Senior Citizens, the Debt Ceiling, and the National Budget.

As our elected officials continue to struggle with the government shut down, a bigger demon is lurking behind them, and behind us.  While essential services continue during the government shut down (though some delays may occur in benefits as time increases), a failure to have funds to pay the nations bills could have a more profound effect on these essential services.

Technically speaking a default will occur when the government can not, or does not, make regular payments to bond holders for borrowed money.  But even if these payments are made there can be catastrophic consequences in terms of benefit payments, availability of services, and both the national and world economies.  It appears there will be enough money to make interest payments to bondholders for November but there will not be enough money to pay those bills and to make payments for social programs, like Social Security and Medicare, and to pay soldiers, civilian staff, and other liabilities. 

What order will other bills be paid?  Unfortunately it is not a simple question and is indeed new territory for our nation.  The decision will not be as clearly defined as it is for the shut down.  Strategies have been introduced to suggest a method to prioritize payments but each has problems and none has been widely accepted as feasible.  During the shut down, funds are available in the budget for all programs.  If a debt ceiling solution is not reached then money simply will not be available and the government will not be authorized to borrow more.  The government, in effect, will be living pay check to pay check incurring more bills than it is able to pay.

The Treasury Secretary is scheduled to address the debt ceiling and the prioritization of bills when he testifies in front of the Senate on Thursday, which has been dubbed by some press organizations as "prioritization day".

The Treasury Department maintains that even if some prioritization agreement could be reached it is not technically feasible to implement.  Government computer systems are programmed to automatically make payments as they come due.  With millions of checks issued each day and with aging technology, choosing which bills to pay and which to hold just isn't possible.  If there is not enough money to pay the bills, all checks would continue to be printed and mailed but some will bounce.  It might be a Social Security check, a pay check, or an interest payment.  There is one way the Treasury could have some control over what is paid. The Bureau of the Public Debt could make payments to bond holders while the automated system for paying bills is simply turned off, however, this does not address how any other payments will be made.

There are legal issues as well.  There is no legal order for the payments to be made.  It is unclear if the Treasury has the legal ability to make those decisions.  Does Congress need to approve each payment?  Can the President decide without input Congress or the Treasury?  There are just no clear answers.

The most likely scenario is that the Treasury will turn off the automated payment system and will pay bills as they accumulate enough cash to make all of a given days payments.  For example, the payments due to be paid on November 1, 2013 (including Social Security) will be paid when the Treasury has enough cash to cover all of the payments due on November 1.  That might be on November 2, or 4, or 10, or 30.  The automated system will make payments as they come due, as it is designed, and will be switched off again until enough cash is available to make the payments due the next day.  This solution allows the Treasury system to function without significant adjustments and also removes the responsibility of deciding what to pay for.  No services will be cut but payments for all programs will be delayed.

It is important to remember that borrowed money accounts for about one third of the money spent each month.  Money will continue in to the government every month even if a debt ceiling agreement is not reached, but those funds will not be sufficient to pay everything.  While there may be a delay in payments for a few days for November 1, 2013, payments due November 30, 2013 may be delayed by a week, a month, or more.

While I can not provide specific answers regarding social programs and the debt ceiling, I can caution you to be aware of the possibilities and to have a back up plan in place. 

Government Shut Down and the Elderly

No matter which side of the aisle you're on or who you want to blame for the government shut down, we find ourselves dealing with the consequences.  "Essential" services will continue while "non-essential" services will be suspended.  What does that mean for us and our loved ones? I have identified many government programs that our seniors depend on and noted the status of each during the shut down.

These programs will continue to be operational during the government shut down:

• US Mail - Should continue without any interruptions
• Food safety inspections - Should continue without any interruptions
• Social Security Checks - Should continue without any interruptions
• Food Stamps - Should continue without interruptions
• CDC - Will continue to operate though there will be significant limitations, see below
• Medicare - Will continue to operate with some limitations, see below
• VA - Will continue to operate with limitations, see below
• Medicaid - Should continue without interruptions

These programs will not operate or will operate with limited services during the shut down:

• Social Security Applications - New applications for benefits may not be processed
• Social Security Appeals - Will not be processed
• Social Security Replacement Card Requests - Will not be processed
• Social Security Benefit Verification Statement Requests - Will not be processed
• Social Security Earnings Record Requests - Will not be processed
• Social Security Appeals for Denial of Benefits - Will not be processed
• Medicare Applications - New applications for benefits may not be processed
• Medicare Appeals for Denial of Benefits - Will not be processed
• VA Appeals for Denial of Benefits - Will not be processed
• CDC Ability to Investigate - CDC will have extremely limited resources to investigate reports of outbreaks and other serious health concerns
• CDC Assistance to State and Local Governments - Will be unavailable
• CDC Annual Influenza Program - (Tracks the flu and helps people get shots) Will be closed

If you or a loved one depends on these or other programs that depend on federal funding, begin making contingency plans now.  The shut down may last hours or it may last weeks, but when these offices resume "normal" operations it will take time for them to catch up with work that accumulated during the shut down.

If you or a loved one experiences significant difficulties because of an unavailable service a qualified Elder Care Consultant or Geriatric Care Manager may be able to help you make suitable arrangements until services resume.

Flu Shots for Care Givers: Necessary?

The short answer is yes.  I see the eyes rolling. I see your mouth forming the words "...and I always get sick after I get the shot!" I hear "I've never had one before, I'm not starting now!" and "I'm healthy and never get the flu, I don't need one." and (in your best martyr voice) "It's more important for at risk people to get the shot first so I'll wait!."  If you can personally identify with any of these, let me explain why you need to change your position on the flu shot. Let's start with some facts.

• Every year the strain(s) of flu viruses change.  The shot you had last year (or 5 years ago) most likely will not be effective this year.
• More than 50% of hospitalizations for flu are people aged 65 or older.
• 90% of flu related deaths are people aged 65 and older.
• The flu is contagious about 24 hours before there are symptoms.
• The flu shot does not contain any live or active virus of any kind. Though you may have had an illness after getting a flu shot it is not possible to get ill from the shot, short of having an allergic reaction, which can happen in a small percentage of people.

"But" I hear you say "I'm not that old!"  

In Pennsylvania, and I'm sure across most of the nation, emphasis is not only to vaccinate those we serve but to vaccinated ourselves. Experience has taught us that if we keep the flu out of our homes and out of our facilities, we can greatly reduce the incidence of the flu in those we serve.  In my own facilities and in two other facilities I have run, when we get more than 90% of the caregivers vaccinated we have gone some years without even one flu related hospitalization. Increasingly, health care facilities are taking a strong stand on the flu shot, requiring caregivers to either get the shot or to wear a mask while working, recognizing that reducing the risk of transmission is the most effective tool to protect our seniors.

Many of those we serve rarely get out into the community.  So where do they get the flu? From us. Remember that you are contagious before you begin to get symptoms. Remember that just because your immune system is able to effectively fight off the virus, you are still very capable of spreading it to others you interact with.

Managers - you need to set the example for your staff.  If you don't take the issue seriously your staff won't either.

Care givers - Family and friends providing care in someone's home, home health workers, nurses aides, nurses, therapists, environmental service staff, dietary staff, activities staff, and any other worker who has regular contact with our seniors - you have daily contact with those you care for and pose the greatest risk of spreading the flu. Your residents are counting on you to help them stay healthy.

Employers - Looking for a way to reduce resident/patient hospitalizations? Need to get employee sick time under better control? Find your agency staff usage skyrocketing during the flu season? Provide the flu shot to you staff free of charge, it is inexpensive insurance against increased resident care costs and staffing costs.

Having opened your mind and having carefully considered the information above I'm sure you now agree that getting the flu shot this year is a great way to keep your residents/patients healthier this flu season. 

Laughter

Laughter is in fact good medicine.  It is also a good coping mechanism to help you get through a stressful situation.  Other times we need a distraction for a few moments to clear our minds.  In light of these I bring you the following which might fit both bills.

• Why is it a package transported by ship is cargo while a package transported by car is a shipment?
• If con is the opposite of pro, is congress the opposite of progress?
• Why do we put garments is a suitcase and suits in a garment bag?
• Why do tug boats push?
• Why do we call the benches at the ball park stands when they are made for sitting?
• Why do we call them apartments when they are stuck together?
• Why is phonics not spelled the way is sounds?
• Why is abbreviation such a long word?
• Who was the cruel person who put an "S" in the word lisp?
• Why does the word "monosyllabic" have 5 syllables?
• How can there be interstate highways in Hawaii?
• We know the speed of light is 299,792,458 meters per second.  What is the speed of dark?
• If it is 0 degrees outside today and it is supposed to be twice as cold tomorrow, how cold will it be?
• Why are there Braille dots on drive up ATM's?
• Why does your nose run and your feet smell?
• Why do we call it a building if it is already built?
• If corn oil comes from corn, olive oil comes from olives, and vegetable oil comes from vegetables, what is baby oil made from?
• If crime fighters fight crime and fire fighters fight fires, what do freedom fighters fight?
• Is there another word for thesaurus?  
• Is there another word for synonym?
• How can there be self help groups?
• If you ask the librarian where to find the self help books should she tell you or would that defeat the purpose?
• If a turtle loses its shell, is it naked or homeless?
• If you try to fail and succeed, which have you done?
• What should you do if you see an endangered animal eating an endangered plant?
• At the movie theater, which arm rest is yours?
• How far east must you travel before you are traveling west?
• Why is it that everyone driving faster than you is an idiot and everyone driving slower than you is a moron?
• What is the difference between regular ketchup and fancy ketchup?
• When does it stop being party cloudy and becoming partly sunny?
• How can an item be new and improved.  If it is new, what was it improving on?
• Ever notice that lemon scented cleaners have real lemon but lemon flavored drinks have artificial flavors?
• Why does someone believe you when you say there a 4 billion stars in the sky but have to check when you tell them the paint is wet?
• Why do we have to click the start button to turn off the computer?
• Why are boxing rings square?
• Why does one recite at a play but play at a recital? 
• If superman can dodge a speeding bullet, why does he need to duck when someone swings a chair at him?
• Why do people who know the least know it the loudest?
• Where do homeless people have 90% of their accidents?
• If white wine goes with fish, do white grapes go with sushi?
• How is it that we put men on the moon before we figured wheels on luggage is a good idea?
• Is atheism a non-prophet organization?
• What if there were no hypothetical situations?
• Is it possible to have a civil war?
• Light travels faster than sound.  Is that why some people appear intelligent until you hear them speak?
• We were taught that the universe includes everything.  Scientists are claiming the universe is expanding.  What is it expanding into.
• I before E except after C...except the word science...
• Why is it called re-search when we are looking for something new?
• Why do we wait until a pig is dead before we cure it?
• If quitters never win, and winners never quit, who was the fool who said quit while you're ahead?
• What ever happened to preparations A through G?
• Who is General Failure and why is he trying to read my hard disk?
• What if the Hokey Pokey IS what it's all about?
• Why are wrong number never busy?

Have a great weekend!

Medicare and Obamacare

Will Obamacare have an effect on Medicare?  There is considerable confusion over the topic not only among those eligible for the benefit but also among social workers and other professionals.  Here I will address the most significant issues.

• Enrollment for Obamacare (Affordable Care Act/ACA) begins October 1, 2013 and runs through March 2014.  Open enrollment for Medicare begins October 15, 2013 and ends December 7, 2013.  Do I need to sign up for coverage under ACA?  Medicare beneficiaries do not need to enroll in coverage under the ACA.  In fact, if they are satisfied with their current coverage they need do nothing for that coverage to continue.  
• Will Medicare be ending?  Medicare is not ending and there are no current plans for Medicare to end.
• Will I have to pay the "penalty" if I don;t sign up for coverage?  Medicare is health insurance and meets the requirements for health coverage under the ACA.  There will be no penalty for Medicare beneficiaries.
• Do I need to get Medi Gap or Part D coverage through ACA enrollment?  State  health care exchanges will not be offering Medi Gap or Medicare D coverage.  Those who call looking for that type of coverage will be referred back to Medicare.
• Will my medications cost more under the ACA?  Maybe.  If you are single and make more than $85,000.00 per year or married and together make more than &170,000.00 you might be paying more for Part D coverage.  Any other increases will be program increases not directly associated with the ACA.
• Will I be able to continue seeing the doctors I choose?  Yes.  There are no new limitations to Medicare coverage.
• Will my Medicare premium increase?  Most likely, but this increase is the typical annual increase in Medicare and is not associated with the ACA.

Medicare is reportedly working on a booklet for Medicare beneficiaries to answer these and other questions.  Plans are to have them out to consumers sometime next month.  

If you are not happy with your current Medicare coverage, or if you want to make changes to your coverage, make sure to take advantage of the open enrollment period as you normally would.

Confusion and misunderstandings of this scope provide a very attractive opportunity for health coverage scams.  Be cautious of phone calls, mail, door-to-door sales, and electronic contact.  Though all of these may be employed by legitimate companies marketing their coverage, there is no need for a person on Medicare to take any action as the ACA is implemented.

Caregiver Neglect

What is neglect?  Neglect is the failure to provide necessary services to a care dependent person and can take many forms.  Not providing proper nutrition, failing to give medications, not assisting with daily hygiene, or failing to provide any other needed service.  Neglect is also a form of abuse.  Who can be a victim of neglect?  Any person who is dependent on another person for any care.  Who can perpetrate neglect?  Any caregiver from a family member, to an in home caregiver, to the caregiver in a facility.  We all want to believe that we have made the best choices to get the best care for our loved ones.  Fact is neglect happens.  Even if you implicitly trust the caregivers it is important that you remain vigilant and watch for signs of neglect.  So, what should you look for?  Neglect can cover a lot of ground depending on what services should be provided but there are some general signs to look for, and there are common areas of neglect.  

Let me begin by saying you need to listen to your loved one and you need to watch their behavior.  If they report being uncomfortable with a caregiver, if they say they have not received certain care, if they shy away from touch, or if you see a negative change in behavior, you need to investigate.  Yes, even for the person with dementia, especially if they are uncomfortable around certain people or there are behavior changes.  Dementia does change the way they see the world and their surroundings but the body retains it's ability to sense and react to danger well into the progression of the disease.  Caregivers often don't understand dementia and believe the person will not know the difference.  But they do know, and we have to be open to receiving the signals they give us.  Over more than twenty years in the industry I have observed how the demented person interacts with caregivers.  Every time the resident had a negative reaction to a caregiver there has been a reason.  Not every reason was abuse or neglect, but in every case I could identify a reason.

Other signs to be alert to:

• Weight loss - if getting a weight is not practical, look for clothing that seems too big and changes in the face.
• Dehydration - Look for red, irritated eyes, dry mouth and lips, dry skin, decrease or absence of voiding, and constipation.
• Sores - Bed sores and pressure ulcers.  These always occur in areas that bear weight.  A person in bed not regularly re-positioned may get them on their heels, buttocks, back, and shoulders.  A person spending too much time sitting up without re-positioning may get them on hips, buttocks, and thighs.  They are usually painful and often times smell of infection.  If you suspect a sore but are uncomfortable looking in these areas ask a trusted spouse, family member, nurse or friend.  The sooner it is identified the quicker it can be healed.  It is worth noting here that ulcers developed or present at end of life may never be successfully healed.
• Dirty home, apartment, or room - If part of the services provided is to include cleaning, look to see if it is happening.  Be alert for offensive smells.  Proper attention to cleaning will eliminate persistent smells.  Look at floors, bath rooms, and the kitchen.  These areas are typically the first to show signs.
• Hygiene - In my experience hygiene is a commonly overlooked area with oral hygiene being the most commonly overlooked or skipped service.  Be alert for complaints of mouth or tooth pain.  Monitor hygiene supplies, are they being used?  Are there bodily odors of sweat, urine, or feces?  Is the same towel and wash cloth in the same place for days on end?  Have finger nails been trimmed and cleaned?  Is hair combed and clean?
• Clothing - Do you see your loved one in the same clothing day after day?  Are clothes soiled?  Can you identify the most recent meal by the stains?  Are socks soiled?  Your nose can be an effective tool here as well.
• Lack of medical aids - Are eye glasses on and clean?  Are hearing aids in place and working?  Are braces or special orthotics in place?  Is the walker, cane, or wheel chair within reach?
• Medications - Are there medications missing or do you find they need refilled before they should be?  Have you been notified that medications need refilled on a regular basis?
• Caregiver behavior - Does the caregiver answer questions you ask your loved one?  Does the caregiver get defensive when you ask question about the care they provide?  Is there always an excuse why something was not done, or why something happened?

This is by no means an all inclusive list but it should help to put you in the right mind set.  If a service should be provided do a little investigating to make sure it is.  Show up unannounced at unexpected times.  Is there a used towel and wash cloth when you show up at 8:00 am?  Are there dishes in the sink after meal time?  Is the care giver coming in late or leaving early?  

If your loved one requires care and you are not personally providing it for them, be their eyes and ears.  If there is significant distance between you, many reputable Elder Care Consultants offer monitoring services to help you know what is, and isn't, happening.

Can You Be Responsible for a Family Member's Nursing Home Cost?

We know that a power of attorney (POA) laws are well established and a person legally acting as POA is not personally financially responsible.  Most of us know that when a nursing home asks us to sign a guarantee of payment agreement, it is not required but rather a personal ethical choice.  So it is clear you can not be held responsible for Mom's nursing home bill, right?  Not so fast.  Pennsylvania and twenty-nine other states have a little known law on the books called the Indigent Support Law or Filial Support Law.  Language for the Pennsylvania law can be found at 23 Pa.C.S.A §4603.  

Let's look at the case of John Pittas.  John's mother went to Liberty Nursing Home to rehabilitate for six months after an auto accident.  While there she applied for Medicaid benefits to cover the costs, as she did not have the means to cover the costs.  As sometimes happens the application was pending at the time of discharge in March of 2008.  John's mother left for Greece shortly after discharge, the Medicaid application still pending and the bill outstanding.

Liberty Nursing Home sued Mr. Pittas for his mother's care:  $92,943.41.  Mr. Pittas did not sign a guarantee of payment nor did he agree to private pay for his mother.  How can he be liable?  The Indigent Support Law establishes that certain family members, including a spouse, child, or parent, have a responsibility to care for and maintain or financially assist an indigent person.  Pennsylvania courts have allowed nursing homes and other providers to sue children under this law for unpaid costs.  When appealed, the Pennsylvania Appeals Court upheld the ruling noting the Mr. Pittas' mother was indigent because she could not pay for her own care.  She was neither destitute nor helpless.  The inability to pay her bill was sufficient to declare her destitute for the purpose of this law.  The court further noted that a child (spouse, or parent) can be liable if they have the means to pay the bill.

The court also noted that Liberty Nursing Home was allowed to sue even though the Medicaid application was still pending and there had been no determination on the status of that funding.  Mr. Pittas questioned why he was sued but a spouse or other children were not.  The ruling also noted that a provider can determine the financial ability of each family to pay, and to decide which member(s) to go after.

While these laws have been on the books for a while, it is only recently that providers have been using them.  As funding and payments to nursing homes and other providers decline I expect to see an increase in these law suits.

Most families are shocked to learn they could be financially liable for the care of a family member.  Providers aren't telling us before services are rendered.  It isn't contained in the informational materials distributed by local, state, or federal agencies.  Social workers and admission coordinators don't seem to know.  Many "experts" are as surprised as families are.  

The bottom line?  Determine if you (or your loved ones) live in a state (including Pennsylvania) where an Indigent Support Law or Filial Support Law is on the books.  If you believe your parent or other family member may require expensive care that is not covered by insurance and they may be unable to pay for, find out now what you may be liable for and what to do about it.  While you may not be able to change the law you can use this information to better understand the issue and plan accordingly.  

It is also important to note here that applying for Medicaid, or any other, benefits can be a trying experience for the resident, the family, and the facility.  You will be asked to provide specific information including financial information.  The longer it takes to provide this information, the longer the process takes.  I have also noticed that a cooperative family typically fairs far better than a family that is difficult to work with.  Though there are strict guidelines they follow, there can be leeway for a reasonable, documented explanation.  

When a Hospital Stay is NOT a Hospital Stay.

There has been an increasing trend nation wide for hospitals to keep a patient for observation.  Often times the patient may not even be aware, but every time it can result in significant costs.  Observation, or outpatient observation services is loosely defined by Medicare and CMS.  The regulations do, however, state that observation should be for 24 hours, or 48 hours.  Recent cases have shown observation periods as long as 14 days!  Unless you are told there is no way to tell the difference: Same hospital bed; same IV; same medications; same doctors and nurses.  So why is it important?  There are a few reasons it is important for you to know the status of your stay.  Observation is classified as an outpatient service, therefor it is covered as an outpatient service.  All of your co-pays apply and you will likely get a bill for hospital services and medications.  It is even more important if you will require services in a Skilled Nursing Facility (SNF) upon discharge from the hospital.  In order for Medicare to cover the costs there must be a three day (three mid nights) inpatient hospital stay.  With out the 3 day stay, Medicare will not cover the costs of skilled nursing care. (Contracted Medicare Plans often do not have this requirement.  I'll cover that in a different post.) Lets assume you went to the hospital through the emergency room and you were "admitted".  During the stay it is recommended you go to a SNF for rehabilitation or nursing services.  During the conversation you are told you were never admitted but were there for observation.  You are financially responsible for the services the hospital provided that are not covered, including medications, and you will also be responsible for the cost of the SNF.  Even if your physician orders admission, the utilization review board has the power to change your status to observation.  Even worse, your status can be changed from inpatient to outpatient during you stay, retroactive to your "admission" date.  Though Medicare and CMS allow this change the language clearly states that this should be the rare exception, not common practice.  My experience shows it happens more than rarely.

So how do you know if you in the hospital under observation or if your status is changed to observation?  Hospitals are required to inform you if services are not medically necessary.  If treatment is not medically necessary Medicare will not pay for inpatient services but they will cover outpatient services: Observation.  This notice must be given to you in writing and it must include information for you to appeal.  Medicare and CMS assume you are not aware and the provider must be able to produce evidence you were notified.  If you were not notified in writing and there is no reasonable expectation that you would know about the observation status, you may not be legally required to pay for the services.

If you are given notice that your stay is, was, or will be for observation, appeal immediately.  Appeal information should be on the written notice and should include the name and telephone number to contact.  Ask that the case be reviewed to determine if qualifications for admission have been met.  If you were not notified in writing immediately file a request with the Medicare Administrative Contractor (MAC) and ask for a review to determine if the stay qualifies for inpatient status.  To determine which MAC covers your state click http://www.entnet.org/Practice/MAC-websites.cfm.  In Pennsylvania our MAC is https://www.novitas-solutions.com/transition/j12/lcd.html.  You may also be able to get information at 1-800-Medicare or www.mymedicare.gov.

If you have already found yourself in this situation it is still wise to contact the MAC in your area.  For medications, follow the instructions in you Part D coverage for payment to out of network providers.  Remember, this applies only to Medicare and not to other Medicare products, so if your Medicare coverage is through a commercial insurance company this information does not apply to you.

Helpful Gadgets for the Elderly

First a confession.  Ask anyone in my family and they will tell you I'm a "gadget guy".  Gadgets and elderly are two words that aren't often seen together, and I believe marketers are missing a lot of potential customers.  While many electronic devices are marketed at kids, teens, and young adults the fact is that many can fill very specific needs for the older adult.

We are all aware of the common place large button remote controls and cell phones (some of us might have actually received them as gifts!)  There are many other devices we see or use every day that can nicely meet a need for an elderly friend or relative living independently.  Below I have tried to identify categories, but you'll notice some items may fit into more than one.

1. Vision - As mentioned earlier, large button devices have been around for a while and all kidding aside, they do meet a need.  Larger buttons are easier to see and they are also easier to use for those with limitations in dexterity.  Talking devices are cropping up in many places too.  You can program your cell phone to read out the number or name of a personal calling you, and you can place a call by saying a name.  There are talking watches, blood sugar monitors, and blood pressure monitors.  Alarms on your pill box can remind you it's time to take your medication.  Electronic organizers can be programmed with alarms to remind you of, well, anything!  Love reading but find the type in books, magazines, and newspapers too small?  Consider a Kindle or similar devise.  Type size can be adjusted to meet your need.  Not only can you get books (you can find many for free) but you can change to an electronic subscription so the magazine or paper is automatically sent to your device.  Computer keyboards can also prove difficult to see for many people.  A keyboard with yellow keys and black letters may be easier to see, or maybe lighted keys solve the problem.  There are numerous accessibility options.  Computers also include accessibility adjustments from a high contrast theme to larger fonts and even text to voice and voice to text.  A quick internet search for a specific problem should produce several solutions.  MP3 players make an excellent device for audio books and of course CD (and sometimes cassette tape) audio books are available for purchase.
2. Transportation - Speaking of things that talk to you, have you spoken to your car lately?  Place a call, get directions, or summon help from your car.  Safety technology in cars is developing at a very rapid rate.  Sensors help you avoid hitting objects while backing up and brakes can automatically be applied if you get too close to the vehicle in front of you.  Sensors in your side mirrors can alert you if someone is in your blind spot and additional sensors on the back can alert you if a car or pedestrian is approaching from the side as you back up.  Yet other sensors will alert you if you are veering from your lane.
3. Monitoring Services - Many of us are familiar with Mrs. Fletcher who's fallen and can't get up.  The options for monitoring have come a long way since then.  There are paid monitoring services that can do anything from monitor the pendant worn around the neck to a complete system to monitor security, fire, and push button devices.  Some also include motion detectors that will alert the monitoring service if there has been no activity in the home for a period of time, if an hour has passed and the person has not come out of the bathroom, and even pressure sensors in the floor to monitor for falls.  Pill reminder alarm hasn't been effective?  Sign up for a service that will place a call (often times an automated call) for medication reminders.  You can also install and monitor your own system with a camera (or 6 or 10) that you can view over the internet any time.  Motion censors and other options are also available for these systems and they do not incur monthly monitoring charges.  Living in the same home and need low tech ways to keep track of Mom or Dad?  Wireless monitors and intercoms can be purchased almost anywhere.  Maybe you need to know when s/he gets up from a chair or out of bed.  Both pressure alarms and pull string alarms should be available at your local medical supply store.  These alarms emit a loud beep or buzz when activated letting you know as soon as the person is trying to get up.
4. Lighting - In my post yesterday about preventing falls I covered the importance of good lighting.  However, if the lights are never turned on they can't help.  Consider motion activated light switches.  When an area is dark the light will be turned on when motion is detected.  The light will remain on for a set period of time (usually up to 30 minutes).  Still in the hall when the light turns off?  Just wave a hand to reactivate.
5. Hearing - Many devices also exist for those with hearing impairments.  Someone missing phone calls or not answering the door because they don't hear it?  Grab a device that blinks a lamp or flashes a strobe when the phone rings or the door bell is pressed.  A phone amplifier can be added to both home and cellular phone.  Wireless headphones can allow a person to watch TV or to listen to music without bothering anyone else in the home.  Some hearing aid manufacturers make hearing aides that are compatible with wireless headphone systems so the sound is broadcast straight to the hearing aid.
6. Physical and mental fitness - The Nintendo Wii has many physical fitness programs available.  Some include progress tracking.  Walking and balance exercises are a few of the offerings.  Traditional games also offer fitness benefits.  Be aware, however, that if mobility issues exist this type of exercise should be done with your physician's consent and with supervision to avoid injury.  There are also many brain exercising titles from riddles to cross word puzzles to math.
7. Convenience - Some other items to consider.  Doors, especially entry doors, can pose difficulty for people using assistive mobility devices (wheel chairs, walkers, etc) or when carrying items into or out of the house.  Automatic door closers will close the door for you.  Your local or big box hardware store should have a few; some that look like their commercial cousins to spring loaded hinges that replace existing hinges.  An Automatic blood pressure monitor can make blood pressure checks easier; remember, though, they are often not as accurate.  Compare your reading with your doctor's when at the office.  A high or low reading with an automatic monitor should be rechecked in the other arm.  If the reading is still high or low don't panic, but get your blood pressure checked with a cuff and stethoscope.  A paper shredder can be an easy way to reduce the risk of identity theft.

This is by no means an exhaustive list but instead should serve as an illustration that a little creativity can go a long way toward addressing problems the elderly face in living independently.  Look beyond the obvious to better provide a safe environment for your loved one.

Preventing Falls in the Home

Falls are the leading cause of hospitalizations for the elderly in the US and can lead to life changing events including surgery to repair broken bones, rehabilitation in a nursing home, and loss of mobility.  Fortunately the risk of falls can be significantly reduced with observation and some no and low cost adjustments.  Below are some places to start.

1. Medications - Many medications include side effects like drowsiness or dizziness but the combination of several medications may also produce side effects of their own or increase the side effects of certain medications.  Ask your physician to review current medications and to look for combinations that may be of concern.  You can also check with your pharmacist; many times they are more attuned to looking for interactions between medications.  A gerontologist - a physician specializing in geriatric medicine - however, may be the best choice.  As we age our metabolism changes and medication doses may need to be adjusted to produce the desired effect.  It is not uncommon for an elderly patient to require far less of a medication than a younger adult, even if they have been on that medication for many years.  Periodically check medications to see if they are being taken properly; skipped or additional doses can complicate the issue.
2. Limitations - Be aware of any physical limitations that may exist.  Weakness from a stroke or injury, Parkinson's, or other medical condition.  If these conditions are present, talk with your physician, home health nurse, or Elder Care Consultant about what specific dangers are present.
3. Assistive Equipment - Wheel chair, walker, cane, braces, or special footwear can all limit mobility in the home.  Make sure all areas of the home are easily accessible using assistive equipment.  Does the wheel chair or walker fit into the bathroom and to the commode?  Are floor transitions smooth and manageable?  The other concern here is that the needed equipment is actually used.  All the time.
4. Stairs - Stairs may be one of the most frightening obstacles for care givers.  Develop a plan to make the home suitable without using the stairs.  Even if you don't need that limitation today I can guarantee you will at some time, either during short term recovery or because of a permanent change in condition.  Can a bedroom be set up on the first floor?  Is there a bathroom, or at least a commode?  Where are laundry and kitchen facilities located?  Having a plan in place will definitely be worth your while.  Are there hand rails?  It's probably a good idea to have a hand rail on each side to be prepared for any limitations in the future.  The treads of the stairs should be covered in non-slip material.  If the stairs are carpeted, make sure the carpeting is secure.  For wooden and other hard surfaces you can install stair treads made of carpet or vinyl; again, make sure they are securely attached.
5. Outside Access - How easy is it to get in to and out of the home?  Again, this may not be an issue today but I promise you it will be an issue some day.  The ideal is to have ground level access to the outside from the main floor.  If this is not possible a ramp can be built.  There are even portable ramps you can purchase!
6. Bathrooms - Bathrooms, statistically, are the most dangerous room in your home.  Spend some time here to look for potential trouble spots and correct them.  Grab bars are cheap and easy to install around at least the back and one side of the commode and inside and outside of the tub or shower.  Though there are guideline for installation heights, you may need to consider the short or tall person using them and adapt as necessary.  Make sure that non-skid materials are installed in the tub or shower.
7. Lighting - As we age our eyes require more light to see properly.  Diseases of the eye can also reduce visibility.  Look at every area of the home; kitchen, bathroom, bed room, living area, stairs, hallways and entry ways.  Make sure there is good lighting in every area.  A higher wattage bulb or adding a lamp may be all that is required.
8. Reach - Reorganize storage areas and place the most commonly used items within easy reach to eliminate stretching or climbing.
9. Clutter - Remove clutter from frequently used areas and walkways.  Look at the arrangement of furnishings and other items.  Rearrange so there is a clear path to other areas of the home.  
10. Throw Rugs - This is a personal pet peeve (hence the photo).  Loose rugs in any room, including the kitchen and the bathroom, pose a problem for walkers, canes, and yes, even feet.  This is the area where I find the greatest resistance.  
11. Footwear - This is another area where I get resistance.  Safe footwear is a complete shoe, with toes and a heel, and a firm, non-slip sole.  Soft slippers and sandals, though comfortable, tend to fit loosely and do not provide support.
12. Spills - Spills should be cleaned as soon as possible.  Though I know this should go without saying, it may be difficult for an older person to reach the floor to clean up a spill.  Keeping a light mop handy may help remove the bulk until the spill can be properly cleaned.

It is important to approach this task with an open mind and objective observation.  If this has been the home for a long time it may be a good idea to have an impartial person with you.  A healthcare professional or an Elder Care Consultant can add a different perspective.  Once you've made the necessary changes to the home make sure to monitor from time to time to ensure everything is still as safe as possible.

Behavior Changes Associated With Alzheimer's and Dementia

A loved one has been diagnosed with Alzheimer's or other type of dementia and lately you notice uncertainty, fear, frustration, periods of greater memory loss, and even anger!  What's causing these changes and how can I manage them?  In order to understand these behaviors, we need to understand the disease.  In basic terms dementia is the development process in reverse.  Reasoning, judgement, and abstract thinking are among the last abilities to develop and among the first to go.  Memories are much the same; more recent memories will be lost quickly while memories from earlier in life will remain intact longer.  This helps to explain why a person might do fairly well in the home they have lived in for the past fifty years but can't manage well at all in an unfamiliar setting.  How does all of this relate to behavior changes?  Early stages of Alzheimer's and dementia are typically the most difficult for the patient.  They realize something is wrong but can't figure out why.  Many times this translates into either frustration or anger.  This is also a period in the disease process where you will notice confabulation - a plausible but imagined memory that fills in gaps in what is remembered.  The person often seems more on edge and may get agitated when asked questions.  As the disease progresses fear becomes more prevalent.  There can be two causes.  First, frustration and anger can become fear as the person feels less control over themselves and their surroundings.  The other relates to memories.  As the disease progresses fewer new memories are available to recall so the brain brings up older memories it can still access that relate to the current situation.  The actual situation, however, may not relate completely to the memory.  In the earlier stages, confabulation helped make the pieces fit.  Now things just don't make sense.  The more things don't make sense, the more fear plays a part.  Every person's reaction to fear is different: Some become protective of themselves, pull away from people and may seem paranoid; some may react with fight or flight - an innate reaction to danger to either stay and fight the danger or run away from the danger to protect yourself - and elopement can become a risk; some may seek protection from others, never wanting to be alone.  You may also begin to notice that anything out of the ordinary will increase the frequency and/or intensity of these behaviors.  While dementia can ultimately affect intelligence it may not occur in the early stages so your loved one will look for solutions to the problem and react.  The problem here is that you may not understand what they are reacting to and the actions will seem irrational or harsh.

So how do you cope with these nightmare?  Begin with the realization that all types of dementia are progressive and will get worse with time.  Again, everyone is different.  I've had people who moved slowly through the disease over two decades, and I've had people who progress through the disease in less than two years.  Establishing a time line is nearly impossible but understanding the disease will help you be prepared.  Routines and rituals are your go-to tools.  When each day is like the last and the next, behaviors will be less frequent and less severe.  Awake at 7:00, breakfast at 8:00, lunch at noon, supper at 5:30, bed time at 10:00.  Meds at 8:00, noon, 5:00 and bedtime.  A walk after breakfast, a nap at 2:00.  The routine itself is not as important as having the routine.  The body will develop a natural rhythm.  When you need to break the routine be prepared for increases in behaviors.  Plan to have extra help for the day.  Explain things in small steps and be prepared to repeat yourself.  Try to include something that will bring back a good memory.  Need to go to an appointment?  Stop at a favorite restaurant for lunch or a cup of coffee afterwards.  Appear organized and at ease.  If you are upset, your loved one will be too.  Finally, be prepared to recognize when the situation progresses to the point where you can no longer do it all yourself and need help.  

Top stressors for sibling caregivers

Often times, as parents age and require more help, children become the caregivers and enter the "sandwich" generation; caregivers to their own children and their own parents.  In more than twenty years I can not recall one situation where care giving responsibilities have been equitably divided between siblings.  Please don't misunderstand, some are much more equitable than others but none are truly equitable.  One child often ends up with greater responsibilities than the other(s).  It may be the child believed favored by the parents, one with the most flexible schedule, or it might be the child geographically closest to the parents.  S/he might be self appointed or elected by other siblings.  However, there is almost certainly one sibling carrying a greater share of the responsibility.  This arrangement, though, often times leads to misunderstandings, hurt feelings, and even anger.  Siblings may not understand the level of care needed, or they may question costs for equipment, supplies, or paid caregivers.  So, how does a family cope?  How does every one do their part?  How can you minimize or even avoid hurt feelings?  Below are some suggestions.

1. Dividing responsibilities:  While in many cases is simply makes sense for one child to take the lead in care giving responsibilities duties still can, and in most cases should, be divided among siblings.  Financial and legal issues can be handled from any distance so even a sibling living far away can help with or take over these responsibilities.  Though one or some siblings may have more flexible schedules providing care is a 24/7 responsibility.  Other siblings can offer to offer care giving for a weekend, or use some vacation time to provide the primary care giver a needed rest.  In larger families a schedule can be implemented: Mary will stay over Monday, Bob will stay Tuesday, etc.  Every family is different and no two solutions will look the same.  The key here is to communicate.  Have a family meeting, identify the needs, and divide the work as evenly as possible.
2. Understanding needs:  Though immediate needs may be painfully obvious, other needs may not be initially apparent.  Developing a running list can be helpful to keep track.  Also remember that needs can change over time.  Regular family updates can be an effective way to keep everyone up to date.
3. Financial issues:  Money is frequently an area that can lead to arguments, misunderstanding, and even distrust.  Review assets, cash, and savings.  Identify current expenses, current needs, and consider what care related expenses may be on the horizon.  Preparing a budget can be a very effective tool both to keep you on track and to help other siblings understand finances.  Funeral arrangements, though difficult to discuss, should also be reviewed.  An irrevocable burial trust or other means to prepay is often a wise move.  Also be aware that prepaid funeral expenses are often times not counted as assets.
4. Legal issues:  Is there a will?  Advanced directives?  Living will?  Power of attorney, Medical proxy?  If these documents are in place and executed locate them, review them with the family, and keep them in a safe place.  If they are not in place they should be.  Though hospitals and other providers will routinely ask for a living will or advance directives I always suggest that a medical proxy or medical power of attorney also be in place.  Standardized forms for living wills and advance directives are ambiguous and leave little room to further define a person's wishes.  In addition, you are making medical decisions for a situation that has not occurred yet.  A medical proxy has the legal power to make medical decisions specific to the situation.

All of this sound too overwhelming?  It can be.  Planning in advance can make the process much easier and allows the family to discuss these issues without the emotions stress of making immediate plans.  Be aware too that help is available.  An Elder Care Consultant or Geriatric Care Manager can assist you in through the entire process from assessing current needs and projecting future care to getting legal affairs in order.  The consultant also acts as an unbiased third party who can provide a written report of current needs and suggestions for planning, allowing less involved family members true picture of the situation.

Need caregivers?

It is commonplace for individuals or families to hire caregivers to go into the home to provide assistance.  Needs can vary widely from person to person but common needs include housekeeping, laundry, shopping, meal preparation, and bathing.  Most, if not all, of these tasks allow a caregiver access to sensitive information, valuable property, money, and even banking information.  It is of the utmost importance to find a caregiver who is skilled and patient.  It is equally important to find a caregiver who is also discrete and honest.  Add in someone willing to work for the wage you can afford to pay and you find yourself with a difficult task to say the least.  Word of mouth from others in your community can be a good start but be sure to personally interview a candidate before you hire; your expectations may be different.  Also check with your local Area Agency on Aging.  Many keep a current list of caregivers who have been successful providing care for others.  Family members and close friends can be caregivers but proceed very carefully if they want paid for their work.  If you want to alienate a family member or lose a close friend, hire them.  Don't be afraid to check in while a caregiver is working, it's beneficial for them to know you are watching.  Also check valuables in the home and review purchases and banking statements if caregivers have access.  Don't forget to check with the person receiving care, it is they who often have the best insights.  Finally, don't hesitate to fire a caregiver if you are uncomfortable or if you suspect they may be taking advantage.  While it may be inconvenient as you look for someone else, it is much less inconvenient than if your loved one is injured, not cared for, or if you find an empty bank account.

Will Medicare (or other health insurance) pay for long term care?

The short answer is no.  Let me explain.  Medicare and other health insurances pay only for medical care but they will not pay for ongoing long term care.  Need rehabilitation in a nursing home?  That's covered.  Need skilled nursing care for an acute condition?  That's covered too.  If, however, you need to stay long term in a care center neither Medicare nor you health insurance will cover the cost.  All medical plans will cover up to 100 days of skilled nursing care.  This does not mean you will get 100 days, it means 100 days is the maximum they will cover.  Every insurance is different and co-pays may also apply.  With Medicare only, co-pays may begin on day 21.  Medicare is the only insurance that allows the facility to determine what length of stay is necessary, as long as it is justified.  Most insurances will authorize a skilled stay  for a week or two at a time, some only a day or two at a time.  If continued progress is demonstrated most, though not all, insurances will continue to authorize additional time.  An insurer will decide to stop paying once they believe there is no additional improvement to be gained from additional time in the facility.  If you believe additional time will be beneficial you do have remedies.  You can appeal the decision, and the insurer will review the case and make a determination.  This typically happens within a day or two of your appeal as the company pays for care while the appeal is reviewed.  If an appeal is not successful you can request a "peer review".  This requires cooperation and action from your physician, who will make a case for continued care.  The request is reviewed by a panel of physicians to determine if your physician made a good case to continue care.  Neither of these remedies is guaranteed to be successful, but they can buy you an extra day or two even if they are denied.  Also remember that once an insurance company decides to discontinue skilled care they must give notice to the facility, usually 48 hours, to allow the facility to put a discharge plan in place.  Not sure what your insurance covers or if there are co-pays?  Once you provide all of the insurance information to a facility they should be able to tell you exactly what is covered and what co-pays apply.  Typically they can provide you with this information in a few business hours.  Still have questions?  Call the customer support telephone number on the back of your insurance card.