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.

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.

Trump Administration deploys Medicaid Scorecard

In June, the Trump administration embarked on a basic change to Medicaid that for the first time evaluates states based on the health of millions of Americans and the services they use through the vast public insurance program for the poor.  Centers for Medicare and Medicaid Services CMS), deployed a “scorecard” that compiles and publicizes data from states for both Medicaid and the Children’s Health Insurance Program (CHIP), a companion for youngsters in working-class families.

This first scorecard includes state-by-state information showing that, on average, just over half the women on Medicaid are getting care while they are pregnant and after giving birth. Only three in five babies get checkups during their first 15 months, and less than half of children and teenagers have preventive dental visits.These and other measures show wide variations among states, though the initial version does not explicitly rank them. The scorecard also makes public for the first time measures of governments’ performance, such as how long both state and federal health officials take when states request “waivers” to deviate from Medicaid’s ordinary rules.

The Trump administration did not initially attach any consequences to how states make out, and indeed has declined to "rank" states.  That could change over the next few years as CMS refines and adds to the scorecard and members of Congress assess what it shows.  

The Trump Administration, through Seema Verma, head of CMS, explained that the scorecard is intended to initiate a conversation about health outcomes.  Medicaid pays for roughly half the nation’s births, but there is no data or discussion how or why states vary in birth outcomes.

The scorecard is part of a fundamental recalibration of the power relationship in Medicaid between the federal government and states. Since the program was created in 1965 as part of Lyndon Johnson’s War on Poverty, both have shared responsibility for paying for and defining the eligibility and benefits.  Medicaid now covers more than 67 million individuals, while CHIP covers nearly 6.5 million.

In the Trump era, federal health officials have been eager to give states more flexibility over Medicaid’s rules and benefits. Most significantly, the administration told states this year that it will allow them to require people to work or participate in other forms of “community engagement” to qualify for the program.

Such flexibility must be accompanied by heightened federal efforts to keep tabs on how well each state’s Medicaid program is functioning. Verma has said that “With all the flexibility must come accountability. We must be honest with ourselves and honest with our stakeholders . . . about how well we are doing.”

The scorecard’s initial information is based on states that voluntarily report a series of measures about the health of their Medicaid and CHIP enrollees. It shows, for instance, that the percentage of adults on Medicaid with high blood pressure under control as of 2016 varied from 26 percent in Louisiana to 72 percent in Rhode Island. The percentage of children ages 3 to 6 on Medicaid and CHIP who were getting adequate doctors’ care varied from 48 percent in Alaska and Idaho to 86 percent in Massachusetts.

Verma did not specify what additional information will be in later scorecards, but she said federal officials might be interested in how many people on Medicaid are working or volunteering, regardless of whether a state has imposed work requirements in its program.

Patients Are Not Given Quality-Of Care Information When Discharged From Hospitals to Nursing Homes

"Aging in Place" as a discreet estate planning objective requires knowledge, planning, and proper assessment of risks.  One persistent risk is the health care system's incentivizing institutional care.  Another risk is that of short term institutional care turning what should be a short term need for care into a long term or permanent need for institutional care.  

These are important risks given that a significant number of nursing home residents are shorter-term residents who are recuperating from surgery or illness. A recent study centered on the information provided when patients are discharged from hospitals to nursing homes, and they or their families are tasked with choosing a post-acute care facility.

As a result of regulations and incentives imposed by CMS and the Affordable Care Act, hospitals began being held partly accountable for Medicare patients’ care after discharge. The process of patients choosing a post-acute care facility was, however, a subject of speculation.

Researchers have recently illuminated the process.  Researchers used a case study approach to determine how patients select a post-acute care facility. The study explored how patients requiring post-acute care decide which skilled nursing facility to select. Further, the study examined the role of hospital staff members in the patients’ decision-making process.

Researchers interviewed 138 staff members of 16 hospitals and 25 skilled nursing facilities, as well as 98 patients in 14 of the skilled nursing facilities. The study found that most patients reported that they received only lists of skilled nursing facilities from hospital staff members, with no other data or information regarding quality of care. The researchers concluded that  hospital staff members provided little guidance to patients when they were selecting a facility for postacute care:

Hospital staff members do not appear to provide patients who need care in a skilled nursing facility with data that would allow them to select better-quality facilities. This is in spite of the fact that hospitals are now held at least partly accountable for the postacute care their patients receive, including for rehospitalizations. A system based on quality reporting and competition for patients cannot succeed if patients do not have the data necessary to make an informed choice. Hospitals should provide these data and help patients and their families understand them. 

Staff members reported that patient choice regulations precluded them from sharing data about facilities’ quality with patients. Consequently patients’ choices of a skilled nursing facility following hospitalization were usually not based on quality data that is readily available.

According to the report:

"Across the country, the postacute care patients we interviewed made strikingly similar comments—reporting that hospital discharge planners offered them lists of SNFs containing names and addresses but little else. Patients’ experiences did not vary based on hospital characteristics, bed availability in the market, or the patient’s diagnosis or condition. In the cases where patients were Medicare Advantage beneficiaries, either they were given lists of the managed care organization’s contracted facilities, or the managed care organization staff handled discharge planning. When we asked patients what information they had been given by hospital staff members to help them select a SNF, only four patients said that they had received any information about SNF quality or instructions about where to find such data.

Instead, patients made comments such as this: “I got a two-page list of different facilities that I could go to. It basically was the name, the address, and a phone number.” Several patients in one market reported receiving a list of all SNFs in the region, which contained over 100 such facilities. When asked to describe the list she received, one patient said: “Well, there were— there’s like a hundred of them. It’s all the facilities in the area.”

What we heard from patients was consistent with what we had heard from hospital staff members. Almost all of the discharge planners we interviewed reported providing lists of SNFs to patients, with no qualitative information. Only one discharge planner reported pointing patients and their family members to the Nursing Home Compare website, which provides data to aid consumers in their selection of a postacute care facility. Typical of what we heard from hospital staff members was this comment: “So right now, how it works is everybody gets a list with all of the local SNFs on it, and everybody can choose.” Another discharge planner similarly reported: “We hand them the list. The patients usually do it [choose a SNF] based on location or preference, but we try absolutely not to sway it. In fact, we do have a form that the patients do sign with their choice.” 

Consumers have greater accesss to information regarding the quality of nursing homes.  It is unfortunate that hospitals are not aiding patients and their families access and understand this information at a time when they are in need, and vulnerable to poor decision-making.  

Half of Most Dangerous Nursing Homes Remain Treacherous for Residents After Homes Are Cleared By Regulators

The Centers for Medicare and Medicaid Services (CMS), sets the federal standards for nursing homes and determines whether they are in compliance based on inspections performed primarily by state health departments. States license facilities and have  authority to revoke the licenses.  CMS designates "special focus status" to the poorest-performing facilities out of more than 15,000 skilled nursing homes. In an arbitrary system befitting government bureaucracy, the federal government assigns each state a set number of special focus status slots, roughly based on the number of nursing homes. Then state health regulators pick which nursing homes to include.

More than 900 facilities have been placed on the watch list since 2005. But the number of nursing homes under special focus at any given time has dropped by nearly half since 2012, primarily because of federal budget cuts negotiated by President Barack Obama and Congress. This year, the $2.6 million budget permits only 88 nursing homes to receive the designation, though regulators identified five times as many facilities, 435, as warranting such scrutiny. California and Texas each has six slots, the most of any state. Twenty-nine states have just one.

Especially troubling is that more than a third of operating nursing facilities that graduated from the watch list before 2014 continue to hold the lowest possible Medicare rating for health and safety, a one of five possible stars, according to an analysis performed by Kaiser Health News (KHN).  But worse, nursing homes that were forced to undergo such scrutiny often slide back into providing dangerous care, according to a KHN analysis of federal health inspection data. According to KHN, of 528 nursing homes that graduated from special focus status before 2014 and are still operating, slightly more than half — 52 percent — have since harmed patients or put patients in serious jeopardy within the past three years.These nursing homes are in 46 states. Some gave patients the wrong medications, failed to protect them from violent or bullying residents and staff members, or neglected to tell families or physicians about injuries. Years after regulators conferred clean bills of health, levels of registered nurses at these facilities tend to remain lower than at other facilities.

Yet, despite recurrences of patient harm, nursing homes are rarely denied Medicare and Medicaid reimbursement. Consequences can be dire for patients  According to a KHN analysis, in 2012, Parkview Healthcare Center’s history of safety violations led California regulators to designated Parkview nursing home, a “special focus facility,” requiring it to either fix lapses in care while under increased inspections or be stripped of federal funding by Medicare and Medicaid — a financial deprivation few homes can survive. After 15 months of scrutiny, the regulators deemed Parkview improved and released it from extra oversight.

But a few months later, Elaine Fisher, a 74-year-old who had lost the use of her legs after a stroke, slid out of her wheelchair at Parkview. Afterward, the nursing home promised to place a nonskid pad on her chair but did not, inspectors later found. Twice more, Fisher slipped from her wheelchair, fracturing her hip the final time. The violation drew a $10,000 penalty for Parkview, one of 10 fines totaling $126,300 incurred by the nursing home since the special focus status was lifted in 2014.

The cost to injured residents is incalculable.  Fisher "used to go to bingo every day and she was very involved in the nursing home,”  her son-in-law, Eric Powers, told KHN. Although Fisher moved to a different nursing home for better care, Powers related that “after this whole thing, she has to be on painkillers. She’s mainly in her room all the time. It’s the saddest thing in the world.”

In 2010, NMS Healthcare of Hagerstown, Md., left the watch list after 10 months.  Last year, Maryland’s attorney general sued the facility and its owner, Neiswanger Management Services (NMS), alleging that they evicted frail, infirm and mentally disabled residents “with brutal indifference” when their health coverage ran out or the facility had the opportunity to get someone with better insurance.

Among those evicted was Andrew Edwards, who was told by NMS that he was being discharged to an assisted-living center, according to the lawsuit. Instead, in January 2016, the staff sent him to a crowded, unlicensed Baltimore City row house where the owner confiscated his bank card and withdrew $966 over his objections, the lawsuit said. Although NMS said it had arranged for his outpatient kidney dialysis, “that was false,” Edwards said in an interview. He ended up in an emergency room after he missed his treatment.

NMS maintains it stopped referring patients to that owner when told of the conditions. This month, CMS expelled the Hagerstown nursing home from Medicare and Medicaid after citing it for more violations. The company is closing the facility. NMS, which still runs other homes in Maryland, has sued state regulators, claiming they are vindictively trying to drive the chain out of business.

Too few nurses, particularly registered nurses, provide care at some of the most troubled homes, KHN’s analysis showed. Registered nurse staffing was still 12 percent lower than at other facilities, even three years after the homes were released from the watch list.

In 2009, Pennsylvania health regulators released Golden LivingCenter-West Shore in Camp Hill after 17 months of supervision. The company said in a recent statement that when a home was put on that list, “we mobilize the resources necessary to help get that LivingCenter back into compliance.”

But data from Medicare’s Nursing Home Compare website show the facility has among the worst nurse-to-patient staffing ratios in the nation, with registered nurses devoting an average of 12 minutes for each patient daily. The state average is 58 minutes daily per patient.

Golden LivingCenter-West Shore was fined $59,150 in 2015 after being cited for, among other violations, "allowing a resident’s feeding tube to become infested with maggots." Also, according yo KHN, Golden Living agreed to pay $750,000 to settle three cases involving patient injuries from falls that occurred after extra oversight ended, court records show.

Last year, Golden Living sold its Pennsylvania homes to Priority Healthcare Group.  Priority is following a common strategy for shedding an unwanted reputation: changing the facility’s name. In California, Parkview — where Fisher slipped out of her wheelchair — is being rebranded too, as Kingston Healthcare Center.

CMS defended the program to KHN, saying that "nursing homes on the watch list showed more improvement than did comparably struggling facilities not selected for enhanced supervision."  In other words, putting 88 facilities on the watch list meant that they showed more improvement than the 435 other facilities deserving special focus status, but which were permitted to continue with no special oversight or ultimatum.  That is a defense of a program that asks advocates and critics to applaud what appears to be a system in failure, if CMS is, as it appears to be, acknowledging that th 435 other facilities aren't improving as a result of a failure by the government to demand that they improve, or implement stricter oversight, or threaten to stop Medicare/Medicaid reimbursement.  

“CMS continues to work to improve oversight to prevent any facility from regressing in performance,” reads a CMS statement to KHN.  

Some nursing homes on the watch list do maintain improvements. After Evergreen Nursing Home in southern Alabama was designated a special focus facility in 2005, the owners brought in new managers and added nursing supervisors.  Medicare now rates Evergreen a five-star facility. 

But even prolonged supervision does not guarantee progress. Poplar Point Health and Rehabilitation in Memphis stayed on the watch list for 2½ years until 2009. A federal lawsuit brought last year claims that Poplar and its owner, Vanguard Healthcare, regularly provided “nonexistent, grossly substandard, worthless care” as far back as 2010. Vanguard, now in bankruptcy court, declined to comment to KHN.

Our seniors simply deserve better.  Aging in Place planning is vitally important if you hope to avoid the risks of institutional care.  If you want to learn more about Aging in Place planning, go here.

Health Care Ageism And Senior Profiling

Those of us who regularly work with and for the elderly are painfully aware of pervasive latent ageism that often adversely impacts decision-making  concerning them.   Dr. Val Jones has penned an excellent article in the blog, better health warning of ageism in the health care industry.  Dr. Jones is  board certified in Physical Medicine and Rehabilitation,  and serves as a traveling physician to hospitals in 14 states.  She is a graduate of Columbia University College of Physicians and Surgeons and an award-winning writer.  She writes:

 Over the years I’ve become more and more aware of ageism in healthcare – a bias against full treatment options for older patients. Assumptions about lower capabilities, cognitive status and sedentary lifestyle are all too common. There is a kind of “senior profiling” that occurs among hospital staff, and this regularly leads to inappropriate medical care.

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Hospitalized patients are often very different than their usual selves. As we age, we become more vulnerable to medication side-effects, infections, and delirium. And so, the chance of an elderly hospitalized patient being acutely impaired is much higher than the general population. Unfortunately, many hospital-based physicians and surgeons — and certainly nurses and therapists — have little or no prior knowledge of the patient in their care. The patient’s “normal baseline” must often be reconstructed with the help of family members and friends. This takes precious time, and often goes undone.

Years ago, a patient’s family doctor would admit them to the hospital and care for them there. Now that the breadth and depth of our treatments have given birth to an army of sub-specialists, we have increased access to life-saving interventions at the expense of knowing those who need them. This presents a peculiar problem – one in which we spend enormous amounts of resources on diagnostic rabbit holes, because we aren’t certain if our patients’ symptoms are new or old. Was Mrs. Smith born with a lazy eye, or is she having a brain bleed? We could ask a family member, but we usually order an MRI.

My plea is for healthcare staff to be very mindful of the tendency to profile seniors. Just because Mr. Johnson has behavioral disturbances in his hospital room doesn’t mean that he is like that at home. Be especially suspicious of reversible causes of mental status changes in the elderly, and presume that patients are normally functional and bright until proven otherwise.

Dr. Jones gives examples of ageism impacting elderly care.  She describes the plight of an elderly woman admitted to a local hospital where it was presumed, due to her age, that she had advanced dementia. Hospice care was recommended for the woman at discharge. The woman had been leading an active life in retirement, serving  as the chairman of the board at a prestigious company, and caring for her disabled adult son.  She was physically fit , and an "avid Pilates participant."   It turns out that a new physician at her practice recommended a higher dose of diuretic, which she dutifully accepted, and several days later she became delirious from dehydration.  Dr. Jones concludes, "All she needed was IV fluids." 

Dr. Jones explains her recent treatment of an attorney in her 70’s who had a slow growing brain tumor that was causing speech difficulties. The attorney was written off as having dementia until an MRI performed to explore the reason for new left-eye blindness revealed the tumor.  The patient's tumor was removed successfully, but she was denied brain rehabilitation services because of her “history of dementia.”

Another patient, an 80-year-old male, was presumed to be an alcoholic when he showed up to his local hospital.  The patient, had, in fact, suffered a stroke.

These cases, and the countless cases like them, underscore the importance of good health care planning as part of a comprehensive estate plan.   I recommend that every client select and appoint a  trusted primary care physician, by name, in his or her estate planning documents.  I recommend that this person be given the authority to render decisions regarding competency and capacity.  I urge clients to develop a healthy on-going relationship with this physician, so that the physician will be aware of the client's lifestyle, speech patterns, comportment, and the like.  I urge clients to nurture this relationship even during periods during which the client is healthy, and without need for acute care.  Too often, the first time that a medical professional is evaluating a patient is immediately after an acute event or occurrence, inviting erroneous presumptions and judgements.  

Particularly for my clients hoping to Age in Place, this lifetime planning is vitally important. Inviting or acquiescing to a set of circumstances that result in health care decisions being made by professionals without knowledge or experience about you, only increases the possibility that institutional  long term care is your outcome.  Most of my clients work with legal counsel, their families, and their health care professionals to prevent unnecessary and avoidable long term institutional care.  

For more information regarding Aging in Place planning, go here.  For more information regarding LegalVault®, a system through which health care and legal documents are stored, protected and made available to health professionals upon demand, twenty-four hours a day, seven days a week, 365 days a years, go here.  

Aging in Place: CMS Reports Success in Reducing Medicare Cost for Long-term Care Residents by Reducing Hospitalizations

Infringing on the autonomy of Medicare patients to seek quality care is paying off in massive dollar savings for the federal government.   This blog previously reported on the controversial sign-off rule that prevents Medicare patients discharged from hospitals to nursing facilities from returning easily to the hospital for necessary care.  Before the rule, if you were discharged to a nursing home, but later felt that hospital care was necessary, you could simply ask to be transported back to the hospital.  Your wife, your health care proxy, or the nursing home could transport you back to the hospital.

After implementation of the rule, not even the nursing home, if it believes the hospital  is better able to care for you, can return you to the hospital, unless there is a life-threatening condition, or a doctor first examines you and "signs off" on the the transfer.   The nursing home industry objected to this hard-to-justify restriction on its authority and discretion. 

Since 1984, the federal policy of reducing the hospital stays of Medicare patients, which some have characterized as "quicker and sicker," has increasingly transitioned elderly health care from hospitals to highly regulated skilled nursing facilities in order to reduce the cost of Medicare.  There is increasing evidence that there are significant resulting adverse outcome outcomes.  Now, the federal government implies that these same facilities cannot be trusted to make decisions regarding choice of care. Physicians are relegated to gatekeepers for more expensive care, even where necessary. 
   

In the first assessment since the controversial rule was implemented, the Centers for Medicare & Medicaid Services (CMS) reported that the rate of potentially avoidable hospitalizations among dual-eligible long-term care residents fell by nearly a third in recent years.  In a data brief posted on the CMS blog, officials documented the “real progress” made in reducing cases of potentially preventable hospitalizations among long-term care residents over the last decade. Overall, the hospitalization rate for beneficiaries eligible for both Medicare and Medicaid — including those outside of long-term care facilities — fell 13% between 2010 and 2015.

In that same five-year timespan, the rates of hospitalizations among dual-eligible long-term care residents caused by potentially avoidable conditions, such as dehydration, urinary tract infections and skin ulcers, dropped 31%. That decrease was widespread, with improvement documented in all 50 states. In total, the decrease meant dually-eligible residents avoided 133,000 hospitalizations between 2010 and 2015.  The brief does not, however, report that the overall incidence of avoidable conditions decreased — only that hospitalizations for the conditions decreased.    In fact, the only reported reduction in incidence (i.e., improvement in actual health outcomes), appears to have come from the Agency for Healthcare Research and Quality (AHRQ) Safety Program for Long-Term Care, which "significantly reduced catheter-associated urinary tract infections in hundreds of participating long-term care facilities nationwide."  This 2001 project helped prevent a recognized cause of hospitalizations in residents of these facilities.  One can assume that the absence of reported reductions in other potentially avoidable conditions means that there was no significant reduction attained.

CMS is applauding its ability to reduce expensive hospitalizations, but is tacitly acknowledging that these weren't achieved by better quality care, but rather from impediments and disincentives to more expensive, higher quality care. There is nothing in the recent report that suggests overall  improvements in healthcare outcomes for the nation's elderly.     

Blog authors Niall Brennan, chief data officer for CMS, and Tim Engelhardt, director of CMS' Federal Coordinated Health Care Office, attributed the decrease to the “committed work by those who directly serve older adults and people with disabilities,” as well as programs such as the agency's “Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents.” The post also highlighted CMS' Hospital Readmission Reduction Program, Accountable Care Organizations and bundled payments as drivers behind the hospitalization rate drop.

This article was inspired by an article in McKnights, the original of which can be found here.  

National Health Care Decisions Day: Conflicting State Laws Interfere with Patient's Health Care Choices

The results of a new study underscore the importance of advanced directives and health care proxies in routine estate and health care planning.  The researchers concluded that the ability of medical professionals to understand and honor patients' medical decisions is made more difficult by conflicting state laws, a problem anticipated to only grow along with the nation's booming senior population.

The study of medical decision-making rules,  is the first  of its kind.  Researchers with Beth Israel Deaconess Medical Center, the Mayo Clinic, and the University of Chicago reviewed laws from all 50 states regarding the medical choices of patients. Their findings, published Thursday in the New England Journal of Medicine, show a conflicting system of rules that is difficult to navigate.  The complexity and conflicts may impede professionals ihonoring patients' wishes.

Fewer than 30 percent of Americans have “advance directives” or legal documents outlining their treatment preferences that can also grant someone power to make medical decisions on their behalf. These documents are often necessary, and when available, used when a patient is unconscious, incapacitated or unable to speak for him/herself.  Such documents cam dictate how to treat – or not treat – anything from a minor illness to a life-threatening injury. On average, 40 percent of hospitalized adults cannot make their own medical decisions. In some intensive care units, that figure reaches 90 percent.

Erin Sullivan DeMartino, MD, a pulmonary and critical care medicine physician at Mayo Clinic in Minnesota who led the study as part of a fellowship with the University of Chicago’s MacLean Center for Clinical Medical Ethics, explained in a release accompanying the publication of the study:

“Decisions about withdrawing or withholding life-sustaining care are incredibly emotional and challenging.  But when there is ambiguity about who is responsible for decision-making, it adds much more stress to that moment.

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We have medical technology we didn’t have 50 years ago, so we have a whole group of people who – transiently or sometimes permanently – can’t communicate with us and can’t participate in their own life-and-death decisions."   

Thirty states require the “alternative decision makers” of patients to have an ability to make difficult medical decisions, such as withdrawing a feeding tube or other life-sustaining treatment. But there's no way to assess that ability, the review said. Thirty-five states employ a “surrogacy ladder,” which creates a hierarchy of people able to make medical decisions when patients don't have a power of attorney. But even those systems vary when it comes to the types of decisions surrogates can make.

"One important message from this study is that, in the absence of a clearly identified spokesperson, the decision-making process for incapacitated patients may vary widely depending on where they live,” said senior researcher Daniel B. Kramer, M.D., MPH, in a release on the study.

The study also found states varied in how they defined an appropriate decision maker. Some require surrogates to have an in-depth knowledge of a person's beliefs, while others only require the decision maker be an adult.  The biggest takeaway from the review, according to the research team, is that despite ongoing disputes in healthcare facilities about patients' decisions, no nationwide standard or guide exists for family members or providers.

It is unclear whether the variation in statutes impacts clinical care, according to the research team.  One thing is certain: disputes about medical treatment are happening on a regular basis inside hospitals and hospice programs, and there’s no national standard or benchmark to guide families or physicians.  The more an individual plans, and reduces their decisions to writing, the more likely the individual's decisions will be implemented. 

National Health Care Decisions Day is April 17, 2017.  Throughout the week, August 17-21, our office, and the offices of legal and health care professionals will assist you at no charge in putting in place Durable Powers of Attorney for Health Care and Living Wills (Advance Directives).  If you, a family member, or friend don't have, and need these, please call our office at 877-816-8670.   

Antipsychotics and Psychotropic Drugs Increase Fall Risks in Nursing Homes

McKnight's Long Term Care News reports that psychotropic drugs, including antipsychotics and antidepressants, increase the risk of falls among nursing home residents, according to a recently published study.

Previous research suggested a link between psychotropic prescriptions and falls in nursing home residents, but little was known of how "as-needed" prescriptions impacted fall rates. The study, published in the December issue of JAMDA - The Journal of Post-Acute and Long-Term Care Medicine by Dutch researchers, not only backed up earlier research, but found a relationship between falls and drugs taken on an as-needed basis as well.

Of the 2,368 nursing home residents in the study, nearly 70% had a prescription for at least one psychotropic drug per day. An additional 8.8% had an as-needed psychotropic prescription. The study's authors found that 33.5% of residents had at least one fall, which most often occurred on days when a psychotropic drug was prescribed on a scheduled basis.

Residents receiving the drugs on a scheduled basis had a nearly threefold increase in falls. An increase in fall incidence also was noted in residents prescribed the drugs on an as-needed basis. Results of the study also showed that male residents had a fall risk nearly two times higher than female residents.

Study results showed no link between fall incidence and the prescription of benzodiazepines, drugs commonly used to treat anxiety and insomnia.