Lawsuits Don’t Lead to Better Nursing Home Care - New York Times

By PAULA SPAN


We tend to think of a lawsuit as a kind of slingshot allowing the little guy to take on a daunting Goliath — a large nursing home chain, say. If you can’t persuade a facility to provide proper care, if your elderly relative has suffered unnecessarily as a result, then you can sue.

By doing so, you not only force the responsible parties to make amends for negligence or other errors, the logic goes — you also compel them to shape up, and thus provide better care for everyone.

It’s disturbing, therefore, to learn from a recent analysis in The New England Journal of Medicine that this notion doesn’t really hold. If lawsuits were a quality-control measure, then lousy nursing homes would be sued far more often than good ones. Providing excellent care would prevent litigation.
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Participatory Action Research for Culture Change

by JOHN DAVY

The culture change movement brought a much-needed emphasis on the dignity and humanity of those receiving long-term care. Research has identified many outcomes of culture change—reduction in over-medication, more home-like environments in LTC, improved social life for residents, and many other targeted benefits. However, as an article in the most recent Gerontologist notes, “little evidence suggests that elders them­selves have participated in the identification of areas in need of improvement within their LTC communities and in the development of culture change initiatives.” (Shura et al 2011). This article presents a study that involved older adult residents directly as experts and participants in implementing culture change in LTC.
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For Elderly Muslims, Few Options Outside the Home - NYTimes.com

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By KAREN STABINER

Nazli Currim lived for 14 years at the intersection of tradition and frustration. After her father died, her mother moved into Ms. Currim’s home. She cared for her mother full time, even after a stroke six years before she died.

Ms. Currim, 69, founder of the American Muslim Women’s Association, never considered finding a nursing home for her mother. Her attitude is common among Muslims in the United States, many of whom are reluctant even to consider placing an aging family member in a facility.

Part of that decision was a personal one, but part of it was practical: It is difficult for Muslims to find nursing homes and assisted living facilities that reflect their way of life.

Cultural competence has become a buzzword as adult children seek elder care solutions that acknowledge an older person’s cultural and religious identity. But the Muslim community faces a particular challenge. The elderly segment of that population is quite small, representing “only 0.5 percent of our American Muslim population,” according to Aneesah Nadir, president of the Islamic Social Services Association U.S.A., based in Phoenix. “Most of the elders of those who have immigrated here are still overseas. We’re a youthful population.”

Older parents who do come to the United States often live an insulated existence. “They don’t speak the language, so people can’t communicate with them,” said Ms. Nadir. For them, life in a majority of residential facilities would be an alien experience.
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Style Without End - NYTimes.com

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By PAULA SPAN

Ari Seth Cohen can probably blame his fascination with glam older women on his grandmothers.

His mother’s mother, whom he describes as “my best friend, growing up,” successfully lobbied for him to leave Seattle, where he’d been working in galleries and in a men’s store, and to move east. “She always told me New York was where everything is happening, and if I wanted to do something creative, I should be there,” he told me.

His father’s mother was a fashion plate who took him shopping at Escada. “She wore beautiful suits and jewelry, a very elegant woman,” Mr. Cohen recalled.

When he did move to New York, initially taking a job in a museum bookstore, he noticed a number of idiosyncratically chic older women on the streets. He took to carrying his Canon Rebel digital camera with him everywhere, snapping their photos. The result is the blog Advanced Style, launched in 2008, which declares itself “proof from the wise and silver-haired set that personal style advances with age.”

“Older people are comfortable in their own skin, and they wear their style with confidence,” Mr. Cohen explained, sounding a bit envious. He’s a mere 29.

That appearance matters, at least to a number of old people, is something lots of nursing home, assisted living and adult day staffers can testify to. There’s a reason so many of these facilities have beauty salons on site, a reason many women cling to their red lipstick and hair color when even walking becomes difficult.


I often hear complaints about the limited range of clothing designed for older women who disdain pastel velour tracksuits. You won’t see a lot of those on Advanced Style.

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U.S. GAO - Medicare: CMS Needs to Collect Consistent Information from Quality Improvement Organizations to Strengthen Its Establishment of Budgets for Quality of Care Reviews

Full Report (PDF, 24 pages) Accessible Text Recommendations (HTML)

Summary

Medicare funds health care services for more than 46 million beneficiaries. The Centers for Medicare & Medicaid Services (CMS)--the agency that administers Medicare--contracts with private organizations known as Quality Improvement Organizations (QIO) to, among other core functions, improve the quality of care for Medicare beneficiaries. CMS contracts with one QIO for each of the 50 states, the District of Columbia, Puerto Rico, and the U.S. Virgin Islands. One of the QIOs' many responsibilities is to review quality of care concerns, raised by Medicare beneficiaries or others, to determine whether Medicare-financed medical services meet professionally recognized standards of health care. Quality of care reviews may address a range of issues, such as inappropriate treatment or hospital staff not administering medications on time; may involve a variety of health care services and settings; and may include a range of Medicare providers or practitioners. CMS enters into 3-year contracts with QIOs for a range of activities and reviews, including quality of care reviews. For each QIO contract, CMS establishes a budget reflecting the estimated costs of these activities and reviews. For the most recent contracts, which cover August 1, 2008, through July 31, 2011, CMS's budgets for the QIOs totaled about $1.1 billion, with approximately $208 million for all types of reviews, including QIOs' quality of care reviews, as well as some other activities. Questions have been raised about CMS's ability to set budgets appropriately for QIOs' quality of care reviews. A 2006 report by the Institute of Medicine (IOM) and a 2008 internal report commissioned by CMS identified weaknesses in CMS's ability to accurately compare costs across QIOs. Based on reports of wide variation in the costs that QIOs report for conducting these reviews, Congress raised questions about how CMS establishes QIOs' budgets. Ensuring that QIOs' budgets are based on accurate information is particularly important because CMS's contracts with the QIOs are funded from the Medicare Trust Funds, which are primarily used to support inpatient and outpatient health care services for Medicare beneficiaries. QIO contracts are funded from the Medicare Trust Funds in proportions from each that CMS determines to be fair and equitable, and the QIO program is not subject to the same kind of congressional oversight as other CMS programs, which are funded through the annual appropriations process. Policymakers are concerned about the long-term solvency of these Trust Funds and thus their ability to fund health care services for Medicare beneficiaries in the future. Congress raised questions about the information QIOs report to CMS for budgeting purposes and how CMS uses this information. To assist congressional consideration of this matter, this report describes and assesses the information CMS uses to establish the portion of QIOs' budgets for quality of care reviews.

To help establish QIOs' budgets for quality of care reviews for the current contract, the 9th Statement of Work, CMS used information that QIOs are required to provide to the agency about the volume of QIOs' quality of care reviews and the costs associated with conducting these reviews. CMS requires the QIOs to record information about the volume of their quality of care reviews in CMS's Case Review Information System (CRIS) and to record information about their labor costs in CMS's Financial Information and Vouchering System (FIVS). However, CMS has not established clear instructions for how QIOs should record volume and cost information in these systems. We found inconsistencies among some QIOs in the ways they record certain volume and cost information in CRIS and FIVS. As a result, the historical quality of care review volume and cost information CMS obtains is inconsistent across QIOs and CMS cannot be assured that the budgets it establishes for QIOs' quality of care reviews are appropriate.


Recommendations
Our recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.

Director:	Kathleen M. King
Team:	Government Accountability Office: Health Care
Phone:	No phone on record

Recommendations for Executive Action

Recommendation: To ensure that QIOs consistently record volume and cost information for their quality of care reviews and to help ensure that the budgets CMS establishes for these reviews are appropriate, the Administrator of CMS should develop clear instructions specifying how QIOs should record information about the volume and costs of their quality of care reviews in CRIS and FIVS.

Agency Affected: Department of Health and Human Services: Centers for Medicare and Medicaid Services

Status: In process

Comments: When we confirm what actions the agency has taken in response to this recommendation, we will provide updated information.

Medicare Coverage Standards Are Too Strict, Courts Find - NYTimes.com

Image via CrunchBaseby Robert Pear
Two federal courts have ruled that the Obama administration is using overly strict standards to determine whether older
Americans are entitled to Medicare coverage of skilled nursing home care and home health care.

Medicare will pay for those services if they are needed to maintain a person’s ability to perform routine activities of daily living or to prevent deterioration of the person’s condition, the courts said.

Medicare beneficiaries do not have to prove that their condition will improve, as the government sometimes contends, the courts said.

The rulings are potentially significant for many people with chronic conditions and disabilities like multiple sclerosis, Alzheimer’s disease and broken hips. Skilled care may be reasonable and necessary and covered by Medicare even if the person’s condition is stable and unlikely to improve, the courts said.
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Medical Marijuana Raises Tough Questions in Nursing Homes - NYTimes.com

Image via WikipediaBy NUSHIN RASHIDIAN AND ALYSON MARTIN

Every night before bed, Norma Winkler, 82, opens a small jar of cannabis oil and measures out a quarter-teaspoon to mix with homemade applesauce. Soon after she eats it, she drifts off to sleep.

Ms. Winkler, who lives in Rhode Island, where medical marijuana is legal, has endured chronic back pain since a car accident fractured her skull and spine at age 15. Operations haven’t helped, and other medicines don’t touch the pain that can keep her up through the night.

“It’s really been a lifesaver for me,” Ms. Winkler said of her cannabis oil. “I used to walk into the walls sometimes. I was so tired because I didn’t sleep.”

Today, she’s healthy enough to remain independent in her home and to operate the jewelry factory she owns. But she worries about what will happen if she needs institutional care. Would a long-term care facility allow her to use this particular medicine?

“I wouldn’t go if they didn’t allow me to take it,” Ms. Winkler said.
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ADA Encourages Less-Restrictive Diet Options for Older Adults in Health Care Communities

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by John Davy on October 7, 2010

“Food nourishes the spirit as well as the body.” That might sound like something you’d hear from your favorite, and not quite diet-friendly, restaurant, but it’s actually part of a paired Practice Paper/Position Paper from the American Dietetic Association (Dorner et al 2010b). While the ADA is perhaps more commonly thought of as the agency who tells us things we don’t want to hear about our favorite foods, the newly-released companion papers emphasize the importance of providing older adults with food options that fit their desires, tastes, and rights.

The papers present this new emphasis on enjoyable foods in a culture change/person-centered care framework. (See our previous post on the topic.) The position paper states that “[c]are for individuals who reside in health care communities must meet two goals: maintain health and preserve quality of life,” and that while these two goals can conflict, food must also “enhance quality of life” (Dorner et al 2010a). Person-centered care, the paper argues, has reminded us that individual dignity, autonomy and choice should guide caregiving.

Such reminders, however, often sound like obvious platitudes without any clear means of implementation. Fortunately, the position paper also presents more specific arguments for tasty food. It reminds us that, due to changes in health and sensory ability, food can be less appetizing as we age. For individuals in care facility, the very desire to eat is often a victory. As most of us have experienced, diet foods restrict our range of food choices and our food pleasure. Citing a literature review on the high rate of malnutrition and undernutrition in older adults, the paper stresses weight maintenance as a pragmatic measure of adequate nutrition, and states that restrictive diets tend to lower food intake, while “more liberal diets are associated with increased food and beverage intake.”

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THE GREENHOUSE COTTAGES OF SOUTHERN HILLS IN RISON, ARKANSAS

Let's Kick It Off! - Residents' Rights Week

This year's theme aims to educate people about Residents' Rights and improved dining experiences for residents by highlighting residents' concerns and comments on this issue. Residents were encouraged to think about and respond to the following questions:

• 
  
  How can dining services be improved to make your meals more enjoyable?
• 
  
  What makes your meals and dining experience positive?
• 
  
  What is your favorite recipe? Why is it special to you?

Ms. Carolyn Higginbotham, a resident of the Milton Home in South Bend, Indiana, submitted two wonderful recipes for our Residents' Rights Week cookbook (learn more about purchasing the cookbook below). Carolyn also shared that her facility has recently improved meals by adding a salad bar to the regular menu. She says residents can also order al carte and that "this makes the meals and dining much more pleasant." Carolyn also shared that her favorite recipe is homemade noodles served over dressing and mashed potatoes.
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Canadian Residential Care Facilities Statistics

The term "residential care facilities" refers to facilities with four beds or more that are funded, licensed or approved by provincial/territorial departments of health and/or social services. This report focuses on homes for the aged, facilities for persons with mental disorders and other facilities which provide health or social care. Facilities for the aged include homes for the aged, nursing homes, lodges for senior citizens and rest homes. Certain facilities such as apartments or other homes for seniors not providing any level of care were not included. Facilities for persons with mental disorders include facilities for the psychiatrically disabled, developmentally delayed, emotionally-disturbed children and centres for those with drug/alcohol problems. Some psychiatric institutions are included here. Other residential care facilities include those for persons with physical disabilities, for delinquents, for transients and facilities that do not fit in any of the other categories.

History Note
The survey data were published unadjusted for non-response for the period from the 1984/1985 fiscal year to the 1993/1994 fiscal year. This new publication includes data adjusted for non-response for all fiscal years since 1984/1985, except 1994/1995 and 1995/1996, for which no publishable data are available. CANSIM data include correction for non-response for all years. To maintain comparability with published data, few changes were made in the historical data for the period from 1984/1985 to 1993/1994. However, a number of homes for the aged that had erroneously been included with residential care facilities in Alberta were removed from the data for all periods.

CANSIM data
Free access to the data is provided through a special CANSIM interface. The CANSIM tables can be linked directly from three different locations in the HTML product:
Tables section:
• Related CANSIM tables
• Individual tables, in the Source
Related products section:
• Selected CANSIM tables from Statistics Canada

New Resource for Geriatric Pain Management

The Geriatric Pain Website

The purpose of this  Web resource is to share best practice tools and resources with nurses responsible for pain care in older adults who reside in nursing homes.

Why was the Geriatric Pain Web site created?

• To provide nurses working in long-term care environments access to resources, a new Web site — www.geriatricpain.org — has been developed. This site, a one-stop resource, shares free best-practice tools and resources that support recommendations for good pain assessment and management in older adults, including implementation of quality improvement processes focused on pain management.
• Up to 80 percent of older persons living in long-term care facilities suffer from pain problems. Although aging contributes to the likelihood of pain conditions, effective assessment and management can ensure good quality of life.
• The Web site is easy to access and user friendly. It’s organized into categories of emphasis, including pain assessment, pain management, education, quality improvement, guidelines and resources.

Who was Geriatric Pain Web site developed for?

• The tools available are for nurses and administrators in nursing homes and long-term care facilities to help them improve pain outcomes for residents, change organizational standards for pain outcomes and save time identifying and evaluating quality tools.

Is there a cost to access the resources

• The Geriatric Pain Web site resources are free to registered users. Registration is quick, easy and requires only your e-mail address, password, name and zip code. 

Ombudsman: Director of Iowa Dept. on Aging had employee 'hit list' | The Des Moines Register

The director of the Iowa Department on Aging reportedly created a "hit list" of employees he wanted to force from the agency, Iowa's chief advocate for the elderly says.

Iowa Long-Term Care Ombudsman Jeanne Yordi made the allegation in a letter Monday to Gov. Chet Culver.

Yordi told the governor she was among the targeted workers at the Department on Aging. She said she had planned to take early retirement because she had been subjected to a hostile work environment created by department director John McCalley and because she had been "forced to violate federal law."
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Programs to Manage Aggressive Behaviour in Long-Term Care Patients: A Review of Clinical-Effectiveness, Cost-Effectiveness, and Guidelines

Resident physical aggression such as hitting, kicking, pushing, or hair pulling, whether intentional or not, is a concern that most long-term care (LTC) facilities share. One prevalent goal is to decrease resident physical aggression through minimal use of physical restraints and pharmacologic restraints.One way some LTC facilities are trying to handle this issue is through providing effective staff training programs that focus on non-physical and non-pharmacological restraints to reduce resident violence.
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Final Rule: Grants to States for Construction or Acquisition of State Home Facilities--Update of Authorized Beds

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This document adopts as a final rule the proposed rule to amend Department of Veterans Affairs (VA) regulations regarding grants to States for construction or acquisition of State homes. This final rule updates the maximum number of nursing home and domiciliary beds designated for each State and amends the definition of ``State'' for purposes of these grants to include Guam, the Northern Mariana Islands, and American Samoa. Effective Date: This final rule is effective May 10, 2010. Additional Information

Voluntary End-of-Life Measures Banned at Catholic Hospitals - The New Old Age Blog - NYTimes.com

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By PAULA SPAN

In the 600 Catholic hospitals and hundreds of Catholic nursing homes around the country, such issues may grow more contentious in the wake of a new directive adopted by the United States Conference of Catholic Bishops.

As Harris Meyer recently reported in Kaiser Health News, the directive establishes “an obligation to provide patients with food and water, including medically assisted nutrition and hydration” for those who can’t eat or drink, and it specifically includes patients in “chronic and presumably irreversible conditions.”

Patients whose advance directives prohibit feeding tubes if they have terminal illnesses or have entered a persistent vegetative state (as mine does) would either have to accept such treatment or transfer to another facility.
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Long-Term Care Financing Reform: Lessons from the U.S. and Abroad - The Commonwealth Fund

Broad health care reform legislation being considered by Congress would effect a major change in the way the United States finances long-term care. The Community Living Assistance Services and Supports (CLASS) Act would create a voluntary national long-term care insurance program. As lawmakers debate the potentially far-reaching proposal, they may learn from the experiences of other developed nations and from recent experiments in the U.S.

Long-term care is the personal assistance that the frail elderly and other adults with disabilities require to maintain the best possible quality of life. The assistance may be delivered at home or in a nursing facility or other congregant care setting. In the U.S., most long-term care is provided by family members, and some by paid aides. The cost of formal care is quite high, averaging $75,000 per year for residence in a skilled nursing facility and $20 per hour for home health aides.

In Japan and much of Europe, public benefits for long-term care of the frail elderly have become a pillar of social policy, along with retirement and health care. While many nations have enacted major reforms over the past two decades, they have taken somewhat different approaches.
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Come on HUD, Free People from Nursing Homes

by Steve Gold
Information Bulletin # 301 (2/2010)

Ah, the hopes raised by a new HUD administration. Early last year, Congress provided funds for 4,000 Mainstream Vouchers for Non-Elderly People with Disabilities. New Secretary of HUD, Shaun. L. Donovan, met with ADAPT and agreed with ADAPT that 1,000 of these vouchers should be used to help disabled people move out of nursing homes.

On June 22, 2009, HUD issued a "Proposed Notice" in the Federal Register. Comments were due by July 14, 2009. A number of you responded with comments.

Before any of these 4,000 vouchers can be used, HUD must publish in the Federal Register a Notice of Financial Availability (NOFA) so that Public Housing Authorities and others can submit competitive bids for these vouchers. Yes, another Federal Register publication. After that occurs, HUD must review the bids and then allocate the vouchers.

How many people will die before one voucher is used? How many people with disabilities will develop bed sores in nursing facilities? Urinary tract and other infections in these institutions? How many people in what President Obama called "the year of community living" exist in nursing homes waiting for these vouchers?

Hmm. Why has it taken more than SEVEN months and still NO NOFA? Doesn't HUD understand that there are people unnecessarily institutionalized solely because they cannot afford to rent an apartment without the rental assistance of a voucher? Doesn't HUD and the White House realize there are actual cost savings from using the vouchers and having people live in the community? Doesn't anyone in the White House or HUD have a relative in a nursing facility who wants to get out? Don't they understand how dangerous nursing facilities are?

Here is one excuse we've heard - approval of the NOFA is "in process at OMB." Well, tell Secretary Donovan to at least pretend that these vouchers and ending discrimination against people with disabilities is a HUD priority. Tell him to get his butt down to OMB and tell them he's not leaving until these vouchers get out of OMB! If he needs company at OMB, let us know!

Send HUD an email - Shaun.L.Donovan@hud.gov to "Free Our People."

Steve Gold, The Disability Odyssey continues

Back issues of other Information Bulletins are available online at http://www.stevegoldada.com with a searchable Archive at this site divided into different subjects.

To contact Steve Gold directly, write to stevegoldada@cs.com or call 215-627-7100.

What Is Malnutrition? What Causes Malnutrition?

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from Medical News Today

Malnutrition is a broad term which refers to both undernutrition (subnutrition) and overnutrition. Individuals are malnourished, or suffer from undernutrition if their diet does not provide them with adequate calories and protein for maintenance and growth, or they cannot fully utilize the food they eat due to illness. People are also malnourished, or suffer from overnutrition if they consume too many calories.

Malnutrition can also be defined as the insufficient, excessive or imbalanced consumption of nutrients. Several different nutrition disorders may develop, depending on which nutrients are lacking or consumed in excess.

According to the World Health Organization (WHO), malnutrition is the gravest single threat to global public health.

While malnutrition used to be seen as something which complicated such diseases as measles, pneumonia and diarrhea, it often works the other way round - malnutrition can cause diseases to occur.

Globally, as well as in developed, industrialized countries, the following groups of people are at highest risk of malnutrition (subnutrition):
* Elderly people, especially those who are hospitalized or in long-term institutional care
* Individuals who are socially isolated People on low incomes (poor people)
* People with chronic eating disorders, such as bulimia or anorexia nervosa
* People convalescing after a serious illness or condition

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Outbreaks of 2009 Pandemic Influenza A (H1N1) Among Long-Term--Care Facility Residents --- Three States, 2009

CDC Morbidity and Mortality Weekly Report (MMWR)

Hospitalization and death from seasonal influenza are more common among older adults and in long-term--care facilities (LTCFs) (1). Early data from the 2009 pandemic influenza A (H1N1) outbreak indicated that attack rates among persons aged ≥65 years were lower than in other age groups, and anti-influenza A antibodies that cross-react with 2009 H1N1 could be detected in up to one third of healthy adults aged >60 years (2). Based on these early data and anticipation of limited initial supplies of 2009 H1N1 vaccine, the Advisory Committee on Immunization Practices (ACIP) identified priority groups for vaccination (3), which did not include persons aged ≥65 years who did not have higher risk for influenza or its complications (3). During October and November 2009, CDC received reports of 2009 H1N1 outbreaks in LTCFs in Colorado, Maine, and New York. This report summarizes the three outbreaks, which involved facilities primarily housing older patients. These outbreaks illustrate that, despite the lower risk for infection with 2009 H1N1 among persons aged ≥65 years compared with seasonal influenza, 2009 H1N1 outbreaks still can occur in LTCFs. These outbreaks also underscore the importance of respiratory illness surveillance and recommended infection-control procedures in LTCFs. All health-care personnel should be vaccinated against seasonal influenza and 2009 H1N1. LTCF residents should receive seasonal influenza vaccination, and should be vaccinated against 2009 H1N1 after assessment of vaccine availability at the local level indicates that demand for vaccine among younger age groups is being met (3).

Outbreak Reports:

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