New Rating System for Nursing Homes Launches Today

The Nursing Home Compare website and Five-Star Quality Rating System were created to help consumers, their families, and caregivers compare nursing homes and identify areas of possible inquiry when considering and comparing nursing home care providers. Highly anticipated changes to the federal Five-Star Quality Rating System for nursing homes are supposed to commence today, ending a freeze on survey results. Providers will learn whether they have gained or lost stars, or, as is expected for about half of facilities, remained the same.

Nursing Home Compare has a quality rating system that gives each nursing home a rating between 1 and 5 stars. Nursing homes with 5 stars are considered to have above average quality and nursing homes with 1 star are considered to have quality below average. There is one Overall 5-star rating for each nursing home, and a separate rating for each of the following three factors:

• Health Inspections: Inspections include the findings on compliance to Medicare and Medicaid health and safety requirements from onsite surveys conducted by state survey agencies at nursing homes.
• Staffing Levels: The staffing levels are the numbers of nurses available to care for patients in a nursing home at any given time.
• Quality Measures: The quality of resident care measures are based on resident assessment and Medicare claims data.

CMS has periodically made improvements to the website and ratings system. Each update has been part of CMS’s ongoing effort to increase the accuracy of information available to consumers and to encourage quality improvement at nursing homes across the country.

The set of changes also will bring the addition of new measures tied to long-stay hospitalizations and emergency room transfers, along with removing some “duplicative and less meaningful” metrics. The Centers for Medicare & Medicaid Services has said it wanted separate quality ratings for short-stay and long-stay residents, and it has revised rating thresholds to better pinpoint quality variations among SNFs for consumers.

Technology and Experts Assist in Aging in Place

"Karie" organizes, schedules, and dispenses pills.
This picture is subject to
 copyright of AceAge Inc.,
but is used without permission under the
"fair use" doctrine that permits
 use for educational purposes

I often tell clients stories to illustrate why gerontologists, and other experts, are indispensable in Aging in Place Planning, and why technology empowers seniors, and their families, and caregivers to prefer home over institutional care. One such real life story involves a client who I thought, based only upon the information available to me and her family, would require institutional care.  In that case, I and the family were wrong, and the client remained independent, at home, with technology providing  the necessary solution.

The challenge involved memory deficits and medication. The client, "Jane Doe" had recently been prescribed a blood thinner.  The client's children were understandably concerned, because they, and Jane Doe's doctors, had previously suspected that Jane Doe had "over-medicated."  Fortunately, the previous instance of over-medicating, presumably occurring because Jane Doe simply forgot that she had taken her medication, was not life threatening.  Now that Jane Doe's medication included a blood thinner, where the effects of mistaken over-medication might be life-threatening, the children inquired whether it was time to consider institutional care.

The concern was well-intentioned, and justified. Like her children, I presumed the time had come for Jane Doe to relent to institutional care, especially since her rural location would make professional care at the home difficult and expensive.  Jane Does was ruggedly independent, and like most of my clients, had expressed intentions to remain at home for as long as possible, despite worsening health or impairment.  She had, in fact been independent, capably managing her rural challenging existence for more than thirty years. I suggested that the family consult a gerontologist.

The gerontologist confirmed the legitimacy of the concern, and, in fact, believed that Jane Doe had a variety of additional challenges, about which we were unaware, that warranted consideration of institutional care.  The gerontologist, however, felt that institutional care would be traumatizing and destabilizing for the rural woman who had remained independent for so long.  She developed a plan for Jane Doe to remain at home, with the help of technology, and simple, inexpensive changes made to her "environment." 

The challenge of medication risk at home is common. Nearly one-third of older home health care patients have a potential medication problem or are taking a drug considered inappropriate for older people. Elderly home health care patients are vulnerable to adverse events from medication errors, in part, because they often take multiple medications, for multiple conditions, prescribed by multiple health care providers. The majority of older home health care patients routinely take more than five prescription drugs, and many patients deviate from their prescribed medication regime. The potential for medication errors among the home health care population is greater than in other health care settings because of the unstructured environment and unique communication challenges in the home health care system.  It is not surprising, then, that some suggest that almost one-quarter of patients in long term care are institutionalized because they cannot take their medication properly. 

One available solution is a product called "Karie" a product of AceAge Inc.  "Karie" is a personal health companion that organizes, schedules, and dispenses pills with one-button technology, ensuring that patients are taking the right medication at the right time. According to its manufacturer, Karie is "easy to use, enables greater patient autonomy and ensures better healthcare through a highly coordinated program."  Technology is providing solutions precisely in the time frame for which there is great need. 

  

The Strange Case of Crypto Exchange QuadrigaCX: Death and a Missing $200 million

 A major Canadian cryptocurrency exchange is in the spotlight following the sudden death of its founder, Gerald Cotten, which has left customers unable to access $190 million in funds.

The 30-year-old founder of QuadrigaCX died in India on Dec. 9, 2018 due to complications from Crohn’s disease, according to a sworn affidavit by his wife, Jennifer Robertson. At the time of his death, Cotten was the only person with the password to access the customers' funds.

“For the past weeks, we have worked extensively to address our liquidity issues, which include attempting to locate and secure our very significant cryptocurrency reserves held in cold wallets, and that are required to satisfy customer cryptocurrency balances on deposit, as well as sourcing a financial institution to accept the bank drafts that are to be transferred to us,” QuadrigaCX said, in a statement posted on its website. “Unfortunately, these efforts have not been successful.”

Referring to Court filings, the Chronicle Herald notes that “cold wallets” harness technologies such as USB drives and electronic devices that are not connected to the Internet.

I noted in my Facebook post on the subject that:

This would NOT have happened had the owner set up a LegalVault® account with my firm. I warned that this would happen in an article I published last November. I also described how my clients who use LegalVault avoid this risk. See my article here: http://bit.ly/2GrallA. 'A man who does not plan long ahead will find trouble at his door.' ― Confucius, Chinese philosopher."

You can read more in the Fox News article that first alerted us about the fiasco. Apparently the owner was concerned more for the welfare of his pet chihuahuas, than for his family or investors.  

More:  

LegalVault® Offers Solution to Estate Planning Challenges of Bitcoin and Cryptocurrencies;

Most Procrastinating on Planning; Those That Plan Don't Protect Their Plans;

Considerations in Crafting Health Care Proxies or Durable Powers of Attorney for Health Care;

Where Are Our Family Photos?!? Planning for a Digital Legacy;

The Trouble With Advance Directives;

More than 50% of Dual-eligibles Steered to Low-rated Nursing Homes

ID 106271439 © motortion | Dreamstime.com

Accepting the risks of the current health care system, for seniors, their families, and caregivers, often includes accepting the risks of referral to a nursing home after Medicare hospital benefits expire. Most assume that the transition is, like other aspects of health care, handled carefully and competently, and with the patient's best interest being paramount.  Unfortunately, that assumption is dangerously incorrect.

A recent study found that seniors who are eligible for both Medicare and Medicaid are more likely to wind up in low-quality skilled nursing facilities rather than available higher quality alternatives.  The authors summarize by concluding "(duals) are concentrated in lower quality [with ratings from 1 or 2 of five stars] nursing homes, relative to those not on Medicaid." Implicit is that Medicaid residents find themselves in the lowest quality facilities.

The study is significant because "dual eligible" seniors have, or should have, access to the widest variety of institutions, since they can be referred to both institutions accepting Medicaid and Medicare, and are not excluded from either those that don't accept Medicaid, or Medicaid-only facilities (the latter characterization is often misnomer since most institutions will accept both, but some institutions become Medicaid-primarily, or Medicaid-only). Medicaid residents often find themselves relegated to  the lowest quality facilities. The results of the study are the subject of an article published in McKnight's Long-term Care News. 

The study identified patient education and proximity to quality skilled nursing facilities as key reasons for the disparity.   This blog has repeatedly warned that the proximity of a care choice to the resident's home, or family, or hospital is a poor bases upon which to select a care provider.  

The study is published in the Journal of Applied Gerontology. According to the study's authors, the solutions are is not limited to investment in formal education and relocating high-quality facilities into areas where dual-eligible beneficiaries live. Rather, experts suggest that health care leaders should work to better disseminate information on high-quality care options to duals, and to improve lagging nursing homes in low-income areas:

“More interactions among nursing home leaders from both high-quality and low-quality facilities can help identify ways to improve low-quality facilities in poorer neighborhoods,” lead author Hari Sharma, Ph.D., an assistant professor in the University of Iowa’s Department of Health Management and Policy, told McKnight’s on Thursday.

Sharma and colleagues reached their conclusions based on nursing home quality data from 2009 — the first year after Five-Star ratings were made public, before facilities had a chance to substantially improve scores (by 2011, a large proportion of SNFs were rated as four or five stars, authors wrote). They found that duals were 9.7 percentage points more likely than non-duals to be admitted to a SNF rated as one or two stars (50.7% compared to 40.9% for non-duals).  

Authors note that healthcare leaders must find ways to address those additional factors that contribute to disparity. For instance, hospitals might work to steer duals to high quality nursing homes, Sharma said. Another important takeaway for SNF leaders from the study is the need to form partnerships with legislators to help eradicate inequalities:

“Our research highlights the need to invest more resources to improve existing low-quality nursing homes in areas that do not have many alternatives. Since investment of additional resources requires the commitment from both policymakers and nursing home leaders, it is imperative that both sides actively work together to improve existing low-quality nursing homes.”

For those planning to "Age in Place," this study provides more evidence for justification, and illustrates the importance of educating caregivers and fiduciaries regarding the workings of the health care and legals systems.   

Hospice Use by Nursing Homes on the Rise, but still Underutilized

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For those who implement an "Aging in Place" plan, hospice plays an integral part in the planning.  First, hospice care is "person-centered care" of the type and kind those who seek to stay home want and need.  Hospice focuses on "palliative care", a specialized type of care focused on relief from the symptoms and stress of a serious illness, with the goal being to enhance or improve the quality of life for both the patient and the family. Second, hospice is a benefit paid for by Medicare, meaning that there is no need for 'spend down," or planned or unplanned indigence to obtain the care.  

Now, according to an article in McKnight's Long-term Care News, more nursing homes are providing hospice care.  The article reported the results of a new LeadingAge report. The Report also finds that hospice care, nonetheless, remains largely underutilized. 

The report notes that the hospices’ prevalence has skyrocketed in recent years, with the number of providers nearly doubling since 2000, at about 4,200 in 2016:

Over the same period of time, the hospice patient population has changed drastically: hospice is now serving more individuals residing in nursing homes and assisted living in addition to its traditional home-based population. In 2016, half of all Medicare hospice beneficiaries died at home and a third died in a nursing home. The terminal conditions experienced by hospice enrollees are also changing. Whereas hospices initially served primarily patients with cancer, they now serve individuals with many different diagnoses, including neurological conditions such as dementia, as well as progressive cardiac and pulmonary diseases [citations omitted]. 

In 2016, about half of all Medicare hospice beneficiaries died at home, while one-third died in a nursing home. Terminal conditions treated by the benefits have changed too. While the service was almost exclusively limited to cancer in the past, patients with dementia and heart disease are increasingly using it, too.

Though hospice use has grown exponentially in recent years, utilization remains low, according to the report. More than one-fourth (28%) of Medicare beneficiaries who used the benefit enrolled for fewer than seven days immediately before death, a length of stay thought to be of less benefit to patients and their families than a longer stay. According to the report, these short stays relate to:

• Physicians being reluctant to discuss hospice or delay such discussions until the patient is close to death;
•  Some patients and families having trouble accepting a terminal prognosis;
• The requirement that patients forego intensive conventional care in order to enroll in hospice; and,
• Financial incentives in fee-for-service Medicare that encourage increased volume of clinical services.

Congress and CMS have introduced a number of initiatives to promote earlier hospice enrollments and better-quality end-of-life care.