Tuesday, May 26, 2020

Barbara Pfeffer Billauer: An International Perspective on Ageism in the Time of Corona

George Washington Law Professor Naomi Cahn recently shared a piece by Israel-based law and policy author Barbara Pfeffer Billauer on  "Al Tashlichaynu L'Et Zichna: Ageism in the Time of Corona."  This thoughtful piece begins with a theme I've been discussing with others, how close to dystopian science-fiction the last 10 weeks have seemed.  She makes the opening comparison of current policy-based decisions to the science-fiction movie Logan's Run, where the "acceptable" price paid for a civil society was a mandatory limit on life spans -- to just 30 years. Logans_run_movie_poster  Professor Pffeffer Billauer observes "In this world of COVID, the age of devitalization is a bit older. But us oldsters are subject to truncation just the same."

She continues:

It’s time to expose the flawed basis on which morbidly dystopic and discriminatory responses toward the aged have been become public health policy– both as a warning that initial and instinctive public health responses must be constantly re-evaluated and updated – and as an alert that discriminatory responses can be couched as public health concerns, even as their main purpose is to further political goals.

 

At first glance, “protection of the vulnerable” seems laudatory and compassionate. Nevertheless, this approach should trigger concerns of discrimination. In the case of age-related discrimination, the dangers are, perhaps, exacerbated, as those affected are more likely to just accept it. Others accept these pronouncements without delving into the “scientific” or epidemiological underpinnings of the pronouncements. Even worse, is that rationale that might, in actuality, be political can be camouflaged as nobly “helping the needy.” 

Professor Pfeffer Baillauer warns that even as governments begin to ease virus-related restrictions, in many instances "the 'vulnerable' (aka the elderly)" are still locked down, and that the "differential relaxation of lockdowns is problematic, both from legal and public health perspectives."

Based purely on early (and stagnant) reports, we bought into this protectivist age-related response: The elderly were — and are — to have their liberty disproportionately restricted –because they are considered “vulnerable”. It’s time to question this approach and unmask the rank discrimination behind it, or at the very least, reveal the dangers of blind acquiescence without serious inquiry into the scientific basis.

She questions the statistical basis for some governments' decisions to impose mandatory isolation:

The Italian debacle, notably lots of deaths, was attributed to their older population. But these pronouncements were based on gross, oversimplified statistical calculations. Germany, with a similar age distribution, suffered far fewer deaths. So did Japan, with a population even older than Italy’s . Compare the case-fatality in Italy of 14% (as of March 19) with that of Germany (at 4.5%), or the even older Japanese demographic with a similar case-fatality (4.7%). Basic tools of epidemiological assessment, such as standardized age-adjusted rates, appear not to have been performed to sustain the extrapolation of the Italian experience to other countries. Basic epidemiological constraints, such as the ecological fallacy, were never even considered.

 

But there is more to the misleading assertion that the elderly are at greater risk than just flawed statistics. The approach obscures the key question: greater risk of what? Of disease susceptibility, of spreading it to others – or of dying?

She is provocative.  She notes that if there is legitimacy to mandating isolation of the elderly based on nursing home statistics on infection and death, perhaps the same rule should be assigned to the "financially flush," such as those who make up the majority of cruise ship passenger rosters, whether or not they are embarked on an actual cruise.

For more, read the full blog post linked above.  For MUCH more, keep an eye on Barbara's SSRN account for her next piece. Thanks, Naomi, for another great share!

 

May 26, 2020 in Advance Directives/End-of-Life, Consumer Information, Current Affairs, Discrimination, Ethical Issues, Health Care/Long Term Care, Housing, International, Statistics | Permalink | Comments (0)

Monday, May 25, 2020

NYT: A Wife's Worries about the Crisis at Her Husband's Nursing Home

On Memorial Day, we have important opportunities to think.  Today, I've been thinking about those lost in wars and those who survive.  A year ago, I joined a group doing a World War II memorial tour of England and France. I was unprepared for how much walking the beaches at Normandy and the nearby cemeteries would affect me.  Normandy France 5.2019Even though my family was not directly impacted by that war, it was a reminder that we are all affected by tragic losses of life.

Today I also just read a very thoughtful piece written by Marcella Goheen for the New York Times.  An image of another war emerges. She explains how her husband at age 65 has been affected by a neurodegenerative disorder that makes it impossible for him to care for himself, and eventually became so severe that it also was impossible for her to care for him at home.  We forget that "nursing homes" are often not just for the very elderly, and can become the short-term or long-term homes of anyone with severe disabilities.  But that doesn't mean that people go there "to die." 

She writes:  

There is life in a nursing home. My husband worked in special education for over 20 years. He understands deeply the value of a life, no matter what form that life takes. He would fight for his fellow residents if he could. I feel betrayed because, while leaders like Gov. Andrew Cuomo and Mayor Bill de Blasio were speaking in their daily news conferences of the “vulnerable population” that needed the most help, not one federal, city or state agency prioritized preventing the loss of life in nursing homes. Instead, officials fought over whose responsibility it was to serve the chronically ill, elderly and disabled people who live in New York State nursing homes. In a mid-April news conference, Governor Cuomo said that “it’s not our job” to provide personal protective equipment to nursing homes in New York City. 

My husband was thrown into a war on the vulnerable without a chance — he cannot care for himself or protect himself from a virus that doesn’t have a vaccine. The fact that he is still alive is a miracle. As of May 10,it was likely that over 5,000 residents in nursing homes statewide had perished. They matter. To be given a chance to live is a human right, and the business of care that impedes this right in any way needs a major reckoning. Not testing health care workers and residents, not addressing staffing shortages, not updating families on loved ones’ conditions and not producing effective plans for managing infections within nursing homes is unacceptable.

There is much more to The Crisis at My Husband's Nursing Home, where she reports that 98 have died with diagnoses of Covid-19. 

May 25, 2020 in Consumer Information, Current Affairs, Ethical Issues, Health Care/Long Term Care, Housing | Permalink | Comments (0)

Friday, May 22, 2020

Lawyering Challenges in Pandemic Times: How to Tell Clients What They Don't Want to Hear about Waivers of Liability

Recently, I had two overlapping communications.  One was via email, with a lawyer who is advising community groups on whether, how, and when to reopen summer activity programs for children.  The second was by phone, when a gym I belong to called to advise it was reopening in a few days and would honor my prepaid short-term membership, the otherwise expired membership I'd just happened to purchase on February 1.  One condition of returning to the gym would be my signature on a Covid-19 specific release of liability.  These conversations caused me pause, in part because I teach Contracts, a first year course, and we often discuss the viability of "releases of liability."  

In connection with the first conversation, I reread and shared a copy of a Pennsylvania Supreme Court case, Feleccia v. Lackawanna College, 215 A.3d 3 (Pa. 2019). The parties presented two questions to the court:  (1) whether the Pennsylvania college was required to have qualified medical personnel present at intercollegiate athletic events to satisfy a duty of care to the student-athletes, and (2) whether an exculpatory clause releasing "any and all liability" is enforceable as to negligence in the absence of any specific reference to "negligence." In a detailed analysis, with two justices filing concurring and dissenting opinions, the Court concluded:

For all the foregoing reasons, we hold appellants [the College parties] had a duty to provide duly licensed athletic trainers for the purpose of rendering treatment to its student athletes participating in athletic events, including the football practice of March 29, 2010, and there is a genuine issue of material fact regarding whether appellants breached this duty. Moreover, although the Waiver bars recovery for appellees' damages arising from ordinary negligence, we hold the Waiver does not bar recovery for damages arising from gross negligence or recklessness, and there remain factual questions regarding whether appellants' conduct constituted gross negligence or recklessness.

I think it is fair to predict that clients who actually seek a lawyer's advice before reopening operations in the wake of easing Covid-19 restrictions are hoping to hear that "a release" will protect them from liability.  I think I can also predict that lawyers, in any state, will find it challenging to give legal advice in this environment without significant caveats, especially about the use of releases. 

May 22, 2020 in Consumer Information, Current Affairs, Ethical Issues, Health Care/Long Term Care, Housing | Permalink | Comments (0)

Tuesday, May 19, 2020

It Isn't Just "Nursing Homes"

One way to frustrate anyone operating an assisted living, life plan community, continuing care community or other congregant living situation is to refer to their centers as "nursing homes."  Many people have a fixed, negative mental image of a nursing home.  And when it comes to quality of life indexes, senior living settings that offer options for meal arrangements,  independent living units, daily activities, participation in off-campus events, recreational outlets (such as swimming, gyms, billiards, or golf), assistance with a range of activities of daily living, assistance with memory-based tasks such as medications, etc., typically defy the negative stereotypes. At least they do for those who actually take the time to visit.  

But, sadly, the potential for wide transmission of Covid-19 does not spare the more "active" senior living models. A Philadelphia Inquirer May 18 article reports that Coronavirus Invaded These South Jersey Senior Communities, Despite Managers's Best Efforts.  Some of the locations described in the article I recognize as very high-end, continuing care communities. But money alone isn't insulation.  How money is used can be a factor.  Some especially interesting excerpts from this article:

  • A facility’s government quality rating, whether it was a for-profit business, and how much of its budget came from Medicaid, did not predict whether it had cases, said David Grabowski, a health-care policy professor at Harvard University whose study looked at whether nursing homes had any cases, not how many. He said facilities with more staff, PPE and ability to group patients with similar disease status together might have better odds of avoiding major outbreaks.
  • Most of [the cases as one continuing care community in New Jersey, known as ] Lions Gate . .  . have been in its nursing home, but there have been 18 in assisted living and one in independent living. Their first case was on March 30, again in a staff member. As the numbers mounted, Lions Gate started testing more widely and found cases among people without symptoms. [CEO Susan Love] does not know how the first employee got it or how it spread. The community tried to confine sick patients to one floor of the nursing home and to assign specific employees to care only for them. Some assisted-living residents were also seen by outside private aides and hospice workers. The average age of the 12 residents who died was 93, Love said. Four were on hospice care. Only five residents who tested positive went to the hospital. Most did not want to go
  • [At another New Jersey CCRC],  seven of the 13 residents who died were on hospice. None wanted aggressive medical care, [Executive Director] Clancy said. He takes comfort in knowing that "we abided by the wishes of every single one of them who passed away.”
 

The highlighted sentences in the last two paragraphs raise an important concept I haven't seen discussed often in Covid-19 themed articles.  A friend of mine who is a lawyer who works outside of aging issues asked me recently why I thought the death rate "in" nursing homes or other senior care facilities was "high."  I think one possibility is that such facilities have honest conversations with new residents and their families about "end of life decisions" and it is entirely possible the residents and their family members have given clear, written directions that they do not want to be transferred to hospitals in the event of a life-threatening development.  

 

 

May 19, 2020 in Advance Directives/End-of-Life, Consumer Information, Current Affairs, Ethical Issues, Health Care/Long Term Care, Housing, State Cases | Permalink | Comments (1)

Monday, May 18, 2020

Is This the Time for Renewed Consideration of "Negotiated Risk Agreements" in Care Settings?

In 2011, Joshua R. Wilkins, then a graduating student at Dickinson Law, won one of the top awards for a student writing competition sponsored by the National Academy of Elder Law Attorneys (NAELA).  Joshua wrote about "Consumer Directed Negotiated Risk Agreements."  His introduction began:  

Negotiated risk in the assisted living context is a largely misunderstood concept. Opponents and proponents of the concept often fail to agree on fundamental concepts underlying negotiated risk. Similarly, states have enacted legislation authorizing or prohibiting what is described as negotiated risk – however those states have defined the concept so differently than other states that it is difficult to understand the concept as a cohesive whole. Negotiated risk can be broadly defined as the shifting of responsibility for certain consequences between the resident and the assisted living facility. Further concepts of definition vary greatly between lawyers and industry actors, and will be discussed later.


As a polestar, the general opinions regarding negotiated risk should be summarized. Opponents of the concept believe that negotiated risk is an illegitimate and unenforceable imposition upon the rights of assisted living residents by facilities attempting to contract away liability for resident injuries.  Proponents color negotiated risk as a method for residents to exercise greater control over their living conditions and tailor the services supplied and guidelines imposed by the resident’s facility.

 

This paper proposes an alternative approach to negotiated risk that incorporates concerns of opponents of negotiated risk, and the selling points of proponents. A consumer directed negotiated risk agreement – one prepared by the resident’s independent attorney, would assist the resident in directing their standard of assisted living, while protecting their interests. A document of this type would require new state legislation authorizing the enforceability of risk shifting, and also delineating the boundaries that such an agreement could be used for. Additional benefits to this type of negotiated risk is that concerns over resident safety and welfare during the admissions process could be addressed without completely overhauling the market-based approach that is a hallmark of assisted living. Also, because residents seeking negotiated risk agreements would have to enlist the aid of an independent attorney, they would be more likely to benefit from advice regarding many other aspects of aging that they may not have otherwise obtained – including Medicaid and estate planning, education about possible exploitation, and review of pertinent resident admissions forms and contracts.

In proposing a consumer-driven approach, Joshua recognized critics' past reasons for opposing "negotiated risk" agreements, including the serious concern that facilities could mandate such "agreement" as an automatic wavier of all appropriate standards for care.  That's not true choice.  Attorney Eric Carlson, long-known for his advocacy for seniors, wrote an early article, Protecting Rights or Waiving Them?  Why 'Negotiated Risk' Should be Removed from Assisted Living Law, Journal of Health Care Law & Policy (2007).   

The specific risk that I'm thinking of these days is the risk that attends continued interaction with family members and friends for residents of assisted living or dementia care facilities.  Coronavirus is just one of the risks that comes about through such interaction, and certainly the emerging details of facilities that fail to adopt or enforce sound infection control measures are, at best, disturbing even without this particular disease.  Further, just because one resident is willing to "accept" risk coming from outside interactions, that doesn't mean the entire resident community would feel the same, and yet their own exposure to the risk increases with every fellow resident's outside contact.  And staff members' safety is also impacted by third-party interactions.  

Perhaps negotiation of the risk agreement provisions regarding community/family interactions should be made viable only where stronger safeguards can be developed against "casual" infection sources.  We have standards for "green" architecture.  Are there similar standards for "clean" architecture in senior living settings (and beyond)?  

May 18, 2020 in Consumer Information, Current Affairs, Ethical Issues, Federal Statutes/Regulations, Housing, Property Management, Science, State Statutes/Regulations | Permalink | Comments (0)

Friday, May 15, 2020

Is "What Kinds of Tests?" Just As Important As "Whether to Test" in LTC?

Another interesting conversation with a long-term care administrator this week was about "what kind of tests" are important in the Covid-19 context, especially for older adults in a congregate setting.  A first question is whether every member of the staff and the residents should be tested regardless of the presence or absence of any symptoms.  A Washington Post editorial on May 14, 2020 called for "extreme measures"  Of course, the utility of such threshold testing mandates depends upon the availability of the means to test and how quickly the results of the tests will be processed.  It is unlikely that the nation's  number of residential care facilities will have the White House's "instant" testing equipment, right? 

But when Covid-19 is present in any congregate care setting, the administrator explained a second test may be even more important.   The test is for oxygen levels, taken with a monitoring device, sometimes referred to as an oximeter and often attached to a finger of the person in question. She explained to me that with Covid-19, the impairment of the lungs can occur with dramatic quickness and not necessarily with any complaints from the patient about shortness of breath.  The director explained that donations of oxygen concentrators to her community meant they are able to respond to lowered oxygen levels within seconds -- rather than within life threatening minutes or hours -- to provide enhanced oxygen for the resident.  Further, many at-risk people resident not in nursing homes, but in the many other variations of congregate senior care. 

Have you tried to convince a person with a cognitive impairment or an anxiety disorder to wear a mask or agree to keep that oximeter attached to their hand?  Will "extreme measures" include funding to support needed increases in care-staff ratios?  

May 15, 2020 in Advance Directives/End-of-Life, Cognitive Impairment, Current Affairs, Ethical Issues, Health Care/Long Term Care, Housing, Medicaid, Medicare | Permalink | Comments (0)

Thursday, May 14, 2020

"Hey, how about giving it a rest, Bro?" -- The Importance of Achieving Consensus in Family Care Giving

Earlier today I had a conversation with someone about family dynamics during the Covid-19 crisis in the context of caring for elderly family members.  The caller is the one who holds Power of Attorney for her older family member and who has been doing a lot of tough stuff, including care decisions for more than an year, decisions such as whether assisted living was appropriate, whether the beloved (but annoying) cat can go to assisted living with the family member, whether the larger family will somehow find a way to pay for a single occupancy room when the resident's own finances aren't enough, and whether the family member's increasing dementia will require additional one-on-one support, also requiring additional money.  

But the call wasn't about any of those complicated parts of third-party decision-making challenges.  It was about "can I tell my brother to back off? He's driving me crazy. He's 600 miles away from here. On the one hand he says, its up to me to make the decisions; on the other hand, when he hears from [our loved one] about being unhappy, he tells me what I should have done. Why didn't he say that before I had to make a decision?" 

And then, not ten minutes after that conversation, I talked with a friend who is a director at a long-term care facility.  She told me about how a big blowup occurred, because an adult child of one of their residents "found out" about the parent's Covid-19 diagnosis because of Facebook.  The adult child called the director, upset about not hearing this information directly.  The director, staying calm, tried to explain that the decisions about timing of communication on this topic were made by the resident's spouse -- and suggested the child call the spouse for more details.  That in turn resulted in the spouse calling the director, in tears, about what the child had said.  

So, perhaps in any context of long-term care, we all need to recognize that caregiving decisions are complex, fact specific, often requiring quick action.  If the person who is the center of the care, the one who is loved (right?),  and about whom the family is worrying, has made his or her own decisions about who is the Power of Attorney or other agent, we just need to take a deep breath before we criticize.  

Or as one person wrote to me, in still another caregiving context, he was lucky he was "not having to navigate this alone," because he, his brother and sister were working hard to use their respective backgrounds (medicine and law) to strive for family consensus when called upon to make tough decisions for their parents.  But when consensus isn't possible -- and that will happen -- he knew that one or more of them might have to "give it a rest" with well-meaning, post-decision advice.  

 

 

May 14, 2020 in Advance Directives/End-of-Life, Cognitive Impairment, Current Affairs, Dementia/Alzheimer’s, Ethical Issues, Health Care/Long Term Care, Housing | Permalink | Comments (0)

New Research: How Timing Affects Low-Income and Aged Bill Payers

New research described in the Bulletin on Retirement and Disability published by the National Bureau of Economic Research provides new support for thinking about ways to help maximize use of benefits to pay for core living expenses.  Researchers Lint Barrage (UC Santa Barbara), Ian Chin (Michigan), Eric Chin (Dartmouth),and Justine Hastings (Brown) examine how timing of receipt of Supplemental Nutrition Assistance Program (SNAP) benefits affects a household's ability and success in paying for utilities, such as electric bills.  They observe:

Our results suggest that, for low income households, timing of income from government benefits and the timing of bills due may have long-run consequences. If bills are not received when income is received, households are more likely to miss payments, which may compound into disconnections which may further impact family financial and health outcomes.

 

These results add to a growing literature suggesting that government benefits programs and/or private industry innovate in ways to help low income households balance budgets throughout the month and avoid potential poverty traps. In the case of electricity bills, moving bill receipt to coincide with SNAP benefits receipt could improve repayment rates. This could help low income families avoid poverty traps, but also lower electricity rates for all rate payers in regulated markets, since collection and electricity service disruption are costly and must be covered by regulated electricity rates. Further research is needed to implement and measure the impact of changes in timing of bill receipt through, for example, a randomized controlled trial, and to expand the outcome measures of impact to include measures of financial well being such as credit scores. 

For more, read How Bill Timing Affects Low-Income and Aged Households, NBER RDRC Working Paper 19-09) and the Bulletin summary

Our thanks to George Washington Law Professor Naomi Cahn for this reference.  I suspect that the timing of core household bills and public receipt of pandemic-driven federal stimulus payments would make for another interesting study.  

May 14, 2020 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Housing, Retirement, Social Security, Statistics | Permalink | Comments (0)

Thursday, April 30, 2020

AALS Call for Papers/Presenters on Intersectionality, Aging and the Law

The AALS Section on Law and Aging is joining forces with the Sections on Civil Rights, Disability Law, Family and Juvenile Law, Minority Groups. Poverty, Sexual Orientation, Gender-Identity Issues, Trusts & Estates and Women in Legal Education to host a program for the 2021 Annual Meeting, scheduled to take place in San Francisco in January.  The theme for the program is appropriately broad -- "Intersectionality, Aging and the Law."  

I like this definition of "intersectionality": 

The interconnected nature of social categorizations such as race, class, and gender as they apply to a given individual or group, regarded as creating overlapping and interdependent systems of discrimination or disadvantage.  Example:  "Through an awareness of intersectionality, we can better acknowledge and ground the differences among us."

We need great presenters!  

From Naomi Cahn at George Washington Law:

We are interested in participants who will address this subject from numerous perspectives. Potential topics include gray divorce, incarceration, elder abuse (physical or financial), disparities in wealth, health, housing, and planning based on race or gender or gender identity, age and disability discrimination, and other topics.  The conception of the program is broad, and we are exploring publication options.

If you are interested in participating, please send a 400-600 word description of what you'd like to discuss.  Submissions should be sent to Professor Naomi Cahn, ncahn@law.gwu.edu, by June 2, 2020, and the author[s] of the selected paper(s) will be notified by July 1, 2020.  

AALS is planning on hosting the annual meeting from January 5-9 and I personally feel the overall theme for the conference is apt in these fraught times:  The Power of Words

 

April 30, 2020 in Advance Directives/End-of-Life, Cognitive Impairment, Consumer Information, Current Affairs, Discrimination, Elder Abuse/Guardianship/Conservatorship, Estates and Trusts, Ethical Issues, Grant Deadlines/Awards, Health Care/Long Term Care, Housing, International, Legal Practice/Practice Management, Programs/CLEs, Property Management, Science, Statistics, Webinars, Weblogs | Permalink | Comments (0)

Friday, April 24, 2020

Transparency Issues in Long-Term Care: The Potential for Misuse of Confidentiality Policies to Hide Infection Facts from the Public

Recently I was talking with a friend in another state who is the director of an assisted living facility that largely serves older adults who have significant risks factors.  I asked, "Have you had any residents or staff members that have tested positive for COVID-19?"  I asked her directly, because there was no way to know the answer to that question from public websites, either in her state or on a national basis.  The good news was that her facility had had no such diagnoses, either among staff or residents.  I also asked what she felt was key to avoiding infections, and we talked about the rates uncovered in other facilities in her own state.  She said bluntly, "We learned from our experience with influenza the last two years that we had to make real changes, and we did so before the COVID-19 was a reality and doubled down when we started hearing about the coronavirus." 

Internal infections have long-been a documented problem in residential care settings, and certainly not limited to so-called "nursing homes."  Contributing factors include residents who may have physical or mental conditions that make self-protection difficult and perhaps impossible.  My sister and I used to struggle mightily with a family member whose dementia interfered with the simple task of hand-washing -- even though this same person was the one who taught us the importance of soap and water from the time we were small children. It is perhaps ironic to recall that as a horse-mad girl I had tried to persuade both of my parents that there should be an exception for "barn dirt," on my theory that horse-related dirt was "clean dirt."  My mothers still insisted I undress on the back porch and wash thoroughly before coming in for dinner.  Wise woman, one who was quick to dismiss utter nonsense.

Fast forward decades and every day I hear new arguments regarding why facilities that have experienced life-threatening infections should not be required to report this in a public venue.  The most problematic argument is one that says an individual's infection is confidential medical information that prevents the facility from reporting statistical information, and thus an infection cannot be made public.  I've seen arguments about federal or state record-keeping policies such as HIPPA privacy rules or Pennsylvania's confidentiality rules  as the rationalization.  I think I know what my mother would call this kind of argument.

Syracuse Law Professor Nina Kohn tackles the history of mishandled safeguards against infections in long-term care with an Op-Ed for The Hill. In "Addressing the Crisis in Long-Term Care Facilities," Professor Kohn  points to specific actions at the federal level that have weakened, rather than strengthened, potential safeguards.   She makes five specific recommendations, including prohibitions on staff working in more than one-long-term care facility, to reduce cross-contamination, and the need for family members and others to make it clear that we "are paying attention to what is happening."  She reminds us:  "Those who are health care agents for nursing home residents should not be afraid to request access to medical records, as federal law entitles them to do, if facilities are not forthcoming with information about the care being provided."

April 24, 2020 in Cognitive Impairment, Consumer Information, Current Affairs, Dementia/Alzheimer’s, Ethical Issues, Health Care/Long Term Care, Housing, Medicaid, Medicare, State Statutes/Regulations, Statistics | Permalink | Comments (0)

Friday, April 17, 2020

How COVID-19 is Revealing a Transparency Dilemma in Long-Term Care

My students at Dickinson Law often suggest important law and aging issues to explore and certainly the COVID-19 crisis is a daily source of topics.  High on the list in my students' minds have been the tragic stories connected to diagnosis and prognosis of the disease in "nursing homes."  Sometimes it is hard to even keep up with the stories.  Consider these headlines from the last few weeks:

When my sister and I first realized that the novel coronavirus was likely to have a devastating impact on anyone with a compromised immune system, we quietly and sadly acknowledged our minor relief that our parents, who had both experienced dementia in the final months before their deaths, were spared at least this particular situation.   My sister went further and said, "If this had happened while Mom or Dad were still alive, I would have quit my job to apply for a job in their living center.  I wouldn't have been able to live with being forced to stay away, in essence abandoning them."

Anyone who knows my sister would know that would have been her heartfelt plan.  But it was also a reminder of something we knew so well from our experiences.  Even the very best of care settings -- whether in the individual's home, in assisted living, in supported independent living (such as in a CCRC), or in a skilled nursing facility -- need a loved-one's involvement.  On the one hand, the cared-for individual "lights up" when they see a family member arrive, even if the visit is just for a few minutes and even if the older person cannot quite remember the identity of the visitor.  No activity-based care program can entirely reproduce that positive impact.

But even the best facility also benefits from having the eyes and ears of family members to observe and make appropriate reports about concerns.  On my last sabbatical,  I stayed in Arizona to be near both of my parents, in their 90s.  Mom was still in the family home and Dad was in a truly caring, small, personal and well-staffed dementia care center.  One day I arrived to find my father deeply upset.  He said "I can't find my room."  I was worried that this meant his cognition had taken another turn for the worse. But, when I offered to walk him from his favorite outdoor bench to his room, it turned out he was right.  Everything that was once his -- his favorite chair, his clothes, his photographs -- were gone from his room.  I found out they were on their way to a different cottage.  More distressing, it was a cottage for individuals who no longer left their rooms -- and that wasn't my father's profile at all.  Suffice it to say, that "move" was reversed.  

That's a small example.  But when a pandemic means that family members cannot visit at all -- the opportunities for confusion and short cuts can increase in any care setting.  I don't know what the solution is; but I do know that the need for transparency in care, and for family members to feel welcome every day in every care setting, are important to quality of care.  And, of course, to quality of life for everyone.  

I'm hopeful that the COVID-19 pandemic will stimulate creativity and identify new ways of safely maintaining relationships for frail elders or others with delicate health profiles, while also still taking appropriate precautions to reduce the potential for high rates of cross-contamination and infection, including infections that cross the borders of the setting.  On my father's last full day, before a nighttime stroke left him in a coma, he and I had lunch together, we walked in the sunshine, and he had his favorite ice cream for a snack.  How I would hate to think of others missing such opportunities.  

April 17, 2020 in Cognitive Impairment, Current Affairs, Dementia/Alzheimer’s, Ethical Issues, Health Care/Long Term Care, Housing | Permalink | Comments (0)

Tuesday, April 14, 2020

Physical Distancing in Multi-Generational Housing

I've intentionally avoided posting on stories about elders and COVID-19. There's just so many stories daily. Here's a story, though, that I think is important to consider. That is-how do you protect your elder family member when multiple generations live in the same home? Kaiser Health News (KHN) tackled this issue in this story, Staying Away From Grandma’ Isn’t An Option In Multigenerational Homes.

Opening with the story of one family, the article describes the advantages ... and risks as follows:

Their living arrangement — four generations together under one roof — has its advantages: financial support, shared meals and built-in child care for [the] kids, now 5 and 3. But this “tier” generational setup also heightens their concerns as the coronavirus continues to march across the world, with young people positioned as potentially inadvertent carriers of the virus to vulnerable elders for whom COVID-19 could be a death sentence.

And there are a lot of families with this type of living arrangement. According to the article, "[m]ore than 64 million Americans live in multigenerational households ...  often a combination of adult children, their parents and grandchildren. That’s 1 in 5 U.S. residents."

These living arrangements seem to be increasing in popularity:

In some cultures, within the United States and elsewhere, multigenerational households are the norm. In recent years, more American families have adopted the lifestyle, some building homes with “granny flats” as baby boomers move in with their kids and vice versa. To be sure, the idea of combining households has always helped families get through tough economic times and life transitions such as death, divorce or job loss.

But did we anticipate the implications when a pandemic like COVID-19 hits?  The article offers some tips from experts on keeping everyone safe and how to make this "tiered" generational living situation continue to work, even as the virus continues to march into our communities.

Stay safe everyone.

April 14, 2020 in Consumer Information, Current Affairs, Health Care/Long Term Care, Housing | Permalink | Comments (0)

Sunday, March 29, 2020

US Has More Elders Living Alone

I blogged a couple of times about social isolation's impact on elders as we move through this pandemic. Imagine social isolation when you live alone and how that compounds your loneliness. This report from Pew Research, released before the pandemic swept the U.S., reports that elders in the U.S.  live alone in greater numbers than other countries.  Older people are more likely to live alone in the U.S. than elsewhere in the world shows that:

Living with an extended circle of relatives is the most common type of household arrangement for older people around the world, according to a recent Pew Research Center study. But in the United States, older people are far less likely to live this way – and far more likely to live alone or with only a spouse or partner.

Let me share some stats from the article:

  • "In the U.S., 27% of adults ages 60 and older live alone, compared with 16% of adults in the 130 countries and territories studied."
  • "U.S. adults ages 60 and older also are more likely than their counterparts around the world to live as a couple without young children at home. Almost half of Americans in this age group (46%) share a home with only one spouse or partner, compared with three-in-ten globally (31%)."
  • "Globally, living in extended-family households – those that include relatives such as grandchildren, nephews and adult children’s spouses – is the most common arrangement for people 60 and older. "

March 29, 2020 in Consumer Information, Current Affairs, Housing, International, Statistics | Permalink | Comments (0)

Monday, March 23, 2020

Latest Issue of BIOFOCAL, Publication of ABA- COLA

Tuesday, March 10, 2020

3-D Printed House!

3-D printers are amazing. I've read some stories about the application of 3-D printers to solve real-world problems. Now comes another one. Kaiser Health News is reporting about Around The Corner: 3D Housing Designed For The Homeless And Needy Seniors.

In a Northeast Austin neighborhood, these homes are taking their distinctive shape on the grounds of Community First Village, where about 180 formerly homeless people have found shelter and camaraderie in the most expensive city in the state. The 51-acre development (which will eventually include more than 500 homes) provides affordable permanent housing, including the 3D variety.

In this city of disruptors, Austin-based construction technology company Icon has formed a variety of partnerships to explore how 3D-printed homes could not only provide housing for people on the margins but also demonstrate how to dramatically reduce the time and money spent on construction.

...

These 400-square-foot houses are the nation’s first 3D-printed residences, according to Icon. Its process — which incorporates an 11-foot-tall printer that weighs 3,800 pounds — relies on robotics. Beads of a pliable concrete material dubbed Lavacrete ooze from the behemoth printer in ripples that stack and harden into a wall with curved corners.

The idea is to cut the time and as much as half the cost associated with traditional construction, limit the environmental footprint and trim the number of workers on crews, said Jason Ballard, Icon’s co-founder and CEO.

The article talks about supporters and detractors of the concept and gives more info about the project. Check it out!

March 10, 2020 in Consumer Information, Current Affairs, Housing, Other | Permalink | Comments (0)

Thursday, March 5, 2020

Do You Know Enough About the Legal Issues Surrounding Subsidized Housing?

If you answer to that question was no, then register now for this free webinar from the National Center on Law and Elder Rights, Legal Basics of Subsidized Housing Rents: Income, Formula-Based, and Tax Credit Properties Here's information about the webinar:

A variety of rules govern the setting and adjustment of rents in different federally assisted rental housing programs. For most tenants in these programs, a tenant’s share of the rent is based on the tenant’s income, usually at 30% of adjusted household income. For some tenants, however, the rent may be unrelated to tenant income. This is true for: 1) tenants in privately owned, federally supported housing, without deep rental subsidies or with formula rents; 2) for certain public housing tenants who pay a “flat rent” based on reasonable market value or who are subject to minimum rents set by statute; and 3) tenants in Low Income Housing Tax Credit (LIHTC) properties where rents are set based on a percentage of the local area median income. This webinar will provide an overview of the rules governing tenant rent contributions in the major federal programs, including public housing, project-based rental assistance programs, the Housing Choice Voucher program, and LIHTC. The webinar will also review how a tenant’s rent contribution is established and adjusted in different programs, with a particular focus on the rules governing income determinations.

To register, click here.

March 5, 2020 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Housing, Programs/CLEs, Webinars | Permalink | Comments (0)

Wednesday, March 4, 2020

Where Do You Plan to Live When You are "Old"?

It's never too early to start making plans about where you will live once you are "old".  According to the Washington Post, Even in midlife, it’s smart to start thinking about where you’ll live when you’re old.

According to AARP, people turning 65 these days will probably live another 20 years — and 70 percent will need some level of long-term care. I needed a plan — actually a revised plan, because until then [the author] expected[the] husband to be part of [the] plan. But ... [divorce happened and the need] to think about an aging plan ... [With]contemporaries .... now approaching (or passing) Medicare age, [the author] asked for their thoughts on senior living. [A]  former work colleague [responded]  “Denial, Steven. Sheer denial.” A high school friend, ... hit the nail on the proverbial head: “Call me Peter Pan. My plan is to never grow up and need senior living.” ....

Like 90 percent of older Americans, [the author]  hoped to “age in place” — until [seeing] how difficult it was for [the author's] parents (and worrisome for their kids). And expensive: premiums for long-term care policies ... now average $2,700 a year, according to the industry research firm LifePlans, which AARP reports “puts the coverage out of reach for many Americans.”

The author, undertaking due diligence, visited examples of some housing options, ultimately sending in money to be placed on a waiting list. 

"I understand better now why my parents couldn’t make a plan: It’s scary to contemplate one’s own old age. I love my current house (with a ground-floor master, making it feasible for aging in place), but I’m glad to have a Plan B with that deposit check as my safety net. Without a spouse (at least for now), I’m guessing my three 20-something nieces will be pleased, too."

March 4, 2020 in Consumer Information, Current Affairs, Health Care/Long Term Care, Housing, Other | Permalink | Comments (0)

Wednesday, February 19, 2020

Prospective Residents Need More Info About ALFs

Friend and colleague, Professor  Naomi Cahn sent us this story. In the article,  Incomplete and inadequate: Information lacking for seniors looking for assisted living, early on the authors explain the reasons for their research:

We and our colleagues track the ever-changing circumstances of long-term care in the U.S. As we study policies and practices, we have observed that the expansion of assisted living is clearly a game-changer, creating new challenges in the industry. Many states have increased assisted living regulation in recent years. Some consumer advocates have called for nursing-home style federal rules, though others oppose this, saying assisted living should remain flexible enough to serve residents with a range of needs, from personal care only to end-of-life comfort.

Now we know why they did the research, here's what they did: "Using criteria formulated from prior research, along with information provided by some states, we examined 39 key elements of each website. Those elements included the size of the facility, cost, license status, the insurance it accepts, and any special services offered, such as memory care. We also looked at each website’s usability – the ease in finding critical information."

The article reports they found gaps in provided info, websites that they thought were difficult to navigate although they found some websites that had better info and were easier to use. "True, the state websites are better than they were 15 years ago. But they are less than what they should be. Many of the elderly, the disabled, and the families who love them require more to make appropriate choices. When navigating the internet, the principle of “buyer beware” should not be the driver."

February 19, 2020 in Consumer Information, Current Affairs, Health Care/Long Term Care, Housing, Other, State Statutes/Regulations, Web/Tech | Permalink | Comments (0)

Tuesday, February 4, 2020

What Type of Multi-Generational Housing is Right For You?

Threr are a lot of choices.... The New York Times covered this in  this article: In They Wanted a Multigenerational Home in Brooklyn. Which Apartment Did They Choose?  the goal for the recently married couple with a baby on the way was to have a home where her parents could live with them. The article is interactive, after summarizing the 3 properties reviewed by the couple, the readers can select which property they would choose, and guess at the property actually chosen by the couple.  (I guessed wrong).  Check it out-and see if your reasoning is the same as the couple featured in the article.

February 4, 2020 in Consumer Information, Current Affairs, Housing, Other | Permalink | Comments (0)

Thursday, January 30, 2020

Too Young for Senior Living?

My colleague and dear friend, Mark Bauer sent me this article, An orphaned teen is being forced out of his grandparents' senior community because he's too young.   Here's what happened. The kid's parents both died and he moved in with his grandparents in Prescott, Az, where they live in a 55+ community.  "[T]he homeowner's association said it could face legal issues if he stayed."  He has about 5 months to move out. Although younger folks can live there, the minimum age noted in the article is 19.  Both sides have representation and no solution was noted in the article.  My sense from the article is  the positions boil down to these: have some compassion from the one side, and from the other-there are rules and those who live there have an interest in the purpose of the rules.  The young man is 15 years old.  I do understand both sides of the argument-there are those who chose to live there because they wanted to live in a community with age restrictions. But on the other hand, both of his parents died.....  This is a great fact pattern for our students, and I'm planning to assign them to represent each of the sides and make their arguments.

Stay tuned.

 

January 30, 2020 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Housing, Other, State Statutes/Regulations | Permalink | Comments (0)