I was watching a major professional golf tournament a few years back. Many of the golfers were having a very difficult day. In fact, many would hit their shots and get into trouble. What followed for many of them was an attempt to make too much out of an already bad situation, which in turn led to even more problems for many of these golfers. A frequent commentator for many of the major professional golf events is former golf great Johnny Miller, and he was the commentator for the tournament on that day as well. As Miller watched many of these great golfers err by attempting to make heroic shots out of almost impossible situations, what ultimately transpired to Miller's amazement was a number of great golfers with exceptional skills making very stupid mistakes and ultimately taking themselves out of contention for winning the tournament. Yet, this did not need to happen and it could have been easily prevented. It was at that time that Johnny Miller said something quite simple, yet incredibly cogent. After watching the mess that many golfers were unnecessarily making for themselves he stated, "It's like my father said, the first thing you do when you get into trouble is get out of trouble." As I listened to Miller's statement I thought what an economically well stated managerial principle, not just for golf, but for all phases of life in which we need to manage the situation.
How many times have all of us found ourselves in a troubling situation, in which we often attempt to do more with the situation than we really had to do, with the result being even a worse outcome than we could have imagined. Instead of following the dictum that Miller promulgated, and simply attempting to get out of trouble, we attempt to use an overly complex solution to eradicate the issue when all that was needed was a much simpler and more straightforward solution that held a higher probability for achieving success. Why do you need to run as fast as you can over a rough and dangerous terrain, if you have the option to walk over a smoothly paved sidewalk and still get to where you need to be without risk of injury or encountering further problems? This was what Miller was saying. Why are these golfers making it more difficult than it has to be, especially with a game that already has considerable difficulty built into it? This also applies to many managerial situations within healthcare. Why do many individuals make it more difficult for themselves by attempting to implement arcane and impractical solutions that often lead them over rough and dangerous terrain, when they could simply get out of their trouble using much simpler solutions? Probably part of the answer lies in the misconception that most of us hold: If a difficult problem exists, we must always attempt to eradicate the problem with a solution that is equally difficult. This misconception often leads us to myopically only look for complex solutions with higher probabilities for failure, when often the first step is simply to use a straightforward strategy to "get out of trouble."
Even Albert Einstein stated " a theory should be simple but not more so," implying that we need to address the issue at hand in a practical manner and not get involved in unnecessarily convoluted theoretical concepts that can ultimately obfuscate what we are attempting to address and explain.
Think of a few scenarios here that often exist in health care facilities and their management in what often violate what I will refer to as the "Johnny Miller Principle of Management." Remember, we often have to manage the situation, and no single individual can manage the totality of any facility or organization at any single point in time. Yet, what often happens with many administrators, executive directors, chief operating officers, and yes, even the President of the United States? They often attempt to tackle a problem that may be relegated to a particular situation by addressing not just the problem, but even moving beyond the boundaries of the problem. In so doing they will frequently dilute the solution to the problem and even create problems in other areas of the organization that may not have existed before their attempt to reorganize and become too expansive in their problem-solving efforts. What happened? Miller's Principle was violated. When you are in trouble, the first thing you should do is get out of trouble. If X is the problem, simply address X, the problem, and get out of trouble. There is no need to change Q, R, and S if they are 1) not part of the problem, and 2) if doing so increases the probability for further problems.
Think about the issue of what is often referred to as "sunk costs." This is where a cost exists and cannot realize any return on the cost. Yet a common psychological heuristic that exists among individuals is that if any investment has been made, and you suffered a loss, continue to invest since you have already committed yourself. However, this is not rational. If your cost has been incurred it is lost. Yet we often feel compelled to continue to chase an illusory loss that we feel can be resurrected is a Lazarusian manner. If an investment is a bad investment the best managerial strategy is to prevent any future losses and move on. Again, Miller's Principle-when you are in trouble, the first thing you do is get out of trouble, not compound it and make it worse.
I have witnessed individuals attempt to remedy health care deficiencies that surveyors have found to exist. Here is another issue that is frequently found to violate Miller's Principle. In addressing the problem, what often entails is the thinking that more words and more remedies often implies more solution(s) to the problems that they are attempting to correct and have been found in violation of federal and/or state regulations. Often this same type of poor logic not only exists among the managerial and administrative staff of a health care facility, but also among the regulatory personnel as well. "If you get into trouble, the first thing you do is get out of trouble." If A is the problem, then address A. If A and B are the problem, then address each one. No more or no less is needed. Too little and you are not solving the problem and getting out of trouble. However, often the problem is with too much. If you do too much you are frequently diluting your solution toward the problem at hand, and furthermore, you often are mathematically increasing the probability of more problems that will ultimately 1) fail to solve the original issue, and 2) make for a refractory issue in which the solutions add further problems, which in turn can lead you to even greater problems. To use a golfing analogy that Miller would probably agree with, if you are in the rough, do not think about aiming for a green surrounded by water and sand. Get out of the rough first (the current trouble you face) and get into the fairway. Then you can plan your next shot, or managerially speaking, you next plan of action. "When you are in trouble, the first thing you do is get out of trouble."
Health care facilities will often attempt to increase their income by taking residents with higher acuity to enhance reimbursement, especially rehabilitative reimbursement through Medicare. However, what if you extend your services beyond the resources you have available to serve the clients within your health care facility? Again, it would be extremely idealistic to say that money is not a concern. Money is a concern regarding whether you are a for-profit or not-for-profit organization. However, attempting to increase the patient or resident-base beyond your resources available to further enhance your net income will not only be counter-productive to the clients you are servicing, but to your organization as well. How do you solve the problem? You could get the resources you need to appropriately service your clientele. If this is not tenable, reduce the type and kind of clients you service that will allow you to safely and effectively address the situation. "When you are in trouble, the first thing you do is get out of trouble."
Let me provide one last example. Many individuals often want and need to mathematically quantify problems in management. However, often their attempt to find and quantify problems can lead to more problems. For sure, one needs to look at their income statement for the month and see if a problem exists. Furthermore, using a T-test to examine the statistical effectiveness of one group to another may be very important for addressing and quantitatively analyzing a problem as well. However, often individuals will think if one measurement is good, then each additional measurement that I add will further help to solve a problem. In today's world management is often based on the many quantitative tools that are available. They think quantity leads to quality. Many also think these tools aid magically in addressing the problem. They still need to be interpreted and used correctly. Furthermore, frequently there is the problem with over-management by overuse of these tools. Often if one tool does show a problem it is often common to use another tool to help triangulate the issue and provide greater validity. However, to continue to use one measurement tool after another, all showing a problem exists is redundant, and you are then left with attempting to correct the results of each tool, which does not necessarily correct the problem and is an incredible waste of time, not to mention an inappropriate use of needed resources. The measuring devices, whether it is a cash flow statement, and correlational measurement, or a forecasted regression analysis, which are means that should be used judicious to find and correct the desired end or goal have now become the goal in themselves. Here again, if a tool or even a few tools have found and confirmed an problem, address the problem and get out of trouble. There is no need to compound your tool usage and continue to waste time, money and valuable resources just to advance the pursuit of an intellectual counting exercise. "When you are in trouble [and trouble has been identified], the first thing you do is get out of trouble." If the managerial analogy of your trouble is that you are just off the green and are terrible pitching up safely unto the green, use your putter and safely get it on the green. Then plan your next shot if you need to at that point.
Using golf as a strategic analogy for thinking about managerial problems is highly beneficial. Good golfers are always managing the situation over the entire course. As Bobby Jones stated, the success of any golfer exists within a space of about six inches between both ears. That is because golf is strategic and is based on sound management of the course. They do not plan to manage the entire course all at once. Their management is situationally based, predicated on each shot that they take over the 18 holes. Jones' statement however can also apply to all management. Furthermore, successful management of the course often means that you avoid foolish errors and employ Miller's Principle-The first thing you do when you get into trouble is get out of trouble. The course however does not just have to be a golf course, but the business, facility or organization can also be viewed as a competitive course environment as well.
Management in general and managing health care facilities in particular are quite similar to managing the golf course. Attempting to manage an entire facility or organization at a single point in time will lead to failure. Each management decision is based on the situation that one finds oneself in and all decisions that have been made up to that point in time. Therefore, next time you encounter a problem think about the Johnny Miller Principle: "The first thing you do when you get into trouble is get out of trouble." It is simple, clear and apparently obvious. However, how often does one violate the principle in attempting to manage their health care organization? Thank you Johnny Miller for giving impetus to the introduction of a principle that can have an important managerial impact for so many if they adhere to just a few simple words.
Aging is often accompanied by the dreaded sagging midsection. This is not an evitable consequence of aging. It typically happens due to engaging in more sedentary activity. Unfortunately, as we age, the tendency to become less active not only has consequences for the abdominal area, but for the entire body. Add to this the tendency for many Americans to eat poorly and it is not so much age, but poor lifestyle habits that often lead to increased girth and sagging muscle tone.
Most recommendations for addressing excess weight and abdominal obesity have emphasized aerobic forms of activity, such as walking, running, using a treadmill or exercising on an elliptical machine. This type of exercise provides continuous movement and emphasizes slow twitch muscles that are more dependent on higher levels of oxygen, placing greater focus on the heart and respiratory system. Also, due to the continuous movement, it typically burns greater levels of calories during the time the exercise is done. However, in a study that was conducted at Harvard University's School of Public Health, the importance of weight training for older individuals may be at least equaling important in controlling one's abdominal girth.
The study however used only males, so whether the same results apply to females can only be hypothesized. The study at the Harvard School of Public Health used 10,500 volunteers, all men who were 40 years old and older. The study participants all had varying levels of body mass indexes. The individuals were monitored for 12 years, from 1996 to 2008. The study participants demonstrated important benefits from weight lifting. Although the study participants that increased their aerobic activity also decreased their waistline measurements, those that had the greatest levels of success were those that used both aerobic exercise and weight training. Individuals who increased their aerobic exercise duration and intensity attained a 0.33 cm reduction in their waistline compared to a reduction of 0.67 cm found among those that used both aerobic and weight training. The study's author Frank Hu, professor of nutrition and epidemiology at Harvard's School of Public Health states, "This study underscores the importance of weight training in reducing abdominal obesity, especially among the elderly ... to maintain a healthy weight and waistline, it is critical to incorporate weight training with aerobic exercise."
Weight training is especially important for older adults in helping them ward off the dreaded belly bulge due to the enhancement of muscle tone in the abdominal area as well as in other areas of the body. With age, sarcopenia, or significant muscle mass loss can not only be potentially aesthetically unsightly as it relates to midsection distention, but it can also be accompanied by other problems such as back pain, leg weakness and falls, all that can be potentially damaging to one's health and longevity.
Another benefit that needs to be addressed here is that although aerobic activity, due to its continuous nature, tends to burn more calories over the time the exercise is done, there is a precipitous return to one's resting metabolic rate over the next couple of hours after the completion of the exercise. However, with weight training, the more anaerobic nature of the exercise leads to a higher metabolic rate for up to 24 hours after the weight training session. Therefore calorie expenditure continues for a period of time well after the weight training is discontinued. Moreover, muscle is a highly metabolically active tissue, and as muscle growth is added through weight training, which happens among older adults as well, one's resting metabolic rate is increased, leading to a greater amount of calories burned over a 24 hour time period. This all leads potentially to less fat around the midsection and strong muscle tone within that area as well.
Frequently, the thought of weight training for older adults is counterintuitive. Many think it is only something that should be untaken by younger individuals and athletes. It is also thought that weight training can only enhance muscle growth among younger individuals, which is a very inaccurate misconception. Finally, many think that the flabby and pouching midsection is an inevitable part of aging. In fact, aging is often used as the scapegoat for justifying one's increasing weight, flabby midsections, and increasingly sedentary forms of activity that often prevent adequate exercise and caloric expenditures. However, as has already been stated, these are not natural or even inevitable facets of aging. They are facets of unhealthy lifestyle habits that we have come to adopt. As the Harvard School of Public Health study has shown, individuals that add weight training to their lifestyle activities can appreciably benefit their midsections. Furthermore, weight training in addition to aerobic activity helps to play a multifaceted role on the overall health of the individual. Overcoming some of the major misconceptions regarding age that often lead individuals to accept complacency and sedentary activities is probably the biggest obstacle that needs to be addressed. Therefore, if you want to stay strong, stay healthy, and stay slim, start moving and also add some weight lifting exercises to your daily regime to not only maintain muscle tone in those arms, shoulders and chest, but to enhance your waistline as well.
Pumping Iron Gives You a More Sculptured Waistline than Engaging in Aerobics (Dec 26, 2014). Empire State Tribune.
Over two decades ago the report from the Institute of Medicine (IoM) led the way for monumental changes to take place within the nursing home industry. The report of the IoM basically stated that nursing homes needed significant reform and that it was an industry that was loosely regulated, potentially compromising the lives of many who reside within our country's nursing homes. What subsequently followed was a monolithic effort to reform the nursing home industry. Over 28 years has passed since the report came out leading to widespread regulatory changes within the nursing home industry. However, nearly three decades later, we are still left with an industry that continues to face significant problems. Although many do not question that nursing homes have improved, one may nevertheless question that the changes that have ensued have really not been as monumental as was initially planned. In 1987, when the Nursing Home Reform Act or OBRA was introduced, most would have foresaw that in approximately three decades hence, major changes would have resulted with many of the problems that plagued nursing homes then failing to exist as one looked down the road into the new millennium. However, in reality, although some improvements have come to fruition, in reality many of the same problems exist. Furthermore, other problems have also become quite prominent that may have even left the industry in even greater disarray. I would like to take a look at some of these major issues and briefly address each, as well as what needs to be done to correct the issues that are currently found in our country's nursing care centers.
The Primacy of Economics
A major issue driving many of the other issues found in nursing homes is the economic primacy that surrounds care. Peterman and Williams (2006) have pointed out that many major companies have faced issues of bankruptcy due to the increasing loss of revenue. With the advent in particular of assisted living facilities (ALFs), many individuals who would have once been admitted to nursing homes are now placed within ALF environments. The assisted living environment has cut into the financial backbone of the nursing home industry, leaving it with a lower occupancy rate and with it, less money to take care of an increasingly older and sicker population.
Another major cost-containment reform was the passage of the Balanced Budget Act of 1997 (BBA). Prior to then the payment system was retrospective and nursing homes were paid in full for care provided to qualified Medicare residents. With the passage of the BBA that changed. Payment went to a prospective payment system, similar to DRG's that were instituted in hospitals a decade earlier. Now payments were based on specific diagnostic and rehabilitative codes that were associated with a particular reimbursement level. This made payment more unwieldy and typically what is billed for and what is authorized by Medicare left many nursing homes short of the actual cost of services rendered (http://www.adaction.org/pages/issues/all-policy-resolutions/social-amp-domestic/140-the-nursing-home-crisis-public-policy-gone-awry.php.)
Furthermore, most payments received by nursing homes for services were paid for through Medicaid. Medicaid, a medical policy initially put in place for the indigent, has come to be responsible for approximately 70 percent of the remuneration found within the nursing home industry. However, Medicaid has notoriously paid low amounts, often far below the cost of services for the resident. In addition, Medicaid has often fluctuated upwards and downwards without much notice, leaving many nursing care facilities at the whim of what Medicaid will eventually pay (Peterman and Williams, 2006). Moreover, with many assisted living facilities admitting many older adults, who then pay for their assisted living services through their own cash savings, this has left the nursing home environment admitting many who only are able to pay with Medicaid, which as previously stated often pays far below the cost of services that are rendered to an older and sicker clientele that needs much more continuous and ever-increasing levels of invasive and professionalized care. So here is a major quandary. Assisted living services are often getting considerable cash income and have an environment with low overhead costs. Conversely, nursing homes are taking on an older and more infirm population and are (1) having to work within a climate in which Medicare reimbursement is becoming more parsimonious, and (2) Medicaid, the prevailing level of payment, is often paying an unrealistically low level for service costs that frequently far exceed the Medicaid payment rendered to the nursing home. What do nursing care facilities do to address this dilemma?
The largest cost to the nursing care environment is staffing. Approximately 70 percent of the operational cost is due to staffing. Therefore, the most common and reflexive knee-jerk response for nursing home companies in reducing operational costs is to reduce staff. In addition, having to recruit better personnel is often difficult if one is attempting to cut costs in staffing by reducing the number of personnel as well as through offering lower wages to professional staff. This is not conducive to nursing home environments that are witnessing higher levels of acuity. Recruiting professionals with important skills that address the myriad of needs that are now found in the nursing home environment require offering workers competitive wages and having an appropriate number of skilled professionals working all shifts within the nursing facility. This however is not found among most nursing care facilities.
With a lower nursing home census coupled with further reductions in private pay, Medicare reimbursement, and an increasing dependence on a lower pay funding source (Medicaid), nursing homes are streamlining operational budgets, especially through reduced staffing and minimizing the number of more qualified skilled nursing personnel. This all too common strategy toward addressing these pervasive issues has often led to compromised levels of care (http://parkemorris.com/wpsmp/wp-content/uploads/21_Issues_21st_Century.pdf).
Here is the irony to the above stated issue. During an era when nursing home reform has emphasized the need for adequate staffing requirements, appropriate staffing often fails to exist. Furthermore, at the same time that the federal and state levels of government have continued their adjuration for improved staffing, they have also failed to maintain adequate funding to nursing homes. Reimbursement has not kept pace with 1) the increasingly higher level of acuity found in nursing homes; 2) the need to competitively recruit highly skilled personnel that often gravitate toward higher paying hospital environments; 3) the increasingly higher rates of inflation in many areas of health care services; and 4) the unrealistic assumptions found within Medicaid payments and bundled packaging of Medicare that often encourages extreme streamlining with the thought of fostering greater efficiency when in reality it often encourages reduced caregivers and an elimination of important services that could be provided if funding was available.
Moreover, recently the Centers for Medicare and Medicaid have added penalties to hospitals that receive residents back within a 30 day window, and these same penalties will also be introduced into the long-term care setting starting in 2018 (Luke, 2014; Rau, 2014). Many hospitals have started working with nursing homes to share in the penalties for residents returning within a 30 day period that are now instituted. Here again, however, this often will take further money away from treating many individuals that often have very severe conditions that may lead to unavoidable returns to the hospital. Having this type of policy could 1) potentially lead to many individuals staying within nursing care settings too long during periods of acute exacerbations, further jeopardizing their lives when they should return to the hospital due to fears that they may be financially penalized by CMS, and 2) Medicare regulators often paying excessive attention to financial bottom lines that are unrealistically promulgating policies that may do more harm than good (http://www.elderlawanswers.com/how-bad-off-is-the-nursing-home-industry-9828).
Other Problems That Continue to Exist
The guardian of nursing home quality is the survey process. These surveys are typically completed by state inspectors, although at times federal surveyors will conduct surveys as well. The survey process was instituted to assure compliance with the federal regulatory requirements. Surveys are done annually, conducted within a nine-to-15 month window. Complaints surveys are also done when complaints are received on nursing homes. Although surveys create a monitoring device that oversees nursing home compliance, it is far from a process that has worked well. First, many surveyors often have never worked within long-term care themselves. Many become surveyors after a short period of training and subsequently are then placed into an environment in which many have never had any firsthand experience with as direct-care workers and caregivers.
Furthermore, the survey process, instead of being facilitative toward a common goal of improving the care of the nursing home resident, is often adversarial. The nursing care facility and its staff and the survey staff are often viewed as being on opposing sides. Unfortunately, the survey process, which could be a very productive process if it was developed for both parties to cohere and work together has devolved into a divisive interaction. In fact, surveyors often state that they cannot provide information in assisting the facility with their plan of correction even though they are well aware what they would like to find in a plan of correction for it to be accepted.
The survey process also continues to notoriously be a very subjective process. Far from being objective and guided by objective indicators, the surveyors often use their own perspectives to determine whether they should establish that a violation does exists and whether a citation should be levied against the facility. The surveyors are still guided by federal regulations that they cite, but their own unique perspectives help to further determine whether a regulatory violation exists. Different survey teams found in different areas and different states often give different numbers and levels of violations. Therefore, the survey process is far from objective and standardized (Ornstein & Groeger, 2012).
Another issue that also needs to be addressed is the issue of ownership. It is well-established that for-profit nursing care facilities often have higher rates of citations and lower staffing ratios. Furthermore, the Government Accountability Office (GAO) has found that for-profit facilities were demonstrably poorer performers nationally as compared to not-for-profit facilities (Centers for Medicare and Medicaid Advocacy). What is often more disconcerting is that many nursing facilities have now been purchased by larger equity firms whose expressed goal is to focus on the profit incentive. In fact, for-profit facilities are now the most common form of nursing care facilities and most of these facilities are now becoming co-opted by large equity firms with individuals who often have very little, if any experience, in health care.
Private equity firms have become a common type of group that has come to play a significant role in American business. Their goal is to invest and make a profit. However, this form of business endeavor, using a traditional business model with individuals who have little knowledge of the long-term care industry often leads to problems that have continued to haunt the nursing home environment. Maintaining cost-control is very important. An important problem in health care today is attempting to curtail the inflationary environment that is found in health care.
However, attempting to make profit at the expense of cutting costs within a long-term care environment that has become increasingly more complex and diverse in the types of conditions and clientele that they treat is a problem that continues to plague nursing homes.
Even more problematic is that the ownership that often is insisting on instituting many of the cost-cutting maneuvers are oblivious toward understanding how their decisions are having or will have a negative impact on the clientele that they are ultimately suppose to be servicing. They are unable to disentangle their concern of profit margins from the nursing home resident. Profits and residents are compiled together as a form of capital that needs to be invested in and monitored for their returns. This kind of attitude has led to an instrumentalism that conceives of the nursing home resident as a type of capital investment.
One final thing should be mentioned before we leave this topic. It has been mentioned that the economic primacy of the nursing home environment is the prevailing issue that often foments many of the problems that have been mentioned. As has already been mentioned, Medicare and Medicaid payments have not kept up with the inflationary health care costs found in long-term care. In addition, many nursing homes have now lost further economic resources due to the assisted living facility industry admitting many individuals who would have been formerly admitted to nursing home environments. In addition to this loss in reimbursement and loss of resident population, many nursing care facilities have further been plagued by civil monetary penalties (CMP) that the government places on nursing homes that have poor compliance. However, the problem with using a monetary penalty levied against nursing homes is that a punitive financial measure is ultimately harming the residents that it is supposedly intended to help. There is an inherent contradiction in this logic of using CMPs as a corrective action. Since the government is stating we will not provide financial payment to a facility as a penalty for not providing appropriate care, and subsequently since residents are inclusive in that nursing home environment that is penalized, the residents are ultimately the one's that a further harmed, not just by the facility's noncompliance in care, but also through taking money away from the facility that would go toward allocating appropriate provisions and care to nursing home residents.
Although there has been some appreciable advances in nursing home care since the advent of the Omnibus reconciliation Act or OBRA of 1987 that created widespread nursing home reform, to think that the nursing home industry has made quantum leaps since OBRA was introduced would be to delude ourselves. In reality, there has been improvement in some areas. In other areas the improvement has been negligible at best. Moreover, when one examines the landscape in totality, the level of improvement from the middle part of the 1980s to now is far from what one would have hoped for given the high aspirations that were often associated with the nursing home reform movement. This being stated, we should not be dismissive toward the small changes that have occurred, but look at them realistically and use them to build further and more progressive changes. However, as has been detailed in this paper, we have to move beyond the current environment that exists within long-term care. A paradigm shift needs to be instituted. This paradigm shift has to be a true paradigm shift, not a fallacious shift as has been witnessed over the past 30 years. A true paradigm shift will see surveyors and nursing home staff working collaboratively and not at disparate ends. A true paradigm shift will hold ownership increasingly responsible for many of their decisions. A true paradigm shift will focus on enhancing resident care and resident's lives within nursing homes as an end in itself and not associate the resident as a type of capital. A true paradigm shift will not continue to add layer upon layer of regulations, which ultimately leads to nursing homes being more concerned with the regulatory environment and not the resident who becomes lost in the regulatory labyrinth. Finally, a true paradigm shift will not institute punitive measures and say they are an attempt to enhance compliance and better resident care when in fact they work quite to the contrary. What was mentioned in this paper was by far not an all-inclusive list of problems and remedies. However, enough has been stated at this time to allow those who read this to assimilate and ponder the information as well as being an initial step toward helping to stimulate discussion on how to enhance an industry that continues to need much remediation.
Centers for Medicare and Medicaid Advocacy (n.d.). Non-Profit vs. For-Profit Nursing Homes: Is there a Difference in Care? http://www.medicareadvocacy.org/non-profit-vs-for-profit-nursing-homes-is-there-a-difference-in-care/
ElderLawAnswers (n.d.). How Bad Off Is the Nursing Home Industry? http://www.elderlawanswers.com/how-bad-off-is-the-nursing-home-industry-9828
Luke, J. (2014). SNF readmission penalties announced: Is your facility ready? Californial Association of Long-Term Care Medicine. http://www.caltcm.org/index.php?option=com_content&view=article&id=242:snf-readmission-penalties-announced--is-your-facility-prepared-&catid=22:news&Itemid=111
The Nursing Home Crisis: Public Policy Gone Awry No. 140. Americans For Democratic Action. http://www.adaction.org/pages/issues/all-policy-resolutions/social-amp-domestic/140-the-nursing-home-crisis-public-policy-gone-awry.php
Peterman, N. A. & Williams, C. B. (2006). Skilled Nursing Home Facilities: The Challenge of the 21st Century. American Bankruptcy Institute Journal. http://www.gtlaw.com/portalresource/lookup/wosid/contentpilot-core-2301-5994/pdfCopy.name=/peterman07a.pdf?view=attachment
Ornstein, C. & Groeger, L. (2012). What we found using nursing home inspect. ProPublica. http://www.propublica.org/article/our-latest-news-app-nursing-home-inspect.
‘21 ISSUES FOR THE 21st CENTURY"NURSING HOME ABUSE & NEGLECT (nd). http://parkemorris.com/wpsmp/wp-content/uploads/21_Issues_21st_Century.pdf
Rau, J. (2014). Medicare Fines 2,610 Hospitals In Third Round Of Readmission Penalties. Kaiser Health News. http://kaiserhealthnews.org/news/medicare-readmissions-penalties-2015/
Living longer. Many individuals are often attempting to find some fountain of youth that can enhance their lives. Commercials and advertisements abound with supposed remedies that will increase one's life. Yet, a very simple technique that dentists have been advocating for years can be an important enhancement for one's longevity. Research has been finding that oral care is very important for not only warding off diseases of the mouth, but also other more systemic ailments. Furthermore, gum health and regular flossing of one's teeth can be an incredibly important lifestyle feature that can be an important preventative form of health care as well as a technique that can be used to enhance one's life.
For years dentists have advanced the importance of using that simple piece of string to mechanically remove debris that settles in between teeth and at the gum line. The gums often become inflamed due to bacterial infections, many of which go unnoticed. Food particles that remain between teeth and in the gum lines can further produce a very good growth environment for bacteria. Bacteria within the gums does not just stay within the oral cavity, but further migrates to other areas of the body. In particular, recent research has paid particular attention to how poor oral care and infections in the oral cavity can contribute to heart disease. In addition, chronic inflammation of the gums due to bacterial infections can lead to further health issues as the bacteria moves to other areas of the body. These continuous levels of infection within the gums and oral cavity can continue to lead an assault on the body that reduces one's life expectancy.
Many simple solutions often fall far short of their stated results. However, a simple piece of string or dental floss used regularly appears to be one of those important simple, yet profoundly impactful lifestyle habits that can hold significant consequences for a person's longevity. Many individuals often have minimized the importance of oral care in general, and flossing in particular, as part of a healthy lifestyle behavioral intervention that can enhance one's health and longevity. In fact, it has been estimated that sound oral health can add approximately 1.5 to 6 years to one's longevity.
Most of the older adult population fails to recognize the importance of flossing. Moreover, most of the older adult population also show signs of gum disease. This is problematic since not only is gum disease the leading cause of tooth loss, it is evidence of a constant and unabated infection that exists. A continuous level of bacterial buildup infecting the body can have a pervasive impact on one's health. That can ultimately lead to more health issues and premature death. Yet, a very simple mechanical measure of flossing daily can provide important dividends for one's overall health.
As problematic as gum infections are in the mainstream population, among the institutional population it is even a greater epidemic issue. Among those older adults within nursing homes, dental hygiene is often overlooked by caregivers. A large portion of the nursing home population not only fails to receive adequate professional dental care, but they are also failing to get the appropriate level of daily care that can lead to not only good dental and periodontal health, but also assist in forestalling greater levels of infection, compromised health, and possibly unnecessary hospitalization. Again, much of the inadequate dental care provided to older adults is frequently due to the lack of knowledge among the staff regarding the importance of oral and dental health to the overall systemic health of the person.
Given the growing level of research on dental health and its connection to the overall health of the person, it is becoming increasingly apparent that aging in a healthy manner, compressing overall morbidity as we age, as well as increasing our longevity is dependent upon paying greater attention to our dental care, and in particular being sensitive to our gum health and our need for proper flossing to assist in this area. It appears that individuals can often be dismissive about the importance of flossing, particularly due to it being a very simplistic modality which intuitively does not seem to fit with the complexity that we often seek for increasing health and longevity. Yet, this very simple dental procedure, if used daily, can aid in gum health, and aid in the general health of the person, which in turn can potentially add years to one's life.
Stibich, M (2014). Simple steps to increase your life expectancy. http://longevity.about.com/od/liveto100/ss/life-expectancy_4.htm
Adult dental health: Healthy aging (2014). https://www.deltadentalins.com/oral_health/adult-dental-health.html
One of the buzzwords in long-term care is looking for the "root-cause" for various problems that arise. Many of these "root-cause" searches are often based on resident care. Others are often facility-based, especially related to financial information, staffing, and general supplies and facility maintenance. However, many of these supposed "root-cause" analyses often fall far short of ever finding the supposed cause that they were set to initially determine. In fact, many frequently become side-tracked and move into other areas, compromising their focus on the initial target. What follows is a brief overview of a few major issues that lead to problems in long-term care never being discovered and subsequently addressed.
Failure to Understand and Find the True Problem
To be able to address a problem, the problem has to be clearly defined. It is common to find and address a problem. However, whether it is truly the problem that is leading to the issue is a totally different story. The successful amelioration of a problem is incumbent upon defining the appropriate problem. All too often attempting to isolate what the true problem is provides considerable difficulty. The reason for this is that often there are a number of potential issues that are closely related. Yet, each of these issues may have considerably different ramifications. However, without being able to isolate the specific issue or problem that leads to the particular health care consequence, the person is left chasing rainbows.
Finding the specific issue and then defining the problem is much more difficult that it appears. This author has provided simple, single paragraph problems to his classes in which they were instructed to find and isolate the problem that brought about a particular scenario. When the problem was imbedded with other superfluous information most individuals often failed to identify and isolate the specific problem or issue. Many targeted the consequence, and not the problem. Furthermore, many others often would isolate the superfluous issues that were not even close to being related to the true problem. Without any training, isolating a problem that is leading to the consequence of a particular situation is quite difficult. Yet, in health care situations, adjurations are often made for health care professionals to undertake this task as if it is easy or as if long-term care professionals and administrators are well-practiced and proficient at this task. Many of these individuals are often surprised to find out how a seemingly very simple problem in a single paragraph is unable to be clearly isolated and articulated. Therefore, given these results it should be no surprise to find that many individuals often fail to find and express the true problem in real-life situations when these problems are often much more intertwined with a myriad of other closely aligned, yet different problems, all leading to very different consequences.
The Illusion of Cause
Cause if often referred to as the goal in examining problems faced within any health care area, including long-term care. However, the image of a person often finding and isolating a single cause, as is often misleadingly made during such techniques commonly referred to as "root-cause" analysis, leads to an impression that there is often a single root cause that can be found for everything. This is a residual aspect of the Platonic vertical process of thinking, which asserts if you dig deep enough you will always find the quiddity for anything. However, this is far from being the reality that exists. A single "root-cause" is often not a reality, since often there is frequently more than one antecedent that can lead to a single cause. Furthermore, a single antecedent can lead to more than one consequence. Moreover, often the best that we can find is not a cause but a number of correlations, often failing to understand the distinction between causative and correlational findings. As one can see, something that is often conveyed as being a facile assignment of finding a problem is quite complex and needs considerable training. Far from what most higher level managers or executives assume when they mandate these problem-solving assignments onto their staff, this assignment, looking for a "root-cause" or any type of cause, is far from manageable for most individuals who fail to have proper training in this area, including most upper level managers.
Moreover, think of a simple cause that you do find. A simple cause (C) will often have many subcomponents involved (C1...........Ca). Take for instance something apparently simple such as turning on a light. What causes the light to be turned on (C)? The person flipping the electrical switch? However, is that the cause? Yes, but not the sole cause. What about the switch making proper contact? What about having a proper electrical conduit? What about the need from proper electrical wiring? What about paying the electrical bill to maintain electricity coming into the home so the switch can activate the process? Also, what if all of this is in place and there is no bulb within the light socket? As one can see, C (turning on the light switch to turn on the light) actually subsumes a number of other features that also are part of the causative process.
What about a person that has a medical issue such as an ischemic cardiac incident? Apparently, since it is an ischemic issue that should be the cause (C = ischemia). Although that may be viewed as the proximal cause, could there be others. Could volumetric changes in the blood and viscosity also be issues that are even more proximal? What about the inadequate nature of certain clotting factors? What about continuous lack of mobility leading to thrombotic features to form? Could a poor diet of fried food and saturated fats be causative? Could the lack of exercise have led to this issue? Could heavy smoking, along with a generally unhealthy and sedentary lifestyle have been the true ultimate or root cause? Here again, we see a number of causative factors that often are inclusive in what many individuals have assumed is the apparent cause. Is what was thought to be the apparent cause (ischemia) just the most recent and proximal of many other linkages that were more distally causative? Look at the complexity that just in these brief few paragraphs have been brought to the attention of the reader. And yet, when many long-term care personnel are instructed to find root causes, personnel who have often little if any training in this area, the assumption is that they will assuredly find the root cause. What is even more disconcerting is that those that do the investigation, frequently in a cursory manner, often come away with a false self-confidence in their results, thinking that without exception they have found the elusive, quintessential factor that led to the problem.
So What are the Consequences?
Problems are an endemic part of life. Finding the reason for their existence and attempting to solve these problems are an unending quandary that we face as part of life. Problems in long-term health care situations are no different? Whether it is attempting to find the reason behind unanticipated hospital admissions, or why average staffing ratios are running higher than in other facilities, or even why family members are selecting other facilities over your facility, many mistakes are often made toward attempting to find and solve important problems.
Thinking that one will always find the so-called "root-cause" is one major misattribution. Many problems quite simply will never manifest a clear "root." Furthermore, assuming that there is only a single cause is also quite problematic in itself. Even though many executives are adjuring their staff to "find the problem," they themselves, referring to the "problem" in its singular form are framing the issue in such a manner that those that will approach the problem will think that there is a single cause. Even the concept of "root-cause analysis" often conveys that a singular cause can be found and is always there to be apprehended.
Furthermore, another issue that has been mentioned is that individuals will often approach problems in health care without a clear understanding of what the problem is. Failing to clearly isolate and identify the problem will provide a totally misguided approach to solving any particular problem. Regardless of the assiduous nature of your investigatory endeavor, you could painstakingly follow a wonderfully deductive and logical approach that achieves a perfectively sensible result and solution. Yet, if you start off with the wrong problem, the solution will nevertheless be incorrect. For instance, consider the following:
- All dogs have three legs,
- Buck is a dog,
- Therefore, Buck has three legs
Is the syllogism above logically correct? Yes, but is it true since it started out with an incorrect major premise (All dogs have three legs)? No, it is absolutely not true. Even though it is deductively valid, following the steps to achieve a logical conclusion, starting out with an incorrect premise still leaves us with a valid conclusion but one that is not true-all dogs do not have three legs. The same exists for those that start off by defining the problem correctly. A valid conclusion may be deductively found, but it may have nothing to do with the correct problem.
Thinking that solving problems correctly in long-term care can be achieved by anyone and just by using a little hard work is a very misguided assumption. Problem solving is something that needs considerable practice and training. All too often, problem solving, not just in long-term care but in all health care is approached with an ill-conceived, loosely structured, and even a somewhat cavalier attitude. However, hopefully after reading this paper, individuals will see that problems, finding them and solving them are often far more complicated than many think and that it often entails a considerable level of training and practice to become proficient at such a practice. Understanding the complexity of problem solving and consistently practicing your skills and avoiding some of the common errors that have been discussed will ultimately lead to addressing many concerns that arise within long-term care in a more insight and productive manner.
The fountain of youth and eternal life has been something that has been sought and spoken about for a number of years. We still often hear the term, "anti-aging" used in reference to various types of supplements that are frequently advertised, as if using these supposed products will reverse aging or prevent any further aging in the person. However, some recent research has provided a level of authenticity to claims of age-enhancement.
However, who would have thought that the answer to some of these questions may be found in the jellyfish. One researcher thinks that these marine animals may be able to provide important contributions to our knowledge regarding aging. These gelatinous, strange-looking aquatic forms of life are now being looked at for holding some possible answers to the questions for life-enhancement.
A professor at Kyoto University in Japan, who has been studying jellyfish for over three decades, feels that these creatures may hold important clues toward potentially enhancing human life expectancy. Shin Kubota has been studying the jellyfish since 1979. According to Kubota, one type of jellyfish has a particular quality to regenerate itself and take on a level of immortality. The type of jellyfish that has this potential is referred to as the scarlet jellyfish. He stated that this species of jellyfish have the ability to "rejuvenate" themselves. Furthermore, he has also noted that there are two other species of jellyfish that also hold this potential.
According to Kubota, the adult scarlet jellyfish, referred to as a medusa, when injured, goes to the ocean floor. However, instead of dying, it goes through a process of rejuvenation. It goes back into an infant state of development referred to as a polyp. The polyp continues to develop back into the adult medusa. Kubota, in his laboratory work with this species of jellyfish has been able to successfully make the jellyfish rejuvenate 12 times in his laboratory studies.
Kubota states that genetically the jellyfish and humans are not that different. Therefore, he is hopeful that the studies will result in finding out further information about this regenerative ability found in the scarlet jellyfish that may be able to be applied to human beings, which may ultimately help enhance their longevity. However, the research is still in its early stages. However, it does lend a level of excitement, witnessing one living species that may have some level of immortal ability being able to possibly lend some secrets that may help human beings enhance the overall life expectancy as well.
One note of caution has to be mentioned. Kubota himself recognizes the possibilities that this research may hold for human development. However, at this time there is still much more research and many questions that need to be answered. Yet, there are some products that are currently being advertised as anti-aging or longevity enhancing products that are taking advantage of the scientific findings of the jellyfish research and marketing themselves has having "the chemical compound" that is found in jellyfish and that will enhance human longevity. So watch out for those products that are attempting to use scientific research, such as has been discussed here, and often misrepresenting that research as if it were definitive in an attempt to sell a product that has no proven standards.
Said-Moorhouse, L. & Sealy, A. (2014, Aug 29). Does 'immortal' jellyfish have the secret to everlasting life? CNN World. http://www.cnn.com/2014/08/28/world/asia/can-immortal-jellyfish-unlock-everlasting-life/?c=&page=1
The European Journal of Public Health has found some important news: Many medications prescribed to the elderly may potentially lead to more harm due to falls, which subsequently can lead to certain life-threatening injuries. It was found that one-half of the 20 most commonly prescribed medications that are used frequently among the older adult population increase the risk of falls. This is very sobering news since many of these medications may be needed for other health related conditions, yet the cost may be falls that could in fact lead to more serious issues than the initial conditions that the medication was prescribed for.
Among the most serious medications that contributed to the increased fall risk were painkilling medications and antidepressants as well as sedatives and hypnotic agents used for sleep. All of these medications have an impact upon the central nervous system. They can cause grogginess, lethargy, a lack of coordination, and a clouding of one's consciousness, all of which may greatly increase an older adult's likelihood of falls.
The researchers analyzed data on nearly seven million Swedish elderly and they found 64,399 cases of falls that lead to hospitalizations that were contributed to by the use of medications that had fall-inducing effects. The researchers found that those that were taking opioid and antidepressant medications had more than twice the likelihood of experiencing an injury due to a fall as compared to those that did not take these medications. Opioids are powerful pain killing medications, such as codeine, morphine or Vicodin just to name a few. They are opiate or opiate derivatives that have can not only have a pronounced pain killing effect, but they also can have a powerful effect on a person's consciousness as well as well as leading to an unsteady gait. Antidepressant medications, prescribed for depression or anxiety, often can lead to anxiety or feeling jittery, lightheadedness, and an unsteady gait. These are just a few of the common side-effects that can be found among these medications. Furthermore, the likelihood for these side-effects, all of which can lead to greater likelihoods for falls, increases with age. Although older adult males and females who took opioid medications appeared to be equally likely to experience adverse side-effects leading to falls, older women who took antidepressants had approximately 75 percent greater likelihood of falls.
There were some surprising medications that appeared to be correlated with an increased risk for falls. Medications used to treat GERD, calcium, often used for bone health supplementation, Vitamin B12, frequently given at higher doses by way of injection by physicians, and certain non-opioid pain killing medications demonstrated an increased risk of falls that ranged from 15% to 75%. Diuretics, often referred to more colloquially as water pills and frequently prescribed for edema due to congestive heart disease also was found to increase the probability of falls
It must be stated however that these were correlational findings. In other words, this was not a cause-effect finding. It is often very difficult to differentiate between the falls being due to the affects of the medications or due to the underlying medical conditions of the elderly. However, as one physician stated, one needs to pay attention to symptoms caused by many drugs that can potentially lead to falls. Individuals, including the older adult's physician, have to be vigilant for such things as vertigo, drowsiness, motor movement impairment, muscular weakness and cognitive impairment.
The likelihood for experiencing side-effects that may cause falls does not in itself mean that these medications are not justified for use in the elderly. What it does state is that the physician needs to always consider weighing the fall risk that is incurred versus the therapeutic value that the medication may have for helping the quality of life of the older adult.
Older adult's become more sensitive to the side-effects of almost all medications as they age. The medication's dosage levels are often not determined based on different adult age group variations. This in itself is problematic since different ages, based on changes in the biological organism's structure and function as we age also alter the pharmacokinetic effects of medications. Therefore, given this, one needs to make sure that individuals are judiciously followed and evaluated for adverse effects that may potentially lead to falls and offset any therapeutic value of using the drug.
Kennedy, M. (2014/Aug). Many Meds Taken by Seniors Can Raise Risk of Falls. Medscape. http://www.medscape.com/viewarticle/829826?src=wnl_edit_medn_wir&uac=87637DR&spon=34
Dementia is a prominent concern among the older adult population. As the elderly population continues to increase, the number of those with dementia also will increase in number. Recent research on dementia and cognitive impairment in the aging has targeted a new disorder and with it, a new symptom that may be related to the likelihood of acquiring dementia.
A recently newly defined disorder found among older adults, referred to as motoric cognitive risk syndrome (MCR) is characterized by cognitive decline with motor-based symptoms. The disorder appears to be common in older adults. However, those that have the disorder also appear to be at greater risk of developing further cognitive impairment that leads to various forms of dementia, including Alzheimer's disease. In fact, those that developed MCR were approximately two times more likely to develop dementia.
The current syndrome, motoric cognitive risk syndrome, is diagnosed by simple questions related to memory as well as measuring gait speed over a fixed distance. MCR is able to be diagnosed independent of cognitive tests. The group under study was composed of 26,802 older adults, with an average age of 71.6 years. Slightly more than half of the sample was women. There were 22 cohorts from 17 different countries that made up the sample.
Gait speed was measured using a stop watch and measuring the fixed distance that one walks within a given period of time. The average or mean gait speed was 81.8 cm/s, which is slightly less than three feet traveled per second. Those who were one standard deviation below the average walking speed were viewed as slow walkers and therefore comprised motorically.
The finding showed that those that were diagnosed with MCR had worse performance on all cognitive tests than those who were not diagnosed with MCR. Those with MCR also had a higher prevalence of disease, especially vascular diseases. The diagnosis of Motoric Cognitive Risk Syndrome has appeared to be able to have important predictive value as well. As Dr. Joe Verghese, lead study author states, "You would expect that the people who actually have dementia but are being classified as MCR would meet dementia criteria pretty soon over the next 2 or 3 years, but if you take them out, that would suggest that MCR can predict beyond the initial few years and capture cases that are going to develop dementia more than 3 years out."
The study emphasized the importance of gait speed as being an important predictor of future dementia. As Dr. Verghese states, gait speed is highly reliable and has been a very sound predictor of health outcomes. In addition, gait speed measurements are simple, highly accessible, and easily done in most health care settings. However, he also stated that it may not be the only, or even the strongest motor predictor of dementia. However, the research in this area has been limited up to this time.
Given that predementia testing is often quite expensive and frequently not covered by insurances, simple and expensive forms of testing and diagnostic evaluations are often welcome. Although this study appears to shed some light on a new diagnosis that may be an important predementia diagnostic, as well as the use of simple and less expensive diagnostic assessments for anticipating future progression to dementia, the new syndrome and its concomitant diagnostics will probably not be fully embraced at this early level. Furthermore, more research will be need to be completed before one can provide greater assurance regarding the validity of this new diagnosis and whether it is truly an important predementia diagnostic that can enhance our ability toward slowing down the progression of dementia.
Furthermore, the study did not appear to address the cause and effect nature of the issue of motor decline as it relates to dementia. Is motor decline a sign of, or even cause, of impeding dementia, or is it a related effect of dementia, albeit incipient stage brain changes that may already be occurring due to the dementia process. Moreover, if a person stays active and maintains a better gait speed, will that reduce the likelihood of dementia? Finally, is MCR a diagnosis that is truly separate from the dementia diagnoses and by creating a new diagnostic category will it be useful for treatment intervention or is it just another label being attached to the elderly person?
Many of the above questions I feel still need to be answered before we enthusiastically embrace a new diagnostic category. For the most part, some of the discovery that motor involvement may be related to dementia is not a great surprise since many forms of dementia will demonstrate motor issues as the disease progresses due to further insult upon brain tissue. I feel that the main question that really is of concern here and that needs to have greater clarification is whether:
- maintaining enhanced gait speed through exercise will reduce the likelihood of future dementia
- whether the diagnosis of MCR will be useful so that successful intervention can be brought about that would ultimately prevent or slow down further neurological disease progression.
Anderson, P. (2014, July). Slow Gait, Cognitive Complaints Predict Cognitive Decline. Medscape, http://www.medscape.com/viewarticle/829135?src=wnl_edit_medn_wir&uac=87637DR&spon=34#1
The baby boom cohort, those who were born between 1946 and 1964, is the largest birth cohort that has ever been produced in the United States. As soldiers returned home from the war, the birth rate increased and subsequently for a decade and a half, we witnessed a very large number of children being born. Furthermore, we also have witnessed an increasing life expectancy as many acute illnesses that formerly lead to early mortality have now been controlled or conquered. Given the burgeoning birth cohort, coupled with an increased life expectancy, our population will be witnessing a large increase in those who are 65 years of age and older. The impetus for much of this increase will be found in the baby boom cohort as more and more of the group continues to age and move into the later stages of life. Inevitably, as the population ages, there will be a need for many older adults who will need placement in nursing care facilities. However, given the need, will they actually be able to afford such care is a question that is being asked.
A recent report, released by the National Institute on Aging, states that the problem of affordability for nursing home care may be very serious in the years ahead and may limit those in the baby boom cohort from being able to obtain the needed nursing home care that many will need. One of the changes that occurred among the baby boom generation is that as they aged and married, their birth rates went down. Many of those baby boomers had significantly less children than their parents and grandparents did. As the baby boom cohort ages, many of them will have more chronic illnesses and will be in need of extended care. However, since they have had fewer children, who in past generations often assisted with parental care, nursing home care for many may be the only alternative. Yet, nursing home care is expensive and will continue to be even more expensive in future years. Furthermore, with a greater life expectancy, more chronic illnesses, and less adult children to assist with care, the baby boomers will be facing the potential need for a greater number of years in which care will be provided from an extra-familial source like a nursing care facility.
Richard Suzman, who is director for the National Institute on Aging's Behavioral and Social Research division states that this demographic change that will be part of the baby boomers entering later adulthood will approach a crisis situation in the years ahead, stating "Baby boomers had far fewer children than their parents. Combined with higher divorce rates and disrupted family structures, this will result in fewer family members to provide long-term care in the future. This will become more serious as people live longer with conditions such as cancer, heart disease and Alzheimer's"1.
The National Institute on Aging examined the average cost of nursing home care. In 2010, the average cost of a private room within a nursing care facility was $229 a day, which equated to $84,000 each year1. Although semi-private rooms, which most older adults are placed in are less expensive, the costs still are typically well over what most can afford, especially on an extended level. Furthermore, the National Institute on Aging also found that given the cost of nursing home care, less than one-fifth of all older adults in the United States can afford to live within a nursing home for more than three years. Even more disconcerting, nearly two-thirds are unable to afford the cost of nursing home care for even a single year1.
As one can see, given the current problems of affordability, coupled with the increasing size of the future older adult cohort, a serious problem for servicing the chronic health care needs of the older adult population is quite evident. Since the current older adult population makes up approximately 13 percent of our population and will expand over the next 35 years to approximately 20 percent of the total population, one can start to see the important issue that arises as it relates to older adults and their potential long-term health care needs. How will they as a group be able to get the needed long-term care to assist with their needs if it is a resource that they will not be able to afford?
Another concern that needs to be mentioned is that Medicare payment covers at most only 100 days of skilled nursing home care after a qualifying hospital stay. However, even this level of small assistance is not a given. As mentioned, not all individuals qualify for 100 days, and even if they do there are also copayments that also are applied as well. Moreover, as the high inflationary costs of the medical industry continue to place a tremendous burden on our social system, one has to ask will there be any cuts in Medicare as it applies to nursing home care in future years.
Furthermore, Medicare, an insurance for the indigent, pays almost one-half of the long-term care nursing home expenses in the United States1. However, to qualify, most individuals have to severely reduce most of their personal assets to an indigent level. This has to give many a time to pause and consider that after a lifetime of accruing some level of net worth, at the end of their lives when they need care most, they have to become indigent just to be able to obtain the care they need. This is not a dignified level of existence as one moves to their final stage of life.
Moreover, currently, the Affordable Care Act has mandated greater allocation of assets to increase the state Medicare coffers. However, that is not explicitly for nursing home care. Furthermore, here again, one has to wonder, given the inflationary health care climate, how long additional resources diverted to Medicaid will be able to last to support this endeavor.
As one can hopefully see, we are approaching a crisis mode for individuals of the baby-boom cohort. As this large birth cohort now is moving into the older adult stages of life, the population that is 65 years of age and over will start to increase dramatically and will be approaching approximately 20 percent of the total population over the next 35 years. However, the question remains, how will many of these individuals, with increasing life expectancies and the greater burden of an ever-increasing amount of chronic conditions be cared for? Will they be able to afford the long-term care options to assist them with their health care needs? Furthermore, with less children available to shoulder the burden of care for their older adult parents, the need for long-term placement, which may be a placement even longer for many in future years than it has been in past years, may become an insurmountable financial burden. This situation definitely is legitimately able to be termed a "crisis" situation that will be part of our future health care years and that we cannot ignore.
Preidt, R. (2014, June 30). Nursing Home Care Out of Reach for Many 'Boomers'? WebMD. http://www.m.webmd.com/a-to-z-guides/news/20140630/nursing-home-care-may-be-out-of-reach-for-many-aging-boomers-study
Oxytocin, secreted by the posterior pituitary, is not a new hormone. Nor is its importance for the biological health of the organism something new. Oxytocin has been known about for many years. It was known to be instrumental in helping uterine contraction during childbirth, for enhancing breast contraction during breast feeding, and even more recently, it has been found to be instrumental in helping to establish bonds between parents and infants as well as enhance bonding and trust in social relationships. Furthermore, oxytocin increases dramatically during sexual intercourse, and has often been referred to as the love hormone. However, this hormone that already has been found to be so instrumental in so many areas of our life is now providing us with new findings, and these findings may be the most significant yet.
Recent research out of the University of California, Berkeley has found that oxytocin may help to heal and reverse atrophic changes in muscles as we age, countering many of the sarcopenic changes in muscle mass and strength that is often found among older adults. This is a particularly important discovery since falls resulting in severe injuries, such as fractures, exist at epidemic proportions in the elderly. Generally, the probability for such falls and injuries, some even resulting in death, are due to muscle weakness associated with aging.
In studies on mice, injections of oxytocin on a subdermal level enhanced the regenerative potential of muscle in aging mice. Older mice that were given oxytocin injections demonstrated greater muscle healing and regeneration as compared to those older mice that did not receive oxytocin injections. Furthermore, the oxytocin appeared to work on muscle healing and muscle regeneration very quickly. As one of the lead researchers, Christian Elabd stated, "The action of oxytocin was fast ... The repair of muscle in the old mice was at about 80 percent of what we saw in the young mice"1. This is an incredible reversal, with older mice having a repair and regenerative potential that is 80 percent of the more youthful mice.
The synthetic form of oxytocin has existed for years to assist women with delivery. Since the Food and Drug Administration already has a synthetic agent approved, if the hormone continues to show promising results, using the already approved synthetic form could be very important in bringing it to use for diseases related to aging. Since it already has been brought to market and is in use, the already approved drug could lead to new therapeutic interventions for reversing muscle aging in the near future.
One of the first clues that oxytocin might have important effects on muscle cells was when scientists noticed that women who had their ovaries removed also experienced a reduction in oxytocin levels. They also noted that the precursor cells to mature muscles cells had oxytocin receptors. Since many ovarectomized women experienced effects that were similar to those found in aging individuals in their muscle tissue, they hypothesized that a connection between oxytocin and muscle aging may exist.
There is also further good news about the introduction of oxytocin into the bodies of mice. In young mice it did not seem to cause an appreciable effect in changing muscle regeneration. At first this may not seem very encouraging. However, it points to important safety concerns. Since oxytocin appears to focus on aging stem cells without affecting more youthful muscle, this seems to address the issue of whether it may lead to controllable mitotic division, leading to cancerous changes. In this case since it did not appear to do so in the more youthful mice, the drug appears to have answered some important concerns about its safety.
The reduction of oxytocin in later years may also be strongly genetically driven. The researchers investigated the oxytocin gene and the effects of the gene after it was disabled. They found that when they disabled the gene it did not automatically manifest results when the mice were young. However, as the mice became older, they started to show early senescent changes, aging changes that occurred at ages much earlier than one would anticipate and as compared to a control group of mice who did not experience the genetic manipulation.
Although these are exciting results, one has to be cautious against using terminology and references to oxytocin as an "anti-aging" drug or hormone. Senescence is a natural process. There is nothing that reverses aging or is an "anti-aging" remedy as some will have you believe through media sources. Yet, the important scientific finding that oxytocin may help regenerate muscle may eventually lead toward helping address many diseases and the symptoms of these diseases that are often associated with aging. Furthermore, it may help prevent many injuries such as falls resulting in fractures, especially of the hip, that often result in premature mortality.
Oxytocin is an exciting agent. It became known almost exclusively for its biological effects during childbirth and infant feeding. However, recently, just over the last couple of decades, the research on oxytocin has shown that it also has important social effects on individuals, especially regarding bonding and trust. And now comes another connection with this hormone that is growing in stature. In fact, this may be the most important one of all, and may have important implications for enhancing healthy aging and eliminating many common diseases or illnesses associated with aging. Is it not deserving of being known as the "wonder hormone"?
1. Choi, C. (2014/June 11). Aging Muscles May Just Need a Little 'Love Hormone.' LiveScience. Accessed at: http://news.yahoo.com/aging-muscles-may-just-little-love-hormone-140029679.html
Generally speaking, fasting is often viewed quite negatively. However, a new study done by the University of Southern California has found that fasting could help the body fight disease, showing that a two day fast may actually regenerate the immune system. The study sheds some hope for those with compromised immune systems such as those receiving chemotherapy and the elderly.
Studies were done on both mice and humans. It was found that long periods of fasting significantly lowered white blood cell counts, demonstrating that long periods of fasting could have a negative effect on one's immune, subsequently increasing a person's susceptibility to disease.
In mice, it was found that each fasting cycle "flipped a regenerative switch" that led to the regeneration of new white blood cells. Apparently a short period of fasting was found to shock the immune system, renewing the body's defense. It was analogous to the immune system being given a wake-up call, with the fasting period reviving the immune system and more or less communicating to it and saying "you are sluggish and need to get moving." Valter Longo, who is a professor of gerontology at the University of Southern California said, "it gives the OK for the stem cells to go ahead and begin proliferating and rebuild the entire system. And the good news is that the body got rid of the parts of the system that might be damaged or old, the inefficient parts, during the fasting."
The study also found that fasting for a short period led to a reduction is the enzyme PKA, as well as reducing levels of IGF-1, all of which have been related to reduced longevity, accelerated aging and cancer cell development. How fasting leads to these reductions was not definitively stated.
The results appear promising, yet it is too early to start recommending periodic fasting. I think they must be interpreted very cautiously at this point. It must be remembered that overall, nutritional sustenance is typically much more important, and that deprivation of important nutritional components for extended periods of time can have deleterious effects for individuals, including a reduced immune capacity.
It must further be remembered that for many older adults, their immune systems are often compromised by inadequate dietary intake of proper nutrients. Therefore, the question I would ask the researchers that conducted this study is if fasting would have similar effects for those who fail to take in the proper levels of nutrition in their daily diets. Here again, I do not think any answer to that particular question could be ascertained from the study's very preliminary findings. However, this does not mean that we should be dismissive of the results either. If the results can be further replicated, it may have some important significance for addressing many older adults who need a jump start immunologically to ward off many diseases that they become more susceptible to as a result of aging. However, until more results are found that support this type of intervention, caution and a healthy level of skepticism should continue to guide our approach in this area.
Delhidailynews.com (2014/June 8). Fasting Twice a Year Rebuilds Immune System. http://www.delhidailynews.com/news/Fasting-regenerates-immune-system-1402181003/
Recent research that has been conducted at Washington University Medical School and the University of Pennsylvania has found that the use of an commonly prescribed antidepressant medication may help prevent or reduce the likelihood of acquiring one of the most feared diseases-Alzheimer's disease.
Beta amyloid is a protein that has been instrumental in the development of plaques that has been found to exist in the brains of those with Alzheimer's disease, although these plaques have also been found to a lesser degree among those who did not have Alzheimer's disease. Nevertheless, these plaques and the amyloid beta buildup that has contributed to their development, has been strongly associated with Alzheimer's disease. Amyloid beta is normally produced in the brain, but an excessive amount of this protein that builds up in the brain appears to be strongly associated with the impairment in memory and cognition that is found among those with Alzheimer's disease.
Some previous studies have demonstrated that serotonin, a normal neurotransmitter chemical found in the brain and metabolized from tryptophan, an amino acid, has been associated with also helping to alleviate depression as well as calm anxiety. Most new forms of antidepressants have been developed to specifically target serotonin in a much more focused manner than was found with many of the first generation antidepressants.
The researchers worked with mice that were genetically altered to develop Alzheimer's disease. The mice were young and subsequently did not experience age changes normally found within older brains, especially those associated with increased levels of plaque formation. Amazingly, the researchers found that after introducing a serotonin-enhancing antidepressant into the mice, their amyloid beta protein level was reduced on an average by 25 percent after 24 hours of treatment. This was an astonishing result to say the least.
In a more recent test, using citalopram, the antidepressant commonly known as Celexa, the researchers administered this medication into older mice that already had a significant level of beta amyloid build up and subsequently significant plaque formation in their brains. After administering the medication they tracked the plaque growth over 28 days using a sophisticated type of brain scanning. Here again, the results were quite amazing. The mice that were given citalopram had their existing plaque development halted. However, even more astonishing was new plaque formation was reduced by 78 percent!
Interestingly, in another phase of the experiment, citalopram was tried on humans. Citalopram was given to 23 human participants between the ages of 18 and 50. Citalopram is a common medication administered to humans for depression and even anxiety, so it is not an experimental medication by any means. In these phases of the experiment, none of the participants in the study suffered any cognitive impairment or depression. After the citralopram was administered, spinal fluid was obtained from the participants 24 hours after the administration of the medication. Here again, the spinal fluid showed that amyloid beta production had dropped in this group as well, by 37 percent!
However, one of the study's authors, Dr. John Cirrito has stated "There is still much work to do." Cirrito states that, "Antidepressants appear to be significantly reducing amyloid beta production, and that's exciting ... But while antidepressants generally are well tolerated ... they have risks and side effects. Until we can more definitively prove that these drugs help slow or stop Alzheimer's in humans, the risks aren't worth it. There is still much more work to do."
The next step in the research according to the study's authors is that they need to examine more closely if serotonin is truly causing this reduction. If the reduction is directly related to the increase in brain serotonin, than the scientists will have to work out what it is doing on a molecular level that is preventing and halting the development of amyloid beta and its associated plaques.
What is very interesting about this research is not only the preventative and possible treatment modalities associated with enhancing serotonin in the brain toward reducing amyloid beta production, but that we may already have medications that have been in use for some years that could be immediately available to many individuals who suffer from this disease or for those who could benefit from preventative intervention to preclude earlier development of this disease. Furthermore, given that the medications are already available, the need to further research drugs that are already being used helps to decrease the time lag often associated with the development of a new drug. Although these studies are not stating that using serotonergic antidepressant agents by any means is a cure, the encouraging results that have been found to exist in reducing amyloid beta up to this time, which is the protein that when built up to higher levels in the brain is associated with Alzheimer's disease, is very encouraging to say the least. However, as the authors warn, we should not start randomly prescribing these medications. More research is still needed. However, this research up to this point has shined brightly.
McNamee, D. (2014/May). Could a commonly prescribed antidepressant slow onset of Alzheimer's? Medical News Today. Accessed at: http://www.medicalnewstoday.com/articles/276838.php
In a recent survey, when centenarians were asked how old they felt, they stated they felt approximately 17 years younger, on average 83 years of age. Also, when those who were 65 years of age were surveyed on how old they felt, they said they felt on average 10 years younger than their chronological age, or approximately 55 years of age.
The results sound somewhat unwieldy. One may ask how are they measuring these subjective evaluations provided by the older adults surveyed. The results are part of the ninth annual 100@100 survey conducted by United Healthcare, which has polled 65 year olds and 100 year olds to compare the attitudes and lifestyles of American adults who were about to enter retirement with those that have already done so 35 years ago. In other words, the survey compared the subjective statements of the most recently surveyed older adults with those who were surveyed in past years in the previous surveys. The current survey looked at the responses of 104 centenarians and 302 baby boomers entering retirement.
In evaluating some of the common responses that were found among centenarians, some of the following were found among those surveyed.
- When asked how it felt to be 100 years of age, the top three responses given were 1.) blessed at 36 percent, 2.) happy at 31 percent and 3.) surprised at 12 percent.
- Another interesting common theme found in the responses was that 53 percent of the centenarians felt they had achieved everything in life. However, approximately one-third said 100 years of life was not enough and one in five stated they would like to live just a few more years. So much for the misconceptions that view older adults as inevitably suffering and welcoming death.
- Another fascinating finding was that the centenarians were far from a totally dependent group. The survey found that 53 percent said they lived independently and were able to carry out their activities of daily living without any assistance!
- An interesting psychological finding was that not one centenarian described themselves as being sad, and only 3 percent said they experienced feelings of loneliness.
In comparing the responses of the 104 centenarians with the 302 baby boomers on a number of questions, there were some common similarities and some noted differences that were found. For instance, when both the centenarians and the baby boomers were asked to give the three top keys to healthy aging, the centenarians stated:
- 1) Staying close to friends and family (91 percent)
- 2) Keeping a sense of independence (88 percent)
- 3) Eating right (86 percent)
The baby boomers had similar views on this question as well stating the following:
- 1) Maintaining a sense of independence (87 percent)
- 2) Laughing and having a sense of humor (87 percent)
- 3) Staying close to family and friends (84 percent)
Centenarians and baby boomers also appear to be getting much more health conscious, especially on a preventative level. Both of these groups stated they see their family physician at least once each year for a physical examination, as well as maintaining current with their vaccines. Furthermore, both the centenarians and baby boomers are remaining physically active and are apparently becoming more conscious of doing so for their health. Most stated they walked or hiked at least once each week. In addition, approximately one-third reported engaging in regular strength training weekly.
Dr. Rhonda Randall, the chief medical officer for the United Healthcare Retiree Solutions was quite encouraged by the results found in this year's 100@100 survey. According to Randall, "This year's 100@100 survey paints an encouraging and exciting view of longevity." Randall is especially optimistic about the number of older adults who are actively involved in their health on a proactive level. The increasing level of self-efficacy found among older adults toward becoming proactively involved in their health to forestall or attenuate disease is very encouraging to Randall, stating, "This is a good reminder for all Americans to take charge of their health now so that they can enjoy life for many years to come"(Paddock, 2014).
It is definitely encouraging that, in this study, older adults were more involved in managing their health more proactively and not just their disease as was often the case in the past. Some of this may be due to a more informed and better educated older adult population, as well a public health measures that have often encouraged greater levels of health consciousness as an important preventative health care measure. However, one must also look at these results cautiously. The sampling methodology may preclude one from generalizing these results beyond the current study's sample. Nevertheless, the current results, as compared to previous 100@100 surveys, demonstrating greater levels of health, activity, independence and demonstrable levels of optimism are to say the least, quite encouraging.
Paddock, C. (2014, April 25). American centenarians and baby boomers feel 'younger than their years.' http://www.medicalnewstoday.com/articles/275940.php
It has been known for some time that nursing home care is not the same in every nursing care facility. In a recent study published by a nonprofit advocacy group, Families for Better Care, the group's review looked at nursing homes and care found in these facilities found in each state. The Families for Better Care state that it is the first state-by-state review of nursing home care that has been undertaken.
The data for this undertaking was obtained from three major existing data sources: The Kaiser Health Foundation, Performance measures from the Centers for Medicare and Medicaid Services Nursing Home Care site, and from the Office of State Long-term Care Ombudsman regarding complaint data information. The data obtain compiled information regarding the following areas as they relate to nursing home care:
- State's average registered nurse (RN) hours per resident per day
- State's average certified nurse assistant hours (CNA) hours per resident per day
- Percentage of facilities with above average registered nurse staffing
- Percentage of facilities with above average direct care staffing
- Percentage of facilities with above average health inspections
- Percentage of facilities with deficiencies for the 2012 calendar year
- Percentage of facilities with severe deficiencies for the 2012 calendar year
- Percentage of verified ombudsman complaints for the 2011 federal fiscal year
The abovementioned nursing home data was examined on a state-by-state basis, averaged and then a final letter grade provided to each state based on the quantitative state average. The grades given to the state were letter grades such as A, B, C, D, and F.
The study found that the following states were ranked the highest, or in other words, received an A grade. These states had that highest overall average nursing home care performance:
- Rhode Island
- New Hampshire
- South Dakota
- North Dakota
Conversely, there were a disconcertingly large number of states that had failing marks. These states had the lowest overall average nursing home care performance ratings. These states were as follows:
- New Mexico
- New York
Key Findings From This Study
The study revealed some important findings found among nursing homes and nursing home care throughout the United States. Many of these finding were directly linked to the type of care they provided on a state aggregate level and subsequently the grade that the states received on the basis of the data examined. Here is a brief summary of some of the major findings:
- States who had greater levels of average nursing home staffing, both professional nursing care staffing and paraprofessional caregivers such as nursing assistants, had higher grades.
- A very disconcerting finding is that only seven states were found to provide more than one hour of professional nursing care per resident day. Furthermore, it was found that 96 percent of the states offered residents fewer than three hours of direct resident care each day, which entails care not just from nurses, but all staff such as physical therapists, nursing care assistants and activity therapists.
- Nearly 90 percent of all nursing homes were cited with a deficiency. This statistic has to be viewed cautiously, since it does not say anything about the type or severity of deficiency. However, when looking at the severity of the deficiency as a separate category, Rhode Island nursing care centers scored the lowest with less than four percent of their deficiencies falling into the severe range. Conversely, Michigan performed worst on this statistic, with more than 50 percent of the nursing care facilities receiving a severe deficiency.
- Resident abuse and neglect in nursing homes was quite common. It was found that one in five nursing homes experienced issues of abuse, neglect or mistreatment in almost one-half of the states.
- When complaints were submitted and the proper authorities were notified, certain states were found to have higher levels of verified complaint verification. Montana, Connecticut, Wyoming, Washington DC, Missouri, and Massachusetts had extraordinary high complaint verification rates. Conversely, New Hampshire, Nevada, and New Jersey had the fewest. Again, this has to be looked at cautiously as well since those who investigate complaints have a level of subjectivity in their investigative protocol.
- Health care inspections for nursing homes was found to be low.
The study that has just been discussed is a very large state-by-state study that is the first of its kind in examining nursing home care on a national basis. It provides an important level of information in that it is not just conducting an inter-facility based comparison, but a state-by-state comparison, showing that some states on an aggregate level are doing better than others. However, more needs to be discussed why these states are not doing as well as other states that received superior grades in this area? In particular, why are those states with failing marks not providing enough staffing for the provision of quality care in relation to those states that are given an A grade. This is just but one indicator that needs to be examined in greater depth regarding the disparity found to exist. Nevertheless, the study provides a picture of state-based nursing home care and which states are doing better than others. However, here again, caution has to exist in interpreting the results. The data was obtained from pre-existing databases, which themselves hold data from surveyors and groups that often obtain data in not exactly the same manner. In other words, although surveys and survey protocol do follow a standard federal basis for surveyors to use, states probably have considerable variability in how they employ and carry out this protocol. This being stated, the study does provide some very interesting, if not attention getting information, that could be used to further nursing home care on a national level.
Renovating seniors' homes may lead to longer independence. Accessed at: http://www.cbsnews.com/news/renovating-seniors-homes-may-lead-to-longer-independence/
Families for Better Care. Accessed at: http://nursinghomereportcards.com/about/
[Editor's note: the following blog post was written by Brian Garavagli]
A national report on nursing homes, conducted by the Office of the Inspector General of the United States Department of Health and Human Services, has found some very sobering, if not frightening, results. The study found that as many as one-third of all nursing home residents were harmed by their treatment!
The Office of the Inspector General used a large sampling of Medicare patients that were discharged from hospitals to nursing homes within a particular year. It found approximately one-third of the patients that were studied in these nursing homes experienced treatment that harmed them in some way. It was also found that most of these cases of harm were preventable.
Ruth Ann Dorill of the Department of Health and Human Services stated, "We were surprised at the seriousness of many cases." Many of the problems were not based on case or treatment complexity. Dorrill states that many of the issues were oversights and failures in carrying out proper everyday care. In other words, many of the cases of harm that existed were due to failures in carrying out normal standard protocol correctly. Paying proper attention or failing to monitor an individual correctly were often some of the apparently simple, yet highly important oversights, which lead to many harmful forms of nursing home care, or maybe better stated, lack thereof. Dorrill states that many of these forms of improper treatment intervention leading to harm fall under the classification of "what clinicians would call substandard medical care."
The study found that approximately 60 percent of the nursing home residents that experienced harmful treatment eventually ended up being readmitted back into the hospital. The Office of the Inspector General estimates that the cost to Medicare for such improper and substandard care is approximately 2.8 billion dollars annually. This 2.8 billion dollar estimate is just considering the hospital cost, and it does not entail the cost of physician care and extra time spent being readmitted to a nursing home. Therefore, the cost of improper medical treatment in nursing home care may be adding considerably to the overall health care expenditures that exist in our country. This, during a period in which the government and many third party paying sources are strongly attempting to curtail health care costs, which has become a serious economic problem for our country. However, given the serious economic impact that it has on our health care system, more serious are the concerns related to the potential harm, and in some cases death, that has resulted from improper care.
Dorill states that today's nursing homes are harboring sicker individuals than in the past, and many have a greater complexity of care found within their nursing home populations. Given this, they need to have staff that pays particular attention to the regimentation of treatment protocol, covering a greater number of patients than had previously needed such types of oversight in past decades. As the population ages, this will become an ever-increasing problem as more individuals may be in need, at least for short-periods of time, of care and rehabilitation provided within a nursing home setting. That being the case, what is quite disconcerting is that many of these forms of inappropriate treatment that lead to harm, or even to the death of the patient, were often simple human factor issues. Paying attention to the administration of certain medications, providing proper attention to prevent falls, or providing proper food administration to prevent aspiration are some of the issues that were found to exist. Many of the problems therefore were not due to a technical inability found to exist in the provider of care. They were acts of omission or commission that could be considered very preventable forms of negligence.
What can be drawn from this current study? First, there are still considerable care issues that need to be addressed in the nursing home industry. There have been considerable improvements over the past couple of decades, especially since nursing home care improvement was targeted by the federal government and the Institute of Medicine in the 1980's. However, to paraphrase Robert Frost, the nursing home industry still has miles to go until we can sleep. Furthermore, a more effective and efficient form of care has to be focused on, especially toward eliminating unnecessary behaviors and interventions that can actually not only harm individuals, but exacerbate their conditions that lead to greater health care costs in the long run. As was found, many of the clinical aspects that may need to be targeted to avoid harmful treatment interventions are not highly complex issues, in as much as they are human factor issues. Subsequently, better logistical processes, focusing on human factor engineering issues may be of considerable importance. One last thing to note as well is that iatrogenic forms of illness or treatment are not unique to the nursing home area. Nevertheless, the study's finding of approximately a third of all Medicare nursing home residents experiencing some form of harm has to give one great pause, as well as sensitize the nursing home industry toward addressing this deficiency properly and expediently.
Jaffe, I. (2014, March 5). One-third of nursing home patients harmed by their treatment. Accessed at: http://www.npr.org/blogs/health/2014/03/05/286261742/a-third-of-nursing-home-patients-harmed-by-their-treatment