesday, September 28, 2016
The Federal Nursing Home Reform Act went into effect back in 1987. Those accompanying regs have been in place a long time. Now CMS has issued final rules that revise the LTC regs. The official publication date is Oct. 4, 2016. The regs are being implemented in phases, with phase one going into effect on November 28, 2016. Here is the Federal Register summary:
This final rule will revise the requirements that Long-Term Care facilities must meet to participate in the Medicare and Medicaid programs. These changes are necessary to reflect the substantial advances that have been made over the past several years in the theory and practice of service delivery and safety. These revisions are also an integral part of our efforts to achieve broad-based improvements both in the quality of health care furnished through federal programs, and in patient safety.
The regs are over 700 pages and are available here. Here are the effective dates: "Phase 1 must be implemented by November 28, 2016... Phase 2 must be implemented by November 28, 2017 ... Phase 3 must be implemented by November 28, 2019 ... A detailed discussion regarding the different phases of the implementation timeline can be found in Section B. II 'Implementation Date.'"
42 C.F.R. 483.10 is updated but CMS is "retaining all existing residents’ rights and updating the language and organization of the resident rights provisions to improve logical order and readability, clarify aspects of the regulation where necessary, and updating provisions to include advances such as electronic communications."
There's a new reg, 42. C.F.R. 483.21, "Comprehensive Person-Centered Care Planning" wherein CMS, among other things, is "requiring facilities to develop and implement a baseline care plan for each resident, within 48 hours of their admission, the instructions needed to provide effective and person-centered care that meets professional standards of quality care."
One of the most watched sections involved the use of arbitration clauses. 42 C.F.R. 483.70 now includes, among other things, the following: "Binding Arbitration Agreements: We are requiring that facilities must not enter into an agreement for binding arbitration with a resident or their representative until after a dispute arises between the parties. Thus, we are prohibiting the use of pre-dispute binding arbitration agreements."
This is just a brief overview of a few provisions. We'll blog about more of them later, but for now, be sure to read the new regs. They're important!
P.S. this post has been updated to correct the publication and effective dates (I was too excited)
Tuesday, September 27, 2016
We blogged last week regarding the release of a new report by the National Academies Press: Families Caring for an Aging America. The National Academies is holding a webinar briefing on September 29 from 1:30-3:00 p.m. edt.
Here is some information about the briefing:
At least 17.7 million individuals in the United States are family caregivers of someone age 65 and older who has a significant impairment. The circumstances of individual caregivers are extremely varied. They may live with, nearby, or far away from the person receiving care. The care they provide may be episodic, daily, occasional, or of short or long duration. The caregiver may help with household tasks or self-care activities, such as getting in and out of bed, bathing, dressing, eating, or toileting, or may provide complex medical care tasks, such as managing medications and giving injections. The older adult may have dementia and require a caregiver's constant supervision. Or, the caregiver may be responsible for all of these activities. With support from 15 sponsors, the National Academies of Sciences, Engineering, and Medicine convened an expert committee to examine what is known about the nation's family caregivers of older adults and to recommend policies to address their needs and help to minimize the barriers they encounter in acting on behalf of an older adult. The resulting report, Families Caring for an Aging America, provides an overview of the prevalence and nature of family caregiving of older adults as well as its personal impact on caregivers' health, economic security, and overall well-being. The report also examines the available evidence on the effectiveness of programs and interventions designed to support family caregivers. It concludes with recommendations for developing a national strategy to effectively engage and support them.
This 90 minute webinar is free, but registration is required. To register, click here.
Monday, September 26, 2016
The Wall Street Journal ran an article about retirement planning for women. The article, Retirement planning for women, offers some specific tips for women in their planning. Are there a lot of challenges? Perhaps the biggest one? Getting started. "If you’re a woman, the bad news is that you face some specific challenges that men don’t. The good news? Women tend to invest and save in a way that bodes well for their retirement success." Here is a look at their tips: start saving, invest savings, consider carefully before drawing Social Security, and complete an estate plan which includes "[a] financial power of attorney ... [a] health-care power of attorney, for health-care decisions, [a] living will for your end-of-life wishes, [and a] will naming a guardian for minor children." The article also offers a quick quiz on tips for women in retirement planning. Check it out.
Thursday, September 22, 2016
Ok, ok, I know I've blogged several times about self-driving cars and how I can't wait to try one. I know they are being extensively tested. But in the meantime, it looks like I don't have to wait for a self-driving car for drivers to be safer. Driving tech is already supplementing many driving tasks for drivers as reported in an article published in the NY Times. Tech May Help Steer Older Drivers Down a Safer Road explains that tech is making cars smarter, allowing cars to do things that make driving safer (for the driver, passengers and other drivers).
[S]marter cars ... can detect oncoming traffic, steer clear of trouble and even hit the brakes when a collision appears imminent.... A few of these innovations, such as blind-spot warning systems, are already built in or offered as optional features in some vehicles, primarily in more expensive models....But more revolutionary breakthroughs are expected in the next few years, when measures such as robotic braking systems are supposed to become standard features in all cars on U.S. roads.
Sure, sure drivers of all ages will benefit from smart cars. But, as the article notes, the application for elders has great value.
[T]hose in their 70s and older are more likely to become confused at heavily trafficked intersections and on-ramps. Aging also frequently limits a body's range of motion, making it more difficult to scan all around for nearby vehicles and other hazards. And older drivers tend to be more fragile than their younger counterparts, suffering more serious injuries in traffic accidents.
"Anything that reduces the likelihood or severity of a collision is really a technology that is primed for helping tomorrow's older adults," says Bryan Reimer, research scientist for the Massachusetts Institute of Technology's AgeLab and associate director of the New England University Transportation Center. "We are moving toward an ecosystem where older adults will increasingly be supported by the technology that may help enhance their mobility."
Thinking about buying a car in the near future. Well consider this. "The presence of safety technology will be a key consideration for three-fourths of the drivers older than 50 who plan to buy a car in the next two years, according to a recent survey by auto insurer The Hartford and MIT AgeLab. In an indication that priorities are shifting, only one-third of the surveyed 50-and-older drivers who bought a car during the past two years focused on safety technology."
Some of the driving technology is already available, with rear view backup cameras proliferating. There are cars that can parallel park for the driver, and as seen on commercials, do other tasks to make driving safer. The article mentions several that are either in use, can be added to a vehicle, or will be available before much more time passes.
[T]he auto industry vowed to make automated emergency brakes a standard feature by September 2022, but it won't be that long before the technology is widely available. Toyota plans to build it into most models, including its Lexus brand, by the end of next year....Cameras on a dashboard screen that show what's behind the car have become commonplace in recent years and will be mandatory on all new cars by May 2018. The equipment is expected to be especially helpful for older drivers with a limited range of motion....Other technology expected to assist older drivers includes automated parking, and adaptive headlights that swivel in the same direction as the steering wheel and adjust the beams' intensity depending on driving conditions and oncoming traffic. ...Robotic systems that temporarily assist with highway driving already are available, most notably in Tesla Motors' high end Model S. The electric-car maker released its Autopilot feature last fall, prompting some Model S owners to entrust more of the driving to the robot than Tesla recommends while the system is still in testing mode. For instance, some drivers have posted pictures of themselves reading a newspaper or book with the Model S on Autopilot, or even sitting in the back seat.
(On that last point, Yikes and should I point out that we're talking about driving technology, not self-driving cars). All of these safety innovations are great, and maybe they will allow people to continue driving longer than they would be able to do without the innovations. Of course, we still want to be sure that unsafe drivers are off the road. At least it looks like I have some cool options while waiting for my self-driving car.
Karen Miller, a lawyer and former administrative law judge from New York who has become a very good friend, recently shared with me reports about a long-time project of hers, to inspire direct dialogue between generations about aging. As an engaged resident of a CCRC in Gainesville, Florida (Oak Hammock which is affiliated with the University of Florida), Karen and others in her community embody the notion of active, healthy, and realistic aging. Karen knows that "aging in the right place" is a better goal than simply "aging in place." The right place may or may not be the long-time family home.
Over the course of three days in mid-September, Temple Shir Shalom and Oak Hammock hosted conversations on "Giving and Receiving Care" that were open to the public. From the Gainesville-Sun coverage of the events:
[Rabbi Michael] Joseph said joking around with his wife about his forgetfulness becomes less funny, as he grows older. “It becomes a real anxiety, it becomes harder to talk about,” Joseph said. “Because I don’t really want to know the answer, part of me.”
Saturday’s festivities will address Joseph’s anxiety head-on. The Oak Hammock retirement community will serve as the backdrop to a lecture about age-related cognitive changes. The 3 p.m. non-clinical presentation by guest speaker Dr. Steven DeKoskey of the University of Florida's McKnight Brain Institute will take a look at what is and isn’t normal when aging.
[Karen] Miller said that as people age they may need help with numerous things, ranging from simple things like writing a check, to more complicated things, like making medical decisions. “There will come a time, unless you get hit by a car, where your faculties are not as sharp as they were at one time,” she said.
Concluding Sunday at the temple, the program will open its doors at 10:30 a.m. to a wider audience spanning at least three generations, Joseph said.
The combination of community hosts, professional caregivers, science-based speakers, and public round tables strikes me as an inspiring model for effective conversations about aging. Well done, Karen.
Wednesday, September 21, 2016
Remember that line from the song "My Way" immortalized by Frank Sinatra, "[r]egrets, I've had a few...." For some people, telling their families how they feel about them, especially at the end of life, can be daunting and not having done so sooner may be a regret. An ethical will or even the 5 Wishes document can be helpful in explaining things in writing that are too difficult to say.
I was interested in learning about the Stanford Letter Project with its goal "[t]o help, empower and support all adults to prepare for their future and take the initiative to talk to their doctors and their friends and family about what matters most to them at life's end." So what does this project do? The website explains:
All of us will face the end of life one day. Contemplating one’s own death and doing some basic preparatory work is certainly not an easy task. However, the emotional, physical and the financial toll of not doing so is exorbitantly high. People who do not clearly document their wishes and preferences for care at the end of life are often subjected to futile medical treatments that they neither seek nor benefit from. Their families are burdened by the medical bills accrued from the numerous ineffective treatments many patients get at the end of life. In fact, a large research study showed that 62 % personal bankruptcies are due to medical expenses. Over 75% of the people who became bankrupt due to medical expenses had some form of health insurance (i.e., having health insurance does not protect you and your family from medical expense related financial crises).
A major reason for all these problems is that most Americans don’t like to talk about and prepare for the last phase of life. Our research has shown that people find it extremely difficult to discuss this important issue both with their doctors and with their friends and family.
We started the Stanford Letter Project in 2015 based on many years of research and discussions with people from various cultural and social backgrounds. We conducted interviews and focus groups in multiple languages with people in the community and talked to numerous patients and their family members as well as health professionals. We found that while almost all doctors agree that it is important for them to have end-of-life conversations with their patients, most doctors struggle with these conversations. We also found that patients from all ethnic backgrounds feel that is is very important for them to have end of life conversations with their doctors and their family members. However, patients do not quite know how to initiate these conversations.
Based on these research findings, we created the Letter Project tools to help you write letters about your wishes for care in the future.
These letter templates are specifically designed to help you voice the key information needed to help you prepare for the future. Use the Stanford Letter Project tools today to write to your doctor, your friends, and your family. It is free, easy, and extremely important.
The website includes some video letters to friends and families, as well as to doctors. There is also a "template" for an advance directive generated from a user's responses to questions as well as a "life review letter" template.
The goal of our Friends and Family Letter template is to help all Americans complete the seven vital tasks of life review while they still can. We designed this project based on years of clinical experience caring for thousands seriously ill patients and families. ... The template was pilot-tested and refined after extensive discussions with patients from diverse cultures and traditions to identify the seven tasks of life review.
There are 7 tasks for a life review, which include:
Acknowledge the important people in your life...
Remember treasured moments from your life....
Apologize to those you love if you hurt them....
Forgive those who love you if they have hurt you...
Express your gratitude for all the love and care you have received....
Tell your friends and family how much you love them... [and]
Take a moment to say "goodbye.
Check out the website.
Stetson's 18th annual National Conference on Special Needs Trusts & Special Needs Planning takes place on October 19-21, 2016 at the Vinoy Hotel in St. Petersburg, Florida. Early Bird Registration rates end September 23, 2016. The national conference spans two days, with general sessions in the mornings and three tracks of breakout sessions in the afternoons (basics, advance and administration) Information about the conference, including the agenda, speakers, and links to register is available here. (Full disclosure, I'm the conference chair. Hope to see you at the conference!)
Tuesday, September 20, 2016
While we are on the subject of caregivers (in case you missed yesterday's post ....) I was interested in the article published in the NY Times earlier this month on the impact caregiving has on caregivers. After all, it is a 24/7/365 job. Love and Burnout: Caregivers, Too, Need Care discusses both the emotional and financial costs of caregiving. "Though caregiving can be a profound and moving journey, caregivers’ needs are often overlooked. The health care system is mainly focused on patients; caregivers who are slowly burning out can slip by unnoticed until it is too late."
We have all seen studies about the physical manifestations of stress, but do we all realize that the physical impact can continue long after the stress is gone? "Researchers have found that the human immune system can be weakened by stress and strain for up to three years after caregiving ends. As a result, caregivers can be more prone to having serious illnesses. Yet they rarely complain."
Caregivers are true superheroes for what they do, but even superheroes can benefit from help (after all many superheroes have sidekicks or other superhero pals!) The article offers information about help and services available to caregivers, from information, to support groups, to resources to respite care.
Ever thought of which caregivers might be more affected by the role of caregiving? The article explains that "[m]en, who generally have smaller networks of friends than women, are at even greater risk. “They are less likely to maintain relationships and seek help,” said Zaldy Tan, medical director of the UCLA Alzheimer’s and Dementia Care Program. 'They’re less prepared for the caregiving role. So they have a higher burden and burnout rate.'"
Burnout is a real thing and manifests itself in a variety of physical symptoms. The article offers that the best way to combat burnout is to have help. "Perhaps the best antidote to burnout, many experts say, is building a team, rather than handling everything yourself." But there is a risk in assuming that the family will automatically pull together. "The best family teamwork involves meeting, talking and sharing responsibility ... One team member, for example, can handle medical appointments, another might be good at preparing meals. 'Have weekly phone calls if you’re in crisis....'"
Regardless of the planning, it's not going to be an easy job to be a caregiver. But it is going to be an important one.
I'm currently on sabbatical and working on a couple of big projects. I've been digging deeper into how banks approach consumer protection issues for older customers. Awareness of the potential for financial exploitation of elders among bankers is clearly at an all-time high.
One of the practical lessons, however, is that each banking institution does it differently when responding to concerns. For example, one bank I met with has a system of "alerts" for tellers about prospective transactions, such as where an older customer is accompanied into the bank by "problematic" befrienders. Another bank said that before it could take any action in response to a request made by a valid agent with a broadly-worded power of attorney, the agent would have to be added as a party "on" the account in question. The latter approach, although understandable on one level, seems to pose the potential for additional problems. One-on-one meetings with high-level officials at major banks makes me realize just how challenging this would be for the average family member or concerned friend of a prospective victim.
Along this line, I recently received news of a timely CLE program. The Pennsylvania Bar Institute is hosting an "update" program on Consumer Financial Services and Banking Law on October 18, with simulcasts offered in several locations around Pennsylvania. The Pennsylvania Bankers Association is co-hosting the program.
Hon. Robin L. Wiessmann
Leonidas Pandeladis, Esq.
Jeffrey P. Ehrlich, Esq.
Deputy Enforcement Director, Consumer Financial Protection Bureau, Washington, DC
The planned program will include updates on the latest rules affecting consumer protection measures, and -- I suspect -- will likely address some of the "hot" issues, such as the Wells Fargo "mess."
September 20, 2016 in Consumer Information, Elder Abuse/Guardianship/Conservatorship, Estates and Trusts, Ethical Issues, Federal Statutes/Regulations, Property Management, State Statutes/Regulations | Permalink | Comments (0)
Monday, September 19, 2016
The National Academies Press (NAP) has released a prepublication report (uncorrected copy) of a new report, Families Caring for an Aging America. The prepublication version of the report can be downloaded now as a pdf or read online. Downloading requires a NAP account or selection of the guest option. (Regardless of the method, the download if free). You can also preorder the report in hard copy now.
The description of the report offers this information:
Family caregiving affects millions of Americans every day, in all walks of life. At least 17.7 million individuals in the United States are caregivers of an older adult with a health or functional limitation. The nation’s family caregivers provide the lion’s share of long-term care for our older adult population. They are also central to older adults’ access to and receipt of health care and community-based social services. Yet the need to recognize and support caregivers is among the least appreciated challenges facing the aging U.S. population.
Families Caring for an Aging America examines the prevalence and nature of family caregiving of older adults and the available evidence on the effectiveness of programs, supports, and other interventions designed to support family caregivers. This report also assesses and recommends policies to address the needs of family caregivers and to minimize the barriers that they encounter in trying to meet the needs of older adults.
The entire 297 page report is likely too long to be assigned in its entirety to students, but portions would be a good addition to reading assignments. The report is also a good resource for students working on scholarly papers on the topic. The report is divided into 7 chapters, the last of which is devoted to discussing the 4 recommendations made by the committee. Those 4 recommendations:
RECOMMENDATION 1: The committee calls upon the Administration that takes office in January 2017 to take steps to address the health, economic, and social issues facing family caregivers of older Americans.
RECOMMENDATION 2: State governments that have yet to address the health, economic, and social challenges of caregiving for older adults should learn from the experience of states with caregiver supports, and implement similar programs.
RECOMMENDATION 3: The Secretaries of Health and Human Services, Labor, and Veterans Affairs should work with leaders in health care and long-term services and supports delivery, technology, and philanthropy to establish a public private, multi-stakeholder innovation fund for research and innovation to accelerate the pace of change in addressing the needs of caregiving families.
RECOMMENDATION 4: In all the above actions, explicitly and consistently address families’ diversity in assessing caregiver needs and in developing, testing, and implementing caregiver supports.
On Friday, November 18, 2016, Mitchell Hamline School of Law and Children's Minnesota are hosting a one day seminar on "Ethics, Law and Futility" in Minneapolis. The target audience is described as "Nurses, Physicians, Social Workers, Lawyers, Patient Advocates, Parents/Guardians or anyone interested in ethics, law and futility." The premise is intriguing, as explained in conference promotion materials:
There is a knowledge gap between what is presumed as one’s ethical and legal obligations to patients during cases of futility and what actually their responsibility is. This conference will assist in clarifying these issues and provide the audience with tools for managing futility cases.
Thaddeus Pope, Director of the Health Law Institute at Mitchell Hamline School of Law, speaking on "When may you stop life-sustaining treatment without consent? Leading Dispute Resolution Mechanisms for Medical Futility Conflicts.”
Emily Pryor Winston, Associate General Counsel at Children’s Hospitals and Clinics of Minnesota, on "Minnesota Law and Medical Futility Analysis."
Jack Schwartz, Adjunct Professor at the University of Maryland School of Law and Former Maryland Assistant Attorney General, on "The Ethics of Legal Risk."
For more, see the home page for the symposium, which provides registration materials.
September 19, 2016 in Advance Directives/End-of-Life, Consumer Information, Current Affairs, Ethical Issues, Health Care/Long Term Care, Programs/CLEs, State Statutes/Regulations | Permalink | Comments (0)
Sunday, September 18, 2016
I was reading an article in the Washington Post about a young woman who was bullied at school. Drawing on her experiences, she created an app for kids who don't have anyone to sit with at lunch. This once-bullied teen has a simple solution so no one has to eat alone in the cafeteria ever again describes this app and her motivation in creating it.
[She] came up with an idea that would allow students a judgment-free way to find lunch mates without the fear of being rejected. She developed an app called “Sit With Us,” where students can sign up as “ambassadors” and post that there are open seats at their lunch table. A student who doesn’t have a place to sit can look at the app and find an ambassador’s table and know they are invited to join it. When signing up as an ambassador, the student takes a pledge that they’ll be kind and welcoming to whoever comes to sit with them.
Kudos to this inventor!
Although we may think of bullying as a problem faced primarily by children and young adults, happening in schools or in cyberspace. Of course, that is not the case. Elders can be bullies as well. So I was thinking-this app could have use beyond lunch at a school cafeteria. What about its use for an event at a senior center, independent living facility, CCRC, ALF or SNF. It seems it could be incredibly useful in providing a boost to socialization. I realize not every elder is tethered to her smart phone, but that surely may change over time. So, what do you think? Would this be helpful? Is this already being done?
Friday, September 16, 2016
Jeffrey Skatoff, Esq. sent me a link to his firm's recent blog post (written by an associate) about a Florida appellate case concerning capacity to sign a deed. I thought this was an interesting case, and wanted to share it with you. Here is the post, Partially Incapacitated Ward Makes Valid Deed
When a person is found incapacitated and placed under a guardianship, the exercise of some or all of that person’s rights are exclusively delegated to the guardian. That is, those rights which the court finds the person (ward) unable to personally exercise can only be exercised by the guardian. Thus, when a ward takes an action which he or she has lost the right to take, that act is typically void ab initio and treated by the courts as if it never happened.
Recently, Florida’s Third District was called upon to review a trial court’s judgment invalidating a deed executed by a ward in Marcinkewicz v. Quattrocchi, 2016 Fla. App. LEXIS 13403. The facts in Marcinkewicz were as follows: The Ward’s son moved into her home in 2007. The son maintained that he had reached an understanding with his mother that she would leave the home to him upon her death in exchange for his agreeing to care for her. In 2009, the Ward moved into the home of her daughter and son-in-law. A year later, the Ward was declared incapacitated and her daughter became guardian of her person and property. Two years later, the guardianship over the Ward’s property was dissolved but a limited guardianship over her person remained. In 2013, the Ward visited her longtime attorney and executed a deed transferring her home to the son-in-law.
Upon receiving the deed, the son-in-law filed suit to eject the son from the property. The son counter-sued to invalidate the deed and for other relief. The trial court found that the Ward lacked capacity to execute the deed and that, as a result, the deed was void. The trial court further found that because the deed was void, the Ward still owned the property and the son had to vacate the property.
The Third District reversed the trial court’s finding that the deed was void but affirmed its ruling that the son had no rights in the property. The appellate court began by noting that the validity of the document is presumed and that this presumption can only be overcome with “clear, strong and convincing evidence." (quoting Espriella v. Delvalle, 844 So. 2d 674, 676 (Fla. 3d DCA 2003) (internal citations omitted). The appellate court noted that the trial court erred in assigning the burden of proving the deed’s validity to the son-in-law/grantee when it was the son who should have had to produce evidence in support of a finding that the Ward lacked capacity to execute the deed. Because the son failed to produce any evidence that the Ward lacked capacity at the time she executed the deed, the trial court’s finding was without evidentiary support. Because the deed was valid, the son had no rights in the property, equitable or otherwise. Accordingly, the trial court’s order that the son vacate the premises was upheld.
Thursday, September 15, 2016
One of our recent grads sent me an article about a new design for an ALF, This Assisted Living Facility Is Designed To Look Like Homes On A Golf Course. Another article, published in the local newspaper, the design is for residents with dementia. Svayus takes a different approach to Alzheimer's explains that this ALF is a place out of time
What they’re about to enter is a world more reminiscent of one that existed in the 1930s and 1940s. The exteriors of the residences are designed to look like homes commonly found during that time period, down to the color of the paint.
The world of Svayus houses 22 residents, most of whom have Alzheimer’s disease. As the disease progresses, Makesh said, people begin to revert back to their childhood. Svayus serves as something of a time capsule.
The reasoning behind this is emotional: to provide the residents with a familiar "feel" to their residences. The company has several ALFs designed with the residents in mind. One of them offers this:
Entering into Svayus is like walking outside. In addition to the period-accurate home exteriors, residents are also greeted with a grass-green floor, (artificial) plants, a small waterfall and audio of birds chirping. Overhead is the sky ceiling, designed to help with residents’ physiological clock. During the day, residents will see a sunny sky, even on the grayest Northeast Ohio days. ...
At night, the sky ceiling darkens and the porch lights come on.
“Every little thing you see, the wall color, the paint, actually has a therapeutic benefit, a therapeutic value" ...[according to the CEO].
Different aromas also are pumped into the air, providing a therapeutic benefit. Peppermint and frankincense, for example, help with anxiety.
As far as the ALF designed as though the residents live on a golf course, "rooms designed to look like houses on a golf course. Not only is this aesthetically pleasing, the point is to help residents feel more at home. Compared to your average retirement or assisted living facility, this place looks so much more inviting and calming. The hallway features a ceiling painted like the sky, porches and even porch lights that turn on at night."
Very cool idea. I wonder what one designed for the Boomers would look like? (tie-dye curtains, peace symbols, Beatles posters anyone?)
Wednesday, September 14, 2016
The American Journal of Alzheimer's Disease & Other Dementias ran an article on Pain in Hospice Patients with Dementia: The Informal Caregiver Experience. The abstract explains:
Introduction: At the end of life, patients with dementia often experience high levels of pain due to complex interplay of disease processes and numerous barriers to symptom management. In the hospice setting, informal caregivers play an essential role in pain management. This study describes their experience managing pain in hospice patients with dementia.
Methods: We conducted a qualitative analysis of audio-recorded interviews with informal caregivers of hospice patients with dementia who had chosen pain as the challenge they wanted to work on within a problem-solving therapy intervention.
Results: The thematic analysis of sessions with 51 caregivers identified 4 themes: difficulty in communicating with patients, lack of consistent guidance from health-care professionals, perceived uncertainty about the etiology of pain, and secondary suffering.
Discussion: Our findings indicate the possible need for increased support for caregivers, including educational interventions targeting pain etiology and assessment, and improved communication with health-care professionals.
I thought the points made in the discussion were well-taken. Think about a person with dementia and her ability to communicate regarding her pain level.
[The study] findings indicate that caregivers of persons with dementia in hospice face numerous and significant challenges when it comes to managing their loved ones’ pain. Several studies have already demonstrated that the needs of people with dementia at the end of life are not fully met and that caregivers require more support at this time as they may feel exhausted and alone. Furthermore, while communication between health-care providers and caregivers is important, it does not often take place at times of crisis, affecting overall quality of care... Caregivers described uncertainty about the etiology of pain, difficulties in communicating with patients, lack of consistent guidance from health-care professionals, and secondary suffering as the factors that prevented them from properly and effectively managing pain in their loved ones. Thus, these findings indicate the possible need for increased support for caregivers, including educational interventions targeting pain etiology and assessment, and improved communication with health-care professionals.
Well worth reading!
Tuesday, September 13, 2016
A recent study was published in Health Affairs, Home-Based Care Program Reduces Disability And Promotes Aging In Place. The abstract explains:
The Community Aging in Place, Advancing Better Living for Elders (CAPABLE) program, funded by the Center for Medicare and Medicaid Innovation, aims to reduce the impact of disability among low-income older adults by addressing individual capacities and the home environment. The program, described in this innovation profile, uses an interprofessional team (an occupational therapist, a registered nurse, and a handyman) to help participants achieve goals they set. For example, it provides assistive devices and makes home repairs and modifications that enable participants to navigate their homes more easily and safely. In the period 2012–15, a demonstration project enrolled 281 adults ages sixty-five and older who were dually eligible for Medicare and Medicaid and who had difficulty performing activities of daily living (ADLs). After completing the five-month program, 75 percent of participants had improved their performance of ADLs. Participants had difficulty with an average of 3.9 out of 8.0 ADLs at baseline, compared to 2.0 after five months. Symptoms of depression and the ability to perform instrumental ADLs such as shopping and managing medications also improved. Health systems are testing CAPABLE on a larger scale. The program has the potential to improve older adults’ ability to age in place.
A subscription is required to access the full article. A Kaiser Health News (KHN) story about the study, Study Finds Benefits When Seniors Call Shots To Help Them explains "A federally funded project that researchers say has potential to promote aging in place began by asking low-income seniors with disabilities how their lives at home could be better ... At the end of the program, 75 percent of participants were able to perform more daily activities than they could before and symptoms of depression also improved, the researchers said in the journal Health Affairs."
According to the KHN article, the study is based on two ideas: "environment influences health" and elders "should set goals to improve their health." So asking the elder what the elder needs, and then providing the right services leads to a good result, it seems. "Instead of dictating health goals to the patients, the therapist’s first two visits were about listening to what the seniors thought their biggest problems were and creating plans on how to tackle them." The positive impact continued after the study ended, according to one of the researchers interviewed for the article, who noted environment plays a big role as a barrier to aging in place.
Sunday, September 11, 2016
Have a fitness tracker? A standing desk? Exercise regularly? If you answered yes to any (or all) of these questions, you know how important it is for us to be active. It turns out that being active is more important than we thought, perhaps. Kaiser Health News (KHN) ran an article in August, Elderly Patients In The Hospital Need To Keep Moving that features a project at a hospital to keep elders active. The article highlights "the coordinator of a unit designed to address the challenges specific to caring for the elderly. She told her new patient that throughout her stay, one of the main goals would be to keep her active... The medical center’s effort to get older patients up and moving while they are in the hospital is far from typical. Despite a growing body of research that shows staying in bed can be harmful to seniors, many hospitals still don’t put a high priority on making them walk."
Part of the success of such a project is changing the mindset of patients and others.
In addition to employing specially trained staff who work together as a team, the Alabama unit has special handrails attached to the walls, low-glare lighting and non-skid floors. Every room has a walker and plenty of space to move around. Volunteers walk with patients, and therapists work with them on maintaining their strength.
Staff members try to disabuse patients of the idea that they are there to rest. “People walk in the door of a hospital and think it’s OK to stay in a bed. It’s not,” said ["the coordinator of a unit designed to address the challenges specific to caring for the elderly."].
The article notes changing mindsets isn't without challenges, and this project started with changing caregiver attitudes. Why might there be some reluctance to buy-in to the idea of getting patients moving? Well, the Affordable Care Act might be one reason: "The Affordable Care Act explains some of the reluctance by staff at many hospitals to get patients moving, experts say. Under the law, hospitals are penalized for preventable problems, including falls. Researchers believe that hospital staffers, to ensure their patients don’t fall, often leave them in their beds." The article offers other reasons, such as lack of staffing or fear of being sued are offered. The physical layout of the hospital room and hospital may be more conducive to patients staying in bed rather than moving about. (think about the beds, the hospital tables, the remote controls, and more).
The results of not moving go beyond the hospital stay.
The impact of remaining so sedentary in the hospital can be devastating for older patients: It is puts them at greater risk for blood clots, pressure ulcers and confusion.
Immobility can also reduce patients’ ability to take care of themselves when they go home — a difficulty that persists a month after their discharge, according to Brown. And it puts them at higher risk of readmission to the hospital, according to research.
Immobility hurts older patients more than younger ones, in part because the elderly are generally weaker, have less bone density and are at higher risk of falling. Ironically, keeping a patient in bed, which is often intended to prevent falls in the hospital, can increase their risk of falling after they are discharged, experts said.
Being more mobile in the hospital can save money, too, as well as improve the patient's health. So now that you have read this post, put down your computer and go for a walk. See you when you get back!
Over the weekend, I caught the recently released movie, Hell or High Water. Both "contract law" and "elder law" figure into the plot. Warning: Spoilers ahead -- so don't keep reading if you don't want to know.
The timeless and yet still "modern" plot -- with sons trying to save the family homestead from the bank -- has a few good West Texas twists (although the movie was mostly filmed in my old stomping grounds of New Mexico). I enjoyed the play on words with the title of the movie from a legal perspective. The bank's "reverse mortgage" on the homestead has a payoff clause that bars any excuses for nonpayment, such as Acts of God or other hardships. In legal circles such clauses have are called "come hell or high water" terms, rejecting any "force majeur" excuses for late payments. So the brothers are up against the clock. Can they steal enough from the very bank conglomerate that made the loan in order for them to get the mortgage paid off by the deadline? Good character actors abound, including two waitresses who steal the scenes in small town diners and Jeff Bridges at the other end of a Texas journey he began 45 years ago with The Last Picture Show.
The reverse mortgage is the elder law part of the plot. The movie hints the aging mother was loaned just $25,000 on the homestead (where oil may be found) -- enough to be difficult to pay off (especially with taxes and fees), but not enough money to truly save her from her debts. While the plot stretches the realities of reverse mortgages, in truth such mortgages are typically very high cost loans, and are not easily refinanced.
Thursday, September 8, 2016
The Commonwealth Fund released issue briefs examining "high-need" patients. High-Need, High-Cost Patients: Who Are They and How Do They Use Health Care? is a 14 page issue brief, which is available as a pdf here. Here is the abstract
Issue: Finding ways to improve outcomes and reduce spending for patients with complex and costly care needs requires an understanding of their unique needs and characteristics. Goal: Examine demographics and health care spending and use of services among adults with high needs, defined as people who have three or more chronic diseases and a functional limitation in their ability to care for themselves or perform routine daily tasks. Methods: Analysis of data from the 2009–2011 Medical Expenditure Panel Survey. Key findings: High-need adults differed notably from adults with multiple chronic diseases but no functional limitations. They had annual health care expenditures that were nearly three times higher—and which were more likely to remain high over two years of observation—and out-of-pocket expenses that were more than a third higher, despite their lower incomes. On average, rates of hospital use for high-need adults were more than twice those for adults with multiple chronic conditions only; high-need adults also visited the doctor more frequently and used more home health care. Conclusion: Wide variation in costs and use of services within the high-need group suggests that interventions should be targeted and tailored to those individuals most likely to benefit.
Looking at this from an elder law perspective, I was interested in the age data in this brief. "High-need adults are disproportionately: ... Older. More than half were age 65 and older; of these, most were 75 and older. In contrast, only about a third of adults with multiple chronic diseases, and less than a fifth of the adult population as a whole, were age 65 and older."
The companion issue brief, Health System Performance for the High-Need Patient: A Look at Access to Care and Patient Care Experiences, is available here as a pdf. The abstract for this brief explains
Issue: Achieving a high-performing health system will require improving outcomes and reducing costs for high-need, high-cost patients—those who use the most health care services and account for a disproportionately large share of health care spending. Goal: To compare the health care experiences of adults with high needs—those with three or more chronic diseases and a functional limitation in the ability to care for themselves or perform routine daily tasks—to all adults and to those with multiple chronic diseases but no functional limitations. Methods: Analysis of data from the 2009–2011 Medical Expenditure Panel Survey. Key findings: High-need adults were more likely to report having an unmet medical need and less likely to report having good patient–provider communication. High-need adults reported roughly similar ease of obtaining specialist referrals as other adults and greater likelihood of having a medical home. While adults with private health insurance reported the fewest unmet needs overall, privately insured high-need adults reported the greatest difficulties having their needs met. Conclusion: The health care system needs to work better for the highest-need, most-complex patients. This study’s findings highlight the importance of tailoring interventions to address their needs.
Wednesday, September 7, 2016
As Baby Boomer partners retire, law firms face increasing costs and client issues was published in the ABA Journal. The article focuses on the upcoming retirement of law partners from the Baby Boomer and Silent Generations cohorts. "Nearly half of the partners in the nation’s top 200 law firms are Baby Boomers or members of the older Silent Generation. And that means there will be a wave of upcoming retirements that will be the most ever experienced by BigLaw...Sixteen percent of partners will retire in the next five years and 38 percent will retire in the next decade, the American Lawyer (sub. req.) reports...."
The impact of these potential retirements will ripple across law firms, including leadership, client relations, and revenues. The firms will also face other costs-the actual costs of paying for retirements from pensions, revenues, return of capital, etc. The article also notes that some firms are taking specific steps to weather this retirement wave by "trying to reduce retirement costs by raising the retirement age; capping the annual payout from annual earnings; or changing the payout formula, and switching to defined contribution plans in which the lawyers carry the risk of a declining market."