Opioids Sending More Seniors to ER

ID 130219425 © Skypixel | Dreamstime.com

If you thought that the current opioid crisis is relegated primarily to younger people, you are sadly mistaken.  According to an article in McKnight's Long-Term Care News, Emergency room visits by seniors who have misused opioids more than tripled between 2006 and 2014. Visit rates to ERs by adults older than 65 for opioid misuse increased a tragic 217% during the study period.

The statistic comes as a result of a new study which suggests that misuse of painkillers has had a snowball effect for seniors, leading to an increase in the number of chronic conditions, greater injury risk and higher rates of mental health diagnoses:

“Findings demonstrate the breadth and scope of opioid misuse and dependence among older adults visiting emergency departments — and indicate that targeted programs aimed at screening, intervention and treatment specifically geared toward older adults are warranted,” authors wrote in Innovation in Aging. “Results from this study also highlight the complexity of treating opioid dependence in this population, which reflect in part, high rates of coexisting mental health and other substance abuse disorders.”

Researchers studied multiple years of nationally representative data from the Nationwide Emergency Department Sample, which includes more than 950 hospitals, across 34 states and the District of Columbia. 

Justice Department Announces Elder Fraud Sweep

On March 7, 2019, the U.S. Department of Justice ("DOJ") announced the largest U.S. elder fraud sweep in a detailed press release entitled, Justice Department Coordinates Largest-Ever Nationwide Elder Fraud Sweep. A related press release from the U.S. Attorney General, entitled, Attorney General Focuses on Threats Posed by Technical-Support Fraud offers a look at the staggering extent of elder fraud:

The cases during this sweep involved more than 260 defendants from around the globe who victimized more than two million Americans, most of them elderly.  DOJ took action in every federal district across the country, through the filing of criminal or civil cases or through consumer education efforts. In each case, offenders allegedly engaged in financial schemes that targeted or largely affected seniors. In total, the charged elder fraud schemes caused alleged losses of millions of more dollars than last year, putting the total alleged losses at this year’s sweep at over three fourths of one billion dollars.

If you are interested, you can review the state-by-state results of the sweep, here.   The sweep included cases filed against perpetrators of tech support fraud, mass mailing fraud, and  money mules. Although there were no cases filed in Ohio or Illinois, there were cases file in the State of Missouri.  There are  consumer education efforts dedicated to both Ohio and Illinois:

[DOJ] and its law enforcement partners focused the sweep’s public education campaign on technical-support fraud, given the widespread harm such schemes are causing. The FTC and State Attorneys General had an important role in designing and disseminating messaging material intended to warn consumers and businesses.

Public education outreach is being conducted by various state and federal agencies, including Senior Corps, a national service program administered by the federal agency the Corporation for National and Community Service, to educate seniors and prevent further victimization. The Senior Corps program engages more than 245,000 older adults in intensive service each year, who in turn, serve more than 840,000 additional seniors, including 332,000 veterans. Information on Senior Corps’ efforts to reduce elder fraud can be found here.

Elder fraud complaints may be filed with the FTC at www.ftccomplaintassistant.gov or at 877-FTC-HELP. The Department of Justice provides a variety of resources relating to elder fraud victimization through its Office of Victims of Crime, which can be reached at www.ovc.gov.

Long Distance Caregiving

ID 69022089 © Rawpixelimages | Dreamstime.com

A new article, published by the Institute of Family Studies, authored by Professors Naomi Cahn and Amy Zietlow, The Sandwich Generation on Wheels: Tips for Long-Distance Family Caregivers, discusses the all too common issue of caregiving from afar.  Based on their respective research and experiences,  they note "that it is helpful for family caregivers to define the "sandwich" layers they face in order to proactively plan for what role they can and should play." 

The first layer requires one to "clarify who in your older generation depends on you in some way. List your parents, stepparents, in-laws, grandparents, aunts or uncles, etc. In conversation with them, formalize your caregiving role. This is particularly important in [a] stepfamily situation."  With this layer, not only must you identify who needs or might need assistance, you must identify the legal documents, and financial assets necessary to facilitate and provide help and assistance,  and you must articulate the limitations that arise from long-distance caregiving.  The authors briefly explore the potential for caregiving to help in such situations, and the practicalities of such planning:

"Then, acknowledge that by living at a distance, you cannot be available 24/7 to everyone, in person. Determine your trigger points for travel. For scheduled procedures, is there an acuity level that must be met before you fly or drive to be present? A major surgery? Yes. A physical therapy appointment? No. For emergencies, what is a reasonable expectation for arriving? Next, plan for how you will manage planned or emergency travel. We know this sounds a little advice column-y, but it’s good to be prepared for that 2 A.M. phone call that requires you to drive several hundred miles.   

The second layer, "your job, " focuses on caregivers who are employed and how to juggle a job and  caregiving responsibilities.  The third layer, "spouse and child" recognizes the sandwich issue- caregivers also have responsibilities to their own immediate family as well as the elders for whom they are caregiving.  "Communicating with your spouse and your children about your goals for this season of life is critical. Acknowledging how you will be dividing your time, and why, will help them feel engaged and involved. You will need their moral support in your role as caregiver."

Many of these circumstances will demand a "team approach," i.e., several different persons, sometimes including non-family lay persons, as well as third party professionals.  Consideration and utilization of a Private Care Agreement to define roles, responsibilities, expectations, and remuneration can aid in implementing a plan, managing expectations and concerns, and resolving foreseeable and unexpected disputes and disagreements.   

Technology can make such planning for care from a distance less risky and burdensome:

When you cannot be physically present, consider how you will stay connected and whether technology may help. Entire industries are developing applications that connect to smart homes, surveillance cameras, and interactive devices, such as Google’s Alexa, to meet the needs of elders and their family caregivers. Personal health monitors, as well as smart home technology, can monitor for falls and track weight gains and losses, play a favorite television show, or adjust thermostats, and thus contribute to the safety, entertainment, and comfort of older or ill adults. Already, senior-living residences have considered adopting “Addison,” a robot caregiver, who rewards residents when they meet goals, monitors changes in movement, and talks to the residents with screens strategically placed around the apartment or room. Technology can help connect when a loved one lives at a distance.

Of course, like with many solutions, senior appreciation, acceptance, and utilization may be vital to success.  In the past few years, we have watched and often guided seniors and their families in a suite of solutions for distance care.  These tools should be considered, and, if necessary, utilized in any Aging in Place Plan. 

Caregiving is complex, potentially overwhelming, and, draining, financially, mentally, emotionally, and physically. It is, nonetheless, rewarding and routinely ranked as “highly meaningful.”  Staying connected at a distance  is possible when expectations are clearly defined.   

Nursing Homes Push Dying Patients Into Unnecessary and Hazardous Rehab

An alarming study contends that Skilled Nursing Facilities (SNFs) may be pushing dying patients into unnecessary and potentially harmful high-intensity rehabilitation services. The study suggests that nursing homes may be sacrificing patient preferences and comfort for profit.  The study is another in a long list of reasons to plan to Age in Place.

University of Rochester Medical Center researchers noted that the number of residents receiving “ultra-high” rehab services in New York state increased by 65% during the three-year period ending in 2015. Most of those services were delivered to individuals in the last seven days of their lives, according to the analysis of data from 647 nursing homes in the Empire State that was published in the Journal of the American Medical Directors Association.

“These are often sick and frail patients in whom the risks of intensive levels of rehabilitation actually outweigh the benefits,” Thomas Caprio, M.D, a geriatrician and hospice physician at URMC and co-author of the study, said in a statement. “It can increase the burden of pain and exhaustion experienced by patients and contribute to their suffering.”

Researchers studies residents in the Very High (520 minutes per week) to Ultra-High (720 minutes) groupings of rehab services in the last 30 days of life. Authors speculated that rehab levels for the dying may actually be higher in other states with less regulatory oversight. They also acknowledge that some rehab is needed at the end of life, though more commonly of the low or intermediate variety.

The motive for unnecessary and burdensome rehab is profit. According to the report accompanying the study results, "recent reports from the Office of the Inspector General (OIG), the Centers from Medicare and Medicaid Services, and from popular press suggest that the volume and the intensity of rehabilitation therapy provided to residents in US SNFs may be more extensive than is warranted by the residents' care needs." The OIG report from 2010 found that the proportion of seniors referred to ultrahigh therapy (>720 minutes/wk) increased from 17% to 28% during 2006-2008 while the recipients' age, admitting diagnoses, and proportion of seniors with high functional impairment scores remained largely unchanged. The report also noted that for-profit SNFs were more likely to bill for high-intensity therapy compared to not-for-profits—32% versus 18%, respectively.

A 2015 OIG report showed that SNF billings for higher levels of therapy have continued to increase. Between 2011 and 2013, the percentage of ultrahigh therapy days grew from 49% to 57%, whereas residents' characteristics stayed the same. In 2015, SNFs were reported to make a six times or six hundred percent (600%) higher average daily profit margin from providing ultrahigh compared to low therapy intensity. 

According to the study's author's, "[a]t least as concerning as the evidence suggesting some nursing homes may have exploited the prospective payment system to “optimize their revenues” is the claim by the OIG investigators that SNFs billed for therapy levels that were higher than reasonable or necessary, even among the most vulnerable residents." The OIG cited an example of a hospice patient who “received physical therapy 5 days a week for 5 weeks, even though her medical records indicated that she asked that the therapy be discontinued.” Similarly, a 2016 report appearing in the Wall Street Journal quoted interviews with more than 2 dozen former SNF therapists and rehabilitation directors asserting that “managers often pressure caregivers to reach the 720-minute threshold” (required for ultrahigh therapy billing). 

Although the benefits of rehabilitative therapy in nursing homes are well established, pressures to maximize therapy may be inappropriate or even potentially injurious to some patients and may create obstacles to the provision of palliative and end-of-life (EOL) care in nursing homes.  Numerous previous studies have shown that, despite preferences, many residents are hospitalized in the final weeks of life, and receive burdensome treatments that may have few benefits.  Consider the following:

• Potentially avoidable hospitalizations of nursing home residents: Frequency, causes, and costs. J Am Geriatr Soc. 2010; 58: 627–635;
• Site of death among nursing home residents in the United States: Changing patterns, 2003-2007. J Am Med Dir Assoc. 2013; 14: 741–748;
• Hospitalizations of nursing home residents in the last year of life: Nursing home characteristics and variation in potentially avoidable hospitalizations. J Am Geriatr Soc. 2013; 61: 1900–1908;
• End-of-life transitions among nursing home residents with cognitive issues. N Engl J Med. 2011; 365: 1212–1221.

The resident's quality of care may, in such cases, be horrifically impaired. Nursing homes may actually be reluctant to refer their dying residents to hospice so as not to lose the opportunity to maximize a higher Medicare rate by providing rehab.  In other words, preferences and comfort are sacrifices for profit. This conclusion is at least suggested by two separate studies:

• Dying in U.S. nursing homes with advanced dementia: How does health care use differ for residents with, versus without, end-of-life Medicare skilled nursing facility care?. J Palliat Med. 2012; 15: 43–50;
• Influence of hospice on nursing home residents with advanced dementia who received medicare-skilled nursing facility care near the end of life. J Am Geriatr Soc. 2012; 60: 2035–2041.

In one study, nearly one-third of Medicare beneficiaries who were hospitalized received SNF-level care in the last 6 months of life and 9.2% died while on a SNF benefit.  Researchers argue that although such care may be appropriate for some, the receipt of SNF services at the end of life is likely to prevent many patients from receiving hospice and/or palliative care that may be more consistent with their wishes and care needs. A recent study reporting on staff experiences with palliative care in nursing homes noted that staff's desire to develop and provide quality palliative care services may conflict with the nursing homes' need to maximize the provision of rehabilitative therapies. In the words of a staff member, “[t]he goal is to get comfort measure people in therapy. They [residents] get the therapy; they [facility] get higher payment [reimbursement].”

Providers defended their practices to McKnight's Long Term Care News, noting that there is a deliberate system in place to regulate rehab levels. "When individuals request admission to a nursing home, they typically come with documentation on the type of care required. And once they’re at the facility, they must be able to maintain those levels of therapy," Nancy Leveille, executive director of the Foundation for Quality Care, part of the New York State Health Facilities Association, told McKnight's reporter Marty Stempniak. "If their condition is such that they cannot maintain, then nursing homes are unable to make a claim for those rehab minutes," Leveille explained.  "Plus, a significant sample of high-level rehab patients are then audited on a regular basis by Medicare or Medicaid, to validate that the services were appropriate," she added.

“There are checks and balances on the system and there are people who come in with terminal diagnoses and are trying to get back on their feet to be able to get back home or back to a different level of functioning for themselves for quality of life,” Leveille said. “But even within that, if they can’t meet the requirements of ultra-high rehab or any level of rehab, they can’t be scored on that.”

In other words, because billings are approved, the care is justifiable.

Respite for Family Caregivers

Respite is planned or emergency care provided to a child or adult with special needs in order to provide temporary relief to family caregivers who are caring for that child or adult. 

The ARCH National Respite Network and Resource Center provides useful resources on its website for family caregivers to navigate respite care. ARCH's Nine Steps to Respite for Family Caregivers, provides readers with facts sheets to guide caregivers to getting respite care. 

Each fact sheet is designed to be relevant to distinct caregiving situations, such as military caregivers and family caregivers of individuals with dementia.

Other resources on ARCH's website include the following:

• A Consumer Guide to Respite;
• The National Respite Locator;
• Financial Assistance for Family Caregivers.

The website also is where you can find Charting the LifeCourse Respite materials.  These materials include a Respite guide book, portfolio and other tools designed to help family caregivers caring for anyone of any age or disability and/or those who support them create a plan to access respite services within and outside the formal services system.

The materials provide:

• information on the importance of respite for the well-being of the family caregiver and all family members;
• tools for thinking about and planning for respite; and
• additional resources for finding respite in the community. 

Missouri Family to Family, which is housed within Missouri’s University Center for Excellence in Developmental Disabilities Education, Research and Services (UCEDD) at the University of Missouri–Kansas City Institute for Human Development, in collaboration with the ARCH National Respite Network and Resource Center, developed Charting the LifeCourse Respite materials.