A new study shows that many sick elderly people, with advanced dementia or near death, are still being prescribed drugs that cause uncomfortable side effects or adverse reactions. The question among doctors is how sick and disabled, how far into dementia, how close to death, must a nursing home patient be before stopping drugs that cause these unfortunate side effects but show scant evidence of actually helping?
New Study on Overmedication
The Journal of the American Medical Association (JAMA) released a report last week that measures the amount of medication being overprescribed to near death nursing home patients when the evidence that such medication is helping is slim. The report took a nationwide sample of 5,406 people with a diagnosis of advanced dementia that spent at least 90 days in a nursing home between 2009 and 2010. Most of the participants were over the age of 85 and had other ailments, as well. The majority, over seventy percent, had a "Do Not Resuscitate" order.
By definition, dementia is terminal, degenerative disease. Seniors stricken with dementia no longer recognize family members, can no longer walk, bedridden, with an inability to feed themselves or communicate with others. Many victims of dementia also face swallowing issues, and the mortality rate within six months is high.
Yet, the study revealed that over 54% of patients received at least one medication considered "of questionable benefit." The types of drugs given to these patients are considered never appropriate for palliative care patients with advanced dementia. Even with patients that have mild to moderate dementia these drugs only bring small improvements to cognitive abilities but the clinical significance is uncertain.
Effects on Elderly Patients
If the only problem with giving these patients unnecessary medications was cost, averaged at around $816 per person per quarter, this study would be less of an issue. However, that is not the case. There is also a personal cost to administering these medications to patients with advanced dementia or near death.
Two of the most commonly overprescribed medications are known to cause nausea, fainting, and uncomfortable urinary retention. They can also cause heart arrhythmia, which can lead to implanting a pacemaker. People with severe dementia are more likely than seniors with normal cognition to receive pacemakers.
People with advanced dementia cannot verbalize to their family members or doctors the pain or discomfort that they may be feeling. And when they lash out, it can cause another round of medication to be administered instead of signaling that something is wrong. Discontinuing the drugs can help patients remain alert and relaxed; however, there is no published research either way.
Reasons for Overmedication
There are a variety of reasons why advanced dementia patients are continuing to be overmedicated in nursing homes. Geography plays a role in some of the decision making. Geographic areas like Mid Atlantic and South prescribed more often than in other areas. In addition, nursing homes, hospitals, cities, and regions have their own culture and practice patterns that lend more to overprescribing these drugs.
Emotions play a large part, too. Family members try to do everything for their ailing loved one and that includes giving them every drug despite warnings from professionals. Stopping medication is a fairly radical concept for many people, despite the full blown campaign asking people to weigh the pluses and minuses of continuous medication.
A new study shows that many sick elderly people, with advanced dementia or near death, are still being prescribed drugs that cause uncomfortable side effects or adverse reactions. The question among doctors is how sick and disabled, how far into dementia, how close to death, must a nursing home patient be before stopping drugs that cause these unfortunate side effects but show scant evidence of actually helping?
A large scale study recently published by The Gerontologist looked at the effects of the fuzzy concept, resilience, and how it impacts the lives of seniors. The surprising results of the study showed that this intangible concept can have a major effect on aging seniors' lives.
What is Resilience?
Resilience is a concept that is difficult to define. The study's lead author described resilience as "how people manage adversity and hardship over the life course." As one U.S. Supreme Court Justice once said about pornography, we know it when we see it.
The effects of resilience are easy to point out. Many elderly people deal with illness or loss in their later years. Some withdraw into isolation and inactivity even though they physically remain strong. However, others maintain a bright and sunny attitude despite the challenges, and they continue to be active physically as well as socially. Age, health, and finances cannot fully explain the differences in people, and the study focused on how that intangible, resilience, plays a role.
The Gerontologist Study
Scientists have been discussing and studying the concept of resilience for years. In this latest study, 10,753 people at an average age of 69 were drawn from three waves of the National Health and Retirement Study. The team of researchers created twelve items and asked each participant to rate the statement on a scale based on how strongly they agreed or disagreed.
These statements included things like "when I really want to do something, I usually find a way to succeed at it," and "I have a sense of direction and purpose in life." The study also included statements like, "if something can go wrong for me, it will," and "there is really no way I can solve the problems I have."
Over the course of two years, eleven percent of the participants developed a new chronic condition, yet the higher that the person scored on the resilience scale the less likely this new ailment disabled them. The study found that most of the seniors developed their resilience and ability to negotiate obstacles by overcoming tough experiences in their lives.
Effects of Resilience
The study looked at participants' ability to do daily living activities. It found that when a new ailment or challenge struck, those with the least amount of resilience had three times the amount of daily living activity disabilities than the most resilient seniors. The effects of resilience seem to create a "moderating effect" in seniors' lives. Even among the youngest participants in the group, when a new illness hit the amount of daily living activity disabilities among the least resilient were two times as many as the most resilient. The seniors with the most resilience are able to bounce back better and faster than those with less resilience. They are able to maintain function better and for a longer period of time.
Other Intangible Studies
Resilience is not the only amorphous concept being studied by researchers. Other reports that have been published show that a sense of purpose correlates to a lower rate of Alzheimer's disease, and volunteering in schools is linked to better cognitive ability.
Even the concept of religiosity, regardless of what specific religion, appears to help lower rates of depression and certain physiological problems. Self-efficacy, mastery, and gratitude have all also been shown to have real world effects on the lives of seniors, and it's becoming clear that health in old age is more than just medication and exercise.
While more people are beginning to draft estate planning documents like a will, trusts, and power of attorney forms they forget that estate planning can also be utilized to make more immediate changes in your life. One of the biggest changes that people in retirement go through is downsizing their home and belongings from a large, family-sized home to something smaller. The following includes tips that you and your loved ones can use to make the process of downsizing easier and more efficient.
Reasons to Downsize
There are many reasons why people in retirement choose to downsize. Some couples realize that they no longer need such a large home once all of their children are grown. Others wish to save money in retirement and move to reduce bills or eliminate a mortgage. Many more downsize because one or both spouses are in declining health and want to live closer to family, medical professionals, and have services included in their new home (maintenance, lawn care, etc.) to alleviate the amount of work that needs to be done.
Tips for Downsizing
· Plan Ahead of Time
Downsizing can take a long time, so planning ahead can take a lot of stress out of the experience. Take time to think about the lack of storage space going from a large home to a smaller one, or how you can take advantage of what space there is to organize what you want to keep.
· Scan It and Digitize It
Scanning all important documents like diplomas, pictures, and certificates can allow you to keep these important items without taking up wall space. After scanning and digitizing the items you can send them to family members, keep them on a hard drive, or put them on an internet cloud like Dropbox. The originals can be taken down, the frames sold, items stored in a book, and they can be reprinted by anyone from the digital form.
· Give Away to Family
Everyone has a lot more stuff than they think, and attempting to downsize from a larger home to a smaller one can really illustrate that fact. When getting rid of all of the unnecessary stuff, give your children and extended family first dibs on what they want. That way some of your belongings will remain with the family before giving the rest away.
· Give Away to Charity
If you still have a lot to get rid of consider about giving it to a worthy charity. Habitat for Humanity, Goodwill, the Salvation Army, and other charities are in constant need of furniture, home goods, clothing, and more to help others.
· Consider One Floor Living
If one or both spouses are facing a chronic illness, or just to combat the process of aging, consider living in a one floor home. Look for even floor surfaces without steps or sills between rooms to reduce the chances of tripping and falling.
· Consider Accessibility
This area goes beyond wheelchair accessibility. Make sure there is room to place stools, chairs, and benches around the home and in the bathroom. Also look to see if the garbage drop-off is nearby or included in concierge services.
· Ask About Concierge Services
Any services that are included in your new place mean that there is less that you have to do. Ask about whether there is maintenance, lawn care, housekeeping, security, and similar services for your new place.
· Automate It
Consider automating as much of your new place as possible when downsizing. Systems can be installed that easily controls the lighting, temperature, security, garage doors, and even the stove. In addition, bills can be automated as well to eliminate the need to remember to pay every month.
For the last four years, doctors, pharmacies, and medical clinics have all offered seniors a higher dose version of the annual flu shot. At the time that the vaccine was released the science was lacking but the hope from medical professionals was that the higher dosage would provide better protection for the elderly. Now, the first studies on this version of the flu shot are in, and the results are looking positive.
Higher Dose Flu Shot
The annual flu shot for seniors, known as Fluzone High-Dose, contains up to four times the amount of antigen found in the typical flu shot. Antigens are chemicals within the shot that stimulate the immune system. Previous research has shown that the increased antigens in the Fluzone produced a greater antibody reaction in seniors. This is significant because as the body ages the immune system becomes less effective.
When Fluzone High-Dose was approved by the FDA in 2009, the administration also asked for further testing to provide more rigorous proof of effectiveness for seniors, specifically for those ages 65 and older. The organization wanted proof that the higher dosage reduced the number of flu cases in the elderly. Since releasing the vaccine in 2009, the manufacturer of Fluzone has distributed nearly 21 million doses of the vaccine, and between eight to ten million more doses are expected to be delivered this season.
Flu Shot Study
The most recent study was published in the New England Journal of Medicine, and researchers have found that the higher dose flu shot had reduced cases of flu in the elderly by twenty-four percent when compared with the normal dosage. Scientists worked with the manufacturer of Fluzone to compare the number of flu cases reported from seniors with the higher dose vaccination and seniors who received the normal dose.
The result was a statistically significant difference between the two groups, with seniors taking the typical vaccine getting the flu more often than those taking the higher dose. These results have led experts to continue their research on flu shot vaccines. The next big task is to compare how often seniors get the flu after being vaccinated with a high dosage shot and seniors who get no flu shot at all.
Importance of Flu Shots
Experts believe that the standard flu vaccine prevents the illness around 50% of the time in older adults; however, that figure is old and more recent research has not been done on the topic. In 2012-13, the Centers for Disease Control found that the standard flu vaccine was effective for adults ages 65 and older around 27% of the time. In the 2013-14, the effectiveness for the same age group was closer to fifty percent.
Because seniors' immune systems worsen with age, it is incredibly important to receive a flu shot every year. Medicare covers one shot of Fluzone per year, but the cost of one shot is only $28.65 per dose. The Centers for Disease Control encourages seniors to get the higher dose flu shot when they can. There have been no reports of unusual side effects from the vaccine, and all studies point to this option being more effective for older adults.
Only one-fifth of all 15,000 nursing homes in the nation hold the distinction of a five star rating by the Medicare system, but an examination into the process has found that many top ranked nursing homes have been given their rating due to incomplete information regarding the conditions at their homes. This misinformation has an effect on the facilities' residents, potential consumers, and investors regarding the communities.
Medicare Nursing Home Ratings
The Medicare ratings system is considered one of the best ways to evaluate nursing homes in the country. When nurses and doctors discharge patients from the hospital, they often use the ratings in referral decisions. Insurers also look at the ratings when creating preferred insurance networks. Medicare ratings are also the first metric that investors and lenders look at when deciding whether a nursing home is a safe bet.
However, these ratings are accumulated through self-reported data given by the facilities that the government does not verify. In fact, only one of the three main criteria for rating a nursing home, the result of the annual health inspection, is verified by an independent source. Other criteria such as staff levels and quality statistics are reported by the nursing homes and accepted by Medicare at face value.
In addition, the Medicare ratings system does not take into account a variety of negative factors and information about the nursing home communities. Fines, enforcement actions by the state, and complaints filed against the facilities are not factored into the ratings system.
Gaming the System
Many nursing homes are now taking advantage of the rampant self-reporting and using it to their advantage in order to raise their rating in the Medicare system. Nationally, the number of nursing homes with above-average ratings has risen steadily. In 2009, around 37% had above-average marks, and by 2013 that percentage was closer to half.
Even nursing homes that have a history of poor care rate highly in the areas that rely on self-reporting. Of the more than fifty nursing homes in the country on a federal watch list for quality, nearly two-thirds of those communities have four or five star ratings in the Medicare system for self-reported staff levels and quality metrics. The worst facilities in the country can still self-report that their quality is the best while simultaneously being on watch lists for failing state health inspections.
Using the System as an Elder Care Resource
Some advocates agree that the current Medicare ratings system is the best option available, but other experts believe that the ratings are so inflated their only remaining purpose is to weed out the worst homes. A provision in the Affordable Care Act requires that Medicare use payroll data in order to ensure that nursing homes are not padding their staffing around inspections to receive a better rating, but Medicare has not implanted the system yet. The agency has said that it is still working on the verification system and hopes to have it running soon.
Until a better ratings system is introduced, experts encourage people looking into nursing home care to do their research and rely on more than just the Medicare rating. Check annual health inspection records, visit the facilities multiple times, talk to residents, and make sure that you are getting the true picture of the place before making a decision.
Elderly couples are divorcing at a higher rate than ever before for a surprising reason: soaring medical and long-term care costs. These expenses are being aggravated by longevity and uninsured risk from a lack of long-term care insurance. Although these senior couples still care for each other very much, the cost savings from divorce are inflicting the least amount of damage when compared to other financial options.
Medicare and Medicaid
Seniors are now turning to divorce to stave off financial ruin trying to qualify for Medicare and Medicaid coverage. In terms of Medicare coverage, the program only covers 100 days of nursing care. If you or your spouse needs long-term nursing care you must either pay out of pocket until your assets fall beneath a certain threshold or tap into your long-term care insurance if you have it.
If you do not have long-term care insurance, you must pay out of pocket as a couple until your assets are spent down and Medicaid steps in as a last resort. If you're married, all liquid assets must be tapped regardless of which spouse's name is listed on the asset. However, once Medicaid steps in the spouse is guaranteed care for the remainder of his or her life.
Divorce as a Financial Option
The divorce rate for seniors has doubled since 1990, and now over 28% of people divorced in the last year were over the age of fifty. According to the Census Bureau American Community Survey, in 2011 a total of 15.4% of seniors were divorced and another two percent were separated. There are a number of reasons behind the rising divorce rate, but one of the main causes cited was an increase in long-term health costs.
Considering divorce as a cost-saving option can be an emotionally fraught issue for loving couples. For the healthy spouse, it can feel profoundly wrong or immoral to divorce an ailing spouse despite the good intentions behind the decision. However, it is important to remember that a paper divorce does not mean that the healthy spouse is any less present in the ailing spouse's life.
An Example of Elderly Divorce
Take for example the hypothetical situation of an elderly couple, married but with separate assets and dealing with the ailing health of one spouse. For years, they have engaged caregivers to help, but now the costs are reaching over $3,000 per month for care. The ailing wife's resources are completely depleted, and the husband's separate assets are dwindling as he pays for her care.
For this couple, one of the best options for her care and his assets would be to get a paper divorce. With her assets depleted, the ailing wife will qualify for Medicaid, and his resources will remain intact in case he requires care in the future. If they remain married, he will be forced to continue to spend his assets on her care until they are both left with nothing, and he will have very little to cover his own living expenses or future care.
A paper divorce does not interfere with his responsibilities for her, and he can still oversee and coordinate her care through the use of a healthcare proxy and power of attorney. While the husband may feel like he is betraying his wife and taking advantage of the system, he also realizes the logic of divorce and how the decision is the best for both of their interests and long term care.
The Centers for Medicare and Medicaid Services says that it reviews more than 100,000 complaints and appeals every year. Beneficiaries of the programs file around 16,000 complaints relating to hospital care and discharge orders as well as 18,000 complaints against nursing homes, home health services, and hospice programs. Another 30,000 complaints and appeals are specifically geared towards the Medicare Advantage programs. How Medicare handles its complaint and appeals process is no trivial matter, and the program has recently revised its complaint process.
Updated Medicare Complaint Process
On August 1, Medicare made a change to its complaint filing system: it added new, toll-free numbers to call to lodge a complaint. The new phone numbers represent a larger change in the Medicare complaint system. Each state used to have a quality improvement organization, or Q.I.O. Up until August 1, these organizations worked with providers on issues like hospital readmissions or preventing infections, reviewed beneficiary complaints, and expedited appeals.
However, experts saw a major conflict of interest issue with the Q.I.Os - could an organization that advised providers also be able to fairly review complaints against them? In order to prevent any perception of bias, Medicare has set up a new system to handle complaints. Now, complaints and appeals go to two large regional contractors known as Beneficiary and Family-Centered Care Quality Improvement Organizations, or B.F.C.C. Q.I.Os.
One of the main goals of the new system is to transition seamlessly for the beneficiaries. The only difference is that there is a new number to call. However, finding that new number and accessing the information about the new system is not as easy as Medicare would have you believe.
How to Find the Information
Some Medicare beneficiaries have received the new phone numbers when visiting a hospital or through their nursing home service, but many other providers have not informed their beneficiaries of the change. If you have the old number, dialing it will automatically redirect you to one of the new regional contractors. But what if you do not have the number, or have never called in a complaint to Medicare before?
There are a couple of different resources available to help you find the new information regarding Medicare complaints and appeals, but you must know where to look in order to find it. If you are looking for the new phone numbers in the Medicare.gov website you must first go to the Medicare Helpful Contacts Page, look down the "select an organization" menu for "Quality Improvement Organization (Beneficiary and Family Centered Care)," then enter your state.
Another way to find the new information is to look at the state by state guide provided by the United Hospital Fund. The organization has posted the correct phone number for each state because it was concerned about the number of Medicare beneficiaries that did not know about or how to access the new phone numbers for the program. The concern is justified because there is a limited deadline for certain types of Medicare appeals, and people can be affected by this change in real time.
When Medicare was expanded in 2003, the expansion that established prescription drug coverage was called a "promise, a solemn promise, to America's seniors." Part D Medicare officially took effect in 2006, but still some seniors were afraid of falling into the infamous "doughnut-hole" coverage gap.
Initial Benefits of Part D
In Part D's first few years, national data has shown that the program had helped seniors make progress with their prescription drugs. Overall, out of pocket costs decreased for medication, seniors took their medication more regularly, and were less likely to forego basics like food or heat in order to afford for their prescriptions.
One study recently published by the Harvard Medical School and University of Massachusetts shows that people who are more ill and need more medications are having significant problems with Part D Medicare. In 2005, before the beginning of Part D nearly fifteen percent of Medicare beneficiaries admitted that they would stop taking their medication, skipped or reduced dosages, or delayed refills for cost reasons. However, after the advent of Part D, the percentage of seniors engaged in this practice decreased down to nearly ten percent.
Similarly, the same pattern emerged when it came to forgoing basic needs, like food or heat, to pay for prescription drugs. In 2005, nine percent reported engaging in this practice, and after Part D the number dropped to four percent. But in the last three years the number of senior beneficiaries for Part D has once again started to skip their medications and sacrifice basic needs for their prescription drugs.
New Trends in Part D Care
In the last three years, the percentage of seniors engaged in risky medication practices or giving up basic needs in order to afford their medication is rising back up towards pre-Part D levels. In 2011, the number of seniors who would stop taking their medications or skip dosages increased back to 10.8%, and the percentage of people foregoing basic needs increased back up to 5.3%.
An even more disturbing trend is that the affordability of medication has eroded the most for the elderly that have the greatest needs. For Part D beneficiaries that have four or more chronic conditions like heart disease, hypertension, diabetes, stroke, cancer, pulmonary disease, and similar issues the percentage of seniors participating in risky medication habits or sacrificing basic needs has almost reached pre-Part D levels.
Eroding Gains in Part D Care
There are a few reasons why the gains are no longer as great for Part D Medicare. For seniors with multiple chronic issues, the co-pay costs of multiple medications can begin to add up. People with fixed incomes can struggle to pay bills and the costs of medication. These seniors are also the most likely to fall into the "doughnut hole" of coverage until it closes in 2020 through the Affordable Care Act.
Another reason for the decline in Part D gains are the changes being made within Medicare plans. Part D plans are covering fewer medications every year. In addition, Part D plans have also been implementing tier strategies for certain medications, requiring pre-authorization from doctors, and placing other restrictions on plans that make it more difficult to get the medication
that seniors need.
At the annual meeting of the American Association for Geriatric Psychiatry, researchers presented a study that showed that older adults contemplating suicide do not cite depression as the primary reason. More often, seniors blame their struggles with illness, disability, financial concerns, family difficulties, and bereavement for their suicidal thoughts. While many of these factors may contribute to depression, the findings are that treating depression alone may not be enough to curb the rates of senior suicide.
Suicide Rates Among the Elderly
In 2011, a total of 39,518 suicides were reported in the United States, making it the tenth most common cause of death in our country. The age group with the second highest rate of suicide, 16.9 people for every 100,000, occur in people ages eighty-five or older. Researchers believe that the number of elderly suicides is actually much higher because many senior suicides go unreported. With such a stigma surrounding suicide many coroners will go out of their way to label a senior's suicide as something else. For example, in many cases of suicide via overdose most are labeled as an accident.
The suicide rates for elderly men continue to climb even as screening and prevention techniques improve. After the age of sixty the suicide rate for women decreases dramatically, but the rate among men keeps climbing. Elderly white men have the highest rate of suicide with 29 deaths per 100,000 people, and white men over the age of 85 have a staggering suicide rate of 47 people per 100,000.
Past Research on Elderly Suicide
Previous research suggested that as many as 87% of all seniors who committed suicide suffered from major depression before choosing to end their lives. However, those statistics were drawn from research on elderly people after they had actually committed suicide. The newest research presented at this year's meeting focused instead on living seniors who had acknowledged suicidal thoughts but chose not to follow through.
New Research on Senior Suicide Rates
This new study asked seniors exactly what they were thinking about when considering suicide, rather than relying on retrospective analysis to understand the seniors' mental states. In this study, seniors were screened for symptoms of depression, and one question asked about whether or not the senior had considered suicide or had suicidal thoughts in the previous two weeks. To those elderly participants that responded yes to that question, those that were willing to follow up answered more questions regarding their state of mind.
Researchers then tallied the reasons for the seniors' despair and the results were quite different from previous studies. Around seventy-five percent of seniors cited illness, financial concerns, pain, family difficulties, bereavement, or other problems as reasons for their suicidal thoughts. Depression was cited as a reason for only one quarter of the participants in the study.
The researchers also asked why these seniors decided not to take their own lives. The majority of seniors cited family relationships as the main answer. Another significant portion cited their faith as why they had chosen not to commit suicide. The results of the study show that focusing on the treatment of depression alone is not enough to deter many seniors who have thoughts of suicide and that context is needed to properly treat those in need.
The Jewish Home Lifecare nursing home is starting a new program later this month geared towards patients suffering from both elderly ills and addiction issues. This unusual rehabilitation program is the first of its kind in the country. Traditionally, nursing home patients that have the complication of alcohol or prescription pill addiction are considered "undesirable admissions" and have been a population that nursing home communities have shied away from.
Why Elderly Addiction is Dangerous
Elderly adults often have addiction issues that go unnoticed. It can stem from a lifetime of drug and alcohol abuse or come from a recent misuse of doctor prescribed pharmaceutical drugs. Alcohol abuse can be particularly dangerous because as a body ages it metabolizes alcohol differently. In addition, it can cause serious interactions with any medications that a senior may be taking. A general stigma surrounding the subject also prevents people from discussing the mental illness in the elderly that can come with substance abuse.
The Nursing Home Rehabilitation Program
This program will deal specifically with patients suffering from alcohol or prescription drug addiction. The nursing home decided that until the program is more developed it will not admit seniors with addictions to illegal street drugs. Jewish Home Lifecare hired a director and procured multiple grants to set aside forty beds in the nursing home for these patients. The facility hopes to treat as many as 480 addicted seniors per year. Medicare and Medicaid are expected to cover the costs of the program.
The elderly participants will get a thorough screening, individual and group therapy, participate in a twelve step program, and get counseling to prevent relapses. When they are ready to leave the facility, the nursing home will connect them with community programs and professionals to aid in the continuation of their recovery.
Challenges to the Program
The first question most skeptics have about the program is whether a twenty-five day stay is long enough to make progress? The director of the program believes that if the patient seeks outside community programs and help that the program will be long enough. Another major issue is family support. Some families are convinced that their loved one is simply too old to change their ways and as a result the family can be obstructive or indifferent to the treatment program.
One of the largest questions is how to treat seniors suffering from addiction while simultaneously helping them recover from other elderly ills, most of which require some level of pain management. Steve Wollman, the director of the new rehab program, has few illusions about the task. He has discussed the strategies necessary to wean seniors off of certain addictive substances while still treating their pain from other ailments. He has also talked about the additional training that the staff will need to deal with these issues.
Denial and evasion are the two most commonly seen tactics used by addicted seniors. If they are newly addicted they do not believe that they have a problem, or they think that because their doctor prescribed the medication it is okay. Seniors suffering from long-term addiction often have multiple doctors and pharmacies where they get their drugs, and most of the time the doctors are unaware that their patient is getting multiple prescriptions. But regardless of age, Mr. Wollman believes that anyone can recover from alcohol and prescription drug addiction if they want to and have the guidance.
With the name "nursing home" most people assume that registered nurses are always on the premises. However, some of the time that is not the case and in certain nursing home facilities, most of the time. This is because of an old law from 1987, and lawmakers today are attempting to rectify the situation.
Old Registered Nurses Law
In 1987, a federal law was enacted that required registered nurses to only be on-site at nursing homes for eight hours per day. This rules applied regardless of the size of the facility. Supporters of the law at the time realized that in a building of sick and ailing elders a health crisis could arise at any time, but the legislation required compromises to be passed that included reducing registered nursing hours.
Since the passing of that law, certain legislators have been working to increase the number of hours that registered nurses should be required to be on-site at nursing home facilities. Most feel that their constituents would be shocked to learn that their loved ones are only cared for by registered nurses a fraction of the time.
Proposed Registered Nurses Law
Representative Jan Schakowsky, a Democrat from Illinois, was completely shocked when she learned of the few hours required by registered nurses in nursing home facilities. As a result, on July 31st she introduced a bill bluntly entitled "Put a Registered Nurse in the Nursing Home Act," otherwise known as House Vote 5373. This law would require that a direct-care registered nurse, not an administrator, be present in a nursing home facility 24 hours per day, seven days a week. It would apply to all 16,000 nursing home facilities across the country that receives Medicare or Medicaid reimbursement.
Implications of the New Law
It is difficult to determine how many nursing home facilities would be affected by the new law. Thirteen states already have some level of requirement for registered nurses to be on staff 24 hours per day. In Tennessee, Rhode Island, Hawaii, and Connecticut the rule is absolute. However, in other states like California the rule only applies to nursing homes that have more than 100 beds. There is little published research on this subject, but some experts believe that around eleven percent of all nursing homes around the country do not have the current staff to support 24 hour care.
Necessity for Registered Nurses
The new law specifies registered nurses for a reason. Unlike licensed practical nurses or aides, registered nurses are trained and licensed to evaluate a patient's care and conduct assessments when rapid condition changes occur. Multiple studies have proven the importance of registered nurses in nursing home communities. When more registered nurses are staffed, patients have fewer bed sores, urinary tract infections, and catheterizations. Patients also stay out of hospitals longer, the nursing homes get fewer serious deficiencies from state inspectors, and cares improves but costs less.
Registered nurses also do not come as a large expense. The average salary for a registered nurse is around $68,000 per year. However, rural nursing home facilities worry about finding enough nurses when they typically prefer working for higher pay in urban or suburban hospitals. Adding registered nurses all day in nursing homes will not solve every problem, but it is a great start to improving the overall quality of care for every nursing home resident across the country.
Whether it is moving to a retirement community, nursing home facility, or simply closer to the kids the changes associated with moving an elderly parent or relative can be fraught with stress and logistically challenging. There are few transitions in life more difficult for a person than when a senior needs to give up their home and independence. Giving up a house and friends of many years is an emotional and difficult experience for everyone involved.
Easing the Transition
There are many different ways to ease the transition for your loved one, but the most important is giving the older adult the opportunity to make their own choices about the decision. In addition, planning ahead for this type of transition is also a big help for everyone involved. Making plans early, instead of waiting for an emergency to hit, goes a long way in minimizing the stress for everyone.
Initiating these types of discussions can take a lot of effort, and the reluctance to talk can cut both ways. Of course, some elderly parents simply refuse to discuss the idea of losing their independence at all, and it is not difficult to see why. The best way to deal with a situation like this is to explain that the reason why the talk needs to happen is because you value their input as your parent or elderly loved one.
Making a Plan
Some seniors take issue when their children say that they want their input for this type of decision. Seeking input can sometimes be misconstrued as saying that the child has the final say in their parent's independence and living arrangements. Another way to approach the situation is to tell your loved one that you want to carry out their wishes as best as you possibly can.
The adult children also need to sit down and discuss the plan amongst each other. Families need to sit down and discuss who will play what role in the transition. You need to decide who will help with the move, help with the finances, and who can visit when. The children should also do the majority of the legwork in seeking out homes, retirement communities, or nursing home facilities for their parent to choose from.
During and After the Move
When it comes time for the actual move to occur, make sure that your senior loved one is still involved in the decision making process. Make sure that they have a say in what furniture and other personal belongings will be coming with them. If help is needed, there are a number of companies that help with senior moves, including the National Association of Senior Move Managers.
Another way to ease the transition during and after the move is to have the new home or living space completely unpacked before the first night, making the new space as homey as possible. In addition, try to spend as much time as possible with your elderly loved one in their new space over the next few weeks until they get acclimated with their new living arrangements. By following these tips, hopefully you and your elderly loved one can make the transition with as little stress as possible.
The California Supreme Court ruled that people suffering from Alzheimer's disease are not liable for injuries that they may cause to paid, in-home caregivers. The court ruled in favor of a couple sued by their in-home caregiver when she was hurt by the wife, who suffers from Alzheimer's disease.
Facts of the Case
In the California case, Gregory v. Cott, the facts were undisputed. In 2005, Bernard Cott hired Ms. Gregory as a paid, in-house nurse to help care for his wife, Lorraine, who was suffering from Alzheimer's disease. Ms. Gregory had worked with other Alzheimer's patients in the past and was specifically warned that Ms. Cott could be combative by biting, scratching, flailing, and kicking.
In 2008, when Ms. Gregory was washing dishes Ms. Cott came up behind her at the sink and bumped into her. As Ms. Gregory tried to restrain Ms. Cott she dropped the knife that she had been washing, striking her in the wrist, and ultimately causing her to lose feeling in multiple fingers. Ms. Gregory received workers' compensation for her injuries, but she also sued the Cotts for negligence, premises liability, and battery specifically against Ms. Cott.
The Court's Ruling
The California Supreme Court ruled 5-2 that people hired to take care of Alzheimer's patients should know that the disease commonly causes aggression and agitation in later stages. The court concluded that it would therefore be inappropriate to allow in-home caregivers who get hurt while caring for Alzheimer's patients to sue their employers.
Writing for the majority, Judge Carole Corrigan stated that "It is a settled principle that those hired to manage a hazardous condition may not sue their clients for injuries caused by the very risks they were retained to confront." However, the two dissenting judges argued that it was unfair to bar private caregivers from suing because of the dangers of their work. They unsuccessfully argued that the families of people suffering from Alzheimer's should bear the responsibility and "weigh the benefits of in-home care against the costs that it may impose on others."
The law in California and other states already prohibits caregivers in institutional settings like hospitals and nursing homes from suing Alzheimer's patients that injure them. The court concluded that by applying a different standard to in-home caregivers the families would only be benefitted financially by putting their loved one in a nursing home.
Effects of the Ruling
The effects of the case in California have far reaching implications across the country. The California Supreme Court case can now be cited by other families of Alzheimer patients who have injured their in-home caregiver and are facing repercussions. With the growing number of seniors and elderly people who are developing symptoms of Alzheimer's this case serves as protection for those suffering from the disease as well as their families.
However, there are limits on the ruling in the Cott case. It does not preclude future lawsuits by private caregivers who are not warned in advance that the patient could be violent and are injured as a result. In addition, in-home caregivers who are injured by their clients when it is not related to Alzheimer's disease are also still allowed to file claims for damages.
One of the most confusing aspects of the Medicaid program is the look back period for asset transfers and how it can affect the eligibility for applicants to the program. The Medicaid program is different than the Medicare program, although people often think of the two terms as interchangeable. Medicare is an entitlement program paid for through withholdings in paychecks. Medicaid is a social welfare program designed for people who need medical care and cannot afford it. Medicaid is administered by each state, which means that the rules and benefits can vary from place to place.
The Medicaid program goes into effect once a person no longer has the money to pay for medical care on their own. This means that as long as you have assets that you can sell you are not eligible for the Medicaid program. Long-term planning can protect some portion of savings and assets for a spouse or children while still allowing you to qualify for Medicaid coverage. One way to keep assets and still qualify is to transfer assets to family before applying to the Medicaid program, but you must beware of the Medicaid look back period.
Medicaid Look Back Period
When you apply for Medicaid, the program looks back five years (sixty months) from the date of the application for any transfers of gifts or assets. Any gifts or transfers made within the five year window are subject to penalties under the Medicaid program, but any transfers made outside of that window are safe.
For example, if you made gifts of a few thousand dollars to your child over the last three years each gift would be subject to a penalty under Medicaid. This is why long-term planning for Medicaid is so important and should be done long before the need to apply for Medicaid arises.
Consequences of the Look Back Period
The penalty for transferring assets within the five year window can be very harsh. Typically, a person is barred from the Medicaid program for the amount of time that the assets transferred would have paid for care. The penalty period is measured by dividing the value of the asset transferred by what Medicaid determines to be the average cost of care for a private nursing home in your state. There is no set limit for how long a person can be barred from Medicaid coverage due to gift or asset transfers.
The rules do allow for an escape hatch from the penalties incurred by transferring assets within the five year look back period. The penalty is considered "cured" if the transferred asset is returned in its entirety. Some states will also allow a partial reduction in penalties if part of the asset is returned; however, not all states allow partial returns and your state's rules should be examined first.
Exceptions to the Look Back Period Rules
Certain assets and gifts do not apply for the Medicaid look back period rules. Therefore, if transfers are made to these people within the five year window you are still eligible for the Medicaid program. These exceptions include the following:
· A spouse (or for a spouse's benefit)
· A blind or disabled child
· Trust for the benefit of a blind or disabled child
· Trust for the sole benefit of a disabled person under the age of 65
Special exceptions also apply for the transfer of an applicant's home within the window, but the transfer can only be to specific people within the family. These people include the spouse, disabled child, a trust for a disabled child, a sibling, or a caretaker child who meets certain qualifications for the role.
One of the main topics of conversation among the Baby Boomer generation is caring for their aging parents. One of the benefits of increasing medical technology is that our elders are living longer lives. However, one of the detriments of providing this type of long-term care is affording it. Arguably one of the biggest concerns about long-term care for elderly parents is cost and what to do when the money runs out.
Talking about affording parents' care is often seen as a taboo subject. People do not want to look like they are wishing that their parents' lives will end soon or that money is more important than family. But the truth is, the longer that parents live the more expensive it becomes. With six million Americans over the age of eighty-five, a number expected to hit fourteen million by 2040, the issue of affording parents' care is only going to increase with time.
Issues With Affording Parental Care
Every expert on the issue agrees that there is no one solution to affording the long-term costs of parents' care. The more complicated issue when dealing with this problem is trying to plan for the unknown. Financially planning for a child is much easier because you can predict the costs of education and care. But it is incredibly difficult to try and predict how long your parents will need money or for what kind of care, especially as the average lifespan continues to increase.
Recommendations for Planning the Costs of Care
One point that most experts agree on is that you need to put yourself first, and do not assume that you will need to tap into your own savings to deal with this problem. Even if it feels selfish, you need to consider your own needs and costs like retirement, children, education, and the like. Other tips for planning to afford parents' long-term care include:
Talk to your parents about your concerns
The sooner this discussion occurs the better off everyone will be. It gives your parents the opportunity to discuss their wishes and allows you to weigh them against the financial considerations.
Meet with professionals who can offer sound advice
An estate planning or elder law attorney can sit with you and your parents to discuss what options are available and how best to structure your assets to pay for elder care. Speaking with your parents' doctors can also give you an idea about what care will be needed down the road.
Look for money saving benefits for your parents
The government provides a wealth of information on this topic. Try looking at The National Council on Aging's BenefitsCheckUp.org, the federal Benefits.gov, or The U.S. Administration on Aging's Eldercare.gov
Improve your parents' financial situation
You can think creatively about ways to improve your parents' current financial situation. Consider getting a renter, moving to a smaller home, selling unwanted personal belongings, or looking into getting a reverse mortgage on the home.
When moving into long-term care, see if the cost is negotiable
Some nursing homes won't consider taking an applicant who is already on Medicaid because of the low returns by the government, but other facilities can be a lot more willing to negotiate the costs of care. Some places will agree to upfront payment for multiple months or years of care in exchange for a deal on long-term care later on.
Instead of paying outright for care, make it a loan
As an alternative to paying directly out of your own pocket for your parents' care you can structure it as a loan. The money can be repaid from the proceeds of the sale of the house upon your parent's death, or it can be taken from some other asset in the estate.