Tuesday, April 20, 2021
Kaiser Health News recently provided an overview of the changes proposed by the Biden Administration to long term care. Biden Seeks $400 Billion to Buttress Long-Term Care. A Look at What’s at Stake provides this overview:
The services in question. Home and community-based services help people who need significant assistance live at home as opposed to nursing homes or group homes.
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The need. At some point, 70% of older adults will require help with dressing, hygiene, moving around, managing finances, taking medications, cooking, housekeeping and other daily needs, usually for two to four years.
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Medicare limitations. Many people assume that Medicare — the nation’s health program for 61 million older adults and people with severe disabilities — will pay for long-term care, including home-based services. But Medicare coverage is extremely limited.
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Medicaid options. Medicaid — the federal-state health program for 72 million children and adults in low-income households — can be an alternative, but financial eligibility standards are strict and only people with meager incomes and assets qualify.
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The article additionally reviews the impact on family caregivers and the workforce, questions about the Administration's proposal and some suggestions for reform. Stay tuned; this isn't going to be a quick or easy journey.
Here are some of the highlights:
Facilities should allow indoor visitation at all times and for all residents except in certain specific circumstances.
There are now fewer circumstances under which indoor visitation can be completely suspended.
Fully vaccinated residents can have close contact, including touch, with visitors as long as they wear a mask and practice hand hygiene.
Visitors should not be required to be tested or vaccinated as a condition of visitation.
CMS continues to emphasize that facilities shall not restrict visitation without a reasonable clinical or safety cause and that nursing homes must facilitate in-person visitation consistent with the federal nursing home regulations.
Visitation must be person-centered and “consider the resident’s physical, mental, and psychosocial well-being, and support their quality of life.”
The summaries and significant takeaways are available here.
As well the Consumer Voice has released the Summary of the Centers for Disease Control and Prevention's Guidance on Quarantine for Residents of Long-Term Care Facilities, which is available here.
Monday, April 19, 2021
The National Consumer Coalition for Quality Long Term Care announced the release of a podcast, The Care For Individuals With Dementia. Here's a description of the podcase.
When the needs of residents living with dementia are met, incidences of resident stress are significantly reduced. Practicing person-centered approaches and interventions increase the likelihood that the message being communicated by the resident will be heard and addressed, leading to better outcomes and more satisfaction for the individual. In this episode of the Pursuing Quality Long-Term Care podcast, Dr. Jonathan Evans and Lori Smetanka of Consumer Voice talk about caring for human beings with dementia.
The podcast can be accessed here.
Thursday, April 15, 2021
Kaiser Health News ran an interesting story about aid in dying in Montana. Getting a Prescription to Die Remains Tricky Even as Aid-in-Dying Bills Gain Momentum
[I]n 2009, the Montana Supreme Court had, in theory, cracked open the door to sanctioned medically assisted death. The court ruled physicians could use a dying patient’s consent as a defense if charged with homicide for prescribing life-ending medication.
However, the ruling sidestepped whether terminally ill patients have a constitutional right to that aid. Whether that case made aid in dying legal in Montana has been debated ever since. “There is just no right to medical aid in dying in Montana, at least no right a patient can rely on, like in the other states,” said former state Supreme Court Justice Jim Nelson. “Every time a physician does it, the physician rolls the dice.”
The article discusses the legislative efforts on both sides of the issue. Fascinating story!
Tuesday, April 13, 2021
WGBH, a PBS station, ran this story a bit ago. New Studies Show Dire State Of Nursing Homes Even Before The Pandemic opens with a focus on staff turnovers and highlights recent studies:
The pandemic has shined a harsh spotlight on nursing homes. Despite less than 1% of the population living in nursing homes and longterm care facilities, they account for about a third of all COVID-19 deaths. Now, two new national studies show that, even before the pandemic, the nursing home industry was in a dire situation. The studies paint a picture of places where it is unappealing to work and risky to stay.
[T]he first national study of staff turnover in nursing homes before the pandemic, published this month in Health Affairs. The study found an extraordinarily high rate of staff turnover, with an average of over 100%.
“That means the average nursing home in the U.S. has their entire nursing home staff change over the course of the calendar year,” [said one study author]. “And we found that some nursing homes had turnover as high as 300%, suggesting the staff is turning over every four months.”
That doesn't necessarily mean that all employees leave during a year. A facility with 10 staff members could have 100% turnover if everyone leaves and is replaced by a new person or if one job is filled 10 different times because the new hires keep leaving.
The article also discusses private equity involvement in the long term care industry.
Thursday, April 8, 2021
A recent study, Family Matters: Multigenerational Living Is On The Rise And Here To Stay, was recently published.
Generations United wanted to learn more about the effect of the vast COVID-19 pandemic on multigenerational living specifically, and at the end of January 2021 commissioned a public opinion poll, conducted online by The Harris Poll, to determine if multigenerational households were growing and what makes them tick. The survey results reported here give us insights as to the growth, why families plan to continue living together – and why it helps them be strong and resilient.
The findings are very interesting:
Our results are clear: multigenerational living is indeed on the rise in 2021, with more than 1 in 4 Americans (26%) living in a household with 3 or more generations. Given our finding in 2011 that 7 percent of Americans lived in a multigenerational household,4 this means that multigenerational living has nearly quadrupled in the past decade (a 271 percent increase from 20115 to 2021). This finding is incredibly striking, and our survey reveals some of the impetus for this staggering growth. As expected, the pandemic does play a strong role. Among those living in a multigenerational household, nearly 6 in 10 (57%) say they started or are continuing to live with multiple generations because of the pandemic.
The full report is available here.
Wednesday, April 7, 2021
Published recently in the Washington Post, Diane Rehm tackles ‘death with dignity’ again, this time in a new documentary. "In 2016, Diane retired from NPR station WAMU after working there for more than 30 years. Since then, she has championed what she and other advocates call “death with dignity.” On Wednesday, PBS will broadcast her new documentary, 'When My Time Comes.'" The article is a Q&A with the author about her book and the resulting documentary. Check it out!
Tuesday, April 6, 2021
POLST and other advance medical planning should not be a one-time conversation according to a recent study.
Two new studies from Indiana University and Regenstrief Institute focus on POLST, a medical order form widely used in nursing homes that documents what life-sustaining treatments a person prefers to receive or not receive, such as hospitalization or comfort-focused care. The studies, published online ahead of print in the Journal of the American Geriatrics Society (JAGS), found discrepancies between medical orders recorded in the POLST form and nursing home residents’ (or surrogate decision-makers, for those unable to make their own decisions) current treatment preferences and explore reasons for the lack of agreement.
The researchers found that less than half of all POLST forms of the 275 study participants matched current treatment preferences for resuscitation, medical interventions, and artificial nutrition. However, the POLST was more than five times as likely to agree with current treatment preferences when these orders reflected preferences for comfort-focused care. In interviews, participants reported the mismatch was due to factors including a lack of key information when they filled out the form and not revisiting POLST when the resident experienced a change in condition.
Thanks to my friend Morris Klein for sending me the link to this story.
Friday, March 26, 2021
Published a few days ago in the New York Times, Fully Vaccinated and Time to Party: If You Are 70, notes "[o]der people, who represent the vast majority of Americans who are fully vaccinated against the coronavirus, are emerging this spring with the daffodils, tilting their faces to the sunlight outdoors. They are filling restaurants, hugging grandchildren and booking flights." The article features a number of elders who are resuming their pre-COVID lives now that they have been vaccinated. Or, as the author describes it, "[f]or now, about two-thirds of Americans over 65 have started the vaccination process and nearly 38 percent are fully vaccinated, compared with 12 percent of the overall population, giving the rest of the nation a glimpse into the after times."
The stories will make you smile.
Wednesday, March 24, 2021
First, have you read this article from the New York Times? Maggots, Rape and Yet Five Stars: How U.S. Ratings of Nursing Homes Mislead the Public
Twelve years ago, the U.S. government introduced a powerful new tool to help people make a wrenching decision: which nursing home to choose for loved ones at their most vulnerable. Using a simple star rating — one being the worst, five the best — the system promised to distill reams of information and transform an emotional process into one based on objective, government-blessed metrics.
The star system quickly became ubiquitous, a popular way for consumers to educate themselves and for nursing homes to attract new customers. During the coronavirus pandemic, with many locked-down homes unavailable for prospective residents or their families to see firsthand, the ratings seemed indispensable.
But a New York Times investigation, based on the most comprehensive analysis of the data that powers the ratings program, found that it is broken.
Then, a couple days later, another article from the New York Times, this time about California, California Sues Nursing Home Chain, Saying It Manipulated Ratings System
California prosecutors sued the country’s largest chain of senior living communities on Monday, accusing the company, Brookdale Senior Living, of manipulating the federal government’s nursing-home ratings system.
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The lawsuit is among the first of its kind to accuse nursing homes of submitting false information to Medicare’s ratings program. The system assigns stars — one being the worst, five being the best — to the nation’s more than 15,000 nursing homes.
Health News Florida explained that COVID Cases Plummet 83% Among Nursing Home Staffers Despite Vaccine Hesitancy, "Federal records show a steep decline in staff cases since December, when health care workers at thousands of nursing homes began getting their shots. Still, many are reluctant to get vaccinated."
Then, this New York Times article from Canada, Elderly, Vaccinated and Still Lonely and Locked Inside
Long-term care homes, as they are called in Canada, were prioritized for the first precious doses of vaccines, to few objections — they were ground zero for the pandemic’s cruel ravage. Around 66 percent of the country’s terminal Covid-19 victims lived in nursing homes, among the highest rates in the world.
But while the vaccines have given the majority of nursing-home residents protection from death by the virus, so far they have not offered more life....
March 24, 2021 in Consumer Information, Current Affairs, Elder Abuse/Guardianship/Conservatorship, Federal Cases, Federal Statutes/Regulations, Health Care/Long Term Care, International | Permalink | Comments (0)
Sunday, March 21, 2021
Kaiser Health News recently published a story, Texas Winter Storm Exposes Gaps in Senior Living Oversight. The storm
brought power failure and burst water pipes to millions of homes and businesses throughout Texas. But the impact, as is often the case in emergencies, was most profound on the state’s most vulnerable — including residents of senior living facilities.
Of the state’s 1,200 nursing facilities, about 50% lost power or had burst pipes or water issues, and 23 had to be evacuated, said [the] long-term care ombudsman for Texas. Of 2,000 assisted living facilities, about 25% had storm-related issues and 47 were evacuated. Some facilities reported building temperatures in the 50s.
The article discusses revisions to the regulations regarding emergency preparedness and the industry's responses, as well as the issues with other types of supportive housing. The article also highlights how these "disasters of a century" are actually occurring more frequently, and the focus on disaster preparedness includes a conversation about requiring facilities to have generators. "In Texas, assisted living facilities are required to have emergency plans but not generators. The legislation introduced in the wake of [the recent] winter storm ... seeks to change that. Independent living facilities ... might not be covered, though; they already have even fewer state guidelines to follow."
Thursday, March 18, 2021
California has released its Master Plan FOR Aging. Here's the rationale for having a master plan:
Aging is changing and it’s changing California. California’s over-6o population is projected to diversify and grow faster than any other age group. By 2030, 10.8 million Californians will be an older adult, making up one-quarter of the state’s population.
The Master Plan for Aging outlines five bold goals and twenty-three strategies to build a California for All Ages by 2030. It also includes a Data Dashboard on Aging to measure our progress and a Local Playbook to drive partnerships that help us meet these goals together.
This is not a plan simply for today’s older adults. Instead, the Master Plan is a blueprint for aging across the lifespan. The Master Plan calls on all California communities to build a California for All Ages: for older Californians currently living through the many different stages of the second half of life; for younger generations who can expect to live longer lives than their elders; for communities of all ages – family, friends, neighbors, coworkers, and caregivers – surrounding older adults. As Californians, we can create communities where people of all ages and abilities are engaged, valued, and afforded equitable opportunities to thrive as we age, how and where we choose.
The five goals address health, housing, equity and inclusion, affordable aging, and caregiving. The plan is available here.
PHI issued a report regarding the direct care workers and the California Master Plan For Aging. Quality Jobs Are Essential: California’s Direct Care Workforce and the Master Plan for Aging
[P]rovides a detailed overview of the state’s direct care workforce and examines how California’s Master Plan for Aging can improve jobs for this rapidly growing workforce. It describes how the Master Plan supports this workforce, highlights where it incorporated the LTSS Subcommittee’s recommendations, and proposes where and how the Master Plan can be strengthened. This report also includes various stories from direct care workers in the state.
The report is available here for download.
Monday, March 15, 2021
CMS recently announced that it was expanding visitation, but with some safeguards still in place. CMS Updates Nursing Home Guidance with Revised Visitation addresses indoor visits, indoor visits during an outbreak, compassionate care visits, ombudsman visits, and vaccinations for both visitors as well as surveyors. The revised guidance is available for download here.
Prior to the CMS revised guidance, there was some effort to increase visitation, including efforts by the National Consumer Voice for Quality Long-Term Care. Consumer Voice, Other Advocates Call on CMS to Safely Open Nursing Home Doors offers this call to action: "[C]alling on CMS to restore full visitation rights as soon as possible. In the interim, and during the Public Health Emergency only, we are urging CMS to ensure that: ... [e]ach resident is allowed an essential support person (ESP) ... [and] [a]ll residents are allowed indoor and outdoor visitation in addition to visits with an ESP. " Their letter of recommendation is available here. More info about their efforts, including a virtual rally, are available here and here.
Friday, March 12, 2021
Mark your calendars now for this upcoming webinar from AARP and the D.C. Office of the A.G. on Person-Centered Services and Long-Term Care,scheduled for March 10 at 11 eastern. Here's more info about this webinar:
People living in long-term care facilities, or receiving long-term care services, have the right to make their own decisions about their care and to lead those discussions. Join us to learn more about what Person-Centered Services means for people receiving long-term care, for their families and for service providers, especially now with the challenges imposed by the public health emergency.
Click here to register.
Thursday, March 11, 2021
The New York Times discussed planning and saving for your longer life in the article, If You Live to 100, You’ll Need More Than Money. As more folks reach the 100 years old marker, it's more than just having enough money to live on. The article focuses not just savings, but planning and identifying a purpose. According to one financial advisor featured in the article, "[w]hile focusing on their savings goals, [he] also helped them embrace life planning, which asks: Besides not outliving your money, how can you make your life meaningful in retirement, which could last three decades or more?"
Here's some interesting data about centenarians from the article. "The growth in the 100-plus age group is partly a result of better medical care and a combination of improved lifestyle factors. This cohort has expanded 44 percent since 2000, according to a C.D.C. study. Eighty percent of centenarians are women. And in about 40 years, the number of people 100 and older will be six times as high as it is now, according to the Census Bureau."
The article discusses factors that may lead to reaching the 100 year old mark. If you are feeling optimistic, you might check out this calculator:
In recent years, estimating longevity and planning for it have become more sophisticated. The LivingTo100 longevity calculator, developed by Dr. Perls, is a good place to start to get a rough estimate of your life span and what you can do to improve your odds of living longer, should you want to go down that path.....
Wednesday, March 10, 2021
It was only a matter of time, once the COVID vaccines became available, that we saw this question being discussed. Can Long-Term Care Employers Require Staff Members to Be Vaccinated? was the subject of a recent article in the New York Times.
It’s a question that many long-term care employers, from individual families to big national companies, are confronting as vaccines become more available, although not available enough: In a pandemic, can they require vaccination for those who care for very vulnerable older adults? Should they?
Some employers aren’t waiting. Atria Senior Living, one of the nation’s largest assisted living chains, has announced that by May 1 all staff members must be fully vaccinated.
These requirements are not without controversy. How many employers will mandate this remains to be seen. Think about this in the long term care setting, where employees are in close and frequent contact with vulnerable residents. The article offers this interesting info:
Experts say it is probably legal for employers to make vaccination a condition of employment. The federal Equal Opportunity Employment Commission has agreed, so long as mandates permit health and religious exemptions. A University of Pennsylvania analysis found last fall that nationally, about half of American adults would consider employer mandates acceptable.
One expert mentioned that these vaccines were approved under an emergency mandate, and are not yet approved by the FDA, although that is expected to be coming soon. As far as the mandate, this expert offered this view "Ethically ... it’s entirely justified. People have the right to take chances with their own health, but they absolutely do not have the right to endanger others.”
The article discusses incentives employers may offer to get more folks vaccinated and the challenges in getting direct-care workers vaccinated.
PS-for those who are members of ASA, this issue was part of a podcast offered in February for members
Tuesday, March 9, 2021
Not everyone wants to retire. Some folks continue to work because they need to while others continue to work because they want to do so. The Washington Post addressed this in a recent article, Don’t want to retire? Here’s how to maintain a fulfilling career into your 80s and beyond. "People age 75 and over, including our fresh-on-the-job president, are the fastest-growing group in the labor force, even though “age discrimination is very real,” said Susan Weinstock, vice president of financial resilience at AARP." The author of the article explores the wellness advantages of continuing to work and reviews the habits of those interviewed for the article:
- view work as pleasure
- healthy eating and exercise is a must.
- Keep stress in check.
- Mentor and nurture others, as well as yourself.
Thanks to Professor Naomi Cahn for sending me the link to this article.
Sunday, March 7, 2021
NBC News ran this story, America now knows that nursing homes are broken. Does anyone care enough to fix them? . Once COVID starting sweeping through facilities last year, more folks learned about the current model of providing long-term care, and their short-comings. Experts began calling for reform on the way we provide SNF care in the US. But did that call for reform get drowned out by the daily news about the havoc COVID was wreaking on our country?
The NBC News story ran yesterday (thanks to my colleague and dear friend Professor Bauer for sending me the link).
The pandemic turned nursing homes into a death trap for more than 170,000 long-term care residents and staff members who have lost their lives to Covid-19.
But the virus also revealed how America’s system for long-term care is fundamentally broken in ways that will continue to harm vulnerable residents and workers, long after the pandemic has faded away.
The biggest underlying problem? For all the billions of taxpayer dollars that the United States spends on a system meant to care for frail, elderly residents, not enough money is being invested in caregiving itself, according to interviews with more than a dozen nursing home researchers, advocates, industry representatives and staff members.
There are two sides to this issue, as noted in the story, as well as an opportunity for reform, complete with roadblocks to achieving it.
Nursing homes, by their nature, are ideal breeding grounds for Covid-19: Frail, elderly residents live in close quarters, often requiring support from aides to eat, get out of bed, bathe and get dressed.
This hands-on caregiving is the backbone of what a nursing home provides, and the reason that most residents are in long-term care to begin with. But a chronic failure to value this work, and compensate it accordingly, helped accelerate the pandemic’s catastrophic spread, experts said.
Staffing shortages are discussed in the article, along with explaining how those shortages contribute to a greater risk of a COVID outbreak. The work these folks provide is undervalued both in terms of salary as well as the role they play in providing care.
The section of the article on funding is quite illuminating
America’s long-term care system was created as an afterthought, when nursing home coverage for poor, frail Americans was included, without much fanfare, as part of the 1965 law .... A half-century later, the elderly population has ballooned, and life expectancy has shot up, while personal savings have not, leaving millions of aging Americans unable to pay for the care they need. But unlike most major industrialized nations, the U.S. has no universal public system that covers elder care, which means that many patients, as well as nursing homes, are ultimately left to rely on Medicaid.
The trouble with Medicaid — the only federal program that pays for long-term care — is a reimbursement rate that the industry has long complained is too low, about $200 for each day of care, on average. Medicare pays at least twice as much, but it only covers up to 90 days of post-acute care and rehabilitation, typically following a hospital stay.
The article discusses accountability, the use of third-party contractors, quality of care transparency (or a lack thereof) and lobbying efforts. The article looks at proposals to change the industry. I'm assigning it to my students and we will discuss it in class. I recommend it to you.
Friday, March 5, 2021
Let's end the week with a happy story, shall we? The New York Times featured the return to "normal" for one nursing home. After Vaccines, Joy, Relief and Game Night
The first day back was full of ordinary moments: small talk over coffee, bidding wars at an afternoon auction, a game of dice. But after a year of loss, loneliness and disruption, the very ordinariness of it all brought joy and relief.
There's losses, sadness and joy. It's a happy way to end the week.
Thursday, March 4, 2021
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.