Assisted Living Focus Changing from Hospitality to Aging in Place

According to Senior Housing News, the assisted living industry is changing from a hospitality-based model to one incorporating more health care options to allow seniors to "age in place."  

The shift in operational strategy comes as more seniors indicate a preference for assisted living to moving in with family members.  Whether seniors want to avoid becoming burdens to their children,  want to avoid loss of autonomy many seniors believe follows moving in with family, or simply want to avoid the practical, financial, and legal challenges cohabitation presents, older adults seem to increasingly view assisted living as a better option than moving in with family members.

The shift in operational strategy coincides with an industry-wide effort to improve quality of care. As reported here, a January GAO Report raised serious questions regarding whether CMS could properly oversee and regulate the quality of assisted living care, in what some called "a national scandal."  The industry has reportedly responded with efforts to improve, maintain, and demonstrate quality outcomes.  The Long Term Care Community Coalition (LTCCC) recently released its own report identifying key best practices and policies for assisted living facilities to regulate their own operations, and ensure the safety and dignity of residents. The report lays out guidelines and requirements for staff training including cross training across multiple subject areas, establishing licensing and certification requirements where appropriate, allowing for alternative training methods, and required training assessments, LTCCC Executive Director Richard Mollot told Senior Housing News.  

Although there is still both risk and uncertainty for consumers, there is great promise for seniors and their families if the industry shifts its focus to meet the objectives of seniors, while simultaneously tightening operational standards.  Regardless the short-term outcome, the recognition and incorporation of Aging in Place as a discreet objective means that the industry is seeking to meet the goals and objectives of seniors and their families, rather than simply achieving bureaucratically imposed requirements of a health care system concerned primarily with cost containment.  An industry leading the government is a welcome and promising possibility.         

You can read more here.

New Alzheimer’s Vaccine Could Cut Cases In Half

Scientists at the University of Texas, Southwestern have created a DNA vaccine for Alzheimer’s.

It’s thought that the formulation could decrease cases by half.

The vaccine utilizes DNA from Alzheimer’s proteins, from which the immune system learns to fight the compounds and prevent them from collecting in the brain.

The researchers believe human trials are finally in sight.

Dr. Roger Rosenberg, Director of the Alzheimer’s Disease Center at UTS (and also the organization’s founder), said the breakthrough is the result of many years of trial-and-error:

“[It’s] the culmination of a decade of research that has repeatedly demonstrated that this vaccine can effectively and safely target in animal models what we think may cause Alzheimer’s disease.”

According to the Alzheimer’s Association, every 65 seconds, someone in the U.S. develops the disease. 1 in 3 senior citizens die with it or another form of dementia. 5.7 million Americans currently suffer from the terrible condition, for which there are noted risk factors but very little treatment. By 2050, that number is expected to reach nearly 14 million.

Seniors with Dementia Abandoned by Family Caregivers at Hospitals and Homeless Shelters

Jeremy Jojola, investigative reporter for Denver KUSA/9NEWS, has published a heart-wrenching story uncovering a horrifying, but all-too-common, practice of family caregivers abandoning seniors suffering from dementia by abandoning, and stranding  seniors in public airports, malls, hotels, hospitals, homeless centers, and in at least one instance, a local McDonald's.  Jojola described the plight of 80-year- old Jerry Ellingsen, who suffers from Alzheimer's:

Within the bustle and organized chaos of Denver's massive airport, an 80-year-old man with Alzheimer's disease named Jerry Ellingsen was found wandering alone after traveling with his small dog from Fort Myers, Florida. 

Jerry didn’t know where he was or why he was in Denver.

A United Airlines supervisor found Jerry confused and alone, with only a small dog, near an exit door outside the ticket counter, and promptly called the police.  A police report indicated a flight attendant described Jerry as possibly suffering from Alzheimer’s.  One Denver police officer spoke with Jerry, and noted in his report:

“He was very confused about general details of his life to include where he was at, where he was coming from, who he was coming to visit and his family members’ names."

Police looked up the woman who checked him into his flight, and ended up talking to his daughter.  Police soon learned that Jerry's daughter, who was his agent under a Power of Attorney, put him on the one-way flight from Fort Myers, Florida.  She intended for Jerry to live with his estranged wife, but had texted the estranged wife only the day before with a simple notification that Jerry, and his dog "will arrive on a flight in Denver tomorrow afternoon."  The daughter made no other arrangements to transport her father, or communicate with her father's estranged wife, until sometime after he arrived, and then only texted the estranged wife, "[i]f you need to drop my dad at a homeless shelter, it’s fine. I just want him to have a roof over his head. Please." 

Jerry's family refused to rescue Jerry so police transported Jerry to University of Colorado Hospital. Laws require hospitals to admit and keep at-risk adults who’ve been abandoned until caseworkers can find safe placement for them, which can lead to extended stays for months and even years.

Jerry’s story sparked a 9Wants to Know investigation into at-risk adults who end up languishing in hospitals because they have no family to take care of them, or a facility willing to take them in due to a lack of space, finances, or appropriate scope of care.  The investigators conducted a point-in-time survey with the help of the Colorado Hospital Association because hospitals do not keep track of stays by people like Jerry.  Investigator Jojola described what the investigation discovered:

A three-month long 9Wants to Know investigation is uncovering a growing health care epidemic where hundreds of people like Jerry are abandoned every year at metro-area hospitals. The epidemic is costing hospitals and in some cases, taxpayers, millions of dollars a year.

Nineteen metro area hospitals participated in the survey, which revealed on a single day in September, 113 at-risk adults were stuck in the system, beyond medical necessity.  Of those patients, about 30 percent had mental health issues like Alzheimer's and dementia. Most of the stranded people were men over 40 years old.  The longest stay was 577 days!  

According to the article, Denver Health has a special wing called the "Oasis Unit" that houses around 30 at-risk adults on any given day. Denver Health reports it expected to spend $18 million on the Oasis Unit in 2018.  Anecdotally, Denver Health officials cited a case that resulted in a stay of eight years in the Oasis Unit.  Tax payers and consumers end up bearing the cost.  Hospitals in Colorado can cost up to $2,500 per day, per patient. 

A Knoxville television station also broadcast a report about Jerry's case.  Both reports indicated that charges were unlikely to be filed against and member of Jerry's family. The video broadcast identified the daughter's name, who, ironically worked for a health care agency specializing in providing health care for seniors.  

Instances of professional caregivers abandoning patients and residents are well-documented (see, for example, here, here, and, see here, what is hopefully an usual case in which professional caregivers abandoned a couple, who were then later abandoned by a privately paid professional caregiver who had worked for the first professional caregiver).  Family abandonment is less well understood and documented.

Given the stress and strain of caregiving, and the feelings of helplessness and abandonment that caregivers often feel, it is possible that caregivers simply surrender, leaving their vulnerable wards at risk.  Regardless, the only solution is advanced planning, including considerations of the demands and risks of caregiving, and the costs of same.  Greater education and support for caregivers from the community is also well past due.   

Nursing Home Compare Does not Accurately Reflect Patient Safety In Nursing Homes

The standard measure for capturing quality at nursing homes does not paint an accurate picture of patient safety, and changes are needed to aid residents in their decision making, reports an article in McKnight's Long-term Care News.

That’s according to a new study, published in the November issue of Health Affairs. Researchers took a closer look at data from the Certification and Survey Provider Enhanced Reporter (CASPER) and the Nursing Home Compare archives, aiming to see if star ratings accurately represented potential safety dangers at SNFs.  The researchers compared nursing homes’ performance in standard quality measures with six noted patient safety measures — including pressure sores, infections, falls and medication errors. They noted that the relationship was weak between the two measures, “leaving consumers who care about patient safety with little guidance.”

Changes must be made to give potential residents a better sense of the safety landscape, said Daniel Brauner, an associate professor in the Department of Medicine at the University of Chicago and lead author of the study.  “Nursing home compare should look more specifically at these safety measures because consumers are quite concerned about those things, for their loved ones,” he told McKnight’s. “The rating system should take these specific safety measures more seriously and make them a bigger part of its methodology.”

Results were gathered using data for the first quarter of 2017 from NHC and CASPER, representing more than 15,600 facilities. They found that, overall, performance on falls and urinary tract infections for long-stay residents, along with pressure sores for short-stay, showed “little meaningful difference” across star ratings. Meanwhile, medication errors and pressure sores for long-stay residents tracked more closely with star ratings, though with a weak correlation.

At Death's Door- Shedding Light on How to Live

Kaiser Health News recently published a story about Ronni Bennett, a  popular blogger who writes about aging, a blog aptly entitled "Time Goes By- What its Really Like to Get Old."   The story highlight's Ms. Bennet's decision to write openly about living with her own recent terminal diagnosis.

At Death’s Door, Shedding Light On How To Live explores the impact of a terminal diagnosis on how one person decides to live the rest of her life and how she is coping with the diagnosis. Her blog posts are illuminating, poignant, and of course, heart wrenching.  She lists the things she no longer does, like regularly exercising, or finds concerning:

All kinds of things... fall away at just about the exact moment the doctor says, “there is no treatment” (which is their common expression for “you're terminal.)”At least, that is true for me and one of those things that fell away is any concern at all about what any person thinks about me in any regard. How others identify me is not my concern.

She continues in another post:

"I live in a different country now – the land of the terminally ill.  

 Isn't that a horrible phrase, “terminally ill.” It's too clinical, even industrial. It ignores the humanity of the life that will be extinguished and it sounds so imminent, as if I am already on the first bus out of here - a bus being driven, of course, by the grim reaper, hood in place and scythe in hand.

But that's not true of me. For awhile anyway, I've got some time. None of the doctors and nurses knows exactly how long in my case but, given some chemotherapy, six to eight months before symptoms begin to kick in has been mentioned.

Me? I take the prediction with some caution. The time could be shorter or it could be longer and since there is nothing I can do to affect the timing, the only rational choice for me is to carry on living.

Without, however, losing sight of the impending exit date. To ignore it would be absurd.

On the day I learned of my new status, some decisions came to me immediately. I've mentioned giving up the daily workout I've always despised, and now I get to eat all the ice cream and cheeses – my two favorite foods – as I want."

Bennet's posts have found positive responses from readers.  Still, the Kaiser article acknowledges that others may not prefer to share their lives with strangers:

"Other people may have very different perspectives as they take stock of their lives upon learning they have a terminal illness. Some may not want to share their innermost thoughts and feelings; others may do so willingly or if they feel other people really want to listen."

The blog is insightful and compelling.  

I have never before mentioned in this blog another of my favorites, The Blog, by Rory Feek.  Rory's blog, too, concerns life, and coping with a terminal illness, but more profoundly, it is about love.  My  wife and I were fans of husband and wife country music artists Joey and Rory Feek from the first time we watched them on the CMT talent show "Can You Duet."  We have purchased every CD, and I have combed over every line of prose and poetry germinated and nurtured by their love- love of life, love for each other, love for their children, love for their family and friends, and love of God.  Like millions we wept when Joey lost her battle with cervical  cancer. 

My eyes still well with tears when I see the song, "When I'm Gone," in my playlist, and am reminded of Rory's testimony of the song's impact on his life in the blog post entitled, aptly, "when I'm gone:"  

Our ‘make-believe‘ song and video seems to be coming true.
Some call it ‘life imitating art’.  I don’t.
I call it God.
He knew I would need her to tell me goodbye… not just once, but a thousand times.  And I’d need to know that no matter how much time passes, that she loves me still.  And He made it so that if I needed to be reminded of her beautiful life and heart and voice… she would only be a ‘click’ away.

While there are likely no words uttered from human lips, or written by human hands, that can guide entirely any individual in his or her own meeting with mortality, it is both comforting and inspiring that others share their insights and wisdom.  The rest of the great mystery is perhaps the province of the divine. 

LegalVault® Offers Solution to Estate Planning Challenges of Bitcoin and Cryptocurrencies

Cryptocurrency and blockchain technology are approaching mainstream, with more people appreciating the unique investment attributes of Bitcoin and other cryptocurrencies. Advisers  and owners, however, should be aware of the potential pitfalls these assets present in estate planning. 

Typically, an owner will want to ensure that these assets transfer appropriately upon death, but this desire must be balanced with the desire or need to retain control of the asset as long as is possible.  Like cash in hand, availability and access to cryptocurrency keys and passwords means the power to direct, spend, liquidate, or transfer the asset. Therefore, the challenge is in ensuring that one does not prematurely relinquish the keys to the  cryptocurrency.

When a person buys bitcoin, it’s associated with crypto-graphic public and private keys. The public key identifies that specific bitcoin and all of its transactions on the blockchain—a public ledger that records transactions on a network of decentralized computers across the world. The private key is the owner’s secret.  The private key proves ownership and authorizes transfers. The private key typically remains secret until the owner passes away, otherwise anyone could steal the cryptocurrency.  

Cryptocurrency can be held in online exchanges, software wallets or hardware wallets, each requiring a slightly different planning perspective. Hardware wallets are similar to USBs and an estate plan needs to spell out where the device is located and the necessary seed phrase. Cryptocurrencies other than bitcoin are becoming common and securing significant capitalization:

Each form and brand of cryptocurrency has unique features that require specific communication to and deployment by an owner's fiduciaries or family.

The challenge with most planning methods, such as software or hardware wallets is that the physical or virtual location must be provided to counsel and/or fiduciaries, otherwise the asset is inaccessible and may lost. The owner may not desire to provide this information to either, since access means the ability to direct funds. Physical wallets are also subject to risks such as loss, damage, or destruction, even if they are known and identifiable. If they are not known or identifiable by fiduciaries or counsel, even if working, they are useless to discover and direct assets.

LegalVault® is a great tool which allows you to safely and securely store your cryptocurrency's key, along with your health care and advance directives, and your estate planning documents.  The brilliance of the LegalVault® program is that each type of document or information is treated specifically for the discreet needs of the owner: health care directives are available to third party health care professionals during the owner's life; estate planning documents are available to the owner's fiduciary and legal counsel during the owner's life; but keys and passwords are inaccessible to everyone but the owner, and only become available upon the owner's death or permanent incompetency or incapacity. 

Even if an owner does not have a complete or comprehensive estate plan, LegalVault® provides a cryptocurrency owner the ability to safely and securely keep, store, and maintain passwords and keys, while providing an elegant solution to prior notification to the fiduciaries and counsel of the existence and location of, and access to, passwords and keys.    

Here’s how LegalVault® works when used by a cryptocurrency owner who has a comprehensive estate plan:

• Each  owner is given a secured LegalVault® account created specifically for the owner;
• Our firm, or your lawyer, uploads the image of the owner's health care and advanced directives to the owner's LegalVault® account;
• We immediately print a temporary Emergency Access Card, and LegalVault® shortly thereafter sends out a durable Emergency Access Wallet Card which contains instructions for healthcare providers on accessing healthcare-related documents online or via a 24/7 fax back service;
• Once an account has been created, the LegalVault® physician notification system sends a notice to the primary care provider informing him or her of this invaluable service and the storage of advance directives, ensuring that these important planning documents never fall to the back of a medical chart where they go unnoticed for weeks; 
• The owner controls what information is available to health care providers, and can quickly update the account with up-to-date documents or information (such as medications or allergies) from their home computer or smart phone;
• With the owner's permission, images of other estate planning and legal documents (Wills, Trusts, Powers of Attorney, Competency Directives, Rights of Sepulcher, Deeds, Contracts, etc.) are uploaded to the owner's LegalVault® account; 
• Owners can log in to their accounts to share other non-healthcare-related documents with our firm, or even upload copies of family keepsakes (photos, home videos, letters to children, family trees) to ensure these are safely secured and passed down to younger generations;
• Owners can keep or maintain important legal and financial records such as insurance policies, annuities, savings bonds, stock certificates, leases, contracts, and other instruments, potentially lost, stolen, discarded, or destroyed by third parties at a time of death or disability;
•  Owners can alert authorities of significant needs or concerns, such as "disabled child at home," "pets at home," or the like;
• A separate vault, inaccessible to legal counsel, inaccessible to other professional advisers, and inaccessible to family and friends, and accessible only to the owner, and an owner's executor, successor trustee, or personal representative upon the owner's death or incompetency, can store passwords, keys, and/or seed phrases to bitcoin or other cryptocurrencies, as well as other online investment and bank accounts, along with combinations and instructions for physical storage devices such as safes, lockers; storage units, and the like;
• Upon renewal of the LegalVault® account (every 3,5, or 7 years) updated documents are executed, ensuring that the documents and information are never out-of-date.

There is no limit to the storage space available for estate planning documents, pictures, letters, financial documents, and the like.  The cost of such a service is probably less than you might imagine. Contact us if you want to add this valuable service to your estate and/or financial plan. 

For more information regarding estate planning needs for bitcoin and cryptocurrencies, please consider the following excellent article: Angela Morris,  "With the Rise of Cryptocurrency, Estate Lawyers Caution that it Shouldn’t be Treated like any Other Asset," ABA Journal, November 2018.

Nursing Homes Unprepared for Natural Disasters

Although natural disasters are uncommon, like fires, blackouts, domestic and workplace violence, terrorism, and disease outbreaks, they are a foreseeable risk.  One hopes that particularly institutions responsible for caring for vulnerable groups like the sick, impaired,end elderly, would foresee these event and have contingency plans in place.  Not so, says Sen. Ron Wyden (D-OR), ranking member of the Senate Committee on Finance, who concluded nursing homes were woefully unprepared for natural disasters.  He made public his concern, and called for greater oversight in a recent report.

Wyden said hurricanes Harvey and Irma caused problems that were not accidents, including the well-reported deaths of 12 seniors at one facility. He called them “preventable tragedies that resulted from inadequate regulation and oversight, ineffective planning and communications protocols, and questionable decision-making by facility administrators.”

“My investigation found that in too many cases, nursing homes were ill-equipped to keep their residents comfortable and safe in the face of natural disasters, in some cases with fatal consequences,” he said in a statement. “This is a failure of responsible governing from top to bottom.”

The Democratic senator said that federal rules need to be “more robust and clear,” along with “dramatically” improving planning and communication between local and state officials, and nursing home leaders.  “Until changes are made, seniors in America’s nursing homes will continue to be at risk when disaster strikes,” he said.

In a lengthy statement, LeadingAge President and CEO Katie Smith Sloan acknowledged that the nursing home field shares senators’ concerns. She noted that the deaths of more than a dozen residents at a Hollywood Hills, FL, facility in 2017 “should never have happened."  "We make no apology for poor quality nursing home care. Errors should be addressed. Continual improvement is a must,” she said.

She noted that substantial changes were put into place in late 2017, as part of new Centers for Medicare & Medicaid Services (CMS) regulations, in response to concerns arising from hurricanes. She suggested that elected officials should wait for those new rules to take hold, along with speaking to nursing home leaders before enacting any further regulations.  “Room must be allowed for human judgment in emergency and disaster situations,” Smith Sloan said.

“Nobody entrusted with making the decision to evacuate or shelter in place takes it lightly. As we’ve seen, lives depend on leaders making the right decision — and learning from what happened before,” she said, later adding, “Let’s give the new system a chance to work.”

According to an article in Skilled Nursing News, in a separate statement, American Health Care Association (AHCA) President and CEO Mark Parkinson noted that the “vast majority” of long-term care facilities have successfully implemented their emergency response plans. The industry’s focus is learning from best-in-class operators.  “Unfortunately, this report largely focuses on isolated incidents with tragic outcomes where existing regulations were ignored,” he said.

Parkinson added that nursing homes and assisted living facilities “must be a priority” for power restoration and supplies in emergency situations. And systems must be put in place so that providers can work more closely with authorities when deciding whether to evacuate or shelter in place.

The report, entitled "Sheltering in Danger,"produced by minority staff of the Finance Committee, comes in response to hurricane-related deaths that followed Irma, along with incidents at Texas long-term care facilities after Harvey. It asserts that rules put in place by CMS are “wholly inadequate” when it comes to giving nursing homes direction in an emergency.

The report offers 18 recommendations that officials can take to help providers better prepare for such natural disasters.  The recommendations range from revising the safe and comfortable temperature standard, to highlighting the vulnerability of seniors in heat emergencies. A two-page summary of the report and its recommendations can be found here.

Eldercare Locator Service Gets Facelift

The Administration for Community Living ("ACL) announced the launch of its newly redesigned Eldercare Locator website. Located online at eldercare.acl.gov, the updated website makes it easier for older adults and their caregivers to find essential aging resources. Launched in 1991, the Eldercare Locator is a national information and referral resource providing support to consumers across the spectrum of issues affecting older Americans.

According to the announcement, new features include:

• A mobile-optimized design to easily access the Eldercare Locator on a computer, phone, or tablet;
• A geographical search bar allows visitors to search for local aging resources from any page on the site;
• Caregiver Corner with answers to the most frequently asked questions the Eldercare Locator Call Center receives from caregivers;
• A new “Learn More About” section that provides information on popular topics like transportation, support services, elder rights, housing, health, and insurance and benefits;
• A centralized location that enables older adults and caregivers access Eldercare Locator brochures on topics important to their health and well-being.

For more than 25 years, the Eldercare Locator Call Center and website have served as critical tools to assist older adults and those who support them in navigating the range of services and options available to seniors. In 2017, more than 470,000 visitors accessed the Eldercare Locator’s website. The Call Center receives more than 350,000 calls every year and answered its 4 millionth call earlier this year.

ACL encourages all consumers to explore the new website. ACL will continue to expand and update resources to provide valuable information for older adults and their caregivers to serve its vital and ever growing aging population.

Study Confirms that Quality of Care Higher in Non-Profit Nursing Homes

Older adults who reside in for-profit nursing homes are nearly twice as likely to have health problems linked to poor care than those in nonprofit nursing homes and those who live in private homes.  This is the conclusion of newly released research published in the Journal of Gerontology. 

According to a press release from the University of Illinois at Chicago, the researchers, led by Lee Friedman, associate professor of environmental and occupational health sciences in the University of Illinois at Chicago School of Public Health, also found that community-dwelling adults 60 years old and older who need assistance with tasks related to daily living but do not live in a nursing home had the fewest number of clinical signs of neglect compared with those living in any type of nursing facility.

"We saw more -- and more serious -- diagnoses among residents of for-profit facilities that were consistent with severe clinical signs of neglect, including severe dehydration in clients with feeding tubes which should have been managed, clients with stage 3 and 4 bed sores, broken catheters and feeding tubes, and clients whose medication for chronic conditions was not being managed properly," said study leader Lee Friedman in the press release.  Friedman added that substandard care falls within the definition of elder abuse.

The study included more than 1,100 people, aged 60 and older, who were seen in five Chicago-area hospitals between 2007 and 2011 for health problems that could be related to poor care.

Along with finding that neglect-related health problems were more common in for-profit nursing homes than in nonprofits, the researchers also found that community-dwelling patients had fewer of these problems than those in any type of nursing home.  Community-dwelling patients need help with daily living but live in private homes, often with family members or friends.

According to the researchers:

"For-profit nursing facilities pay their high-level administrators more, and so the people actually providing the care are paid less than those working at nonprofit places, so staff at for-profit facilities are underpaid and need to take care of more residents, which leads to low morale for staff, and it's the residents who suffer."

Friedman said more oversight of nursing homes is needed, along with improved screening and reporting of suspected neglect.

This study is unique in that it also included consideration of community based health care residents.  The conclusion that non-profit homes are superior to their for-profit competitors, however, is well established. According to the report:

"As reported in prior research, for-profit facilities caring for the patients in this study were  significantly inferior across nearly all staffing, capacity, and deficiency measures. Furthermore, the most serious clinical signs were consistently more prevalent among residents of for-profit facilities, including dehydration with presence of gastrostomy, not being provided basic medications to manage chronic conditions, stage 3 or 4 pressure ulcers, and complications with urinary catheters and feeding tubes.

Many studies show that neglect is the most common form of elder mistreatment but is more likely to be overlooked because of its muted nature, although the outcomes of neglect can be as pernicious as physical abuse. 

Aging in Place requires planning and accurate information.  Implementing an objective to remain at home, a senior or family member acting on his or her behalf may nonetheless be forced to institutional care, even if for only a short period of time.  Selecting the institution most likely to provide positive health outcomes is paramount, as is acknowledgement that short-term institutional care can result in long term institutional care if health outcomes are negative.