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Medicare: Peeking Into the Database

It’s been an eventful week for Medicare: Not only did the top Medicare official resign, but he's now publicly stating that as much as 30% of ALL Medicare spending is wasted. This means that, in his words, as much as $250 billion per year is wasted by Medicare and Medicaid.

Chief Dr. Donald Berwick stepped down because Senate Republicans did not confirm his recess appointment which was about to expire. In an interview with the New York Times Berwick said that between 20 percent and 30 percent of health spending is wasteful. The five reasons for the "extremely high level of waste” include overtreatment, little coordination of care, fraud, a complex health care system and regulations that are pointless and archaic. Berwick defines waste as “activities that don't have any value” and estimates that Medicare and Medicaid could save between $150 billion to $250 billion a year by eliminating waste.

Hopefully, Marilyn Tavenner, a top official at the agency, who has taken Berwick’s place will continue efforts to reform the system. She’s off to a good start. In a major policy shift the Department of Health and Human Services implemented a provision to make the Medicare claims database available to the public. The massive Medicare database is considered the mother lode of medical information for the U.S. health-care system. The computerized record itemizes medical bills for 48 million beneficiaries.

Nationwide, an assortment of 25 groups will be granted access to the data. These groups are working to improve health care at the local level and will be comprised of doctors, health insurers, businesses, consumers and government agencies. They will analyze, study and publish results on procedures, hospitals and doctors in order to help consumers make better-informed decisions about their care.

However, opening the $500 billion data base to 25 groups is merely the opening act of a more transparent system. The Wisconsin Collaborative for Healthcare Quality, one of the groups selected, discovered daunting challenges due to both mechanical problems as well as the sheer complexity of the information involved in a recent Medicare project.

Marilyn Tavenner says she is striving to "ensure consumers have the access they deserve to information that will help them receive the highest quality care at the best value for their dollar." To do this she must do more than scratch the surface. She must create more opportunity for access to the data.

Reform of the Medicare system is urgent. Allowing many experts access to the data will lead to valuable insights and the most appropriate treatments. Before cutting services and benefits for older adults shouldn’t waste be eliminated? After all, we wouldn’t tolerate squandering 25% of our own personal resources – how is wasting Medicare tax dollars any different?

Congress is looking for solutions to control escalating Medicare costs. Ask your local advisory group to support the Grassley-Wyden DATA Act. Go to your Senator’s page and let them know you support the Grassley-Wyden DATA legislation. The author, Candice Rose, specializes in aging and elder care. She is currently serving as the Chairwoman of the Arlington County Commission on Aging in Virginia. You can follow her on Twitter at www.twitter.com/CandiceRose.

“Be the change you want to see in the world.” M. Gandhi

#Medicare #Medicare database #berwick #Tavenner #fraud #waste #care coordination #Grassley-Wyden #DATA Act #Wisconsin Collaborative for Healthcare Quality

An Open Invitation to Advisory Groups on Aging Everywhere in the U.S.

Wouldn’t it be beneficial to have the opportunity to learn what peer advisory groups across the country are doing? Wouldn’t it be in the best interest of the public to inform them about the success and challenges of these groups? Most people don’t realize that for the past 45 years 650 advisory boards across the country have been working on aging issues. Advisory Boards were created as a result of the Older Americans Act of 1965. The OAA required each state to establish a unit on aging. The state units then designated Area Agencies on Aging. And each Area Agency on Aging is required to have an advisory board or council. The format and structure of advisory groups varies in each jurisdiction but all share common goals. Most work, however, is done in isolation without knowledge of what peer groups are doing. State Units on Aging have a National Association. Isn’t it about time advisory groups had a forum in which to compare strategies, talk about what works and what doesn’t, to share success stories? Isn’t it about time to coordinate and leverage all the separate experiences of local groups into an integrated force? 10,000 baby boomers turn 65 everyday – it’s time to draw on the knowledge and expertise developed in local communities to find the most effective solutions to critical issues. Many leading advocacy and service organizations are taking advantage of innovative options to create greater awareness about their work and to engage with their constituents. The Administration on Aging, AARP, n4a, The National Council on Aging, for example, goes where their audience is: Facebook and Twitter. Advisory groups should do the same. But as of October 1, only about 10% of the 650 advisory groups are using Facebook pages to connect with their constituents. While some news may be unique to a specific organization many concerns are universal. And, on occasion, a majority of the 650 advisory groups could choose to present a unified voice on a specific issue. The opportunity to present a cohesive view directly to Congress would be powerful. To capture these opportunities I’ve setup a Facebook page as a resource for all Advisory Groups on Aging. Come to the page by clicking on the link: National Forum for Aging Advisory Groups. Introduce yourself. “Like" the page. If your area group is not using this venue please let them know about this resource and opportunity. Let’s create greater community awareness and learn what’s happening across the country.

The author, Candice Rose, is a specialist on the topic of aging and elder care. She is currently serving as the Chairwoman of the Arlington County Commission on Aging in Virginia. You can follow her on Twitter at www.twitter.com/CandiceRose.

#advisory groups #aging #Older Americans Act #OAA #Area Agencies on Aging #baby boomers #AoA #AARP #n4a #NCOA

Medicare: Check out tomorrow's event!

Tomorrow, Wednesday, 9/28, is Medicare Call-In Day. LeadingAge, an association of 5,600 not-for-profit organizations dedicated to expanding the world of possibilities for aging, is hosting the day-long event. The purpose of the event is to urge members of Congress to preserve Medicare payments to providers of long-term services at current levels.

The Congressional Deficit Supercommittee is threatening Medicare cuts in services which jeopardize care for the most financially vulnerable older adults. Providers of long-term services and support have already absorbed substantial Medicare cuts and beginning October 1, Medicare payments will be cut again by 11%. But before benefits are cut shouldn’t Congress act to eliminate abuse, fraud, wasteful practices, and overbilling? The New York Times estimated that $100 Billion dollars is stolen from Medicare and Medicaid each year. Cutting benefits, which directly affect the lives of those with annual incomes of less than $18,500 isn’t the answer.

Help protect seniors' access to quality care. Urge your congressman to support a plan that preserves Medicare funding for long-term services. For details on how to participate check out this link: http://www.leadingage.org/call_congress.aspx

“Be the change you want to see in the world.” M. Gandhi

#medicare #LeadingAge #long-term care #nursing homes #DATA ACT #deficit commission #fraud #abuse #Grassley #Wyden #Berwick #Aunt June

The Arlington County Commission on Aging supports the Grassley-Wyden Data Act, which opens up the Medicare database.

#Grassley #Wyden #Medicare #Medicare fraud #Medicare reform #DATA Act #Medicare Transparency #Medicare accountability #Sen Jim Webb #Sen Mark Warner #Arlington County Commission on Aging

Medicare: Cut Fraud, Not Performance

Yesterday, September 8, 2011, the American Hospital Association offered a money-saving suggestion to reduce Medicare costs: raise the eligibility age for beneficiaries from 65 to 67 years-old. Like most cost-reduction ideas, this policy will restrict access to care for a greater number of people. When patients who have delayed treatment of chronic conditions enter the Medicare system they are in poorer health and need more extensive services.

We should focus on solutions which provide the best and most efficient services for the broadest constituent group. Creating an effective system requires a focus on prevention and management of chronic diseases rather than acute care for emergencies. In addition to providing relevant value to patients, the Medicare system should operate without fraud, waste and abuse.

Previously I have discussed my 95-year-old Aunt June’s predicament in “Caught in the Medicare System.” Like most Medicare beneficiaries, she rarely used her benefits until the last year of her life. But once she entered the hospital, she was trapped in a cycle of 7 institutional settings and Medicare footed the bill for 700 transactions. Were all the medical interventions medically necessary? Did they even happen?

For some patients, apparently not. On Wednesday, September 7, Attorney General Eric Holder and HHS Secretary Kathleen Sebelius, announced that the Medicare Fraud Strike Force charged 91 defendants, including, doctors, nurses, and other medical professionals in eight cities for their alleged participation in Medicare fraud schemes. Defendants submitted claims to Medicare for treatments which were either not provided at all or which were medically unnecessary. Some Medicare beneficiaries received kickbacks for supplying information to providers. Investigators used data analysis techniques to uncover $295 million dollars in false billing.

These investigations are a good start in eliminating fraud so Senator Chuck Grassley (R-Iowa), ranking member of the U.S. Senate Committee on Finance, must be relieved. He has been concerned about the inadequate management and lack of oversight for federal contractors. Last spring, Grassley and Ron Wyden (D-Oregon) introduced the Medicare Data Access for Transparency and Accountability Act to help combat fraud. The bill would require Medicare claims and payment data to be available to the public. In 2009, the federal government spent $502 billion on Medicare. Don’t taxpayers have a right to see how their hard-earned dollars are being spent? Public accessibility may not only deter medical providers from wasteful practices and overbilling, it will give citizens a tool for community policing. Medicare data should also be reviewed and analyzed to understand changing trends and effective treatments. This will enable providers to prescribe the most appropriate and successful treatments for their patients. Congress is looking for solutions to control escalating Medicare costs. Go to your Senator’s page and let them know you support the Grassley-Wyden DATA legislation.

“Be the change you want to see in the world.” M. Gandhi

#medicare #medicare fraud #medicare reform #deficit commission #grassley #Aunt June #Wyden #American Hospital Association #chronic care #case management #Sebelius #Eric Holder #DATA Act

Elegance in the Sky

Did you manage to escape the miserable record-breaking East coast July heat wave without travel troubles? Were your flights disrupted by the earthquake? Are you fleeing from Hurricane Irene? Take a moment to think about a more romantic era in the travel business.

In the 50’s, business travel was just beginning and pleasure trips by plane were a novelty. In fact, many travelers were feted with pre-trip “bon voyage parties.” Travelers dressed up for the occasion and were treated with great consideration by the airline staff. 95-year-old Aunt June told me that meals were served on elegant Rosenthal china.

Enjoy a look at this TWA menu which captures the spirit of the time.

I would have chosen the Sole “Bela Moleira” with capers and parsley, presented with rice Madrilena and Green Beans Amandine. Maybe my companion would have picked Chicken Balboa topped with Chasseur Sauce, a complex concoction of stock, white wine, tomatoes, mushrooms and seasonings, accompanied by peas with Vichy Carrots and Pommes Boulangere. We could have shared. And then we would have both had tarts “At the End.”

As delectable as the food sounds, we no longer need an “Enviable Opportunity to Taste and Savor the Cuisines of Each Land.” Globalization has provided everyone access to almost every cuisine. Yet somehow, along with the fine dining, the romance and civility have also been cut from the menu.

“Be the change you want to see in the world.” M. Gandhi

#Aunt June

Matters of Appearance

Treating people with respect doesn’t require a billing code.

The contents of 95-year-old Aunt June’s closet intrigued her rehab roommate and made her look forward to meeting June. June enjoyed a lifelong interest in fashion and never allowed her age to be a negative factor in her clothing choices.

June believed that she had a responsibility to present herself in the best way possible, and, that the whole world would be better off if everyone made the same effort. Difficult circumstances shouldn’t make a difference. But her conviction was sorely tested throughout her 7-institution, 12 month stint in the Medicare system.

During her three hospitalizations, June adjusted to a reduced wardrobe, but refused to give up wearing her jewelry despite admonitions from the staff. The case manager warned me about a patient who had the diamond gouged out of her ring while she was sleeping. “The family had the last laugh, though. They had already substituted a cubic zirconium.”

Though June’s friend, Wanda, insisted on doing June’s personal laundry, her clothing still disappeared into the institutional laundry system. If it reappeared it was often damaged. Theft was a recurring problem.

Hygiene and grooming were bigger issues. In every institution, scheduled bath and shower times were disrupted by conflicting appointments and staff changes. An aide explained that when the staff was reassigned grooming tasks could slip through the cracks. June was distressed by the erratic schedule and long periods between bathing.

In the skilled nursing and assisted living facilities June had more clothing options but little help. One morning she phoned me from Florida, “You won’t believe this. The aide came in at 5:30 and dressed me without a brassiere. She said there was no time for that.” The aides condescendingly chided June when she specified coordinated colors in her outfits.

Wanda tried to ease the situation by helping June brush her teeth, wash her face and comb her hair when aides were unavailable. Though Wanda was unsuccessful in arranging site visits for June’s hairstylist, she took June to the hair salon when June was well enough. These rare outings were a highlight for June.

In the rehab facility, where the therapists and patients were indistinguishable in their sloppy sweat attire, June stood out in her snappy outfits. During my visits to Florida, we read fashion magazines to learn new trends and we went shopping. On one of our final outings, June spotted a rose-colored leather jacket in one of her favorite shops. She was confined in her wheelchair, weak and unsteady. But when the sales woman informed her, that to try on the jacket, she was required to stand June suddenly was motivated. “Well, then, I guess I will stand” she agreed. Studying her image in the mirror she said “I will need a lipstick with a little more blue in it to go with this.”

Even when June was disappointed by the condition of her body she was not deterred from striving to maintain her best possible appearance. Fashion was essential to June’s quality of life and it far outweighed the routine management of her medical problems.

Paying attention to a patient’s concerns is a fundamental to treating them with respect and ensuring their dignity. Respecting June’s efforts to maintain her appearance would not have cost anything but would have made a huge difference in her final year.

“Be the change you want to see in the world.” M. Gandhi

#Medicare #Aunt June #assisted living #skilled nursing #rehab #quality of life #medical management

Medicare: This Business About “Free"

Before my 95-year-old Aunt June began her seven-institution, 12-month, stint under the Medicare system, June had considered herself extremely healthy. After all, she had never suffered from a major disease. But was her perception accurate?

Her doctor had assured June that she would live to be 100. A former pharmacist, his only recommendation was that she begin a Lipitor regiment at the age of 93. He was inattentive to her concerns. “He never hears a word I say” June complained to me. “I have no energy and I’m having trouble distinguishing changes in level so it’s hard for me to walk up and down stairs.” It was obvious to everyone but June, that her mobility was impaired. Her gait gradually turned into a shuffle and she tried to hang on to people and objects when she walked. Then June began to fall. “It’s no problem at all,” June told me. “Those EMT men are so strong and good looking – they just pick me right up! They asked if I wanted to go to the hospital and, of course, I said no. There’s nothing wrong with me.” But after a certain number of “pick-me-up calls” to 911 the Florida authorities stepped in. After giving June a thorough assessment, she was strongly encouraged to make accommodations and begin an occupational and physical therapy program to improve her balance and walking. This was June’s first real encounter with Medicare. June was thrilled to learn that the majority of services were “free” because of her Medicare and supplemental insurance policies. She and her friend, Wanda, began researching additional Medicare opportunities that might be available. I was startled when Wanda called me in Virginia to suggest I order a motorized scooter for June. “She doesn’t need that” I told Wanda. I had visions of June, not especially savvy about machinery, crashing into things and falling off. It was the worst idea ever. “But it’s free – Medicare pays for the whole thing!” Wanda told me. This wasn’t the first time the issue of Medicare fees had come up. “I don’t want to hear that phrase again. Nothing is free. Every Medicare service costs money - even if you are not the one paying for it. This is not medical Christmas” I told Wanda. June is not alone in her perception that Medicare services are “free.” Unlike patients outside the Medicare system, beneficiaries, especially those with comprehensive supplemental insurance, are often unaware of cost. Now, even Medicare itself is advertising “Free Services.” As of January 1, 2011, a number of tests and treatments, such as colonoscopies, mammograms and pelvic exams, became available to beneficiaries at no charge. Medicare beneficiaries can also now get an annual no-charge "wellness visit" with a health-care provider that is supposed to provide a baseline health assessment. I applaud preventive healthcare and hope it will lead to fewer crises. It’s important to make the most effective medical management available at a reasonable fee. But I object to insulating beneficiaries, who are also medical consumers, to the cost of care. Medicare is being exploited on many fronts and consumers must be informed in order to make responsible choices. Especially in an era of economic crisis, everyone needs to be stewards of our common resources. We have the responsibility to use them wisely and preserve resources for all. There is no free lunch. The author, Candice Rose, is a specialist on the topic of aging and elder care. She is currently serving as the Chairwoman of the Arlington County Commission on Aging in Virginia. You can follow her on Twitter at www.twitter.com/CandiceRose “Be the change you want to see in the world.” M. Gandhi

#Medicare #health care reform #Aunt June #Cost of care #financing health care #insurance #aging #durable equipment

Medicare: Changes Beyond the Vocabulary ?

A paradigm shift in health care is happening at every level from medical providers to patients. Dave deBronkart refers to the “Year of Patients Rising” during his recent TED talk. He states that “patient is not a third-person word. Patients must take control of their cases and define the terms of their success.” Dave became part of the E-Patients Movement, a group of patients who are equipped, engaged, empowered and enabled. deBronkart, aka “e-Patient Dave,” stresses that “the patient is the most underutilized resource in heath care. If all patients could talk with one another and know their own health data they could make health care better one e-Patient at a time. If patients are allowed access to their raw data and could share it with others great strides could be made in medicine.” Patients would not only have the opportunity to improve their own health status – they would contribute to overall medical knowledge benefitting the community. E-patient Dave is focused on acute care but what about managing chronic disease? At the June 27, 2nd Innovative Communities Summit held on the Georgetown University campus, Kathy Greenlee, posed the rhetorical question “Is health reform about the acute care-medical model?” She answered “YES. What we need now is integration of all services.” At the summit we learned that “Person-Centered Living” will replace “Person-Centered Care.” Patients in this system will learn how to accomplish their own medical management. The new vocabulary is designed to encourage best outcomes. For example, PT will no longer mean physical therapy but personal trainer. And how will health care reforms apply to Medicare? A new model “The Care Support Model” will replace the “Medical Model.” Medicare was established in 1965 to cover acute care after a patient was sick. Now, due to medical advances over the past 46 years, patients can learn to avoid and manage chronic conditions with the proper support. The Care Support Model integrates long-term health care and social services at the community level and will eliminate fragmented health care. An essential difference is a focus on the quality of an individual’s life vs. his health status. Hopefully, proactive preventive management will lead to fewer crises and will delay institutionalization. But what happens when institutionalization is unavoidable? Care between hospitals, medical providers, nursing homes, long-term care facilities and residences will be integrated. “Care Transitions” including community resources will enable seamless care between institutions and community. Let’s hope that the changes don’t start and stop with the vocabulary and are merely the reflection of the changes in the underlying systems. The author, Candice Rose, is a specialist on the topic of aging and elder care. She is currently serving as the Chairwoman of the Arlington County Commission on Aging in Virginia. You can follow her on Twitter at www.twitter.com/CandiceRose. “Be the change you want to see in the world.” M.Ghandi

#Dave deBronkart #E-patient #aging #greenlee #health care policy #health cre reform #home & community based services #medicare

Medicare Reform: What Kind of Change Is Needed?

Navigating the Medicare system was a challenge to both 95-year-old Aunt June and to me, as her caregiver. Though I suspected her treatment problems were not unusual, it was impossible to know if her case was an extraordinary example, completely typical, or somewhere in-between. Recently I learned that the hazards she confronted are happening to many patients throughout the medical system. The 2nd Innovative Communities Summit convened at the Georgetown University campus on June 27, to raise awareness about resources which reduce avoidable rehospitalizations and improve care transitions. I’m glad that experts are working on solutions but I’m sorry we’re still in the talking phase on this objective. Participants at the summit agree that our current system is incentivized in all the wrong ways and that patient experience is considered dead last. Everyone also agrees that health care delivery must be changed to reduce all harm done to patients. In particular, this means that: * Hospital-acquired infections must be reduced * Rehospitalizations must be avoided * Transitions between institutions and homes must be improved June could have benefitted from all of these initiatives but especially from an integrated approach to her care. With a focus on case management and supportive services in her long-term-care settings June may have had a successful final year. By focusing on June’s experience I hope to illustrate how these problems in our health care system create misery in patients’ lives and waste huge amounts of resources. It is time to make changes to prepare to meet the needs of aging baby boomers. Let’s not forget that each person deserves a meaningful and dignified end-of-life experience. To learn more about these issues read the report from the 1st Innovative Communities Summit: Innovative Communities: Breaking down barriers for the good of consumers and their family caregivers: http://www.ltqa.org/wp-content/themes/ltqaMain/custom/images//Innovative-Communities-Report-Final-0216111.pdf Check out the new Center for Medicare & Medicaid Innovation: http://innovations.cms.gov/ Next: Person-centered living vs. person-centered care The author, Candice Rose, is a specialist on the topic of aging and elder care. She is currently serving as the Chairwoman of the Arlington County Commission on Aging in Virginia. You can follow her on Twitter at www.twitter.com/CandiceRose. “Be the change you want to see in the world.” M.Ghandi

#medicare #health care reform #Aunt June #hospital-acquired infection #rehospitalizations #care transitions #aging #baby boomers #ltqa #long-term care

The Medicare System: A review of Aunt June’s experience

7 Institutions, 700 billable services, 172 days: Is this success? June had a simple expectation when she arrived at the emergency room: The doctors, medical authorities, would cure her pneumonia and send her home in a day or two. But June developed complex problems almost immediately. Her pneumonia was stubborn and prolonged. Her condition was then compromised by institutionally-acquired infections which damaged her internal organs. Certainly, June enjoyed a fully medicalized terminal year with unrestricted access to care. However, the Medicare system was impossible to navigate. Most physicians remained nameless to June; none had time to develop an ongoing relationship. Services which could have made a significant difference in her daily life were elusive. When I asked June’s hospital-care-supervisor who was in charge of June’s care, she told me “Medicare. Medicare’s in charge. She’s in the Medicare system. They decide.” But despite hundreds of therapeutic interventions designed to improve her fitness, June never regained even a fraction of her previous ability. Why did June persist with all the interventions? June wanted to live at any cost. She not only expected to recover, she expected to thrive. June believed that medical professionals were experts with her best interest at heart. She didn’t realize that she had a choice about any prescribed procedure or medicines. June was unconcerned about financial implications. Though she would have abhorred spending her money on treatments, June believed, correctly, that Medicare and her supplemental insurance would cover all costs. June felt entitled to every resource possible. I don’t know whether June’s treatment was appropriate or not. Certainly, she was victimized by avoidable infections. Medicare is apparently coming to the same conclusion based on a recent move to withhold payment for hospital-acquired infections. Had the pneumonia been treated effectively and had she not contracted institutional infections maybe she would have recovered. If her care was approached as a team effort (and I saw no evidence of this) her team was at the bottom of the league. If her care had been a coordinated “team effort” maybe the outcome would have been better. I wonder who benefited most from the terminal care. Food and care which could have improved the quality of June’s life were hard to come by but there seemed no end to elaborate diagnostics. A physician friend told me that June should have simply been given antibiotics and left at home. Everyone knows that hospitalization is expensive and that old people tend to need a lot of it. But how much is too much? At what point is the patient no longer served? What I do know is that June had a miserable final year. She endured an expensive but dismal quality of life in a confusing array of institutional settings. She died disabled, lonely and bored. She was baffled by her demise which stood in stark contrast to what she had imagined: Living a productive and fulfilling life right up to the moment of some instantaneous death. When I called to let people know she had died I was puzzled by their responses. “Oh, I hope that’s the way I die” was a common sentiment. Having been through it once, I hope that’s not the way I die.

#Aunt June #Medicare #aging #death #dying #institutionally-acquired infections #long term care #terminal care #pneumonia #Medicare reform #health care policy

Aunt June’s Final Phase in the Medicare System

After being admitted to a third hospital in less than a year, a new team of pulmonary experts, cardiologists, infectious disease and cancer specialists once again subjected 95-year-old Aunt June to rigorous testing, scanning and probing. The results from the extensive array of diagnostic procedures showed that June’s pneumonia and other infections had never been fully resolved and new medical issues had emerged since her initial hospitalization. To solve her problems they ordered more medications. The 13-day hospitalization may have managed her illness but it left June weaker than ever. When it was time for discharge she was forced into another transition. Though assisted living facilities can often offer comparable care to nursing homes, June couldn’t meet the criteria even given the highest level of care. Not allowed back to her assisted living apartment, June was faced with her 7th institution. June chose the third nursing home, a place of little hope, solely on location. Inconvenient and far from June’s home, it was down the street from her last reliable friend, Wanda. The building was low and old, patient rooms small and dark. Because the facility lacked a community social room, the staff arranged wheelchair-bound-patients at a central corridor intersection for social activities. Mobile patients zoomed their wheelchairs around the outer hallway corridor for exercise and entertainment. Unkempt dementia patients wandered about, some silently, others talking to themselves or a captive audience. June’s inner social circle was reduced to a tight and complicated threesome. Wanda, caregiver to her own 93-year-old mother, managed to visit June daily. Wanda’s mother, suffering from dementia due to stroke, regarded June with affection and envy because Wanda had grown to love June as a second mother. June thought Wanda’s mother sweet and, of course, she loved Wanda. But the demanding routine took a toll on all of them. June was growing impatient, frustrated and resentful of her situation. She occasionally lashed out at Wanda. “I just hate being beholden to Wanda for everything!” June told me. “I can’t wait to get back to my apartment.” Daily life was a more extreme trial here than in the previous six institutions. June’s overall condition was more tenuous, and she had trouble remaining optimistic. “I am defeated” she told me at one low point. But finally, after 39 days in the 7th institution, and after 172 days total in all medical institutions, she was informed that the correctable medical problems had been solved. June was relieved to finally return to her assisted living apartment. June reestablished routines, resumed physical therapy and appeared medically stable. She resumed planning her return to her real home. One day, after she had been out of the nursing home almost 7 weeks, she called me to see if I’d received photos of my sister. Barely able to contain her excitement June said “Martha’s wearing the outfit I selected for her awards ceremony! I’m so relieved that she presented herself as the executive she is.” This was to be our last conversation. Later that evening, June complained to an aide of chest pressure and difficulty breathing. The aide adjusted her pillow and tried to make her more comfortable in bed. June died a few hours later, alone. The facility director’s call startled me from sleep at 1a.m. I was annoyed, wondering what new crisis had developed. That this was the final call was both shocking and a relief. Shock at the abruptness – we had just talked. And relief, that she was released from her ordeal. Next: A Great Way to Die? The author, Candice Rose, is a specialist on the topic of aging and elder care. She is currently serving as the Chairwoman of the Arlington County Commission on Aging in Virginia. You can follow her on Twitter at www.twitter.com/CandiceRose.

#Medicare #aging #assisted living #skilled nursing facility #dying #Aunt June

Meet Aunt June, Patriotic American (June, center, with DC friends) Though June lived much of her life in a midsized, Midwestern town, she was cosmopolitan in outlook. She was well educated, grounded in history and used travel to broaden her perspective. When national holidays roll around I remember June’s dismay that commemorative occasions have been turned into sales-shopping days. In Blue Island, her hometown, everyone celebrated the 4th of July with parades, picnics, and fireworks. During WWII, June moved to Old Town Alexandria, VA near the torpedo factory. Because of her love of history, June was thrilled to work at the National Archives in Washington, DC where she had direct access to original documents. Naturally, she worried about her brother and many friends, who were overseas, fighting in the war. She endured the hardships shared by everyone in her generation. But at the same time she enjoyed her life during that period. In this photo, taken on February 3, 1945, a few months before the end of the war, June and her friends are having fun at a Washington restaurant. Next: The Final Phase of Caught in the Medicare System The author, Candice Rose, is a specialist on the topic of aging and elder care. She is currently serving as the Chairwoman of the Arlington County Commission on Aging in Virginia. You can follow her on Twitter at www.twitter.com/CandiceRose.

#Aunt June #aging #WWII #WW2 #history #travel

Meet Aunt June – Before She Was Caught in the Medicare System I planned to write about the final phase of 95-year-old Aunt June’s institutionalization but have decided to take a breather this week. The process of writing about her personal experience is not only a great deal of work, it is emotionally draining. Today, I want you to meet June – at a prime time in her life. June was the first and, at the time, the only woman executive at Eastern Airlines to handle corporate business travel. In fact, her job was to help create the need for business travel after WWII when Ricky Rickenbacker was at Eastern’s helm and the Mad Men era was in full swing. As the only woman executive, June had to out-compete the men. She won the annual prize for highest sales, but her immediate boss didn’t want a woman winner. He awarded the prize to the much lower-achieving candidate. When June objected, her boss proposed a coin flip. June won the coin toss also. This picture shows June leaving for her 3-week trip around the coast of South America. Next: The Final Phase of Caught in the Medicare System The author, Candice Rose, is a specialist on the topic of aging and elder care. She is currently serving as the Chairwoman of the Arlington County Commission on Aging in Virginia. You can follow her on Twitter at www.twitter.com/CandiceRose.

#Aunt June #Medicare #Aging #health care policy

June Enters Her Third Hospital. Is this it?

Aunt June called me in Virginia and she was furious “It’s entirely Dr. Allen’s fault I’m in this predicament. He’s never even checked to see what happened to me. Why aren’t you angry with him? ” my 95-year-old Aunt demanded. Dr. Allen, her regular internist, had seen June in his office and done an x-ray four months ago. The x-ray showed a shadow across her lung but the doctor had sent her home without treatment. The following morning June was taken by ambulance to the ER. She hadn’t set foot inside her home since. I was angry. But I was angry that routine treatment for pneumonia had escalated into a series of life-threatening crises caused by institutionally-acquired infections and complications. I could see nothing to be gained by venting at this point. “We need to focus on making the best of your current situation” I told June.

For the next six months, from summer to winter, June tried to recover. Her medical conditions were routinely monitored and she continued physical therapy. No matter what she did she couldn’t make any progress. Her chronic conditions piled up and she was beset by new problems. She developed a cancerous growth on her scalp; she lost interest in eating, and began to lose weight; her teeth deteriorated. Her therapists offered new diagnoses “She shuffles her feet as if she has Parkinson’s” and suggested that she had chronic obstructive pulmonary disease. We were advised to see specialists.

June was dissatisfied with her doctors. “It’s worse than being ignored. They act as if they are repulsed by me. They not only don’t want to touch me – they don’t want to look at me.” June was unable to control the saliva leaking out of her mouth, her eyes were often gooey, her nose runny and the surgical wound on her scalp oozy. Even though she always had a handkerchief handy she couldn’t keep up with her body. Her bathing schedule was irregular, disrupted for every possible reason.

“I’m so tired of fighting” June admitted to me. She couldn’t talk about her own death but June began to talk about the deaths of others. “My mother threw a party and attended another celebration the weekend before she died. She told me she had chest pain, she felt sick, and she was having trouble breathing but she was running around! She was very uncomfortable – it went on for a few days. I didn’t do anything to help her! Now, I see, I should have called the doctor.

“Remember Shorty? She went out shopping for furniture and suddenly dropped dead! Her ungrateful niece didn’t even hold a service. She just collected all Shorty’s new stuff and had it shipped to her home!”

June depended heavily on a longtime friend, Wanda, for relief from her daily routine. Wanda cheered June up with food treats, flowers and walks in her wheelchair. Wanda’s husband, Gene, occasionally took June out to a restaurant or shopping. Wanda came to treat June as a member of her family and included her in holiday plans. I was in Virginia serving Christmas dinner to my family, when Wanda called “We’re at the ER. June felt so sick we didn’t have any other choice.”

What soon became obvious was that her original pneumonia, the hospital-acquired infections and complications, had never been cleared and June was in medical crisis. The new medical team was determined to finally solve the problem. She was admitted to a third hospital, the sixth institution in a year, for 13 days. Following her hospitalization, June was too weak to return to her assisted living facility and was forced to enter a new skilled nursing facility, her seventh institution, for 39 days.

Next: When Does It End?

#medicare #aging #institutionally-acquired infection #pneumonia #Aunt June #rehab #physical therapy

How Long Can Living Be Assisted?

95-year-old Aunt June survived 4 institutions over the last 120 days but was now deemed incompetent to live independently. She was forced to relocate to a 5th institution, an assisted living facility. The location was tantalizingly close to her apartment, in fact, just outside the gate of her 55+ active adult community, 7 Lakes. June could view the golf course with flocks of ibis nibbling the greens from her balcony. She hoped to return to her condo of 30 years quickly.

June’s friends had seldom visited in the four distant institutions. Unfamiliar with the locations and often ill themselves, they could no longer drive and lacked transportation options. Now that she was close by June anticipated a steady stream of friends to both visit and to take her on outings.

However, in earlier years when June’s friends moved to assisted living facilities, she was loathe to visit them herself. “It’s so depressing to see Annie in that place – I really can’t force myself to go there” she told me. Now she experienced the same reaction from her friends.

“I want to go home” became a constant plea. She begged her friends to take her back to her apartment. Her friends, frail themselves, weren’t capable of handling her. Distressed, they called me in Virginia. “Absolutely not!” I told them. Not only was the condo not prepared for wheelchair use, it was a mess. Movers had transferred her favorite furnishings to her new assisted living apartment. The few remaining possessions were disorganized, the vacant space tired and shabby.

June’s new environment was a significant improvement. She was comforted by her familiar belongings and relieved to escape the chaos of the hospitals and nursing facilities. She no longer had to contend with unpredictable roommates exhibiting bizarre behaviors, the sounds of uncontrolled wailing, the never-ending testing, poking and prodding, the loss of personal effects and the lack of privacy.

The mounting challenge, over the next six months, was how to fill the time outside physical therapy and medical appointments. Mostly, June was isolated in her apartment and suffered unrelenting boredom. Macular degeneration and eye infections hindered reading and watching television. Malfunctioning hearing aids and ear infections hindered phone conversations. Even interpersonal conversations were tough. Many aides weren’t fluent in English. Staff seated wheelchair-bound residents together for meals at large round tables - artificially increasing the distance between hearing-impaired individuals. June disdained organized social games. June’s condition went up and down. Some days she would inform me “I’m really on the beam!” and other days “I’m just lopping around.”

On my visits to Florida we did our best to focus on her dreams about the future. I grew adept at hauling the wheelchair in and out of cars as we visited her favorite restaurants and went shopping – the main pleasures she continued to enjoy. She hadn’t lost her sense of style. Her lipstick was always perfectly coordinated with her outfit. Strangers would exclaim “You look fabulous!”

But did her appearance belie her frail condition? Occasionally, in public, June and I would be approached by strangers who would exclaim that June was “sweet” or “dear” or “that we were darling.” She found these encounters disturbing “Those people must have a different view of me than I do of myself.” Over a scotch at dinner one evening in her favorite restaurant she asked me “How am I reduced to this? I can’t really understand what happened to me.”

Next: Christmas Day: Is this it?

#medicare #assisted living #skilled nursing #hospital #Aunt June #macular degeneration #hearing aids

Assisted Living: Transition #5

Shuffled through four institutions over 120 days Aunt June was deemed ineligible for further Medicare treatment in a nursing facility. She was anxious about the disruption telling me “It’s very confusing moving to all these strange places.” Her case manager refused to authorize a move back to her own apartment and wouldn’t consider her as a self-paying customer. 95-year-old June was forced to make a fifth transition.

June resented footing the bill for her long-term care. Managing 24-hour care in her apartment was out of the question. Also out of the question was any assisted living arrangement which required a large down payment. She settled on a facility which charged several thousand dollars as an entry fee. She was alarmed by the $5000 monthly fees but viewed the situation as strictly temporary. She was determined to recuperate and return home or, possibly, move to Virginia and live with me.

In contrast to the other institutions, this facility was up-to-date, cheerful, and in a convenient location. June, an interior design buff, delighted in recreating her original apartment within the new space. The process was different though “I’m not really doing anything – I’m telling everyone else how I want it and then watching them do it.”

While June focused on decorating her space in Florida, I completed her registration paperwork in Virginia. Tucked into the documents requiring my POA signature was a preprinted form stating that June suffered from Alzheimer’s disease. When I demanded to know why the form was included I was informed that it was simply a routine error. But the matter was not settled and I was repeatedly requested to sign this form.

On my next visit to Florida, June and I stopped by the nursing station to review June’s medical records. The aide-on-duty was clearly taken aback by my request and disappeared to find a supervisor. The supervisor told me “You can’t look at those records. They are strictly for institutional use. Institution to institution only.”

I knew this was, at best, inaccurate. Hoping not to upset June I asked “Please explain to me why you are repeatedly requesting that I sign a document stating June has Alzheimer’s disease.” The administrator insisted June’s chart indicated the diagnosis. When I demanded she confirm the exact wording she poured over a massive binder finally uncovering “mild cognitive impairment” in the thick documentation of one hospitalization record.

Several questions occurred to me. Which one of the dozens of doctors who cared for June made the notation? Did it occur to the doctor that “mild cognitive impairment” could be a transitory condition caused by the dozens of medications prescribed simultaneously to a tiny woman? Or that “mild cognitive impairment” could be a side effect of debilitating pneumonia and hospital-acquired infections? What did the facility have to gain by a signed statement? None of my questions had answers but I did learn that once a notation appears in a medical record it is permanent.

Despite the change in location no discernable difference existed between the level of care June needed in the skilled-nursing facility and in the new assisted-living residence. She still depended on aides for all her daily activities. Her therapy routine didn’t change either. Because June was categorized as medically healthy with the potential for improvement she was eligible for many types of ongoing therapies through the Medicare system. The rehab center, a standalone business, operated within the AL facility. Aides or therapists would transport June in her wheelchair to and from therapy most weekdays.

Therapy was the highlight of her day, often the main social event, though she thought many of the activities lame. “I don’t know why they persist in these stupid exercises.” As in the previous facility, rehab wasn’t available on the weekends. “I’m completely immobile all weekend! By the time Monday comes I can hardly do anything all over again! I have nothing to do on the weekends but sit and stare!” Periodically, Medicare would review June’s status before reauthorizing therapy. In the interim she was wheelchair-bound for two weeks or more losing all progress.

When June entered the first facility for pneumonia she was able to walk and live on her own. Now, four months later, she was unable to move herself in her wheelchair; and unable to transfer herself from her wheelchair to another chair, her bed, or the bathroom. Despite numerous interventions from trained therapists she never regained the ability to move herself from one place to another. I later learned that patients must be independently mobile to qualify for assisted living. June should never have been admitted in her condition. But in the LTC industry exceptions can be made, particularly when it’s in the best interest of the institution.

Next: How long can living be assisted?

#Aging #Alzheimer's #Assisted Living #Aunt June #Medicare #Seniors #long term care #skilled nursing facility #physical therapy

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