Showing posts with label hospice. Show all posts
Showing posts with label hospice. Show all posts

Wednesday, June 17, 2020

Hospice Provides Comfort for Veterans and Their Families

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The following is a reprint of an excellent article from Veterans Family Matters and VAGA News:
At the end of life, every patient is unique. When a patient with an advanced illness is ready to start the conversation, hospice care focuses on improving quality of life. When that patient is a veteran, providing appropriate care requires insight into the challenges they face throughout life, not only at its end.
In general, hospice patients are estimated by their physicians to have six months or less to live. But receiving hospice care doesn't mean "giving up" or compromising comfort and dignity. As part of the Medicare Part A hospice benefit, hospice patients are entitled to whatever their terminal diagnosis requires. This includes medications, home medical equipment, supplies, supportive services and care from a team of experts.
The interdisciplinary hospice team-nurse, hospice aide, social worker, physician, chaplain, bereavement specialist and volunteers-provides clinical, spiritual and psychosocial care to the patient and their family wherever they call home. 

Unique Care for Veterans

Veterans face experiences throughout their military careers that test the limits of the human body and mind. The repercussions of these experiences may linger long after a veteran's service ends, and their needs at the end of life can be severe and varied.
Hospice experts are trained to support these difficult circumstances, including financial and benefit concerns, post-traumatic stress disorder, unresolved issues associated with military service, depression and suicide. Veteran liaisons ensure the patients have access to every benefit to which they're entitled.
Some hospice providers also participate in We Honor Veterans, a program developed by the National Hospice and Palliative Care Organization and the VA to improve care for vets in hospice. Veterans are shown how much their service is valued through special events and activities, including trips to the Washington, DC, war memorials via the Honor Flight Network®.
 For patients with advanced illness, hospice helps make the best of those final months, weeks and days. Hospice patients enjoy being home among loved ones, free of medical expenses, and in the care of a team dedicated to their comfort and dignity.
Larry Robert, Bereavement Services Manager/Veteran Liaison
VITAS Healthcare of Atlanta
www.vitas.com

Friday, January 10, 2020

Hospice Comprehensive Assessment Measure - One Pager Now Available while the Administration develops HOPE

CMS has posted a document that articulates key information about the current Hospice Comprehensive Assessment Measure. This "one pager" provides a visual depiction that helps providers, seniors, their families, and caregivers, understand how the seven Hospice Item Set (HIS) measures contribute to the one Comprehensive Assessment Measure (CAM), and helps providers to stay on target by completing all seven HIS measures for each patient. The  CAM helps to ensure all hospice patients receive a holistic comprehensive assessment at admission, although it does not replace a comprehensive assessment. 

Of course, while helpful, HOPE is on the way.  Section 3004 of the Patient Protection and Affordable Care Act, requires the Secretary of Health and Human Services to establish procedures for making data available to the public and to ensure hospices have the opportunity to review that data prior to public reporting. CMS is developing a new patient assessment tool to be proposed in future rulemaking. As finalized in the Fiscal Year 2020 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Requirements Final Rule, the hospice patient assessment instrument is identified as the Hospice Outcomes & Patient Evaluation (HOPE). This new tool is intended to help hospices better understand care needs throughout the patient’s dying process and contribute to the patient’s plan of care. It will assess patients in real-time, based on interactions with the patient, as opposed to the HIS retrospective chart review. Finally, HOPE will support quality improvement activities and calculate outcome and other types of quality measures in a way that mitigates burden on hospice providers and patients. 

Objectives of the HOPE
The HOPE will provide standardized data as all Medicare-certified hospices will be collecting the same assessment items for all patients. Standardization will allow CMS to analyze the data by patients, hospices, and recognize the differences between hospices. Through data analytic summaries and comparisons, hospice providers will have information to help them identify opportunities to adjust and improve patient- and agency-level decisions about the care they provide. Furthermore, patients and their families will be more informed about the hospice they choose based on quality measures that measure outcomes throughout the hospice stay and public reporting.
The two primary objectives of the HOPE are to:
  • Provide quality data for HQRP requirements through standardized data collection
  • Provide additional clinical data that could inform future payment refinements.
CMS seeks to develop quality measures associated with the new assessment tool that are meaningful to all stakeholders and reflect critical outcomes of care throughout the hospice stay. The measures will meet the Meaningful Measures Initiative objectives to identify high priority areas for quality measure development while reducing burden on hospice providers. They will focus on outcomes and also fit well with the hospice business model. 
Differences between HIS and the HOPE
Currently CMS collects data at admission and discharge via the Hospice Item Set (HIS) that are used to calculate measures in the Hospice QRP. However, while HIS is a standardized mechanism for extracting medical record data, it is not a patient assessment tool because the data is not collected during a patient assessment. Instead, HIS focuses on whether hospices have performed care processes using data from chart abstraction. CMS’s goal for the HOPE is to be more comprehensive than the HIS by capturing patient and family care needs in real-time and throughout the hospice stay, with the flexibility to accommodate patients with varying clinical needs. The HOPE will take into consideration hospice workflow and the Medicare Conditions of Participation. Data in patients’ baseline status and changes in their outcomes from the HOPE will contribute to care planning and inform quality measurement for the Hospice QRP, including outcome measures, and support providers’ quality improvement efforts.
Process for Developing the HOPE
The general process for the development of the HOPE includes, but is not limited to, the following calendar year 2019 activities: information gathering, stakeholder engagement, and preparing for initial testing of the HOPE. After the initial testing, the HOPE will be revised based on test findings before moving forward to national-level testing. After conducting the national-level testing of the HOPE, CMS will incorporate learnings by refining the HOPE and propose the tool in rulemaking and seek public comments. When finalized in future rulemaking, the HOPE will be implemented in the Medicare Hospice Benefit to provide value to hospice providers, patients, and families.   

Monday, April 15, 2019

Hospice Use by Nursing Homes on the Rise, but still Underutilized

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For those who implement an "Aging in Place" plan, hospice plays an integral part in the planning.  First, hospice care is "person-centered care" of the type and kind those who seek to stay home want and need.  Hospice focuses on "palliative care", a specialized type of care focused on relief from the symptoms and stress of a serious illness, with the goal being to enhance or improve the quality of life for both the patient and the family. Second, hospice is a benefit paid for by Medicare, meaning that there is no need for 'spend down," or planned or unplanned indigence to obtain the care.  

Now, according to an article in McKnight's Long-term Care News, more nursing homes are providing hospice care.  The article reported the results of a new LeadingAge report. The Report also finds that hospice care, nonetheless, remains largely underutilized. 

The report notes that the hospices’ prevalence has skyrocketed in recent years, with the number of providers nearly doubling since 2000, at about 4,200 in 2016:
Over the same period of time, the hospice patient population has changed drastically: hospice is now serving more individuals residing in nursing homes and assisted living in addition to its traditional home-based population. In 2016, half of all Medicare hospice beneficiaries died at home and a third died in a nursing home. The terminal conditions experienced by hospice enrollees are also changing. Whereas hospices initially served primarily patients with cancer, they now serve individuals with many different diagnoses, including neurological conditions such as dementia, as well as progressive cardiac and pulmonary diseases [citations omitted]. 
In 2016, about half of all Medicare hospice beneficiaries died at home, while one-third died in a nursing home. Terminal conditions treated by the benefits have changed too. While the service was almost exclusively limited to cancer in the past, patients with dementia and heart disease are increasingly using it, too.

Though hospice use has grown exponentially in recent years, utilization remains low, according to the report. More than one-fourth (28%) of Medicare beneficiaries who used the benefit enrolled for fewer than seven days immediately before death, a length of stay thought to be of less benefit to patients and their families than a longer stay. According to the report, these short stays relate to:
  • Physicians being reluctant to discuss hospice or delay such discussions until the patient is close to death;
  •  Some patients and families having trouble accepting a terminal prognosis;
  • The requirement that patients forego intensive conventional care in order to enroll in hospice; and,
  • Financial incentives in fee-for-service Medicare that encourage increased volume of clinical services.
Congress and CMS have introduced a number of initiatives to promote earlier hospice enrollments and better-quality end-of-life care.

Wednesday, April 10, 2019

Why Hospice is Integral to Most Aging in Place Plans - Palliative Care Paid for By Medicare

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For those who implement an "Aging in Place" plan, hospice care plays an integral part in the planning.  First, hospice care is "person-centered care" of the type and kind those who seek to stay home want and need. Hospice is "palliative care", a specialized type of care focused on relief from the symptoms and stress of a serious illness, with the goal being to enhance or improve the quality of life for both the patient and the family.  Second, hospice is a benefit paid for by Medicare, meaning that there is no need for "spend down," or planned or unplanned indigence to obtain the care, in most cases.  Simply, Medicaid is unnecessary for most hospice benefits. 

Hospice Care Improves the Quality of Care and Life


Hospice Volunteer
ID 64539590 © Katarzyna Bialasiewicz | Dreamstime.com
Numerous studies demonstrate that many seriously ill patients and their families receive inadequate care, characterized by untreated pain and physical symptoms, spiritual and emotional distress, high family caregiving burdens, and unnecessary or unwanted treatments inconsistent with their previously stated wishes and goals for care.  Hospice care greatly improves the quality of care for patients and their families near the end of life. Palliative care services provided through hospice delivered by a team of professionals, including physicians, nurses, social workers, chaplains, home health aides, and volunteers, to dying patients (patients with a life expectancy of six months or less), who are willing to forgo curative treatments, have been demonstrated to greatly reduce symptoms  of distress, improve outcomes for caregivers, provide a high level of patient and family satisfaction, and reduces the use of hospital-based services, including emergency department visits and intensive care unit stays, together with the likelihood of death in the hospital.

Medicare Pays for Hospice Care 

The Medicare program pays a daily rate to hospice providers, who assume all financial risk for costs and services associated with caring for the patient’s terminal illness and related conditions. The hospice program is paid for each day the individual is enrolled, whether or not the program visits the client that day. This enables the program to cover other costs, such as palliative care, and management of the terminal condition plus “related services” such as care planning, on-call services, drugs, medical equipment, supplies and transportation. Payments are made based on four levels of care, distinguished by intensity and setting of services: 
  • Routine Home Care, the most common (98% of all hospice days in 2016). With this type of care, the individual has elected to receive hospice care in his or her residence.
  • Continuous Home Care (CHC). This care is provided for eight to 24 hours a day to manage pain and other acute medical symptoms. It is predominantly nursing care and maintains the person during a pain or symptom crisis. 
  • Inpatient Respite Care. This care provides temporary relief to caregivers by offering temporary care in a hospital, nursing home or hospice facility, where 24-hour nursing personnel are present. 
  • General Inpatient Care (GIC). This type of care is provided in a hospital, hospice or nursing home when pain or acute symptoms cannot be controlled at home.

The Quality of Hospice Care is Regulated

The quality of hospice care is highly regulated.  The Patient Protection and Affordable Care Act mandated a Hospice Quality Reporting Program (HQRP) that required that all hospices submit data on quality measures. Medicare Hospice providers that do not submit data face a loss of 2% of the payment increase they would get for the year under Medicare. The law further required that CMS publicly report on quality measures related to the care provided by hospice programs across the country.

In 2017, CMS released the Hospice Compare website to help consumers compare hospice providers based on their reported quality data. The quality measures that are reported by hospices are based on consumer feedback from hospice patients and their family members on aspects of care, such as communication with family members, training family members to help with care, their rating of the hospice and their willingness to recommend the hospice provider. Additionally, the hospice provider completes the “Hospice Item Set,” which includes information on how the hospice considers and addresses patient preferences, assessments and pain management.

Hospice Care Integrates in Supported Decision-making Plans

Hospice Care fits well in an estate and health care plan that implements "Supported Decision-making" precisely because it serves the objectives of most people who are concerned with and consider more than just themselves.  Simply, hospice, like your planning, considers and concerns itself with your loved ones.  For example, bereavement support, which is delivered to family members in preparation for and after an individual’s death (for 13 months), considers and is concerned with your loved ones. Medicare does not reimburse for bereavement support. This support is, nonetheless, required by hospice regulations and is a unique and crucial function of the Medicare hospice benefit.  Another way of understanding this benefit, is that it is a community-based benefit, for which the government does not pay, but which is available to a patient and a patient's family simply because it is humane! 

ID 107903000 © Robert Kneschke | Dreamstime.com
Because bereavement support is not reimbursed, hospices attempting to cut costs may, admittedly, see it as an easy place to limit services. For example, a hospice may choose to send a letter with a phone number for bereavement care or ask social workers to assume bereavement responsibilities rather than employ a bereavement counselor to meet with and support families. Some hospice providers may even simply refer the families of their patients to other hospice programs for bereavement support, which circumvents their responsibilities and increases the burden on hospices that do offer complete bereavement services.

Fortunately, nonprofit, community-integrated hospices have been shown to be more likely than their for-profit counterparts to provide certain bereavement services, such as support groups and workshops, and to offer services to the community.  Many nonprofit, community-based hospice programs provide services, such as group therapy, one-on-one grief counseling and specialized programs like grief camps for children. These hospices often serve as first responders for trauma in their communities, regardless of whether the recipients of the grief support or trauma counseling services have family members who utilized the hospice program. For example, a school that experiences the sudden death of a student may rely on its local hospice to meet with grieving staff, students, and affected family.  

Hospice Care Utilizes Volunteers More Likely to Be Concerned with You than with any Other Competing Concern

Why do you trust your spouse, your child, or your most closest friend or loved one, and why do you select him or her as your fiduciary?  Chances are that your answer includes a belief that he or she will consider your interests and needs above their own, and certainly above other less important but competing concerns such as cost, or convenience. The people that you have the most trust and confidence in are those who, because of their love and affection, will consider your needs first.  

Hospice providers utilize volunteers for this same reasons.  Because volunteers are people who volunteer their time, and have no financial or other incentive other than their altruistic desire to "help," they are more likely to consider your needs and wishes as being paramount.  These volunteers are usually people who have themselves benefited from hospice care, and having receive the benefit of the selflessness of others, commit themselves to providing that same benefit.  Most hospice volunteers will, if asked, share their journey and experiences.  

Hospice is the only Medicare benefit that requires community volunteers to deliver a significant portion of patient care hours. Medicare sets a 5% threshold for volunteer involvement.  Some providers struggle to meet this threshold, and the requirement is, unfortunately, not well enforced despite being a condition of participation. Of course, oversight is properly more concerned with quality of care provided than ancillary services.  Nonprofit hospices are, fortunately, leaders in using volunteers. Moreover, non-profit and for-profit providers that well utilize volunteers often expand the typical volunteer role by creating specialty volunteer-driven programs tailored to the needs of patients and families. These programs include: 
  • Veteran-to-veteran programs that match patients who have served in the military with volunteers who have also served;
  • Pet therapy teams, in which registered animals and handlers visit hospice patients to provide companionship; and,
  • Vigil programs, which provide around-the-clock care for patients in the final hours of life.
One study noted that, compared to nonprofit hospices, for-profit and government-owned hospices used proportionally fewer volunteer full-time equivalencies as a proportion of total staff. The use of volunteers by providers ensures that hospice programs have ongoing integration with their local communities. 

The Choice Between Non- and For-Profit

Whatever the statistics, there are good and bad nonprofit and for-profit hospice care providers.  Among the "Supported Decision-making" objectives, then, should be the evaluation and selection of competing care providers.  Only by understanding hospice care, hospice providers, and the competing costs and benefits of different providers can you, and those who make decisions on your behalf, effectively consider and evaluate hospice care, and its providers.  Utilization of government data, such as is available through Hospice Compare, formal and informal interviews, inspections, and visits, as well as advice and counsel of professionals, such as with physicians, health care professionals, socials workers, and elderlaw attorneys, can ensure a more appropriate selection of provider.    



Wednesday, March 6, 2019

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:

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:
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.

Monday, June 12, 2017

Do-Not-Hospitalize Orders Underutilized, Could Reduce Hospital Stays

Do-not-hospitalize (DNH) orders help reduce the number of hospital stays and emergency department visits for nursing home residents, but they are used by a relatively small portion of the population, according to a new study reported by McKnight's.
Researchers with Rutgers University and State University of New York at Albany analyzed data for more than 6,000 nursing home residents to determine the impact of DNH orders. Their findings showed 61% of residents had do-not-resuscitate orders and 12% had feeding restrictions, but just 6% had DNH orders.
Residents with DNH orders had significantly fewer unnecessary hospital stays and emergency department visits in their last 90 days of life than residents without them, the researchers reported in the May issue of JAMDA. The orders also helped reduce hospital stays for residents with dementia.
The findings suggest skilled nursing providers should encourage residents to complete DNH orders, researchers said, in order to “promote integration of the resident's values and goals in guiding care provision toward the end of life."

Saturday, April 29, 2017

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.
 *          *          *
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.  

Saturday, April 1, 2017

Aging In Place- Pre-hospice Care Helps Patients Stay Home

Among the growing number of tools and resources aiding consumers to "age in place" is "pre-hospice." Kaiser Health News recently published an encouraging article, Pre-Hospice" Saves Money By Keeping People At Home Near The End Of Life, that well explains the concept and its promise. 

The article first discusses the practical impediments consumers face in an effort to age in place:
"Most aging people would choose to stay home in their last years of life. But for many, it doesn’t work out: They go in and out of hospitals, getting treated for flare-ups of various chronic illnesses. It’s a massive problem that costs the health care system billions of dollars and has galvanized health providers, hospital administrators and policymakers to search for solutions."
According to the article, Sharp HealthCare, a San Diego health system, devised the pre-hospice program called Transitions as a way to fulfill patients' desire to stay home, keep them out of the hospital, provide necessary care in their home, and reduce the costs of care. Social workers and nurses from Sharp regularly visit patients in their homes to explain what they can expect in their final years, help them make end-of-life plans, and teach them how to better manage their conditions, illnesses, and diseases. Physicians track their health, and eliminate unnecessary medications and treatments.  Unlike hospice care, patients don’t need to have a prognosis of six months or less to live, and they receiving curative treatment for their illnesses - not just relief from symptoms.

Transitions was among the first of its kind, but now there are several such "home-based palliative care" programs around the country. They are part of a broader push to improve people’s health and reduce spending through better coordination of care and more treatment outside of hospitals. Palliative care focuses on relieving patients’ stress and pain as their health declines, and aims to maintain quality of life. For people with serious illnesses, such as cancer, dementia, and pulmonary and heart failure, the plan is to provide patients palliative care and then transition naturally to hospice care when necessary.  The 2014 report “Dying in America,” by the Institute of Medicine, recommended that all people with serious advanced illness have access to palliative care. 

Transitions is one of the many good ideas that has come from Kaiser Permanente. Nearly 20 years ago, Kaiser created a home-based palliative care program in California and later in Hawaii and Colorado. Studies by Kaiser and others found that participants were far more likely to be satisfied with their care and more likely to die at home than those not in the program. One of the studies found that 36 percent of people receiving palliative care at home were hospitalized in their final months of life, compared with 59 percent of those getting standard care. The overall cost of care for those who participated in the program was a third less than for those who didn’t. A more recent study confirms these conclusions. 

The article also discusses that although the need for such services is increasing, "not enough trained providers are available. And some doctors are unfamiliar with the approach, and patients may be reluctant, especially those who haven’t clearly been told they have a terminal diagnosis." 

Of course hanging over ever the entire health care industry is what becomes of the Affordable Care Act.  The Affordable Care Act  established new rules and pilot programs that reward the quality rather than the quantity of care, such as “accountable care organizations,” networks of doctors and hospitals that share responsibility for providing care to patients. These organizations also share the savings when they rein in unnecessary spending by keeping people healthier. Innovations such as these are helping to make pre-hospice and home-based palliative care a more viable option.

Sunday, February 26, 2017

Institutional Care: America's Most Vulnerable Seniors Raped and Sexually Abused

The headline alone is nauseating.  "SICK, DYING AND RAPED IN AMERICA'S NURSING HOMES," screams the headline of the recent CNN report detailing the incidence of sexual assaults in America's nursing homes, and the indifference of the government and regulators to the epidemic of violence visiting the most vulnerable in America's nursing homes. The facts elicited by CNN reporters in individual cases sicken and disturb. 

That such a story even exists is maddening.  More than 16,000 cases of sexual abuse have been reported in nursing homes and assisted living communities since 2000, according to the CNN report.  But the figures do not tell the complete story.  They don't even come close. The reason is that the government does not specifically track sexual abuse.  Despite the frequency, and indeed, the devastating impact upon victims and their families, state and federal government simply does not track or keep statistics of sexual assault.  CNN explains: 
Despite the litany of abuses detailed in government reports, there is no comprehensive, national data on how many cases of sexual abuse have been reported in facilities housing the elderly.
State health investigators examine all types of abuse reported at nursing homes and assisted living facilities, whether reported by the facilities or flagged by complaints to the state from witnesses, family members or victims. In the case of nursing homes, state officials typically conduct these investigations, as well as routine inspections, on behalf of the federal Centers for Medicare & Medicaid Services (CMS), which regulates the more than 15,000 facilities that receive government reimbursements that pay for many residents' care. Both state health agencies and the federal government then use the information to rate facilities and issue financial penalties for the worst offenders.
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CNN surveyed the health departments and other agencies that oversee long-term care facilities in all 50 states. Of the states that could provide at least some data, the responses varied widely. 
Illinois, for example, said 386 allegations of sexual abuse of nursing home residents had been recorded since 2013, 201 of which involved a caretaker. Hawaii said eight allegations of sexual abuse were investigated between 2011 and 2015 -- five of which involved a caregiver. And when states provided a further breakdown of how many allegations had been substantiated, the results demonstrate just how few accusations end up being proven -- whether it's because of the extreme hurdles posed by aging victims, the destruction of evidence, or half-hearted investigations by facilities and regulators.
Of the 386 cases in Illinois, 59 were considered substantiated. And in Texas, 11 of 251 sexual complaints in the 2015 fiscal year were substantiated. Wisconsin said it didn't have a single substantiated report of abuse in the last five years.
But most states could not say how frequently abuse investigations involved sexual allegations, often stating that sex abuse allegations are not categorized separately from other forms of abuse.
The federal government doesn't specifically track all sexual allegations either.
The reported figure comes from federal data maintained by the U.S. Department of Health and Human Services' Administration for Community Living (ACL), the cable network said, noting that ACL officials said that it includes only cases that involved state long-term ombudsmen.

To arrive at the figure reported, CNN reviewed civil and criminal court documents, state health investigations and CMS information (which included data only on nursing homes), and also interviewed experts, regulators and the families of victims. Although the investigation focused on nursing homes it also addressed assisted living communities, singling out two specific cases.

In one such case, a former cook at a Louisiana assisted living community,  was indicted and charged with first-degree rape of a resident. An executive at the community has also been charged for  failing to report abuse of adults and obstruction of justice, a charge she and the community that hired her denies.  

CNN also cited a 2013 case in Minnesota in which an 89-year-old assisted living resident with dementia was transferred to the mental health ward of a local hospital after she said she had been raped. A certified nursing assistant said he had consensual sex with the resident, and a director at the community believed him, according to CNN.

Most of the report focused on the abuse in nursing homes.  Before reciting specific, repeated, and heart-wrenching details of case after case, the news organizations made a stark and horrific assessment of its findings:

The unthinkable is happening at facilities throughout the country: Vulnerable seniors are being raped and sexually abused by the very people paid to care for them.
It's impossible to know just how many victims are out there. But through an exclusive analysis of state and federal data and interviews with experts, regulators and the families of victims, CNN has found that this little-discussed issue is more widespread than anyone would imagine.
Even more disturbing: In many cases, nursing homes and the government officials who oversee them are doing little -- or nothing -- to stop it.  
Sometimes pure -- and even willful -- negligence is at work. In other instances, nursing home employees and administrators are hamstrung in their efforts to protect victims who can't remember exactly what happened to them or even identify their perpetrators.
In cases reviewed by CNN, victims and their families were failed at every stage. Nursing homes were slow to investigate and report allegations because of a reluctance to believe the accusations -- or a desire to hide them. Police viewed the claims as unlikely at the outset, dismissing potential victims because of failing memories or jumbled allegations. And because of the high bar set for substantiating abuse, state regulators failed to flag patterns of repeated allegations against a single caregiver.
It's these systemic failures that make it especially hard for victims to get justice -- and even easier for perpetrators to get away with their crimes.
According to the report, perpetrators get away with their crimes in too many instances, sometimes through the intentional or negligent handling of the nursing homes themselves. Some perpetrators are first reported by other employees for assaults upon them, causing the nursing home to treat the issue as a labor matter, leaving vulnerable residents under the perpetrator's care. If you want to read more about the specific cases, go here.  The news network recommended that facility owners and operators investigate all incidents, preserve evidence, train employees on reporting practices, and employ sufficient staff to enable proper supervision of workers.

If you are a senior, a family member of a senior, or a caregiver, advocate, or fiduciary for a senior, it is imperative that you evaluate carefully institutional care.  Sexual abuse is only one of many risk factors about which you should be aware. This blog has included articles detailing many of these risk factors, warning that institutional care should be a last resort, and not an ordinary health care option as it is utilized by Medicare, Medicaid, and the current health care system.  These articles include the following:  



You should ensure that you, or those for whom you are or may be responsible,  adopt a comprehensive estate plan adopting and implementing an "Aging in Place" plan, and providing both guardianship planning and guardianship protection. Guardianship and institutionalization are cruelly related in that court appointed guardians often prefer institutional care for their wards, and institutions often refer residents for guardianship. For more information regarding the risks associated with guardianship, visit the National Association to STOP Guardianship Abuse.  Among the best planning tools developed to avoid the risk of institutional care is avoiding institutional care altogether. 


If you want to attend in person or online a seminar on "Aging in Place," its meaning, its importance, and how to incorporate it into your estate and financial plan, simply send us an email with your name and location.   

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