Friday, November 27, 2020

Health & Income Security Gaps For Older Americans of Color

This is not a happy article for the day after Thanksgiving-but it is a darn important topic.  The Conversation published this article, Nearly two-thirds of older Black Americans can’t afford to live alone without help – and it’s even tougher for Latinos explains that

Older Americans who want to live independently face serious economic challenges. Half who live alone don’t have enough income to afford even a bare-bones budget in their home communities, and nearly 1 in 4 couples face the same problem.

Those numbers add up to at least 11 million older adults who are struggling to make ends meet, a new analysis shows.

The numbers are worse for older people of color. Dramatically higher percentages of Black, Latino and Asian older adults live on incomes that don’t meet their cost of living, even with Social Security. That can mean skipping needed health care, not having enough food, living in unhealthy conditions or having to move in with family.

These disparities often reflect lifelong disadvantages that add up as people of color encounter structural racism and discrimination that shape their ability to buy property and save for the future.

The authors used some data available about elders "to measure the true cost of living for older adults. It tracks expenses for housing, health care, transportation, food and other basics, county by county. We paired the index with state-level income data to determine the percentage of people who don’t have enough income to cover their cost of living." The results show that "disadvantages people of color face can extend through their lifetimes and can pass on to future generations."  Not only is income security an issue, so is health security "[s]ecuring and protecting health into later life is also more challenging for many people of color."

The results also showed state by state variations. The article concludes with various recommendations:

Today’s older adults who are struggling financially can’t go back, but there are several ways to help them now:

  • Policies can promote affordable housing and affordable health care, which represent the biggest components of older Americans’ budgets.

  • Governments can promote mechanisms that allow people to keep working into later life, which allows people to continue generating income and building wealth, and also delays drawing down other income sources such as pensions or Social Security benefits.

  • Social Security and Medicare — the foundations of a secure retirement for millions of Americans — are essential for these groups. Older people of color rely more heavily than their white counterparts on Social Security and are at heightened risk when these programs are threatened.

  • Making sure government assistance programs such as SNAP benefits for food and housing subsidies are accessible to the people who need them can also help. Ensuring access includes providing information in multiple languages and hiring outreach workers who understand the population’s needs.

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

November 27, 2020 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Health Care/Long Term Care, Medicaid, Medicare, Social Security | Permalink | Comments (0)

Wednesday, November 25, 2020

Medicare's Care Compare

Remember those cool tools on Medicare.gov that allowed you to compare nursing homes, doctors, hospitals and more?  They are being retired as of the end of the year, and replaced with Medicare's Care Compare. All the info about the various services are there-but located on one page. It's easier since you can go to any of the 8 compare services from one landing page, rather than hunting for each one from the Medicare.gov website. Here's what CMS has to say about this new website:

We’ve combined our 8 original provider compare sites, giving you one place to start finding any type of care you need. New features include updated maps, new filters that help you identify the providers right for you, and a clean, consistent design that makes it easier to compare providers and find the information that’s most important to you.

. . .

What can this tool do for me?

For people with Medicare or their caregivers who want to choose a Medicare provider (like physicians, hospitals, nursing homes, and others), this tool provides a single source search and compare experience, that lets you:

  • Find information about providers and facilities based on your individual needs
  • Get helpful resources to choose your health care providers
  • Make more informed decisions about where you get your health care

The information here should be used with other information you gather about providers and facilities in your area. In addition to reviewing the information here, you should talk to your doctor, social worker, or other health care providers when choosing a provider.

. . .

Although the tool was created for people with Medicare in mind, many of the measures shown here apply to people who may not have Medicare.

 

November 25, 2020 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Health Care/Long Term Care, Medicaid, Medicare, Web/Tech | Permalink | Comments (0)

Tuesday, November 24, 2020

Recent AP Report on Nursing Homes-It's Not Just About COVID

Last week I tweeted a link to an article from the AP about poor care in SNFs that wasn't due to COVID, Not just COVID: Nursing home neglect deaths surge in shadows. The National Consumer Voice for Quality Long Term Care wrote a response;  and their full statement is available here.

Consumer Voice has heard from hundreds of families whose loved ones have been harmed by neglect. Family members report that many residents have experienced significant physical decline, such as losing their ability to move, or sit up or stand up without assistance. Others no longer talk because almost no one has spoken to them since March. There are residents who have not been bathed nor had their teeth brushed for months, and residents who have been confined to their rooms -while missing their eyeglasses and hearing aids. One resident sat in her room with a fractured hip for a month – the result of a fall and lack of medical attention, despite complaints of pain for weeks. Weight loss, bed sores, infections, and cognitive decline are ravaging nursing home residents. Much of this suffering could have been prevented.

The statement called on Congress for changes, including '"[ensuring] adequate numbers of well-trained and well-compensated staff. ... [and] [opposition of] any kind of immunity from civil liability for nursing homes" They also called on CMS to "[i]ncrease oversight of resident care ... [and] [r]equire facilities to permit family to conduct compassionate care visits."

November 24, 2020 in Consumer Information, Current Affairs, Elder Abuse/Guardianship/Conservatorship, Federal Statutes/Regulations, Health Care/Long Term Care, Medicaid, Medicare | Permalink | Comments (0)

Thursday, November 5, 2020

SNF Infection Control Oversight-Does It Work?

I think we can all recite the COVID #s from the spring vis a vis SNFs.  Is the infection control process enough? Is more needed? The Washington Post recently published this story, As pandemic raged and thousands died, government regulators cleared most nursing homes of infection-control violations.

At the outset of a looming pandemic, just weeks after the first known coronavirus outbreak on U.S. soil, the woman responsible for helping to protect 1.3 million residents in America’s nursing homes laid out an urgent strategy to slow the spread of infection.

In the suburbs of Seattle, federal inspectors had found the Life Care Center of Kirkland failed to properly care for ailing patients or alert authorities to a growing number of respiratory infections. At least 146 other nursing homes across the country had confirmed coronavirus cases in late March when Seema Verma, the administrator of the Centers for Medicare and Medicaid Services, vowed to help “keep what happened in Kirkland from happening again.”

And yet, we know what happened.  The plan was for complete "a series of newly strengthened inspections to ensure 15,400 Medicare-certified nursing homes were heeding long-standing regulations meant to prevent the spread of communicable diseases. It was another key component of a national effort, launched in early March, to shore up safety protocols for the country’s most fragile residents during an unprecedented health emergency."  With that in mind, the Washington Post conducted an investigation and found that "during the first six months of the crisis [the inspectors] cleared nearly 8 in 10 nursing homes of any infection-control violations ...." The article notes that these facilities included those that had COVID outbreaks before the inspections and others that had outbreaks after inspections concluded there were no violations.  We can all realize that with COVID, not every transmission can be prevented, but the article notes that "the number of homes flagged for infection-control violations remained about the same as last year."

The article gives examples of violations and fines discusses actions taken by CMS, the lack of consistency, the imposition of small fines, and gaps in communication,  postponement of collecting fines and more.  This is a lengthy detailed article that is important to read to order to have some understanding of how COVID was able to rampage through SNFS. 

The Executive Director of the Long Term Care Coalition observed "“Nursing home residents were never more vulnerable in our lifetime, if ever... I don’t like to overuse the expression, but we literally abandoned them when the need for monitoring was the highest, when the need for quality assurance was the highest. They needed that oversight more than ever.”

And let's remember, the numbers of cases are spiking again. Have we learned any lessons from the spring?

November 5, 2020 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Health Care/Long Term Care, Medicaid, Medicare, Statistics | Permalink | Comments (1)

Thursday, October 29, 2020

More on Nursing Homes & Federal $

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

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

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

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

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

So why is this problematic? The article offers this insight

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

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

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

 

October 29, 2020 in Cognitive Impairment, Consumer Information, Current Affairs, Federal Statutes/Regulations, Health Care/Long Term Care, Medicaid, Medicare | Permalink | Comments (0)

Thursday, September 24, 2020

Updates on SNFs and COVID

Wednesday, September 16, 2020

Coronavirus Commission Releases Report on SNFs

Hot off the press.  CMS has released the report of the Coronavirus Commission for Safety and Quality in  Nursing Homes.  The purpose and objectives of the Commission:

Convene a commission of experts to address safety and quality in nursing homes in relation to the public health emergency. The main purpose of the independent Coronavirus Commission for Safety and Quality in Nursing Homes (Commission) was to solicit lessons learned from the early days of the pandemic and recommendations for future actions to improve infection prevention and control measures, safety procedures, and the quality of life of residents within nursing homes. 

The 25 member commission met 9 times and made the following:

27 recommendations and accompanying  action steps organized into 10 themes. These themes intersect with the Commission’s four objectives, and reflect responses to:
• Ongoing supply and affordability dilemmas related to testing, screening, and personal
protective equipment (PPE)
• Tension between rigorous infection control measures and quality of life issues that exist
in cohorting and visitation policies
• A call for transparent and accessible communications with residents, their representatives
and loved ones, and the public
• Urgent need to train, support, protect, and respect direct-care providers  Outdated infrastructure of many nursing-home facilities
• Opportunities to create and organize guidance to owners and administrators that is more
actionable and to obtain data from nursing homes that is more meaningful for action and
research
• Insufficient funding for quality nursing home operations, workforce performance, and
resident safety.

The commission did not unanimously adopt the report. The 186 page report is available here. Stay tuned.

September 16, 2020 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Health Care/Long Term Care, Medicare | Permalink | Comments (0)

COVID and SNFs: Deaths Preventable?

The New York Times asked the hard question, whether COVID deaths in SNFs were preventable, in a recently published opinion from the editorial board. How Many of These 68,000 Deaths Could Have Been Avoided?

Around 40 percent of all coronavirus-related deaths in the United States have been among the staff and residents of nursing homes and other long-term care facilities — totaling some 68,000 people.

Those deaths were not inevitable. The novel coronavirus is adept at spreading in congregant living facilities, and older people face an increased risk of contracting and dying from it. But most of the nation’s nursing homes had months of warning about the coming threat: One of the first coronavirus outbreaks in the country was in a nursing home near Seattle, making it clear that such facilities ought to prepare.

The opinion discusses steps SNFs could have taken to reduce the chances of spread, the financial model for SNFs in the US. The opinion also discusses the reduction of oversight and notes

Every effort should be made to ensure that the bulk of the money that the government puts into this industry goes to patient care, not providers’ pockets. An investigation started by the House of Representatives into the nation’s largest for-profit homes is a meaningful step in this direction. The Justice Department should follow suit.

The opinion discusses the way SNFs get supplies for their PPEs, etc. as well as staffing shortages. The editors conclude with 3 recommendations

In the near term, lawmakers should provide for hazard pay for nursing home workers in the next relief package and should require all nursing homes to enact non-punitive sick-leave policies so that workers don’t infect colleagues or residents.

In the longer term, federal officials need to consider revising Medicaid reimbursement rates for long-term care so they support higher than minimum-wage salaries, and shifting reimbursement policies so at least some long-term care can be reimbursed with Medicare dollars.

Lawmakers and nursing home operators also would do well to consider a national initiative, perhaps involving student volunteers and internship programs, to recruit future workers to nursing home care. That work, which can be deeply rewarding, will remain urgently needed long after this crisis passes.

September 16, 2020 in Consumer Information, Current Affairs, Federal Cases, Federal Statutes/Regulations, Health Care/Long Term Care, Medicaid, Medicare, Science | Permalink | Comments (0)

Monday, September 14, 2020

Dual Eligibles and COVID Coverage

Mark your calendars now for a free webinar on How Health Plans Serving Dual Eligibles Can Center Equity During COVID-19.  The webinar is set for October 6, 2020 from 2-3:30 p.m.  Here's a description of  the webinar.

The COVID-19 pandemic has brought to the forefront longstanding racial disparities in our healthcare system, and data show that older adults – especially older adults of color and those in residential congregate settings – are disproportionately impacted by the virus. Aging advocates play a key role in holding health plans and government agencies accountable to meeting the needs of those most at risk during this time. In this webinar, How Health Plans Serving Dual Eligibles Can Center Equity During COVID-19 , we will provide an overview of dual eligibles and the types of health plans that serve them. We will also present specific programmatic recommendations that advocates can push health plans with dual eligible members in their community to adopt. These recommendations are measures that plans can take to center equity in their ongoing response to COVID-19 and ensure they are meeting the needs of older adults of color during this challenging time.

To register, click here.

September 14, 2020 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Health Care/Long Term Care, Medicaid, Medicare, Programs/CLEs, Webinars | Permalink | Comments (0)

Sunday, August 23, 2020

Elder Abuse, SNFs & COVID. An Article in Harper's Magazine

The September issue of Harper's Magazine has a compelling article, Elder Abuse, Nursing Homes, COVID and the Bottom Line.  Just a warning-parts of this article are heart-rending.

Inevitably ... the virus has found its most ideal conditions in the warehouses storing America’s elderly population. No one knows the current death toll. As of early July, CMS put the number at 33,509, but the count covered only federally regulated nursing homes, not assisted-living communities. The homes, moreover, were not required to report deaths that occurred before May 8, although the agency said it was confident that “the vast majority” did so. One in five nursing homes didn’t bother to report their numbers at all. A New York Times study in late June put the number of deaths in U.S. nursing homes at a staggering 55,000, but even this figure did not necessarily include all of those who became infected in a home but died in a hospital, as was the case for Sharon Mitchell. In some states, the vast majority of COVID-19 deaths were in homes: 64 percent in Massachusetts, 68 percent in Pennsylvania, 77 percent in Minnesota. In New Jersey, one in every ten people housed in nursing homes or assisted-living centers died. This was a helpless population, helpless because so often confined in a state of neglect and squalor. But despite or perhaps because of their conditions, they were worth a lot of money. In effect, they were being harvested for profit.

The article looks at the financial model of long term care facilities in the U.S. It offers a  comprehensive history of the development of LTC facilities in the U.S., culminating with a discussion of the ownership of LTC facilities by private equity firms. The article covers the impact of the pandemic and the efforts by the industry to get shield laws to provide them immunity.  

As noted by the article, it's not only U.S. facilities that have faced these deaths from the pandemic.  It notes one company that made changes early in the pandemic, which resulted in less cases, at least in some facilities.  If we are to change the way we provide ltc in this country, in my opinion, this article is important. I'm assigning it to my students. 

August 23, 2020 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Health Care/Long Term Care, Housing, Medicaid, Medicare | Permalink

Thursday, July 23, 2020

Reduced SNF Training Requirements Because of COVID

Politico reported that the Trump team relaxed training rules for nursing home staff just as pandemic hit.

Shortly after the first coronavirus outbreak ravaged a nursing home in Kirkland, Wash., the Trump administration moved to fulfill a longstanding industry goal — waiving the requirement that nurse’s aides receive 75 hours of training and allowing people who study only eight hours online to become caregivers during the pandemic.

The industry had been fighting for years to reduce training requirements, saying they make it harder to recruit staff. The day after the administration announced the change, the industry rolled out a free online training program for certifying the new role — called a "temporary nurse aide" — that has since been adopted by at least 19 states.

The article reports that advocates for elders and others think this was poorly timed and may have resulted in the spread of COVID in SNFs, especially when considering that CNAs are typically  "the main caretakers of residents, some of whom need round-the-clock monitoring; nurse’s aides are also on the front lines in implementing the cleaning and disinfecting practices that prevent the spread of Covid-19." CMS emphasized this is temporary and as soon a COVID is done with us, the  CNA 75 hour training requirement will resume.

However, we don't know how well this is working. "[C]ritics are questioning why the waivers were applied so quickly and broadly, and why they’re lasting months into the pandemic when little is known about whether there are, in fact, larger-than-usual staff shortages in nursing homes. They also question the wisdom of waiving the rules for removing residents and making quarterly reports on their condition, which are among more than two dozen regulations temporarily suspended by the administration."

Stay tuned.

July 23, 2020 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Health Care/Long Term Care, Medicaid, Medicare | Permalink

Tuesday, July 21, 2020

Has the Time Come to Reinvent the Nursing Home? Or Change the Funding?

Charlie Sabatino, the rock star of elder law and the Director of the ABA Commission on Law & Aging recently wrote an opinion piece for Next Avenue  on this important topic. OPINION: It’s Time to Defund Nursing Homes: How the traditional nursing home model can be replaced. Sabatino writes that:

[T]he COVID-19 pandemic ravaging nursing home residents underscores a deep-seated ageism inherent in our institutional model of nursing home care. I believe it is time to defund the institutional model and replace it with a radically different model.

Today’s typical nursing home has never come close to meeting the public’s desire for humane and dignified long-term care. Warehousing large numbers of frail elders in hospital-like buildings with residents in double or triple rooms along with staff turnover as high as 100% unavoidably creates a high risk for resident safety and compromises quality of care.

We've all read the stories about the horrors occurring in the nursing homes as the pandemic rolls across the country (for patients and caregivers too). A number of calls for change have been made, but as Sabatino aptly observed, "

[M]ultiple recommendations for change have gained attention. They include ensuring adequate personal protective equipment in nursing homes; disaster plans that facilitate quarantining; more and better trained staff and heightened monitoring and oversight of care.

But let’s be clear: These measures do little more than rearrange the deck chairs in a failing system.

The COVID-19 pandemic is a 9/11 moment for nursing home care and a test of our ability to reimagine nursing home care that puts the “home” into nursing homes.

Sabatino then turns to specifics regarding change and suggests the key to change is to tie it to Medicare and Medicaid funding. 

As the largest payor for nursing home care, Medicare and Medicaid hold the key. Now is the time to change facility requirements to gradually limit participation in the program only to facilities that provide the following:

  • Small home-like facilities
  • Single rooms and bathrooms
  • A flattened, more flexible staff hierarchy with cross-trained staff
  • A culture focused first on residents’ goals, interests and preferences.

Sabatino concludes "[a]s long as the nursing home industry can rely on the flow of federal money for the current model of care, it has no financial incentive to change, not even after the coronavirus catastrophe. ... Change that flow, and a major cultural change in long-term care will follow."

Hello Congress??

Stay safe and healthy everyone.

July 21, 2020 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Health Care/Long Term Care, Medicaid, Medicare | Permalink

Thursday, July 2, 2020

CMS Coronavirus SNF Commission

More good news from CMS-the members of the Independent Coronavirus Commission on Safety and Quality in Nursing Homes have been announced.  The 25 experts

The commission members are:

  • Roya Agahi, RN, MS HCM, WCC; Chief Nursing Officer, formerly of NYC Health + Hospitals, soon to be of CareRite, New York
  • Lisa M. Brown, PhD, ABPP; Professor of Psychology, Palo Alto University, California
  • Mark Burket, CEO, Platte Health Center Avera, South Dakota
  • Eric M. Carlson, JD; Directing Attorney, Justice in Aging, California
  • Michelle Dionne-Vahalik, DNP, RN; Associate Commissioner, State Health and Human Services Commission, Texas
  • Debra Fournier, MSB, BSN, ANCC RN-BC, LNHA, CHD, CPHQ; COO, Veterans’ Homes, Maine
  • Terry T. Fulmer, PhD, RN, FAAN; President, The John A. Hartford Foundation, New York
  • Candace S. Goehring, MN, RN; Director, State Department of Social and Health Services, Aging and Long-Term Support Administration, Washington
  • David C. Grabowski, PhD; Professor of Healthcare Policy, Harvard University, Massachusetts
  • Camille Rochelle Jordan, RN, BSN, MSN, APRN, FNP-C, CDP; Senior Vice President of Clinical Operations & Innovations, Signature Healthcare, Kentucky
  • Jessica Kalender-Rich, MD, CMD, AGSF, FAAHPM, FACP; Medical Director, Post-Acute Care, University of Kansas Health System, Kansas
  • Marshall Barry Kapp, JD, MPH; Professor Emeritus of Law, Florida State University, Florida
  • Morgan Jane Katz, MD, MHS; Assistant Professor of Medicine, Johns Hopkins University, Maryland
  • Beverley L. Laubert, MA; State Long-Term Care Ombudsman, State Department of Aging, Ohio
  • Rosie D. Lyles, MD, MHA, MSc, FACA; Director of Clinical Affairs, Medline Industries, Illinois
  • Jeannee Parker Martin, MPH, BSN; President and CEO, LeadingAge California
  • G. Adam Mayle, CHFM, CHC, CHE; Administrative Director of Facilities, Memorial Healthcare System, Florida
  • David A. Nace, MD, MPH, CMD; President, AMDA – The Society for Post-Acute and Long-Term Care Medicine, Pennsylvania
  • Lori Porter, LNHA, CNA; CEO, National Association of Health Care Assistants, Missouri
  • Neil Pruitt, Jr., MBA, MHA, LNHA; Chairman and CEO, PruittHealth, Inc., Georgia
  • Penelope Ann Shaw, PhD; Nursing Home Resident and Advocate, Braintree Manor Healthcare, Massachusetts
  • Lori O. Smetanka, JD; Executive Director, National Consumer Voice for Quality Long-Term Care, Maryland
  • Janet Snipes, LNHA; Executive Director, Holly Heights Nursing Home, Colorado
  • Patricia W. Stone, PhD, MPH, FAAN, RN, CIC; Professor of Health Policy in Nursing, Columbia University, New York
  • Dallas Taylor, BSN, RN; Director of Nursing, Eliza Bryant Village, Ohio

Here's the info about the Commission's mission:

The Commission will conduct a comprehensive assessment of the overall response to the COVID-19 pandemic in nursing homes. Based on its assessment, the Commission will make recommendations on actions and best practices for immediate and future actions.  Three key areas of focus for the Commission include:

  • Ensuring nursing home residents are protected from COVID-19 and improving the responsiveness of care delivery to maximize the quality of life for residents;
  • Strengthening efforts to enable rapid and effective identification and mitigation of COVID-19 transmission (and other infectious disease) in nursing homes; and
  • Enhancing strategies to improve compliance with infection control policies in response to COVID-19.

Crossing my fingers....

July 2, 2020 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Health Care/Long Term Care, Medicare | Permalink | Comments (0)

Wednesday, July 1, 2020

Using Advanced Age as a Factor in Rationing Health Care? Consider the Arizona COVID-19 Crisis Plan

I've recently returned from a week in Arizona with family.  I managed to arrive in Phoenix just in time for a surge in COVID-19 cases, traffic headaches connected to President Trump's campaign visits, a couple of new wildfires, and a few more degrees up the summer temperature gauge.  Probably the most newsworthy part of the trip was the announcement by Arizona authorities that the state was activating a COVID-19 crisis plan that involves triage -- or "rationing" as some  people interpreting the plan are calling it.  One component of the Arizona plan involves "protocols for scarce resource allocation."  An Arizona public statement describing the protocols attempts to reassure the public (emphasis provided with blue color):

If resources are sufficient, all patients who can potentially benefit from therapies will be offered therapies. If resources are insufficient, all patients will be individually assessed. No one will be categorically denied care based on stereotypes, assumptions about any person’s quality of life, or judgement about a person’s “worth” based on the presence or absence of disabilities.


All patients, regardless of resource availability, will be treated with respect, care, and compassion. Triage decisions will be made without regard to basis of race, ethnicity, color, national origin, religion, sex, disability, veteran status, age, genetic information, sexual orientation, gender identity, quality of life, or any other ethically irrelevant criteria.

When resources become inadequate -- implicit in the Governor's recent news conferences -- triage involves a color-coded system of triage "priority scores."  According to the statement, "All patients will be eligible to receive critical care beds and services regardless of their triage score, but available critical care resources will be allocated according to priority score, such that the availability of these services will determine how many patients will receive critical care."

The guidelines indicate health care providers must make an active assessment of the "patient's goals of care and treatment preferences.  It is imperative to know whether aggressive interventions such as hospitalization, ICU admission or mechnical ventilation are consistent with a patient's preferences.... All hospitalized patients should be asked about advance care planning documents, goals of care, and are strongly encouraged to appoint a proxy decision-maker (e.g., medical durable power of attorney... or health care agent) if not previously in place.  Patients in nursing homes, skilled nursing facilities, other long-term care settings, and outpatient care settings should also be asked about their goals of care and advanced care planning documents.... If advance clare planning documents are in place and available the healthcare provider should verify the patient's goals of care and treatment preferences remain the same....."

Will the patient's age, especially an advanced age, be relevant to a Arizona's Covid-19 crisis plan?  On the one hand, the guidelines indicate "age" is  expressly "removed ... as a specific factor for Triage Priority scores or Triage Color Groups."  On the other hand, when determining the Triage Priority Score, points assessed must reflect an evaluation of whether the patient is "expected to live more than 5 years if patient survives the acute illness [zero points added]" or whether death is "expected wtihin 5 years despite successful treatment of acute illness [2 points added]." If "death [is] expected within 1 year regardless of successful treatment of the acute illness," 4 points are added.  The patient's prioritization for critical care resources is best with a low score (1 to 3 total points), while priority is reduced to "intermediate" (4 to 5 points) or "lowest," if they are assessed with more than 6 total points.  Further, "age" is implicitly involved as the prioritization process somehow examines the specific patient's "opportunty to experience life stages (childhood, young adulthood, middle years, and older years)."

These are obviously tough calls in any health care assessment contect, but especially so in the middle of a pandemic.  Public health professionals have experience with these kinds of assessements. I suspect that many families also have engaged in a type of informal assessment when serving as a loved one's health care spokesperson or agent. 

My sister and I were thinking about last summer as I visited this summer.  Last summer, the two of us talked about similar factors when making the call on whether our mother would have hip-surgery at age 93 following a fall-related fracture.  The doctor said that without the surgery our mother was unlikely to walk again because of pain; with the surgery there was a significant chance she would be able to walk without pain.  She ended up sailing through the surgery -- and began taking steps again the same day.  Ironically, probably because of her increasing dementia, she had no fear of falling nor any memory of the surgey and thus was soon fully ambulatory (although she did sometimes substitute a walker for her occasional cane) and remained so for all but the last few days if the next six months of life.  That took her into the summer of 2019 in Arizona.

If the cornonavirus pandemic had occurred in the summer of 2019, and if safe access to hospitals and surgery were the issues, my best guess is Mom would probably have had a "high" score on any health care triage assessment -- in other words, not good news.  We are glad we never confronted decisions about respirators or ventilators.  We do know that our very elderly mother had a much better quality of life with major surgery than she would have had without it. Just one case, of course.  Again, tough calls (and yes, expensive calls for Medicare) with or without a pandemic to complicate the decision process.  

July 1, 2020 in Advance Directives/End-of-Life, Cognitive Impairment, Current Affairs, Ethical Issues, Health Care/Long Term Care, Medicare | Permalink | Comments (2)

Monday, June 29, 2020

CMA Releases Family Caregiver Brief

The Center for Medicare Advocacy (CMA) has released an issue brief on Medicare and Family Caregivers. "This Issue Brief examines the role Medicare currently plays, and could play, in assisting
beneficiaries and their family caregivers." The issue brief covers Medicare law, the need for coverage, issues with receiving Medicare home health care services, problems with access to coverage, the limited number of aides, and more. The Brief also discusses Medicare Advantage and in-home services.

CMA makes theses recommendations 

  1. Ensure the scope of current allowable home health benefits, generally, and home health aides, specifically, are actually provided. Simply put, ensure that current law is followed;
    2. Create a new stand-alone home health aide benefit that would provide coverage without the current skilled care or homebound requirements, using Medicare’s existing infrastructure as the vehicle for the new coverage; and
    3. Identify other opportunities for further exploration within and without the Medicare program, including additional Medicare revisions, demonstrations, and initiatives overseen by the Center for Medicare and Medicaid Innovation (CMMI).

After providing some actual examples, the Brief provides insights into other additions to Medicare that would provide more services to beneficiaries.  The conclusion  provides that "Medicare home health coverage is not being implemented to the full extent of the law. If it were,
countless beneficiaries and families would be better off. Nonetheless, at best, the current Medicare benefit leaves far too many patients and caregivers behind. In order to provide quality home-based
care for individuals, and support for their caregivers, significant changes are needed to the
Medicare program and the broader health insurance system." (citations omitted).

June 29, 2020 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Health Care/Long Term Care, Medicare | Permalink | Comments (0)

Sunday, June 28, 2020

FAQ from CMS on SNF Visits

A few days ago CMS released a four page FAQ re: visiting residents in SNFs. Frequently Asked Questions (FAQs) on Nursing Home Visitation.

The FAQs include

1.What steps should nursing homes take before reopening to visitors? 

2. The reopening recommendations maintain that visitation should only be allowed for
“compassionate care situations.” Do compassionate care situations only refer to
end-of-life situations?

3. Can facilities use creative means, such as outside visits, to begin to allow for
visitation within the CMS and CDC guidelines; even before reaching phase three?

4.Can nursing home residents participate in communal activities before reaching
phase 3 of the nursing home reopening plan?

5.What factors should nursing homes consider when making decisions about
visitation?

6. Should residents or visitors who have tested positive for COVID-19 participate in
visits?

7. Are nursing homes required to allow visits from the ombudsman when requested by
a resident?

June 28, 2020 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Health Care/Long Term Care, Medicaid, Medicare | Permalink | Comments (0)

Friday, June 26, 2020

Nursing Homes: Making Room for COVID-19 Residents?

Each day I get a email from Kaiser Health News (KHN) that contains articles collected from the prior day on various health topics.  Since COVID-19 arrived, the number of articles concerning nursing homes has greatly increased. I've refrained from writing about those-mainly because there are so many of them.  But here's a recent article that I felt was too important to pass by.

The New York Times,ran an article with this eye-popping headline:  ‘They Just Dumped Him Like Trash’: Nursing Homes Evict Vulnerable Residents. "Nursing homes across the country are kicking out old and disabled residents and sending them to homeless shelters and rundown motels." The article makes the point that caring for COVID-19 patients is more lucrative than long-term care residents. 

"Many nursing homes are struggling in part because one of their most profitable businesses — post-surgery rehab — has withered as states restricted hospitals from performing nonessential services. ... Treating Covid-19 patients quickly became a popular way to fill that financial void... Last fall, the Centers for Medicare and Medicaid changed the formula for reimbursing nursing homes, making it more profitable to take in sicker patients for a short period of time. COVID-19 patients can bring in at least $600 more a day in Medicare dollars than people with relatively mild health issues, according to nursing home executives and state officials."  Don't forget, however, that profit isn't the motive in every instance-remember back when the hospitals were jammed with COVID-19 patients and asked nursing homes to take some?

With SNFs shut down to outside visitors, Ombudsman visits may also be curtailed. And although the law requires that SNFs "find a safe alternative location for the resident to go, whether that is an assisted living facility, an apartment or, in rare circumstances, a homeless shelter... some homes have figured out a workaround: They pressure residents to leave. Many residents assume they have no choice, and the nursing homes often do not report them to ombudsmen."  Only a handful of facilities have a moratorium on resident evictions during the pandemic.

Hello CMS-are you watching this?

 

June 26, 2020 in Consumer Information, Current Affairs, Federal Cases, Federal Statutes/Regulations, Health Care/Long Term Care, Medicare | Permalink | Comments (0)

Wednesday, June 17, 2020

This "Should" Be Easy: Support DACA Workers in Health Care and Long-Term Care

The Supreme Court 's ruling on the fate of DACA-residents and workers in the U.S. could be issued this week.  Regardless of the outcome on the case itself, everyone who cares about quality of health care, including long-term care, should also care about the United States' need to be honest about how much health care depends on the hard work and commitment to care provided by temporary-status and undocumented-status  workers in health and personal care jobs.  I've seen DACA workers in action in elder care, and I've seen their families ripped apart by harsh immigration rulings.

NPR's Morning Edition had a short and yet deeply important segment today on Health Care Workers Who Are Awaiting Supreme Court DACA Decision.   Do listen to the podcast replay --  it is just 4 minutes -- and think about whether this is a key opportunity for a true, bipartisan solution for DACA-children (families) who so often are working in some of the most challenging (and dangerous) U.S. jobs during the COVID-19 pandemic.  Let's do the right thing.  

June 17, 2020 in Consumer Information, Current Affairs, Ethical Issues, Federal Cases, Federal Statutes/Regulations, Health Care/Long Term Care, International, Medicaid, Medicare | Permalink | Comments (0)

Thursday, June 11, 2020

Nursing Homes and the Right to Visitors During a Pandemic

The seminal 1987 Nursing Home Reform Act requires all nursing facilities to care for their residents in a manner that that "will promote ,maintenance or enhancement of the quality of life of each resident." 12 USCA Section 1396r(b)(1)(A).  The same law, at Section 1396r(e)(3),  addresses "access and visitation rights:" 

A nursing facility must - ... 

(B) permit immediate access to a resident, subject to the resident's right to deny or withdraw consent at any time, by immediate family or other relatives of the resident;
 
(C) permit immediate access to a resident, subject to reasonable restrictions and the resident's right to deny or withdraw consent at any time, by others who are visiting with the consent of the resident;
(D) permit reasonable access to a resident by any entity or individual that provides health, social, legal, or other services to the resident, subject to the resident's right to deny or withdraw consent at any time .... 
During the pandemic lockdown, states prohibited most visitations, citing the risk of infection from the outside community that could endanger not just the visitor's loved one, but potentially all residents.  States are now beginning to lift or at least ease visitation restrictions, and families are beginning to talk more openly about the impact of the isolation on residents who have not contracted the virus.  
 
This week, NPR has begun airing stories about the challenge of balancing the risks of visitors against the benefits of not just family member visits, but family member involvement in care and socialization for residents.  From one story about Luann Thibodeau and her husband Jeff, who has multiple sclerosis:
 

It wasn't candlelight and soft music that made the 40th anniversary of Luann and Jeff Thibodeau so memorable. It was gazing at each other through the window of Jeff's nursing home in Texas and eating carryout from the Olive Garden. Just the two of them. And a nursing assistant.

 

"She fed him, and I ate mine, and that was it," Luann Thibodeau says. "So that was our 40th wedding anniversary."

 

Luann Thibodeau would bring her husband, Jeff, dinner every night, except Tuesdays, when she had Bible study. Since she's been unable to visit, she says that her husband has become increasingly disinterested in food as his multiple sclerosis has worsened.
 

The Thibodeaus have not been in the same room since mid-March. That's when visitors were banned from nursing homes to slow the spread of the coronavirus. But family members say that talking via FaceTime and holding up signs at windows are no substitute for the hands-on care and emotional support their visits provide.

 

Family members often are an integral part of the care residents in nursing homes receive. They make sure meals are being eaten, clothes are being changed. They also offer invaluable emotional support. . . . 

 

Luann Thibodeau has seen that decline in her husband. She used to bring dinner for him every night except Tuesdays when she goes to Bible Study. She says that as his multiple sclerosis has worsened, he's become increasingly disinterested in food. [She explains]. "I bully him into finishing a meal. And I'll say to him, 'Jeff, you know, this is what an adult man eats. So you need to eat this.' "

 

A staff member can't do what she does. Nursing home residents have rights. So if Jeff Thibodeau tells a nursing assistant that he's done eating after three bites, she has to abide by his wishes.

 

Without his wife's push, the results of her absence is striking.

For more, listen to the NPR podcast or read the parallel written narrative in "Banned From Nursing Homes, Families See Shocking Decline In Their Loved Ones." 

The federal Nursing Home Reform Act's Bill of Rights has never been an easily enforceable mandate, and particularly in a global crisis the needs of the many can override the rights of individuals.  But there does need to be a long-range plan on how better to facilitate visitation, recognizing it as an important part of any person's quality of life.  

 

June 11, 2020 in Consumer Information, Current Affairs, Dementia/Alzheimer’s, Elder Abuse/Guardianship/Conservatorship, Ethical Issues, Federal Statutes/Regulations, Health Care/Long Term Care, Housing, Medicaid, Medicare | Permalink | Comments (2)

Friday, June 5, 2020

Medicare Trustees Report 2020

And you know when the SSA Trustees Report is out, the Medicare Trustees Report is soon to follow. The Medicare Trustees report is available here.   There's no quick summary available, but the introduction and the overview provides some helpful info.

First, and importantly, this report doesn't take COVID-19 into account: "The projections and analysis in this report do not reflect the potential effects of the COVID-19 pandemic on the Medicare program. Given the uncertainty associated with these impacts, the Trustees believe that it is not possible to adjust the estimates accurately at this time."

Second, "Projections of Medicare costs are highly uncertain, especially when looking out more than several decades. One reason for uncertainty is that scientific advances will make possible new interventions, procedures, and therapies. Some conditions that are untreatable today may be handled routinely in the future. Spurred by economic incentives, the institutions through which care is delivered will evolve, possibly becoming more efficient. While most health care technological advances to date have tended to increase expenditures, the health care landscape is shifting. No one knows whether future developments will,on balance, increase or decrease costs."

Third, "Notwithstanding recent favorable developments, current-law projections indicate that Medicare still faces a substantial financial shortfall that will need to be addressed with further legislation. Such legislation should be enacted sooner rather than later to minimize the impact on beneficiaries, providers, and taxpayers."

Fourth, "The estimated depletion date for the HI trust fund is 2026, the same as in last year’s report. As in past years, the Trustees have determined that the fund is not adequately financed over the next 10 years. HI income is projected to be lower than last year’s estimates due to lower payroll taxes. HI expenditures are projected to be lower than last year’s estimates because of lower-than-projected 2019 spending, lower projected provider payment updates, and incorporation of time-to death into the demographic factors used in the projection model. Partially offsetting this decrease in expenditures is higher projected spending growth for Medicare Advantage beneficiaries." (citations omitted)

Fifth, for Part B, "The SMI trust fund is expected to be adequately financed over the next 10 years and beyond because income from premiums and general revenue for Parts B and D are reset each year to cover expected costs and ensure a reserve for Part B contingencies."

Finally, note this: "The Trustees are issuing a determination of projected excess general revenue Medicare funding in this report because the difference between Medicare’s total outlays and its dedicated financing sources is projected to exceed 45 percent of outlays within 7 years. Since this
determination was made last year as well, this year’s determination triggers a Medicare funding warning, which (i) requires the President to submit to Congress proposed legislation to respond to the warning within 15 days after the submission of the Fiscal Year 2022 Budget and (ii) requires Congress to consider the legislation on an expedited basis. This is the fourth consecutive year that a determination of excess general revenue Medicare funding has been issued, and the third
consecutive year that a Medicare funding warning has been issued."

June 5, 2020 in Consumer Information, Current Affairs, Federal Statutes/Regulations, Health Care/Long Term Care, Medicare | Permalink