Vol. 19, No. 8
October 23, 2019

In This Issue: A National Volunteer Care Corp :: lowering sky high drug prices :: the devil in the surprise medical bill “fixes” :: a Presidential Medicare executive order :: MedPAC worries about primary physicians’ supply ::  discharge planning finality :: a new payment system for SNFs :: a warning icon on Nursing Home Compare :: TennCare seeks a block grant :: House committee chairman proposes aid for direct care workers :: opioid withdrawal collateral damage :: an HHS guide to proper opioid tapering :: an unexpected transitional care caution :: the fungal threat to highly compromised patients :: combating hospital-induced delirium :: integrating medical social care :: the march of treatment breakthroughs :: paid family leave laws :: acknowledging Alzheimer’s caregiver needs :: “subjective” aging :: overwhelming documentation needs ::  preventing falls while discouraging immobility :: improving facility navigation :: the pain of prior authorization requirements :: upbeat moments for Alzheimer’s families :: and in France the postal worker delivers eldercare with the mail
Autumn in DC: Amid the growing rancor of an impeachment inquiry, partisan strife and legislative logjams, the nation’s capital has managed to experience some moments of unbridled joy and unity as it watched its baseball team finally break a fall season curse and bat and pitch its way to a World Series contest for the first time in 86 years. As for autumn’s legislative health policy agenda, the sound emanating from Capitol Hill was that of much air going out of the summer flurry of efforts to attack surprise medical bills, skyhigh drug prices, and rising out-of-pocket healthcare costs. Nevertheless, there have been some noteworthy developments.
National Volunteer Care Corp Announced
Fifty-eight years after Pres. Kennedy sent the first Peace Corp volunteers to far-flung outposts in Africa, Asia, and Latin and Central America, the Administration for Community Living has announced the formation of a National Volunteer Care Corp. If it is successful, writes Kaiser Health News’ Judith Graham, “healthy retirees and young adults would take seniors to doctor appointments, shop for groceries, shovel snowy sidewalks, make a bed or mop the floor, or simply visit a few times a week. Older adults would not only get a hand with household tasks, but also companionship and relief from social isolation. And family caregivers could get a break. Younger volunteers might get class credit at a community college or small stipends. Older volunteers could enjoy a satisfying sense of purpose. Four organizations will spearhead the Care Corps project: the Oasis Institute, which runs the nation’s largest volunteer intergenerational tutoring program; Caregiver Action Network; the National Association of Area Agencies on Aging; and the Altarum Institute, which works to improve care for vulnerable older adults. The initial grant to the group is $3.8 million; total funding for the five-year project is expected to be $19 million, according to Greg Link, director of the ACL’s office of supportive and caregiver services. This fall, project leaders will invite organizations across the country to submit proposals to serve ‘non-medical’ needs of older adults and younger adults with disabilities. Next spring, up to 30 organizations will get 18-month grants of $30,000 to $250,000, according to Juliet Simone, director of national health at the Oasis Institute. The goal is to discover innovative, effective programs that offer services to diverse communities (geographic, racial and ethnic) and that can be replicated in multiple locations.”
Pelosi’s Bill to Lower Prescription Drug Costs
The House Energy and Commerce Committee has approved House Speaker Nancy Pelosi’s recently introduced, 100-page drug pricing bill that, as Modern Healthcare’s Susannah Luthi reports , “harnesses Pres. Trump’s controversial proposal to control U.S. drug prices by tying them to prices paid in other developed countries.” Pelosi’s bill, explained CNBC’s Berkeley Lovelace, Jr., “would allow Medicare to negotiate lower prices on as many as 250 of the most expensive drugs per year and apply those discounts to private health plans across the U.S. The bill also includes a penalty on drug makers that refuse to negotiate or fail to reach an agreement with the U.S. government, starting at 65% of the gross sales of the drug in question. Republican members on the committee expressed concerns with the legislation, particularly that it would discourage innovation for new medicines in the pharmaceutical industry. But a patient-friendly and long-sought element of the Speaker’s plan — Medicare negotiation of some prescription medicine costs — drew praise from AARP. “Medicare should be able to use its bargaining power to get a better deal for the more than 55 million seniors who rely on Medicare, especially for the highest-priced drugs and those drugs with little or no market competition,” said Nancy LeaMond, AARP executive vice president and chief advocacy and engagement officer. The bill also would cap annual out-of-pocket prescription drug expenses for Medicare beneficiaries at $2,000 (A measure approved by the Senate Finance Committee this summer also would cap Medicare enrollees’ drug costs and has other provisions to lower drug prices, but does not include authority for HHS to negotiate drug prices). Pelosi’s bill was buttressed by potential cost savings projected by the Congressional Budget Office. “CBO estimates that applying the provisions in Title I to prescription drugs covered under Part D of Medicare would reduce federal direct spending for Medicare by $345 billion over the 2023–2029 period. The largest savings would come from lower prices for existing drugs that are sold internationally, for which the price ceiling would be binding in most but not all cases. The lower prices under the bill would immediately lower current and expected future revenues for drug manufacturers, change manufacturers’ incentives, and have broad effects on the drug market.”
‘Surprise’ Medical Bills: House and Senate Bills Advanced
The other big healthcare challenge for lawmakers before the end of the year: a “fix” for “surprise” medical bills. There, too, FierceHealthcare’s Robert King reported , some slight movement was discernible amid the overall partisan divides. House Ways and Means Chairman Richard Neal has written a letter to his Democratic colleagues Sept. 27 “detailing a compromise to address provider demands for an arbitration process instead of a benchmark out-of-network rate. The negotiated rule-making process would require three agencies — the departments of Health and Human Services, Labor, and the Treasury — to form a committee to identify standards for rates for surprise bills, according to the letter. It would be up to the committee whether to add a dispute resolution and to define the parameters of that resolution process. The result would go through a public comment period. Both the House Energy and Commerce Committee and the Senate Health, Education, Labor and Pensions (HELP) Committee have advanced bills to ban surprise medical bills. However, the HELP bill would set a benchmark rate for any out-of-network charges. Energy and Commerce’s legislation would also use a benchmark but would have an arbitration backstop if an agreement on a benchmark rate can’t be used.”
Executive Order on Medicare Sparks Controversy
Pres. Trump traveled to a Florida senior center to unveil an executive order on “Protecting and Improving Medicare for Our Nation’s Seniors.” To say the reaction was mixed would be an understatement. The order, writes Modern Healthcare’s Shelby Livingston, “focuses largely on bolstering the privatized Medicare Advantage program — where one-third of beneficiaries are enrolled — while condemning Medicare for All proposals championed by some Democratic lawmakers. In one section that’s giving experts pause, the order directs HHS to submit a report on ways to modify Medicare fee-for-service payments to more closely reflect the prices paid for services in Medicare Advantage and the commercial insurance market. Some are questioning why there’s interest in increasing prices paid for services to align with the commercial market, because that would increase Medicare spending, which in turn would increase premiums and increase the financial instability of the Medicare Trust Fund. The order also called on HHS to ensure the traditional Medicare program is not promoted or does not receive an edge over Medicare Advantage. But some advocacy organizations have long been concerned that the federal government has done the opposite by giving more attention to the Advantage program. HHS Secretary Alex Azar in a media call last week said the order “commissions us to examine all practices, regulations and guidance to just make sure that we are not steering people into fee-for-service as opposed to giving them a genuine choice of Medicare Advantage or fee-for-service.”

Not so fast, patient advocacy’s Medicare Rights Center cautioned . “The executive order seems to support a return to ‘private contracting’ in Medicare. Before current protections were in place, far too many people with Medicare were unable to afford care because their providers were permitted to charge amounts far above Medicare’s payment. Congress put a stop to this practice in the 1980s and prohibited providers who accept Medicare from charging beneficiaries more than the Medicare-allowed cost sharing. Private contracting would once again permit providers to charge whatever they wish, violating the Medicare guarantee and leaving many beneficiaries behind. We also urge CMS to level the playing field between Medicare Advantage and original Medicare. While many beneficiaries are enrolled in Medicare Advantage plans, nearly two-thirds of all people with Medicare, or approximately 40 million people, are in original Medicare. They must not be left behind or disadvantaged by agency actions that benefit only those in Medicare Advantage plans.”
Primary-Care Physicians in Decline
Whatever the future of healthcare delivery in the U.S., the availability of front-line healers will be a critical component. Modern Healthcare’s Michael Brady reports that MedPAC, Congress’ Medicare advisory body, has sounded a cautionary alarm about the effect on patients’ access to care by a potential decline in the number of practicing primary-care physicians. “The Commission found that about 1 in 5 physicians that it previously considered primary-care physicians are actually hospitalists — physicians whose focus is providing medical care to hospitalized patients. It now estimates that the number of primary-care physicians was closer to 140,000 in 2017 than the 186,000 it initially reported, a decrease of about 46,000. The Commission noted that Medicare beneficiaries are still less likely to wait for routine care than people with private insurance. But MedPAC is concerned by a steep decline in the growth rate of new primary-care physicians, which fell from 0.7% to -0.6% in 2017 after the agency excluded hospitalists. Some MedPAC members were hesitant to carve hospitalists out of the primary-care physician measure because most of them provide some level of primary-care services, especially for patients with severe illnesses. They also wondered whether an increase in advanced practice nurses and physician assistants might support primary-care access, even as the number of primary-care physicians relative to Medicare recipients drops off.”
Final Rule on Discharge Planning Requirements from CMS
Four years in the making, CMS has published a final rule pertaining to discharge planning requirements across the healthcare delivery spectrum. The discharge planning rule, reports Modern Healthcare’s Michael Brady, “requires hospitals and critical access hospitals to evaluate patients that are likely to experience adverse health consequences and create a discharge plan if necessary. They must also assess patients for discharge planning if a patient, their representative or physician requests it. Hospitals, critical access hospitals and home health agencies will need to provide specific medical information when they transfer patients to another facility. The rule aims to give patients more information about post-acute providers, such as quality measures so that they can make informed choices about their care transitions. Hospitals will also need to give patients electronic access to their health records, part of what CMS sees as its mission to expand interoperability across healthcare settings.”
New Nursing Home ‘Patient Driven Payment Model’: The Impact on Skilled Therapy
October brought a major overall to the payment system for the nursing home industry. Scrapping the resource-utilization group framework, which primarily based pay on the volume of therapy services, CMS has replaced it with the Patient Driven Payment Model (PDPM) based on acuity and other data-driven characteristics akin to bundled payments. The change, writes Modern Healthcare’s Alex Kasick, “creates a new set of ‘winners’ and ‘losers,’ likely pinching SNFs that have boosted investments in therapy as well as those treating fewer medically complex patients. Therapy hours will likely fall under PDPM, which includes a provision that group and concurrent therapy minutes can account for up to 25% of the total services provided to the patient. In the new model, clinical needs related to nursing, physical therapy, occupational therapy and speech language pathology, as well as nontherapy ancillary, such as having cystic fibrosis or needing a feeding tube, will determine payment. A sixth component is the adjusted daily rate over the course of the patient’s stay. SNFs will get paid more as length of stay decreases, but will have to balance that with preventing hospital readmissions. Anxiety about the potential impact of the reimbursement upheaval is clearly being felt in both the therapy and patient advocacy communities. Associations representing therapists have urged CMS to intervene as skilled-nursing facilities lay off and cut the pay of thousands of therapists nationwide in response to the new patient-driven payment model. Those who remain have been asked to boost their productivity and quickly cycle through patients as well as increase their use of group and concurrent therapy rather than one-on-one sessions. ‘While PDPM changed Medicare payment methodology for SNFs, it did not change the value of physical therapy services or patient needs,’ said Sharon Dunn, president of the American Physical Therapy Association. ‘Reducing PT and PTA staff 48 hours into this model reflects poorly on the commitment to patient access and quality of care. Responding, The American Health Care Association, which represents long-term and post-acute providers, said that PDPM represents a shift to value-based, cost-effective care that incorporates nursing and rehabilitation to ensure the best care. ‘This will mean changes in care,’ the AHCA said in a statement. ‘The most important measure of the success of PDPM should be resident health outcomes and the quality measures that CMS reports.’”

Meanwhile, the Center for Medicare Advocacy and the Long Term Care Community Coalition  took aim at possible negative outcomes of PDPM’s implementation. “PDPM makes clear that skilled therapy will no longer be driving Medicare-covered nursing home care. Thus, a major concern is that residents may receive less therapy under the new payment system. Unfortunately, making matters worse for residents in need of skilled therapy, PDPM also allows 25% of a resident’s total therapy regimen, by discipline, to be provided in group and/or concurrent therapy settings. Although CMS acknowledges that individual therapy is the best option because it is tailored to specific care needs, CMS makes clear that nursing homes will not be penalized for going over the 25% limit. As a result, in addition to less therapy services overall, residents may receive less individualized therapy under PDPM. We are especially concerned by PDPM’s impact on maintenance therapy. Medicare beneficiaries in nursing homes are entitled to receive skilled therapy to maintain their condition or to slow/prevent further decline. PDPM’s preference for skilled nursing over skilled therapy, and incentives to discharge residents sooner, may mean that Medicare beneficiaries in need of maintenance therapy will ultimately pay the biggest price under the new payment system.”
Reported Violations of Abuse to Be Identified on Nursing Home Compare Website
While voicing concerns about the new payment system, SNF patient advocates had nothing but praise for an early October CMS announcement of changes to Nursing Home Compare — the Medicare online facility rating site — that the agency believes will make it easier for residents and families to identify facilities with a history of resident abuse, neglect, or exploitation. The agency’s Nursing Home Compare website will add an icon next to nursing homes with reported violations starting on Oct. 23. The icon will warn consumers about the harmful abuse of a resident within the past year and potentially harmful abuse of a resident during the last two years. The CMS said it will update the data monthly and that the information will supplement nursing home five-star ratings, which provide more information about the quality of a nursing home facility. CMS’s action, noted the National Consumer Voice for Quality Long Term Care, “follows two hearings on nursing home abuse and neglect held earlier this year by the U.S. Senate Finance Committee. Consumer Voice commends CMS for this action which is a step forward in providing critical information to consumers, their families and the public, and creating an incentive for nursing homes to prevent abuse and neglect.”
Tennessee Seeks Block Grant for Its Medicaid Program
As the future of Medicaid work requirements remains under review by a U.S. Circuit Court of Appeals, Tennessee, write Health Affairs bloggers Sarah Rosenbaum and Alexander Somodevilla “wants to add a new experimental phase to its Medicaid program, TennCare, to test the effects of aggregate federal Medicaid spending limits (commonly referred to as a block grant) on more than 1 million Medicaid beneficiaries. The decision to test aggregate spending caps in Tennessee is a curious one. First, Tennessee has remained a non-expansion state. This means that only traditional Medicaid populations (the state’s poorest parents and children, pregnant women, children and adults with severe disabilities, and the elderly) would be subject to the experiment. Furthermore, the state proposes to exempt Medicare/Medicaid dual enrollees, beneficiaries whose coverage even the administration has viewed as essential to the program’s historical mission. Second, TennCare has effectively been managed under tight budgets for years. Where, exactly, the state proposes to achieve additional savings from is unclear. Presumably, were such a waiver to be granted, this would spell the end of the state’s obligation to run TennCare in accordance with actuarial soundness, leaving it free to operate managed care on a cut-rate basis, free of any payment floor. In effect, the state appears to want immunity from all future laws that could affect Medicaid. However, Section 1115 allows the secretary of the Department of Health and Human Services (HHS) to waive only certain provisions of Medicaid, and states operating on an experimental basis are expected to operate in compliance with all laws other than those explicitly waived. Tennessee’s plan thus paves the way for an end to Medicaid as a health insurance safety net. Even as Tennessee moves forward with its application, the administration’s actual federal block grant guidance continues to await final Office of Management and Budget approval. The federal government could thus be in the position of evaluating block grant experiments designed even prior to the release of its own guidance.” Not surprisingly Tennessee does not see the same landscape as Health Affairs bloggers. “We have routinely underspent what the federal government projects for our cause by billions of dollars,” Tennessee Medicaid director Gabe Roberts told Kaiser Health News’ Phil Galewitz. ‘What this proposal does is to ask CMS to reimagine the state-federal funding mechanism as a value-based one, so that states that operate well and serve their populations well, but also contain costs, are rewarded with additional federal dollars to invest in that population without the requirement to come up with a state match.”
Congressional Bill to Support Direct Care Workers
In recent months the growing and dire projections of the coming lack of direct care workers to serve older Americans with disabilities and chronic care needs have generated considerable media attention. The challenge has now spawned a congressional response in the form of the Direct Creation, Advancement, and Retention of Employment Opportunity Act (Direct CARE Opportunity Act)— H. R. 4397. The bill, reports Vox’s Alexia Fernandez Campbell, “would fund projects to create a sustainable career path for home care workers, who often look after clients with dementia or Parkinson’s. That could include apprenticeships, on-the-job training, professional development, or mentoring programs. The bill doesn’t include a dollar amount; that’s something members of Congress would have to agree on. The point is to invest in one of the fastest-growing jobs in America, a service that nearly all Americans will one day need.” Direct care workers, said House Education and Labor Committee chairman Bobby Scott, one of the bill’s lead sponsors, “would furnish daily assistance to millions of older Americans, people with disabilities, and others with chronic care needs. Direct care workers include personal care aides, home health aides, and nursing assistants. These workers are the backbone of the long-term care workforce assisting individuals with daily tasks by preparing meals, managing medications, providing transportation, and providing much needed relief for family caregivers. However, the workforce itself is also vulnerable to low wages, harsh working conditions, and economic insecurity. Nine in ten direct care workers are women, half are people of color, and a quarter are immigrants. Many direct care workers do not have education beyond high school and lack access to a career pathway or advanced training. The rate of injury among direct care workers is over three times higher than other professions while the current median wage for direct care workers is just over $11 an hour.”
Next Avenue Announces 2019 Influencers in Aging
Next Avenue recently released its fifth annual list of Influencers in Aging , which includes 12 advocates, researchers, thought leaders and innovators who are breaking ground and changing how we age and think about aging. The list includes Calif. Governor Gavin Newsom, who is creating a Master Plan for Aging for the state. Others on the list include a geriatrician who's exploring new approaches to health care for older adults, the leader of a nonprofit that advocates for health, social services and economic well-being for American Indian and Alaska Native Elders, and a gerontologist who designs technology for aging populations.
Forced Tapering of Opioids
As Caregiving Policy Digest has reported, the nationwide crackdown on opioid-induced addiction and death has engendered some collateral damage, namely, sudden withdrawals of therapeutic regimens legitimately easing the suffering of pain-riddled patients. The Washington Post’s recent account of one couple’s experience of “forced tapering” portrays the emergence of such “unintended” consequences. “There is little doubt among medical experts,” write Joel Achenbach and Lenny Bernstein, “that opioids have been prescribed at unsound and dangerous levels, particularly in their misuse for chronic pain. But at this point there’s no easy way to dial those dosages back. Long-term use of opioids creates dependency. Tapering can cause extreme pain from drug withdrawal, regardless of the underlying ailment. The United States is now in the midst of a national experiment as misguided as the one it conducted 20 years ago, when doctors put millions of patients on opioids with little understanding of the consequences, says Tami Mark, senior director of behavioral health financing and quality measurement for RTI International, a North Carolina think tank. ‘This national effort at “de-prescribing” is again being undertaken with limited research on how best to taper people off opioid medications. You can’t just cut off the spigot of a highly addictive medication that rewires your brain in complex ways and not anticipate negative public health consequences.’”
Newly Released HHS Guidance on Opioid Dosage Reduction
Chronic pain patients form a vast constituency in America, and millions of them take opioids for relief. Changes in medical guidance covering opioids have left many of them frustrated, confused and sometimes howling mad. They feel demonized and yanked around. HHS has been listening to the outcry and, as a result, in early October the department issued the “HHS Guide for Clinicians on the Appropriate Dosage Reduction or Discontinuation of Long-Term opioid Analgesics.” A main point of the new guidance on tapering, writes Achenbach in a separate article, “is that clinicians should be slow, cautious and deliberate in reducing dosages and should consult patients to ensure they are tolerating the process. ‘Risks of rapid tapering or sudden discontinuation of opioids in physically dependent patients,’ states the HHS guide, ‘include acute withdrawal symptoms, exacerbation of pain, serious psychological distress and thoughts of suicide. Patients may seek other sources of opioids, potentially including illicit opioids, as a way to treat their pain or withdrawal symptoms.’ ‘The guidelines,’ said Brett P. Giroir, an assistant secretary for health at the Department of Health and Human Services, ‘emphasize personalized care tailored to the specific circumstances and unique needs of each patient. All of us are extremely empathetic to people living with severe chronic pain.’ Giroir reiterated the need to take steps to limit opioid addiction and reduce the number of fatal overdoses. ‘That can be done while still treating pain with opioids in a responsible manner. We can achieve both goals. They are not mutually exclusive.’”
Unexpected Results from COPD Transitional Care Study
A funny thing happened on the way to a research finding about transitional care services: The expected and already published result had to be retracted due to a coding error and replaced with an opposite conclusion. “In a single-site randomized clinical trial of patients hospitalized due to COPD, a 3-month program that combined transition and long-term self-management support resulted in significantly greater COPD-related hospitalizations and emergency department visits, without improvement in quality of life. Further research is needed to determine reasons for this unanticipated finding.” As Boston-based editorial writers commented , “The increased risk of harm associated with the study intervention was both unexpected and important. As the authors indicated, these results should be interpreted with caution, and additional research is needed to understand why this intervention was associated with increased acute events. At the same time, this work is consistent with other literature. Numerous clinical trials on strategies to prevent COPD hospitalizations have produced conflicting results, with all recent studies failing to demonstrate benefit and some reporting harm. With this study further contributing to inconsistent COPD trial outcomes, an important question is: Why do well-designed and well-intentioned care management interventions for individuals with COPD often fail to improve outcomes? These behavioral interventions are complex and the mechanism of harm when it occurs is rarely clear.”
Drug-Resistant Fungus Threatening Patients in Long-Term Care Facilities
New York Times reporters Matt Richtel and Andrew Jacobs have sounded a new alarm over the spread of a highly contagious, drug-resistant fungus, Candida auris, that is striking care settings where severely ill and ventilated patients are prone to infection and often take multiple antibiotics, which in turn can spur drug resistance. “Scientific research on nursing homes and drug resistance is sparse, but some recent studies offer evidence of the problem. A study published in June in the Journal of Clinical Infectious Diseases found that patients and residents in long-term care settings have alarmingly high rates of drug-resistant colonization, which means they carry the germs on their skin or in their bodies, usually without knowing it, and can pass them invisibly to staff members, relatives or other patients. Elderly or severely ill people with weakened immune systems who carry the germ are at high risk of becoming infected. The study, which focused on Southern California, found that 65 percent of nursing home residents in that region harbored a drug-resistant germ, as did 80 percent of residents of long-term acute-care hospitals. By comparison, only 10 to 15 percent of hospital patients carried such germs, the study found. The phenomenon is apparent globally. A study published in 2017 found that elderly residents of long-term care facilities in Britain were four times as likely to be infected with drug-resistant urinary tract infections as elderly residents living at home. Soaring levels of resistance were found in long-term care facilities in Italy. And a 2019 study found that long-term care facilities in Israel are ‘a major reservoir’ of carbapenem-resistant Enterobacteriaceae, or CRE — a major family of drug-resistant germs — contributing to their rapid regional dissemination. Experts said the problem is pronounced in the United States, given changing economics that push high-risk patients out of hospitals and into skilled nursing homes.”
Reducing Hospital Delirium
A potentially catastrophic event during hospitalization, writes Next Avenue’s Edie Grossfield, afflicts as many as half of patients age 65 and older: delirium. “Once thought of as something ordinary — something that “just happens” to people as they get older — today, geriatricians and hospitals across the U.S. recognize the dangers of delirium and are increasingly creating programs and protocols to prevent, detect and treat it. Delirium refers to a change in the brain’s neurochemistry that causes a person to become highly confused and unable to think clearly. The condition usually comes on quickly, but the symptoms can come and go. Delirium manifests in two primary ways: high agitation (which is called hyperactive delirium) or, more commonly, as inactivity (which is called hypoactive delirium). It’s possible to experience both hyperactive and hypoactive delirium throughout the course of an illness. When patients have hyperactive delirium, they’re doing things like shouting at family members or hospital staff, trying to pull out intravenous tubes or even striking out at people. Delirium’s mortality rate is high — the same in-hospital mortality rate as having a heart attack, says Dr. Stephanie Rogers, a geriatrician and physician lead for the University of California, San Francisco’s (UCSF) Delirium Reduction program. In the medical/surgical intensive care unit at Helen Diller Medical Center at Parnassus Heights, UCSF’s main hospital, nursing staff encourage family members to help with the process of bringing their loved ones with delirium back from confusion, says ICU registered nurse Denise Barchas. ‘We encourage family members to help us orient their loved ones, tell them where they are, talk to them, tell them news of the day about their family and their lives.’ Family and friends can help by bringing in photos and familiar items from the patient’s home to recognize and talk about. Meanwhile, at UCSF’s medical/surgical ICU, nurses screen patients for delirium at least once during every 12-hour shift. The screen for all patients is called ‘AWOL,’ designed by UCSF researchers to determine whether a patient is at low or high risk for developing delirium. AWOL is an acronym for the screen’s assessments of cognitive function and severity of illness: Age: Is the patient 80 or older? World: Can the patient spell “world” backwards? Orient: Is the patient oriented? Does the person know their name, city and state, as well as the hospital and floor they’re on? Illness: How ill is the patient, from moderate to severe?”
National Academies Report on Social Care Integration
The National Academies’ Health and Medicine Division has published its final report on “Integrating Social Care into the Delivery of Health Care: Moving Upstream to Improve the Nation’s Health.” Known for its previous landmark studies on nursing home quality, medical errors, and healthcare workforce issues, the latest consensus document, writes Urban Institute senior fellow and aging expert Howard Gleckman, “calls for a major initiative to better integrate health care and social supports. Five complementary activities can facilitate the integration of social care into health care: awareness, adjustment, assistance, alignment, and advocacy. While all of the activities will ultimately benefit patients, adjustment and assistance focus on improving care delivery provided specifically to individual patients based on information about their social needs. Alignment and advocacy relate to roles that the health care sector can play in influencing and investing in social care resources at the community level. Doctors and hospital administrators have learned to say the words, ‘social determinants of health,’ but all too often they have no idea what they mean. NAS has done an important service. But it has achieved more than that. Take, for example, the difficulty many people have getting to medical appointments. A frequent cause: A lack of transportation. That’s where the NAS’s five common-sense steps come in. It recommends that health systems increase awareness by asking people about their access to transportation; make adjustments by using telehealth or other tools to reduce the need for patients to travel to medical appointments; provide transportation assistance through vouchers; improve alignment with social service programs by investing in community ride-share or time-bank programs; and advocate for policies that improve their community’s transportation infrastructure. Improving the links between medical care and social supports is critically important but much easier said than done. The changes NAS suggests requires a fundamental redesign of the health and social support delivery and financing systems. And it will require the U.S. to decide how to pay for these services. It is a special challenge in fee-for-service medicine, where payers, including Medicare and private insurance, rarely compensate doctors or health systems for, say, providing transportation vouchers.”
Social Determinants of Health JAMA Study
Just how great the challenge will be to realize the vision of the NAM report emerges from a JAMA study that appeared almost simultaneously. University researchers looked at how extensively U.S. physicians and hospitals are screening for one or more of five social determinants of health. The conclusion, reports Modern Healthcare’s Harris Meyer: “Most U.S. physician practices and hospitals are screening patients for at least one social need, but only a small percentage are screening for all five social determinants of health prioritized by the CMS — food insecurity, housing instability, utility needs, transportation needs, and interpersonal violence. Screening for interpersonal violence was the most common, while checking patients for utility needs was the least common. Providers with higher screening rates were federally qualified health centers, academic health centers, bundled payment participants, primary care improvement programs, Medicaid accountable care organizations and physician practices in Medicaid expansion states. Several organizations including the National Association of Community Health Centers, the American Academy of Family Physicians and the American Academy of Pediatrics have developed tools to help physicians and hospitals identify patients with social needs and offer them community-based support. NACHC launched a protocol called Prapare – available for free to all types of providers — that offers a series of questions that staff ask patients in order to discover social conditions that may harm their health, such as lack of transportation.”
Health Tech Developments for Older Adults
From AARP come several articles related to patient care and family caregivers, beginning with a list of treatment breakthroughs that are becoming available:
  • Robotic underwear that can augment core strength by about 25%; originally developed for the military, the undergarment is currently available for lease in Seattle.
  • An updated A-fib tracker; Abbott’s Confirm Rx Insertable Cardiac Monitor is placed under the skin during an outpatient procedure. It records 24 hours a day and sends data to your doctor through a smartphone app, so they can track your heart rate. With better feedback and monitoring, physicians can direct patients to the best possible medication.
  • A possible boost to sleep and cognition through the use of clear post-cataract-surgery UV-blocking lenses that allow blue light to enter; clear lenses increased slow-wave sleep time by roughly 50 percent and boosted performance on sustained attention tests by an average of 70 percent, compared with amber lenses that block part of the blue light.
  • Vibrating ingested pills similar to restaurant call buzzers that induce natural muscular waves known as peristalsis, moving stool through the body without chemical action; “We expect to treat chronic constipation of all kinds,” says Satish Rao, a gastroenterologist at the Medical College of Georgia at Augusta University.
  • By next summer, a $450 robotic dog that can offer comfort for dementia sufferers; the hope is that the “pet,” modeled on a 10-week-old Labrador puppy, can alleviate some behavioral and psychological symptoms.
  • A visor, expected to be available to physicians next year, that can diagnose stroke types; effective treatment requires that doctors understand which type of stroke the patient is experiencing. Forty percent of stroke deaths are caused by hemorrhagic strokes, during which blood escapes from a ruptured vessel in the brain. A newly developed visor, when strapped to a patient's head, can detect hemorrhagic strokes by using low-energy-frequency waves at an accuracy rate of 92 percent, thereby cutting time to treatment.
State Paid Family Leave Laws and Benefit Programs for Family Caregivers
In the second article, AARP provides a summary of the current landscape regarding paid family leave laws. As of March 2018, fewer than 1 in 6 workers had access to employer-provided paid family leave, according to the federal Bureau of Labor Statistics. As of September 2019, four states had government-sponsored family-leave insurance programs in effect. Five other states and the District of Columbia have enacted similar measures that have not yet taken effect. State profiles include California, Connecticut, District of Columbia, Maine, Massachusetts, New Jersey, New York, Oregon, Rhode Island, and Washington. At the same time, the National Academy for State Health Policy (NASHP) has identified several other state initiatives that support family caregivers. They include Minnesota’s Essential Community Supports program, Hawaii’s Kapuna Caregiver Program Washington’s first-in-the-nation Long-Term Care Trust Act, and Minnesota’s Elderly Waiver Program.
Caregiver Advise, Record, Enable (CARE) Act Update
Finally, from AARP, the latest tally of states that have enacted the CARE Act: 40, along with Puerto Rico, the U.S. Virgin Islands, and the District of Columbia. Tennessee, Iowa and North Dakota are the most recent adopters. “It’s been a remarkable journey and it’s not over,” said Elaine Ryan, AARP’s vice president of state advocacy and strategy integration.
Recent Study: Engagement with Alzheimer’s Caregivers by Health Care Providers
A new study from the Mayo Clinic and UsAgainstAlzheimer’s spotlights the often-overlooked need for family caregivers of people with Alzheimer’s disease to be more engaged by physicians during medical appointments with their loved ones. The research team recommends as best practices that health care providers recognize the important perspectives of both the patient and the caregiver, including the need to provide opportunities for caregivers to have separate interactions with providers. Other best practices in the paper include ways for health care providers to build trust with caregivers and people with dementia, increased coordination among health care providers on care, and greater use of a “family-centered” approach to care, where the caregiver’s well-being is considered an important part of the care for the person with Alzheimer’s and dementia.
Your Age May Be Subjective
Some good news from Emily Laber-Warren: “You are only as old as you feel.” Each of us, she writes in The New York Times, “has a chronological age, the number we commemorate on birthdays. But some 50-, 60- and 70-year-olds look and feel youthful, while others do not. Scientists can measure these differences by looking at age-related biomarkers — things like skin elasticity, blood pressure, lung capacity and grip strength. People with a healthy lifestyle and living conditions and a fortunate genetic inheritance tend to score younger on these assessments and are said to have a lower biological age. But there’s a much easier way to determine the shape people are in. It’s called ‘subjective age.’ When scientists ask: ‘How old do you feel, most of the time?’ the answer tends to reflect the state of people’s physical and mental health. A few intriguing studies suggest that a youthful frame of mind can have a powerful effect. In a 2013 experiment, for example, people’s grip strength significantly improved after they were told that they were stronger than most people their age. A Chinese study published last November found that people performed better on a memory task after being told they were sharper than others their age. But critics assert that for many, subjective age simply reflects cultural obsessions with youth. ‘People cultivate a younger identity to fend off stereotypes of frailty and senility,’ said David Weiss, a life span psychologist at the University of Leipzig. ‘If old age weren’t negatively valued, you wouldn’t have the need to say that you feel younger.’”
A Doctor’s Frustration with Documentation
“Don’t let patient care interfere with documentation,” Dr. Christopher Johnson sarcastically blogs . “That’s often how it seems some days. Those are the days when I’ve been busy at patients’ bedsides all day and then struggle to get my documentation done later — typically many hours later. I jot notes to myself as I go along, but it can be hard to recall at 5 p.m. just what I did and why at 8 a.m. Patient charts are burdened with several purposes that don’t always work together. The old notion of each physician having separate records for the same patient made no sense; it was far more logical to have a single record that traveled from physician to physician with the patient. That concept meant the medical record now was a means for one physician to communicate with another. So progress notes were sort of letters to your colleagues. You needed to explain what you were thinking and why. Even today’s electronic medical records are intended to do this, although they do it less and less well. Now, however, the record is also the principal way physicians document what they did so they can get paid for it. Patient care is not at all part of that consideration. The record is also the main source for defending what you did, say in court, if you are challenged or sued. Doctors may only rarely make eye contact these days as they stare at a computer screen and type or click boxes. But to some extent, we brought this on ourselves. In our fee-for-service system physicians once more or less said to payers: ‘We did this — trust us, we did it — now pay us for it.’ I can’t think of a formula more guaranteed to cause over-utilization or even outright fraud. But there is only so much time in the day. In my world, an ever-smaller proportion of it is spent actually with the patient.”
Addressing Immobility: A Downside of Falls Prevention Efforts
September 23 was the annual Falls Prevention Awareness Day, and to mark it Modern Healthcare published a striking one-page depiction of the annual toll falls take: 2.8 million injuries among seniors treated in the emergency department, 27,000 deaths annually, $67.7 billion in estimated costs in 2020, with Medicare accounting for $52 billion. But, asks Kaiser Health News’ Melissa Bailey, is there nonetheless a downside to falls protection efforts? “Falls remain the leading cause of fatal and nonfatal injuries for older Americans. Hospitals face financial penalties when they occur. Nurses and aides get blamed or reprimanded if a patient under their supervision hits the ground. But hospitals have become so overzealous in fall prevention that they are producing an ‘epidemic of immobility,’ experts say. To ensure that patients will never fall, hospitalized patients who could benefit from activity are told not to get up on their own — their bedbound state reinforced by bed alarms and a lack of staff to help them move. ‘Nurses feel that if somebody falls on their watch, they’ll be blamed for it.’ said UCSF geriatrician Dr. Kenneth Covinsky ‘The result: patients are told not to move, and they don’t get the help they need. To make matters worse, when patients grow weaker, they are more likely to get hurt if they fall.’ Nancy Foster, the AHA’s vice president of quality and patient safety policy, said that federal financial penalties, introduced in 2008 and increased by the Affordable Care Act ‘sent a strong signal to the hospital field about things CMS expected us to be paying attention to. Limiting patient mobility certainly is a potential unintended consequence,’ she said. But at the same time, Foster said, ‘hospital staff are getting people up and moving. Walking even a little can pay off. Older patients who walk just 275 steps a day in the hospital show lower rates of readmission after 30 days, research has found.’ Across the country, efforts are underfoot to encourage hospital patients to get up and move, often inside special wings called Acute Care for Elders that aim to maintain the independence of seniors and prevent hospital-acquired disabilities. Another initiative, called the Hospital Elder Life Program, which is designed to reduce hospital-acquired delirium, also promotes mobility and has shown an added benefit of curtailing falls. In a study of HELP sites, there were no reported falls while staff or volunteers were helping patients move or walk.”
What’s Needed to Make Hospitals and Medical Centers Age Friendly
The risks for seniors inherent in hospital visits, writes Kaiser Health News’ Judith Graham, stem not only from post-treatment adverse events but from the challenges posed by the facilities’ design as well. Graham offers a host of suggestions for improvement related to parking, signage, doors, and assistive devices. “For older adults, especially those who are frail, who have impaired cognition, or who have trouble seeing, hearing and moving around, health care facilities can be difficult to navigate and, occasionally, perilous. Grab bars may not be placed where they’re needed. Doors may be too heavy to open easily. Chairs in waiting rooms may lack arms that someone can use to help them stand up. Toilets may be too low to rise from easily. Examination tables may be too high to get onto. Lettering on signs may be too small to read. And there may not be a place to sit down while walking down a hallway if a break is needed. ‘Most hospitals and clinics have been designed for 40- or 50-year-olds, not 70- or 80-year-olds,’ said Dr. Lee Ann Lindquist, chief of geriatrics at Northwestern University’s Feinberg School of Medicine in Chicago. ‘Additional thought has to be given to seniors who have functional disabilities.’ Take signage, for example. All too often, easy-to-read signs indicating where patients should go can’t be found, either inside or outside medical centers. For older patients, this can lead to confusion and unnecessary wandering, accompanied by pain, fatigue and annoyance. Last year, a committee examining how Long Island Jewish Medical Center should handle patients with special needs identified better signage as a priority. Now, signs in the parking lot and outside the medical center are bigger, with larger type. Inside the medical center, large signs have been placed at bathrooms, showing clearly if they’re accessible to those with disabilities. And the staff is creating a comprehensive map of the hospital campus — a handout — to help patients find their way more easily.”
Momentum Grows to Remedy the Burden of Prior Authorization Requirements
It is the bane of so many physicians and their patients: prior authorization requirements. Radiation oncologist Dr. Paul Harari, writes Modern Healthcare’s Shelby Livingston, “likened it to torture. The interminable back and forth. The outdated fax machines. Wasting time on the phone to convince a health plan’s medical director that a cancer treatment the plan denied is the right way to go when he could be off taking care of his patients. ‘Cancer patients are super anxious about delays and that’s what we continue to see more and more of with prior authorization: delays in getting recommended treatment underway,’ said Harari. Health insurers and other payers insist prior authorization is a tool used sparingly to ensure patients are getting the right treatment in the right place; reducing costs is secondary. They contend it’s not a means to deny claims, as HHS’ Office of Inspector General has suggested. But they do admit the cumbersome process is a pain, and some insurers are at the center of collaborative industry initiatives to modernize the process. Momentum is finally building behind those efforts. Health plans, providers, electronic health record vendors and federal agencies are working together to reduce the prior authorization burden by automating it. Other organizations are experimenting with reducing the sheer volume of authorization requirements foisted on doctors. The bulk of the work being done to fix prior authorization focuses on automation. But experts say barriers that exist between healthcare’s EHR and administrative systems complicate that goal. Clinicians use an EHR for clinical work and a separate administrative system to bill an insurer. Even though prior authorization is an intrinsically clinical task, it’s governed by an administrative standard mandated by HIPAA that leaves no room for the medical notes, test results and patient history found in the EHR and no way for the insurer and doctor to exchange that data efficiently. Providers want national rules, such as a bipartisan bill introduced in June — the Improving Seniors’ Timely Access to Care Act of 2019 — that would require Medicare Advantage plans to use an electronic process and prohibit prior authorization for certain services. It also aims to create more transparency around prior authorization by requiring health plans to publicly post which services require it, how often those services are denied and approved, and how long it takes to make a decision.”
Finding the Light in the Darkness of Alzheimer’s
Can any good come from a loved one’s Alzheimer’s condition? Blogger Bill Ward approaches the sensitive question with an open mind and discovers some upbeat experiences among families coping with the pervasive burdens of Alzheimer’s caregiving. “Two sisters, Heidi O’Neill and Amy Springer, both called their late father’s Alzheimer’s ‘a gift’ for the way it repaired and enriched relationships between the two of them and both parents. ‘Yes, it’s extremely hard — I’m not going to put lipstick on it,’ says Springer, a family-law attorney in Denver. ‘There were moments when he was frustrated, moments when he was catatonic and he would say he didn’t have anything to give you. But then he would be the kindest, most generous life form I’ve ever seen. I saw my father experience joy every single day, and he fell in love with people and they fell in love with him.’ ‘The moment-to-moment love we got to share, just being accepting to where he was with the disease allowed us to super-bond,’ O’Neill says. ‘It was just pure connection. Relationships were forever changed and forever better as a result of that. I don’t feel like we’re coming from two different places anymore.’ Granted, such beneficial outcomes are likely more the exception than the rule. But increased awareness and improved communication around these diseases are helping many spouses and children cope, and sometimes find some light in the darkness. ‘The thing with Alzheimer’s is that it’s here, and to be wringing our hands and really focusing on the loss is an absolute disservice and doesn’t provide the caregivers an opportunity to connect,’ says Megan Carnarius, a registered nurse and author of A Deeper Perspective on Alzheimer’s and Other Dementias: Practical Tools With Spiritual Insights. ‘Yes, it’s difficult. And there are emotions that need to be supported. But loved ones should also focus on ‘what a person can still do, to be really present rather than getting into anticipatory grief. That’s unfair to the patient and unproductive for family members,’ adds Leah Challberg, senior program manager at the Alzheimer’s Association’s Minnesota-North Dakota Chapter. ‘We have a long way to go because of the stigma. This is the most feared disease. People think immediately about only the late stages. The thing I’m always very careful about is to make sure people know that when they are starting to deal with this, there are two opposing truths: One is that the disease has a very sad end and the other is that the patient can have a full, meaningful life.’”
Mail Carriers Offer Eldercare in France and Beyond
From a small village in England, Caregiving Policy Digest reported in the last issue, has come the spreading phenomenon of “chat benches,” an antidote to the debilitating “disease” of loneliness. Now, writes the New Yorker’s Zoey Poll, across the English Channel in a small French town near the Belgian border, “eldercare, comes with the mail. On a quiet afternoon house owner Jeannine Titeux appeared after the fifth knock. ‘You’re early,’ she said. Jeannine, who is eighty-eight years old, led mail carrier Aurore Raguet inside, into a living room so rigorously decorated that it inspired good posture. Aurore smiled and glanced down at her tablet. Ordinarily, she uses it to scan packages. Now it displayed a list of scripted lines designed to initiate conversation: Introduce yourself to the client and talk about a subject that might interest her; What weather we’re having! Did you watch TV last night? Have you received any visits lately? A month of these weekly visits plus an emergency-call button costs Jeannine €37.90. The fee is collected by La Poste, the French postal service, as part of a program called Veiller Sur Mes Parents (‘Watch Over My Parents’). Every day except Sunday, postal workers inform the program’s subscribers, through an app, if their elderly relatives are well and if they require assistance with groceries, home repairs, outings, or other needs. Since VSMP. was introduced, in 2017, about six thousand elderly women and fifteen hundred elderly men have been enrolled across the country. The program mandates no minimum visit time, but data collected by La Poste shows that conversations tend to last from six to fifteen minutes, long enough to soft- or hard-boil an egg. At the end of each visit, the elderly person signs the carrier’s tablet, providing proof of life as though accepting a package. Meanwhile, at home in Jersey, the largest of the Channel Islands in 2012, Joe Dickinson was recovering from a stroke, when he had an idea for the local post office, where he worked as an ‘innovator.’ Much like V.S.M.P., the resulting service, Call&Check, enlists mail carriers to monitor the sick and elderly. In the U.K., the privately owned Royal Mail has piloted its own version of the program, called Safe and Connected, funded by the Home Office. As of last year, South Koreans with parents over the age of sixty-five can sign their elders up for visits from postal workers, who send relatives photo updates. In Japan, monthly conversations between mail carriers and senior citizens have been available since 2013. For several years, Finnish post offices offered seasonally appropriate services, such as lawn-mowing or leaf-raking, on a weekly basis; now there is a year-round ‘befriending’ service, through which elderly customers can request long walks through subarctic snowscapes with a postal worker, described as an ‘outdoor buddy.’ Back in the Channel Islands Joe Dickenson observed that , unlike caretakers or social workers, who ‘sort of intruded into residents’ lives on official business, mail carriers offered a relaxed form of connecting with people who are particularly lonely and isolated. Loneliness,’ he explained, ‘is the new smoking; epidemiologically speaking, it’s as unhealthy as smoking fifteen cigarettes a day.’”
FCA Webinar on Advance Care Planning
FCA will present a free webinar — Take Charge: Tips for Advance Care Planning — on Wednesday, October 30, at 11 a.m. (Pacific Time). Further information and free registration are available here.
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FCA's Connections e-newsletter focuses on issues and information important to family caregivers. The newsletter regularly covers tips, articles, and helpful advice that can assist families with the numerous daily care tasks that caregiving for loved ones presents—including the often overlooked “caring for yourself.” While much of the content can prove helpful to caregivers nationwide, the events included are local to the six-county region of FCA’s Bay Area Caregiver Resource Center.

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