Elder Law Prof Blog

Elder Justice Policy Highlights

The National Center on Elder Abuse has released the latest elder justice policy highlights.  Here is a summary:

The elder justice legislation found in this document was elicited and finalized from the National
Center on Elder Abuse (NCEA) Listserv and independent websites in February 2021. The
compilation is intended to reflect highlights across the nation and does not include all legislation related to elder justice. However, updates will be sent biannually and states are encouraged to send updates on significant legislative action to Ageless Alliance. This document reflects activity in 15 states and highlights at the federal level.

In addition to summaries by state, the highlights include links to the individual legislation. 

 

Oh and btw, mark your calendars now for the 2021 World Elder Abuse Awareness Day, June 15, 2021.

New Alzheimers Website from Federal Government

If you haven't seen this yet, check out the new website, Alzheimers.gov. This site compiles a significant amount of great info. As the website explains

Alzheimers.gov is the federal government portal to information and resources on Alzheimer’s disease and related dementias, including Lewy body dementia, frontotemporal disorders, and vascular dementia. Alzheimers.gov is managed by the National Institute on Aging (NIA) at the National Institutes of Health (NIH), a part of the U.S. Department of Health and Human Services (HHS). HHS is the U.S. government’s principal agency for enhancing the health and well-being of all Americans.

. . . 

A primary goal of Alzheimers.gov is to connect people to the many federal resources available to educate and support people whose lives are touched by these devastating diseases in their various roles. Whether you are living with dementia, a family member or friend, health care provider or other health care professional, researcher, or advocate, Alzheimers.gov is designed for you.

. . . 

Guardians' Role in Fighting Elder Abuse

Check out this new factsheet from the National Center on Elder Abuse, Role of Guardian Standards
in Addressing Elder Abuse. This five page fact sheet answers 16 wide-ranging FAQs and includes resources both within some of the FAQs and at the end of the fact sheet. It's worth checking out!

COVID and Individuals With Dementia

Two articles that bear reading, both from the New York Times.

First, an op-ed  We Are Going to Keep You Safe, Even if It Kills Your Spirit’ in the New York Times, examining the impact of COVID and isolation on folks with dementia. This is an important read. The article highlights the challenges for those individuals and mask-waring and social distancing, as well as how the disruption of their routines impacts them.

People with dementia “may not adequately comprehend, execute, or recall any of the suggested public health measures,” as the Alzheimer’s Association puts it. Also, it’s not possible to social-distance when you live in a nursing home, as about 15 percent of people with dementia do, and when you need help eating and going to the bathroom.

Even those who stay free of the virus have suffered disproportionately from the disruptions of pandemic life. Dementia responds well to routine: rigid, time-blocked schedules and familiar faces. But the pandemic has shown us, and warned us, how quickly the fragile channels of dementia care — the muddled blend of formal and informal networks that sustain those routines — can collapse under strain.

Second, another New York Times article,  People With Dementia Are Twice as Likely to Get Covid, Huge Study Finds

People with dementia had significantly greater risk of contracting the coronavirus, and they were much more likely to be hospitalized and die from it, than people without dementia, a new study of millions of medical records in the United States has found.

Their risk could not be entirely explained by characteristics common to people with dementia that are known risk factors for Covid-19: old age, living in a nursing home and having conditions like obesity, asthma, diabetes and cardiovascular disease. After researchers adjusted for those factors, Americans with dementia were still twice as likely to have gotten Covid-19 as of late last summer.

More COVID articles

First, good news from California. Recognizing the issue with elders who may not be able to get to vaccine sites (or sign up online....), Kaiser Health News reports on one solution in California.  Vaccines Go Mobile to Keep Seniors From Slipping Through the Cracks

The team of county nurses and nonprofit workers is targeting Contra Costa County residents who are eligible for covid vaccines but have been left out: residents of small assisted-living facilities that haven’t yet been visited by CVS or Walgreens, and occasionally people who live in low-income senior housing. The retail pharmacy giants have a federal government contract to administer vaccines in most long-term care facilities.

Launched a few weeks ago, the strike team moves through each vaccination clinic with practiced choreography. At a small group home in Antioch recently, a nurse filled syringes while another person readied vaccine cards and laid them on a table. An administrative assistant — hired specifically for these clinics — checked everyone’s paperwork and screened them for symptoms and allergies before their shots, logging them into the state’s database afterward. After the shots, a strike team member told each person when their 15 minutes of observation was up.

The endeavor is going to take time because there are so many of these facilities, many of which have just a handful of residents.  It may be slow-going, but it's going!!!!

So that was the good news. Now for the not-so-good, but not surprising news from this article also published in Kaiser Health News: Family Caregivers, Routinely Left Off Vaccine Lists, Worry What Would Happen ‘If I Get Sick’.

Tens of thousands of middle-aged sons and daughters caring for older relatives with serious ailments but too young to qualify for a vaccine themselves are  ...  terrified of becoming ill and wondering when they can get protected against the coronavirus.

Like aides and other workers in nursing homes, these family caregivers routinely administer medications, monitor blood pressure, cook, clean and help relatives wash, get dressed and use the toilet, among many other responsibilities. But they do so in apartments and houses, not in long-term care institutions — and they’re not paid.

““In all but name, they’re essential health care workers, taking care of patients who are very sick, many of whom are completely reliant upon them, some of whom are dying... Yet, we don’t recognize or support them as such, and that’s a tragedy.”

If the caregiver is older and meets the age-threshold for the caregiver's particular state, then the caregiver is eligible for vaccination that way. But the younger caregivers are out of luck right now.  This is an important article. Read it!

Webinar on Guardianships

Mark your calendars now for this important webinar, Advancing Guardianship Reform through Working Interdisciplinary Networks of Guardianship Stakeholders (WINGS) on Feb. 9, 2021 at 2 eastern.

Improvements to state adult guardianship systems can include the promotion of less restrictive options, strengthening rights, and ensuring accountability. To make real changes in law and practice requires the collaboration of courts with stakeholders in the legal, aging, and disability communities. Working Interdisciplinary Networks of Guardianship Stakeholders (WINGS) or similar collaborative entities in many states have begun to forge positive changes.  

The 2020 American Bar Association Commission on Law and Aging WINGS Briefing Paper makes key findings and recommendations about the effectiveness of WINGS and the need for their long-term, systemic support. This webinar will highlight the WINGS Briefing Paper findings and recommendations, and summarize guardianship reform obstacles and efforts and the development of WINGS. Presenters will also offer tips to establish or enhance WINGS in your state.

Click here to register.

2020 Summary of Guardianship Legislation

The American Bar Association Commission on Law & Aging has released its 2020 summary of guardianship legislation.  The summary, Directions of Reform: 2020 Adult Guardianship Legislation Summary, American Bar Association Commission on Law and Aging is available .here.

The summary is divided into the following: pre-adjudication issues,  multi-jurisdictional issues, guardian selection, guardian actions, fees, rights of the individual, capacity matters, guardian & fiduciary misconduct, and post-adjudication/monitoring matters. The summary includes a chart at the end for a quick reference. The link  to the archives for prior year summaries is available here.

COVID and Elders: Some Recent Articles to Close Out 2020

It's the end of 2020---finally---so here are a few recent items about Elders and COVID  to close out 2020.

Bankruptcies, Closures Loom for Nursing Homes Beset by Pandemic.

Nursing Home Patients Are Dying of Loneliness

State COVID-19 Data and Policy Actions

Some states buck federal vaccine recommendations and prioritize the elderly over essential workers.

There is a lot to unpack in these articles. COVID has had a significant impact on elders, and it will be some time before we learn the full impact on elders, their families and the professionals who serve them.  I expect several of my students in my spring seminar will write papers on these various issues.

Sorry to not end 2020 on a happy note. Here's to 2021 and rapid availability of the vaccine to all. Stay smart, stay masked and stay home. Thanks to our health care providers, first responders and those who keep us going.

 

Santa's Grandkids Reach Out to SNF Residents

We all need good news these days.  So here's one story for the holidays that should make you smile. Santa’s ‘Grandchildren’ Spread Joy In Italian Nursing Homes explains the Santa's grandkids project:

Despite a grim year marked by death and loneliness, the holiday spirit is descending on the Zanchi nursing home, one of the first in Italy to shut its doors to visitors after a COVID-19 case was confirmed in the nearby hospital on Feb. 23.

The bearers of glad tidings were the so-called “grandchildren of Santa Claus,” people who answered a charity’s call to spread cheer to elderly nursing home residents, many of whom live far from their families or don’t have any family members left.

The program, in its third year, continues to grow in popularity, with  almost 6000 gits distributed to 228 SNFs.  The featured nursing home had 43 residents participating which included virtual visits with Santa's grandkids, during which the SNF residents opened presents.  It is worth noting that the volunteer grandkids also benefited from participating in the project.

Well done everyone!

 

 

Hugs in Time for Christmas

A couple of days ago, the Washington Post ran an uplifting article about a hug room in a SNF.  After months of isolation, a ‘hug room’ lets Italian nursing home residents touch family for the first time tells us about "a 7-foot-tall piece of plexiglass, molded into a three-sided booth. It had four cutout holes, where protective sleeves would be added for arms. It was known, in the strange language of the pandemic, as a “hug room,” but it was less a room than a barrier: residents on one side, relatives on the other."  Although not as ideal as living in a COVID free world (or at least a vaccinated one), this "plexiglass represented the sort of modest step some nursing homes are now taking in a year when they have faced excruciating decisions about how protective to be and how best to reduce their risks."  The article references similar efforts taken by other SNFs.

A  little bit of good news, then, for Christmas.

PS: Florida announced that the second round of vaccines will go to those 70 and older, and Texas, to those 65+ and older.

PPS-remember to thank first responders, health care professionals and all who keep us safe and going through this trying time. Stay safe and stay healthy.

 

More on SNFs and COVID

It's going to be some time before we see good news stories about residents of SNFs---although the vaccination of SNF residents is good news.  So here are several recent articles regarding SNFS and COVID-but be forewarned, these first two are not easy to read.

51 lost lives: A portrait of the pandemic’s tragic toll in America’s nursing homes

South Dakota’s COVID-19 Surge Is Turning Nursing Homes Into A ‘Battle Zone’

There are just no words....

Then: 

An investment firm snapped up nursing homes during the pandemic. Employees say care suffered.

(Thanks to Morris Klein and Professor Bauer for sending me the link to this article).

and finally

With Vaccine Delivery Imminent, Nursing Homes Must Make a Strong Pitch to Residents.

This last article brings up some interesting issues for class discussion-such as consent, refusal of consent, and inability to consent.

Please everyone-stay safe and remember to thank our first responders, health care professionals and essential workers. And let us never forget those we have lost to this pandemic.

Hands on Learning From Caring For Elder Parents

JAMA network published this article, What Caring for My Aging Parents Taught Me That Medical Education Did Not is a first person account by the author of what he went through with his parents, and what he learned from the experience.

Slowly, however, things started to change. My parents seemed to have increasing difficulty staying organized. Instead of me calling them, they began calling me—at first weekly, then daily, and then multiple times per day. My father’s blood pressure was out of control, and he could not tell me what medications he was taking. My mother’s scoliosis, a problem since adolescence, now caused her to have significant difficulty walking. She looked thinner each time I saw her. Their physicians seemed not to be communicating well with each other. Finding their cell phones became a daily project.

Then came the identity theft: strange addresses on their credit card statements, charges to their accounts from Florida businesses when they were not living there, and even their telephone being answered by the identity thief himself. Managing these problems became my part-time job. Since credit card fraud departments are typically open only during business hours, I would sometimes spend afternoon hours on hold from my hospital office, waiting for someone to pick up, rather than charting, talking to a consultant, or doing research.

The move from their home of 30 years was the next step. They simply could not manage the house. Once spotlessly clean, it was now increasingly cluttered with tchotchkes from circa 1993. The garden was overgrown, the dishes dirty. After work, I typically spent an hour every day helping organize, donate, and throw away their belongings, so that we could put the house up for sale. Thankfully, the renovations went smoothly and the house sold quickly. Although not without drama, my parents moved to a retirement facility nearby.

The  author created a list of what he wished he had known as he cared for his parents:

1. If you have the feeling that something may be an issue for your aging parents, it is almost definitely an issue.

2. Make sure you know about all your parents’ financial accounts. 
3. You (and they) may need emotional support from people you would not expect. 
4. Advocate for your parents in the best way you can, but do not expect everything to be cut and dried.
5. Use technology to help you (and them).
6. Do not expect too much from the medical system. 
7. You must have the difficult conversations if the physicians will not.
8. You may need to get them daily help.
9. Do not forget to keep some perspective and occasionally laugh.

Great article! Thanks to Amos Goodall, Esq. for sending me the link.

Podcast on End of Life Decisionmaking in Guardianship Cases

GeriPal, a geriatrics and palliative care blog, has released a podcast, Guardianship and End-of-Life Decision Making: A Podcast with Andy Cohen and Liz Dzeng, discussing  a recent study led by Dr. Cohen.

The big surprise finding of this study was veterans who were nursing home residents aged 65 and older with moderate to severe dementia and who had a professional guardian were no more likely to receive high‐intensity treatments than the same population who died with decision makers who were not professional guardians.   We talk to Andy about his study, potential reasons behind the study, and what, if anything, we should do differently knowing these results. We also talk to Liz about whether substituted judgement is really all that it’s cracked up to be.

The article, Guardianship and End‐of‐Life Care for Veterans with Dementia in Nursing Homes  and editorial, We Need a Paradigm Shift Around End‐of‐Life Decision Making,  are available here and here.

Register Now for This Webinar

On Thursday, December 17, 2020, for a webinar through the National Center for State Courts Elders and Courts. The webinar covers "a new web-based interactive tool: the Judicial Response Protocol for Guardianship and Conservatorship abuses (http://www.eldersandcourts.org/guardianship_conservatorship/guardianship-conservatorship-resources-for-courts/responses-to-allegations-of-wrongdoing). This webinar will be helpful for judges and for court staff. This project was developed with the support of the State Justice Institute..'

To register, click here: https://zoom.us/webinar/register/WN_EuKscJoASJaNSY4hJs2jlg

Is It Bad Money Management or is it Dementia?

JAMA Internal Medicine published the results of a recent study, Financial Presentation of Alzheimer Disease and Related Dementias.

Here are the key points from the study: 

Question  Are Alzheimer disease and related dementias (ADRD) associated with adverse financial outcomes in the years before and after diagnosis?

Findings  In this cohort study of 81 364 Medicare beneficiaries living in single-person households, those with ADRD were more likely to miss bill payments up to 6 years prior to diagnosis and started to develop subprime credit scores 2.5 years prior to diagnosis compared with those never diagnosed. These negative financial outcomes persisted after ADRD diagnosis, accounted for 10% to 15% of missed payments in our sample, and were more prevalent in census tracts with less college education.

Meaning  Alzheimer disease and related dementias were associated with adverse financial events starting years prior to clinical diagnosis.

The full article is  available here.

Catching up on Nursing Home Articles

It's hard to keep track of all the articles coming out, most of which are about COVID and SNFs. There have been so many recently, I decided to just list them here.

COVID-19 Is Still Devastating Nursing Homes. The Trump Administration Isn't Doing Much to Stop It  (Sept. 11, 2020)

They Work in Several Nursing Homes to Eke Out a Living, Possibly Spreading the Virus (Nov. 2, 2020)

Judge says care home residents in England are legally allowed visitors (Nov. 3, 2020) (Thanks to my dear friend Professor Feeley for sending this to me)

Nontraditional nursing homes have almost no coronavirus cases. Why aren’t they more widespread? (Nov. 3, 2020)

40 Dead, Now 40 Laid Off: Inside a Nursing Home in Crisis (Oct. 29, 2020).

It has the highest death rate of any nursing home in the US. Families want to know why (Oct. 28, 2020)

Kansas nursing home faces severe federal penalties after deadly coronavirus outbreak (Oct. 27, 2020)

and finally, but maybe most significantly, this obituary,  Carter Williams, Who Unshackled Nursing Home Residents, Dies at 97 (Oct. 5, 2020).  Thank you Ms. Williams!

With the COVID numbers skyrocketing, I expect we will see more of these stories-and restrictions on visitation that have been previously lifted, are likely going to be imposed again.

Making DC More Dementia-Friendly?

My friend Morris Klein sent me this article a couple weeks ago (thanks Morris). Good urban design can make Greater Washington more dementia-friendly explains that "Greater Washington’s population of older adults is growing. So too is the number of people with dementia and other age-related memory loss. That makes designing for dementia one of the key ways we can make our urban spaces work for the people using them."  The article explains that many folks with dementia live within the community rather than in a facility.  As a result, city planners need to consider this when updating their urban planning and  their zoning ordinances.

[M]ost people with memory loss age in their communities, cared for by family members who do not receive enough support. Those in nursing homes often face abusive, unhealthy, or unhappy environments. Thousands of people with dementia and memory loss died from the coronavirus pandemic in nursing homes. As a result of these trends, more families are now seeking to keep loved ones with dementia in the community.

But public spaces are often unusable by people with cognitive abilities affected by dementia. People with dementia often feel overwhelmed, get lost, have trouble, or face dangerous situations while trying to navigate cities. Skills that we take for granted are difficult for older adults with dementia, including the ability to find alternative routes, filter out extraneous sensory information, or remember directions. Much of this is unintentional: designers and planners are often unaware of these needs. That intent, however, does not change the impact.

The article discusses various suggestions and techniques, such as wayfinding, signage and invigoratingly-designed spaces. Of course, safety parking, and types of seating must also be considered.  Most importantly is "listening to people with dementia, who should be engaged in design processes in some way, even if just in informal conversations. Planners and designers can learn from social programs for older adults with memory loss."

More on Nursing Homes & Federal $

Earlier this week I posted about the nursing homes seeking additional $ from the federal government because of the number of COVID 19 cases. I thought this article in TIME magazine, COVID-19 Is Still Devastating Nursing Homes. The Trump Administration Isn't Doing Much to Stop It, provided a nice follow up.

Ar least 75,000 Americans in nursing homes and other long-term care facilities have already died from COVID-19—and the devastation is far from over. After a decrease earlier this summer, the death toll is now rising once again, and as the country heads into the fall and then flu season, millions of Americans who require institutional long-term care remain at the greatest risk.

But, so far, the Trump Administration has talked a big talk—and mostly failed to deliver.

There have been issues with the amount and quantity of the PPEs sent to facilities, CMS hasn't ensured that SNFS will have s sufficient supply of COVID test kits and there was nothing specific for SNFs in the latest relief package. The article discusses the lack of a coordinated federal response and what assistance is provided comes with new requirements. For example,  as pertains to the new testing requirements:

The Administration’s new testing schedule assigns counties to “green,” “yellow” or “red” categories based on their rate of positive COVID-19 tests, and requires that nursing homes test their staff as often as twice weekly depending on the severity of their location. They must also test all residents during any outbreak or whenever a new COVID-19 case is identified. Facilities can face steep fines if they don’t comply and must keep up with testing to receive Medicare and Medicaid reimbursement, which are the industry’s main source of income.

So why is this problematic? The article offers this insight

Those requirements are fine in theory, industry experts say, but they don’t reflect the reality on the ground. If nursing homes test at the required frequency, the supply of free tests provided by HHS will run out rapidly. Long-term care facilities, which are often financially stretched, will be required to purchase more tests on their own.

There is also concern about the sustainability of the current model of nursing home care and notes the problem with adequate staffing.

The staffing issue is even thornier. Nursing homes typically operate on thin margins, and long-term care workers—mostly poor women of color—are underpaid and overworked in the best of times. During the pandemic, staffers have been falling ill themselves, staying home to care for family members or children who are attending school remotely, and leaving the field for less dangerous jobs. While Congressional Democrats pushed for hazard pay for frontline workers this spring and included it in their relief bill that passed the House in May, no federal plan has been approved. Without specific money dedicated to worker salaries, long-term care facilities say they can’t hire the staff they need.

 

COVID 19 and Dementia

COVID-19 has hit residents of nursing homes hard.  But it’s also hit hard those with dementia.   Dementia deaths rise during the summer of COVID, leading to concern was published recently in The Conversation. The article opens with this sobering observation

Deaths from dementia during the summer of 2020 are nearly 20% higher than the number of dementia-related deaths during that time in previous years, and experts don’t yet know why. An estimated 61,000 people have died from dementia, which is 11,000 more than usual within that period.

“There’s something wrong, there’s something going on and it needs to be sorted out,” Robert Anderson, chief of mortality statistics at the U.S. Centers for Disease Control and Prevention, said in a recent interview with Politico. “This is highly unusual.”

The author analyzes the four factors that may have played a role in the deaths of these individuals. Those include social isolation (“[s]ocial isolation, which essentially is little or no contact with others, is the last thing seniors with dementia need. But it’s what many have received, as caregivers are forced to limit visits during the pandemic”), caregiver burnout (“during COVID-19, caregivers have been isolated too. What help they had from the outside is now probably gone. Burnout becomes more likely”),  decreased access to medical care (“[f]or dementia patients, accessing care may even be more problematic. Telemedicine, often an option for other patients, may not be manageable for those with dementia”), and staying home or using the health care offered by the facility, when they’ve decided the risk of leaving the house is greater than the medical issue (“a good example of something we doctors call goal-concordant care: when doctors understand a patient’s health goals, and then provide them with the best they can within the scope of those goals”).

The author concludes with some advice: check on the folks with dementia whom you know, check in on the caregiver…and be a good listener, and talk to your family about your wishes if this becomes your future.

Thanks to Professor Naomi Cahn for sending the link to this article.

NPR aired a timely podcast on nursing homes seeking federal government funding do to the increased number of COVID cases. For-Profit Nursing Homes' Pleas For Government Money Brings Scrutiny explains that

Nursing homes have been overwhelmed by the coronavirus. Residents account for more than a quarter of all COVID-19 deaths nationwide. The industry says that facilities have also been overwhelmed by costs, and they're asking for billions in aid from the federal government… But recent studies suggest that for-profit ownership may have endangered residents by skimping on care, while funneling cash to owners and investors.

The article highlights some facilities that have had issues and focuses on the for-profit business model.  “Studies looking at thousands of nursing homes across the country have connected for-profit ownership and low nurse staffing to increased coronavirus infections.

The nursing home industry rejects those studies and promotes earlier research that concluded that outbreaks are largely caused by community spread of COVID-19 outside of nursing homes.”  With residency numbers declining but costs increasing, nursing homes are facing another hurdle. And they are seeking money from the feds. “Nursing homes have already received about $7.5 billion from federal coronavirus relief legislation and billions more in Paycheck Protection funds. Now the industry is asking for another $100 billion for all health care providers, with a "significant" amount of that going to nursing homes.”

You can listen to the accompanying podcast by clicking here to access it.