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News Roundup: June 3, 2013

Nation at crossroads in home care for elders

Published by Herald Tribune
Barbara Peters Smith
June 3, 2013

First of three parts

Chuck and Rosalie Schockweiler need no words as they execute a smoothly choreographed routine in their Englewood home.

He rinses her feeding tube and hands it to her; she shakes it dry and attaches it to a port on her abdomen as he dissolves three pills in water. Chuck fetches her liquid lunch as Rosalie places a plastic receptacle in an ingenious homemade stand that Chuck fashioned from PVC pipe and an old battery charger, weighted “with imported stones from the front yard.”

He pours in the solution, and as she feels it flow into her belly, she smiles — the same glorious, sunny smile he first noticed back when they worked at Venice Regional Medical Center. He chases the meds with a can of liquid nutrition Rosalie must have five times daily, filling the tube and responding to her prompt when it’s time for another pour.

Usually, as Rosalie finishes her meal, Chuck gets himself something to eat and they sit together at the dining table. Then they stand, every single time, for a long, satisfying hug.

It’s a process they repeat about every two and a half hours, with two more feeding sessions for medication alone.

Early in the day, it looks easy. But, Chuck admits, evenings are tougher because his energy flags.

The Schockweilers have been married for 14 years. At 66, she has lived for a year and a half with amyotrophic lateral sclerosis, an incurable erosion of the central nervous system that’s also known as ALS, or Lou Gehrig’s disease. And at 71, he has endured countless rounds of chemotherapy for liver cancer.

Rosalie took care of Chuck when his chemo side effects were most debilitating. Now, he says, it’s his turn.

“We both have a terminal illness,” he says. “Whoever lives longer, be that as it may. I don’t know; it will work out. We’re just hanging in there.”

The Schockweilers, like many older couples with health challenges, are determined to stay out of a facility and in their own home as long as they can. But what sets them apart from many retired Floridians — aside from their determination to keep laughing, joking and visiting the occasional tiki bar — is the tight network of people willing and able to help.

Rosalie’s good friend comes by often to take over feedings so Chuck can run errands or work on his boat. A neighbor cuts their grass. Daughters, sisters and church members stand by, along with a close-knit community of fishing buddies, retired police officers and firefighters.

This is the traditional American model of home health care, and it is rapidly fading away.

A new workforce

Americans are living longer, meaning more health support is required for an extended time. But fewer people have access to the loving, full-time live-in care that Rosalie Schockweiler gets from her husband. Baby boomers have higher rates of divorce and childlessness than their parents — raising the prospect that there will be fewer family members to care for them.

Long-term care specialists agree that helping elders with care in their own homes could be more cost-effective than institutionalization — and it is what most older Americans prefer. But no one seems to know how the home care alternative would work on a larger scale.

A home care revolution — with extended stays at facilities such as hospitals and nursing homes diminishing — could be daunting, personally and financially, for many working people who struggle to care for aging parents. It would mean an enormous — and enormously bureaucratic — step beyond asking the nice lady down the street to look in on Mom while you’re at work.

Private-duty aides and home care agencies are expanding nationwide to pick up the slack from what has been a loosely organized, almost spontaneous approach to elder care by family and friends. Government-funded programs are scrambling to design networks that make use of this workforce, with the goal of paying less than nursing homes or assisted living facilities would charge.

The rise of for-profit health care providers is no accident; 78 million U.S. baby boomers are poised to become consumers of these services. Already, some 45 percent of Americans over 65 live alone.

Last year the Franchise Business Review named home health care one of the top five most lucrative franchises in the nation, with net profits averaging 12 percent to 15 percent.

The industry is a major source of new jobs, with an estimated 54 percent of the nation’s 4 million direct care workers employed in home and community settings. By 2018, this share is expected to rise to 66 percent.

But the rush to capitalize on this market could offset a crucial element that has made aging in place at home a less costly option than nursing and assisted living: a force of more than 66 million unpaid caregivers who do their demanding jobs out of love or obligation alone.

In the move to professionalize a largely informal — sometimes desperately improvised — process, elder care specialists say, some important questions aren’t being raised.

“What do we want to put in place? Do we want high-quality, person-centered care? Do we really want to make a difference to overburdened family caregivers?” asks Dorie Seavey, director of policy research for the Paraprofessional Healthcare Institute. “Or do we want women quitting their jobs because we have such a poor infrastructure to support their efforts to help their loved ones?”

Larry Polivka, executive director of the Claude Pepper Center at Florida State University, which studies aging issues, is skeptical about an emerging effort to enlist health maintenance organizations — as Florida is doing — in the business of elder care without more evidence about what works.

“I’m not saying for-profit HMOs can’t do the job,” he says. “But we need to have in place more comparative models so we can contrast and compare and decide what’s best. Instead we’re just rushing pell-mell in one direction or another, depending on which way the wind blows — ignoring the fact that this is going to be one of the hugest issues over the next three decades.”

But Bruce Chernof, president of the SCAN Foundation — a California nonprofit that promotes aging with dignity and independence — believes the home care revolution can result in a better quality of life for the next generation of elders.

“The challenge is to not medicalize the entirety of someone’s life,” he says. “How do we build a new system that interacts with the medical system but allows people to have the functionality that they want, as opposed to being framed as a hospital patient?”

Steep challenges

The federal government is lined up solidly behind this goal, funding an array of experiments in diverting frail or cognitively impaired elders from traditional end-of-life care at nursing facilities, and trying to make it possible for them to survive with assistance at home.

“All Americans — including people with disabilities and seniors — should be able to live at home with the supports they need, participating in communities that value their contributions — rather than in nursing homes or other institutions,” Health and Human Services Secretary Kathleen Sebelius said last year.

But it is a long way from “should” to “can.” The cobbled-together care plans that families devise to handle a health crisis — subsidized heavily with their own labor — may not translate easily to government-funded systems operated by an array of for-profit service providers.

The challenges are steep:

• Aside from promising pilot projects, few states have shown real progress in setting up viable, large-scale home care networks that offer quality care and realize tangible savings.

• The dollars available for elder care won’t just be stretched thin as the baby boomers age. The total amount of funding available is almost sure to be sliced as the “Greatest Generation” leaves the stage and numerous boomers begin to draw on their entitlements.

• Professionals in the home care field predict that families will continue to bear a larger share of the burden — in dollars where possible and in hands-on availability where needed.

For unpaid caregivers, quitting or scaling back their jobs can seem like an expedient, less costly way of making sure they meet their family obligations. But they should think long and hard before taking such a drastic step, according to research by the MetLife Mature Market Institute.

An institute study of more than 1,000 family caregivers over the age of 50 found that the lifetime effect of lost wages, Social Security benefits and retirement savings comes to more than $300,000 for the average caregiver.

In trying to make sure a parent or spouse is safe and comfortable, says MetLife Institute research director John Migliaccio, it can be easy to make a decision that may prove devastating financially. About 25 percent of all adult children in the United States are responsible for the well-being of an older relative, he says, and the cost of their dropping out of the workforce came to $3 trillion in 2008 dollars.

“That’s a significant economic impact that goes unrecorded,” he adds. “Potentially, the costs are much higher.”

Meanwhile, little attention has been paid to the growing medical sophistication of what family caregivers are being asked to do, says Susan Reinhard, vice president for public policy at AARP.

According to the organization’s 2012 report, “Home Alone: Family Caregivers Providing Complex Chronic Care,” these unpaid friends and relatives are doing the work not of personal aides, but of highly trained health care providers.

“More than half of them are giving five or more medications, and more than 25 percent are giving 10 or more injections,” Reinhard says. “About 35 percent of them are doing wound care, sterile dressings, colostomy care. These are things that make nursing students tremble the first time they do it. And here we’re saying, ‘Go home and do this to your mom.’ ”

Priceless care

It would be hard to calculate the value of care provided in homes like the Schockweilers’.

Rosalie’s voice is nearly gone; she relies on her expressive face, lively hand gestures, pen and paper and an iPad to make her point.

“I believe God put us in each other’s life for a reason. We take care of each other, and our weakness makes us strong,” she writes on lined yellow paper. “We don’t understand how people cannot believe in God. It is amazing how I can help myself, and all the things I still do.”

Rosalie, an ex-New Yorker, and Chuck, a retired police officer from Chicago, know that all the care routines they improvise are temporary — that Rosalie will lose the ability to control her arms and legs and will need more assistance. And Chuck might not have the strength to offer it.

But they plan to carry on, Chuck says, “as long as possible.

“I tell my buddies, ‘When I go, I want to check out in my La-Z-Boy chair.’ ”

He wants them to strap him in, put the chair on his boat and light it all on fire, “like a Viking,” out in the Gulf of Mexico.

He and Rosalie laugh, clearly more comfortable talking about the hereafter than the here and now.

“Once they tell you you have a terminal illness and you adjust to that, it’s easier to deal,” Chuck says. “You can kind of joke about it.”

Barbara Peters Smith wrote this article as a John A. Hartford Foundation Journalists in Aging Fellow, a collaboration of New America Media and the Gerontological Society of America.

NY Times: Will Robots Take the Place of Senior Care Providers?

Published by Home Health Care News
Elizabeth Ecker
June 3, 2013

Robots could be the next big thing in home care, as the newest iterations are being designed to help with activities of daily living and with a specific attention to needs of seniors.

From administration of medicines to helping with the day-to-day, a number of robots currently under development are positioning to come to the aid of the aging population—namely to fill in care “gaps.”

Research under way at several U.S. institutions including the Georgia Institute of Technology and Carnegie Mellon University will change the nature of caring for older people through technology, writes the New York Times in a recent article. Robots, in particular, will be needed to fill in an increasing gap between the number of people who need care and the number of people who are able—and willing—to provide it, the NY Times writes.

“There are two trends that are going in opposite directions. One is the increasing number of elderly people, and the other is the decline in the number of people to take care of them,” Jim Osborn, a roboticist and executive director of the Robotics Institute’s Quality of Life Technology Center at Carnegie Mellon University, told the Times. “Part of the view we’ve already espoused is that robots will start to fill in those gaps.”

One robot under development at the Georgia Institute of Technology, Cody, can perform tasks from kitchen cleaning to bathing. Others in the works, such as Carnegie Mellon’s Home Exploring Robot Butler, “HERB,” can provide reminders, find household objects and help prevent falls, the Times writes.

Hospital-to-home care

Published by Lexington Clipper-Herald
Bob Glissmann
May 24, 2013

Medicare is withholding nearly $1 million from metro Omaha and Lincoln hospitals because too many of their patients returned to the hospitals within a month of being sent home.
Medicare officials, as part of an effort to curb rising costs, are taking aim at avoidable hospital readmissions, which they consider to be one of the biggest problems facing the country's health care system. Twenty percent of elderly patients are back in the hospital within 30 days of leaving, the federal Centers for Medicare & Medicaid Services say.
The penalties are one reason some hospitals are paying nurses to make follow-up home visits and set up doctor's appointments for patients -- tasks that used to be left to patients' relatives or the patients themselves.
If someone is readmitted to the hospital so soon after being treated, it "means they have some problem that wasn't addressed or they developed a new problem at home," said Susan Mende, senior program officer for the Robert Wood Johnson Foundation. Such readmissions, she said, "are really a quality and cost problem that very negatively impacts people's lives and wastes very precious health care resources."
Readmissions for Medicare patients alone cost $26 billion a year, according to a foundation report, and more than $17 billion of that pays for return trips that don't need to happen if patients get the right care in the first place. The health insurance program for people age 65 and older is financed by U.S. taxpayers.
The total reduction in U.S. hospitals' Medicare reimbursements topped $280 million. Hospitals could lose up to 1 percent of their Medicare payments for fiscal year 2013, up to 2 percent for 2014 and up to 3 percent for 2015.
The government says its efforts to address the problem are paying off already: The country's hospitals had about 70,000 fewer readmissions in 2012, and the national readmission rate is estimated to have dropped to 17.8 percent in October after averaging 19 percent for the previous five years.
Local hospital officials say they have been working hard to reduce the number of readmissions and say their numbers are improving.
Earlier this week, Maria Hackenberg, a home health nurse for Methodist Hospital, visited Dan Simpson in his home in Valley to make sure his blood was clotting properly after hip-replacement surgery.
Such patients are prescribed blood thinners after surgery to make sure they don't develop clots that could send them back to the hospital or even threaten their lives.
Simpson's blood was fine. The 50-year-old crane operator for Valmont reported that he also was following the directions he had been given at the hospital: "You can't cross your legs, you have to keep them apart and you can't bend past 90 (degrees)."
It will take awhile for hospitals' improvements to show up in the U.S. government database. The recent penalties were assessed for the qualifying readmissions that occurred between the beginning of July 2008 and the end of June 2011.
The government is penalizing hospitals with high rates of readmitting three groups of patients: those with heart failure, heart attacks and pneumonia. (That list is scheduled to expand in fiscal year 2015 to include patients admitted for treatment of a sudden worsening of chronic obstructive pulmonary disease symptoms and those admitted for elective total hip or total knee surgeries.)
In metro Omaha and Lincoln, the first round of penalties ranged from .01 percent of a hospital's Medicare payments to 1 percent, which translated to losses of more than $1,600 to around $350,000, depending on the hospital.
Three years ago, Methodist Health System convened a readmission task force to look at the care provided in the hospital, through home health providers and in the Methodist Physicians Clinics. Today, care coordinators make sure patients have doctor's appointments scheduled within three to five days of dismissal, said Ruth Freed, Methodist Health System's director of clinical alignment.
Nurses also call congestive heart failure patients and pneumonia patients within 24 hours of dismissal to see if they are taking their medications and to find out how things are going at home. In addition, they make sure the patients know which symptoms, such as weight gain for heart failure patients, are serious enough to require a call to their doctor.
Advanced practice nurses also accompany home health nurses on visits to the homes of some of the very ill, Freed said. They look for safety concerns, review the person's medications to make sure none would conflict with newly prescribed drugs and, if the person is a heart patient, check to see if there are lots of foods containing salt in the house.
Dr. Anton Piskac, vice president for performance improvement for Methodist Health System, said Methodist Hospital and Methodist Women's Hospital had 570 admissions for pneumonia in the years covered in the Medicare report. Within 30 days of their dismissal, 128 of those patients returned to one of the hospitals. If 17 fewer patients had returned during the 30-day window, Piskac said, the hospitals could have avoided the nearly $270,000 reduction in its Medicare reimbursement.
"It's not a small amount," Piskac said. "Believe me, we notice that."
Some of the responsibility for avoiding readmissions lies with patients or their families, said Mende, with the Robert Wood Johnson Foundation.
"When you are going to be discharged, have a written discharge plan," Mende said. "Ask questions, and ask those questions again and again. Make sure you understand."
The printed discharge report, she said, should list the person's medications, the reason the person was admitted, the type of surgery he or she had, any scheduled follow-up appointments and other details.
"We only can really control so much," said Angela Ward, quality and ancillary services executive for Alegent Creighton Health. "What the patients choose to do when they leave is hard for us to control."
Yet the hospitals try anyway, both to avoid penalties and improve the quality of care. Care managers and social workers on the nursing units in Alegent Creighton hospitals work with patients before they leave, and a pharmacist meets with patients to go over their medications. After the patients go home, one of 32 care coordinators from Alegent Creighton clinics checks up on them.
Ward said readmission rates in the system's hospitals have been "trending down very nicely over the last several years."
Some of the readmission-reduction programs get federal help in the form of grants, but others don't. Methodist's Piskac said it's hard to determine how much the programs are costing, as they supplement efforts that already were in place. Whatever the cost, he said, it's the right thing to do.
It's not as if the government effort was the first to target readmissions. Hackenberg, the Methodist home health nurse, said she has visited joint-replacement patients in their homes for years.
The patients at highest risk for readmissions are those with chronic medical conditions, especially if the person is on multiple medications or has no safety net or family support at home, said Dr. Stephen Smith, the Nebraska Medical Center's chief medical officer. As part of a program the med center has with the Visiting Nurse Association, a health coach visits people after they are discharged to make sure they stay healthy.
Sydney Smith, a certified nursing assistant who works as a VNA coach, met this week with Dan Ostergard at his central Omaha home to review his medications. Ostergard, 56, was diagnosed with Type 2 diabetes after being admitted to the med center in early May with pneumonia.
Smith had Ostergard write in a small book the name of each medication, the dosage, the reason for taking it and whether it was new to him or not. He then could take the book to his doctor's appointments.
Ostergard knew what each drug did and why he was taking it. His job is to help organize estate and moving sales, so he's good with details.
Smith asked Ostergard to set a personal goal, medical-related or not. He said he hoped to adhere to a more healthy lifestyle and reduce stress. "I've been notorious for burning the candle at both ends for quite a number of years," he said, "and see where it's gotten me."
In Lincoln, representatives from hospitals, skilled-care centers and home health providers meet quarterly to talk about how they can improve care providers' handoffs of patients, said Pat Hoidal, director of performance improvement at St. Elizabeth Regional Medical Center. Under federal rules, she said, "We will have to function as one long continuum. We will have to build strong relationships with each other.
"We tolerated the readmissions in the past. Clearly it's not the right way to be delivering services."

Home care offers the gift of freedom

Published by Cape Gazette
Rachel Swick Mavity
May 22, 2013

Caring for others is Robert Wampeh's passion.

The Liberia native moved to the United States in 1998 and, after receiving his nursing assistant degree, he found work as a caregiver.

Wampeh was moved to tears May 16 when he received recognition during Older Americans Month for his service to Lewes resident Greg Quinn.

"I love what I do, and I really appreciate Mr. Quinn for all he has given me," Wampeh said.

"He's given me the gift of travel," says Quinn of Wampeh, who works for Griswold Home Care.

The pair went to Hawaii at the end of January and spent two weeks. Quinn had visited the island state 20 years ago and was anxious to return.

"It was my first time, and it was a great experience," Wampeh said. He sent pictures to the Griswold staff to share the experience with them.

"We've had other caregivers go on trips with clients, but never to Hawaii," said Cheryl Jankowski, regional director for Griswold in Lewes.

Quinn, 65, said he plans to travel to Australia with Wampeh next year. This year, he hopes to make it to Panama City, Panama, or Munich.

Quinn has always loved to travel, but the retired priest from Maryland had a stroke that left him unsure on his feet. He later fell and broke his hip. After six months of rehabilitation, Quinn fell again and broke the same hip. He is now wheelchair bound and relies on Griswold Home Care for help 24 hours a day.

After spending summers in Lewes, Quinn moved to Lewes about five years ago, where his well-maintained home sits just down from the Lewes Public Library. Quinn enjoys sitting in his study as the sunlight streams through French doors overlooking a small patio.

Quinn has been a client for more than three years. Wampeh has been his caregiver since the first day; the pair has developed a special bond.

"Robert is great. He gets me out, takes me shopping, and we enjoy sightseeing," Quinn said.

"They have a very special relationship. Because of this caregiver, the client was able to travel, with the caregiver, to Hawaii for a dream vacation," Jankowski said during the certificate presentation.

Serving older Americans

Thirty years ago, Jean Griswold, the wife of a Presbyterian minister in Erdenheim, Pa., a suburb of Philadelphia, started an overnight sitting service for the elderly. "At the time there wasn't any home healthcare," Jankowski said.

An older woman at Griswold's church was afraid to get up at night to go to the bathroom, so another lady from the church stayed with her at night. Then the helper fell and had to be hospitalized.

During the helper's absence, the older woman stopped drinking because she didn't want to have to go to the bathroom. She developed a kidney problem and died.

Griswold was devastated, Jankowski said. That's when she started the overnight sitting service, which formed the roots of Griswold Home Care, which has now served 100,000 clients in 17 states, and more than 5,000 clients in Delaware.