IRS Changes EIN Application Policy - Requires an Individual “Responsible Party”

ID 84890539 © Designer491 | Dreamstime.com

The IRS announced on March 27, 2019 that the “responsible party” on applications for an employer identification number (EIN) must now be a natural person.  Individuals named as responsible party must have either a Social Security number (SSN) or an individual taxpayer identification number (ITIN).  The new requirement is intended to enhance security and improve transparency. 

An EIN is the tax identification number assigned to entities such as trusts, estates, retirement plans, LLCs, partnerships, and corporations.  An entity obtains such a number by completing the IRS Form SS-4 or an online application.  One question in the application process asks the applicant to identify the “responsible party,” which the IRS defines as “the person who ultimately owns or controls the entity or who exercises ultimate effective control over the entity.”  In cases where more than one person meets that definition, the entity may decide which individual should be the responsible party. In the past, a non-natural person, such as a trust, estate, or business entity (LLC, Corporation, or partnership) could be a "responsible party."  According to the IRS,"[t]he change will prohibit entities from using their own EINs to obtain additional EINs." 

In deciding who to list as the responsible party, the IRS encourages applicants to consider whether the party has “a level of control over, or entitlement to, the funds or assets in the entity that, as a practical matter, enables the person, directly or indirectly, to control, manage, or direct the entity and the disposition of its funds and assets.”  The Form SS-4 Instructions provide a detailed explanation of who should be the responsible party for various types of entities. Only governmental entities and the military are exempt from this requirement, and may continue to list non-individual entities as the responsible party.

 If there are changes to the responsible party, the entity can change the responsible official designation by completing Form 8822-B, Change of Address or Responsible Party. A Form 8822-B must be filed within 60 days of a change.

This policy will go into effect for all EIN applications submitted on and after May 13, 2019.

More:

To read an article explaining why you should consider retaining a professional to apply for and obtain a an EIN, go here.

If you are confused about what a TIN, ITIN, and/or EIN  is, go here.

Aging in Place Planning - New Geriatrics Research Offers Roadmap for Person-Centered Care

Person-centered care (PCC) is an approach to health care that puts personal values and preferences of the patient at the forefront of decision-making. Improving healthcare safety, quality, and coordination, as well as quality of life, are important aims of caring for older adults with multiple chronic conditions and/or functional limitations. Person‐centered care is an approach to meeting these aims in a way that assures the primacy of individuals’ health and life goals in their care planning and in their actual care.

Person‐centered care means that individuals' values and preferences are elicited and, once expressed, guide all aspects of their health care, supporting their realistic health and life goals. Person‐centered care is achieved through a dynamic relationship among individuals, in and out of the health care system, and others who are important to them, and all relevant providers. The required  collaboration informs decision‐making to the extent that the individual desires. See, "Implementing “Patient‐Centered Care”: A Revolutionary Change in Health Care Delivery." Person-centered care is consistent with, and one could argue, the objective of "supported decision-making," upon which Aging in Place Planning is based.  

According to an article published in the American Geriatrics Society Newsletter, two new research articles and a corresponding commentary from leaders in the the American Geriatrics Society (AGS) describe ways to make person-centered care more actionable for seniors. The study authors explain that the time is ripe for reform of senior care toward PCC: 

"The U.S. healthcare system is finally at a much anticipated and long‐needed tipping point. For more than half a century, the predominant paradigm for organizing and financing health care in the United States has been based on [two] 2 major factors: care focused on organ systems and reimbursement based on volume rather than quality of service. This system has too rigidly driven what can be done and reimbursed and does not foster care that addresses disorders of multiple organ systems (multimorbidity) and the effect of multimorbidity on overall functional ability, considerations that are critically important in the care of older people. Given recent developments in our healthcare system, the time is ripe for geriatricians to leverage their unique expertise to advocate for a person‐centered approach to healthcare design and delivery that encourages healthcare professionals to organize care around patient priorities, rather than an outdated taxonomy and payment system."

"Making person-centered care a reality for older adults with complex care needs will take time and effort, including significant research to move promising approaches from the lab bench to the clinic,” wrote William B. Applegate, MD, MPH, AGSF, Editor-in-Chief of JAGS and lead author of the editorial addressing the two new studies (DOI: 10.1111/ jgs.15536). “This work is helping test innovative strategies, which will move us toward a broader and more balanced approach to care.”

Though critically important, eliciting and documenting personal values remains uncommon in routine older adult care, particularly for people with multiple health concerns that complicate pinpointing broader health priorities. In “Development of a Clinically Feasible Process for Identifying Patient Health Priorities” a research team describes Patient Priorities Care (PPC), a novel process to identify health goals and care preferences for older people with multiple health conditions. Expertly trained facilitators help older adults and caregivers work through health priorities sensitively, in a process that could be completed across just two sessions totaling 45 minutes or less. According to the research team:

 “Results of this study demonstrate that healthcare professionals can be trained to perform the patient priorities identification process as part of their clinical encounters…[through a process that is] rewarding and enjoyable but requires training and formal feedback.”

A separate team put the PPC processes into practice, reporting their findings in “Feasibility of Implementing Patient Priorities Care for Patients with Multiple Chronic Conditions” Their study involved using Patient Priorities Care among more than 100 patients working with nine primary care providers and five cardiologists in Connecticut. While researchers still hope for improvements in the time needed to complete the process and in avenues for embedding it within practice workflows, they noted that the vast majority of patients returned to their physician with clear goals and care preferences. Follow-up discussions between patients and providers suggest that moving from disease-based to priorities-aligned decisions is “challenging but feasible.”

The foregoing work represents only the latest steps forward for high-quality, person-centered care for older people, and also builds on an even lengthier legacy at  AGS.  Implementation of these strategies for all seniors, even those receiving care outside of institutions, while aging in place, will be a welcome development.  

OIG Finds State Survey Agencies Are Not Verifying Facilities’ Corrections of Deficiencies

State survey agencies ("State agencies") are required to verify that nursing homes have corrected identified deficiencies, such as the failure to provide necessary care and  services, before certifying that the nursing homes are in substantial compliance with Federal participation requirements for Medicare and Medicaid. The Office of the Inspector General (OIG) recently conducted a survey, and its resulting Report says that State Agencies aren’t doing enough to make sure that nursing homes are correcting deficiencies.

Out of nine state agencies that OIG selected for review, seven did not always verify that nursing homes’ had corrected issues, as required. More specifically for 326 of the 700 sampled deficiencies, these State Agencies did not obtain any evidence of nursing homes' correction of deficiencies or maintain sufficient evidence that they had verified correction of deficiencies.  For less serious deficiencies, the practice of six of the seven State agencies was to simply accept a nursing home's correction plan as confirmation of substantial compliance with Federal participation requirements without obtaining from the nursing home any evidence of correction of deficiencies. 

Further, three of the seven State agencies had technical issues with maintaining supporting documentation in the software-based system used to support the survey and certification process; as a result, they did not have sufficient evidence of correction of deficiencies.  The OIG report does not state clearly whether state agencies claimed to have collected any evidence, or if that supporting documentation may not have been available to the OIG. 

The Report offered an example of a serious deficiency where the state survey agency did not follow up and verify the correction of the deficiency:

“A state agency completed a nursing home survey and identified several deficiencies, including a G-rated deficiency related to quality of care (42 CFR § 483.25). The surveyor noted:

• Based on observation, interview and record review, the facility failed to provide the necessary care and services . . . in accordance with the comprehensive assessment and plan of care for 1 of 4 diabetic residents . . . reviewed for medication administration. This failure occurred when the resident received too much diabetic medication and sustained a life threatening event requiring emergency medical intervention.

The state agency conducted the required follow up survey; however, it did not have documentation supporting that it had verified the correction of the deficiency.”

Resident health may be compromised.  "If State agencies certify that nursing homes are in substantial compliance without properly verifying the correction of deficiencies and maintaining sufficient documentation to support the verification of deficiency correction, the health and safety of nursing home residents may be placed at risk" reads the OIG Report. 

In addition, the OIG said, the Centers for Medicare & Medicaid Services’ (CMS) guidance to state agencies on such verification “needed to be improved.” Officials laid out several steps that the agency can take to respond, moves with which CMS has concurred.

LeadingAge spokeswoman Lisa Sanders told McKnight's Long-term Care News, that  it agrees with the OIG’s recent findings, urging federal officials to ensure that state agencies have adequate funding to complete their reviews:

“The unevenness of surveyors’ findings and enforcement actions taken by state surveyors is well documented,” she told McKnight’s. “State survey agencies are frequently short-staffed, and turnover at these agencies is often rampant, which means that those responsible for surveying nursing homes may have neither the training nor the experience to know what they are seeing and whether conditions comply with federal standards and requirements.”

The prestigious law firm Hall, Render, Killian, Heath, and Lyman,  which specializes in health-related businesses identified the following "Practical Takeaways" from the Report:

•  Skilled nursing facilities should expect that state survey agencies will pay increased attention and take actions to confirm that the actions and corrections promised in a facility’s plan of correction were implemented.
• Skilled nursing facilities may see changes to the CMS forms related to the survey and certification process, such as the Forms CMS-2567, CMS-2567B and CMS-1539, so that surveyors can explicitly indicate how a state survey agency verified correction of deficiencies and what evidence was reviewed.
• Skilled nursing facilities should review and establish practices and procedures for proactively documenting the corrective actions promised for any deficiency. Facilities should have those records ready, expecting that the state survey agency will more actively confirm that the actions occurred. 

As CMS reinvigorates state agencies' oversight, resident health will find greater protection.  

The "Human Touch" in Aging in Place Planning

ID 117955757 © Patcharin Saenlakon | Dreamstime.com

Laizer Kornwasser, writing for HomeCare Magazine, reminds that although technology can improve health outcomes, human hands are still needed.  In his article entitled, The Importance of the Human Touch, Kornwasser, President and Chief Operating Officer at CareCentrix, a post-acute benefits management company, suggests that "the future of better health care in this country is not people versus machines," it is in fact, "just the opposite."  

Kornwasser concedes that a "future of improved health outcomes and lower health care cost comes when health care providers use technology to not only inform diagnoses, but also to catch early signs of medical problems, create the most effective treatment plans and recommend the most appropriate post-acute care environment for the patient:"  

"One of the latest health care advancements currently being tested is the use of sensors to track the activity of elderly people in their homes and in their cars, as part of an effort to enable them to live longer and more safely in their own homes. The Collaborative Aging (In Place) Research Using Technology (CART) initiative is a national study currently in progress that tracks seniors’ pill consumption, weight, computer use and movement in and around their home and in their vehicles to generate real-time activity and monitor for any health changes, such as cognitive decline or increasing frailty issues, so that intervention can happen earlier to help prevent or shorten a potential hospital stay.

There are a number of commercially available sensor-based products that can monitor individuals at home, but no company has mastered the logistics of installing and configuring the sensors so an alert can be acted upon, as CART is pursuing. Sending up a red flag with no one to interpret what the red flag means and how to best intervene is like creating a computer system without a backup."

The "human touch" necessary involves connectivity, communication and collaboration among providers, patients, payers and caregivers utilizing technology intelligently and humanely:

While a machine can be programmed to perform given tasks more efficiently and extrapolate needed and advanced learnings better than its human counterparts, the artistry is in the execution of the information and in being able to adjust to the subtleties that may be required in a given situation.

The CART study is an excellent example of the exciting new research being conducted in the “technology meets touch” space, but there are many examples where the practice is already in use. Consider the task of getting prescriptions filled at a pharmacy. What was once an onerous paper-based process that was often filled with roadblocks and safety concerns due to lack of information, multiple providers and polypharmacy is now streamlined through electronic health records, real-time benefit checks and e-prescribing capabilities that allow physicians to make better prescribing decisions for a patient at the point of care.

Within the home health industry, technology is consistently opening new paths that deliver improved patient outcomes, while achieving lower overall health care costs. Nowhere is this transformation more evident than in the adoption of artificial intelligence (AI) and machine learning technology, which is quickly changing the face of patient care.

Using petabytes (1 million gigabytes) of data, clinicians can quickly analyze past results of clinical settings and providers to recommend future paths for better care. For example, a physician can now match the characteristics of an individual in need of a hip replacement to a facility and/or provider with measurable success in caring for patients with similar clinical and socioeconomic characteristics. Matching patients with the right provider at the start of care improves outcomes, increases patient satisfaction and provides cost-saving solutions that can avoid hospital re-admissions.

AI and machine learning, combined with new modes of communication, are making it possible to create smart networks that match the patient’s needs with the best-possible providers. But, it is still the uniquely human ability to deliver on those care needs, once identified, that brings to fruition the highest quality of care, while lowering health care costs.

As technology continues to evolve and predictive analytics advance, we need to challenge the industry to develop products that not only improve the machine learning process, but also seamlessly connect a patient’s clinical care team with real-time medical and pharmacy claims data that will help the team make more informed care decisions.

By teaming technology with the human touch, we will be able to place patients in the center of the care team—whether they are in the hospital, a post-acute care facility or healing at home.

ID 107961566 © Ljupco | Dreamstime.com

Even more tangible than the "Human Touch" about which Mr. Kornwasser writes, is actual physical contact. Research suggests that the physical contact plays a fundamental role in human communication and  physical and emotional health.  Lack of human touch is a real concern for the medically frail elder, leading to feelings of isolation, anxiety, poor trust in caregivers, insecurity and decreased sensory awareness. 

Older adults living with serious conditions are often especially receptive to touch. Unfortunately, they are also among the least likely to receive expressive human touch from health care providers. Nursing students have been shown to experience anxiety about touching older patients. Yet elders report that touch communicates safety, care, reassurance and makes them feel more trust in caregivers.

For individuals with dementia, human touch plays an important role in promoting overall well-being. Since touching the hands is so familiar, hand massage may be gladly accepted by elders living with dementia. Even five-minutes of hand massage have been shown to elicit a physiological relaxation response and decreases cortisol levels. Cortisol is a stress hormone that is produced by the adrenal glands during prolonged stress and is often used as an objective marker of stress. When cortisol levels are lowered it enhances sleep quality and the immune system. Massage has also been shown to increase serotonin levels. Serotonin is a neurochemical that regulates mood; feelings of calm; and subdues anxiety and irritability.

A five or ten-minute hand massage protocol has resulted in:

• Significantly decreased agitation immediately and sustained the decrease for up to one hour;
• Decreased the frequency and intensity of agitated behavior during morning care routines;
• Strengthened the relationship between the person with dementia and their family care partner.

One study evaluated the effects of hand massage on physical and mental function and behavioral and psychological symptoms consistent hand massage protocol. Both aggressive behaviors and stress levels decreased significantly.

ID 104769713 © Katarzyna Bialasiewicz | Dreamstime.com

Slow-stroke back massage (SSBM) uses effleurage, moving the palm of the hand in long, rhythmic, firm strokes. One method applies effleurage in a figure-eight formation on both sides of the back. Massage stimulates production of endorphins which are compounds produced by the body that suppress pain and uplifts mood. Massage also has a generalized effect on the autonomic nervous system, producing a relaxation response.

Three-to-five minute protocols have shown slow-stroke back massage to:

• Help people fall asleep;
• Decrease anxiety;
• Decrease physical expressions of agitation such as pacing, wandering and resisting care;
• Ease pain;
• Decrease blood pressure and heart rate indicating a physiological relaxation response.

One study investigated the effect of SSBM on anxiety and shoulder pain in hospitalized elderly patients who had suffered a stroke. The study compared scores for pain, anxiety, blood pressure and heart rate of two groups of patients. The intervention consisted of 10 minutes of SSBM for seven consecutive evenings. The results revealed that the massage intervention significantly reduced the patients' levels of pain perception and anxiety and blood pressure and heart rate changed positively, again indicating relaxation.

While institutional nursing is employing these techniques in an effort to  to reduce unnecessary use of anti-psychotic medication by replacing or supplementing them with non-medicinal approaches and strategies, home care, too, should incorporate these techniques.  "Touch" initiated by family by hugs, pats, and simple hand holding or affectionate touching,  initiated as greeting and comforting touch by professional caregivers, or scheduled hand, back, or foot massage, can go a long way in comforting an elder, and contributing to positive physical, emotional, and psychological health outcomes.  

"Human Touch," as it refers to both the human component of collaborative information gathering, consideration, decision-making, and implementation, and to human tactile communication and care, is undoubtedly an important component of an Aging in Place plan. 

ID 88477236 © Varandah | Dreamstime.com

Care.com Rocked By WSJ Investigation - Conducts only Preliminary Screen of Caregivers

Care.com pledges to “help families make informed hiring decisions."  The company, however, undertakes only a "preliminary screening," of referred caregivers, leaving the heavy lifting up to the families themselves, sometimes with tragic consequences, according to Kirsten Grind, Gregory Zuckerman and Shane Shifflett writing in the WSJ.

The Journal found some nine instance in the last six years where caregivers on the site had police records, and later were accused of crimes while caring for customers' children or elderly relatives. The paper's probe also found hundreds of instances of day-care centers being improperly listed as state-licensed.

"Care.com is a marketplace platform," said CEO Sheila Marcelo."  The marketplace is designed for “shared responsibility overall," she adds.  Look for a greater effort by Care.com, but in the meantime, and nonetheless, family members should remain vigilant and conduct their own background checks.  Those who will take advantage of the most vulnerable will always seek others to confer upon them some imprimatur of integrity and responsibility.  Wisdom suggests caution in accepting referrals from any third party, especially where there is profit for the listing or referring service.

Opioids Sending More Seniors to ER

ID 130219425 © Skypixel | Dreamstime.com

If you thought that the current opioid crisis is relegated primarily to younger people, you are sadly mistaken.  According to an article in McKnight's Long-Term Care News, Emergency room visits by seniors who have misused opioids more than tripled between 2006 and 2014. Visit rates to ERs by adults older than 65 for opioid misuse increased a tragic 217% during the study period.

The statistic comes as a result of a new study which suggests that misuse of painkillers has had a snowball effect for seniors, leading to an increase in the number of chronic conditions, greater injury risk and higher rates of mental health diagnoses:

“Findings demonstrate the breadth and scope of opioid misuse and dependence among older adults visiting emergency departments — and indicate that targeted programs aimed at screening, intervention and treatment specifically geared toward older adults are warranted,” authors wrote in Innovation in Aging. “Results from this study also highlight the complexity of treating opioid dependence in this population, which reflect in part, high rates of coexisting mental health and other substance abuse disorders.”

Researchers studied multiple years of nationally representative data from the Nationwide Emergency Department Sample, which includes more than 950 hospitals, across 34 states and the District of Columbia. 

Justice Department Announces Elder Fraud Sweep

On March 7, 2019, the U.S. Department of Justice ("DOJ") announced the largest U.S. elder fraud sweep in a detailed press release entitled, Justice Department Coordinates Largest-Ever Nationwide Elder Fraud Sweep. A related press release from the U.S. Attorney General, entitled, Attorney General Focuses on Threats Posed by Technical-Support Fraud offers a look at the staggering extent of elder fraud:

The cases during this sweep involved more than 260 defendants from around the globe who victimized more than two million Americans, most of them elderly.  DOJ took action in every federal district across the country, through the filing of criminal or civil cases or through consumer education efforts. In each case, offenders allegedly engaged in financial schemes that targeted or largely affected seniors. In total, the charged elder fraud schemes caused alleged losses of millions of more dollars than last year, putting the total alleged losses at this year’s sweep at over three fourths of one billion dollars.

If you are interested, you can review the state-by-state results of the sweep, here.   The sweep included cases filed against perpetrators of tech support fraud, mass mailing fraud, and  money mules. Although there were no cases filed in Ohio or Illinois, there were cases file in the State of Missouri.  There are  consumer education efforts dedicated to both Ohio and Illinois:

[DOJ] and its law enforcement partners focused the sweep’s public education campaign on technical-support fraud, given the widespread harm such schemes are causing. The FTC and State Attorneys General had an important role in designing and disseminating messaging material intended to warn consumers and businesses.

Public education outreach is being conducted by various state and federal agencies, including Senior Corps, a national service program administered by the federal agency the Corporation for National and Community Service, to educate seniors and prevent further victimization. The Senior Corps program engages more than 245,000 older adults in intensive service each year, who in turn, serve more than 840,000 additional seniors, including 332,000 veterans. Information on Senior Corps’ efforts to reduce elder fraud can be found here.

Elder fraud complaints may be filed with the FTC at www.ftccomplaintassistant.gov or at 877-FTC-HELP. The Department of Justice provides a variety of resources relating to elder fraud victimization through its Office of Victims of Crime, which can be reached at www.ovc.gov.

Long Distance Caregiving

ID 69022089 © Rawpixelimages | Dreamstime.com

A new article, published by the Institute of Family Studies, authored by Professors Naomi Cahn and Amy Zietlow, The Sandwich Generation on Wheels: Tips for Long-Distance Family Caregivers, discusses the all too common issue of caregiving from afar.  Based on their respective research and experiences,  they note "that it is helpful for family caregivers to define the "sandwich" layers they face in order to proactively plan for what role they can and should play." 

The first layer requires one to "clarify who in your older generation depends on you in some way. List your parents, stepparents, in-laws, grandparents, aunts or uncles, etc. In conversation with them, formalize your caregiving role. This is particularly important in [a] stepfamily situation."  With this layer, not only must you identify who needs or might need assistance, you must identify the legal documents, and financial assets necessary to facilitate and provide help and assistance,  and you must articulate the limitations that arise from long-distance caregiving.  The authors briefly explore the potential for caregiving to help in such situations, and the practicalities of such planning:

"Then, acknowledge that by living at a distance, you cannot be available 24/7 to everyone, in person. Determine your trigger points for travel. For scheduled procedures, is there an acuity level that must be met before you fly or drive to be present? A major surgery? Yes. A physical therapy appointment? No. For emergencies, what is a reasonable expectation for arriving? Next, plan for how you will manage planned or emergency travel. We know this sounds a little advice column-y, but it’s good to be prepared for that 2 A.M. phone call that requires you to drive several hundred miles.   

The second layer, "your job, " focuses on caregivers who are employed and how to juggle a job and  caregiving responsibilities.  The third layer, "spouse and child" recognizes the sandwich issue- caregivers also have responsibilities to their own immediate family as well as the elders for whom they are caregiving.  "Communicating with your spouse and your children about your goals for this season of life is critical. Acknowledging how you will be dividing your time, and why, will help them feel engaged and involved. You will need their moral support in your role as caregiver."

Many of these circumstances will demand a "team approach," i.e., several different persons, sometimes including non-family lay persons, as well as third party professionals.  Consideration and utilization of a Private Care Agreement to define roles, responsibilities, expectations, and remuneration can aid in implementing a plan, managing expectations and concerns, and resolving foreseeable and unexpected disputes and disagreements.   

Technology can make such planning for care from a distance less risky and burdensome:

When you cannot be physically present, consider how you will stay connected and whether technology may help. Entire industries are developing applications that connect to smart homes, surveillance cameras, and interactive devices, such as Google’s Alexa, to meet the needs of elders and their family caregivers. Personal health monitors, as well as smart home technology, can monitor for falls and track weight gains and losses, play a favorite television show, or adjust thermostats, and thus contribute to the safety, entertainment, and comfort of older or ill adults. Already, senior-living residences have considered adopting “Addison,” a robot caregiver, who rewards residents when they meet goals, monitors changes in movement, and talks to the residents with screens strategically placed around the apartment or room. Technology can help connect when a loved one lives at a distance.

Of course, like with many solutions, senior appreciation, acceptance, and utilization may be vital to success.  In the past few years, we have watched and often guided seniors and their families in a suite of solutions for distance care.  These tools should be considered, and, if necessary, utilized in any Aging in Place Plan. 

Caregiving is complex, potentially overwhelming, and, draining, financially, mentally, emotionally, and physically. It is, nonetheless, rewarding and routinely ranked as “highly meaningful.”  Staying connected at a distance  is possible when expectations are clearly defined.   

Nursing Homes Push Dying Patients Into Unnecessary and Hazardous Rehab

An alarming study contends that Skilled Nursing Facilities (SNFs) may be pushing dying patients into unnecessary and potentially harmful high-intensity rehabilitation services. The study suggests that nursing homes may be sacrificing patient preferences and comfort for profit.  The study is another in a long list of reasons to plan to Age in Place.

University of Rochester Medical Center researchers noted that the number of residents receiving “ultra-high” rehab services in New York state increased by 65% during the three-year period ending in 2015. Most of those services were delivered to individuals in the last seven days of their lives, according to the analysis of data from 647 nursing homes in the Empire State that was published in the Journal of the American Medical Directors Association.

“These are often sick and frail patients in whom the risks of intensive levels of rehabilitation actually outweigh the benefits,” Thomas Caprio, M.D, a geriatrician and hospice physician at URMC and co-author of the study, said in a statement. “It can increase the burden of pain and exhaustion experienced by patients and contribute to their suffering.”

Researchers studies residents in the Very High (520 minutes per week) to Ultra-High (720 minutes) groupings of rehab services in the last 30 days of life. Authors speculated that rehab levels for the dying may actually be higher in other states with less regulatory oversight. They also acknowledge that some rehab is needed at the end of life, though more commonly of the low or intermediate variety.

The motive for unnecessary and burdensome rehab is profit. According to the report accompanying the study results, "recent reports from the Office of the Inspector General (OIG), the Centers from Medicare and Medicaid Services, and from popular press suggest that the volume and the intensity of rehabilitation therapy provided to residents in US SNFs may be more extensive than is warranted by the residents' care needs." The OIG report from 2010 found that the proportion of seniors referred to ultrahigh therapy (>720 minutes/wk) increased from 17% to 28% during 2006-2008 while the recipients' age, admitting diagnoses, and proportion of seniors with high functional impairment scores remained largely unchanged. The report also noted that for-profit SNFs were more likely to bill for high-intensity therapy compared to not-for-profits—32% versus 18%, respectively.

A 2015 OIG report showed that SNF billings for higher levels of therapy have continued to increase. Between 2011 and 2013, the percentage of ultrahigh therapy days grew from 49% to 57%, whereas residents' characteristics stayed the same. In 2015, SNFs were reported to make a six times or six hundred percent (600%) higher average daily profit margin from providing ultrahigh compared to low therapy intensity. 

According to the study's author's, "[a]t least as concerning as the evidence suggesting some nursing homes may have exploited the prospective payment system to “optimize their revenues” is the claim by the OIG investigators that SNFs billed for therapy levels that were higher than reasonable or necessary, even among the most vulnerable residents." The OIG cited an example of a hospice patient who “received physical therapy 5 days a week for 5 weeks, even though her medical records indicated that she asked that the therapy be discontinued.” Similarly, a 2016 report appearing in the Wall Street Journal quoted interviews with more than 2 dozen former SNF therapists and rehabilitation directors asserting that “managers often pressure caregivers to reach the 720-minute threshold” (required for ultrahigh therapy billing). 

Although the benefits of rehabilitative therapy in nursing homes are well established, pressures to maximize therapy may be inappropriate or even potentially injurious to some patients and may create obstacles to the provision of palliative and end-of-life (EOL) care in nursing homes.  Numerous previous studies have shown that, despite preferences, many residents are hospitalized in the final weeks of life, and receive burdensome treatments that may have few benefits.  Consider the following:

• Potentially avoidable hospitalizations of nursing home residents: Frequency, causes, and costs. J Am Geriatr Soc. 2010; 58: 627–635;
• Site of death among nursing home residents in the United States: Changing patterns, 2003-2007. J Am Med Dir Assoc. 2013; 14: 741–748;
• Hospitalizations of nursing home residents in the last year of life: Nursing home characteristics and variation in potentially avoidable hospitalizations. J Am Geriatr Soc. 2013; 61: 1900–1908;
• End-of-life transitions among nursing home residents with cognitive issues. N Engl J Med. 2011; 365: 1212–1221.

The resident's quality of care may, in such cases, be horrifically impaired. Nursing homes may actually be reluctant to refer their dying residents to hospice so as not to lose the opportunity to maximize a higher Medicare rate by providing rehab.  In other words, preferences and comfort are sacrifices for profit. This conclusion is at least suggested by two separate studies:

• Dying in U.S. nursing homes with advanced dementia: How does health care use differ for residents with, versus without, end-of-life Medicare skilled nursing facility care?. J Palliat Med. 2012; 15: 43–50;
• Influence of hospice on nursing home residents with advanced dementia who received medicare-skilled nursing facility care near the end of life. J Am Geriatr Soc. 2012; 60: 2035–2041.

In one study, nearly one-third of Medicare beneficiaries who were hospitalized received SNF-level care in the last 6 months of life and 9.2% died while on a SNF benefit.  Researchers argue that although such care may be appropriate for some, the receipt of SNF services at the end of life is likely to prevent many patients from receiving hospice and/or palliative care that may be more consistent with their wishes and care needs. A recent study reporting on staff experiences with palliative care in nursing homes noted that staff's desire to develop and provide quality palliative care services may conflict with the nursing homes' need to maximize the provision of rehabilitative therapies. In the words of a staff member, “[t]he goal is to get comfort measure people in therapy. They [residents] get the therapy; they [facility] get higher payment [reimbursement].”

Providers defended their practices to McKnight's Long Term Care News, noting that there is a deliberate system in place to regulate rehab levels. "When individuals request admission to a nursing home, they typically come with documentation on the type of care required. And once they’re at the facility, they must be able to maintain those levels of therapy," Nancy Leveille, executive director of the Foundation for Quality Care, part of the New York State Health Facilities Association, told McKnight's reporter Marty Stempniak. "If their condition is such that they cannot maintain, then nursing homes are unable to make a claim for those rehab minutes," Leveille explained.  "Plus, a significant sample of high-level rehab patients are then audited on a regular basis by Medicare or Medicaid, to validate that the services were appropriate," she added.

“There are checks and balances on the system and there are people who come in with terminal diagnoses and are trying to get back on their feet to be able to get back home or back to a different level of functioning for themselves for quality of life,” Leveille said. “But even within that, if they can’t meet the requirements of ultra-high rehab or any level of rehab, they can’t be scored on that.”

In other words, because billings are approved, the care is justifiable.

Respite for Family Caregivers

Respite is planned or emergency care provided to a child or adult with special needs in order to provide temporary relief to family caregivers who are caring for that child or adult. 

The ARCH National Respite Network and Resource Center provides useful resources on its website for family caregivers to navigate respite care. ARCH's Nine Steps to Respite for Family Caregivers, provides readers with facts sheets to guide caregivers to getting respite care. 

Each fact sheet is designed to be relevant to distinct caregiving situations, such as military caregivers and family caregivers of individuals with dementia.

Other resources on ARCH's website include the following:

• A Consumer Guide to Respite;
• The National Respite Locator;
• Financial Assistance for Family Caregivers.

The website also is where you can find Charting the LifeCourse Respite materials.  These materials include a Respite guide book, portfolio and other tools designed to help family caregivers caring for anyone of any age or disability and/or those who support them create a plan to access respite services within and outside the formal services system.

The materials provide:

• information on the importance of respite for the well-being of the family caregiver and all family members;
• tools for thinking about and planning for respite; and
• additional resources for finding respite in the community. 

Missouri Family to Family, which is housed within Missouri’s University Center for Excellence in Developmental Disabilities Education, Research and Services (UCEDD) at the University of Missouri–Kansas City Institute for Human Development, in collaboration with the ARCH National Respite Network and Resource Center, developed Charting the LifeCourse Respite materials. 

Aging in Place Seniors Need Additional Assistance

ID 78697343 © Robert Kneschke | Dreamstime.com

About 25 million Americans who are aging in place rely on help from other people and devices, such as canes, raised toilets or shower seats, to perform essential daily activities, according to a new study documenting how older adults adapt to their changing physical abilities.  

A substantial number of these seniors, however, do not receive adequate assistance. Nearly sixty percent (60%) of seniors with seriously compromised mobility reported staying inside their homes or apartments instead of getting out of the house. Twenty-five percent (25%) said they often remained in bed. Twenty percent (20%) of older adults who had significant difficulty putting on a shirt or pulling on undergarments or pants. reportedly don't get dressed. Of those who required assistance with toileting issues, almost thirty percent (27.9%) report accidents where they soil themselves.

The study, by researchers from Johns Hopkins University, focuses on how older adults respond to changes in physical function.  Response to physical impairment is poorly understood, and infrequently studies.  The study suggests that about one-third of older adults who age in in place, nearly 13 million seniors, have a substantial need for assistance with daily activities such as bathing, eating, getting dressed, using the toilet, transferring in and out of bed or moving around their homes; about one-third have relatively few needs; and another third get along well on their own with no notable difficulty.

For older adults and their families, the report is a reminder of the need to plan ahead for changing capacities.  It is also a reminder that families and communities may need to be more proactive in identifying and assisting those whose physical needs change.

"The reality is that most of us, as we age, will require help at one point or another," Bruce Chernof, president of the Scan Foundation and chair of the 2013 federal Commission on Long-Term Care, told Judith Graham, author of special report for the Washington Times, and reprinted in an article for the The Berkshire Eagle. Citing Medicare's failure to cover long-term services and supports, which help seniors age in place, he said, "We need to lean in much harder if we want to help seniors thrive at home as long as possible."

Previous reports have examined the need for paid or unpaid help in the older population and the extent to which those needs go unmet. Notably, in 2017, some of the same Johns Hopkins researchers found that forty-two percent (42%) of older adults with probable dementia or difficulty performing daily activities didn't get assistance from family, friends or paid caregivers. Twenty-one percent (21%) of seniors with at least three chronic conditions and high needs lacked any kind of assistance, according to the prior study.

But personal care isn't all that's needed to help older adults remain at home when strength, flexibility, muscle coordination and other physical functions begin to deteriorate. Devices and home modifications can also help people adjust.  Technologies, too, can aid seniors, their families, and communities in providing assistance.

Until this new study, though, it wasn't clear how often older adults use "assistive devices" such as canes, walkers, wheelchairs and scooters for people with difficulties walking,  shower seats, tub seats and grab bars for people who need help bathing, button hooks, reachers, grabbers and specially designed clothes for people who have difficulty dressing,  special utensils designed for people who need assistance eating easier, or raised toilets or toilet seats, portable commodes and disposable pads or undergarments for individuals with toileting issues.

"What we haven't known before is the extent of adjustments that older adults make to manage daily activities," Judith Kasper, a co-author of the study and professor at Johns Hopkins Bloomberg School of Public Health told the Washington Times.

The data comes from a 2015 survey conducted by the National Health and Aging Trends Study, a leading source of information about functioning and disability among adults 65 and older. More than 7,000 seniors filled out surveys in their homes and results were extrapolated to 38.8 million older Americans who live in the community (excluding those who live in nursing homes, assisted-living centers, continuing care retirement communities and other institutions).

Among key findings: Sixty percent (60%)of the seniors surveyed used at least one device, most commonly for bathing, toileting and moving around. Twenty percent (20%) used two or more devices and thirteen percent (13%) also received some kind of personal assistance. Five percent (5%) report difficulty with daily tasks, but didn't have help and hadn't made other adjustments yet. One percent (1%) received assistance only.

As expected, needs multiplied with age, as sixty-three percent (63%) of those 85 and older reported using multiple devices and getting personal assistance, compared with twenty-three percent (23%) of those between ages 65 and 74.

The problem, experts note, is that Medicare doesn't pay for many of these nonmedical services, with some exceptions. As a result, many seniors, especially those at or near the bottom of the income ladder, go without needed assistance, even when they're enrolled in Medicaid. Medicaid community-based services for low-income seniors vary by state and often fall short of actual needs.

A companion report on financial strain experienced by older adults who require long-term services and supports illustrates how marginal are some seniors financial lives. Slightly more than ten percent (10%) of seniors with high needs experienced at least one type of hardship, such as being unable to pay expenses like medical bills or prescriptions (5.9 percent), utilities (4.8 percent) or rent (3.4 percent), or skipping meals (1.8 percent). Some people had multiple difficulties, reflected in and among these statistics.

These kinds of adverse events put older adults' health at risk,  contribute to avoidable hospitalizations, and result in avoidable nursing home placements. Given a growing population of seniors who will need assistance, "I think there's a need for Medicare to rethink how to better support beneficiaries," said Amber Willink, co-author of both studies and an assistant scientist at Johns Hopkins Bloomberg School of Public Health.

That's begun to happen, with the passage last year of the CHRONIC Care Act, which allows Medicare Advantage plans to offer supplemental benefits, such as wheelchair ramps, bathroom grab bars, transportation and personal care to chronically ill members. But it's unclear how robust these benefits will be going forward; this year, plans, which cover 21 million people, aren't offering much. Meanwhile, 39 million people enrolled in traditional Medicare are left out altogether.