Caring for Parents

I’m Alan Stanford, the founder and CEO of My Health Care Manager.  When my wife and I were called into nearly full-time caregiving for three of our parents, we had no idea how complex, confusing and problematic the health care system is - especially for older adults and their caregiving families.  To help with this enormous problem we created a national company focused on truly understanding the issues and options of aging and sharing our knowledge and guidance with others dealing with these difficult issues.

If you'd like to learn more about me, please visit our website.

Congratulations to Jim Kerr, My Health Care Manager’s Vice President of Business Development and Marketing.  He was recently honored as a finalist of Indianapolis’ Best and Brightest Award in the Health & Life Sciences category.  To learn more about the Best and Brightest Award, visit www.indysbestandbrightest.com.  To learn more about Jim, visit www.myhealthcaremanager.com/aboutUs_manageteam.asp.

We’re pleased to announce an agreement with Anthem and Wellpoint, which was covered in the August 24 – 30 issue of the Indianapolis Business Journal.  My Health Care Manager’s Eldercare benefit (which provides senior care management and caregiver support services to covered employees) will be offered in Indiana through the Anthem 360 Health program.  After the Indiana pilot, My Health Care Manager’s benefit will be rolled out by Wellpoint to all 14 states in which they operate. 

The benefit will help working caregivers balance the challenge of providing care to a loved one with work responsibilities, and also help improve the care and quality of life for the senior.  Employers assisting their employees by offering the Eldercare benefit look to reduced costs associated with working caregivers such as absenteeism, workday distractions, and time taken off to provide care.  My Health Care Manager provides an experienced nurse, a Health Care Manager, to guide the caregiver through their personal situation – and can assess a senior in the home anywhere in the U.S.

To learn more about Eldercare benefits for your business, or geriatric care management services for your family, please contact us at (800) 499-8020.

 

While qualifying hospitalization rules vary for long term and home health insurance policies, sometimes any portion of a day while admitted counts as a full day in determining eligibility.  But for Medicare coverage, REMEMBER the three day rule: In order to received skilled care post hospital such as rehabilitation benefits, the 3 day rule is strictly defined as being admitted for 3 consecutive midnights. 

While nearly all physicians and hospital workers know the rule, there are times when a hospital case manager or “utilization management” social worker or nurse recommends discharge before the qualifying third midnight.  If the decision is subjective or a case exists for a slightly longer stay, seniors and caregivers should discuss all factors – including the loss of some Medicare benefits for rehabilitation – with the physician before the discharge occurs.

While nobody should remain in a hospital any longer than necessary, often there are subjective factors that influence discharge recommendations.  A well-advised senior patient and his or her caregiver need to understand the economic significance of the discharge decision and address any concerns with the health care provider.
 

With open enrollment available through the end of 2008, it might be wise to check out personal options available in Medicare Advantage insurance programs.  The first step is to see which, if any, Advantage programs are available in the county of residence.  The next step is to see which medical and hospital networks are available through the competing Advantage providers.  Then it’s time to compare charges.  Many Advantage plans also have options for Medicare Plan D prescription medicine coverage, but as with all Plan D programs the available medicines, the “formulary,” the deductible and the co-pays have to be evaluated.

The comparison process can be complex and confusing to an older adult, so caregivers and friends can be especially helpful.  Medicare’s Web site, www.medicare.gov, is improved and helpful, and most state governments as well as many not-for-profits serving seniors offer individualized help programs.

Large savings are often possible with Advantage programs over older “Medi-gap” and Medicare supplemental insurance policies, but the terms of coverage need to be carefully compared before considering a switch.

Changing public policy may affect the popularity of the Advantage programs if federal payments to insurance companies offering Advantage products are significantly reduced. 

One of our greatest challenges as caregivers for our aging parents is getting an accurate and complete understanding of their health status.  Unfortunately, it is difficult to find a single source of unbiased guidance to help understand and coordinate our parents’ complicated issues of aging.  A big reason for this is the way the U.S. health care system works.  No health care provider is reimbursed for spending the time necessary to holistically understand all of the issues involved in a patient’s well-being.  With seniors covered by Medicare, the payments for allowable claims are for specific services delivered for single or closely-related issues.  This reality requires older adults to deal with multiple health issues, care providers, prescription medicines, and care plans by themselves or with the help of a trusted caregiver or a competent geriatric care manager.  For the few that can afford the charges, some physicians operate “concierge” practices that charge annual flat fees for unlimited access for primary care services and coordination with specialists.  However, these concierge practices are only able to serve a very small number of seniors, and the concept itself is subject to significant differences of opinion among physicians and health policy specialists.

We are finding that understanding and coordinating these complexities in our eldercare services is one of the greatest values we add for seniors and their families.  If you find yourself in a role similar to what we do, it is wise not to underestimate the difficulty and time it takes to gain a holistic view of an older adult’s health status.   Accompanying seniors to their health care providers’ appointments and participating in the debriefings at the end of the office visits is an excellent way to gain direct knowledge.  Taking good notes or (with the provider’s permission) recording the debriefing allows for accurate recollection when memories often fail to remember the details.  Discussing the various physician’s care plans with your parents’ primary care physician at an office visit can further help with a caregiver’s difficult job of gaining the holistic view necessary to be effective in your critically important role.

Surveys show what most everyone already knows – seniors, by almost a 90% margin, desire to continue living in their current home rather than moving to an alternative living situation.  Many believe they can’t afford an equivalent senior living residence, but most do not want to leave the comfort and memories of their home.

Barring safety or health issues that would mandate a move, there are many ways to provide services that allow staying in the home – at least for awhile.  Some solutions are more expensive than moving to a senior living community, so if economics are an issue the alternatives need to be carefully compared.

The least expensive service (and not medically helpful) is a companion.  Hired directly, companions can be found in the $9 to $13 hourly range, and in the $14 to $20 hourly range if hired through an agency.  Important considerations including screening and background checking, back up for absences and vacations, supervision, taxes, insurance and turnover come in to play when making the decision between independents and agencies.  We have intervened in abusive companion cases as well as screened potential solo companions and agencies to help families arrive at the decisions they prefer.  According to the MetLife Mature Market Institute, the national average for agency-provided companion/homemaker services is $18 per hour.  Many times a companion can be utilized for shorter periods of time to provide assistance and friendship for shopping, errands, cooking or simply conversation. 

When higher skilled services are provided, they start with a certified home health worker and move up through Certified Nursing Assistants (CNAs) to Licensed Practical Nurses (LPNs) and Registered Nursed (RNs).  The national average is $19 per hour for home health aides (from licensed agencies) according to the MetLife Mature Market Institute.  In some areas, the average hourly rate is less than $13 and in other areas, it is more than $30. 

It’s important to assess the skill level and coverage needed to provide the necessary support for seniors living in their homes.  My Health Care Manager does this assessment using a Registered Nurse working with one of our 5,000 networked RNs throughout the U.S.  Using an unbiased professional helps in the analysis so the result is not skewed to a preferred alternative.

There will be more about this issue in my next blog.

Continuing on the family communications theme from my last blog, I want to share our experience with a wonderful product that helps family and friends easily communicate with an older adult.  The product and its service is called Presto, and it’s a one-way email product.  Someone (my wife in our case) serves as the manager to allow approved people’s email addresses to send messages and photos to the senior’s Presto email account.  The community can be as large as desired with adult children, grandchildren, friends and neighbors all authorized to send.  This “authorized sender” status eliminates spam and solicitations which is a great value Presto provides in its ongoing service.

At the receiving end is a HP ink-jet color printer with a dial-in modem that has been simplified for ease of use by a senior.  Adding paper is easily done by my mother and father-in-law, both 95, but one of the family changes the ink cartridges when necessary.  The Presto service dials the printer several times a day and transmits whatever is has received.

The result is the “magic” that appears from friends and family whenever it is sent.  My father-in-law has saved every message and picture he has received over the last 2 years (we bought both of them units at Christmas two years ago), and he eagerly awaits new messages.  The same with mother. 

Since My Health Care Manager is independent of all vendors and health providers, we don’t make a penny on the recommendation.  However, the Presto people will include an additional cartridge (HP95) and 2 months’ free service if you order it from www.presto.com/myhealthcaremanager in recognition of our support.

As the complexities and concerns of aging continue to challenge older adults and their caregiving family members, the resulting stresses call for the best possible family communications.  Luckily for our family, effective and frequent communications have come naturally.  But for many of the situations we have encountered in our helping others, due to life-long reasons and attitudes, communications are difficult and incomplete.  Sometimes it is the senior who shuts off attempts of family members to discuss key issues including housing preferences, medical support, finances and health care support.  And at other times adult family members don’t communicate effectively and build defensive barriers in the process.

Here were our major challenges with Mother:

• Deciding to stop driving.  Following her rehabilitation from her broken hip it would never be “life as usual.”  Fortunately, she recognized the changes and voluntarily offered to stop driving and sell her car.  Had it not gone the way it did, we would have faced the difficult challenge of convincing her to part with an extremely important part of her independence.
• The decision to sell the house and move to a senior living facility went well even though we had promised her she would never have to move in her earlier situation.  We were fortunate to be dealing with a logical and fully functioning senior.  I now see cases where the housing decision, if opposed, threatens to destroy family relationships.
• The third big decision was for her to turn her finances over to me.  We phased it to have  her write checks as long as desired until she voluntarily agreed that it would be even better if all aspects of her finances were handled for her.
 
Our Web site, www.myhealthcaremanager.com, has helpful hints for effective family communications.  We also featured communications in one of our Update emails.  You can read the Family Communications issue of the Update by clicking here.  You can also subscribe to the Update eNewsletter to receive future monthly issues by clicking here.

There are several innovations available to help seniors organize and remember to take their medicines.  Although not necessary for many older adults managing multiple medications, some can benefit by having their medicines pre-sorted and dispensed in pouches that are organized by time of day and day of week.  We’re moving to a system like this as Mother’s filling a 28 compartment pill tray with 14 prescribed medicines and OTC pills each week becomes even more challenging with her aging.  This pre-loaded dispensing solution has been used in nursing homes and some hospitals for several years, but some companies are now offering the program to individuals in their residences.  But before making any change of this type, be sure to check the Medicare Part D prescription medicine plan to be sure the vendor is recognized in the insurance company’s plan. 

Other higher-tech aids are in development that include pill trays that automatically open at the right time and track results (although it is impossible to remotely know if the pills were actually taken).  We’ll be seeing more use of technology in assisting with eldercare- something I imagine caregivers will welcome wholeheartedly.  Many developments are underway by inventors and large health technology companies, and I’ll use a future blog to describe some of the more promising ones.

Even though Mother was safe and secure in Independent Living (IL) in a Continuing Care Retirement Community (CCRC), we quickly realized that managing her prescription and over-the-counter (OTC) medicines was a challenge of its own.  With 10 prescription medicines and 4 OTCs, the variables of continuing supply with many expirations and prescription renewals combined with generic vs. brand names, dosages and time-of-day preferences were an overwhelming task for her … and her caregivers!  Fortunately, we devised a Weekly Schedule and medicine reconciliation program that allowed her to manage her own meds (with our assistance) that has now become a My Health Care Manager computer-based decision aid.  However, loading her pill tray every week and managing the time for her diabetes blood sugar tests and consumption of the pills became (and remains) an ongoing challenge.  Until becoming exposed to the issues of polypharmacy and older adults, I didn’t understand that normally-prescribed medicines and dosages affect many seniors differently – sometimes even causing symptoms such as confusion and loss of balance.  Even multiple medication regimes that were tolerated in the past can at any moment cause problems or unwanted symptoms.

When trying to get my hands around the multiple medications challenge, it became clear that no single health care provider had information on everything that was being taken by Mother.  Each knew what he or she had prescribed, but the rest of their knowledge was based on answers given to the common question, “What medicines are your taking?” at office visits.  Often confused over generic vs. brand names, dosages, and omitting OTC products, older adults often can’t be counted on to correctly answer this important question.  In developing My Health Care Manager’s suite of decision aids, we added a letter that the senior can choose to send to all of their health care providers (or only to the ones they designate). The letter lists the providers, their prescribed medicines, and any other OTC products being taken by the senior.  Several doctors have remarked that this simple summary of information is not available from any single source in our health care system.  You might try this important task on your own if you are immersed in eldercare.  We’ll have more on managing medicines in my next blog.

Again facing an important issue with no trusted advisor, we began meeting with the sales representative for the nursing home where she had several friends.  (Little did we know how many options exist even once a “retirement home” direction is chosen.  Now it’s clear that there are major differences in the economics, quality, safety, security, staffing, meals, ancillary services, transportation options, continuing care availability and long term options among the retirement community  and alternatives.)  So our meetings quickly focused on Mother’s health and economic situation that could meet their entrance requirements.

We didn’t even look at many of her alternatives to living alone.  We now know the options include an independent living community (IL), a continuing care retirement community (CCRC), a “senior-friendly” apartment or condominium, a neighborhood shared home, and several others.
And within the options are many varieties including for-profit or not-for-profit, public or private, local or nationwide chains, and the “scorecards” they all receive from their respective state boards of health.

In the economics criteria alone, we now understand there are monthly rental, deposit, and equity plans with varying percentages of returns if occupancy is ever terminated.  We were fortunate to pick “the gold standard” in our community, and they had a one bedroom unit available within the next 90 days after some desired renovations were completed.

Now we had to figure out which plan was best for our situation.  The variables were the percent, if any, of the initial deposit returned if the person moves out or dies, the costs and credits if the person moves from Independent Living to Assisted Living or Full Health Care, and other important items.

We included Mother in the discussions so the ultimate decision was hers, and with her supporting the move we signed the papers and started planning the downsizing and move for the next 3 months.

Our experience with the decision to move into a Continuing Care Retirement Community was very good, but we hear and are involved with many situations that don’t work out as well for caregivers and their aging parents.  Really working on our family communications throughout the decision process and including her in all decisions turned out to be one of the most valuable lessons learned.

Discharge from the SNF was a big benchmark in Mother’s rehabilitation from her broken hip.  But even with 3 children in the same city sharing eldercare duties, going back home found nearly everything had changed.  Just choosing a home health agency became a case in point.  Dispatched from the SNF with a long list of home health agencies but with no recommendation – only a small step better than tearing out the Yellow Pages – we had to figure out which one to use.  (We didn’t know that thousands had gone before us in making decisions – some right and some wrong.  Additionally, we didn’t know that there were ways to check out the candidate home health agencies to help in the decision.)  The agency we went with sent one worker who had the misfortune of an unreliable car and getting stuck in snow, so with two misses we requested a more reliable worker to assist Mother.  In the second week of the coverage I was surprised by Mother’s advising me she had fired the worker because “she just sat there and made notes in her notebook.”  So we were back to square one.

Luckily Mother offered that she didn’t feel safe driving her car anymore, and we had it sold in a week!  (Giving up driving remains one of the most difficult situations a family has to resolve.)  Still struggling with mobility issues (moving around with difficulty and a walker), we were preparing for 7 day, two shift coverage (around $20-28 thousand a year at $14-18 per hour for qualified companions with no health care services) to let her stay in her home.  Since we had already inspected her home for environmental safety, that plan could have worked.  But Mother perceptively guessed that her opportunities for social interactions would rapidly decline, and she offered that she would be willing to consider a retirement community for more security, easy access to old and new friends, and the peace of mind that she was in a supportive and protective environment.

Having promised her when she was mobile and independent that she would never be forced to move to a “retirement home,” it was now time to consider alternative living options once she brought it up.  I’ll share this next passage in my journey as a caregiver in my next Blog.

Please share any experiences you have had with home health services by posting a comment below.

The admissions process was handled well at the SNF, and we met the director, marketing liaison, and director of nursing in a welcoming visit.  Thankfully Mother came in during the week, as many of these managers are often not available on Friday evenings, or over the weekend, the interval following frequent Friday afternoon discharges from hospitals to geriatric care facilities.  But the first night experience was still ahead, and my experience in care management was only beginning.

Visiting a sobbing Mother the next morning, I learned that she thought help would arrive quickly after she pushed her “Help” button, and it didn’t come for over an hour after her 4am page.  Her accident was totally avoidable, but staffing during third shift was so low that timely rounds and responses were nearly impossible.  After a one-on-one meeting with the director and a frank discussion of expectations and responsibilities, her page was answered promptly from then on.  Fortunately we were right there and not timid in asking for improved service.  My thoughts now focus on those families that don’t have the good fortune of being in the same city during a crisis or rehabilitation.  Eldercare from fifty or over a thousand miles away nearly always stresses both caregivers and their parents sometimes beyond belief.

Learning that Medicare covered the first 20 days in the SNF when preceded by 3 nights in the hospital, we concentrated on making her stay as comfortable as possible.  We quickly moved in her credenza and chair from her home, her TV, and her CDs and stereo.  This turned out to be a great idea, and others facing a similar situation should seriously consider doing it – even if the SNF doesn’t encourage it.  Next came physical therapy (PT) and occupational therapy (OT) to increase her mobility.  Luckily she didn’t need speech therapy (ST).  PT was performed by in-house employees (it is often outsourced), and all went well toward her 30 step benchmark test.

For more information on Medicare coverage of Skilled Nursing Facility care, please click here.

Standing alone in her closet, my then 91 year old Mother’s femur suddenly broke and she fell.  Alone, and up to that moment living well independently in her home, she pulled herself to the phone and made the 911 call.  My wife and I were 2,000 miles away when the call came, and the next flight out got us back to the hospital just after the orthopedic surgeon had spiked her femur and placed an artificial hip cap.  Up to that point, all of the decisions were made for us, and thankfully they were good ones.  Now it was our time, with no map or experience, to navigate the health care maze that older adults and their families have to face alone.

The hospital’s case manager met with us and advised that Mother was going to be discharged after her third night (afterwards, but not at the time, it was clear that her capitated Medicare reimbursement would reach its end so it was time to go) to a rehabilitation facility that we could choose from a list she provided.  Miraculously, a skilled nursing facility (SNF) sales liaison appeared and assured us all details would be handled and a bed awaited Mother.  We were lucky.  Later we learned in another experience that ongoing relationships with the SNF sales liaisons and the case/discharge managers are well lubricated relationships – but thankfully referral fees are illegal.  But the big questions of how well matched the SNF was for Mother, the short or long-term nature of the facility (a big factor in short term rehab motivation), in or out-of-plan for supplemental insurance coverage, the staffing ratios of the SNF (patients divided by nurses and other skilled assistants), and the state’s and Medicare’s results from surprise audits were lost in the emotion of the family decision.

We’ll pick up with the first night in the SNF in my next blog, and you will soon understand what motivated me to create and found My Health Care Manager, as a consumer-side rather than provider-side, professional advisor for older adults and their families for navigating the issues and options of aging and eldercare.  But, in the meantime, please share your experiences and advice as a caregiver or senior from similar encounters involving home safety issues, falls, or unexpected hospital stays.