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

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

The article first discusses the practical impediments consumers face in an effort to age in place:

"Most aging people would choose to stay home in their last years of life. But for many, it doesn’t work out: They go in and out of hospitals, getting treated for flare-ups of various chronic illnesses. It’s a massive problem that costs the health care system billions of dollars and has galvanized health providers, hospital administrators and policymakers to search for solutions."

According to the article, Sharp HealthCare, a San Diego health system, devised the pre-hospice program called Transitions as a way to fulfill patients' desire to stay home, keep them out of the hospital, provide necessary care in their home, and reduce the costs of care. Social workers and nurses from Sharp regularly visit patients in their homes to explain what they can expect in their final years, help them make end-of-life plans, and teach them how to better manage their conditions, illnesses, and diseases. Physicians track their health, and eliminate unnecessary medications and treatments.  Unlike hospice care, patients don’t need to have a prognosis of six months or less to live, and they receiving curative treatment for their illnesses - not just relief from symptoms.

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

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

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

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

Can Aging be Stopped and/or Reversed?

An intriguing article, "Purging the body of 'retired' cells could reverse ageing," published in the Guardian, reconsiders the question: "Can aging be stopped and or reversed?  The articles suggest that recent scientific advances suggest that purging retired cells from the body can reverse the ravages of old age.  New research raises the prospects of new life-extending treatments, and preventative therapies resulting from sweeping away dormant cells, :senescent cells" that  fail to divide genetically due to age, but create mischievous and malicious health impacts as they persis and build-up in an aging body.

The article reads as follows: 

When mice were treated with a substance designed to sweep away cells that have entered a dormant state due to DNA damage their fur regrew, kidney function improved and they were able to run twice as far as untreated elderly animals.

The team are now assessing whether the mice also live longer and are planning a series of safety studies in humans with the ultimate goal of testing whether getting rid of so-called senescent cells could help reverse a range of age-related disorders.

The discovery adds to a wave of new findings hinting at the possibility of a future in which doctors can treat ageing itself, rather than trying to combat the host of diseases that come along with it.

Such a scenario is now supported by science, according to Peter de Keizer, the 36-year-old scientist who led the latest work at Erasmus University Medical Center in the Netherlands. “Maybe when you get to 65 you’ll go every five years for your anti-senescence shot in the clinic. You’ll go for your rejuvenation shot,” he said. “That I can envision when we reach that age.”

Go here to read the rest of the article.  

Man Transported to SNF But Dropped Off at Wrong Location Found Alive Three Days Later

Among the inherent risks of institutional care is transport error.  An object lesson comes in the recent story of an Illinois man  who was dropped off at an intersection nearly ten 10 miles from the nursing home where he was supposed to be admitted.  He was found nearby in a ditch in a three days after.

Michael Bennett, 66, was in the process of being transferred from the Chicago Behavioral Hospital in Des Plaines, IL, to Westwood Nursing Home in Chicago. He was left at an intersection in Des Plaines approximately 10 miles away from the nursing home, according to authorities.  Illinois State Police issued a missing and endangered alert for Bennett. After seeing the alert, a citizen spotted Bennett curled up in a ditch three days later. Bennett was taken to a local hospital for evaluation.

The behavioral hospital is responsible for transporting discharged patients,  An administrator at Westwood told local reporters he was “mystified” that the driver didn't attempt to escort Bennett inside the nursing home, or notice that the facility was not located at the intersection.

The hospital had no comment on the incident.

To read other articles regarding the risks of transport, go here and here.

Aging in Place: Home Health Care Gets Best Outcomes for Knee and Hip Replacement Recovery

Aging in Place continues to be supported by scientific research and surveys.  The most recent research demonstrates that patients who go straight home from the hospital following hip or knee replacement surgery recover as well as, or better than, those who first go to a skilled nursing facility or rehabilitation center. Importantly, the research demonstrates that these health outcomes include those who live alone without family or friends.  

The research was reported in HealthDay, in an article appropriately entitled, "Home Beats Rehab for Knee, Hip Replacement Recovery."  According to the article, 

"We can say with confidence that recovering independently at home does not put patients at increased risk for complications or hardship, and the vast majority of patients were satisfied," said that study's co-author, Dr. William Hozack. He is an orthopaedic surgery professor with the Rothman Institute at the Thomas Jefferson University Medical School in Philadelphia.

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"Considerable evidence has now shown that most patients do just as well at home," he noted.

Hozack and his colleagues are presenting their findings in San Diego at a meeting of the American Academy of Orthopaedic Surgeons (AAOS).  Two other studies being presented at the meeting also found that recovering at home may be the better option.

One study found that patients who are discharged directly home following a total knee replacement face a lower risk for complications and hospital readmission than those who first go to an inpatient rehab facility. The study was led by Dr. Alexander McLawhorn, an orthopaedic hip and knee surgeon at the Hospital for Special Surgery in New York City.

McLawhorn was also part of a second Hospital for Special Surgery study, led by Michael Fu. That study found that hip replacement patients admitted to an inpatient facility rather than being sent home faced a higher risk for respiratory, wound and urinary complications, and a higher risk for hospital readmission and death.

Dr. Claudette Lajam is chief orthopaedic safety officer with NYU Langone Orthopaedics in New York City. She was not involved with the studies, but agrees that home recovery is the best option for most patients.  "The home setting is the single best way to get people back into their routines as quickly as possible after surgery," she told HealthDay.

"In some cases, this cannot be done," Lajam acknowledged. "Some patients live in settings that are inaccessible, [such as] a 5th-floor walk-up apartment where the patient would need to go downstairs to let the visiting nurse and therapist in the door." For some patients, anxiety about the recovery process could also pose a challenge, she added.

But "being in an institutional setting after surgery only reinforces the idea that the patient is 'sick,' " Lajam added. "We have learned that this type of thinking slows down recovery. We want our total joint patients to start using their new joints as quickly as possible, and staying in bed at a nursing facility is not the way to do this."

Because home environments vary, Hozack and his colleagues set out to see whether patients who live alone fare as well as those who live with others.  All 769 patients enrolled in the study by Hozack's team went home following either a total hip replacement or a total knee replacement. Of those, 138 lived alone (about 18 percent).

Once home, all were assessed on multiple levels, including functionality (ability to move); pain levels; hospital readmissions; emergency department visits; unscheduled doctor visits; dependency on assisted-walking devices; and time before returning to work or being able to drive again.  Hozack's team observed no differences by any measure. And while those who lived with others indicated relatively higher satisfaction levels at the two-week mark, by the three-month point there was no appreciable difference between the two groups.

"We feel that giving patients back their independence early on is the best way to promote a safe and effective recovery," said Hozack. His team concluded that single-household patients who go straight home can expect to fare as well as those who have live-in support.

According to HealthDay, a recent Mayo Clinic study calculated that between 2000 and 2010, the number of Americans who underwent hip replacement surgery more than doubled, rising from just under 140,000 to more than 310,000 per year.  Meanwhile, AAOS figures indicate that in 2010 more than 650,000 knee replacement procedures were performed, with about 90 percent involving total knee replacement.  AAOS estimates from 2014 show that 4.7 million Americans now live with an artificial knee and 2.5 million have an artificial hip.

Findings presented at the upcoming meetings are considered preliminary until published in a peer-reviewed journal.

Lawsuit Claims New York's Largest For-profit SNF Operator Kept Nurses in 'Indentured Servitude'

As the consequences of institutional health care for the elderly come to light, so do the consequences to those who work in the institutional elderly care industry. This blog has not before focused on the plight of workers in the industry, but will do so on a going forward basis.  The reason?  One can't expect quality health care from an industry that does not seek, keep, and maintain the highest quality personnel. There is, unfortunately, mounting anecdotal evidence that some in the industry often compromise in staffing decisions in ways one might expect would adversely affect health care outcomes.  

A newly filed class action lawsuit claims that New York's largest for-profit nursing home group allegedly kept more than 350 Filipino nurses in “indentured servitude” and sued those who tried to quit.  The lawsuit was reported in an article published in McKnight's.

The complaint was filed against SentosaCare by former employee and registered nurse Rose Ann Paguirigan. She said she was recruited from the Philippines to work for SentosaCare and eventually signed a contract to work for a Staten Island facility operated by the provider.

The contract stated that Paguirigan would be employed full time as a registered nurse and paid a base salary; instead, she was employed as an RN manager, given 35 hours of work each week and paid less than the wage stated in the contract.

Similar contracts were signed by hundreds of other foreign nurses recruited by the company, although SentosaCare and its recruiter, Prompt Nursing Recruitment Agency, have “policies and practices” to not give foreign nurses full time work or pay them the prevailing wage, Paguirigan's complaint states.

The filing also claims that the provider maintains a “deliberate scheme, pattern and plan” meant to convince foreign nurses that they would “suffer serious harm” if they quit the company or tried to find work elsewhere. This scheme included a reported $25,000 penalty placed in the nurses' contracts that they must pay if they left SentosaCare before the end of their contract term.

Paguirigan argues that a local court found the $25,000 “Indentured Servitude Penalty” unenforceable in 2010, but that SentosaCare, Prompt Nursing and its owners continue to use the penalty in its foreign nursing contracts.

The provider has filed lawsuits against at least 30 nurses since 2006 to collect the penalty, and has sought criminal indictments against at least 10 nurses and a lawyer retained to advise them, according to the complaint.

“The purpose of these lawsuits against plaintiff and other foreign nurses was not to recover actual losses, but to send a message to all foreign nurses that they will face civil litigation and incur substantial attorneys' fees if they stop working for the defendants,” the complaint reads.

The suit seeks compensatory and punitive damages or Paguirigan and other foreign nurses, as well as an injunction barring SentosaCare from threatening to enforce Indentured Servitude Penalties in their contracts, and a declaration that Indentured Servitude Penalties are unenforceable.

SentosaCare has previously been criticized in a ProPublica report for its rapid growth amidst fines and violations.