Sunday, September 15, 2019

How to Make Health Care Age-Friendly

A story in Kaiser Health News, In Search Of Age-Friendly Health Care, Finding Room For Improvement highlights needed design improvements within health care facilities.

For older adults, especially those who are frail, who have impaired cognition, or who have trouble seeing, hearing and moving around, health care facilities can be difficult to navigate and, occasionally, perilous.

Grab bars may not be placed where they’re needed. Doors may be too heavy to open easily. Chairs in waiting rooms may lack arms that someone can use to help them stand up.

Toilets may be too low to rise from easily. Examination tables may be too high to get onto. Lettering on signs may be too small to read. And there may not be a place to sit down while walking down a hallway if a break is needed.

Examining the changes from the "ground-up" so to speak, the article starts with the issues from poorly thought-out parking: inconvenient location of the lot to insufficient spaces for those with disabilities. Don't forget signage---is there enough? Is it logically located? Is it hard-to read? (think poor contrast, glare or hard-to read fonts). Then there are steep ramps, a lack of available walkers and wheelchairs to borrow at the facility's entrance and a lack of automatic doors. Ever been asked by the receptionist to take a clipboard of forms to fill out at your seat? Of course-no big deal--unless you use a walker or two canes--talk about having your hands full!  Oh and let's get started about seats--too low, too soft, no arms or all with arms!

The article is an interesting read and hopefully those who design health care facilities will think about these things--because humans don't all come in one size or all have the same abilities or needs.

September 15, 2019 in Consumer Information, Current Affairs, Health Care/Long Term Care, Other | Permalink | Comments (0)

Wednesday, September 11, 2019

Two Upcoming Webinars on Important Topics

There are two upcoming webinars that I wanted to alert you about so you can register.  The National Center on Elder Abuse is hosting a webinar on September 18, 2019 from 3-4 edt, on Recognizing and Addressing Abuse in Long-Term Care Facilities. According to the email announcement

People living in long-term care (LTC) facilities can be vulnerable to abuse and neglect. Recognizing and addressing abuse and neglect in LTC facilities as well as knowing their rights is crucial for both residents and their family members.   

This webinar presented by the Paralysis Resource Center will help to understand the rights of residents of LTC facilities, identify the signs of abuse and neglect, and learn how to report concerns and complaints to the appropriate agencies. Attendees will learn about the important role of the Long-Term Care Ombudsman Program in addressing complaints and how to contact the program. The webinar will also seek to empower people with paralysis and their family members by providing information on choosing a long-term care facility and tips for advocating for quality care. 

The webinar will be presented by Amity Overall-Laib, Director of the National Long-Term Care Ombudsman Resource Center (NORC). Amity served as a local long-term care ombudsman in Texas for six years advocating for residents in 65 nursing homes and 130 assisted living facilities in a 12-county region. During her tenure in Texas, she led the formation of the Gulf Coast Culture Change Coalition, resulting in two free conferences for long-term care consumers, providers, advocates and regulators promoting culture change practices and has presented at local, state, and national conferences. She also had the pleasure of representing fellow local ombudsmen on the Board of Directors for NALLTCO (National Association of Local Long-Term Care Ombudsmen). Amity was previously a consultant to NORC then served as Manager for Program and Policy. 

To register, click here.

Next, the National Center on Law & Elder Rights is hosting a webinar on Issues at the Intersection of Social Security and Medicare on October 8 at 2 eastern time. According to the email announcement,

Social Security benefits and Medicare benefits are closely intertwined, and most people who receive one also receive the other. The close connection means that a problem with one benefit will sometimes cause problems with the other benefit. It can be difficult to figure out which agency is responsible and where to go for relief. This webcast will focus on why cross-program issues occur and what advocates can do to resolve them.

Presenters will share:

  • Agencies and key players: Who is in charge of what?
  • Situations when Medicare and Social Security benefits are linked and when they are not.
  • Issues that arise and strategies for resolving them, including state buy-in issues for Medicare Part B premiums, and challenges keeping Medicare active during an appeal of the termination of Social Security disability benefits.

To register, click here.

September 11, 2019 in Consumer Information, Current Affairs, Elder Abuse/Guardianship/Conservatorship, Federal Statutes/Regulations, Health Care/Long Term Care, Medicare, Programs/CLEs, Social Security, Webinars | Permalink | Comments (0)

Tuesday, September 10, 2019

Hunger Amongst America's Elders

Kaiser Health News addressed the topic of hunger amongst elders in Starving Seniors: How America Fails To Feed Its Aging.

This is incredibly sobering

[M]illions of seniors across the country quietly go hungry as the safety net designed to catch them frays. Nearly 8% of Americans 60 and older were “food insecure” in 2017, according to a recent study released by the anti-hunger group Feeding America. That’s 5.5 million seniors who don’t have consistent access to enough food for a healthy life, a number that has more than doubled since 2001 and is only expected to grow as America grays.

While the plight of hungry children elicits support and can be tackled in schools, the plight of hungry older Americans is shrouded by isolation and a generation’s pride. The problem is most acute in parts of the South and Southwest. Louisiana has the highest rate among states, with 12% of seniors facing food insecurity. Memphis fares worst among major metropolitan areas, with 17% of seniors like [one mentioned in the article] unsure of their next meal.

You're thinking to yourself, surely there are options. What about those federally funded meals programs? Something else? Uh....not likely.

[G]overnment relief falls short. One of the main federal programs helping seniors is starved for money. The Older Americans Act — passed more than half a century ago as part of President Lyndon Johnson’s Great Society reforms — was amended in 1972 to provide for home-delivered and group meals, along with other services, for anyone 60 and older. But its funding has lagged far behind senior population growth, as well as economic inflation.

The biggest chunk of the act’s budget, nutrition services, dropped by 8% over the past 18 years when adjusted for inflation, an AARP report found in February. Home-delivered and group meals have decreased by nearly 21 million since 2005. Only a fraction of those facing food insecurity get any meal services under the act; a U.S. Government Accountability Office report examining 2013 data found 83% got none.

Oh and by the way-the act expires at the end of this month-it's now up to COngress to reauthorize and determine its budget.  Food stamps may be an option, but "only 45% of eligible adults 60 and older have signed up for ... SNAP, the food stamp program for America’s poorest. Those who don’t are typically either unaware they could qualify, believe their benefits would be tiny or can no longer get to a grocery store to use them."

Government programs have long wait lists but there are those who get help, "2.4 million people a year benefit from the Older Americans Act’s group or home-delivered meals, allowing them to stay independent and healthy."  Poor diet, hunger, and starvation have significant consequences, in some instances resulting in major health issues or even death.

Where you one of those kids growing up whose parent said something along the lines of "eat your vegetables (or clean your plate), there are children starving in (insert country)?  Nowadays it may be "eat your vegetables, grandma is starving...."

Keep an eye on Congress' actions on reauthorization-it's important!

 

September 10, 2019 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Food and Drink, Health Care/Long Term Care, Other | Permalink | Comments (0)

Monday, September 9, 2019

When It's Time to Evacuate-It Takes More TIme

Dorian was a bad, bad storm. For those of you who don't live in hurricane country, it may be hard to grasp the magnitude of needed preparations.  Every area of the country has natural disasters, some (like hurricanes) coming with more notice than others.  How far in advance should authorities order an evacuation, knowing the course can change (see, e.g. Dorian).  There needs to be enough time to move those who are medically , cognitively or physically comprised.  The New York Times examines preparations in 

Hurricane Dorian Tests Florida’s Ability to Move Older Adults Out of Harm’s Way.

Remember Hurricane Irma? The Florida authorities certainly do.

The last major Atlantic storm to hit the state was foremost in officials’ minds. When Hurricane Irma came ashore two years ago, a dozen patients died after a nursing home in Hollywood, Fla., lost its air-conditioning. The tragedy prompted new regulations and an acknowledgment that evacuation orders were not enough to protect the state’s large older population. When it comes to older people, no state has more retirees than Florida, where they make up one-fifth of the population, according to the AARP.

A new state law requires backup generators and enough fuel to maintain comfortable temperatures at nursing homes and assisted living centers, a mandate first tested last year when Hurricane Michael struck the Florida Panhandle. Last week, four nursing home workers were charged in the Hurricane Irma deaths, which were ruled homicides.

Remember the article from a few days ago about the elevator being out of repair?  Look at this: "Jacksonville, Fla., officials advised residents with just a few hours’ notice that it would disable its elevator on Monday afternoon." That leaves residents with two choices: go now, or not be able to go at all, without someone physically getting the resident down the stairs.

Lots of folks live in Florida nursing homes, especially in S. Florida, according to the article. After Irma, Florida now requires SNFs and ALFs to have emergency generators. The week before the threat of Dorian, "[t]he Miami Herald reported ... that nearly 60 percent of the state’s 687 nursing homes did not yet have enough power backup."

The article offers examples of some facilities in Florida that implemented their emergency evacuation plans. In some parts of Florida, we were very lucky. Those in Dorian's path, from the Bahamas on, were not.  In case you missed it, hurricane season goes til the end of November 

September 9, 2019 in Consumer Information, Current Affairs, Health Care/Long Term Care, Other | Permalink | Comments (0)

Sunday, September 8, 2019

Happy Places to Retire

With Dorian finally moving on, I thought it would be good for all of us to post something that was happy. So Kiplinger ran an article, 10 of the Happiest Places to Retire in the U.S.  According to the article, these "10 retirement destinations rank the highest in terms of the overall well-being of residents."  These are Charlottesville, VA; Ann Arbor, MI: Portland, ME;Carlsbad, CA; Durham-Chapel Hill, NC; Cape Coral, FL; Richland, WA;; Provo, UT; Charleston, S.C.; and Burlington, VT. Not having lived in these, I can't comment on if they are happy places to live.

To come up with the rankings, Kiplinger relied on the "Well-Being index" which the article explains " is based specifically on residents' feelings about five elements of well-being: "purpose" (liking what you do and being motivated to achieve goals), "social" (having supportive relationships and love), "financial" (managing your budget to feel secure), "community" (liking where you live) and "physical" (being in good health). "  Using this index, then Kiplinger "factored in the "community" and "physical" components of the Well-Being Index, where available, as well as living costs, safety, median incomes and poverty rates for retirement-age residents and the availability of recreational and health care facilities."

The article is available here.

September 8, 2019 in Consumer Information, Current Affairs, Health Care/Long Term Care, Housing, Other, Retirement, Statistics | Permalink | Comments (0)

Wednesday, September 4, 2019

Assisted Living-Is It the Right Option for Assistance in Living?

My colleague and dear friend Professor Bauer, sent me the link to a recent op-ed in the New York Times,  How Not to Grow Old in America.The assisted living industry is booming, by tapping into the fantasy that we can all be self-sufficient until we die.

Assisted living seems like the solution to everyone’s worries about old age. It’s built on the dream that we can grow old while being self-reliant and live that way until we die. That all you need is a tiny bit of help. That you would never want to be warehoused in a nursing home with round-the-clock caregivers. This is a powerful concept in a country built on independence and self-reliance.

The problem is that for most of us, it’s a lie. And we are all complicit in keeping this dream alive.

The author notes that the ALF industry has a financial incentive to market their product and it's appealing to the kids of those who reside in ALFs.  The author writes, "[t]he irony of assisted living is, it’s great if you don’t need too much assistance. If you don’t, the social life, the spalike facilities, the myriad activities and the extensive menus might make assisted living the right choice. But if you have trouble walking or using the bathroom, or have dementia and sometimes wander off, assisting living facilities aren’t the answer, no matter how desperately we wish they were." Further, the author offers data that most of these residents need more care than that provided and argues in favor of regulation, using several actual cases as illustrations to support the call for regulation.

We need to let go of the ideal of being self-sufficient until death. Just as we don’t demand that our toddlers be self-reliant, Americans need to allow the reality of ourselves as dependent in our old age to percolate into our psyches and our nation’s social policies. Unless we face up to the reality of the needs of our aging population, the longevity we as a society have gained is going to be lived out miserably.

September 4, 2019 in Consumer Information, Current Affairs, Dementia/Alzheimer’s, Federal Statutes/Regulations, Health Care/Long Term Care, Housing, Other, Retirement, State Statutes/Regulations | Permalink | Comments (1)

Friday, August 30, 2019

Accessibility of Elder Housing-What Happens When the Elevator is Out of Order?

A local news station recently ran an article about the impact of a broken elevator on the residents who live on top floors in  8 On Your Side gets results for seniors in building with broken elevator.   Knowing my colleague and dear friend, Professor Bauer, had written an article on 55+ housing that included a discussion of accessibility issues, I asked him if he'd write a guest post for us on this topic. Here it is:

Would You Please Just Fix It?

By
Mark D. Bauer
Professor Law
Stetson University College of Law

 

A recent news story in Tampa Bay reported that the single elevator in a mid-rise apartment building stopped working in late May and would not be repaired until October.  That alone is surprising and seems wrong.  But what makes this story particularly shocking is it occurred in an age 62 and older HUD subsidized building.  Even more shocking:  there are no federal laws regulating elevator repairs in federally managed or sponsored elder housing.

The story was made for television.  A local news station interviewed numerous tenants with disabilities incapable of walking down staircases.  One elder tenant interviewed said she had not been able to leave her home in two months and she found it very depressing.  I have little doubt that most anyone would feel the same way.

The good news is that by airing this story and providing publicity to the tenants, the company managing the apartment complex arranged for free hotel rooms for any resident desiring one.  The elevator still will not be repaired until October because a part needs to be manufactured abroad.  But at least the elder tenants now have an alternative to remaining prisoners in their own homes.

The bad news is that while this particular situation may be extreme, elder residents of multi-story apartment buildings are often trapped in their homes with little warning and no real alternative.  The fact that most elevator repairs take less than six months is little comfort.

Department of Housing and Urban Development regulations require only the most basic life safety features in elder housing, such as smoke detectors.  Most state and local laws covering elevators require that they be inspected and remain in good repair.  It is always hard to search for the absence of a law or a case, but I have found nothing in the United States that regulates how long a repair may take.  Unfortunately, I suspect the answer is “as long as needed.”

I did find one relevant case in Indiana where residents of elder housing suffered without elevators for over a month and then sued.  On procedural grounds, the federal court held that the residents might have a viable argument under the Americans with Disabilities Act but could not sue under traditional landlord-tenant law (here the residents claimed that the broken elevator “constructively evicted” them).  And as you might imagine, once the judge opened the door just a crack for possible litigation, the owners of the elder housing complex immediately fixed the elevator and settled with the residents.

It is ironic that the government sponsors or subsidizes elder housing without ensuring the physical safety of the residents, particularly when private entities often profit through participation in these programs.  In researching this issue, a simple Google search produced literally hundreds of news stories about elders all over the country being trapped in multi-story buildings during lengthy elevator repairs.  Like the situation here in Tampa Bay, the elevators were often repaired quickly after a local news story.

Even elevators in good repair cannot function without electricity.  After many elders were killed or injured in Florida after a major hurricane in 2005 made their apartments inaccessible, a state law was passed requiring all 55 and older housing to add emergency generators for elevators.  The real estate lobby was particularly effective here and got the state legislature to repeal the law a short time later.

Subsidized or government-owned congregate housing for elders is aging; few units have been added since the 1980s, and certainly not enough to replace housing demolished or converted to other uses.  Five elevator companies remain after industry consolidation, and only one is located in the United States.  It is no surprise then that elevators installed in the last century are difficult to repair.  Cities and counties with large elder populations often spend extraordinary amounts of money responding to emergency calls requiring firefighters to carry elders down staircases.

It is easy to ignore a problem like stranded elders in high-rises because any single building has these problems infrequently, and with no publicity.  But nationally we are putting lives in danger and wasting precious public funds by ignoring the problem.  Currently it is very unlikely that HUD will take any corrective action.  But in the long-run, it would be much cheaper to plan for broken elevators by requiring elder communities to provide for temporary accessible housing, or coordinate services necessary for daily living, or require emergency generators in mid- or high-rise buildings with only one elevator.

Professor Bauer's law review article on 55+ housing is available here.  Thanks Professor Bauer!

August 30, 2019 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Health Care/Long Term Care, Housing, Other, State Statutes/Regulations, Television | Permalink | Comments (1)

Tuesday, August 27, 2019

Medicare Observation Status: Post-Trial Report

I reported a couple of weeks ago about the trial in federal court in Connecticut on observation status. The trial has concluded. Here is an update from the Center for Medicare Advocacy

Since 2011 the Center for Medicare Advocacy has been pursuing a nationwide class action lawsuit seeking an appeal for Medicare beneficiaries who are classified as hospital outpatients in observation status. (Alexander v. Azar, 3:11-cv-1703, U.S. District Court, Connecticut.) Co-counsels in the case are Wilson, Sonsini, Goodrich & Rosati and Justice in Aging.

The Alexander trial was held before US District Court Judge Michael Shea from August 12 – 20, 2019. The Judge ordered post-trial briefing, which is expected to take approximately 75 days. Then the parties will await Judge Shea’s decision.

Medicare beneficiaries who received “observation services” in a hospital on or after January 1, 2009 and either did not have Medicare Part B, or, were hospitalized for at least three consecutive days but not three days as an inpatient, may be a member of the Alexander class. No action is required to “join” the class. Individuals who meet the class definition, are in the class (note that the class definition is subject to change). We recommend saving paperwork related to the hospital observation status and to costs that may have resulted from it.

August 27, 2019 in Consumer Information, Current Affairs, Federal Cases, Federal Statutes/Regulations, Health Care/Long Term Care, Medicare | Permalink

Do POLST Forms Require Authorizing Legislation to be Effective?

PA POLST FormsIn Pennsylvania, we've had bills pending for several years that would expressly authorize the use of POLST forms for agreements between physicians and their patients about life-sustaining treatments.  Pennsylvania has a fairly long history of dragging its feet about enacting laws regarding end-of-life decisions, and was one of the last states to formally recognize so-called living wills or other advanced health care directives.   The traditional legal reason for statutory authorization is that statutes validate pre-incapacity decisions that will only become effective once incapacity occurs.  The authorization, in essence, allows the document to survive the incapacity of the principal.  

But is this same reasoning applicable to POLST forms? Is legislation required to make this form of "planning" effective?  As currently used, the forms require a conversation between the health care provider and the patient (or the patient's representative -- and that can get tricky in Pennsylvania), usually in the context of hospitalization or an immediate or looming health crisis, that results in the patient's "informed" decisions becoming the "doctor's order" for treatment.  In 2006, a Pennsylvania law directed establishment of an advisory committee "to assist in determining the advisability of using" POLST forms that "detail the scope of medical treatment for patients' life-sustaining wishes."  The committee included representatives of the state's medical society, the joint state government commission that advises on Pennsylvania law, the Pennsylvania Bar association and relevant state agencies.  Following a grass roots movement to implement the POLST concept, eventually a Pennsylvania Department of Health form was developed and approved on a trial basis with individual hospitals.  The bright pink POLST forms currently in use in Pennsylvania certainly look "official."  

In December 2018, after another attempt to create clear state authority for POLST failed to reach a vote in the Pennsylvania House, one of the Senate sponsors wrote to explain why passage is important.  Senator Gene Yaw takes the position that clarity of scope of authority, prohibitions on improper insurance company use, portability or the orders for transfers between facilities and clarity of application during emergency medical services are all necessary elements of statutory authority, needed to assure that "individuals ... have the right to dictate end-of-life decisions in a manner that is sensitive to the situation at hand." Two bills are currently pending, PA Senate Bill 142 (Printer's No. 117) and PA House Bill 997 (Printer's No. 1118).

In the meantime, it seems that patients are creating POLST orders with physicians in Pennsylvania, without authorizing legislation.  

August 27, 2019 in Consumer Information, Current Affairs, Health Care/Long Term Care, State Statutes/Regulations | Permalink | Comments (1)

Napping More Than Usual? Read This Article.

We have all had that after lunch afternoon slump where we just want a nap. Do you find yourself napping more than usual? There is a new study on changes to sleep-wake cycles and Alzheimer's. For the non-scientist like me, here's the USA Today story:  Napping more? That could be an early symptom of Alzheimer's, new study says.

So wait, don't panic if you are a normal napper.  Here's a segment from the article that explains: "People who develop Alzheimer's tend to sleep more during the day, taking naps or feeling drowsy and dosing off. Sometimes, they wake up during the night; that's called fragmented sleep .... If napping is a part of your routine on a regular basis though, you don't need to worry about taking an afternoon snooze, or mid-morning for that matter."  So it's all about the change in sleep patterns. Whew.

Here's the abstract for the article about the study.

Introduction

Sleep-wake disturbances are a common and early feature in Alzheimer's disease (AD). The impact of early tau pathology in wake-promoting neurons (WPNs) remains unclear.

Methods

We performed stereology in postmortem brains from AD individuals and healthy controls to identify quantitative differences in morphological metrics in WPNs. Progressive supranuclear palsy (PSP) and corticobasal degeneration were included as disease-specific controls.

Results

The three nuclei studied accumulate considerable amounts of tau inclusions and showed a decrease in neurotransmitter-synthetizing neurons in AD, PSP, and corticobasal degeneration. However, substantial neuronal loss was exclusively found in AD.

Discussion

WPNs are extremely vulnerable to AD but not to 4 repeat tauopathies. Considering that WPNs are involved early in AD, such degeneration should be included in the models explaining sleep-wake disturbances in AD and considered when designing a clinical intervention. Sparing of WPNs in PSP, a condition featuring hyperinsomnia, suggest that interventions to suppress the arousal system may benefit patients with PSP.

The full study is available here.

August 27, 2019 in Cognitive Impairment, Consumer Information, Current Affairs, Dementia/Alzheimer’s, Health Care/Long Term Care, Other, Science, Statistics | Permalink | Comments (0)

Monday, August 26, 2019

Abuse of SNF Resident On Video

This is just a sad story.  Margaret Collins resident of a SNF, was abused by those tasked with caring for her, according to an article in Huffington Post. Family Sues After Video Shows Nursing Home Workers Taunting Elderly Dementia Patient summarizes the events. Read the story and watch the video. It can be a good jumping off point for a discussion of the importance of resident rights, and litigation and regulations.   Other stories about this are available here,  here , here, and here to include a few. Additional info is available on the blog of the attorneys for the plaintiffs.

Thanks to Professor Dick Kaplan for alerting me to the story.

August 26, 2019 in Cognitive Impairment, Consumer Information, Crimes, Dementia/Alzheimer’s, Health Care/Long Term Care, State Cases, State Statutes/Regulations | Permalink | Comments (0)

Friday, August 23, 2019

UBER and LYFT as the Answer to Elder Transportation Needs?

The New York Times was considering that question in a recent article,Older People Need Rides. Why Aren’t They Using Uber and Lyft?

More than half of adults over 65 own smartphones, the Pew Research Center has reported. Yet among adults 50 and older, only about a quarter used ride-hailing services in 2018 (a leap, however, from 7 percent in 2015). By comparison, half of those aged 18 to 29 had used them.

In a survey by AARP last year, only 29 percent of those over 50 had used ride-hailing apps. Two-thirds said they weren’t likely to do so in the coming year, citing in part concerns about safety and privacy. (Given data breaches at Uber, that’s no baseless fear.)

So wouldn't these options help people remain more independent, especially while we wait for self-driving cars to become widely available for all of us? One expert quoted in the article said absolutely! "One reason for such optimism: evidence that with personalized instruction, older adults can master the mobile apps and take “networked transportation” to medical appointments, entertainment and leisure activities, social visits and fitness classes."

A recent study from U.S.C. covered in the article noted when the researchers "offered three free months of unlimited Lyft rides to 150 older people in and around Los Angeles (average age: 72) who had chronic diseases and reported transportation problems... [w]ith training, nearly all used Lyft, most through the mobile app (a few used a call-in service), for an average of 69 trips. On follow-up questionnaires, almost all riders reported improved quality of life."

That's great news but the companies are seeing an opportunity here. 

Lyft and Uber and others are contracting with third parties, bypassing the need for older riders to use apps or to have smartphones at all.

They’re joining forces with health care systems, for instance. In the past 18 months, more than 1,000 — including MedStar, in the Washington area, and the Boston Medical Center — have signed on with Uber Health for “nonemergency medical transportation,” the company said.

Case managers and social workers can use Uber or Lyft to ferry patients to or from clinics and offices, reducing missed appointments.

In addition, they are working with various senior communities and exploring other programs for those who have mobility issues, including the ability to order accessible transportation and training drivers of how to assist riders with mobility issues!  There are other smaller companies carving out a part of the market, whether portal-to-portal service or the ability to call for a ride by phone. The article also explores the potential costs in using ride-hailing services.

In the U.S.C. study, the typical trip cost $22; the cost per month, had users actually paid it, averaged $500. After the study, about a fifth of riders said they wouldn’t continue using ride-hailing, mostly because of cost.

Some Medicare Advantage programs now cover rides to medical appointments and pharmacies; Lyft expects to partner with most Advantage plans by next year....But most older Americans still use traditional Medicare, which doesn’t cover such transportation.

 

August 23, 2019 in Consumer Information, Current Affairs, Health Care/Long Term Care, Medicare, Other, Travel | Permalink | Comments (0)

Thursday, August 22, 2019

Filial Friday: Making Decisions about Where and How You Will Live as You Age

I suspect every elder law attorney has experienced the Friday Syndrome, where an individual calls the office to seek an emergency appointment because he or she has flown in to visit parents and has discovered new chaos.  Perhaps it is a parent who is much more ill than anyone was letting on during phone calls.  Perhaps it is discovering a huge pile of unpaid bills with no explanation for why they are overdue.  Perhaps it is because the parents have said -- finally -- we need to make a decision and we want to make it today.

There are many variations on the Friday Syndrome, and frequently they involve a common human trait, procrastination, or as my fifth grade teacher called it, "The Scarlett O'Hara Syndrome."  I didn't understand what she meant at the time, having not yet seen Gone with the Wind with Scarlett's  classic last line, "After all, tomorrow is another day."  But I did eventually figure out that my teacher was referring, in less than favorable terms, to my personal approach to homework assignments!

A friend who I often run into during early morning swims, attorney and financial planning advisor Alvin Blitz, shared with me a variation on the theme with his recent column on "Taking Control of Your Destiny."  He recounts lessons from his 20 years of travel on behalf of Masonic Villages, as he works with individuals and couples who are thinking about a move to a continuing care retirement community (CCRC).  He starts with the premise that while change is a difficult word to swallow, "resisting change usually results in a bad outcome."  He describes two scenarios involving couples facing decisions about whether to stay in their own homes.  

In the successful scenario, the couple began their reckoning with age while still in their early 70s, making a preliminary decision to downsize and live in a townhouse in a 55 plus retirement community, spending many years enjoying their neighbors and participating in activities geared to their stage in life.  "As time went on, the husband was diagnosed with dementia, which required them to make another hard decision," reports Alvin. Eventually they decided that they needed a place where the husband's mental status could be accommodated and the wife would be able to stay active and supported in her new roles with her husband.  In the CCRC, they were able to enjoy a "balance of independence and quality of life together while their health problems are addressed, without needing to rely on other individuals to make life decisions for them."

In the less successful scenario, the couple tried to stick in out in their 1950's castle.  "Finally,  the inevitable happened. the husband had a debilitating stroke. Family members from afar rallied to help, but time took its toll.  The wife had medical problems and landed in the hospital.  Decisions on care and where to live became limited and were thrust upon them by their circumstances."   

Alvin reminds us that making affirmative decisions about housing and care as you age can lead to a much "softer landing" than an alternative that depends on happenstance.   He also explains, helpfully, what it might mean to live in a CCRC where there is a clear mission, such as the fraternal mission at Masonic Villages where members of the Masonic organizations (including Eastern Star) can receive continuing compassionate care, even if the individual no longer has assets to pay for care.  

For more, read Alvin Blitz' August 2019 article, Taking Control of Your Destiny, from  his newsletter, appropriately called "The Blitz." 

 

  

August 22, 2019 in Consumer Information, Current Affairs, Dementia/Alzheimer’s, Ethical Issues, Health Care/Long Term Care, Housing | Permalink | Comments (0)

Wednesday, August 21, 2019

Recent Developments on Guardianship Laws

There are a couple of recent developments I wanted to point out to you. One is a bill recently introduced in the House of Representatives, H.R. 4174, the Guardianship Accountability Act of 2019.  Section Two of the bill contains findings and purposes:

 (a) FINDINGS.—Congress finds the following:

(1) An estimated 1,300,000 adults and approximately $50,000,000,000 in assets are under the care of guardians in the United States.

(2) Most guardians are selfless, dedicated individuals who play an important role in safeguarding individuals in need of support. However, unscrupulous guardians acting with little oversight have used guardianship proceedings to obtain control of individuals in need of support.

(3) Once a guardianship is imposed, there are often few safeguards in place to protect against individuals who choose to abuse the system and few States are able to report accurate or detailed guardianship data.

(4) A full guardianship order may remove more rights than necessary and may not be the best means of providing support and protection to an individual. If individuals subject to guardianship regain capacity, all or some rights should be quickly and efficiently restored.

(5) States should encourage courts to use alter natives to guardianship through State statutes, including the adoption of the Uniform Guardianship, Conservatorship, and Other Protective Arrangements Act, to ensure better protections and control for individuals being considered for guardianship and those pursuing a restoration of their rights.

(6) A national resource center on guardianship is needed to collect and publish information for the benefit of courts, policy makers, individuals subject to guardianship, guardians, community organizations, and other stakeholders.

(b) PURPOSES.—The purposes of this Act are to help States improve guardianship oversight and data collection by—

 (1) designating a National Online Resource Center on Guardianship;

(2) authorize grants for the purpose of developing State Guardianship Databases; and

(3) establishing procedures for sharing background check information related to appointed guardians with other jurisdictions.

The bill calls for the Elder Justice Coordinating Council to establish the National Online Resource Center on Guardianship as well as some steps at the state level regarding data collection and analysis.   Read the bill here.

The second item is from the Governor of New Mexico who in a recent speech at the state's conference on aging indicated improving the guardianship system is a priority. Governor vows to stop guardianship abuse  explains that in her speech the Governor

“Here in New Mexico, veterans, senior citizens and disabled adults have been taken advantage of by unscrupulous court-appointed, corporate guardians,” she told the conference....

Corporate guardians, she said, “have been stealing people’s property, separating them from their families and hiding their benefits, as well as “locking folks away where nobody can find them and nobody can visit.”

Her administration, she said, is working to prevent this and adopt the best possible standards and safeguards. McCoy, who will become the director of the state Developmental Disabilities Planning Council, will lead that effort.

There is more action that just these two items, so keep reading this blog as we report on more updates.

August 21, 2019 in Consumer Information, Current Affairs, Elder Abuse/Guardianship/Conservatorship, Federal Statutes/Regulations, Health Care/Long Term Care, State Statutes/Regulations | Permalink | Comments (0)

Medicare Abroad? Don't Retire Abroad Without Thinking This Through.

Kaiser Health News ran an article about the issues Medicare presents for beneficiaries who want to retiree to other countries. Dream Of Retiring Abroad? The Reality: Medicare Doesn’t Travel Well explains the issues:

As the number of American retirees living overseas grows, more of them are confronting choices ... about medical care. If they were living in the United States, Medicare would generally be their coverage option. But Medicare doesn’t pay for care outside the U.S., except in limited circumstances.

Expatriate retirees might find private insurance policies and national health plans in other countries. But these may not provide the high-quality, comprehensive care at an affordable price that retirees expect through Medicare. Faced with imperfect choices, some retirees cobble together different types of insurance, a mix that includes Medicare.

The article notes that the quality of the health care may be dependent on the country, and as the number of U.S. retirees move to other countries, they need to think hard about how they will pay for health care. The article discusses issues with private health insurance policies, the costs and rates, which may be different depending on the country.  Even with private health insurance, expats need to look at Medicare as the article explains:

Even when retirees buy a private policy, Medicare is another piece of the puzzle that they have to consider. Once people become eligible for Medicare coverage, usually at age 65, they face a 10% premium penalty for every 12 months they are not enrolled in Part B, which covers outpatient services. (People who are 65 but still covered by an employer plan generally do not face that penalty.)

After paying into the Medicare system for decades, it’s no wonder some expats are frustrated that they can’t generally use the program outside the United States.

That’s just the way the law is written, an official at the federal Centers for Medicare & Medicaid Services said.

...

And retirees should honestly consider whether they will spend the rest of their lives overseas.

August 21, 2019 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Health Care/Long Term Care, International, Medicare | Permalink | Comments (0)

Monday, August 19, 2019

Maine as the Bellwether State for the Nation's Elder Care Crisis

The Washington Post offers a feature story on Maine's current care employment crisis for all industries serving frail elders, including nursing, home-care agencies, nursing homes, hospice programs and hospitals.   Pointing to one town's dramatic needs, as the demographic "oldest" city in the "oldest" state in the nation, the article makes clear that the problems are likely coming to communities all across the country -- and certainly I have witnessed it first hand in Arizona.  

With private help now bid up to $50 an hour, Janet and her two sisters have been forced to do what millions of families in a rapidly aging America have done: take up second, unpaid jobs caring full time for their mother.

 

“We do not know what to do. We do not know where to go. We are in such dire need of help,” said Flaherty, an insurance saleswoman.

 

Across Maine, families like the Flahertys are being hammered by two slow-moving demographic forces — the growth of the retirement population and a simultaneous decline in young workers — that have been exacerbated by a national worker shortage pushing up the cost of labor. The unemployment rate in Maine is 3.2 percent, below the national average of 3.7 percent.

 

The disconnect between Maine’s aging population and its need for young workers to care for that population is expected to be mirrored in states throughout the country over the coming decade, demographic experts say. And that’s especially true in states with populations with fewer immigrants, who are disproportionately represented in many occupations serving the elderly, statistics show.

In terms of statistics, one "crucial milestone" is the percentage of a population older than 65, the "super-aged" label.  In Maine, one-fifth of the state's population is in that category, and by 2026, Maine is predicted to be joined by 15 other states, with another dozen reaching the same level by 2030.  

Across the country, the number of seniors will grow by more than 40 million, approximately doubling between 2015 and 2050, while the population older than 85 will come close to tripling.

There are tough statistical realities to confront, including the tension between living wages for workers and affordability for families paying for care out-of-pocket.   One of the subtle issues is how to manage pay.  Employment agencies often retain at least half of the dollars charged for hourly care.  Families who want or need to pay privately must make a very real decision on whether to pay "on" or "off" the books.  For those paying on the books, it means learning to navigate systems for withholding proper amounts for taxes, any insurance and other deductions.  

My thanks to my colleague, Health Law Expert Matthew Lawrence, for pointing to the original Washington Post article, subtitled "This will be catastrophic." 

August 19, 2019 in Consumer Information, Current Affairs, Health Care/Long Term Care, Statistics | Permalink | Comments (0)

Sunday, August 18, 2019

Observation status trial

Last week, the class action suit against CMS on observation status finally went to trial.  According to the story from the Medicare Rights Center, Lawsuit Seeks to Improve Medicare Beneficiary Access to Nursing Facilities explains the importance of the case, as the trial started last week:

Because an observation stay is not officially considered an inpatient stay, it does not count as a qualifying hospital stay for purposes of Medicare SNF coverage—which means Medicare will not pay for any subsequent SNF care. This leaves patients on the hook for the entire cost of a needed SNF stay—potentially thousands of dollars.  Beneficiaries unable to afford this care may self-discharge against medical advice and return home before they are physically or mentally ready, and potentially suffer further devastating and expensive acute health effects.

Currently, people with Medicare cannot appeal the decision to classify a hospital stay as an outpatient stay, but a court case—Alexander v. Azar—may change that. In 2011, seven plaintiffs filed a class action lawsuit to try to gain the right to appeal the decision to classify them as outpatients in observation stay instead of as inpatients who would potentially be eligible for SNF coverage. After many twists and turns, the case has finally made it to trial.

More information about the trial that got underway last week was provided in a Kaiser Health News article, Class-Action Lawsuit Seeks To Let Medicare Patients Appeal Gap in Nursing Home Coverage which contains lots of interesting info about the issue and the litigation.  For example, "'HHS’ Office of Inspector General urged CMS to count observation care days toward the three-day minimum needed for nursing home coverage. It’s No. 1 on a list issued last month of the 25 most important inspector general’s recommendations the agency has failed to implement." The importance of this case can't be emphasized enough.  I'll update you when I know more.

August 18, 2019 in Consumer Information, Current Affairs, Federal Cases, Federal Statutes/Regulations, Health Care/Long Term Care, Medicare, Other | Permalink | Comments (0)

Friday, August 16, 2019

Medical Aid in Dying in NJ on Hold

The AP has reported that a judge has temporarily enjoined the NJ Medical Aid in Dying law that went into effect a few weeks ago.  The hearing is scheduled for October according to the story, New Jersey’s medically assisted suicide law put on hold. 

"The order means that New Jersey’s recently enacted measure cannot be enforced by the state attorney general and comes in response to a lawsuit brought by a doctor practicing in the state... [who argues in the lawsuit] that immediate and irreparable damage will probably result in view of the fact that if its enforcement is not immediately enjoined, New Jersey citizens can actually begin dying.”  The plaintiff, a doctor, contends "that the law is an affront to religious doctors [and] the law violates constitutional rights as well as common law barring suicide."

Stay tuned.

August 16, 2019 in Advance Directives/End-of-Life, Consumer Information, Current Affairs, Health Care/Long Term Care, Other, State Cases, State Statutes/Regulations | Permalink | Comments (0)

Thursday, August 15, 2019

Are Long Term Care Insurance Losses at the Heart of Financial Woes for General Electric?

The Wall Street Journal and other news sources are reporting on a financial research report released publicly today by an accounting expert -- the one who blew the whistle on the Bernie Madoff scheme -- and his investigation team, that alleges massive inaccuracies and fraudulent filings by General Electric Company.  GE officials are fighting back, alleging market manipulation is the motive behind the report.  From a Wall Street Journal article on Thursday, it seems GE's liability for losses on its long-term care insurance products is a key focus:

The Markopolos group includes John McPherson, co-founder of MMS Advisors, forensic accountants specializing in the insurance industry. The group worked for seven months to analyze GE’s accounting.

 

Mr. Markopolos said he is going public with the report now because the group just finished its work. It had been working on another insurance case when GE’s insurance problems caught its eye, he said.

 

The group claims GE’s long-term-care insurance holdings are a bigger liability than the company is letting on. The report estimates GE will need to boost its insurance reserves by $18.5 billion in cash and take a $10.5 billion charge because of an accounting change required by 2021.

 

Those figures are on top of a $15 billion reserve boost already taken by GE over seven years to cover its exposure to long-term-care policies, which cover expenses like nursing homes and assisted living. The policies have proved to be a problem for many insurers. The companies drastically underestimated the number of future claims and how long people would draw on the coverage before dying.

 

“We believe that our current reserves are well-supported for our portfolio characteristics, and we undertake rigorous reserve adequacy testing every year,” GE said in its press release. 

On the one hand, as an occasional observer of LTC industry woes, it seems hard for me to believe that at this point any company would try to hide or downplay the high-profile losses that the LTC industry has encountered for more than 10 years.  Nonetheless, the whistleblower team's  allegations are pretty bold, especially set against the market instability overall this week.  

August 15, 2019 in Consumer Information, Current Affairs, Ethical Issues, Federal Statutes/Regulations, Health Care/Long Term Care, State Statutes/Regulations | Permalink | Comments (0)

Wednesday, August 14, 2019

Caregiver Guilt: "When Will You Be Back?"

Recently I was talking with a friend about the challenges of family caregiving.  She regularly drives many miles to help her mother, who has dementia and is living in another city in her own home.  My friend tried inviting her mother to share the daughter's home.  To put it mildly, that plan did not work. 

Her mother wanted to go back to her own home.  Paid in-home caregivers are often essential components of any such plan, and my friend, as an only child, is the person "on call" whenever one of them cancels at the last minute, as well as visiting regularly to plan meals, do shopping, take her mother on outings and the many loving tasks that tend to fall to family members.   

My friend says that one of the hardest parts of each visit is that her mother always asks, "when will you be back?"  The mother probably isn't intending to put pressure on her daughter, but the pressure is still there, accompanied by the daughter's thought, "Am I doing enough? -- Should I quit my job and move here to be closer to my mother?"  

My sister felt this kind of pressure with our mother, even though she spent almost every evening with her, especially during her last year.  My sister would finish her long day as a primary school administrator and drive 45 minutes in rush hour traffic to be with Mom at dinner and to visit with her while she watched some television, helping her get ready for bed.  And my mother would ask ,"Will I see you tomorrow?"  "Of course,"  was the usual answer.   I know my sister felt guilt, even though she was doing everything imaginable to ease the strain for our mother, as her daily life became complicated by deepening dementia.

My father had slightly different questions for me as the "out-of-state" daughter.   As soon as I arrived from my latest flight on good ol' Southwest Airlines plus a taxi cab drive, he wanted to know,  "When are you leaving?"  I would chuckle and say in mock protest, "I just got here; you can't get rid of me yet." (Of course, with dementia, such questions are often asked not just once, but are repeated multiple times in the course of the same hour.) Eventually I realized that what Dad enjoyed the most was the break in the routine from being trapped at home with dementia, as he would usually ride along with whomever was taking me back to the airport.   He liked rides in general, but he especially appreciated a car trip with a purpose, a purpose he still understood.  

My mother had her own variation for me.  She would be startled when she realized I was leaving at the end of a visit, and she would ask with a worried frown, "Will you be back in time for Christmas?" Whether it was the coldest day in January or the hottest summer day in Phoenix she would ask me about my Christmas plans.  But, that's not  a bad "default" setting for someone with dementia, is it? 

I was always able to say, with sincerity, that yes, I would be back in plenty of time for Christmas. 

August 14, 2019 in Cognitive Impairment, Current Affairs, Dementia/Alzheimer’s, Health Care/Long Term Care | Permalink | Comments (1)