The HHS Office of Inspector General has delivered some very disturbing news in a report based on 2018 Medicare data: Medicare patients have continued to experience alarming rates of harm during hospital stays. Despite more than a decade of intensive efforts to decrease provider-caused adverse effects, writes MedPageToday’s Cheryl Clark, “one in four Medicare patients suffered harm in hospitals, and, of those harmed, nearly half the causes were preventable. In one of many case studies and patient stories included in the report, a patient required surgery to remove dead tissue from the small intestine. ‘However, providers unnecessarily delayed surgery for 5 days while the patient continued to deteriorate. This delay led to a cascade of harms that included worsening of the small intestine, contamination of the abdomen with pus, septic shock with an associated kidney injury, and delirium.’ Ten percent of these adverse events contributed to patient deaths, translating to 1.4%, or 14,800 patients. Leah Binder, president and CEO of the Leapfrog Group, which routinely grades hospitals on various safety measures, called the report's findings ‘outrageous.’ CMS, the OIG noted, has two policies designed to deter hospital-acquired conditions (HACs), including cuts in reimbursement to hospitals with higher rates of such conditions. However, ‘because the policies use narrowly scoped lists of HACs and employ specific criteria for counting harm events, they have limited effectiveness in broadly promoting patient safety. Of the harm events we identified, only 5% were on CMS's HAC Reduction Program list and only 2% were on CMS's Deficit Reduction Act HAC list.’”

Masks are ever rarer and stadium crowds ever larger as Covid-19 fears recede; in New York and elsewhere, however, alarms are being sounded again—and, as the Washington Post’s Fenit Nirappil and Dan Keating write, “The pandemic’s toll is no longer falling almost exclusively on those who chose not to or could not get shots, with vaccine protection waning over time and the elderly and immunocompromised having a harder time dodging increasingly contagious strains. The vaccinated made up 42 percent of fatalities in January and February during the highly contagious omicron variant’s surge, compared with 23 percent of the dead in September, the peak of the delta wave, according to nationwide data from the Centers for Disease Control and Prevention. As a group, the unvaccinated remain far more vulnerable to the worst consequences of infection — and are far more likely to die — than people who are vaccinated, and they are especially more at risk than people who have received a booster shot. A key explanation for the rise in deaths among the vaccinated is that covid-19 fatalities are again concentrated among the elderly. Jason Salemi, an epidemiologist at the University of South Florida College of Public Health, said the deaths of vaccinated people are among the consequences of a pandemic response that emphasizes individuals protecting themselves. ‘When we are not taking this collective effort to curb community spread of the virus, the virus has proven time and time again it’s really good at finding that subset of vulnerable people.’”

LinkedIn, one of the major Internet career networking sites, has added a new feature to its entry profiles: the “career break.” Users, reports the Washington Post’s Julianne McShane, “ can classify their time away from paid work as one of 13 “types” of career breaks — including bereavement, career transition, caregiving, full-time parenting and health and well-being — and add details about what led to the career break and what they’ve done during the break. LinkedIn claims the new feature could be a boon for women, pointing to data the company collected from a survey of nearly 23,000 workers and more than 4,000 hiring managers that found that nearly two-thirds of employees had taken a break at some point in their professional career, and that 68 percent of women surveyed said they ‘wanted more ways to positively represent their career breaks by highlighting skills learned and experiences they had during a work pause.’ ‘I think the message needs to be: Employers need to step up and create pathways for people to return to the workforce,’ said Tami Forman, the founding chief executive of Path Forward, a New York City-based nonprofit organization that supports caregivers seeking to restart their paid careers. ‘There is still a lot of bias around what makes someone an ideal worker. We have to recognize that part of this is a stigma about caregiving.’”

McShane’s Washington Post colleague Abha Bhattarai underscores the potential payoff of recognizing “career breaks” by focusing on just how much caregiving responsibilities impede the work return to employment. “Even as the job market rapidly approaches the levels last seen before the coronavirus pandemic, a lack of affordable care for older and disabled adults is keeping many out of the workforce. At least 6.6 million people who weren’t working in early March have said it was because they were caring for someone else. Whether — and when — they return to work will play a role in the continued recovery and could reshape the post-covid labor force. For all the attention on parents — and mothers in particular — who stopped working to care for children during the pandemic, four times as many people are out of the work force, according to a recent Federal Reserve Monetary Policy Report, caring for spouses, siblings, aging parents and grandchildren. Caregiving is the second-largest factor keeping people out of work, behind early retirements, at a time when job openings continue to outnumber potential workers. Overall, the economy is still short 1.6 million workers, two-thirds of them women, from early 2020. The relationship between caregiving and work tends to be circular: People who are already out of work — as many were early in the pandemic — tend to take on caregiving roles. And once they do, they’re less likely to reenter the workforce, said Yulya Truskinovsky, an economics professor at Wayne State University. And while employers are increasingly more accommodating of child-care needs — offering parents flexible schedules, in some cases, or on-site day care — that hasn’t been the case for adult care, which often becomes more labor-intensive over time. ‘Maybe [adults] can live independently at first, but then they have a fall and suddenly the picture changes. It’s much more unpredictable. Once you start caregiving for an adult, you’re probably not going to stop until your loved one moves into a nursing home or dies.’”

FCA offers a list of the top 17 resources for family caregivers in a PDF format as well as on a website with live links. Topics include dementia, self-care, planning for care, and daily care. Access both here. 

The NAM’s monumental roadmap to nursing home improvement, published in April, sets forth seven “overarching” conclusions: 

NAM’s recommendations within these overall conclusions are voluminous but, as summarized by the Center for Medicare Advocacy, some of the most significant involve SNF workforces, transparency, financing and survey and enforcement:

The Biden administration has started the ball rolling to address the SNF staffing issue highlighted in the NAM study. As part of its annual SNF payment upshot update proposed rule, CMS has requested input on establishing mandatory nurse staffing levels. The pertinent sections of the proposal appear at pages 22789-22795; comments are due no later than June 10, 2022.

Staffing levels are not the only SNF issue generating debate; advocacy groups are taking aim at the matter of who owns the facilities delivering care and whether the role of profit-seeking makes a difference in quality. As Kaiser Health News’ Victoria Knight reports, “From 2010 to 2019, there was a large increase in private equity companies buying up nursing homes, along with other investments in health care. An exact figure is elusive because private purchases are difficult to track, but it’s estimated that such groups own anywhere from 5% to 11% of nursing homes nationwide. A growing body of research shows that health outcomes in private equity-owned facilities are worse than in those under other ownership. A November 2021 Cornell University study, for example, found that residents of private equity-owned nursing homes were more likely to have emergency room visits or be hospitalized than residents of other for-profit homes. Industry trade associations dismissed these findings, saying the studies don’t show the whole picture of how care at private equity-owned homes might differ from that at other facilities. Still, said Robert Tyler Braun, an assistant professor of population health sciences at Cornell University and an author of the November 2021 study, it’s undisputed that private equity firms are buying nursing homes because they’re likely to be profitable. ‘The main appealing thing is the margins are low and they’re getting valuable real estate with the purchase,’ Braun said. ‘Plus, the way these deals are structured, it allows you to bring in parties that private equity firms might own, such as maid and clinician services, and charge higher rates than the market indicates.’”

In California a legislative initiative to tighten nursing home licensure regulations is making some headway. Companies and individuals, reports Kaiser Health News’ Samantha Young, “can buy or run nursing homes in California before they get a license, a process that even an industry lobbyist described at a legislative hearing this year as ‘backward’ and unique to the state. Some California lawmakers want to put an end to those types of business arrangements and ban people or entities from buying or operating nursing homes unless they have a license — which is the situation in most states. They’re also proposing an overhaul of the licensing process to reject applicants with poor performance and those without adequate experience or financial resources. ‘In California, nursing home owners and operators can operate without a license even after they’ve been denied a license,’ said state Assembly member Al Muratsuchi, author of Assembly Bill 1502. ‘Many of these owners and operators have, unfortunately, an extensive history of neglect and abuse.’ Muratsuchi’s bill would require an owner or company to apply for a license 120 days before buying or operating a nursing home and include financial records that contain the names of all owners and investors. The state would reject applicants who fail to meet standards for character, performance in other homes, and the financial ability to run the home. Covid has pushed lawmakers to act; Muratsuchi’s measure has cleared the state Assembly and awaits a hearing in the Senate.”

Tackling the SNF ownership issue from another perspective, the Long-Term Care Community Coalition (LTCCC) has published an Issue Brief on “Direct Care Minimum Spending Laws.” “Until recently,” the brief observes,” nursing homes have not been required to spend a set minimum percentage of the funds they receive on the care of their residents, nor have the public or policymakers had an effective tool to require accountability for these expenditures. In September 2020, the New Jersey Legislature passed and the Governor signed legislation establishing a direct care ratio (DCR) requirement for nursing homes. The New Jersey DCR requires that 90 percent of a facility’s aggregate revenue in each fiscal year is to be expended on the direct care of residents, and facilities that fail to meet the DCR will be required to pay a rebate to the state. New Jersey’s legislation was enacted nearly the same time that the Commonwealth of Massachusetts established a similar requirement for nursing homes to spend at least 75 percent of their revenue on direct care staffing costs. New York followed soon after in April 2021 with the passage of its own direct care spending law, which requires nursing homes to spend at least 70 percent of their operating revenue on direct resident care, of which 40 percent must be spent on resident-facing staffing. Other states are considering similar legislation.”

While policymakers, researchers, advocates and government officials search for solutions to SNF quality issues, the legal profession is entering the fray. As the Wall Street Journal’s Jacob Gershman reports, “Two years after the coronavirus ravaged through nursing homes, families of residents who died from Covid-19 are bringing a wave of negligence and wrongful death lawsuits against the facilities. The surge of suits, spurred by a repeal of liability protections and statutory deadlines to file the suits, largely accuses nursing homes of failing to properly curb the spread of disease, identify infected residents and treat their illnesses. New York’s nursing-home industry says much of the devastation wrought by the virus—particularly in the chaotic early days of the pandemic—was beyond its control, citing staffing shortages, inadequate testing supplies, a lack of masks and other personal protective equipment and a controversial state policy requiring facilities to admit residents who tested positive for coronavirus. While dozens of lawsuits have been filed in New York over the past month, it isn’t the only hot spot of litigation. In Illinois, Levin & Perconti, a Chicago plaintiffs’ firm, says it brought 78 cases in March alone. ‘It’s going to be a knock-down-drag-out battle,’ said Steven M. Levin, the founder and senior partner of the firm. ‘It’s probably going to take years to get some of these cases to trial.’”

Are robots the answer to SNF deficiencies? The New York Times’ John Leland found some intriguing possibilities. “With $2 million from the Minnesota Department of Human Services, University of Minnesota computer science professor Dr. Arshia Khan plans to place two robots in each of eight nursing homes operated by Monarch Healthcare Management, a for-profit company that has about 40 homes around the state. One robot, a two-foot-tall model called NAO, priced at about $12,500, will lead classes in yoga, tai chi and strength training. The larger robot, Pepper, which costs about $32,000, will socialize, tell jokes and play games with residents. Alexis Elder, a philosophy professor and ethicist who works with Dr. Khan, said the use of robots in nursing homes raises a range of ethical issues. Who should get access to the robots’ extensive monitoring data — only the residents and doctors, or should their families also have it? And will the robots ultimately diminish human-to-human contact, an essential part of care? Even in Dr. Khan’s lab, a techno-future where robots serve many human needs seemed tantalizing, but still far away. Robots suddenly started talking unprompted, or crashed in mid-program. They seemed remarkably human one minute, maintaining eye contact and leaning into conversation, but in the next they spoke over any attempts to go off-script, lacking the functional agility of Apple’s Siri or Amazon’s Alexa. On the plus side, unlike human workers, robots never get in a bad mood or tire of having to repeat themselves. For Monarch, the robots’ limitations are not the point. Like other nursing home systems, Monarch has been struggling with severe labor shortages since the pandemic. Marc Halpern, the chief executive of Monarch, said the company ‘1,000 percent’ did not intend to replace workers with robots. ‘But if these robots can help us fill in gaps to help meet the needs of the residents, that’s what we’re looking for.’”

The Centers for Medicare & Medicaid Services (CMS) has announced it will offer more than $110 million to expand access to home and community-based services (HCBS) through Medicaid’s Money Follows the Person (MFP) program. First authorized in 2005, MFP has provided states with $4.06 billion to support people who choose to transition out of institutions and back into their homes and communities. The new Notice of Funding Opportunity (NOFO) makes individual awards of up to $5 million available for more than 20 states and territories not currently participating in MFP. These funds will support initial planning and implementation to get the state/territory programs off the ground, which would ensure more people with Medicaid can receive high-quality, cost-effective, person-centered services in a setting they choose. State Medicaid agencies not currently participating in the MFP demonstration may apply through the NOFO no later than May 31, 2022.  

Fallout from CMS’s decision to restrict Medicare coverage of Alzheimer’s drug Aduhelm manifested itself in a giant insurer United Healthcare’s announcement that it would similarly limit coverage only to patients enrolled in clinical trials who received prior authorization. “UnitedHealthcare,” reported Modern Healthcare’s Nona Tepper, “is the first publicly traded health insurer to announce an Aduhelm coverage decision. Other carriers, including at least six not-for-profit Blue Cross and Blue Shield affiliates, are not covering Aduhelm. In addition, major providers such as Mount Sinai Health System and the Cleveland Clinic won't prescribe the medicine.”    

The amyloid clearance thesis saga, however, does not begin or end with Aduhelm. As Barron’s Josh Nathan-Kazis reports, “All three of the next generation of anti-amyloid beta antibodies—Eisai’s lecanemab, Lilly’s donanemab, and Roche’s gantenerumab—have proven in earlier-stage studies that they can clear the brain plaques known as amyloid beta seen in Alzheimer’s patients. Despite some promising early findings, all have yet to prove that they can also slow the decline of Alzheimer’s patients. Dr. Michael Irizarry, senior vice president of clinical research at Eisai’s neurology business group, says that the outcome of the lecanemab study will effectively prove the theory behind the drugs, one way or the other, in patients with early Alzheimer’s disease. ‘This would be definitive for the early Alzheimer’s disease population.’ Market analyst Ronny Gal, who is slated to join Novartis senior management this summer, observes that ‘if the data readouts are all positive, a three-way market brawl could erupt among the drugs. Gal expects Lilly’s data to look the best, based on the careful patient selection the company has done for the trial. Eisai’s drug, he says, will likely have the best safety profile, while Roche’s is the only one that can be injected, rather than infused, making it more convenient. ‘The first set of trials,’ says Gal, ‘are obviously critical, but the more interesting trials are the ones that look at prevention of Alzheimer’s in patients that are yet to have symptoms.’”

Progress toward earlier diagnosis of A.D., reports MedPageToday’s Judy George, has occurred by virtue of FDA’s approval of the first in vitro diagnostic tool, the Lumipulse G ß-Amyloid Ratio (1-42/1-40) test. “The assay measures the ratio of beta-amyloid 1-42 to beta-amyloid 1-40 in cerebrospinal fluid (CSF). The Lumipulse test is intended to be used in adults 55 and older presenting with cognitive impairment who are being evaluated for Alzheimer's disease or other causes of cognitive decline. ‘The availability of an in vitro diagnostic test that can potentially eliminate the need for time-consuming and expensive PET scans is great news for individuals and families concerned with the possibility of an Alzheimer's disease diagnosis,’ said Jeff Shuren, MD, JD, director of the FDA's Center for Devices and Radiological Health. ‘With the Lumipulse test, there is a new option that can typically be completed the same day and can give doctors the same information regarding brain amyloid status, without the radiation risk, to help determine if a patient's cognitive impairment is due to Alzheimer's disease.’ The FDA’s own decision announcement emphasized that the test is not intended as a screening or stand-alone diagnostic assay. There is also the possibility that a positive test result could be seen in patients with other types of neurologic conditions, as well as in older cognitively healthy people, which underscores the importance of using this test in conjunction with other clinical evaluations.”  

More indications of a link between cognitive declines and modifiable individual risk factors have appeared in a new study by California researchers. “Eight such factors, reports MedPageToday’s Judy George, make up the list: midlife obesity, midlife hypertension, physical inactivity, depression, smoking, low education, diabetes, and hearing loss. ‘Understanding which risk factor plays a role in accelerating cognitive decline can help providers and individuals be proactive in addressing these risk factors early in their lifetime,’ said study co-author Dr. Roch Nianogo ‘We also wanted to understand what that meant for different subpopulations defined by sex and race and ethnicity, as this can be important for designing tailored and targeted interventions.’ Midlife hypertension and midlife obesity were the most prevalent risk factors among all participants, but midlife obesity was more prevalent in American Indian and Alaska Native, Black, and Hispanic populations while low education was more prevalent among Hispanic individuals.”

An intriguing finding in a new National Academy of Medicine paper relates to the role of hypertension in increasing the risk of dementia. The question addressed is whether two similar antihypertensive drugs in the ACE-ARB family show differential impacts on the emergence of cognitive disorders. Hypertension, the paper’s authors write, is responsible for an estimated 2% of all AD and related dementia (ADRD) cases globally, and is the only modifiable risk factor with randomized trial evidence showing a lower risk of cognitive impairment by an intervention that improves the risk factor (i.e., blood pressure lowering). “While mechanistic and clinical data support the hypothesis of a comparative beneficial cognitive effect of ARBs over ACEIs, there is currently limited observational and trial data. The potential implications of switching ACEIs to ARB use are sizable. Approximately 73% of U.S. adults with hypertension and prescribed antihypertensive medication (i.e., 44.3 million) are taking an ARB (13.5 million) or ACEI (19.1 million) annually. Given the prevalence of hypertension and ACEI use, even if ARBs are only 10%–15% more effective than ACEIs at preventing ADRD, switching from ACEIs to ARBs could have an impact on population health and improve brain health equity. For context, one microsimulation analysis found that if an intervention delayed ADRD onset by five years, the prevalence of ADRD would go down by 41%, and costs would be reduced by 40%. Moreover, hypertension disproportionately affects underrepresented groups, particularly in mid-life, and the risk of ADRD is substantially higher in these groups. Thus, the potential contribution of this shift in antihypertensive prescribing toward achieving health equity is substantial.”

The exploding growth of wearable health technology is evident on the arms of millions of Fitbit and Apple smartwatch users. It has fallen to the Economist Magazine to coin a new term – the “Quantified Self”– to characterize the phenomenon. “Smartwatches, fitness trackers and a rapidly growing array of electronically enhanced straps, patches and other ‘wearables’ can record over 7,500 physiological and behavioural variables. Some of them are more useful than others, obviously, but machine learning can filter a torrent of data to reveal the ‘quantified self’—a continuous, numerical picture of you and your health. Wearables and artificial intelligence look set to reshape health care in three big ways: early diagnosis, personalised treatment and the management of chronic disease. The scale of benefits promises to be vast. Just how vast will become clearer as wearables create data, leading to innovation. The reason for optimism is that the technology is ripe. Some 200 million devices were sold in 2020 and twice as many are expected to sell in 2026. One in four Americans has a wearable device. Smartphones serve as a platform for innovators. Within a year or two the device on your wrist may be measuring non-invasively your blood sugar, alcohol and hydration, as well as various markers of inflammation, kidney and liver function—all of which currently require blood to be drawn. As wearables acquire more features, users are less likely to lose interest in them and shove them into the back of a drawer. The pay-off, in money and well-being, is likely to be huge. Time to roll up sleeves and prepare health care for the era of the quantified self.” 

Some reassuring news about telehealth visits since they became widely available in the wake of Covid-19: a study authored by Johns Hopkins University and other researchers, reports Modern Healthcare’s Maya Goldman, finds that “telehealth generally didn't lead to duplicative care in late 2020. (While) patients treated for most acute conditions via telehealth were as likely or slightly more likely to need a follow-up visit as those who sought in-person care to start, patients with chronic conditions were less likely to need follow-up care. ‘Telehealthcare is comparable to in-person care and it really is not a duplication of the service,’ said Dr. Elham Hatef, an assistant professor at Johns Hopkins University and one of the researchers on the latest study. ‘That might help policymakers to consider the continuation of insurance coverage for telehealth services.’ The finding that telehealth resulted in a lower chance of follow-up care for patients with chronic conditions is promising for Medicare beneficiaries, said Krista Drobac, executive director of telehealth policy advocacy group Alliance for Connected Care. ‘What we're most interested in is impact on Medicare. If the researchers found lower rates of follow up for chronic conditions, that might mean that telehealth in Medicare will yield lower overall follow up because more seniors have chronic conditions.’”

On a recent Sunday, I brought my 86-year-old mother, Bunny, a tremendously gaudy fake pearl ring with an elastic band. She loved it. Rings are of great value to her now, as they can dazzle and are never out of reach. My mother has dementia, in its final stage. Each time I put the ring on her finger, it will be the first time. Dementia is a land where my mother lives. It is not who she is. I think of it as an actual place, like the Acropolis or Yonkers. A place where beloved and ancient queens and kings retire, where linear time doesn’t exist and the rules of society are laid aside. Whenever I go to my parents’ double-wide in Hayward, Calif., I am really traveling to Dementia. Thinking of it this way allows for magic to happen — for her to remember my name suddenly and to know my husband — and for there to be a boundary between me and the treacherous drop of despair. Each time I go to see her, it’s different. I’ve learned to set expectations aside, like an umbrella on a sunny morning. Sometimes she completely loses touch, is unreachable. In Spanish there is an expression for this: ni de aquí, ni de allá — not from here, not from there. It’s the national motto of Dementia. She meanders, an invisible suitcase at her side. A citizen of the wind. Yet she always returns, and it is always thrilling, a resurrection. When Bunny travels in her mind, she sometimes takes me along. She demonstrates her own version of what Einstein knew, that time is indeed relative, passing at different rates for different people. She asks after my father, gone 44 years. “Where’s Richard?” “Dad’s not here right now, Mom. But he’s fine.” I’m pleased to speak of my father in the present tense. Visitors to Dementia know that everyone is fine, no matter how long he or she has been dead. There’s a wonderful economy of souls happening here, where no one is actually gone and all are comrades on the road. Living in Dementia isn’t the defining chapter of her life. The terrain here runs inexorably and swiftly downhill, but for my mother, this seems only to make her hair fly behind her like a commemorative flag. She remains mostly cheerful, herself. I take notes, for when my own demise comes. This is how it’s done. There is dignity in Dementia if we say there is. There is wisdom and humor and radiance if only we can see it. I make the effort because my mother does and because it is what she deserves after a long life well lived, harming no one. I am astonished by her courage, even now. Especially now. (Suzanne Finnamore, the New York Times)

Editor: Alan K. Kaplan, (attorney and health policy consultant)

Contributor: Kathleen Kelly (executive director)

Production: Calvin Hu

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