Transport Risk Often Overlooked as Risk of Institutional Long-term Care.

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Among the many risks inherent to institutional care are those associated with transport. The most recent illustration comes as a result of the State of Rhode Island switching to a new Medicaid transportation provider.  

Rhode Island first moved from LogistiCare to Missouri-based Medical Transportation Management on January 1, 2019. According to an article in McKnight's Long-Term Care News, the switch has been a "bumpy ride, literally and figuratively, with a flood of missed appointments, delays and other problems, according to those who testified at a state committee meeting last Thursday."

Advocates warn that, every day, a transport provider has put residents at life-threatening risk.  “Someone is going to die,” former state senator John Tassoni Jr. said bluntly at a recent hearing, according to the Providence Journal.  More than 1,000 complaints have been filed, with many patients missing scheduled chemotherapy, dialysis, methadone treatment or doctor visits. Some local nursing homes leaders have transported residents using personal vehicles as a result of transport failures and deficiencies.

“Frankly, at this point it’s become a fiasco,” said Christopher Ryan, owner and administrator of the 71-bed Pine Grove Health Center nursing facility in Pascoag, RI. “At what point does this end?”

Tassoni, who is now an executive with the Mental Health Leadership Council of Rhode Island, called Medical Transportation Management’s short tenure “38 days of hell.”

In a statement submitted to the committee, the head of MTM apologized and committed to working on the issue, noting that the company is bringing new technology to Rhode Island, and the changeover has proved challenging. The company came under fire in Arkansas for a similar string of missed appointments, McKnight’s reported in January.

This blog has repeatedly highlighted stories illustrating transport risk: 

• Man Transported to SNF But Dropped Off at Wrong Location Found Alive Three Days Later;
• Patient Discharged to Nursing Home 300 Miles Away;
• Ambulance Driver Charged with Homicide in Death of Nursing Home Resident.

Risks inherent to institutional care are among the many reasons that people are employing Aging in Place planning.  

Recent Decision Complicates Consensual Sexual Relations in SNF's

Consensual sexual encounters are normal and expected in everyday life, and so they are commonplace even in long-term care facilities.  Navigating the nuances of nursing home resident sexual encounters is, however, extremely complicated and challenging for nursing home administrators, residents, and family members of residents.  A recent federal court case has further complicated the decision-making and risk assessment. 

The case in question relates to the Neighbors Rehabilitation Center in Byron, Illinois, which had a policy of intervening to stop sexual encounters between residents with dementia only when there were “outward signs” of non-consent.  According to the nursing home, if there was evidence of consent, the institution would generally permit sexual encounters between residents, even if there was some cognitive deficit or decline.  

The Centers for Medicare & Medicaid Services (CMS) determined that the policy was not adequate to protect  residents, noting that the policy left some impaired residents in immediate jeopardy from sexual encounters. The agency fined the facility $83,800, McKnight’s Long-Term Care News  reported.. 

Neighbors appealed the citation, the Immediate Jeopardy categorization and the amount, arguing that residents, even those with cognitive impairments, have the right to have consensual intimate relationships.  The U.S. Court of Appeals for the Seventh Circuit, however, ruled that there was “substantial evidence” to back up CMS, saying the Neighbors policy was “misguided” and left residents at the risk of victimization. This was especially true when the residents had “severe cognitive or other deficits which may have adversely impacted their ability to actively protest or object.”

The court wrote: 

“Certainly, those who reside in long‐term care facilities are entitled to the dignity of maintaining intimate relationships.  It is also true, however, that when those persons are cognitively or physically impaired, care must be taken by a facility to ensure that those intimate relationships are consensual. The record reflects that Neighbors failed to exercise this care.”

The court noted findings that staff, aware of the sexual interactions, did not talk to the residents about their feelings about these "relationships"; did not document the residents' capacity for consent (or lack thereof) or communicate with residents' physicians for medical assessment of how their cognitive deficits impacted that capacity; did not discuss the developments with the residents' responsible parties; and did not record any monitoring of the behaviors or make any care plans to account for them. The court determined that Neighbors' non-intervention policy prevented any real inquiry into consent, except in the extreme situation where a resident was yelling or physically acting out.

In response, Marty Stempniak, staff writer, for McKnight's, penned an article seeking to provide guidance for administrators, entitled, "What nursing homes can learn from a ‘troubling’ court decision on sexual consent." Stempniak writes that "[o]ne longtime industry expert told me that he was deeply “troubled” by the ruling, and especially the fact that it was labeled as 'Immediate Jeopardy' with there being no outward signs of serious injury, harm or impairment. He’s worried that it could have a negative influence on how SNF leaders regulate sexual activity going forward."

“This court decision will have a very chilling effect on nursing homes’ efforts to move to a more enlightened and balanced approach to dealing with intimacy,” said Daniel Reingold, CEO of RiverSpring Health, a Bronx-based provider that established one of the nation’s first sexuality and intimacy policies in a long-term care facility in the 1990s. Reingold believes CMS and the federal court have established “a very difficult standard in the me-too world that we live in.”

“We rely frequently on reactions of residents to determine whether they want or don’t want something. That is a typical standard by nursing staff,” he told me. For instance, if residents are unable to voice displeasure with a meal and a CNA is feeding them something they don’t want. Some may get agitated and push the food away. “That’s telling us, ‘I don’t want this,’ and we make those kinds of decisions every day, in multiple ways to determine the preference or lack of a preference on the part of a resident with dementia.”

Reingold hopes this doesn’t lead to administrators creating blanket declarations that any physical interaction between residents with cognitive impairment must immediately be stopped, regardless of what occurs leading up to the incident. What if they’ve been holding hands for days and showing signs of outward affection beforehand?

“To decide unilaterally and across the board, ‘Break ’em up, they’ve got Alzheimer’s, they’re having sex, that’s a no-go,’ would be a shame,” Reingold said. “We allow people with Alzheimer’s and dementia to make decisions all day long. Do you want the peas or the carrots? Do you want to play bingo or go to the art program? Do you want salt or no salt? And we honor those kinds of things. Just because someone has short-term memory impairment doesn’t mean that they can’t make a decision in the moment. We know that.”

The specific facts of the federal case case involved three residents who were battling some form of dementia or Alzheimer’s.  In one instance, an 80-year-old man suffering from dementia and behavioral disturbances was observed touching the genitals of a 65-year-old man who suffered from Alzheimer’s, dementia and behavioral disturbances. The two lived in separate rooms, connected by a shared bathroom. Coming across the encounter in one man’s bed, a nursing assistant did not see the 65-year-old objecting and did not intervene or investigate further. In another case, that same 65-year-old man was witnessed fondling a 77-year-old female resident suffering from Alzheimer’s, low cognitive functioning and severe impairment. An aide witnessed that incident and separated them because of the woman’s auditory challenges, but did not intervene further.

Reingold said the interaction between the two men suggested consent, "I didn’t think it was unreasonable for a nursing staff member to look at it and say that it’s basically consensual. It’s tricky. It’s a tricky balance to make, but I’m a little disheartened that the court felt this way.”

Reingold, who also holds a law degree and reviewed the court’s decision, believes the decision to be the highest court ruling related to sexual behavior between residents of nursing homes who have dementia. He said it will “absolutely” be used to establish precedent, and is concerned that it will be used by plaintiffs’ attorneys to file lawsuits against SNFs.

Of course, among the concerns for elderly residents, their loved ones, and fiduciaries, are the consequences of what may be deemed to be violations of these policies, especially if they are poorly articulated, or inconsistently enforced or applied.  To make consideration of these matters more dire, there is possible criminal consequence, such as a husband encountered upon seeking to continue sexual relations with his wife after she became a resident of an institution.   

For nursing homes, Reingold offered three steps leaders can take following this precedent-setting court decision:

• Make sure that the facility has very carefully drafted policies and procedures.
• Be sure that nursing staff are well trained in exactly how to deal with cases where there is sexual interaction between residents, particularly those who have experienced cognitive decline.
• Document specific interventions in the chart. 

Of course, elderly residents, their families, loved ones, and fiduciaries can, and should, inform themselves and their principals of these rules, and review incident reports for possible violations.  Inspecting, identifying, and tracking physical injuries, and noting emotional or psychological changes can also aid in identifying violations. 

For its part, in a statement sent to McKnight’s after the initial story ran, a spokeswoman  for the nursing home emphasized that the fine was related to an interaction between two consenting adults:  

“While the facility accepts the court’s ruling we respectfully disagree and continue to advocate that all residents have the right to privacy in their interactions with their peers and loved ones.” 

As if there is not already a host of considerations a senior resident, his or her family members, and fiduciaries must resolve. Of course, staying at home, if possible, avoids these considerations and risks.

CMS to "call-out" Nursing Homes Publicly On Safety Lapses

Centers for Medicare & Medicaid Services (CMS) is considering possible changes to Nursing Home Compare to better capture patient safety concerns, according to an article in McKnight's Long-Term Care News.  The current comparison tool captures only a “subset of harm” that is inflicted on residents in nursing facilities. CMS is seeking to reform the current system by developing a composite measure of healthcare-acquired infections, which would be incorporated into the rankings.

“While we view patient safety and quality improvement as a continuum, we agree that specifically ‘calling out’ facility performance on patient safety can resonate with and be beneficial to consumers,” wrote Kate Goodrich, M.D., the agency’s chief medical officer and  director of the Center for Clinical Standards and Quality in a Health Affairs blog.

A recent study demanded that changes be made to the standard measure for capturing quality at nursing homes.  The study concluded that the current five-star rating system failed to paint an accurate picture of patient safety. The study authors compared nursing homes’ performance in standard quality measures with six noted patient safety standards, including pressure sores, infections, falls and medication errors, and concluded that the relationship was weak between the two measures, “leaving consumers who care about patient safety with little guidance.”

Goodrich emphasized that SNF patient safety is a “crucial strategic priority” for the federal government. She countered the study’s conclusions by writing that Nursing Home Compare does contain measures that either directly capture harm or are highly correlated with it, such as inappropriate antipsychotic use, which may be linked to falls and other events.

Along with the infection-related composite measure, Goodrich wrote CMS will “continue to explore additional facets of and measures associated with safety in nursing homes going forward.” In addition, the agency recently developed measures to gauge the transfer of health information between providers and the patient. Those were designed to meet the requirements of the IMPACT Act, and CMS is intending to propose adopting them for the SNF Quality Reporting Program, Goodrich wrote: “[w]e believe these measures will address the important safety issue of improving the hand-off of medication information during critical care transitions.”

There is no discussion whether or when reporting of intentional actions such as sexual and physical assault by residents and staff will improve.

Nurse Aid Fired for Slapping Dementia Patient's Support Doll

It is tragic that humans find more and unique ways to harm each other.  From an article published in McKnight's Long Term Care News, we learn that an Illinois continuing care retirement community (CCRC) fired a certified nursing assistant for slapping a resident’s baby doll.

The incident at the St. Vincent’s Home, in Quincy, Illinois, first occurred in June, but reached the public eye only recently after the Illinois Department of Public Health released its quarterly violations report. State officials hit the home with a $2,200 penalty, after the CNA slapped a resident’s doll, reportedly to get her “riled up.” 

According to the Herald-Whig, the resident had been diagnosed with dementia, anxiety and depression, and suffered from confusion and short- and long-term memory impairment.  

Brian Inman, assistant administrator at the home, agreed the incident constituted mental abuse.  St. Vincent’s suspended the CNA pending investigation, later deciding to terminate the CNA. Prior to the incident, the CNA had undergone special training for dementia treatment.

While the incident might seem minor to some, it meant a lot to the resident, who views the three dolls as her children, a family member said in an interview with state officials.  Those baby dolls are her everything,” the family member said. “I know this [slapping the baby doll] would have really disturbed her. She thinks those baby dolls are her babies.”

The CNA reportedly told coworkers, who did not immediately report the incident, as required by the state, that slapping those dolls was good way to “keep from being bored during a shift,” later telling state investigators, “[i]t’s kind of cute but probably not to the resident.”

Hopefully the CNA will find another line of work.

Medicare Advantage Plans Receive Additional Enhancements

The Trump Administration announced a broad array of changes to Medicare Advantage plans last week in hopes the changes will further pressure providers to improve senior care.

Centers for Medicare & Medicaid Services (CMS) officials said the “innovations” will include everything from customizing plans based on beneficiaries’ chronic conditions and socioeconomic status to increasing access to telehealth services. CMS also wants to improve incentives for individual plans improve the health of seniors.

CMS Administrator Seema Verma said in a statement that Medicare Advantage was launched over 13 years ago, and was due for a facelift. "The American healthcare system is very different today than it was thirteen years ago when the Medicare Advantage and Part D programs were launched in their current forms, but due to the slow pace of change in government, these programs have not been fully updated to reflect today’s realities,” said Verma. The new CMS Center for Medicare and Medicaid Innovation (CMMI) will ideally spur greater competition among plans, while also “creating pressure to improve quality and lower costs in order to attract beneficiaries.” 

“Today’s announcements are prime examples of how CMMI can test policies to modernize CMS programs and ensure that our seniors can access the latest benefits,” Verma said.

The changes will be tested out as part of the Value Based Insurance Design model for 2020. Eligible plans in all 50 states will be able to apply for the innovations, according to a CMS fact sheets available here and here. Starting in 2021, they’ll also start testing the inclusion of hospice benefits as part of Medicare Advantage. CMS said it is also planning to extend the performance period of its VBID model another three years, to 2024, to sufficiently evaluate the impact of these changes. 

These new innovations supplement prior changes which, among other things, embrace Aging-in-Place:

2019 Medicare Advantage Plans Incorporate Long Term Care, Aging in Place Benefits 

Trump Administration Embraces Aging In Place- 2019 Advantage Plans Permitted to Incorporate Long Term Care

New Ohio Law Gives Probate Courts New Tools to Protect Wards Under Guardianship

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A new law in Ohio is designed, in part, to protect people under court-appointed guardians.  

House Bill 595, signed into law Dec. 21 by outgoing Gov. John Kasich, among other things, allows county probate courts to establish adult guardianship services boards and funds to provide for the oversight of services and care for those under guardianship.  Several probate courts have implemented similar voluntary programs, but the new law enables every probate court to implement what many contend is much-needed oversight over court-appointed guardians. 

When an adult becomes incapable of managing personal decisions or property, a probate court may appoint a guardian to make decisions on behalf of that adult. These decisions can be related to property, medical care, living arrangements, and financial issues. Guardianship cases for adults can be expensive, time consuming and complex. Guardianship, however, can be an indispensable tool in protecting an adult, and the adult's estate.  Guardians can even help prevent elder abuse and financial exploitation.

Guardianship, unfortunately, can itself be abusive, and a guardian with extensive authority, can be a threat to the adult's estate.  This blog contains numerous articles (several listed below) detailing the risk of guardianship abuse, ranging from guardianship appointments that are not well-founded or justified, to financial and physical abuse of adults by their court-appointed guardians.      

The lack of quality court monitoring in guardianship is one factor that can lead to  abusive situations, and sometimes a court will lose track of a ward and the ward's condition, the ward's money, or even the guardian. State courts are responsible for monitoring guardians' performance and ensuring that individuals under guardianship are protected and treated appropriately.  AARP has found that follow-up with reporting requirements and accounting required by guardians is lacking in many states across the country, in part, due to the sheer overload of cases in the system.  

“Cutting red tape for county courts to work together to provide services to individuals under guardianship could save time, money for the individual, their families/caregivers, and the state,” AARP State Director Barbara A. Sykes said in a statement. “Additionally, when state courts work together on such cases, they could not only be more efficient and effective, but they could also potentially detect signs of abuse and exploitation earlier in the legal process.”

Of course, effective planning, especially "Aging-in-Place" planning, does not rely upon the legal or financial system for success.  Reform should always be applauded, because, so often, real change takes time.  Whether and when these changes will reduce the incidence or effect of abusive guardianship remains to be seen.  Regardless, the wise plan for the worst, and with an effective estate, financial, and health care plan in place, hope for the best.       

The new law, is known as the Probate Omnibus Bill, and thus is not limited to just guardianship reform; the law amends several state statutes including those concerning probate, trusts and estates, and elderlaw.  Future articles will discuss other areas impacted by the new law.  

Previous articles include the following:

• Guardianship Reform Helps, but Planning Shouldn't Wait;
• Astronaut Buzz Aldrin Subject of Guardianship Dispute;
• Health Care Ageism And Senior Profiling;
• Contesting Guardianship or Challenging Guardians Is Problematic;
• Estate Plans Should Consider and Attempt to Resolve Guardianship;
• Illinois Permits Guardian Authority to Petition for Termination of a Ward's Marriage;
• GAO reports on Guardianship Abuse;
• National Groups Acknowledge Need for Guardianship Reform;
• Report on Abuse by Guardians and the Guardianship Process Released;
• Another Reason for Guardianship Planning: Guardian Convicted of Homicide in Death of Ward

Guardianship Reform Helps, but Planning Shouldn't Wait

Pennsylvania has implemented a Guardianship Tracking System (GTS), a new web-based system for guardians, court staff, Orphans’ Court clerks and judges to file, manage, track and submit reports. The system integrates statewide guardian information, thereby helping to protect Pennsylvania’s most vulnerable citizens while streamlining and improving the guardianship filing process.  Every little bit helps. One of the unstated benefits of making guardianship reporting easier, is that ease encourages filial and social caregivers to act as guardians. 

Of course, a better plan is to adopt an estate plan incorporating "Aging in Place" strategies, appointing and empowering trusted caregivers (not corporate trustees -banks, financial advisers, or attorneys) and preventing court-appointed guardian control of assets. In addition to making it even easier for filial and social caregivers to act on your behalf, such planning makes court-appointed guardianship more difficult and less lucrative for those who might be interested primarily in financial gain. The National Association to Stop Guardianship Abuse (NASGA) says it best; abusive guardianships have a distinctive pattern: Isolate- Medicate- Liquidate- Drain the Estate.

Guardianship reform helps, and should be encouraged and applauded. Planning, however, shouldn't wait. 

Click here to read the original Facebook post.

Click here to proceed directly to the National Association to Stop Guardianship Abuse Blog article.  

Medicaid Applicant Receives Penalty Period Based on Wife's Transfer on Death

A Missouri court of appeals has ruled that a Medicaid applicant is subject to a penalty period based on his wife's transfer on death of his interest in property to a revocable trust. Hallam v. Missouri Department of Social Services (Mo. Ct. App., No. WD81466, Oct. 9, 2018).  The case demonstrates the complexity of estate planning for farmers, and provides an object lesson in the significance of unintended consequences.

Evelyn and Joe Bell were farmers, and their homestead constituted their farm. They  entered into a postnuptial agreement which provided that each spouse had "the power to dispose of their share of the marital assets at their death free of any statutory or other claims of their spouse."  The Bells thereafter each created a limited liability company (LLC),  in which each served as the sole member. On the same date, the couple transferred into each LLC a one-half interest in the real estate and adjoining farmland that had served as their homestead. 

The Operating Agreement for Mrs. Bell's LLC provided that on her death, her member interest in her LLC would be transferred to the trustee of Mrs. Bell's revocable trust. Mr. Bell was neither the trustee of Mrs. Bell's trust, nor was he a beneficiary.  The foregoing events all took place in 2011.  In 2013, Mr. Bell transferred his LLC to Mrs. Bell, who in turn who transferred the LLC to the trust effective upon Mrs. Bell's death.  The Court agreed that the transfer from Mr. Bell to Mrs. Bell is permitted by state and federal law:

"Relevant to this case, [federal law] provides that: An individual shall not be ineligible for medical assistance...to the extent that -- (A) the assets transferred were a home and title to the home was transferred to -- (i) the spouse of such individual[.]"

Mrs. Bell died in January, 2014, her trust was administered and the assets distributed to the beneficiaries, Mrs. Bell's children.  In December, 2014, Mr. Bell entered a nursing home and applied for Medicaid. The state imposed a penalty period, finding Mr. Bell transferred property for less than market value.

Mr. Bell appealed, arguing that Mrs. Bell's transfer on death of the couple's property was not a voluntary disposal of assets by a spouse that would disqualify Mr. Bell from benefits. After all, Mr. Bell could not control his wife's disposition of her property, and Mrs. Bell did not voluntarily transfer the assets to her children, but were transferred as a consequence of her death. The state upheld the penalty period, nonetheless, and Mr. Bell appealed to court.

The Missouri Court of Appeals affirmed the penalty period, holding that Mrs. Bell's transfer on death was a disposition of assets that subjected Mr. Bell to a penalty period. The court concludes that there "can be no meaningful dispute that the instruments executed by Mrs. Bell 'gave away' her assets, albeit in a delayed manner that first required the condition of her death." According to the court, federal Medicaid law requires that the assets in Mrs. Bell's trust that previously belonged to Mr. Bell were to be treated as assets disposed of by Mr. Bell.  Thus, although Mr. Bell was not in control of his wife's disposition, he and his estate, nonetheless, suffered the consequences.  

Taking Trips Outside the Home can Help Prevent Depression in Older Adults

Click here to see the Facebook post with a link to the article. 

Click here to proceed directly to the Consumer Affairs article.

Retiring to a Foreign Country - Americans Lose $100 Million on Tropical Real Estate Says FTC

Click here to see the facebook post, with a link to the article.

Click here to proceed directly to the Wall Street Journal article. 

Criminals Steal $37 Billion Every Year from the Elderly-- Here's How

Elder fraud is an immense, complicated, and imposing problem, with implications for every aspect of a person's estate, financial, health care, and long term care plan. Effective aging in place planning and post retirement financial planning must include consideration of these risks. It is tragic that criminals take billions from the elderly using telecommunications and the internet, both tools necessary for communication. 

There is an excellent Bloomberg article describing how criminals prey upon the elderly, which article you can find here.  

See the firm's Facebook post here. 

US Law Takes Grand Step to Protect Grandfamilies- Grandparents and Others Rearing Children Of Family Members Receive Support

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In the United States today, children are increasingly being reared and even formally adopted by family members—most often, their grandparents. Many of these grandparents have been caring for their grandchildren as a result of the opioid crisis, taking on unanticipated or unexpected caregiving roles, sometimes even as their own children work through their addictions and treatments.  Given the death and disability associated with the opioid crisis, and the related or unrelated increasing suicide rate, families are increasingly forced by circumstance to make sure that children stay within their birth family and avoid the alternative of the foster care system. 

No wonder; more than half of the children in the child welfare system have endured four or more adverse childhood experiences, leaving them 12 times more likely to have negative health outcomes – substance use disorders, mental health problems, and engaging in aggressive or risky behaviors – than the general child population.  According to the 2017 State of Grandfamilies in America Annual Report, compared to those in care with non-relatives, children cared for by relatives have more stable and safe childhoods and a greater likelihood of having a permanent home. They have better mental and behavioral health, and are more likely to report always feeling loved.  Grandparents and other relatives who step in to care for children play an important role in preventing trauma, which children in the child welfare system experience at starkly higher rates than the general population.

Indeed, it is not only grandparents who are stepping forward to rear the children of parents with substance abuse or other issues: brothers, sisters, aunts, uncles, grandparents, and other extended family members, kinship caregivers, are stepping forward to fill the void created by the death or impairment of a child's parent. But, grandparents are by far the most common to bear the burden; they play the key child-rearing role in the lives of 2.5 million children—that’s 3% of all U.S. children.  All told, 7.8 million children, - that's 10% percent of all U.S. children- are being reared by family members who are not their birth parents.

The number of grandparents who report that they are raising their grandchildren, is reportedly 2.7 million, but it is likely that the actual number is far greater, as many families don't or won't disclose that parent's are unable or unwilling to rear their own children.  Some grandparents quietly assume the role of parent, often without consideration of the financial, legal, or medical challenges they may later encounter. 

This form of kinship care is so prevalent, it has its own name- the grandfamily, a freshly minted moniker born of necessity and tragic circumstance, describing the now common familial sacrifice and commitment.

Kathleen Kelly Halverson, writing for Adoption.com, in an excellent article,  properly characterized the meaning of such sacrifice:

"These grandparents are not just saving their own families: They are literally saving our country as well..."

That is not exaggeration or hyperbole; Generations United, a national nonprofit group, has estimated that grandparents and other relatives who are raising children informally save taxpayers $4 billion each year, but what value can be placed on a single child that is loved, supported, and healthy- physically, mentally, and emotionally- let alone the literally several million children, reared free from impairment, free from the torment of abuse, and able to care for themselves and others?  

And yet, these grandparents and kinship caregivers struggle financially, physically, and emotionally,  and, too often, silently. Grandparents struggle with their own health concerns and their own physical limitations, as they dip into retirement funds to ensure that their grandchildren are properly reared. Some grandparents may not even know that resources and support are available to them.  

The past year has seen the U.S. make a grand step forward in supporting these grandfamilies and kinship caregivers. The Supporting Grandparents Raising Grandchildren Act ("Supporting Grandparents Act"), which cleared the Senate unanimously in June, and was signed into law by President Trump in July, supports these guardian-saviors by creating a federal task force to establish a one-stop shop of resources for grandparents who are raising grandchildren. 

“Grandparents are increasingly coming to the rescue,” when addiction, overdose or other circumstance deprives a child pf parents, said Sen. Susan Collins, R-Maine, who chairs the U.S. Senate Special Committee on Aging. Collins cosponsored the bill with the committee's ranking member, Sen. Bob Casey, D-Pa.

These grandparents are “replacing traumatic pasts with loving and hopeful futures,” Collins said. Stepping up for a second round of parenting, especially when the family is dealing with the fallout of opioid addiction, comes with a barrage of decisions and challenges, such as “delaying retirement, navigating school systems, bridging the generational gap, working through the court system to secure custody and finding mental health services,” said Casey. Grandparents need a one-stop resource that provides contacts and information that will help “in that moment of crisis in that family,” said Casey.

The Supporting Grandparents Act has the backing of 40 advocacy groups for older adults and children, including AARP and the American Academy of Pediatrics.   A federal advisory council will include a grandparent, an older relative raising a child, together with experts from several federal agencies; it is charged with locating established resources across the country, investigating best practices, researching how to most capably rear children, and finding useful information for older relatives rearing and supporting children, with a special focus on those affected by opioid addiction.

Nancy LeaMond, AARP’s executive vice president and chief advocacy and engagement officer, praised Congress for taking action, saying, “[t]he federal advisory council will identify, promote, and disseminate information about this vital support and the resources available to help grandparents create and maintain a stable home environment for their grandchildren so that they can thrive.”

The Supporting Grandparents Act follows passage of the Family First Prevention Services Act ("Family First Act"), which became law in February.   The Family First Act is landmark child welfare law that works from the principle that children do best in families.  The Family First Act addresses an array of services and programs, but specifically provides financial and non-financial support for kinship caregivers, such as grandparents rearing grandchildren.  

The Family First Act provides first time federal reimbursement for prevention services and programs.  Federal child welfare dollars can be used for up to 12 months of services and programs to prevent children from entering foster care by supporting the triad of generations in grandfamilies - children, kinship caregivers and parents. The children qualify for services if they are “candidates” for foster care, meaning at imminent risk of entering foster care and can safely remain at home with parents or with kinship caregivers.  Children whose adoption or guardianship is at risk of disruption or dissolution qualify. 

Kinship caregivers or parents of the children also qualify for services if they are needed to prevent the children’s entry into care. Children and families can receive these services more than once if the child is again identified as a candidate for foster care at a later date.  The prevention services and programs include:

• mental health treatment;
• substance abuse prevention and treatment, and;
• in-home parent skill-based supports.

States, too, receive assistance in the form of federal reimbursement for up to 50% of their expenditures to provide kinship navigator programs that meet certain evidence-based requirements. This federal support is available regardless of whether the children for whom the services are being accessed meet certain income eligibility requirements for Title IV-E foster care funding.

The Family First Act seeks to improve licensing standards for relative foster family homes.  The Secretary of Health and Human Services (HHS) was required to identify a model of family foster home licensing standards by October 1, 2018, which the Secretary dutifully published August 1, 2018, sixty days sooner than required, a fact notable because the speed with which the federal government is working to reform existing law speaks loudly of its commitment to change.  You can, compare and contrast the federal licensing standards with those suggested by advocacy groups, such as the Model Family Foster Home Standards developed by the National Association for Regulatory Administration (NARA), Generations United and the American Bar Association.

By April 1, 2019, each state must report to HHS on the following:

• are the state standards in accord with the model and if not, why not?
• does the state waive non-safety licensing standards for relatives, as allowed by federal law?
• which standards does the state most commonly waive?
• if the state does not waive, why not?
• how are caseworkers trained to use the waiver authority?
• does the state have a process or tools to assist caseworkers in waiving non-safety standards so they can place quickly with relatives?
• what steps are the state taking to improve caseworker training or the process?

The Family First Act does not leave behind those children unfortunate to have no available kinship caregiver.  Under the new law, if children need to come into the custody of the child welfare system, the law encourages the placement of children in foster care in the least restrictive, most family-like settings appropriate to their needs by not allowing the use of federal funds for inappropriate group placements (effective October 1, 2019 although a state may request a delay for up to two years). Federal funds may only be used for a few specific types of group placements, including a qualified residential treatment program (QRTP).  An important component of the appropriate use of QRTPs is the requirement to facilitate and maintain family connections. To be considered such a program, the program must assist and encourage outreach to the child’s family members, including siblings and close family friends known as ”fictive kin,” and the child’s family must be a part of the child’s treatment.  This requirement includes family-based support for at least six months post-discharge. 

As part of the assessment to determine if a QRTP placement is necessary, the placement preferences of the family must be considered, and children must be placed with their siblings unless it is not in their best interest. If the placement preferences of the family are not followed, the reasons must be documented as part of that assessment process.

A QRTP service provider must:

• Be licensed and be accredited by at least one of three federally approved accreditors: The Commission on Accreditation of Rehabilitation Facilities (CARF), Council on Accreditation (COA) or The Joint Commission (formerly JCAHO);
• Use a trauma-informed treatment model;Have registered or licensed nursing staff and other licensed clinical staff, available 24/7, on-site according to the treatment model;
• Demonstrate family engagement and outreach, including siblings, in the child’s treatment;
• Provide discharge planning and family-based aftercare supports for at least six months post-discharge.

The accreditation mandate sets a high bar, but helps ensure the delivery of high-quality care. Organizations that earn accreditation have reached beyond the minimum licensing standards and made a long-term commitment to strong governance, program consistency, outcome measurement and continuous improvement throughout their agencies.

Accreditation also requires organizations to undergo an objective review by an independent accrediting body and signifies that they are effectively managing their resources and enhancing the quality of life for the population served.

The Family First Act also seeks to improves interstate placements, a significant step in an increasingly mobile and diffused society.  The Act expedites interstate placement of children in foster care, adoption or guardianship by requiring states to use an electronic interstate case-processing system by no later than October 2027 for exchanging related data and documents.

Further, the Family First Act extends guaranteed funding for child and family services programs. The Act extends funding for five years (fiscal years 2017-2021) for two critical service programs for children and families in the child welfare system-- the Stephanie Tubbs Jones Child Welfare Services Program and the Promoting Safe and Stable Families Program.  The Act also improves the John H. Chafee Foster Care Independence Program, and extends to age 23 the financial, housing, counseling, employment, education, and other appropriate supports and services to former foster care youth. It further extends eligibility to age 26 for Education and Training Vouchers.

Finally the Family First Act reauthorizes the Adoption and Legal Guardianship Incentive Program for five years.  The Incentive Program allows states to receive incentive payments based on improvements in increasing exits from foster care to adoption or kinship guardianship.  These incentives should encourage and aid in transitioning children to qualified grandparents or kinship caregivers from foster care.

Significant challenges demand significant response.  Fortunately, the federal government has risen to the challenge. 

This article is based upon and largely draws from "Trump Signs Bill to Help Grandparents Raising Kids,"  "Trump Signs The Supporting Grandparents Raising Grandchildren Act Into Law, and those referenced in the body of the article.  This article utilized the Children’s Defense Fund’s detailed summary of the Family First Prevention Services Act of 2016, available at ww.childrensedefense.org, and the Generations United detailed summary of the Act’s grandfamilies’ provisions, available at www.gu.org.