Hospitals Cause or Facilitate Abusive Guardianships

When planning to Age in Place, folks must be aware of the causes of guardianship if they hope to have any chance of preventing abusive guardianships.  Hospitals are increasingly the source of guardianship referrals, and many are compromised or abusive guardianships The ABA Journal recently published an article, Cases Raise Questions about Adult Guardianship and Lawyer-Hospital Relationships,  reporting two recent sets of cases in which lawyers received guardianship appointments as a result of their relationships with hospitals. 

In one case, a Michigan judge removed a lawyer from several cases in which she served as a guardian or conservator after raising questions about a conflict of interest.  The case was originally reported in the Lansing State Journal. The presiding Judge  also referred the attorney to the state bar for a possible ethics investigation.

The lawyer was removed  for failing to disclose an agreement with a hospital in which she was paid to petition for guardianship of certain patients. In at least two of the cases, the hospital paid the attorney for time spent with the patients after she was appointed guardian.  The guardianship turned abusive, though, because the lawyer allowed his granddaughter and her boyfriend  to reside in the home of a ward for which the lawyer was guardian.

In South Carolina, the hospital's general counsel served as a patient’s guardian and conservator. The lawyer, received a public reprimand in an agreement for discipline by consent. The Legal Profession Blog noted the case.  The attorney billed more than $8,600 for her time as conservator and paid her son $700 to do repair and cleaning work at the patient’s home. At some point, the lawyer's son moved into the home without her knowledge; she had meningitis and was hospitalized for three months during the time period. The son also vandalized the patient’s home and sold the patient’s car after forging her name on a car title, the reprimand says. The attorney reported her son to police when she discovered his theft.

The New Yorker, too, is raising questions about the guardianship system in Clark County, Nevada, in which elderly people were removed from their homes without notice and without a lawyer to represent them.  In Nevada, hospitals also play a role in guardianships.

“Hundreds of cases followed the same pattern,” the article reported. “It had become routine for guardians in Clark County to petition for temporary guardianship on an ex-parte basis [meaning without a court hearing or notice to family, friends, or the public]. They [lawyers] told the court that they had to intervene immediately because the ward faced a medical emergency that was only vaguely described: he or she was demented or disoriented, and at risk of exploitation or abuse. The guardians attached a brief physician’s certificate that contained minimal details and often stated that the ward was too incapacitated to attend a court hearing.”

The article focused on one guardian, who was awarded a guardianship once a week, on average, and had up to a hundred wards at a time. There was evidence that the guardian visited hospitals and lawyers to build relationships and generate leads for potential clients.

Debra Bookout, an attorney at the Legal Aid Center of Southern Nevada, told the New Yorker that some hospitals were eager for a guardianship appointment:

 “When a hospital or rehab facility needs to free up a bed, or when the patient is not paying his bills, some doctors get sloppy, and they will sign anything.”

The "anything" is often the physicians’ certificate used to obtain ex parte guardianships.

The lawyer subject of the New Yorker article was indicted for perjury and theft in a case that focused on alleged double billings and sloppy accounting.

The New Yorker article notes that Nevada is reforming its guardianship system; a new law will entitle all wards to be represented by lawyers in court. The New Yorker questions whether that is enough. The guardianship commissioner who approved Parks’ appointments was transferred to dependency court but didn’t lose his job. And another guardian who is considered “the godfather of guardians” in Nevada is still listed as a trustee and administrator in several cases.

Increasing Blood Pressure Drugs Upon Hospital Discharge Poses Health Risks

Increasing blood pressure medications when older patients are discharged from the hospital may also increase falling, fainting or kidney injury risks, according to a new study reported by a recent article in McKnight's Long-term Care News. Investigators claim such dangers outweigh possible treatment benefits.

Researchers from University of California, San Francisco and San Francisco VA Health Care System studied more than 4,000 patients who were at least 65 years old and hospitalized for non-cardiac issues. Patients discharged with greater amounts of blood pressure drugs saw no fewer cardiovascular events and no improvement of blood pressure control after one year. At the same time, risk for readmission and serious adverse events surged for some patients within 30 days of discharge.

“Our findings suggest that making medication changes during this period is not beneficial,” said the study’s lead author, Timothy Anderson, M.D., MAS, MA, a primary care research fellow in UCSF’s Division of General Internal Medicine.  “Instead, deferring medication adjustments to outpatient doctors to consider once patients are recovered from their acute illness is likely to be a safer course,” he added. 

This blog rarely reports regarding hospital health outcomes, but this study impacts directly Aging in Place since it concerns prescriptions written at or near discharge from the hospital. Seniors and their families should be aware of the findings, and the concerns raised by these findings, and may want to independently verify the advisability of such prescriptions with a primary care physician upon discharge. 

Study Shows Some Hospitals Steering Patients Away from Nursing Homes

Put YOU back in your plan!

Good news is on the horizon for seniors and their families hoping to Age in Place, i.e., avoid unnecessary institutional care.  There is evidence the underlying health care system is reforming to embrace Aging in Place preference for non-institutional care.  According to an article  published in McKnights Long Term Care News, hospitals participating in bundled payment efforts are actively reducing the use of skilled nursing care! The evidence comes in the form of a new study out of the University of Pennsylvania, published Monday in Health Affairs.

Skilled care is a big driver of cost growth and variation in Medicare, the authors note. In 2015 alone, about twenty percent (20%) of Medicare fee-for-service hospital admissions went to a Skilled Nursing Facility (SNF), despite scant evidence that this is the optimal post-acute setting, or that a nursing home helps improve quality, Penn researchers wrote.  Of course, that is no surprise to those of us in the "Aging in Place: community.  Long have advocates decried the obvious negative physical, mental, and  and emotional health outcomes so often incident to and consequence of institutional care, and particularly unnecessary or avoidable institutionalization.   

Motivated primarily by concerns for cost growth and variation, however, the Centers for Medicare & Medicaid Services (CMS) has finally arrived at the same destination.  CMS has undertaken both the Bundled Payments for Care Improvement initiative and the Comprehensive Care for Joint Replacement model in an effort to eradicate some of that cost variation. Wanting to better understand how hospitals are navigating these waters, researchers interviewed leaders at twenty-two (22) institutions taking part in those two CMS bundled pay efforts.

"It's clear from the results that hospitals are looking to reduce SNF use," said Jane Zhu, lead author and a national clinician scholar and fellow in the Division of General Internal Medicine at Penn's Perelman School of Medicine.  She explained:   

“For the past couple of decades, we've had a persistent increase in SNF utilization across the country, but it's still very unclear what the benefit ultimately is for patients, and what the optimal post-acute setting is,” she told McKnight's. “As bundled payment incentives force hospitals to think along the lines of total cost of care, they're starting to see that, for certain patients, skilled nursing facilities offer no greater benefit and are more expensive than other venues.”

Often, hospitals are reducing SNF referrals by using risk-stratification tools, better educating patients, providing care support at home, and better linking up with home health agencies to smooth out any discharge hiccups.  Of course, patient choice and directive, not mentioned by the researchers or McKnights may also be contributing to reduced SNF utilization.

Other hospitals, meanwhile, are strengthening bonds with nursing homes, researchers found. Fifteen institutions formed networks of preferred SNFs, aiming to exert influence over cost and quality. Typical tactics found included linking electronic medical records, embedding a hospital provider in the nursing home and hiring dedicated care coordination staffers.  Most often, hospitals are partnering with SNFs with which they are familiar and have trust, rather than reaching out to new partners, authors added.

Zhu's three key takeaways for skilled nursing operators:

Payment really matters. Hospitals have been “really conscientiously and in a very collective manner reorganizing the way that they are thinking about post-acute care, and specifically trying to save costs, along those lines.” The payment structure is having a distinct effect on hospitals' behavior.

The extent to which these practices have been disseminated is unclear. Some of the things hospitals are doing have “enormous implications” for skilled nursing facilities. Hospitals are really trying to move away from SNF use, particularly for joint replacement patients. They are trying to then integrate and coordinate care with skilled nursing facilities through a variety of different structures.

There's uncertainty over what the ultimate implications are for SNFs. There is a question of what sorts of pressures SNFs will face, given these hospital practices.

“SNFs are not only under heavy pressure to work more closely with hospitals and to compete to be the desired referral partner,” Zhu told McKnights, “but they're also facing downward referral pressures as hospitals try to send their patients, more and more frequently, home.” 

Future research may expand on how nursing homes are responding to this trend. 

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.  

You Can Look Up Nursing Home Fines, ER Wait Times On Yelp!

Consumers have one more tool available to help in making informed health and long term care decisions. The website Yelp, which is perhaps best known for publishing crowd-sourced reviews about local businesses, is adding health-care data to its review pages for medical businesses to give consumers more access to government information on hospitals, nursing homes and dialysis clinics.

Consumers can now look up a hospital emergency room's average wait time, fines paid by a nursing home, or how often patients getting dialysis treatment are readmitted to a hospital because of treatment-related infections or other problems.

The review site is partnering with ProPublica, a nonprofit news organization based in New York. ProPublica compiled the information from its own research and the Centers for Medicare and Medicaid Services. The data is for 4,600 hospitals, 15,000 nursing homes, and 6,300 dialysis clinics in the United States, and it will be updated quarterly.

Much of the information about hospitals, for example, is available on Medicare's Hospital Compare Web page. Yelp executives say the information is sometimes difficult to find and more difficult for consumers to understand.  Yelp is therefore adding the information to it's website in a usable consumer friendly format.