Wednesday, February 28, 2007

An Ounce of Prevention

Unless you are a caregiver for a frail friend, parent or grandparent, you might not spend a lot of time thinking about matters of balance and the cost and consequences of falls. But the numbers may surprise you. In the elderly, falls are the leading cause of injury-related deaths. They are more common than stroke (3 in 10 over seventy fall each year); cause over 90% of broken hips; and account for 16 percent of all Emergency Department visits and almost 7 percent of all hospitalizations.

In its 2006 Massachusetts State Injury Prevention Plan, the Mass. Department of Public Health reported that in 2004 Mass. hospitals reported more than 25,000 falls-related admissions. These 25,000 were more than 50% of all injury related discharges. By contrast, motor vehicle injuries requiring inpatient care totaled only 4,532. Total hospital charges for these fall-related injuries exceeded $300 million and Emergency Room care totaled more than $48 million. If you are in the health care delivery system - and whether your concern is ER back-ups, hospital bed availability, or escalating costs - you should be thinking about falls prevention.

Yes, prevention, because there is now evidence-based research that indicates that the causes of many falls are identifiable and the rates of falls can be lowered with appropriate risk assessment and intervention.

Home care agencies, which see primarily, home-bound, chronically-ill and frail elders, are increasingly becoming active in implementing falls prevention programs. This can mean assessing everything from a patient's muscle strength and home environment, to the medications they take and their impact on balance.

The Home Care Alliance will be supporting these efforts, including dissemination of best practices throught the industry, with the help of a grant from the Boston Foundation. Other resources supporting these efforts can be found on the Healthy Aging page of the National Council on Aging, which in 2005 launched a national Falls Free effort.

Can these efforts make a difference and actually bring those numbers down for Massachusetts? It's too soon to tell. But there is no doubt, the home care industry is dedicated to the effort.

Tuesday, February 13, 2007

Home Care Disconnect

Although I must confess to be one of those who are contributing to a steep decline in the percentage of the population watching a network nightly newscast, an NBC promo had me tuning in last night to see anchor Brian William's report on "Trading Places: When Kids Care for Aging Parents." http://dailynightly.msnbc.com/ William's piece was a moving account of his efforts to assure a dignified and quality life for his World War II veteran father, living by choice in a small one room efficiency in a New Jersey Assisted Living unit. Gordon Williams, now nearing 90 years of age, has survived not only his wife of 50 years and two of his children, but a "heart attack, cancer surgery, a broken hip and hip replacement."

Williams admits that he is fortunate to be able to financially care for his father - but physically - due to time and distance - he reports that he is dependent on some "angels" - namely the Visting Angels home care service. They do, he said, what he and so many others like him can not. And they do it quite well.

A few days before the NBC series began to air, the President proposed in his FY08 budget to freeze home care funding within the Medicare program, not only for the upcoming fiscal year, but for the next five years (FY08-FY12). The result would be a reduction over the five years of more than $9 billion nationally, and $302 million in Massachusetts. While many other services sustained cuts in the President's proposed budget, home health care's five year reduction is the most drastic.

Putting aside questions about budget sleight of hand that has the Executive Branch proposing cuts that will extend well past their tenure in office, the proposed cuts leave one wondering if indeed when it comes to care for aging relatives, we will soon be adding a "long term care divide" to our lexicon, along with "digital divide," "generation divide" and all of those other societal demarkations.

I am not saying that the government can or even should pick up the total tab for an aging population that is in large part an American success story: even those with chronic diseases can live longer and full lives due to great medical advances and great care.

But I am asking people to stop and think about Medicare and what it has meant for this country. Whether small government proponents like it or not, the fact is that Medicare remains the largest and I would argue probably the most succesful program our government has ever come up with. To allow benefits to be eroded as the President is proposing and at a time when they will be most needed seems at best short-sighted and at worse mean-spirited.

There is a small book I love called Really Important Stuff My Kids Have Taught Me." One of the sayings in it is the following: "If you want pancakes for breakfast, you got to help make help make them."

The message is if you have aging parents, you need to get off the sidelines and get into the long term care debate.

Thursday, February 8, 2007

Universal Health Insurance

Yesterday, I attended a meeting of very committed and smart individuals dedicated to making Massachusetts Universal Health Insurance Reform Law work and work as intended - to provide access to health insurance to those in our state who are currently without it.

Health Care For All, which has been a major force in advocating for the consumer in this process, estimates that already the number of uninsured folks who have been enrolled in affordable and good quality health insurance plans since the law was signed 4/12/06 total more than 100,000: 58,000 new MassHealth enrollees since 7/1/06 and 47,000 enrollees in Commonwealth Care. (Commonwealth Care is a new state program that offers free or reduced cost insurance for adults 19 or older who meet certain income guidelines.)

But some big decisions loom, and what happens could greatly impact home care agencies. Home care agencies employ many paraprofessional workers (home health aides and homemakers) whose salaries are a product of what government payors (Medicare and Medicaid) will pay for a home visit. Although home care agencies almost universally offer health insurance to their workers, many aides and homemakers "opt out" because the premiums would consume too much in their weekly paycheck. (A $1200 a month family plan subsidized by the employer at 50% would costs the aide $600 a month.)

With the deadline for the individual mandate (at which point most citizens will be required to have insurance) fast approaching (July 1, 2007). decisions have to made. At this point, although many of these workers are income-qualified to access subsidized care through Commonwealth Care, they are at present excluded because their workplace offers insurance. The smart people referenced above, who are working to influence decision-making of the implementation body The Connector, are considering these issues with an eye toward possible changes. Nothing has officially been endorsed, however in the mix are:
  • a process to waive the exclusion from CC for certain workers in companies that offer insurance (if the insurance is too costly or does not meet "credible coverage" guidelines),
  • advocating for premium support to help workers to afford to opt-in to an employer-sponsored plan,
  • and, most drastically, delaying the insurance mandate for certain individuals (according to income, job status or other criteria).

All of these possible changes or mid-course corrections have domino consequences to the delicate balancing act that is health care reform. On the employer side, the mandate holds the possibility that workers who previously opted out (some in favor of higher hourly pay) now will seek coverage. (A good thing, many believe). But our home care agencies have little resources to find revenue to cover drastic increases in the employer cost of providing insurance. Government payors set our rates and we can't raise them at wil - even to cover new government mandates.

Which way all this will go is too early to say. The bottom line: our insurance system is costly and complex and so is the health reform act. That doesn't mean it wasn't a good thing, because it was. It's just going to take a lot of very smart and committed people to make it all work.

Monday, February 5, 2007

Baby, It's Cold Outside



Whether records were set today for temperature or not doesn't matter much, especially to people who have to work outside. It's cold and they know it. When the weather gets like this the media will often run a profile on cops or construction workers doing their jobs despite bone-chilling winds.

But I'd like to give my own shout-out to our home care nurses, aides and therapists who like the proverbial letter carriers are out there "in rain, in sleet and snow" and, of course, cold. Their clients depend on them and they deliver. Today, we estimate about 20,000 home care visits will be made in Massachusetts from sun-up to way past sundown. Medicines will be dispensed and bandages changed. Vital signs will be checked and limbs rehabilitated. Comfort and companionship just come with the service.

It was in 1957 that famous fictional nurse Cherry Ames had her assignment as a visiting nurse in New York City. Cherry worried about how she would be perceived - as "a stranger." Her supervisor corrected her: "It's hard to explain, but when you go to somebody's door and they light up and say 'thank goodness the nurse is here'.... well it's pretty wonderful."

A little warmth on a cold New England day.

Thursday, February 1, 2007

Formal and Informal caregivers

A Caregiver Survey that was just published in the Archives of Internal Medicine has me thinking about the roles of home care agencies and informal caregivers, defined as those who have taken a primary role of caring for a disabled or dying family member or friend. Some recent public policy initiatives on the state and federal levels that would compensate these caregivers for their efforts often seem to be positioned as at odds with professional or home care agency delivered care. But from where I sit, this seems hardly the case.

The survey revealed what many could intuit: Among the caregivers of adults in the last year of life, 41.5 percent were spouses and 39 percent were children; 75.1 percent were female (no surprise!). These caregivers had an average age of 64 years. They provided an average of 43 hours of care per week, and 84.4 percent of them provided daily assistance.

More than two-thirds of family and friends serving as informal caregivers to disabled older adults living in the community during their final year of life found their role rewarding despite providing more than 40 hours of care per week.

Interesting to me the authors concluded that these caregivers made "little use of caregiver-focused supportive services." Yet within the data was the fact that 37.2 percent used personal or nursing care services during the final caregiving year. To me this is significant. As I said in the opinion editorial that I submitted to papers for Thanksgiving 2006: "Professional caregivers - nurses, therapists and aides - are often best position to see the sacrifices family caregivers make for their loved ones. We know we can't replicate the love in the family caregiving relationship; but we can do our best to make their job easier."

To all the family caregivers out there, our industry acknowledges your effort and sacrifice. We need to also let you know that we are here to help if you need us.

Til next time.