October 2010 Archives

After my mother-in-law died suddenly, my wife and I found ourselves caring for my father-in-law. There was so much we didn't know. One area where we were flying blind: We had no idea what financial resources he had, what banks and mutual funds he used, or how to access the funds he needed to pay for his home health aides and, later, assisted living and nursing home care.  

It turns out we were hardly alone. Less than half of adult children say they have ever had a conversation about money with their aging parents. And only 4 in 10 know how much their parents make. Yet, more than 60 percent of these parents think their kids are aware of their financial situation. 

This troubling gap is reported in the Employee Benefit Research Institute's 2010 health confidence study. And it is more evidence that adult children and their elderly parents do a terrible job talking to each other about money. 

There is no doubt that it is awkward. How do you sit down with a parent and say, "So dad, how much money do you have, anyway?" And how often, when adult children try, do parents shut them off with a response that says, in effect, "It's none of your business."

When folks who come to my community programs ask about it, I usually suggest they have this talk when their parents are relatively young and healthy. It is always easier to discuss money--to say nothing of advance directives and other end-of-life issues--before someone is very sick.

It is also easier to make it a two-way street. For instance, adult children can sit down with their parents and first talk about their own planning.

Imgaine starting off a conversation with mom and dad something like this: "We met with our lawyer last week to talk about our own estate plan. We thought it would be a good idea to let you know about our assets and give you a list of our insurance policies and bank accounts. Just in case something happens...."

In that context, it is much less uncomfortable to ask them the same questions. Even if they are unwilling to tell you how much they have, it is critical to know where they keep their funds and, if possible, get a power of attorney that gives you access to their accounts should they be incapable of managing their money. Without those documents, even paying bills on their behalf can turn into a nightmare.

Those of us who are caring for our parents have a huge job. Knowing a bit about their finances can make it a little it easier. But to do that, we need to talk.      

It is an article of faith among many in the elder and disability advocacy communities that aging in place is always the best alternative for someone who needs personal care. I don't believe it, and I recently heard an important panel discussion that confirmed that view.

The panel, sponsored by Washington Grantmakers, was especially interesting because the participants were all supporters of community caregiving. But they agreed that, without a strong infrastructure of family, community, and public support, it is not always possible for people to live at home. Indeed, it can often be lonely and even dangerous.

University of Florida professor Stephen Golant, who has written extensively on housing and care alternatives for seniors, reported that his research finds six major challenges to the frail elderly living at home. They include affordability, physical deficiencies of homes, lack of social supports, neighborhood changes, difficulties accessing community assistance (especially in both inner cities and cul de sac suburbs) and vulnerabilities of old age including greater risks of accidents, poorly trained family and paid caregivers, and even abuse.

Golant concluded that those most at risk staying at home are low-income, very frail, poorly educated women who are 85 or older and either living alone or with a frail spouse. This seems obvious, but these are the very people who have the fewest alternatives. For most, high-quality assisted living or even independent living are far beyond their financial means. Golant says those at most risk are not the very poor but the nearly one-third of seniors he calls "tweeners," who do not qualify for public programs but can't afford to private pay for housing with supportive services. 

Golant suggests that addressing these issues requires "changing the aging in place dialogue." Doing this will require society and families to recognize that living at home is not always the answer, and that focusing on group care may make more sense. This can mean thinking about senior villages and other naturally occuring retirement communities where care can be better coordinated and delivered much more efficiently. 

Charles Smith of the Montgomery County (MD) department of aging and disability services said that it is increasingly difficult for government to deliver the services necessary to support people aging at home. Budgets are being slashed and physical distances make it tougher to provide assistance, especially in the suburbs. Smith said that in sprawling Montgomery County, it costs five times at much to deliver a meal to a suburban house as it does to buy it. Transportation services, the single most common need for those at home, face the same difficult combination of smaller budgets and greater distances.

"We are creating expectations that you should age in place,"  Smith says, but government doesn't have the resources necessary to meet those expectations. 

Rev. Joseph Williams, executive director of Emmaus Services for the Aging, a private non-profit in the District of Columbia, added that grassroots community support is essential for people to age at home. "It can't all happpen in the department of aging," he said.   

None of this means those of us caring for our parents should not do all we can to help them stay at home, if it is appropriate. It does mean that just saying the words won't make it happen. Rather, it will require communities and families to work together to back up the sentiment with real resources, including both time and money. It is a fantasy to believe that assistance will come entirely from government, which will be increasingly strapped for funds in coming years. It will also require us all to recognize that some of our parents will be far better off in a congregant care setting.        

More than half of long-term care residents in skilled nursing facilities made at least one emergency room visit in 2006. A quarter had two or more. Even more troubling, 38 percent were admitted to the hospital at least once that year, and nearly half were admitted twice or more. In all, one-quarter of all hospitalizations for nursing home residents were potentially preventable.

These very troubling statstics are included in a new study released today by the Kaiser Family Foundation. Even more worrisome were the reasons why: Kaiser does not have good statistics on this, but it hired Lake Research Partners, a survey research firm, to ask physicians, nurses, social workers, and family members about these hospital visits. The responses are hair-raising--not because they show uncaring or greedy docs, or sleazy nursing homes, but because they expose the routine systemic problems that drive hospitalizations.

Among the reasons so many nursing home residents land in the hospital:

The Friday effect: Nursing homes don't have the staff to deal with medical issues, especially on weekends. So they send them to the ER.

Nursing facilities and family members prefer that residents die in the hospital.  

Docs would rather care for patients in the hospital, in part because it is more convenient  or because they get test results quicker.

Financial incentives: Physicians think they get paid more for caring for a patient in the hospital, and nursing homes may get paid more after a long-term care resident has been hospitalized for at least three days and returns to their facility.

Lack of a relationship between nursing homes staff and residents: It turns out that residents are more likely to get sent to the hospital in the first months of their nursing home stay.

Families consent.They don't object, perhaps because they believe their loved one will get better care in the hospital. This is especially true if the resident has no advance directive.

Malpractice fears. Docs were afraid they'll be sued if they don't hospitalize a sick resident. 

Dr, Cheryl Phillips, the immediate past president of the American Geriatrics Society and a member of the panel that discussed the studies at Kaiser today, described a typical situation. Imagine, she says, you are a doctor who has several patients in your waiting room. You see patients at multiple nursing homes and you get a call from a nurse at one. One of your patients--a resident in the facility--"is not doing well," the nurse says.She doesn't know quite what's wrong, but things are not right. You could leave your patients in the waiting room and drive to the nursing home. Or you could say, "Send her to the hospitall." It isn't hard to guess what happens.

Thse potentially needless trips to the hospital cost Medicare a bundle, and, most important, hospital stays can be bad for chronically-ill elders. The new health reform law will drive many patients out of the hospital sooner, and many are likely to be cared for in nursing homes. These important studies raise some important questions about whether those facilities are prepared to take on those sub-acute patients.   

The other day, Josh Wiener, who is one of the nation's experts on long-term care, presented three papers on certified nursing assistants (CNAs) in nursing homes. Josh and his colleagues at the consulting firm RTI International looked at quality of care, immigration, and injuries. And some of what they found may surprise you. The papers are available here (some may require subscriptions)

The first question they asked was what workforce issues determined quality of care in nursing facilities. Lots of research has identified the problems: worker shortages and high turnover, low wages and few benefits, poor training, and a sometimes-hostile relationship between aides and managers. But which of these problems could be linked to low quality?

Surprsingly, Josh and his colleagues did not find much difference in some of these characteristics between high- and low-quality facilities. For instance, wages didn't seem to matter much. Neither did staffing levels. But access to health insurance and paid days off did matter and so did a more collegial organizational culture. This last finding suggests that the culture change movement in nursing homes, which attempts to create an environment where aides are given both more authority and responsibility, may be on to something.  

Their second paper looked at immigration, an important issue since about 20 percent of CNAs are foreign-born. Some results were not surprising. For instance, Wiener found only about half of immigrant CNAs reported English as their primary language. And half reported problems communicating with residents. But it turns out that nearly as many (41 percent) native born workers also reported these problems.

Other results were just as interesting. Foriegn-born workers were older, more likely to be married, and better educated than their U.S-born colleagues. Their average wages were about 10 percent higher and while fewer reported getting bonuses or reimbursement for training, more said they got paid holidays and subsidized child care. And immigrants were more likely to work for the highest quality facilities (based on the government's five-star rating system)

Finally, Josh and his colleagues looked at injuries. Aides have among the highest injury rates of any occupation in the country--the Labor Department reports that almost nine percent were hrt on the job in 2006, the third highest among any occupation in the U.S.

But Josh found many more injuries than were officially reported. He found that nearly 60 percent of nursing home aides reported suffering some injury during the course of the year. While most were back injuries caused by lifting, many others were inflicted by residents (12 percent were a result of bites).

One way to reduce back injuries is through the use of mechanical lifts. Josh found that 88 percent of facilities had these devices available, but only 61 percent of aides said they always used them. The research also found that madatory overtime, inexperience, lack of training, and lack of time to spend with residents all contributed to injury.  

These results are contrversial, espcially some of the conclusions about the relatonship between pay and staffing and quality. But, as with all of Josh's research, it is worth looking at.