Vol. 18, No. 3
March 28, 2018

In This Issue: Azar on health system reform | Obamacare market worries | state ACA “fix” efforts | Medicaid waiver implementation | geriatrician recruitment woes | operations on frail elderly | measuring family involvement with SNF residents | the Savvy dementia caregiver training program | rare diseases and caregiving | lay community health workers and health-challenged residents | overusing benzodiazepines | a new guide to visiting your doctor | cheers for the digital health revolution | aging Native Americans | elder self-neglect | caregiver stress in the ER | life without retirement savings | the saga of Edith+Eddie | the future of hospitals | “Alexa, will you please be my bedside friend?”
Azar on the Future of the Healthcare System
Amid the Capitol Hill machinations over the fate of the omnibus spending bill, including Obamacare market stabilization measures, HHS’s new secretary, Alex Azar, went before the Federation of American Hospitals to spell out his intentions regarding the future of the American healthcare system. Azar did not mince his words: “There is no turning back to an unsustainable system that pays for procedures rather than value. In fact, the only option is to charge forward—for HHS to take bolder action, and for providers and payers to join with us. This administration and this president are not interested in incremental steps. We are unafraid of disrupting existing arrangements simply because they are backed by powerful special interests.”

Azar’s formula consists of four elements: “giving consumers greater control over health information through interoperable and accessible health information technology; encouraging transparency from providers and payers; using experimental models in Medicare and Medicaid to drive value and quality throughout the entire system; and removing government burdens that impede this value-based transformation.”
ACA ‘Fix’ Failure
The Secretary’s speech did not touch on the Obamacare issues that have challenged lawmakers and policy experts since the collapse of the GOP repeal effort, followed by President Trump’s executive actions on insurer payments and ACA promotion efforts. As the March 24 Congressional spending deadline approached—and, in the end, failed to produce a viable ACA legislative “fix”— almost daily warnings about the effect a failure to act would have on the availability and affordability of health insurance policies appeared. The Center on Budget and Policy Priorities’ Aviva Aron Dine voiced concerns about some possible negative effects of market fixes. Policymakers, Dine argues, must meet three tests in enacting stabilization measures: “actually avoid making coverage more expensive for moderate income consumers by (combining) cost-sharing reduction payments with compensating adjustments and consumer subsidies; address the greatest risk to the individual market, namely, the administration’s recent regulatory actions expanding the availability of insurance plans that operate outside the ACA’s rules and protections; and avoid weakening consumer protections or coverages, such as a measure that would allow insurers to charge older people much higher premiums.
ACA Premium Increases on the Horizon
Dire warnings about ACA premium increases were sounded by Covered California: “Absent any federal policy action, premium increases for every state could range from 12 to 32% in 2019, with cumulative increases from 2019 to 2021 potentially ranging from 35 to 90%.”  
Proposals in Nine States to Deal With ACA Mandate Repeal
Meanwhile, a number of states, unwilling to await federal action, have been examining possible individual approaches to overcoming the repeal of the Obamacare individual insurance coverage mandate. Kaiser Health News’ Rachel Bluth reports that some states are enacting measures to preserve the effects of mandate by creating their own versions of it. “Maryland is on the cutting edge with legislation moving through both chambers of the statehouse. Proposals have been discussed or advanced in at least nine states, including California, Washington and Connecticut, and the District of Columbia.”
Reinsurance Proposals Under Consideration by GOP Lawmakers
Even some Republican state lawmakers opposed to the ACA, the Wall St. Journal’s Stephanie Armour writes , “are showing interest in proposals to shore up the health law and lower premiums, driven partly by their concerns that escalating insurance costs may hurt them in the midterm elections. State and federal GOP lawmakers are backing or considering reinsurance proposals that aim to curb premiums by offsetting insurers’ costlier claims. In Wisconsin, Gov. Scott Walker, a vocal critic of the ACA, has proposed a $200 million reinsurance program, following the lead of states such as Alaska, Hawaii, and Oregon.”
Hospital Association Leaders Quiet on Medicaid Policy Changes
The debate over what to do about the ACA health exchanges has somewhat eclipsed Medicaid policy changes, but the move to impose work and other requirements continues apace. Modern Healthcare’s Harrison Meyer reports that one significant player in last year’s battles is now sitting things out. “Politically powerful state hospital associations and their members spent most of last year battling Congressional Republicans’ efforts to sharply cut Medicaid spending and rollback its expansion to low income adults. Now they’re very nervously facing narrower but still significant GOP Medicaid rules that are projected to push tens of thousands of low income people out of the program by imposing work requirements, premium payments, rigorous incoming rules, and benefit lockouts for failure to comply. Up to now, however, most hospital association leaders have limited themselves to raising practical issues about how their state will implement the work requirements and other rules, rather than objecting to such fundamental changes to Medicaid. The American Hospital Association also has taken no position on Medicaid work requirements.”
Kentucky’s Medicaid Program: What Are the Costs?
Kentucky, the first state to receive a work requirement waiver, is hard at work implementing the change, but, as RollCall’s Misty Williams points out , “the addition of work requirements and other sweeping changes to Kentucky’s Medicaid program could cost nearly $187 million in the first six months alone to get up and running. Republican Gov. Matt Bevin projects that the program will eventually yield savings but the changes require an upfront investment in administrative expenses. Much of that money is aimed at creating complex electronic systems and other changes needed to track work hours, monthly premium payments and other elements of Kentucky’s recently approved plan to revamp the government insurance program for low income Americans. ‘Work requirements in particular are unprecedented for Medicaid agencies and will likely make up the bulk of the cost to build necessary infrastructure to track whether people are complying,’ said Patricia Boozand, senior managing director with legal and consulting firm Manett. Officials in the Bluegrass State, however, say the program will create an estimated $2.4 billion in savings to the state and the federal government over five years. Most of that would come from people dropping off the Medicaid rolls or not qualifying in the first place because of the rules.”
Where are the Geriatricians? Look at Student Debt
Distressing news about the supply of geriatric physicians comes from National Resident Matching Program data that, as reported by Modern Healthcare’s Maria Castellucci, indicate that “of the 139 geriatric fellowship programs from the 2018 appointment year, just 35 were filled. Furthermore, the fellowships offered 387 positions for residents yet only 176 were filled. The matching program figures highlight a constant problem in the field of geriatrics: It struggles to attract doctors even as the pool of medical school graduates grows as quickly as the demand for the specialty. ‘The main factor at play: The specialty pays comparatively less than other specialties,’ said Dr. Gregg Warshaw, University of North Carolina School of Medicine geriatric adjunct professor. Geriatricians earn less because Medicare is the primary payer and offers historically lower reimbursement rates than commercial insurance. The pressure to pay off debt from medical school usually motivates doctors to go into higher-paying specialties, such as orthopedics and cardiology. Finances is clearly a critical issue.”
Too Old for Surgery?
“Nearly one in three Medicare patients undergoes an operation in the final year of life.” That is one of the findings Kaiser Health News’ Liz Szabo cites in an article casting doubt on the desirability of such procedures. Maxine Stanich, 87, serves as one example. Despite a DNR order ordering doctors not to revive her should her heart stop, “a trip to a San Francisco emergency room for shortness of breath in 2008 left Stanich with a
defibrillator implanted in her chest. During a subsequent visit to a different hospital, a surprised ER doctor explained that the device would not allow her to slip away painlessly, in fact ‘the jolt would be so strong it will knock you across the room.’ Surgery like this has become all too common among those near the end of life, experts say. ‘You have a culture that believes in very aggressive care,’ cardiologist Dr. Rita Redberg observed. ‘We are often not considering the chance of benefit and chance of harm, and how that changes when you get older. We also fail to have conversations about what patients value most.’ While some robust octogenarians have many years ahead of them, studies show that surgery is also common among those who are for more frail.”
Long-term Care and Family Involvement Study
Researchers at Minnesota State University (Mankota) have developed a very comprehensive questionnaire designed to measure the extent of familial involvement in the lives the long-term care facility residents. The 40-item instrument is meant to go beyond visitation frequency and delve deeply into the interactions between residents and family members. “Perhaps the most interesting outcome of the study,” the researchers observed , “was the finding that a significant negative correlation between the participants’ distance from their family members’ long-term care facility and their overall score on the questionnaire ceased to be significant when the effect of questioning visitation frequency was controlled for. This should serve as a warning to those who would consider in-person visitation as the sole measure of family involvement with older adults residing in long-term care facilities. Future attempts to measure family involvement in the lives of long-term care facility residents should make sure to examine methods of family involvement that do not require in-person visitation alongside those that do. Perhaps with some facility training and planning, technologies, such as Skype and Telepresence, might be incorporated to improve the contact the family living greater distances from care facilities might have.”
Savvy Caregiver: Advanced Version of the Program
As the Alzheimer’s Association points out, “the Savvy Caregiver Program is a unique approach to education for Alzheimer family caregivers. The program has been developed by clinicians and educators who understand that caregiving is in many ways a form of clinical work, and have tailored training accordingly.” Now researchers from Emory University and the University of Southern Maine have looked at an advanced version of the Savvy program and found that “participants, previously engaged in psychoeducation intervention, demonstrated significant improvement in competence, personal gain, self-efficacy, and symptoms of depression at five months post program. Gains were sustained for competence and personal gain at 12 months. Because the caregiving situation changes over the trajectory of dementia, episodic interventions or refreshers are necessary to address the evolving needs. Savvy Advanced is such an intervention. Learning activities can be adapted to fit the priorities of participants, try out a variety of problem-solving strategies, and ultimately deploy those that work best for the situation. The focus of the curriculum on future planning, readiness to address anticipated challenges, and using existing competencies enable caregivers to look ahead.”
Study Looks at Rare Disease Caregiving
In a first-of-its-kind study, the National Alliance for Caregiving and Global Genes have examined the impact of rare diseases on family caregivers. Rare diseases or conditions, the study explains, “are those that affect fewer than 200,000 people; the National Institutes of Health estimates that there are approximately 7,000 such diseases It is further estimated that 25 to 30 million Americans currently have a rare disease or condition that exerts broad and lasting impact on caregivers, in both daily life and long-term well-being. In our study over 400 unique rare diseases and conditions were captured, with the most commonly mentioned conditions including cystic fibrosis, pulmonary arterial hypertension, atypical hemolytic uremic syndrome, Ehlers-Donlos syndrome, Fabry disease, and congenital central hypoventilation syndrome. A defining feature of rare disease caregiving seems to be one of expertise; rare disease caregivers very often have to function as nurses, performing medical nursing tasks.” The researchers’ policy recommendations include enhancing the health of family caregivers through access to respite and counseling; achieving financial security and workplace protections for family caregivers; ensuring family caregivers receive comprehensive training and information; improving care coordination between home health providers, direct care workers, and family caregivers; including family caregivers as vital members of the team in health care settings; and recognizing family caregivers’ role in clinical trial research and innovation.
IMPaCT Care Model Shows Positive Results
Several studies attest to the beneficial impact of community health workers on the health outcomes of high risk and disadvantaged patients. One of the first such interventions—the Individualized Management for Patient Centered Targets (IMPaCT) care model—was pioneered by the University of Pennsylvania in Philadelphia. The Penn Center for the Community Health Workers sends lay individuals into poor neighborhoods throughout the city to ask patients what kind of support they need to improve their health. In a newly issued report on the program the authors draw upon earlier evaluations that found, for example that “patients who received help from impact workers were 52% more likely to visit a primary care physician within two weeks of being discharged from the hospital. Also patients reported improved mental health, a stronger sense of ‘activation’ (feeling able and motivated to take care of themselves), and better communication with hospital staff at the time of discharge. Additionally IMPaCT showed a favorable cost-benefit ratio: the evaluations documented a robust return on investment, estimated at two dollars annually for every dollar put into the program.
Effective Lay Health Worker Model in Rural Kentucky
Moving from the urban environment of Philadelphia to Kentucky Appalachia, researchers looked at the effectiveness of a lay health worker model in addressing the social needs and readmissions of high risk patients admitted to a rural community hospital. The LHW intervention involved assessment and development of a personalized social needs plan for enrolled patients (e.g. transportation and community resource identification), with post discharge follow-up calls. The results were impressive: a 47 7% relative reduction of 30 day hospital readmission rates between baseline and intervention phases of the study. LHWs, the researchers concluded, offer an effective hospital-based model to improve transitions in care from the hospital setting, especially those at high risk of persistent social needs.”
Program to Reduce Hospital Utilization by ‘Superusers’
A third study , this one focusing on “community navigators,” looked at “superusers”—patients who have high rates of healthcare utilization and high medical expenditures and place a heavy burden on the healthcare system. Although super utilizers make up roughly 5% of all patients they account for half of all expenditures. Superusers typically have serious and often multiple comorbidities and are hospitalized more frequently for uncontrolled chronic conditions, such as congestive heart failure, chronic lung conditions, and diabetes, compared with typical patients. They are also more likely to suffer from poor mental health and substance abuse problems. Researchers studied the impact of the “Familiar Faces” program, developed by Memphis Tennessee’s Methodist Le Bonheur Healthcare System to address the needs of superusers among the city’s poorest population. The program worked to address those needs by blending the roles of community health workers (CHWs) and patient navigators into a single role of community navigator. Similar to CHWs, the community navigators are members of the community. In addition to connecting clients to health and social resources in the community, navigators focus on building trust between the client and navigator and subsequently with other health care entities and social systems in the community. However, unlike CHWs, the community navigators are employed and embedded within the hospital system and receive the training often provided to patient navigators. The researchers concluded that “the navigators may represent a clinically meaningful and potentially cost saving solution to reduce hospital utilization among super utilizers. Patients in our study had significantly fewer hospital-based encounters and hospital days and experienced longer gaps between subsequent hospital encounters compared with similar superusers in neighboring low income communities. Our findings were similar in both cohorts of Familiar Faces clients, who were assisted by different community navigators, suggesting that the program can be replicated.”
B enzodiazepines: Another Prescription Crisis?
While the opioid crisis dominates the news, a related but similarly devastating substance abuse problem continues to grow in dimension and impact: the inappropriate prescribing of benzodiazepines—controlled substances such as alprazolam, clonazepam, diazepam, and lorazepam. Writing in the New England Journal of Medicine, three Stanford University psychiatrists paint a disturbing picture of the increased lethality and other harmful effects of these drugs. “Benzodiazepines have proven utility where used intermittently and for less than one month at a time. But when they are used daily and for extended periods, the benefits diminish and the risks associated with their use increase. Many prescribers don’t realize that benzodiazepines can be addictive and and when taken daily can worsen anxiety, contribute to persistent insomnia, and cause death. Other risks associated with benzodiazepines include cognitive decline, accidental injuries and falls, and increased rates of hospital admission and emergency department visits.”

Paula Span picks up the topic in her New York Times The New Old Age blog . She profiles Jessica Falstein who began her benzodiazepine odyssey in 1992 to cope with an anxiety disorder, panic attacks, a racing pulse, and sleeplessness. Gradually her dosage of Klonopin increased and then a second drug, Ativan, was added to the mix. Now 67, Span writes, “with her health and stamina in decline, Falstein has been diligently working to wean herself from both medications. ‘They turn on you,’ she said. The most serious consequence of overuse: falls and fractures, already a common danger for older people, because ‘benzos’ can cause dizziness. They are also associated with auto accidents, given that they cause drowsiness and fatigue. Moreover they have a negative effect on memory and other cognitive function,” according to Ann Arbor VA psychiatrist Dr. Donald Maust.“As for Falstein, the road back from benzodiazepam dependence has not been an easy one. ‘I thought I’d be off them in a year, maybe two,’ she said. But it has taken five so far; using a method called liquid titration, she has been able to discontinue Ativan and cut back to less than a daily milligram of Klonopin. ‘I was determined,’ she said. ‘I’m going as quickly but as safely as I can.’ She figured she has two years to go.”
Alliance for Health Policy Discussion to Improve LTSS
In late February the Alliance for Health Policy hosted a wide-ranging discussion about Using State Flexibility to Improve Medicaid Long-term Services and Supports. Four Medicaid experts with federal and state experience explored a wide range of efforts to improve LTSS. A complete transcript of their exchange and interaction with the audience is now available at the AHP website .
States Move to Address Out-of-Network Charges
 Surprise “balance bills”—those received from an out-of-network providers the member did not choose to see—are gaining the attention of state legislatures, according to a survey released by New Jersey-based healthcare technology company Zelis Healthcare. In 2017, the survey finds, six states passed varying types of laws affecting these unexpected charges, with an additional 80 bills awaiting consideration across the country.
How to Have a Good Visit to the Doctor
Adding to the already extensive list of guides to achieving a satisfying visit to the doctor, New York Times contributor Dr. Danielle Ofri offers a very comprehensive and useful contribution . “As a doctor,” Ofri writes, “I often get asked by friends and family how to make the most of the medical visit. Here’s my advice, and it’s basically the same whether you are the patient, or a family member or a caregiver of the patient.” Ofri goes through each step of the doctor-patient encounter, from choosing whom to see, previsit preparation, list making, gathering of background material, the encounter itself, to follow up issues. She cautions that “the number of items that your doctor must attend to do during a visit has skyrocketed in the last decade. The advent of the electronic medical record has changed the nature of the doctor-patient interaction immensely, and most doctors have no choice but to type during your visit. If your doctor looks like someone in a 1950s secretarial pool, typing nonstop, welcome to 21st century medicine. Multitasking is not an excuse for poor communication, however, or a feeling of rushing through the visit. You can be aware of and even a bit forgiving of the bureaucratic labyrinth that your doctor has to deal with, but your doctor should make time for direct, face-to-face communication. That is crucial for accurate diagnosis and treatment.”
Access to Your Healthcare Data Offers Knowledge and Control
While Ofri acknowledges some of the bureaucratic frustration attendant upon computerization in the doctor’s office, the Economist magazine heralds the emerging digital revolution in healthcare. A fundamental problem with today’s system, the Economist argues, “is that patients lack knowledge and control. Access to data can bestow both. Medical data may not seem like the type of kindling to spark a revolution but the flow of information is likely to bear fruit in several ways: better diagnosis, management of complex diseases, greater efficiency of care, and the benefit of generating and aggregating patient care data using artificial intelligence tools. Plenty of countries are now opening up their medical records, but few have gone as far Sweden. It aims to give all of its citizens electronic access to their medical records by 2020; over a third of Swedes have already set up accounts. Studies show that patients with such access have a better understanding of their illnesses, and that their treatment is more successful. Trials in America and Canada have produced not just happier patients but lower costs, as clinicians fielded fewer inquiries. That should be no surprise. No one has a greater interest in your health than you do. Trust in Dr. You.”
Addressing the Needs of Aging Native Americans
Health Affairs blogger Jessica Bylander draws attention to a neglected subject: the needs of aging Native Americans. In Indian country, she writes, “the long-term care infrastructure leaves much to be desired.” Bylander surveys the landscape of resources to meet the exploding demand and urges dedicated funding for LTSS for Native Americans. “Like many older Americans, Native American elders prefer to live at home and homelike settings. However, many native communities are located in extremely rural areas, they lack electricity or running water, and are accessible only by dirt roads. All of this makes it difficult to age in place or receive home-based care. ‘It is not unusual in the Navajo Nation to see elders enter facility-based care in the fall and go back home in the summer,’ Indian Health Service official Bruce Finke observes. You might see the same thing in Alaska. Today American Indians and Alaska natives are living longer with more functional disabilities than the rest of the population, suggesting that the population needing long-term care will balloon in the coming years. Between 2000 and 2010, the number of American Indians and Alaska natives 65 or older increased by 40.5%, growing at double the rate of the overall population. Existing mechanisms for funding long-term care in Indian country will be hard-pressed to keep pace with demand.”
Shining Light on Elder Self-Neglect
Amid growing public discussion of the problem of elder abuse, the New York Times’ Paula Span turns a spotlight on an under-recognized problem: elder self-neglect. “It accounts for more calls to Adult Protective Services agencies nationwide than any other form of elder abuse. Yet efforts to identify and help older people who neglect themselves often collide with Americans’ emphasis on self-determination. ‘If someone has decision-making capacity, do they have the right to live in squalor?’ asked Dr. XinQi Dong, a researcher at the Rush Institute for Healthy Aging in Chicago. ‘As a society we want to respect autonomy and independence.’ In studies, involving more than 4,600 Chicago South Side residents over age 65, researchers who conducted in-home interviews found self-neglect unnervingly common. Mental wellness and social isolation are demonstrated risk factors, but among the many unanswered questions, Dr. Dong said, is cause-and-effect. ‘Do depressed people neglect their care or do people who self-neglect become depressed? Whatever the underlying causes, it’s incredibly dangerous.’”
Caregiver Distress in the Emergency Room
For Brown University emergency medicine professor Dr. Jay Barach, confronting the stresses experienced by caregivers in the emergency room has been an up-close learning experience. Recounting the ER visit of Mrs. G, Barach describes the realization that struck him: “the most acutely distressed person in the exam room wasn’t Mrs. G but her daughter Rosa, her caregiver. In the emergency department, the patient receives the bulk of the attention. Physicians spend far less energy probing the caregivers experience. Caregivers often do their noble work in the shadows. It’s embarrassing to say this, but it wasn’t until I asked Rosa what she was anxious about that I appreciated how worn down she looked, with her uncombed hair, lack of makeup, sweatshirt, baggy sweatpants, and crocs.” Barach discusses the ER phenomenon that has come to be termed, pejoratively, “granny dumping.” “I was introduced to the concept during the first Thanksgiving of my emergency medicine residency. Families drop off their relatives in the emergency department with a packed bag and nebulous complaints and then take off, expecting the hospital to care for them. Eventually experience taught me that this problem is typically a result of systems that don’t provide enough resources for caregivers who often face daunting tasks. These obligations are equivalent to unpaid full-time jobs. Can anyone blame them for seeking a breather? Caring for patients sometimes requires that we reach into the shadows and shine a light on their caregivers. Even if emergency clinicians lack the time and resources to fully implement assessment strategies, at the very least we can recognize that caregiving is difficult and that seeking help or a break is not a sign of weakness or failure. We must also remember caregivers are often reluctant to accept assistance. Rosa doesn’t want to discuss the caregiving challenges she’s experiencing with me or a social worker. So I do what I can. I make a point of saying she is doing a great job with her mother. I home in on the pressure sore in her mother’s lower back. It is clear and healing, at least as well as those things heal. That’s a tough road to care for I say, really tough. It looks for a second like Rosa will crumble into her seat. ‘It is,’ she says. ‘Thank you for saying that.’”
Without Retirement Savings It’s a Struggle to Make It
Alana Semuels, writing in the Atlantic, points to Roberta Gordon as one example of “what life without retirement savings looks like.” “Gordon never thought she’d still be alive at age 76. She definitely didn’t think she’d still be working. But every Saturday, she goes down to the local grocery store and hands out samples, earning $50 a day, because she needs the money.” Today, says Semuel, citing National Institute on Retirement Security statistics, about 12.4% of the population age 65 or older is still in the workforce, up from 3% in 2000. I met a woman named Deborah Belleau who is 67 and works as a manager at a mobile home park in Palm Springs, California. Though she receives money from Social Security, she can’t afford a cell phone or a TV. Her rent is $600 a month. She works full-time at the mobile home park, despite aches and pains in her back and feet. Sometimes when she wakes up she can’t walk. But, she says, ‘I can’t quit. There’s no way I can live on $778 a month,’ the amount she receives from Social Security. At least Belleau and others are physically able to work. Some seniors without retirement savings or safety net have become homeless in recent years as housing costs have risen and they find themselves without the ability to generate income. In America in 2016 nearly half of all single homeless adults were age 50 and older, compared to 11% in 1990.”
The Story of Edith+Eddie: An Oscar Nominated Film
Among the many Oscar-nominated films at this year’s Academy Awards was Edith+Eddie. “The events portrayed in the 29 minute film are quite unsettling,” writes Kaiser Health News’ Judith Graham. “It begins in the fall of 2014 with Edith Hill, 96, and Eddie Harrison, 95, who were married only a few months before, enjoying a series of intimate moments—dancing together holding hands, exercising and chatting comfortably. It ends months later with the couple being separated by Edith’s court-appointed legal guardian, with police on the scene, and Edith taken off abruptly to Florida. Shockingly, Eddie died only a few weeks later. As a columnist who covers aging, I’m familiar with such stories. But as I immersed myself in the details of this case, I found myself reaching a familiar conclusion: real life is more complicated than in the movies.” Graham reconstructs in meticulous detail the back story behind the event shown in the film—involving three daughters in distress over the care of an aging mother and riled by disputes played out in courtrooms among far-flung siblings. It is quite a complicated saga and Graham succeeds in rounding out its many twists and turns. In the end, which came for Edith last March at age 98, after living with her daughter in Florida through the end of her life, Graham observes that she never went to an institution, her home wasn’t sold until after death; there was no attempt to plunder her estate by lawyers or family members. “That,” Graham concludes, “is the other story of Edith+Eddie.”
Hospitals are Adapting and Changing
 “Are hospitals becoming obsolete?” asks University of Pennsylvania Vice Provost Ezekiel J. Emanuel in the New York Times, suggesting that in many ways they are. Emanuel points to a number of reasons including the fact that “the reputation of hospitals has had its ups and downs. Benjamin Rush, a Surgeon General of the Continental Army, called the hospitals of his day the ‘sinks of human life.’ Through the 19th century, most Americans were treated in their homes; hospitals were a last resort, places only the very poor and those with no family went. And they went mainly to die. Fast forward to 1981: That year there were over 39 million hospitalizations—171 admissions per 1,000 Americans. Thirty five years later, the population has increased by 40%, but hospitalizations have decreased by more than 10%. There is now a lower rate of hospitalizations than in 1946. In a throwback to the 19th century hospitals now seem less and less therapeutic and more life-threatening. In 2002, researchers from the Centers for Disease Control and Prevention estimated 1.7 million cases of hospital acquired infections that caused 100,000 deaths. Other problems—from falls to medical errors—seem too frequent.” Emanuel foresees a future where those hospitals that remain “will be devoted to emergency rooms, high-tech services for premature babies, patients requiring brain surgery and organ transplants, and the like. Meanwhile, nearly 1 billion annual visits to physicians’ offices, imaging facilities, surgical centers, urgent care centers, and ‘doc in the box’ clinics will grow.”

Picking up on this topic, the Wall Street Journal’s Laura Landro quotes Johns Hopkins University School of Medicine’s Dr. Bruce Leff: “hospitals will start to evolve into large intensive care units, where you go to get highly specialized, highly technical, or serious critical care.” Landro looks at how hospitals are adapting to the emerging dynamics and economics of healthcare delivery by examining the hospital-at-home model that is gaining traction, the building of smaller facilities such as freestanding emergency rooms and micro-hospitals, commonly called neighborhood hospitals, the transformation of existing hospitals into specialized facilities, the extension of hospital resources into surrounding communities to improve health and avoid hospitalization, and the dramatic increase in telemedicine, enabling doctors in one or more central hubs to monitor and care for patients in widely dispersed intensive care units, such as stroke victims and premature newborns.
Changing How We Age With ‘Monitored Independence’
Technologies helping seniors age in place are the focus of Kaiser Health News’ Gabi Redford, who takes readers on an exciting journey through the world of existing and about-to-arrive tools that can afford continued independence with security for America’s aging population. Scripps Translational Science Institute director Dr. Eric Topol refers to “monitored independence” and says “it is changing how older generations age in America. People want to be autonomous, irrespective of age.” Already voice assistive technologies like Amazon Echo, Google Home, and Homepod are rapidly integrating with the home environment. AskMarvee, Redford reports, “integrates with Amazon echo via an online portal to allow seniors to immediately connect with family members for a quick check-in or if something more serious is going on. LifePod, to be introduced later this year, takes voice assistive technology a step further, according to Laurie Orlov, founder of Aging in Place Technology Watch. It will allow users to engage with the device, much like Alexa, but also periodically check in with them independent of the voice prompt at preprogrammed intervals: ‘Good morning, Nancy. Did you remember to take your medication?’”
Alexa and Healthcare Tech in the Hospital Setting
With the increasing pressures on hospitals, as discussed above, and the exploding availability of patient and elderly oriented technology, the Wall Street Journal’s Lucette Lagnado finds signs of a new synthesis. “Hospitals, she writes , “scrounging for dollars are reinventing themselves as venture capitalists and investing in healthcare technologies. Hospital networks have funded drug research and development for decades; some also have helped finance interventions by staff members. But backing outside health tech startups is a relatively recent phenomenon. In Los Angeles, Cedars-Sinai Medical Center teamed up with Techstars, a private Colorado firm that ferrets out promising startups. Cedars-Sinai is backing a device to field requests patients usually make by pressing the call button for a nurse. Created by a Los Angeles company called Aiva, the device builds on Amazon’s voice activated virtual assistant, Alexa, and tailors it to a hospital setting. Aiva, which answers to Alexa, will route patients’ requests to departments such as housekeeping or the pantry. When Adrienne Edwards was at Cedars overnight for abdominal surgery last month, she took part in the trial of the system. Edwards verdict: ‘it rocks. I was lonely in the hospital and I said, Alexa, will you be my friend and the device replied, of course we can be friends; you seem very nice.’ Ms. Edwards, who lives in Los Angeles, poured on the demands, asking for medicine, a latte, reggae music, even lobster. The latte and lobster requests seemed to stump the system so they were transferred to the still functioning nursing station. When a nurse came, Ms. Edwards asked for and received a cup of tea.”
Aging in America Conference in San Francisco
When the American Society on Aging s annual Aging in America conference comes around to San Francisco, we are especially busy. It’s an opportunity for FCA/NCC to have more staff in attendance and at our exhibit booth speaking with conference-goers from around the country. If you follow us on Twitter ( @CaregiverAlly ), we’ve been busy there, too. (See the following section, FCA Tweets.)

On Tuesday evening, FCA was delighted to host the reception for the 10th anniversary of the Rosalinde Gilbert Innovations in Alzheimer’s Disease Caregiving Legacy Awards. This year’s awardees were in attendance and each presented inspiring stories about their winning programs. Read about the winners here .

FCA also participated in a few sessions, including Online Resource for Comparing Evidence-Based Dementia Caregiving Programs . FCA, in partnership with the Benjamin Rose Institute on Aging (with funding from The John A. Hartford Foundation, Archstone Foundation, and The Retirement Research Foundation) is developing a web-based resource for comparison of evidence-based dementia caregiving programs. Read more about the project here .
Follow Family Caregiver Alliance / National Center on Caregiving @CaregiverAlly
and Executive Director Kathleen Kelly @KKellyFCA.
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Contributing to Caregiving Policy Digest are Alan K. Kaplan, attorney and health policy consultant, Kathleen Kelly, and Francesca Pera (editing and layout).

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