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Elder Care

Low Medicaid Rates Limit Beneficiaries’ Access to Assisted Living Facilities, Quality Care

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More than 700,000 elderly and disabled Americans receive health care in residential care communities, such as assisted living facilities. As the population ages, this number will grow.

A new study by RTI International found that low Medicaid payment rates for services in assisted living and similar settings discourage residential care providers from serving Medicaid beneficiaries, which limits their access to community-based residential care.

The study found that some residential care settings limit the number of Medicaid residents they serve or decrease operating expenses in ways that may also reduce quality of care.

“Medicaid payment rates only cover services in residential care settings; they do not cover room and board,” said Michael Lepore, Ph.D., senior health policy and health services researcher at RTI and lead author of the study. “One of the access barriers is the difficulty that Medicaid beneficiaries have paying for room and board in residential care settings because of their low incomes. This situation dissuades residential care providers from serving Medicaid beneficiaries.”

Residential care settings are community-based homes or facilities that offer room, board and care services, the most popular being assisted living. Compared to nursing homes, these settings often are less institutional and are often the preferred setting.

If Medicaid beneficiaries with long-term service and support needs cannot access residential care settings, then nursing homes may be their only option, ultimately costing taxpayers more money because Medicaid payment rates for nursing homes are higher.

The study, published in the Journal of Housing for the Elderly, found barriers that influence Medicaid beneficiaries’ access to state-licensed residential care include Medicaid reimbursement rates for services, the supply of Medicaid-certified residential care settings and beds, and policies that affect room and board costs for Medicaid beneficiaries.

Researchers examined Medicaid policies in all 50 states and the District of Columbia, interviewed subject-matter experts, and conducted four state case studies informed by reviews of state policies and stakeholder interviews.

“States need to ensure their Medicaid rates for residential care services are sufficient to maintain an adequate supply of these settings and beds available to Medicaid beneficiaries, while also safeguarding quality of care and taxpayer resources,” Lepore said. “Higher Medicaid rates may encourage more residential care settings to serve Medicaid beneficiaries, which may help reduce nursing home use by older adults and people with disabilities and potentially reduce Medicaid spending on long-term services and supports.”

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Elder Care

Stressed Out Caregivers Are Using ER Visits for Respite, Study Finds

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Emergency room staff call it a “pop drop” – when a disabled older person comes in for medical attention, but it seems like the person who takes care of them at home is also seeking a break from the demands of caregiving.

It’s been hard to actually study the phenomenon. A new University of Michigan study suggests that tired family caregivers are associated with greater ER visits and higher overall health care costs for the person they care for.

In a paper in the new issue of the Journal of the American Geriatrics Society, the team reports their findings from a study of 3,101 couples over the age of 65, each with one spouse acting as caregiver for their disabled partner.

The researchers looked at the Medicare payments and emergency department visits for the disabled spouses in the six months after the caregiver spouses took standard tests to measure their fatigue, mood, sleep habits, health and happiness.

Even after they took into account many factors, the researchers found that in just those six months, emergency department visits were 23 percent higher among patients whose caregivers had scored high for fatigue or low on their own health status.

Patients with fatigued or sad caregivers also had higher Medicare costs in that same time period: $1,900 more if the caregiver scored high for fatigue, and $1,300 more if the caregiver scored high for sadness, even after all other factors were taken into account.

The cost of unpaid help

“Many of us who work in clinical settings feel that patients with high home caregiving needs, such as dementia, often rely on the medical system as a source of respite for their spouses or other caregivers, because other respite isn’t paid for,” says lead author Claire Ankuda, M.D., M.P.H. “But there hasn’t been a lot of data about it, and only recently has our society been talking about caregivers and potential ways to incentivize and support them as a way of keeping patients living at home.”

Ankuda, who led the study during her time at in the Robert Wood Johnson Clinical Scholars program at U-M’s Institute for Healthcare Policy and Innovation, is now training in palliative care at the Icahn School of Medicine at Mount Sinai.

“Informal caregivers, including spouses, enable older adults with functional disability to stay out of the nursing home and live at home where they’d prefer to be,” says senior author Deborah Levine, M.D., M.P.H., an assistant professor of internal medicine and neurology at U-M.

We need to do a better job of identifying and supporting caregivers experiencing distress, in order to help caregivers feel better and hopefully improve outcomes in older adults with disability.” Deborah Levine, M.D., M.P.H.

Long-term data gives key insights

The couples in the study were all taking part in the long-term Health and Retirement Study, conducted by the U-M Institute for Social Research on behalf of the National Institutes of Health. Ankuda, Levine and their colleagues probed HRS data because it allowed them to correct for factors that other, short-term studies can’t – such as the baseline level of Medicare costs, demographic differences including income and education, and even whether the couples have adult children living nearby.

The findings add hard new data about the link between caregivers’ own experiences and the amount the Medicare system pays to take care of those the caregivers take care of at home.

Nearly 15 million older adults get help with everyday activities from spouses and other family or friend caregivers. In the new study, the researchers included couples where one spouse got help from the other with activities such as bathing, dressing, walking, getting into or out of bed, shopping, cooking, and taking medications.

Helping with these tasks on a daily basis, without pay or respite, can take a toll on the caregiver’s own health, wellness and mental state – which can lead to burnout. Medicare does not offer payment or formal respite coverage for family or friends who take regular care of older adults – and only covers home care by certified agencies under certain circumstances.

More research & services needed

Ankuda notes that studies on the impact of supporting family caregivers more formally are just beginning to produce results.

Meanwhile, health policy researchers are beginning to suggest that it may make fiscal sense to incentivize home caregiving, to keep seniors from needing more expensive nursing home care.

“I definitely think there are specific services that could help caregivers, if we can identify those people who are highest risk and provide a basic level of support such as an around-the-clock geriatric care call line that could help caregivers feel less isolated and talk to a nurse about whether, for example, to go to the emergency department,” Ankuda says. “This is a high-cost, vulnerable population.”

Formal respite care, peer support groups and other options could also help stave off fatigue and sadness – and the hospital staff who notice “pop drop” practices could help steer caregivers to such options. So could the primary care clinicians who take care of both the disabled spouse and the caregiver.

Because the new study takes into account the level of Medicare spending for the disabled spouse in the six months before their caregiver was interviewed, it may actually underestimate the impact of caregiver fatigue, she notes.

Indeed, before the authors corrected for the full range of factors, they documented that Medicare costs were lower for patients whose spouse-caregivers who reported being happy or rested. They also saw higher costs among patients whose caregivers had higher depression scores on a standard mood questionnaire.

One factor that wasn’t associated with higher costs in the new study was the caregiver’s score on a standard measure of sleep habits. Sleep disruption is harder to quantify in older people, Ankuda notes. But the measurement of fatigue, which can result from both the strain of caregiving and poor sleep, was clearly associated with both higher rates of emergency department visits and higher overall costs.

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Aging

Elder Abuse in the Twenty-First Century

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baby-boomers

In this “silver tsunami” era, elder populations are outnumbering the younger workforce. This creates significant inequity and more than enough opportunity for people to take advantage. Whether financially, neglectfully, emotionally, physically or sexually, seniors in the United States are at a high risk for exploitation.

Seniors can be abused by underpaid and overworked employees. Nursing shortages, along with an explosion of senior populations, lead to less competent care resulting in bedsores, malnutrition, falls, sepsis or other damages from neglect. In addition, economic woes lead to a rise in physical and financial abuse perpetrated by family members, caretakers and even outsiders. Older people are more susceptible in giving of information without asking questions, which makes financial abuse a low-risk, high-reward crime area. Having adequate representation can be a problem as well.

Social Security and other government assistance is typically managed by a person with power of attorney, but occasionally the government will designate someone to perform economic functions. The potential for abuse necessitates records to be very exact and reported regularly. Social security, wills, estate management, retirement portfolios and such accounts are difficult for most clear thinking people. It has been reported that any older person, much less those with dementia, make bad financial decisions.

Trends

Knowledge of elder abuse is not up with the times, decades behind the experts in the field. It’s difficult to even get a report filed. The myriad of potential problems is worsened due to many inappropriate state laws being slow in prosecuting offenses. Institutional Review Boards don’t commonly deal with such cases and there are not many federal regulations. Meanwhile, seniors don’t always have a great memory for testimony to help their cause in getting charges.

It is going to be hard for the courts to catch up with the times. Currently, elder abuse is acknowledged by WHO as a human rights violation with one in ten seniors falling prey to some crime. That ratio becomes one in two concerning people with dementia. As bad as the current populations trends look now, the future looks worse. 85+ is the fastest growing age group in the United States and the 60+ population is expected to double to over 2 billion people by the year 2050.

What to do?

Local district attorneys need tougher laws that focus on stopping predators and ways to enforce those laws. Whether with state or private agencies, seniors need more representation in housing placements or other living transitions and their monetary affairs.

Elders need younger people to show interest. Nursing home staff is going to be more careful with people they know are being checked on. Other relatives that are taking care of a loved one, should be helped out too. Stopping by or ask about older family members shows that someone is cared for, reducing the abuse risk. Importantly, it also breaks the cycle of care and provides everyday caretakers with the knowledge that they could get a break if needed.

The marks of abuse need to be more commonly known and easy to identify. Upwards of 500,000 seniors are victimized, but very few of these cases are ever identified, much less reported and charged. It helps to have advocates who can sense physical harm, negligence, medical malpractice and other atrocities. Physical and sexual abuse are easier to spot than most neglect, so it takes a concerned loved one to spot personality changes or injuries that are inconsistent with the individual.

Mistreatment is more likely to occur to seniors who have experienced past abuse, in part because those people are frequently left in bad situations and never given much help. Senior women are more victimized than men, as are people in poorer health and those with lower incomes. Many other obvious risk factors and tell tale signs exist to make others aware. We need to be more empathetic and better educated.

The onus is on the concerned relatives to care about what facility seniors are placed in. For-profit corporate chain nursing homes often have less than ideal conditions for staff or residents. Relatives should take the time to tour various homes, make observations, and find the right fit. The most important way to combat elder abuse is by being involved. We just can’t put elders into homes and forget about them. It’s not supposed to be a prison for people we can’t help anymore. Nursing homes are expensive places that should be treating residents like royalty. It takes our effort to keep things as they should be.

To facilitate better treatment, we need to listen to both seniors and caregivers. We need to be attuned to what seniors needs and worries are. We need to speak up and file charges when something has happened. One in ten reported cannot be acceptable. If a caregiver is stressed or burned out, we need to make sure they can get the breaks they deserve to provide the best care, just as we must make sure caregivers are getting paid adequately for the grueling work they put in.

As with raising a child, it takes a village to care for our elders. We need to impress upon society in general that it is everyone’s responsibility and how this needs to happen. We are all going to be in this position someday, we should be doing everything we would want others to do for us as we become more helpless.  

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Elder Care

Are We Forgetting About The Sandwich Generation?

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By Ed Kashi and Julie Winokaur

By Ed Kashi and Julie Winokaur

When working with elderly patients in health care facilities, it is likely that we may forget about the needs of their adult children aka The Sandwich Generation. The sandwich generation is adult children typically between the ages of 30-50 who are caring for their aging parents while taking care of their own family as well.

Taking care of young children while caring for aging parents puts a great deal of stress for the adult children. In my experience in working with families in hospice, I’ve noticed some factors that contribute the stresses of this generation:

  1. Financial Concerns – Older Americans are living off on their fixed income such as Social Security, VA pension, personal savings which may not be enough to pay for certain expenses. Many retirees can not afford to live in assisted living facilities, private home attendants, monthly expenses in their current home. The children often struggle as they have to figure out how to pay for these expenses if their income is limited as well. This issue is very common for funeral expenses since many retirees don’t have life insurance.
  2. Feuding Relatives – Adult children may have a long history of sibling rivalry which can leave an impact on the care of their elderly parents. One child may agree to hospice care while the other believes in aggressive treatment. The rivalry can easily be carried into a facility where we, the social workers usually witness the drama.
  3. Lack of Awareness – You will be surprised how may adult children are not aware of health care proxy, advance directives, or how life insurance works. Some assume that their parents insurance will cover everything. Many times I had to inform the children that Medicare does not cover long term cost which brings back to #1 on this list.
  4. Bad Timing– Sometimes adult children may wait till the last minute to make handle their parents affairs. Reasons for this occurrence may be that they learn about the resources too late, procrastination, denial or lax in their own time management. I had adult children asking me how they can get a power of attorney for their parent, and the patient is unresponsive, near death.
  5. Mom and Dad Are Not The Same –  We know our parents from the time we were born. We are not use to seeing our parents getting older and sicker. Many adult children may not be prepared to watch their parents deal with debilitating condition such as Alzheimer’s Disease. On the other hand adult children may have their own personal issues about their parents that was unresolved. These changes can bring emotional distress to the children.

When working in hospitals, assisted living facilities, home care agencies, or adult day programs its very common to see these issues surface with this generation. However, social workers who work in private practice or other settings might encounter someone who experience this as well. Unfortunately, we are unable to prevent adults from getting older and prevent the sandwich generation to face this situation.  We can however, take some steps to reduce the burden and educate this generation at our place of employment. Here are a few things to consider:

  1. Assess All Legal Health Forms –  Many hospital staff are required to ask patients and families about advance directives, and health care proxy. Families should be educated the advantages of having these forms in place. This can make the health care decisions easier for the adult child.
  2. Discuss Available Services –  Be aware of the services in your community which will allow you to share it with your clients. Services include, Medicaid, home care services, senior subsidize housing, elder law attorneys are some of the examples of resources for the elderly. It’s very important to be aware of the referral process of these services. For example, filing for food stamps in NYC is entirely different than filing it on Long Island. If we are knowledge about the services, than the family is well informed of their options.
  3. Review their coping techniques – Care giving is physically and emotionally stressful. It’s very important that we assess how the adult children are coping. Do they have a counselor who they can speak to? Do they receive support through their place of worship? Are they attending care giving support groups? What are their personal issues about their parents that they are struggling with? These questions are some of the examples we can ask when assessing their situation.

How social workers intervene depends on the needs of the adult children. In one situation, the child may have all the concrete needs in place but still requires emotional support. On the other hand, there will be another case where the social worker may have to review health care proxy, discuss Medicaid service, and mediate the feuding siblings.

At the end of the day, you could never give too much emotional support to the sandwich generation.

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