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.