Deaths from Nursing Home Neglect Surged Amid the Pandemic

As more than 180,000 of the nation’s long-term care residents and staff died of COVID-19 in a pandemic that has pushed staffs to the limit, advocates for the elderly say a tandem wave of death separate from the virus has quietly claimed untold tens of thousands more.  The most common causes included neglect occasioned by overburdened workers unable to provide necessary care.

Matt Sedensky and Bernard Condon, writing for the Associated Press (AP), told the soul wrenching story of David Wallace: 

"When COVID-19 tore through Donald Wallace’s nursing home, he was one of the lucky few to avoid infection. He died a horrible death anyway."

Hale, hearty, and reportedly happy before the pandemic, the 75-year-old retired Alabama truck driver became so malnourished and dehydrated that he dropped to 98 pounds.  His son reported that he looked like he’d "been in a concentration camp."  No wonder: septic shock suggested an untreated urinary infection, E. coli in his body from his own feces hinted at poor hygiene, and aspiration pneumonia suggested that  Wallace, who required assistance with meals, had  choked on his own food.  All of these conditions developed while Wallace was under the control, custody, and care of a nursing home.  

Kevin Amerson, Walace's son indicted the institution:

“He couldn’t even hold his head up straight because he had gotten so weak. They stopped taking care of him. They abandoned him.”

According to the AP, as nursing homes were opening up to family visitations nursing home watchdogs were being flooded with reports of residents kept in soiled diapers so long their skin peeled off, left with bedsores that cut to the bone, and allowed to wither away in starvation or thirst.

Beyond that, AP interviews with dozens of people across the country reveal swelling numbers of less clear-cut deaths that doctors believe have been fueled not by neglect but by isolation.  The AP described a common mental state plunged residents into despair as a result of prolonged isolation.  The AP noted that many residents cause of death as reported on death certificates was simply “failure to thrive.”

A nursing home expert who analyzed data from the country’s 15,000 facilities for the APs investigation reportedly estimated that for every two COVID-19 victims in long-term care, there is another who died prematurely of other causes. Those “excess deaths” beyond the normal rate of fatalities in nursing homes could total more than 40,000 just since between last March and November.

The industry's record was not stellar prior to the pandemic; studies have indicated that one 

These extra deaths are roughly 15% more than you’d expect at nursing homes already facing tens of thousands of deaths each month in a normal year.

“The healthcare system operates kind of on the edge, just on the margin, so that if there’s a crisis, we can’t cope,” Stephen Kaye, a professor at the Institute on Health and Aging at the University of California, San Francisco, who conducted the analysis, told the AP. “There are not enough people to look after the nursing home residents,” he admitted.

Comparing mortality rates at homes struck by COVID-19 with ones that were spared, Kaye also found that the more the virus spread through a home, the greater the number of deaths recorded for other reasons. In homes where at least 3 in 10 residents had the virus, for example, the rate of death for reasons besides the virus was double what would be expected without a pandemic.

That suggests the care of those who didn’t contract the virus  suffered, possibly  as healthcare workers were consumed attending to residents ill from COVID-19 or were left short-handed as the pandemic infected employees themselves.

Chronic understaffing at nursing homes has been one of the hallmarks of the pandemic, with a few homes even forced to evacuate because so many workers either tested positive or called in sick. In 20 states where virus cases are now surging, federal data shows nearly 1 in 4 nursing homes reported staff shortages.

The nursing home trade group American Health Care Association disputed that there has been a widespread inability of staff to care for residents and dismissed estimates of tens-of-thousands of non-COVID-19 deaths as “speculation.”

Dr. David Gifford, the group’s chief medical officer, said the pandemic created “challenges” in staffing, particularly in states like New York and New Jersey hit hard by COVID-19, but added that, if anything, staffing levels have improved because of a drop in new admissions that has lightened the patient load.

“There have been some really sad and disturbing stories that have come out,” Gifford said, “but we’ve not seen that widespread.”

Another industry group, LeadingAge, which represents not-for-profit long-term care facilities, said staffing challenges are real, and that care homes are struggling in the face of federal inaction to provide additional stimulus money to help pay for more workers.

“These incidents, stemming from the challenges being faced by too many committed and caring nursing home providers during this pandemic, are horrific and heartbreaking,” said Katie Smith Sloan, LeadingAge’s president. “I hope that these tragedies will wake up politicians and the public.”

When facilities sealed off across the country in March, advocates and inspectors were routinely kept out too, all while concerning reports trickled in, not only of serious injuries from falls or major medical declines, but of seemingly banal problems that posed serious health issues for the vulnerable.

Mairead Painter, Connecticut’s long-term care ombudsman, said with dentists shut out, ill-fitting dentures went unfixed, a factor in mounting accounts of malnutrition, and with podiatrists gone, toenails went untrimmed, posing the possibility of painful conditions in diabetes patients.

Even more widespread, as loved ones lost access to homes, was critical help with residents’ feeding, bathing, dressing and other tasks. The burden fell on aides already working tough shifts for little pay.

“I don’t think anyone really understood how much time friends and family, volunteers and other people spent in the nursing home and supplemented that hands-on care,” Painter said.

Strict rules barring in-person visitation persisted in many homes, but as families and advocates have inched back inside, they’ve frequently been stunned by what they found.

The AP shared the  story of June Linnertz, who, when she returned to her father’s room at Cherrywood Pointe in Plymouth, Minnesota, for the first time in three months, she was struck by a blast of heat and a wall thermometer that hit 85 degrees. His sheets were soaked in sweat, his hair was plastered to his head and he was covered in bruises.  Linnertz would learn these bruises came from at least a half-dozen falls. His nails had been uncut so long, they curled over his fingertips and his eyes crusted over so badly he couldn’t get them open.  

Linnertz father, 78-year-old James Gill, was found screaming, thinking he had gone blind, and Linnertz grabbed an aide in a panic. She snipped off his diaper, revealing genitals that were deep red with skin sloughing off.

Two days later, Gill died from Lewy Body Dementia, according to a copy of the death certificate provided the AP. Linnertz told the AP that she always expected her father to die of the condition, which causes progressive memory and movement loss, but she never thought he would end his days in so much needless and avoidable pain and suffering.

“What the pandemic did was uncover what was really going on in these facilities. It was bad before, but it got exponentially worse because you had the squeeze of the pandemic,” Linnertz said. “If we weren’t in a pandemic, I would have been in there... This wouldn’t have happened.”

The assisted living facility’s parent company, Ebenezer, told the AP: “We strongly deny the allegations made about the care of this resident,” adding that it follows “strict regulatory staffing levels” required by law.

Cheryl Hennen, Minnesota’s long-term care ombudsman, said dozens of complaints have poured in of bedsores, dehydration and weight loss, and other examples of neglect at various facilities, including a report of a man who choked to death while he went unsupervised during mealtime. She fears many more stories of abuse and neglect will emerge as her staff and families are able to return to homes.

“If we can’t get in there, how do we know what’s really happening?” she said. “We don’t know what we can’t see.”

The nagging guilt of unnecessary death is one Barbara Leak-Watkins understands. It was just in February that her 87-year-old father, Alex Leak, went for a check-up and got lab work that made Leak-Watkins think the Army veteran, contractor and farmer would be with her for a long time to come.

You’re going to outlive all of us,” Leak-Watkins remembered the doctor saying.

As nursing home outbreaks of COVID-19 proliferated, Leak-Watkins prayed that he be spared. The prayer was answered, but Leak was nonetheless found unresponsive on the floor at Brookdale Northwest in Greensboro, North Carolina, his eyes rolled back and his tongue sticking out.

After he arrived at the hospital, a doctor there called Leak-Watkins with word: Her father had gone so long without water his potassium levels rocketed and his kidneys were failing. He died two weeks later of lactic acidosis, according to his death certificate, a fatal buildup of acid in the body when the kidneys stop working. For a man whose military service so drilled the need for hydration into him that he always had a bottle of water at hand, his daughter had never considered he could go thirsty.

“The facility is short-staffed...underpaid and overworked,” Leak-Watkins said. If they “can’t provide you with liquids and fluids to hydrate yourself, there’s something wrong.”

The daughter is considering filing a lawsuit but a North Carolina law granting long-term care facilities broad immunity from suits claiming negligence in injuries or death during the pandemic could stymie her efforts. Similar laws and executive orders have been enacted in more than two dozen states.  Critics say the laws are a free pass for neglect.

The owner of the father’s facility, Brookdale Senior Living, said it couldn’t comment on individual cases but that “the health, happiness and wellbeing of each of our residents will always be our priority.”

Around the country, the heartache repeats, not only among families who have already buried a member, but also those who feel they are watching a slow-moving disaster.

In Hendersonville, Tennessee, Tara Thompson was able to see her mother for the first time in more than six months when she was hospitalized in October. The 79-year-old had dropped about 20 pounds, her eyes sunken and her legs looking more like forearms. Doctors at the hospital said she was malnourished and wasting muscle. There were bedsores on her backside and a gash on her forehead from a fall at the home. Her vocabulary had shrunk to nearly nothing and she’d taken to pulling the blankets over her head.

The facility Thompson’s mother lived in had been engulfed in virus outbreaks, with more than half its residents testing positive and dozens of employees infected, too. She never caught it, but shaken by the lack of care, Thompson transferred her mother to a new home.

“It has nothing to do with the virus. She’s declined because she’s had absolutely no contact with anybody who cares about her,” she said. “The only thing they have to live for are their families and, at the end of their life, you’re taking away the only thing that matters to them.”

“Failure to thrive” was among the causes listed for Maxine Schwartz, a 92-year-old former cake decorator whose family had been encouraged prior to the lockdown by how well she’d adjusted to her nursing home, Absolut Care of Aurora Park, in upstate New York. Her daughter, Dorothy Ann Carlone, would coax her to eat in the dining room each day and they’d sing songs and have brownies back in her room. Several times a week, Schwartz walked the length of the hallway for exercise.

When the lockdown began March 13, Carlone feared what would happen without her there. She pleaded to staff: “If you don’t let me in to feed her, she won’t eat, she will starve.”

On March 25, when a staffer at the home sent a photo of Schwartz, Carlone was shocked how thin she was. Carlone was told her mother hadn’t been eating, even passing up her favorite brownies.

Two days later, Carlone got an urgent call and when she arrived at the home, her mother’s skin was mottled, she was gasping for breath and her face was so drawn she was nearly unrecognizable. An hour later, she died.

Dawn Harsch, a spokeswoman for the company that owns Absolut Care, noted a state investigation found no wrongdoing and that “the natural progression of a patient like Mrs. Schwartz experiencing advanced dementia is a refusal to eat.”

Carlone is unconvinced.

“She was doing so good before they locked us out,” Carlone said. “What did she think when I wasn’t showing up? That I didn’t love her anymore? That I abandoned her? That I was dead?”

Before the lockdown, Carlone’s mother would wait by an elevator for her to arrive each day. She thinks of her mother waiting there when her visits stopped and knows the pain of the isolation must have played a role in her death.

“I think she gave up,” she said.

You should never give up.  Plan to age in place.  Learn what aging in place planning entails, develop a plan, and then implement the plan. If you won't for yourself, do it for those whom you love, who may be ravaged by the consequence of there being no plan when it is needed.    

Source: Sedenski and Condon, "Not just COVID: Nursing home neglect deaths surge in shadows," AP NEWS (November 19, 2020) (last accessed 4/15/2021). 

Medicaid Denied Due to Land the Applicant Cannot Sell - Considering Asset Illiquidity

 

An Ohio appeals court has ruled that a Medicaid applicant’s land is a countable resource even though the applicant  is unable to sell the land. Cowan v. Ohio Dept. Jobs & Family Servs. (Ohio Ct. App., 1st Dist., No. C-200025, May 26, 2021).

Mary Cowan entered a nursing home, applied for Medicaid, and named the nursing home as her authorized representative. Ms. Cowan owned two parcels of land that she listed for sale, but she was unable to find any buyers. The county auditor, however, valued the parcels at $3,000 each. 

Unless an exclusion applies, Ohio’s Medicaid guidelines provide that individuals are not eligible for benefits if the value of their personal and real property exceeds $2,000. The $6,000 value assessed by the county auditor exceeded the regulatory threshold, so the state denied her Medicaid benefits for excess resources due to the property.

Ms. Cowan appealed, through the state administrative process, arguing that because she couldn’t sell her land, she did not have the legal ability to access the resource. She argued that Federal SSI regulations explicitly state that a property that cannot be liquidated is not a resource. The state denied the appeal, and Ms. Cowan appealed to court. The trial court ruled that Ms. Cowan had excess resources. Ms. Cowan appealed.

The Ohio Court of Appeals, First District, held that the state properly denied Ms. Cowan’s Medicaid application for excess resources.  The Court held that the federal SSI regulation does not apply to the state Medicaid case. According to the court, under state Medicaid law, “if the applicant has the legal authority to sell the property, the plain language of the Code renders it a countable resource.”  Ms. Cowan had the legal authority to sell the property, evidenced by the fact that she tried to sell the property.  The court noted that Ohio clearly concerns itself neither with practical value, or the ability of the seller to find a buyer: “[w]hether [the applicant] was able to find a purchaser is a wholly different consideration from what the regulation contemplated, namely whether [the applicant] had the legal authority to sell the properties in the first place.” In other words, even if the asset is illiquid (cannot be readily converted to cash) the asset is, nonetheless, countable and potentially disqualifying.  

The case illustrates the importance of considering the illiquid assets comprising the estate, and dealing with these assets before they create challenges or liabilities.    

HAVE A BLESSED MEMORIAL DAY

Originally named Decoration Day, Memorial Day is a call to remember those servicemen and women who gave their lives in service of the United States of America. The holiday was originally conceived as a solemn day of honor for Civil War dead, proclaimed on May 5, 1868 by national commander of the Grand Army of the Republic General John Logan. The date was chosen specifically because it did not fall on the anniversary of any specific battle. In his proclamation on Decoration Day, Logan stated, “The 30th of May, 1868, is designated for the purpose of strewing with flowers, or otherwise decorating the graves of comrades who died in defense of their country during the late rebellion, and whose bodies now lie in almost every city, village and hamlet churchyard in the land.”

While there is some confusion as to when and where Memorial Day actually began, New York was the first state to recognize the holiday in 1873, with all northern states following by 1890. Prior to World War I, Decoration Day, or Memorial Day, as it came to be called, was primarily a “northern state” holiday, with southern states honoring their war dead on different days. At the close of World War I, the holiday transformed from a day to honor Civil War dead to a day to honor all Americans who died fighting in any war.  The National Holiday Act of 1971 established our current Memorial Day, falling on the last Monday in May. 

Additionally, in December of 2000 The “National Moment of Remembrance” resolution was passed. This resolution asks that at 3 pm local time all Americans “voluntarily and informally observe in their own way a Moment of Remembrance and respect, pausing from whatever they are doing for a moment of silence or listening to Taps.”

In 1915, inspired by the poem “In Flanders Fields,” Moina Michael replied with her own poem:

        We cherish too, the Poppy red 

That grows on fields where valor led,

It seems to signal to the skies

That blood of heroes never dies.

Michael then conceived of an idea to wear red poppies on Memorial day in honor of those who died serving the nation during war. She was the first to wear one, and sold poppies to her friends and co-workers with the money going to benefit servicemen in need. See more on the significance of the Red Poppy.

Later Madam Guerin from France was visiting the United States and learned of this new custom started by Ms. Michael. When she returned to France she made artificial red poppies to raise money for war orphaned children and widowed women. This tradition spread to other countries. In 1921, the Franco-American Children’s League sold poppies nationally to benefit war orphans of France and Belgium. The League disbanded a year later and Madam Guerin approached the VFW for help.

Shortly before Memorial Day in 1922 the VFW became the first veterans’ organization to nationally sell poppies. Two years later their “Buddy” Poppy program was selling artificial poppies made by disabled veterans. In 1948 the US Post Office honored Ms. Michael for her role in founding the National Poppy movement by issuing a red 3 cent postage stamp with her likeness on it.

Our staff, family, and friends, salute the men and women who gave their all for us.  

Have a , safe and enjoyable Memorial Day commemoration.

CMS Requires LTC Providers Report Weekly COVID Vaccine Data; Data Made Public

Long-term care facilities are required to report weekly data on COVID-19 vaccination status for both residents and staff under a new interim final rule, putting more pressure on providers to remain transparent with their efforts. 

The Centers for Medicare & Medicaid Services (CMS) announced the new regulation, which apply to long-term care facilities and intermediate care facilities for individuals with intellectual disabilities.  Enforcement begins June 14. 

As data becomes available, CMS will post facility-specific vaccination status information so that it can be seen openly by the public on CMS’ COVID-19 Nursing Home Data website, the agency said.

CMS added that the new mandate is designed to assist in monitoring uptake among residents and staff, and aid in identifying facilities that may be in need of additional resources to respond to the COVID-19 pandemic.

LTC facilities are already required to report COVID-19 testing, case and mortality data to the National Healthcare Safety Network for residents and staff, but they have not been required to report vaccination data.

“These new requirements reinforce CMS’ commitment of ensuring equitable vaccine access for Medicare and Medicaid beneficiaries,” Lee Fleisher, MD, CMS’ Chief Medical Officer and director of the Center for Clinical Standards and Quality, said in a statement. 

“Today’s announcement directly aids nursing home residents and people with intellectual or developmental disabilities who have been disproportionately affected by COVID-19. Our goal is to increase COVID-19 vaccine confidence and acceptance among these individuals and the staff who serve them,” he added. 

Some states had already been collecting and monitoring such data, and Maryland last week said it would require its providers to feed information to a public-facing dashboard.

A growing movement to track

CMS had hinted that a national vaccination reporting requirement could be in the pipeline for providers. The agency put forward a new SNF Quality Reporting Program measure as part of its Skilled Nursing Facility Prospective Payment System proposal for fiscal year 2022. 

The proposed rule would have require skilled nursing facilities to report staff COVID-19 vaccination rates to the Centers for Disease Control and Prevention National Healthcare Safety Network starting Oct. 1. Currently, staff vaccination reporting is voluntary.

The agency on Tuesday added that it’s also seeking comment on expanding the reporting policy to other congregate care settings, such as assisted living facilities, psychiatric residential treatment facilities and group homes.

Regulators said they are specifically interested in comments on “potential barriers facilities may face in meeting the requirements, such as staffing issues or characteristics of the resident or client population, and potential unintended consequences.”

The rule also requires providers to report the use of therapeutics administered to residents for treatment of COVID-19. The agency said reporting their use will help government officials and other stakeholders “monitor the prevalence of these treatments, their impact on reducing the effect of COVID-19 on nursing home residents, and support allocation efforts to ensure that nursing homes have access to supplies to meet their needs.”

Tuesday’s rule would have been more expansive, CMS added, but logistical concerns kept the range limited.

“Because we are not able to guarantee sufficient availability of single dose COVID-19 vaccines at this time, or in the near future, to meet the potential demands of facilities with relatively short stays, we are focusing on facilities that have longer term relationships with patients and are thus also able to administer all doses of and track multi-dose vaccines,” they said in a summary of the interim final rule, scheduled to be published in the Federal Register on Thursday.

Source: D. Brown, "BREAKING: New CMS rule requires LTC providers to report weekly COVID vaccine data, which will be made public," McKnight's Long-term Care News (May 11, 2021) (last accessed 5/11/2021).

Beneficiaries of Trust Can Contest Trust Protector’s Amendment On Grounds of Undue Influence

A "trust protector" is a person or institution appointed by a settlor (a person creating a trust) to protect the trust, or more directly, to protect a vulnerable beneficiary of the trust.  The original idea behind the protector was to appoint somebody who could oversee the Trustee, and, if necessary, terminate the Trustee for misconduct without resorting to a court process.

This planning device is increasingly common, and, as you might expect, takes on different characteristics in design and implementation within different trusts.  Originally crafted, the only power conferred to a trust protector was discretion to terminate a trustee. As design of trusts evolved, protectors were conferred additional powers, such as the power to appoint the successor Trustee if one is fired, or even, sometimes, to amend a trust.

With the rise in the number of trust protectors appointed by trust instruments, it is inevitable that protectors will be embroiled in legal disputes, notwithstanding that the intention of the planning device is to reduce such disputes, and more, to avoid resort to court for a remedy for misconduct, particularly, unresponsive, slow, or distracted trustees.  Of course, the more authority conferred to a trust protector, the more likely any individual  protector is likely to be embroiled in a dispute.  That is what happened to a trust protector in a recent case in Arizona.  

Austin Bates suffered from Parkinson’s disease and was in the process of getting a divorce when he hired an attorney to create a trust for him. The trust provided distributions to his ex-wife, daughters, and his caretaker. Mr. Bates selected a professional trustee and designated his attorney as trust protector. The trust protector could, according to the terms of the trust, alter or amend the trust consistent with Mr. Bates’s wishes. Once his divorce was final, Mr. Bates married his caretaker, Lindi Bates. After meeting with Mr. Bates and his new wife, the trust protector amended the trust adding a "no contest" clause (legally referred to as an in terrorem clause), which invalidated the interests of anyone who contested the trust, and eliminating the distribution to Mr. Bates’s ex-wife, providing instead income to his new wife for her life and making Mr. Bates’s daughters the remainder beneficiaries after the death of the new wife.

Mr. Bates’s daughters sued to invalidate the trust amendment on the grounds that the amendment was procured through undue influence. The new wife moved to dismiss the undue influence claim, arguing that the daughters alleged she influenced Mr. Bates, but that Mr. Bates had no ability to amend the trust. The court dismissed the undue influence claim and enforced the in terrorem clause, disinheriting the daughters as beneficiaries. The daughters appealed.

The Arizona Court of Appeals reversed, holding that the the lower court improperly dismissed the undue influence claim because the new wife could be found to have exercised undue influence over Mr. Bates, and  although Mr. Bates didn’t have authority to amend the trust, the trust protector was duty bound to follow Mr. Bates’s wishes.  Bates v. Bates, (Az. Ct. App., Div. 1, No. CA-CV 19-0845, May 11, 2021). According to the court, state law “does not require a claimant to allege the defendant exerted undue influence directly over the person with final authority to amend the trust; instead, it broadly states that a trust amendment is void if ‘its creation was induced’ by undue influence.”  Bates, at pp. 7-8.

The Bates case is instructive regarding how the court treated the undue influence claim. More, though, the case is instructive regarding the court's treatment of the trust protector given that protector's involvement as, essentially, an agent of the settlor in the case.  It is possible that better design and drafting might have avoided the claim, but there is little question that the broad grant of authority conferred to the protector, and the exercise of that authority, caused the protector to become embroiled in an all-too-common family squabble. 

Note: Photo 140723192 / Protection © Andrii Yalanskyi | Dreamstime.com

Five Trends Driving Potential of Wearables for Older Adults

Laurie Orlov has identified five trends driving the potential of wearable technology for older adults.  Orlov is a tech industry veteran, writer, speaker, elder care advocate, and founder of Aging and Health Technology Watch (an excellent blog to which every reader should subscribe). 

Wearable technology is nothing new, perhaps, but application to and use by the older community has always been a question.  From activity trackers that gained popularity in the past decade, to introduction of smart watches by Apple in 2015, the adoption of wearables by older adults has continued to grow. New products, like the Oura Ring, the Apple Watch Series 6 and the Samsung Galaxy Watch 3 Active, or the Bose SoundControl hearing aid, continue to fuel interest in their potential for older adults.

The five trends she identified are:  

• Forecasts of purchases are rising. The analyst firm Gartner has predicted, in its January 2021 forecast, that worldwide end-user spending on wearable devices will reach $81.5 billion this year, representing an 18.1% increase over 2020, when spending reached $69 billion. The growth is being attributed to increased remote working and a higher interest in health monitoring.  According to Orlov, IDC forecast growth in hearables (397 million units) and smart watch shipments (156 million units) out to 2024, and an Apple Watch insider told her that 3-5 million Apple watches alone have been purchased by adults age 65+.

• Health-tracking devices and usage grew in 2020. According to Rock Health, 66% of those who started using a wearable did so to manage a diagnosed health condition.  And more than 51% of wearables owners use the device to manage a diagnosed health condition.  Specific health attributes included weight, heart rate, blood pressure. It should be noted data was collected prior to the 2020 Covid-19 lockdowns.

• Views on the patient's role in their medical are changing.  In 2013, Leroy Hood published a paper, “Systems Biology and P4 Medicine: Past, Present, and Future” that introduced the idea that patients had a role in their own care, saying that medicine should be ‘predictive, preventive, personalized, and participatory.” That concept became a basis for the growing interest in the role of wearables as capable of assisting in all four attributes.  The public is taking a greater role, in part due to availability of devices that make them active participants, and in part as they discern their own specific goal and objectives regarding health care.

• Consumers show preferences about what to track.  Even before the Covid-19 pandemic, as of January, 2020, the Guidance for Wearable Health Solutions white paper noted that users of wearables were showing preferences about what to track, expressing, for example, interest in tracking blood pressure and heart health. 

• Growing consumer interest in actually utilizing wearable health solution information. Because individuals want to participate in their own health, they not only want to track, but also to share data with their doctor to help with a more accurate diagnosis. The Consumer Technology Association has been surveying consumers – and noted that even in February of 2019, 58% of consumers were willing to share health data with their doctor to gain a more accurate diagnosis and treatment.

Technology can be a game-changer for an older person's ability to age in place,  whether at home, in a community, with friends or family, or even in an institution.  Technology is persistent, does not become weary or burdened emotionally, physically, or mentally, and particularly where incorporated with robust human contact, interaction, oversight, and review, can empower choices that  simply are not otherwise possible.   

Single Rooms Might Have Prevented 31% of Long-Term Care COVID-19 Deaths

A study spanning several countries found that the infrastructure of long-term care has to change drastically to protect residents from health threats like COVID-19, with simulations finding that 31% of coronavirus deaths in Ontario, Canada, would have been prevented if all residents had had single-occupancy rooms. 

“Community outbreaks and lack of personal protective equipment were the primary drivers of outbreak occurrence in long-term care homes, and the built environment was the major determinant of outbreak severity,” George Heckman, a professor at the University of Waterloo in Ontario, Canada, said in a statement  on the study, which was published in the Journal of the American Medical Directors Association.

The study drew from an international virtual town hall held in fall of last year and hosted by Provincial Geriatrics Leadership Ontario (PGLO). The gathering focused on three themes: updating the built long-term care environment, public health versus individual health, and staffing.

Outbreaks in Ontario during the first wave of COVID-9 “were not uniformly distributed, with 86% of infections occurring in 10% of homes,” according to the study. The primary determinant of nursing home outbreaks in the Canadian province — as in the U.S. — was the extent of COVID-19 circulation in the surrounding community, the study observed.

Simulations found that 31% of infections and 31% of deaths would have been prevented by single rooms for all Ontario long-term care residents — but 30,000 additional private rooms would have been necessary for this to occur.

Research in the U.S. found that outbreaks were more likely when staff members commuted from neighborhoods with high COVID-19 circulation — and in large homes with more staff traffic, with high-occupancy rooms associated with large outbreaks. Nursing homes that were less crowded, such as those built on the Green House model, had better outcomes and lower hospitalization costs, the study noted.

“The fact that smaller homes not only support better resident outcomes but are more resilient against infectious outbreaks should prompt policymakers to reimagine LTC infrastructure in a post-pandemic world,” the authors wrote.

Design features of the built environment for long-term care “that promote greater multiplicity and comingling of viral vectors — staff or residents — are strong determinants of the risk and extent of outbreaks,” according to the study; investing in smaller LTC units could minimize those vectors in addition to supporting better resident outcomes.

“However, excessive down-sizing may leave residents vulnerable to situations similar to those reported by small Italian LTC homes, as in the United States where outbreaks led to critical staff shortages,” the study authors added. “The solution may lie in architectural approaches that distinguish small-scale living from small-scale housing, using uncrowded and home-like residential spaces. Such infrastructure must be supported by dedicated staff embedded in a responsive organizational structure sufficiently large enough to ensure adequate staff coverage and to share operation resources.”

Those points echo calls from across the nursing home world to invest in better staffing and smaller, more homelike setups for nursing homes.

The authors of the JAMDA study went one step further.

“Any new large-scale developments based on clearly unhealthy institutional architectural designs should be strongly discouraged,” they wrote.

Aging in Place Planning Heightens Necessity of Trust Funding

Traditionally, the creation and funding of a trust to provide for your loved ones upon your passing was motivated primarily by a desire to avoid probate and make the administration easier and private.  With the advent of Aging in Place Planning, and Guardianship Avoidance and Protection, two modern goals that focus on protecting YOU during YOUR life, trust funding becomes even more important.  

Funding a trust is often described as the process of transferring ownership of your assets from your individual name to your trust. Having your assets owned by the trust provides you many different benefits directly related to the type of trust created, ranging from asset protection, tax avoidance or minimization, and/or probate avoidance. To ensure that you receive the full benefit of your trust, you  physically change the titles from your individual name (or joint names if marries or domestic partners) to the name of your trust. A trust can only control the assets that the trust (trustee) owns.

You may have a well-designed and well-written trust document, but until you fund the trust, it doesn’t control anything. Unlike a will, you aren’t finished with a trust simply by signing the document; you must, with rare exceptions, fund your trust while you are alive, able and of sound mind.

With probate avoidance trusts, so long as title of property is not in an individual name, and non-trust assets avoid probate through direct transfer designations (beneficiary, transfer on death, and payable on death designations), the objective is attained.  With trusts designed to capture additional benefits during your lifetime, however, merely avoiding probate is not sufficient; trust funding must also ensure control and management of the asset during your life.  Even in a simple probate-avoidance trust, the trust-funding strategy should include changing the beneficiary designations of your life insurance policies, annuities,  retirement accounts, and other investment accounts, to insure your trust so proceeds will go into your trust upon your demise.  The limitations and disadvantages of direct transfer designations make them ill-suited to achieve lifetime planning objectives such as aging in place or guardianship planning.   

In a lifetime planning trust such as one incorporating aging in place planning, trust control during you lifetime is paramount.  An illustration will help understand the distinction and it's importance.  Mary Baker has a non-qualified annuity on her life in the amount of $250,000 as part of her estate, and seeks to avoid probate, but also to avoid guardianship and a guardian's control of her assets, and age in place.  Following her financial planner's advice she changes the beneficiary of the annuity to her trust.  Although her attorney provided her with direction to change the ownership of non-qualified annuities to her trust, and forms to accomplish this change, she is comforted by the ease of a simple beneficiary change handled by her agent.  Although she has effectively avoided probate the annuity remains in her individual name.  A court-appointed guardian will quickly control the annuity, and may use it to whatever legal purpose the guardian articulates, including paying the guardian's fees and expenses, paying agents hired by the guardian, and paying for long-term institutional care in a nursing home over the objection of Mary Baker and her family! 

If Mary Baker changes ownership of the annuity to her trust during her lifetime, a court-appointed  guardian is not automatically conferred control of the asset upon appointment;  in most states, a guardian must seek court approval to manage trust assets, and may only do so with prior approval of the appointing court.  This distinction starts to explain the strategy of guardianship protection in a properly designed and implemented trust.  At a minimum,  the asset is not automatically available as incentive to a guardian: an asset generating a percentage fee for control and management.  Moreover, your trustee can fight to protect the asset from guardian control with standing in the probate court.  Better, your trustee can manage the asset to keep it unavailable to the guardian, by, for example, transferring the asset from a revocable trust far too easily accessible to the guardian, to another form of ownership less easily accessible to the guardian.  Most importantly for aging in place planning, use of the asset for unwanted and avoidable institutional care is better controlled.  

Funding your trust is not a difficult process.  It is, nonetheless, a strategic process that will take some time and effort.  The process may differ depending upon your trust, and/or depending upon your  specific situation, circumstances, goals, and objectives. 

Your first step is to make a list of your assets, their values and where they are located. Once you have your assets listed, let the trust funding strategy begin. Remember that any assets you are electing to fund into your trust will require changing the name on each asset to the trust and/or changing the beneficiaries to the trust.

If you have signed trust documents but are not sure if you have properly funded your trust, call your lawyer!  Your lawyer can review your documents and let you know if the funding of your trust is complete.  You can also review your funding effort against a checklist.    

Inflation Indexed Annuities in Aging in Place Planning

Illustration 217469610 © Adonis1969 | Dreamstime.com

Rarely do articles on this blog deal with specific investment options.  Recently, however, while speaking with a client, she shared a feeling of helplessness following a meeting with her financial advisor.  A few phone calls sorted her options and planning.  This article is designed to educate readers regarding a planning option with which, apparently, some advisors and agents are unfamiliar.

Many who plan financially for aging in place focus on guaranteed income, rather than relying on large liquid amounts invested for further growth through investment risk. Aside from other arguments against risking principal, there is the simple fact that alternatives to institutional care (nursing homes and assisted living facilities) involve periodic costs, usually paid monthly or weekly.  In other words, if you have a healthy guaranteed income, within which you can easily meet additional expenses, the prospect of alternative care cost is not as disruptive as it might be otherwise. 

The issue that is increasingly on everyone's lips, however, is inflation.  Whether inflation is already built in to our economy, soon to arrive and/or well-in-hand by our Federal Reserve Bank, this article will leave to others to debate. A college economics professor once characterized inflation as not unlike water- a little bit is necessary and good, but a lot can kill you.  Regardless, even the long-term care industry is concerned.    

Sometimes called an inflation-protected annuity, an inflation-indexed immediate annuity is similar to a fixed annuity. You receive a guaranteed stream of income from the insurance company for the rest of your life. With an inflation-indexed annuity, however, payments increase (or sometimes decrease) each year, keeping pace with the rate of inflation.

An inflation-indexed annuity tracks standard measures of inflation, typically, the consumer price index (CPI)(one measure of the rate of change of the cost of a selected basket of goods, reflecting the rate of inflation). The monthly income from this form of annuity gradually changes with the CPI. Since money loses purchasing power with inflation, inflation index-tracking annuities theoretically allows your money to retain that power as inflation fluctuates.

Inflation-adjusted annuities have one obvious drawback: they initially begin with smaller payments than a traditional fixed payment plan. The effect of this is that it might take decades for the inflation-adjusted income to catch up to the fixed payment, which means there is a distinct possibility of reduced payouts for life if you die before they catch up.

Talk to you investment advisor, financial planner, or insurance agent.  This article doe not constitute financial advice, and is merely educational.  Your advisor can make specific recommendations after considering your circumstances, needs, goals, and objectives.    

COVID Propels Aging in Place; Institutionalization of Seniors Drops

In the wake of the pandemic, Americans are avoiding nursing homes and other rehabilitation homes for the elderly.  Increasingly, Americans are caring for their loved ones in their own homes. This is the assessment of investigative journalists writing for the Wall Street Journal (WSJ).

America has a long history of relying upon institutions to care for the at-risk elderly. "The U.S. has the largest number of nursing-home residents in the world. But families and some doctors have been reluctant to send patients to such facilities, fearing infection and isolation in places ravaged by Covid-19, which has caused more than 115,000 deaths linked to U.S. long-term-care institutions."

Since the spring, there has been a drop in the number of patients in nursing homes and similar facilities. According to the report, "[o]ccupancy in U.S. nursing homes is down by 15%, or more than 195,000 residents, since the end of 2019, driven both by deaths and by the fall in admissions." 

This has created financial problems for nursing-homes, with even the biggest U.S. nursing-home company stating that it may not have the money to fulfill its financial obligations. 

The shift away from institutions may be permanent.  Big insurers, home-health-care companies and some hospital systems are betting the new patterns of referral and care established amid the crisis will remain in place for the long term. They say doctors, hospital managers and families have seen how some older patients with significant care needs can be sent home. Just as the pandemic has spurred greater adoption of long-considered practices such as working from home, it has brought a re-evaluation of the role of nursing homes.

“We implemented a complete switch of mind-set to say home is the default” for patients leaving the hospital, even frail ones,  Peter Pronovost, chief clinical transformation officer at University Hospitals, an Ohio-based system told WSJ reporters.  “I don’t think we’re ever going to go back,” he said. “The drive to get every patient home who can be home is going to continue.”

Home-health-care companies and major hospital systems, including Iowa-based UnityPoint Health and South Carolina’s Prisma Health, are building new offerings to support sicker patients recovering at home, often using technology to allow close monitoring.  Also fueling these efforts are pandemic-related regulatory changes that allow Medicare to pay for digital doctor visits and intense, hospital-level care in patients’ homes.

Some nursing-home companies say they too are adjusting bulking up their own home-focused offerings and aiming to upgrade buildings and staff to capture a new group of sicker patients who might come to them for hospital-level care.  Eventually, nursing-home operators say, demographics will buoy their industry, as more baby boomers require institutional care. Well before that, they say, vaccines should stem the tide of Covid-19 in their facilities.

“Do I think that more patients will be moved to home? Absolutely. It’s the right thing to do for the patient, it’s the right thing to do for the system, and it’s the right thing to do for the cost,” said David Parker, president of ProMedica Senior Care, a major nursing-home operator that also owns a home-health-care provider and is part of ProMedica Health System.

Nursing-home use in the U.S. has been declining gradually for years. In 2019, occupancy was 80%, down from 84% a decade earlier, according to the Kaiser Family Foundation.

Reduction in disability rates is helping to reduce reliance on institutional care.  The non-disabled component of the Medicare-enrolled 65-and-over population has also been rising: in 1982, 74 percent of Medicare-enrolled 65-and-older individuals were “non-disabled.” That number rose to 81 percent in 2004–2005. This trend is reflected in the fact that the percentage of Medicare-enrolled 65-and-older individuals who reside in institutional settings (i.e., nursing homes) has decreased over time, to less than 5 percent in 2004–2005. 

Surveys have long shown many patients don’t want to go to nursing homes. The pandemic has made them even less popular, according to a September survey of adults 40 and older by AARP. Just 7% said they would prefer a nursing home for family members needing long-term care, and 6% said they would choose one for themselves. Nearly three in 10 respondents said the pandemic had made them less likely to choose institutional care.

For years, government policies have paradoxically both encouraged and discouraged intuitional care.  Certain government policies have encouraged alternatives to nursing homes. Medicaid programs, which cover long-term care for poorer adults, have increasingly paid for long-term services that help patients remain at home such as health-care aides, though funding has long fallen short of demand.

In Medicare, which typically encourages a limited nursing-home stay after a hospital visit, more people have been getting their benefits through insurance companies, which have held down costly nursing-home stays. The companies now provide coverage to around 36% of Medicare beneficiaries, according to the Kaiser Family Foundation. Medicare has also begun paying health-care providers in ways that reward them for bringing down overall costs, giving the providers an incentive to reduce referrals to nursing homes.

The Trump administration gave Medicare insurers more flexibility to spend money on things that improve patients’ home setups. It also made pandemic-related tweaks that allow Medicare coverage for more types of care in the home.  The options have been exploited by insurance companies and health care providers to help transform the industry.

Seema Verma, administrator of the Centers for Medicare and Medicaid Services (CMS) predicted the shift from istitional to home-based care: "[w]e should be able to provide more services in the home setting that can enable somebody to be independent."  She noted that "Covid is going to force a national conversation about how we take care of our elderly, and clearly there are issues in nursing homes that go beyond infection control."

During his campaign, President-elect Joe Biden promised to spend $450 billion to make sure people who need long-term care can get support in the home and community.  “There’s no daylight between the Trump administration and the Biden administration on the desire to see more folks cared for in the home,” said Robert Kocher, an Obama White House health adviser now at venture-capital firm Venrock.

The number of Medicare-financed residents of nursing homes fell 28% in April and 34% in May from a year earlier, as the pandemic turbocharged efforts to steer Medicare patients away from nursing homes and as hospitals referred fewer after surgeries, according to an analysis of billing records done for the WSJ by data firm CareSet Inc. The decline occurred even though, during the pandemic, the Trump administration waived a requirement that Medicare beneficiaries stay three days in a hospital before going to a nursing home.

In addition, some nursing homes shut off admissions in the spring,  Susan Craft, vice president of population health at Henry Ford Health System in Detroit told the WSJ.  "It was a forced period for us to work on home-care programs,” said Gloria Rey, the director of post-acute care at Henry Ford. “We’re continuing to work within our organization to make going home the priority.”

Major Medicare-plan providers Humana Inc. and UnitedHealth Group Inc. say they are working to develop programs that would allow sicker patients to be discharged from hospitals to their homes. The shift in nursing-home use “is probably one of the trends coming out of Covid, along with telemedicine, that is going to act as a real accelerant and be sustainable,” said Susan Diamond, who leads the home business of Humana, one of the biggest Medicare insurers and also a major home-health owner.

Nursing homes’ loss has been a gain for home-health companies, which provide services such as therapy and nursing visits, though typically not 24-hour care.

Data from CarePort Health, a unit of Allscripts Healthcare Solutions Inc. that helps manage post-hospital care, show that referrals from hospitals to nursing homes and home-health providers both plunged in April. By October, though, referrals to home-health providers were at 109% of their 2019 baseline level, while nursing-home referrals had flattened at 83% of their baseline.

The falloff has been a disaster for the nursing-home industry, because Medicare pays better than the long-term stays Medicaid covers. Despite billions in pandemic-related government aid, some nursing homes have closed or been sold in recent months.

A November a survey by the American Health Care Association, a nursing home industry group, found 65% of nursing homes were operating at a loss. Mark Parkinson, the association’s chief executive, said 10% to 20% might file for bankruptcy without additional government aid.

Genesis Healthcare Inc., the biggest U.S. nursing-home company, told investors in August it might not be able to continue as a going concern. Its loss in the third quarter deepened, and in November it said it would need ongoing government support to sustain its operations. Its shares have languished at less than $1.

On the other side, shares of Amedisys Inc., the largest publicly traded home-health-care company, are up nearly 75% in 2020. It saw strong volumes and higher profits in the third quarter.  “We want to take care of sicker and sicker patients, and show we can do it,” Amedisys CEO Paul Kusserow said.

Nursing-home officials said they worry that some frail patients could be left without enough supervision and support if sent home. A 2019 study published in JAMA Internal Medicine that compared Medicare hospital patients discharged to nursing homes with patients who got traditional home-health services found the latter were more likely to be readmitted to the hospital. Mortality and functionality of the groups, however, were similar.

To help patients who are sent home, some hospital systems and home-health firms, including Amedisys, are building new, often tech-heavy programs that layer on extra services and aim to reproduce aspects of nursing-home-level care in patients’ homes.

Prisma Health, an 18-hospital system in South Carolina, in May launched Home Recovery Care, a joint venture with a company called Contessa Health Inc. that provides operational support and technology for the service. Some hospital patients who might qualify for a nursing-home stay are instead sent home using the new program, which some insurers pay for, Prisma Health officials said. 

See Anna Wilde Mathews & Tom McGinty, "Covid Spurs Families to Shun Nursing Homes, a Shift That Appears Long Lasting," Wall Street Journal, December 21, 2020.