A Decade of Innovation: AARP Research Highlights Changes in Technology Adoption

A single decade means transformative change in the world of technology, particularly as regards health and aging in place.  In 2008 AARP examined technology use of the 65+ population.  The iPhone had just been released in June of 2007, so this survey did not consider smartphone use – there was no Digital Health “(a check engine light for your body!”); the Longevity Economy hadn’t been invented; Fitbit was a 2007 new clip-on tracker, and Facebook was still a campus toy. The survey was fielded in December of 2007 with a population of 907 adults aged 65-98 (mean age was 74) – rarely surveyed today, despite increasing lifespans.

The survey was conducted by showing responders  still pictures of products from a Leading Age video. Only one third of the 65+ had broadband in the home (the rest used dial-up) or had gone online at the time of this survey. The older responders were less likely to search for health information online or to trust online sources. Responders were also, generally, less willing to use a computer to interact with people at a distance (Skype had just surfaced in 2003).  Perhaps seeing the future, 6 in 10 thought that “personal computers will cost too much to install (62%), maintain (59%) and may not be something I need (58%).”  The 65+ population thought favorably about home safety devices, including mitigating losses from impairment (vision, mobility) – but only for others, not for themselves.

By 2011, according to the report Healthy@Home 2.0, in-home PC was commonplace; 71% of the 65+ population were using PCs to communicate with family and friends. Caregivers were increasingly using technology to help them manage care (although they still objected to being called caregivers). By 2018, tech attitude differences between the 70+ and younger population were obvious: while 90% of all adults owned a computer or laptop, those aged 70+ were more likely to use them, along with feature phones, and smartphone adoption had reached just 55% in the older group.  Among those under the age of 70, text messaging had taken over as the primary tool to stay connected, replacing email and telephone conversation, the latter of which was rarely used by younger individuals after 2015.

Telemedicine was positively perceived in 2008, but more than half of older adults said they would like to be able to monitor their health status at home, sending information to their doctor via telephone and email. By 2008, the VA had completed a study about the efficacy of home telehealth for veterans, in particular, aside from the claims of cost effectiveness, those that had the devices in-home felt more connected to their care providers. That was the good news. By 2019, the so-called tipping point in utilization by doctors has not been reached, though, perhaps it is just around the corner – the VA being the first to allow doctors to ‘practice’ across state lines.  But even though adoption is improving, only one-third of hospitals and 45% of doctors actually offer telehealth services. However, an October poll showed that older adults would still prefer in-person visits and anyway, have generally not encountered telehealth offerings. Their expressed concerns were nearly identical to those noted in 2008  -- more than half did not know if their doctor offered and nearly half worried whether the technology would work.

Technology is providing solutions precisely when they are most needed.  Aging in Place planning should consider and employ technological solutions where possible. 

https://www.ageinplacetech.com/blog/considering-technology-adoption-aarp-s-2008-healthyhome

Missouri Receives a Near Failing "D" on Nursing Home Report Card

Families for Better Care ("FBC"), recently  published its state-by-state nursing home report card. Missouri received  a near failing "D" grade, ranking thirty-ninth (39th) among the fifty states. The only bright news is that current ranking represents an increase in Missouri's relative ranking, up from  fortieth last year, and an improvement to Missouri's near failing "D" grade this year from a failing "F" last year. 

FBC scores, ranks, and grades states on eight different federal quality measures ranging from the number of caregiver hours residents received on a given day to the percentage of nursing homes cited severe deficiencies. The Report Cards include information from the newly revamped Nursing Home Compare reporting, requiring nursing homes to prove staffing levels, a sharp departure from previous administrations that accepted, without proof, representations from nursing homes regarding sufficiency of staffing.  More than one-third of nursing homes saw CMS ratings drop under the new, more deliberate, and more reliable system.

Regarding the Missouri's ranking, the Report Card noted:

• Missouri’s nursing home care climbed eight spots and moved up one full letter grade; ranking No. 39 overall and posting the state’s first non-failing grade in report card history.
• Missouri scored failing or below average grades in 5 of 8 nursing home quality measures.
• Less than 40 percent of Missouri’s nursing homes provide above average direct care staffing, resulting in a high percentage of understaffed homes.
• Missouri nursing home’s professional nursing services are among the most depleted in the nation as facilities provide fewer than 81 minutes of licensed nursing care per resident daily.
• Severe deficiencies in Missouri’s nursing homes climbed higher following the previous reporting period’s decline.
• Despite Missouri’s glaringly high percentage of facilities with deficiencies, the state’s ombudsmen verified 55 percent fewer registered complaints—pushing the state’s ranking into this year’s Top 10 states for this category.
• Missouri’s nursing home care ranks at the bottom of the Central Plains Region

Families for Better Care, Inc., is a Texas-based nursing home resident advocacy group dedicated to creating public awareness of the conditions in our nation’s nursing homes and other long-term care settings and developing effective solutions for improving quality of life and care.

“This year’s nursing home report card exposed an alarming trend that should serve as a wake-up call for us all,” said Brian Lee, Families for Better Care’s executive director. “Nursing home inspection ratings have soured.”

According to survey data collected by federal and state governments, fewer than 30 percent of nursing homes were capable of scoring an above average inspection rating, that’s nearly a 15 percent decline since the last reporting period.

“America’s nursing home care is worsening,” Lee exclaimed. “Erratic inspection performance is, by and large, traceable to a singular reason, the failure by so many nursing home operators to hire enough staff to safely care for residents.”

While Families for Better Care has repeatedly warned that nursing home staffing shortfalls are a grievous problem, the organization is calling for a new solution, one that the nursing home industry should welcome and would be embraced by residents and their families.

“The best way to heal America’s nursing homes is to appropriate additional funding to be used solely for hiring more staff,” Lee stated. “No more excuses, no more threats, no more scare tactics from lobbyists, politicians, operators—or anyone else for that matter—it’s time to do what’s right and stop the infliction of our loved ones with unnecessary injury or harm because of negligent policy making.”

According to the report’s findings, the majority of nursing homes (54 percent) were incapable of scoring an above average staffing rating. Residents received just 2 hours and 33 minutes of direct care daily—an average that’s unchanged from the previous report card. Nearly every state—with the exception of Alaska, the District of Columbia, and New Mexico—suffered a net loss in the percentage of nursing homes with above average staffing levels over the past three report cards.

“Before any checks are written to nursing homes, a rock solid staffing standard must accompany any new funding; otherwise, taxpayer monies could end up being diverted to subsidize the lifestyles of the rich and not-so-famous instead of getting back to the residents and their care,” Lee stated. “Too many nursing homes have demonstrated an unfaithfulness in self-governing their staffing levels to safely care for residents, so it’s time we help them out a little, as a nation, by federally mandating the most stringent staffing requirement that leaves no loopholes through which violators could squeeze.”

 As for the state’s nursing home rankings, the states highly rated in past report cards, once again, dominated the top spots while the chronic underachievers continued to disappoint.

This year’s top nursing home states were Hawaii, Delaware and Alaska while Texas, North Carolina, and Illinois scraped the bottom of the barrel. States with the biggest gains in overall ranking were New York (↑20), Mississippi (↑17), and Nevada (↑14) while Vermont (↓27), Massachusetts (↓24), and Arkansas suffered the biggest losses.

Three of the last report card’s best nursing home states slid out of the top ten, including Vermont, which plunged from No. 3 to No. 31 overall. The remaining states were New Hampshire (down from No. 2 to No. 11) and Florida (falling seven spots from No. 6 to No. 13).

Other key findings included:

• 500,000 elderly living in dangerous conditions—Nearly half-a-million elderly nursing home residents are living in facilities that tolerate below average staffing scores.
• Abuse and neglect vexes nursing home quality—1 in 5 nursing homes abused, neglected, or mistreated residents in almost half of all states for the second consecutive report card.
• States that are downright awful—Texas, Illinois, New Mexico, Michigan, Oklahoma, Louisiana, and Indiana consistently linger at, or near, the bottom in state nursing home care, scoring failing grades in every nursing home report card.

Families for Better Care argues that America desperately needs a nursing home cultural transformation, and the best way for that to happen is for nursing homes to saturate facility hallways with a brigade of well-trained frontline caregivers.

“Nursing home staffing levels must be ratcheted up if care is ever going to improve,” said Lee. “Since nursing homes rely so heavily on federal and state reimbursements, it’s incumbent upon us to pull up our bootstraps and find a way to inject much needed staffing currency as soon as possible.”


Readers of this blog should not be, and probably are not, shocked by either the report card grades, or the news that nursing home quality is generally worsening. These are compelling, but hardly new, reasons for implementing an Aging in Place plan.  If you haven't already, ask to attend an Aging in Place workshop.  

More:

State's [Pennsylvania] Failing Grade for Nursing Home Care is Unconscionable
Nursing Home Care Declines in Florida
Illinois Nursing Homes Rank Third Worst in the Country
Texas Ranked Last on 2019 Nursing Home Report Card
Delaware Ranked No. 2 on Nursing Home Report Card
Hawaii Grabs Nursing Home Report Card's Top Spot
Strong Staffing Boosts Alaska To No. 3 On 2019 Nursing Home Report Card
Rhode Island Slips to No. 4 On 2019 Nursing Home Report Card
Utah Ranks No. 5 On 2019 Nursing Home Report Card
Idaho Ranks No. 6 in 2019 Nursing Home Report Card
Arizona Ranked No. 7 on 2019 Nursing Home Report Card
Washington D.C. Surges To No. 8 On 2019 Nursing Home Report Card
Maine Drops to No. 9 on 2019 Nursing Home Report Card
North Carolina Drops to Second Worst in Nursing Home Quality

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.

Trump Administration Improves Transparency about Nursing Home Abuse and Neglect

Today, the Trump Administration and the Centers for Medicare and Medicaid Services (CMS) announced a major enhancement of the information available to nursing home residents, families, and caregivers on the Agency’s Nursing Home Compare website. Later this month, CMS will – for the first time – display a consumer alert icon next to nursing homes that have been cited for incidents of abuse, neglect, or exploitation. By making this information accessible and understandable, CMS is empowering consumers to make the right decisions for themselves and their loved ones. This critical move toward improved transparency is yet another way CMS is delivering on the Agency’s five-part approach to ensuring safety and quality in nursing homes, which Administrator Seema Verma announced in April 2019:

“The Trump Administration and CMS are committed to ensuring that nursing home residents are safe from abuse and neglect. Through the “transparency” pillar of our five-part strategy to ensure safety and quality in nursing homes, we are giving residents and families the ability to make informed choices,” said Administrator Seema Verma. “With today’s action, the Trump Administration is putting critical information at consumers’ fingertips, empowering them and incentivizing nursing homes to compete on cost and quality.”

The Nursing Home Compare tool displays an array of information about nursing homes – including whether a facility meets federal standards with respect to health and safety compliance inspections, staffing levels, and quality measure performance. Previously, consumers could investigate past instances of abuse citations at a nursing home, but finding this information from its health inspection reports available on Nursing Home Compare required multiple steps. CMS is minimizing the steps, making it easier for patients, residents, and their families and caregivers to quickly identify nursing homes with past citations for abuse.Patients and families will see CMS’ new alert icon for Nursing Home Compare, shown below.

Beginning October 23, the new alert icon will be added to the Nursing Home Compare website for facilities cited on inspection reports for one or both of the following: 1) abuse that led to harm of a resident within the past year; and 2) abuse that could have potentially led to harm of a resident in each of the last two years. To ensure CMS is providing the latest information, the icon will be updated monthly, at the same time CMS inspection results are updated. This means consumers will not be forced to wait for CMS’s quarterly updates to see the latest -related information – and nursing homes will not be flagged for longer than necessary if their most recent inspections indicate they have remedied the issues that caused the citations for abuse or potential for abuse and no longer meet the criteria for the icon. This icon will supplement existing information, including the Nursing Home Five-Star Ratings, helping consumers develop a more complete understanding of a facility’s quality.

There are many factors that indicate a nursing home’s quality, and the Star Ratings may not capture some nuances. For example, a nursing home cited for an incident of abuse may have adequate staffing numbers and provide excellent dementia or rehabilitative care. Previously, consumers would clearly see this facility’s performance in these areas through the Star Ratings, but abuse complaint allegation information may not have been as clear. Under the CMS action announced today, this facility would have an alert icon displayed, allowing consumers to see both its Star Ratings and the icon, helping them easily weigh the facility’s quality. In addition, we are continuing our work to improve the usefulness of the Star Ratings.

As you might expect, the industry is not fond of the change.  Calling the alert icon a "Do Not Proceed," alert, industry representatives called for their own "halt" of it's use.  As reported in McKnight's Long-Term Care News:

Mark Parkinson, president and CEO of the American Health Care Association, said the plan should be halted until there is more clarity.

“We support transparency so that potential residents and their families can make an informed decision on care,” Parkinson said in a statement. “We appreciate CMS’ efforts to improve Nursing Home Compare but as we have previously suggested, we believe that CMS should create a standard and rational definition of both abuse and neglect and then report them separately. That would help provide consumers with the information that they need.” 

“In addition, CMS should add customer satisfaction to Nursing Home Compare because that is the best way for consumers to select facilities. It’s surprising that we can look for customer reviews of restaurants and hotels that we select, but that information isn’t available for nursing homes. We should have a way to let families and residents think of the facilities they are considering,” Parkinson added.

Fortunately, we now have better information for consumers than is available for restaurants and hotels, particularly given that the residents of nursing homes, unlike patrons of restaurants and hotels, are not always able or competent to report "bad service."   

 

Medicare Advantage Premiums Decline to Lowest in 13 Years With Open Enrollment Approaching

Medicare Open Enrollment begins on October 15, 2019, and ends on December 7, 2019.  Ahead of Medicare Open Enrollment, the Centers for Medicare & Medicaid Services (CMS), announced that, on average, Medicare Advantage premiums in 2020 are expected to decline 23 percent from 2018, while plan choices, benefits and enrollment continue to increase. The Medicare Advantage average monthly premium will be the lowest in the last thirteen years for the more than 24 million people with Medicare who are projected to enroll in a Medicare Advantage plan for 2020.

HHS Secretary Alex Azar described the changes as providing “lower costs, more options, and benefits tailored to patients’ needs." 

This news comes as the agency releases the benefit and cost-sharing information for Medicare Advantage and Part D prescription drug plans for the 2020 calendar year. Specific highlights include:

• The Medicare Advantage average monthly plan premium is expected to decrease 14 percent to $23.00 (estimated) in 2020 from an average of $26.87 in 2019. Since 2017, the average monthly Medicare Advantage premium has decreased by an estimated 27.9 percent. This is the lowest that the average monthly premium for a Medicare Advantage plan has been since 2007.
• Beneficiaries will have more plan choices, with about 1,200 more Medicare Advantage plans operating in 2020 than in 2018.
• The average number of Medicare Advantage plan choices per county will increase from about 33 plans in 2019 to 39 plans in 2020. This represents an increase of 49 percent since 2017.
• Medicare Advantage continues to be popular, with enrollment projected to increase to an all-time high of 24.4 million beneficiaries from the current enrollment of 22.2 million, out of approximately 60 million people currently enrolled in Medicare. Enrollment in Medicare Advantage in 2020 is expected to have increased by 30.6 percent since 2017.
• Coupled with the previously announced 13.5 percent decline in the average monthly basic Part D premium, beneficiaries have saved about $2.65 billion in Medicare Advantage and Part D premium costs since 2017. The projected average monthly basic Part D premium of $30 in 2020 is the lowest the Part D basic premium has been since 2013.
• The continued decline in Medicare Advantage and Part D premiums over the past three years is estimated to save taxpayers nearly $6 billion in the form of lower Medicare premium subsidies.

CMS has, according to these recent announcements, " taken several actions over the last two years to protect and strengthen the Medicare Advantage and Part D programs, driving competition and lowering costs," including:

• Providing beneficiaries with more choices due to CMS removing limits requiring meaningful differences among a Medicare Advantage Organization’s plans beginning in 2019.
• Reducing burden for Medicare Advantage and Part D plans through streamlining government review and approval of marketing materials.
• Expanding access to reduced cost sharing and additional benefits for enrollees with certain conditions, such diabetes and congestive heart failure, due to the agency’s reinterpretation of uniformity in 2018. About 300 plans in 2020 will offer up to 1.3 million Medicare Advantage enrollees with access to such benefits.
• Expanding opportunities for seniors to choose Medicare Advantage plans that are providing new supplemental benefits, or extra benefits, that are tailored to their specific needs to help them maintain their health. In 2020, about 500 plans will provide approximately up to 2.6 million Medicare Advantage enrollees with access to expanded primarily health related supplemental benefits, such as adult care services or caregiver support services.
• Expanding opportunities for chronically ill patients to choose Medicare Advantage plans that offer a broader range of supplemental benefits that are not necessarily health-related but may help to improve or maintain their health. For example, chronically ill beneficiaries enrolled in a Medicare Advantage plan can now receive meal delivery in more circumstances, transportation for non-medical needs like grocery shopping, and home environment services in order to improve their health or overall function as it relates to their chronic illness. About 250 plans in 2020 will offer access to these types of supplemental benefits reaching an estimated 1.2 million enrollees.
• Implementing recent legislation  to give seniors access to Medicare Advantage additional telehealth benefits so enrollees can use telehealth technology to access more providers in more parts of the country. For 2020, over half of all plans will offer additional telehealth benefits, reaching approximately up to 13.7 million Medicare Advantage enrollees.
• Providing clinicians with more information on out-pocket-costs and lower cost alternatives for prescription drugs so they can discuss with beneficiaries at the time a prescription is written.
• Providing beneficiaries with more drug choices and empowering beneficiaries to select a plan that best meets their needs by allowing plans to cover prescription drugs differently depending on the reasons for which they are prescribed, an approach used in the private sector.

Although there are additional lower-cost choices, it will, according to CMS, be easier than ever to compare Medicare Advantage and Part D plans on Medicare.gov. As the 2020 Medicare Open Enrollment period approaches, CMS for the first time in a decade launched a modernized and redesigned Medicare Plan Finder – what CMS reports is |the most used tool on Medicare.gov – that allows users to shop and compare Medicare Advantage and Part D plans as well as compare pricing between original Medicare, Medicare prescription drug plans, Medicare Advantage plans and Medicare supplemental insurance or Medigap policies.

CMS anticipates updating Medicare.gov with the 2020 Medicare Advantage and Part D premiums and cost-sharing information and releasing the Star Ratings for Medicare Advantage and Part D plans in early October.

 During open enrollment, Medicare beneficiaries can compare coverage options like Original Medicare and Medicare Advantage and choose health and drug plans for 2020. Medicare health and drug plan costs and covered benefits can change from year to year, so people with Medicare should look at their coverage choices and decide on the options that best meet their health needs.  Even with the assistance of a newly redesigned Medicare.gov., you should consider expert advice and consultation.  For these reasons, we strongly urge clients to establish a relationship with a trusted adviser.  Locally, many of our clients use the advisers at Harding, Harding & Associates. 

If you want to keep your current Medicare coverage, you do NOT need to re-enroll.  But, you may want to seek expert guidance whether this is a wise decision.

If you need additional help you can also call 1-800-MEDICARE, or contact your State Health Insurance Assistance Program. You can obtain contact information for any State here.  Simply type your state name in the first window, and type SHIP in the second.

To view the premiums and costs of 2020 Medicare Advantage and Part D plans, go here.

For state-by-state information on Medicare Advantage and Part D in 2020, go here.

Aging in Place- Postacute Care Payment Reform for Informal Caregivers

Health Affairs has published an excellent article describing the financial challenges imposed by the existing Medicare system for those planning to Age in Place, and making excellent suggestions for legislative changes to support Aging in Place.  Penned by Paula Chatterjee,  Allison K. Hoffman, and   Rachel M. Werner, the article describes in a few short paragraphs the financial challenges:

"In 2015, Medicare spent nearly $60 billion on institutional postacute care, an amount that has rapidly increased in recent years. In fact, nearly three-quarters of the geographic variation in total Medicare spending is driven by the variation in postacute care spending alone. Taken together, these patterns call into question the value of postacute care and especially its return on investment for patients.

Given its growing contribution to US health care costs, postacute care has become a common target for efforts to reduce costs under alternative payment models, such as bundled payments and accountable care organizations (ACOs). These models are increasingly holding hospitals responsible for the costs of care provided during the post-hospitalization period. Recent evaluations have found that cost savings achieved under alternative payment models are driven almost entirely by a decrease in the use of inpatient postacute care. This trend is largely the result of a compensatory increase in the number of patients who are being discharged directly home, and thus bypassing the postacute care setting altogether. 

The push to discharge more patients directly home after hospitalization may seem preferable in some circumstances. In addition to being financially sensible by decreasing spending on postacute care, patients might prefer to be discharged home rather than to an institutional setting. In this way, getting patients home may represent a rare opportunity to align goals across patients, payers, and health systems. However, these gains must be viewed in the context of the costs borne by those who care for patients once they are discharged home—informal caregivers. 

Informal Caregivers In The US 

An estimated 34.2 million US adults report serving as an informal caregiver, providing unpaid care to an adult age 50 or older in the prior year. The economic valuation of informal caregiving for older adults, based on hours spent caregiving, is estimated to be nearly $522 billion annually. However, this value likely underestimates the true cost of caregiving in that it does not account for the physical, emotional, economic, and health-associated burdens associated with these roles. Informal caregivers are more likely to take leave from a job, take out a loan or mortgage, spend savings; hold multiple jobs, or retire early; suffer harm to intimate relationships, family conflict, worsened health, decreased geographic mobility, and an inability to pursue life goals. These effects are more common among women; tend to be more severe among those with low educational attainment, depression, and social isolation; and can contribute to a cycle of household poverty. As a result, the potential spillover effects of payment policies designed to get patients home may cause particular harm to already vulnerable populations.

Do Existing Payment Policies Offer Support For Informal Caregivers? 

Payment policies designed to reduce institutional postacute care do little to support home-based care when patients are more quickly discharged than before. Medicare’s home health benefit provides limited home-based support, with at most one visit per day from a home health provider. Although Medicare Advantage expanded this benefit in 2019 to cover non-skilled needs such as help with daily activities, in the postacute period, when patients frequently need significant support in their activities of daily living, a once-daily visit is unlikely to alleviate caregiver burden. Other alternative payment models that encourage home-based care also do little to support home-based care. There have been a number of recent reforms that focus on improving support for caregivers. Various policies, such as the Caregiver Advise, Record, Enable (CARE) Act, have attempted to provide better supports for caregivers, but they fall short in addressing the true burden and insecurity caregivers face. 

How Could Payment Policies Be Changed?

Changes in payment policies could begin to address this burden. Strategies that directly fund informal caregivers who provide postacute care could begin to fill this gap. This approach is not untested. State Medicaid agencies pay for home-based custodial care for older adults who might otherwise need nursing home–based care, and in some states, family members can be the paid caregivers. Medicare policies could similarly support home-based informal caregivers in the postacute period. Bundled payments could redirect funds that were previously dedicated to institutional postacute care settings to compensate caregiving in home-based settings, including flexible funding to pay for caregiving, transportation, respite care, or compensation for a family caregiver.  

Alternative payment models could similarly incorporate innovative approaches to support informal caregivers. The Next Generation ACO model currently waives the direct supervision requirement for post-discharge home visits, in effect allowing payment for home visits by a licensed clinical staff member without a physician’s direct involvement. This waiver provides some flexibility to tailor home visits to meet patients’ needs and could be extended to include payments to informal caregivers who provide the bulk of daily care. Given their central tenet of care coordination, a logical next step could be for ACOs to incorporate informal caregivers into the care management team responsible for monitoring and treating patients and developing strategies for broader population health management. 

An alternative solution is to indirectly provide funding to informal caregivers through paid leave from work to care for family members requiring help in the postacute period. Several states have pursued a policy of paid family leave, including California, New Jersey, New York, Rhode Island, and Washington. A national policy of paid family leave could help offset the financial burden associated with needing to take leave from work to provide caregiving, especially when caregiving is temporary as it most often is in the postacute period. 

Finally, alternative payment models should balance incentives to control costs of care with incentives to measure and maintain good outcomes, both for patients and for family members during the postacute period. These outcomes might include perceived support and satisfaction with the care plan in the postacute period. Including such outcomes in financial incentives could motivate providers to invest in supporting caregivers and other in-home supports that benefit patients in the postacute period. 

Supporting The Unsung Heroes 

The push to discharge more patients directly home presents an opportunity to align the goals of clinicians, patients, and their friends and families during the postacute period. If support for caregiving is not addressed, however, payment reform will likely result in the unintended consequence of increasing caregiver burden. While hospitals and health systems work to reap the savings associated with alternative payment models, we must ensure that families do not ultimately bear the costs. Future policies must mitigate the burdens, inequities, and economic insecurities that result for families and friends who provide post-discharge care—these are the societal costs of caring for patients at home (emphasis added)."

This excellent article not only describes succinctly the financial disincentives imposed upon family caregiving, the resulting negative outcomes for family caregivers, and the reform necessary to facilitate aging in place planning.  Coupled with the obvious negative health outcomes institutional care presents for seniors, the case for reform is overwhelming. 

Veterans Legacy Memorial

The Veterans Legacy Memorial is the first digital platform dedicated entirely to memory preservation for the 3.7 million Veterans interred in VA national cemeteries. Each Veteran has or will have memorial page. Search the site for Veterans, find out where they are buried or interred and read the details of their lives and service. Future capabilities may be expanded to allow families, survivors, fellow Veterans and others to add photos and share memories to a deceased Veteran’s memorial page.  Check it out here. 

Aging in Place: 39 Million Home and Personal Care Robots A Year By 2024

ID 112050146 © Vladislav Kochelaevskiy | Dreamstime.com

McKnight's Senior Living recently published an article with the headline, "Report Predicts 39 Million Robot Shipments A Year By 2024."  A new report from ABI Research predicts that number of home care and personal/social robots a year will be shipped, and that almost 79 million homes around the world will have robots in them. 

According to the article, "[r]obotic capabilities will be particularly useful for older adults who are aging in place or for ambient assisted living end-users"  Ambient Assisted Living (AAL) tools are designed to be sensitive and responsive to the presence of people, and include,  for example. robots that can detect falls, or track a person's health.

According to Jonathan Collins, smart home research director at the research company: 

"Robotic device start-ups such as Intuition Robotics and Blue Frog Robotics already target the AAL market with devices that can integrate with smart home systems. “While home care robots release residents from time-consuming and repetitive tasks, social robots offer the potential to further extend into physically interacting in homes and the individuals within them in ways that can go beyond monitoring into the realm of kinship and socialization.”

Amazon and Google are positioned well to lead in social robot advances because artificial intelligence and voice recognition are the basis of their Alexa and Assistant platforms, which are already popular, the report authors stated.

This blog has repeatedly reported articles that support the proposition that technology is providing solutions for Aging in Place planning precisely at the time when these solutions are most needed.  

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. 

Class-action Challenges Observation Status Determinations - Seeking Medicare Eligibility for Nursing Home Care

More than 1.3 million Medicare observation stay claims could be appealed if a class-action lawsuit filed against the Department of Health and Human Services is successful.

The lawsuit challenges a rule that requires an individual to spend three consecutive days as a hospital inpatient in order to receive Medicare skilled nursing coverage. The lawsuit was first filed in 2011 by seven Medicare observation patients but now figuratively represents hundreds of thousands.

Patients are often admitted to hospitals under observation status — and remain at that designation without their knowledge, sometimes for multiple days — before being sent to a skilled nursing facility. Medicare normally pays for some nursing home care following a three day hospitalization. Observation care, however, is considered outpatient service and doesn’t qualify as a prerequisite for Medicare’s nursing home coverage, often leaving patients responsible for unexpected medical expenses.  

Patients were often wholly unaware of the fact that they were being treated under observation status, prompting passage of the NOTICE Act, about which you can read more here.  Even with the protections of the Act, however, patients are often unable to make real decisions regarding their care and status, and consequently, patients often find themselves responsible for large nursing home bills which remain uncovered by Medicare if the care follows a hospital stay deemed under observation status.

Worse, the determination that the stay is under observation status cannot be appealed to Medicare. The class-action lawsuit challenges the provision that Medicare disputes involving observation claims are not subject to appeal.

“This is about whether the government can take away healthcare coverage you may be entitled to and leave you no opportunity to fight for it,” Alice Bers, litigation director at the Center for Medicare Advocacy, one of the groups representing the plaintiffs, told Kaiser according to an article in Kaiser Health News.

If successful, people with Medicare who received observation care services for three days or more from January 2009 through 2017 would be able to file an appeal and seek reimbursement for bills the program should have paid, according to the report. About 1.3 million observation claims reportedly meet that criteria.

In March, industry advocates praised legislative efforts that would allow patients under observation stay to be eligible for Medicare skilled nursing coverage.  In a statement to the U.S. House Ways and Means Health Subcommittee in May, the Observation Stays Coalition urged Congress to address observation stays while discussing surprise medical billing. The coalition is composed of several beneficiary and provider organizations, including LeadingAge, the American Health Care Association, the American Association of Post-Acute Care Nursing and the National Association for the Support of Long Term Care.

“Unfortunately, there have been countless heart-wrenching stories from older people and their families who have had to pay high out-of-pocket charges since they were deemed to be on observation status, and Medicare did not cover their necessary skilled nursing facility care. Often, these individuals didn’t even know they were on observation status — or know to ask,” the statement said. “It is simply not right to limit access to quality care for those most in need.”