Gerotalk : News

Do you know what F-Tag changes are coming your way?

Brian Garavaglia — Fri, 24 Jul 2009 13:13:00 GMT

This article addresses some changes in certain F-Tags by the Centers for Medicare and Medicaid. These are important changes that should be noted for those in nursing home care.

Some of these changes have taken what was implicitly known and now made in much more explicit on a regulatory level. Click here to read the article.

Blood Sugar Levels May Be Critical to Preventing Memory Loss

Brian Garavaglia — Tue, 12 May 2009 19:14:00 GMT

Click here to read Brian's column "Gerotalk" on the ADVANCE for Long-Term Care Management Web site.

In the May 2009 edition of Scientific American Mind, a short article is provided on the research conducted by Scott Small at Columbia University. The article entitled, An End to Senior Moments: Lowing blood sugar levels may thwart forgetfulness, addresses the impact that higher blood glucose levels may have on proper brain function. The article also may help explain why exercise is a powerful component to healthy aging, including a healthy brain.(1)

It has been known for some time that as we age there is an increased likelihood for blood glucose levels to increase. Although the brain is a glucose hungry organ, consuming 20 percent of the glucose needs of the body, too much excessive blood sugar can be potentially problematic for the body and the brain. It appears that as we age the cellular membrane becomes less sensitive to insulin, which in turn prevents this important sugar from properly moving into the cells for energy and subsequently leading to elevated levels in the older adult's body. When this happens many older adults are susceptible to Type II diabetes.

Levels of blood sugar have been tied to potentially reversible memory issues at all stages of life. Those that suffer from hypoglycemic or hyperglycemic reactions often report problems with their levels of consciousness as well as with memory. The brain, although very dependent on glucose for its function, needs to strike a balance between not flooding itself with excessive levels of glucose as well as failing to not take in too little glucose. Yet, the brain is a very resilient organ that can often recover from excesses in either direction.

In the recent study completed by Small, he found that as we age the probability for increased blood sugar levels affecting memory can be considerable, and can help explain many of those periods of forgetfulness or less efficient functioning of memory that many individuals experience, and complain about, as they age. In fact, many of these factors that are related to less efficient metabolism of glucose start to happen fairly early in life-in our late 30s and early 40s. This becomes quite interesting. One hypothesis that this leads to is what are the cumulative effects on the brain of uncontrolled blood sugar levels, and do those that have less control over their blood sugar levels become more prone toward dementia as they age due to the cumulative insults on the brain of unchecked blood sugar levels.

Small's study goes further in targeting the part of the brain that the higher blood sugar levels may disrupt, leading to memory problems. Although the hippocampus is known for being an important part of the brain for memory, a particular part of the hippocampal area known as the dentate gyrus appears to be particularly sensitive to higher glucose levels. According to Small's research this area, when inundated with excessive levels of glucose, appears to lead to problematic forgetfulness.

This new research could have very important implications for the need to continue to remain active as one ages. As stated, issues of glucose metabolism start fairly early in life, in ones third and fourth decades of life. Although the current research did not answer any questions on the cumulative effect of unchecked blood sugar levels on the brain, it does lead one to make hypothetical assumptions that need to be answered through future research. However, more important to the current research is the continued support it provides for the need for regular exercise.

Small extrapolates from his current study that exercise may be potentially a very powerful tool for warding off many of the common age-related memory declines that are found among individuals as they age. In fact, due to the potential increase in blood sugar levels starting relatively early in life, the need for regular exercise may actually be more important as we age. Especially as it relates to brain health, as our normal metabolic processes decline with age, exercise can actually enhance the movement of glucose into cells and help reduce the excessive blood sugar levels that may lead to age related memory problems. This is actually very good news since many of the transient memory problems that plague us as we age can be reversed through exercise, leading to greater memory efficiency.

The article in itself does not provide a great epiphany. It has been known for some time that sugar metabolism can dramatically effect memory. Moreover, it has been known that exercise is an important source for warding off illness as we age. More recently, exercise has also been associated with helping to improve cognitive functioning and possibly enhancing neurogenesis.

However, Small's study helps to illuminate and provide some sound, empirical understanding of how glucose metabolism may be implicated in the aging brain. It also addresses the specific area in the brain that inadequate blood-glucose metabolism targets and disrupts, leading to many age related memory issues, and this new finding may aid us in advancing brain health for the elderly. Although many know about the positive benefits of exercise on the body, especially for enhancing cardiovascular, pulmonary, and muscular strength and functioning, less often is exercise associated with the positive benefits it has on brain functioning. The implications that it has for getting more individuals involved in regular exercise are very important.

Since cells become less sensitive toward moving glucose into the intracellular apparatus as we age, leading potentially to higher blood-glucose levels, which in turn can lead to excessive glucose targeting brain sensitive areas, and since exercise is an important mechanism for helping to move this biochemical molecule into cells, it is very important to make sure that individuals are getting the proper level of physical activity and exercise to compensate for age related reductions is glucose metabolism. With increased activity we may be able to ward off those so-called "senior moments" that many have come to assume as inevitable parts of the aging process. Therefore, with this knowledge in hand we know that we need to get up, move around, and pay attention to our carbohydrate intake, which in turn may move us into those later years with a more youthful and better functioning memory that is not inevitably consigned to increased levels of forgetfulness.

Reference

1. Nikhil Swaminathan (2009). An End to Senior Moments: Lowering blood sugar levels may thwart forgetfulness. Scientific American Mind, 20(2): 9.

What Can Long-Term Care Learn From Enron?

Brian Garavaglia — Mon, 30 Mar 2009 17:01:00 GMT

Today, most people are familiar with the story of Enron. A company that was once looked at as one of the exemplary companies in the United States became a buzzword for corruption and mismanagement. Although the problems that came to eventually destroy Enron were monumental, as mentioned it was once viewed as an exemplary company. What happened at Enron is a lesson for those in business and this lesson is transferrable to the health care sector as well.

Enron as mentioned was once viewed as an exemplary company, which was growing and had sound leadership driving its corporate culture. Under Richard Kinder, the president of the company, the company flourished, and a corporate culture of trust was established. Kinder was viewed as a person that was quite meticulous and held others accountable for their behavior and for their roles in the company. Although strict, he did build a culture of trust that many felt comfortable with. They understood their roles and their expectations and although Kinder drew a line in the sand, establishing his area and what his expectations where for others, many felt that he did so without equivocation.

With the movement of Richard Kinder out of the company and Jeffrey Skilling into the role of Chief Executive, things started to change. Skilling had a Machiavellian temperament for control and an unbridled hubris. Skilling introduced evaluation systems that would be made available to others in the company. He also created an environment that found frequent turnover, fostering hegemony and fear throughout the corporate environment. This left many looking over their shoulder wondering if they would be the next person to be cut from the workforce. The environment that had previously been based on a level of trust and stability was now being replaced by a culture of paranoia based on Skilling's capricious and fear-inducing tactics.

Skilling appeared to feel that introducing fear and fostering a sense of insecurity among the workforce culture was a positive management strategy. As the new culture and management style became set in place at Enron, it was almost inevitable that the organizational features that Skilling put into play would led to the formerly successful company to witness a destabilization of their cultural environment. We now know that it did and the stability and trust that was established by Kinder was destroyed by Skilling within a very short period of time. This for sure in not the only problems that Enron faced, which ultimately led to their demise, but the establishment of a "social Darwinism," with a cutthroat mentality and a lack of care for those in their work culture was significantly related to the downward spiral of this company.

So what type of lesson does this hold for those in long-term care? The lesson is significant. In a health care environment, the importance of trust and collaboration is very important. Prior to Skilling's arrival at Enron there was a feeling of consistency and trust. The company flourished under leadership that encouraged a firm management style that emphasized a collaborative and trusting team approach. People were viewed as resources that needed to be tapped. However, when the culture moved to a dog-eat-dog environment, trust waned, collaboration waned and the workers came to view themselves as disposable cogs that occupied positions on a day-to-day basis. How often do we witness this type of style within long-term care?

Think of how often we feel that we need to manage in secrecy, behind closed doors. For sure, there is need for this type of management. But all too often this type of management comes to dominate the administrator or other manager's styles, providing for a less than transparent environment. Workers come to feel that the culture is veiled in secrecy, with workers becoming paranoid about what is being discussed behind those closed doors. This in turn often erodes feelings of trust that are needed for a sound and efficient work environment. Furthermore, a level of hypocrisy often results where managers state they have an open door policy, yet spend most of their days is clandestine discussions or meetings. Workers pick up on these subtle clues that are provided by those in authority.

As we witnessed with Enron, when trust started to erode and when capricious policies were set, the breakdown of trust as well as the breakdown in the cultural environment as being a stable and predictable place eventually led to the downfall of the company. Workers became anxious about their jobs and they also became weary of working in such a strenuous and draining environment. The social Darwinist philosophy of "survival of the fittest," promoted distrust and continuously made workers view others in askance. Moreover, it ultimately led to workers viewing themselves as disposable commodities without any attention being paid to the person's self-worth. All too frequently we provide little attention to developing an environment or organizational culture based on trust. As those at Enron did, letting their profit and loss be the all determining factor that a worker's worth was measured by, many in long-term care fail to nurture the important factors of trust, stability, and security in the organizational environment.

Health care is a business, and long-term care is no exception. Yet, failing to recognize the importance of our human capital, those people that we depend on to carry out the important duties found in long-term care on a daily basis, is critical. If we fail to build a culture based on trust and respect, and fail to recognize that these needs are paramount for those that we manage, we too could face the same type of problems as an Enron. Therefore, rather than look at a company such as Enron and say it could not happen to us, we need to learn and understand how we can obviate such problems from occurring in the environments that we oversee and manage. History does not need to repeat itself if we can learn the lessons that it teaches us.

The Future of Long-Term Care

Brian Garavaglia — Wed, 11 Mar 2009 19:45:00 GMT

In today's challenging economic times, what does the future hold for the LTC industry? Read my latest column on ADVANCE for Long-Term Care Management's web site.

The Nursing Home Rating System Revisited

Brian Garavaglia — Mon, 19 Jan 2009 15:55:00 GMT

In my June 30, 2008 blog post "Can Apples and Oranges be Compared?" I wrote about the anticipated implementation of the nursing home rating system that the federal government was going to introduce. Since that time the Centers for Medicare and Medicaid (CMS) have introduced this system, leading to a system of ranking that has produced controversy and outrage among many long-term care professionals. Nursing homes are rated on three major measures: health inspections, nursing home staffing and quality measures. Out of these data CMS produces a ranking system based on stars with a one star ranking being the lowest and a five star ranking being the highest. Each of the three categories is ranked on one to five stars and each nursing home obtains an overall ranking of one to five stars based on these three criteria.

In my previous article I mentioned that you cannot compare apples and oranges and yet, this is apparently what the federal government has attempted to do in their ranking system. When you look at this system I am very puzzled on how many of the overall ranks are finally attained. I see many facilities that appear to average three or four stars yet receive an overall ranking of two or three stars. Conversely, I also see many that appear to average three or four stars in the areas that are examined, yet they come away with an overall ranking of two or three stars.

This is interesting. I then wonder how they weigh the respective areas. Is one of the three areas weighted differently, or are they all weighted the same, which in turn in some way should lead to the overall rankings that are found. However, I am not sure how they come away with these rankings. Looking at this system reminds me of going into a college course with the professor not providing any information on how grading takes place. Intuitively the system looks quite appealing. We like simplistic systems that do not require much thought. When we hear that a hotel or restaurant is five stars, we automatically assume that it is a quality hotel or restaurant. We often fail to question how the rankings were put together. With the nursing home ranking system it appears to be another consumer friendly ranking system, but what does it really mean, and how are the overall star rankings attained.

A major question that I have to raise is how do individuals at the federal level put together an overall ranking of every nursing facility in the United States by looking at 1) health inspection surveys; 2) nursing home staffing; and 3) quality indicator measures. Of the three variables that are examined, nursing home staffing is the only highly objective and highly empirical variable that can be found. You can count and average out this variable with high levels of objectivity. However, the other two variables, health inspection surveys and quality indicator measures have tremendous variability. Health survey inspection teams have great variability. Some teams provide more citations than others.

In addition, states vary considerably in the survey team's provision of health citations, with some states differing quite dramatically in the average number of citations given. Furthermore, the quality indicator reports provide information on how nursing homes rate in certain areas as compared to other nursing homes, but it fails to take acuity into consideration. For instance, a nursing home can rank very high in pressures sores but it may also have a terribly high acuity of clientele as compared to another nursing home that does not admit residents that are as severely ill or infirm. These are just a few of the major problems that can be found in comparing data of this nature.

So how do those that conduct the analysis to provide these rankings create a common benchmark to compare all nursing care facilities equally? With all these confounding factors that can work to influence the results what type of statistical control exists, if any. It would be naïve to assume that the data that is being used is not compromised in any way. However, it appears that those at the government level that are conducting this rating are assuming that no variability or biases in the data exist and take the data at full face validity. This assumption is an important methodological flaw. Furthermore, how do they measure the data? When things are examined in the scientific community the methodology is always made public to assure that others can examine it as well. However, in this case, what types of measuring tools where used and how the measurements lead to this ranking system that in turn achieved the results are for the most part a mystery.

So where does that leave us. It leaves us with an apparent system that is suppose to rank nursing homes objectively. However, what type of objectivity really exists in this measure? Do nursing homes that take a higher level of severe residents get penalized unfairly in this ranking system? Do nursing homes within lower socioeconomic regions that fail to obtain the funding that other nursing care facilities obtain get penalized by this system unfairly? Can those who do the rating, not knowing if the data that they are using is compromised in some way, say that they are doing a totally objective analysis? These are important questions that this new rating system brings up and needs to answer.

Unfortunately, when people here that a rating system has been done, they often view it as a totally reliable system that one must take unquestionable heed of as if it is the final word. But as I have mentioned, this supposed ranking system poses too many questions. It is interesting to note that as I have mentioned in my previous article, it is very difficult, if not impossible, to say that hotels, restaurants, and nursing care facilities can be ranked on the basis of stars. In an industry that deals with people's lives, with a byzantine complexity, it is interesting that we now feel that we can rank this complexity on a system of stars.

Can Apples & Oranges Be Compared?

Brian Garavaglia — Mon, 30 Jun 2008 14:20:00 GMT

The Bush administration advocated the need to rate nursing homes on a similar ranking system to that found in the hotel and restaurant industry. At first blush this seems an intuitively simple and consumer friendly system. Why not have consumers that are looking to place their loved ones in nursing homes have a simple system of one through five stars to help with their search. It appears to be a completely simple and adequate system that can be put in place quickly to assist the public with nursing home quality. However, remember when your algebra teacher said you cannot add apples and oranges? Can the rules be overlooked here? Can nursing homes be ranked similarly to hotels and restaurants? I think this question begs further consideration.

Currently there are a number of tools that are used to rank nursing homes. Probably the best known is the Medicare site that compares nursing homes on the basis of their number and type of citations. The information for this site is compiled from surveys of nursing homes conducted by surveyors. Yet, what is known about the system as it exists is it is far from perfect. In fact, there is a considerable level of subjectivity that is found in the survey process. Surveyors often make judgments about facilities prior to entering the facility. Furthermore, there is considerable variation from one surveyor to another as well as from one survey team as compared to another. In addition, states demonstrate a considerable level of variation among their surveyors. Surveys and the level of stringency found to exist in the survey process from one state to another differ considerably. Therefore, the system as a whole is filled with considerable variability that often is difficult to account for and would dramatically influence a supposed standardized rating system.

Another problem that exists is that hotels and restaurants do not have to rely on Medicare and Medicaid funding, or other third party funding, as do most nursing care facilities. Consumers in these other industries often pay up front with a fee set by the establishments. This allows hotels and restaurants to know their revenues and cash flows up front. However, in the nursing home industry, state and federal entities and third party insurance regulations place great restrictions on what earnings are actually realized. Most nursing homes operate on very small margins and therefore, many fail to have the funds to engage in extensive renovations as well as have the comfort to pay out large amounts of money for extensive and specialized staffing. In fact, there is also considerable statistical variability between nursing homes and the companies that own them, with larger companies often able to incur much greater capital expenditures to achieve the homelike environment that many seek.

So you may ask, what does all of this have to do with ranking nursing homes? As I hope has been illustrated so far, the complexity for a simple rating system is simply, not that simple. Even with hotels and restaurants, this simple five star system is not so simple. First, how many of us have been in supposed five star restaurants and hotels, only to come away quite disappointed in the food or service we encountered. Also, how many of us have come away saying that I wish I would have went instead to the smaller community restaurant or hotel where I get better quality and more food to eat for the money or better and higher quality customer service.

Yet, these hotels and restaurants, which are smaller and less spacious, are often viewed as the red-headed stepchild of the hotel and restaurant industry, especially when compared with their four and five star competitors. The same holds true for the nursing home industry, where the commodious environment of new, modernized, and large-scale facilities hold a primacy effect on those that rate these facilities.

For a true nursing home rating system to work, the rating system must be multifaceted and use many different indices for measurement. If the rating system is only going to be based on facility survey results, a less than true picture of the facilities that are being rated will result. This is not to say survey results should not be used. For sure survey results are an important indicator of the health of a nursing home facility. However, as was mentioned above, it does have its flaws and our current survey system, which has improved over the pre-OBRA years, is still predominately a subjective system. So with the subjective nature of the survey process, coupled with considerable differences found among state survey agencies as it relates to the level of nursing home survey stringency, other factors have to be considered in ranking nursing homes.

One important consideration is the type of people working in the facility and not just the number. Often, facilities are examined for having an adequate number of staff to residents. However, the quality of the staff is also important. What is the level of training, years experience, education, and level of specialization found among nursing home staff. Just as hospitals are viewed as progressive environments, predicated on the quality of their staff, so to should nursing care facilities be examined in the same manner.

In addition, how does acuity play a role in rating nursing homes? For instance, a facility that provides more extensive and intensive services such as bariatric care, dialysis, or ventilator care often have more critical residents with concerns that are more easily targeted during the survey process. However, they also typically have a clinical skill base that is higher as well. This also needs to be factored into the rating system of any nursing facility.

Moreover, is the nursing care facility a learning, teaching and training environment? Is it a place for training physicians, nurses or other long-term care professionals? Is research conducted among individuals within the long-term care environment? Is it a progressive environment that explores new strategies and techniques, especially toward advancing the care of long-term care residents? Many at this point may be saying you have to be kidding; these are nursing homes and not hospitals. However, many long-term care environments are now involved in many of these areas as well.

There can be more that can be targeted in creating a nursing home rating system with greater levels of legitimacy to help assist consumer knowledge in this area. However, just using survey results is not enough and I hope I was able to emphasize the importance in creating a multifaceted rating scale for nursing homes. Furthermore, I hope I was able to demonstrate that creating a rating system for nursing homes, based on and similar to the one used in the hotel and restaurant industry, would be very difficult. These industries are apples and oranges, and as your elementary algebra teacher explained to you early on, apples and oranges cannot be added together.

That being said, a system of rating nursing homes can be created, however in doing so one cannot create a valid system that is overly simplistic and based on a one-dimensional scale of measurement. It must be a system that adequately captures and reflects the complexity of the long-term care environment. Because of the complexity of the systemic nature of long-term care environments, capturing the complexity in creating a valid rating instrument for measuring nursing homes will be more difficult than for rating hotels and restaurants.

For more information: New Rating System in the Works for Nursing Homes

Do Politicians Understand That Long-Term Care is Part of the Health Care System?

Brian Garavaglia — Thu, 13 Mar 2008 19:17:00 GMT

During this year, a year in which our country will elect a new President, health care has become an important part of the agenda. Liz Rosto in her post entitled Decision 08, writes about the issue of heath care and the apparent lack of emphasis given to long-term care, especially through many of the major candidate’s policy advocacies. This appears to be an interesting phenomenon, which has not just appeared during this current election season, but has existed in past elections as well.

Although the amount of our Gross Domestic Product spent on health care is approaching 15 percent, with an expectation for it to climb to 17 percent by 2012, most individuals fail to apparently want to acknowledge the important contributions of long-term care to the GDP. With the burgeoning older adult population being a very important part of the electorate, an electorate that votes at higher levels than any other part of the population, you would think that politicians would not only focus on acute care, but long-term care as an important issue that needs to be addressed. Although the focus on changing the health care system is definitely important, to fix many of the deficiencies that currently exist in the system itself, it is important to recognize that these problems also extend to long-term care. However, it appears that many of the health policies that are frequently spoken about politically fail to address long-term care issues.

What appears to be an inherent contradiction here is this: Although politicians are aware of the importance of courting the older adult vote since they currently make up 13 percent of the population and have the most solid voting records of any age group, most fail to acknowledge a very important health care concern found in many families and among many elderly as it relates to funding and the provision of health care found in long-term care. Although the stereotypes of the elderly being a predominately nursing home bound population are false (in reality, only 5 percent of the elderly population is in nursing homes at any given period of time), long-term care will continue to have an important place in the American health care system.

It is estimated that there is a 70 percent likelihood that individuals in society will spend some time within a long-term care environment at some point in their lives, which includes home bound care (Gleckman, 2007). Furthermore, as many more long-term care facilities are becoming extensions of the acute care environment, especially for rehabilitation purposes, it becomes almost unfathomable to understand why the political environment often gives minimal to no attention to this area.

Total Medicaid costs for long-term care as a percentage of the GDP has increased from 0.7 percent in 1975 to 2.1 percent in 2003 (Gleckman, 2007). Furthermore, in 2000, the amount of long-term care expenditures that were part of the approximately 14 percent that made up the GDP was equal to 1.3 percent and it has been increasing. In fact, Medicaid and Medicare expenditures that are part of the GDP have been increasing. Moreover, public payment sources such as Medicaid and Medicare make up 60 percent of long-term care payment with another 23 percent of the payment coming from out of pocket expenses (Walker, 2002). When you couple this with budget constraints being placed on many long-term care programs and anxiety over the drying up of the coffers that support many long-term care programs, both on the state and federal level, one has to wonder why advocates for the elderly have failed to make this a more prominent concern to be addressed by politicians on both sides of the aisles in the 2008 political races.

So where does that leave us in the 2008 political race not only for the Presidency, but also for many other congressional offices that will be up for grabs. Unfortunately, it appears that long-term care will continue to be treated as the redheaded stepchild of health care policy. Possibly the most vociferous advocate of health care in the current presidential contest is Hillary Clinton and even Mrs. Clinton fails to address long-term care on a substantive level. It is without doubt that escalating costs, physicians forced to practice defensive medicine, escalating third party insurance costs, as well as too many individuals failing to get preventative care, or failing to be insured or underinsured is a national crisis. However, one needs to add to this the problems found in long-term care as part of the national health care system crisis as well.

Long-term care has to be recognized as part of the larger system of health care that exists in the United States. Yet, as has been evident, most politicians know very little if anything about the concerns faced by older adults, and in particular, the concerns that are faced by this population in long-term care. Therefore, not only is the national crisis in health care problematic since it often fails to address the long-term care part of our health care system, but it is exacerbated by the lack of knowledge by those who hold the most advantageous positions in our society to address this issue. With congressional subcommittees on aging having existed for some time, one has to wonder whether these committees have helped to educate the political faction on these very important issues?

With a plethora of elderly age groups in existence to address the concerns of the elderly, one has to wonder why they have not placed greater political pressure on our country’s politicians? And with the increasing level of the population that is currently over 65 years of age, a part of the population that is increasing quickly and have concerns about long-term care issues, one has to wonder why they as a group have not continued to place increasing pressure on the politically powerful to address many of their concerns in this area?

The above are all important questions that need to be addressed and addressed quickly. With each election that goes by, and with each year of failed response, the elderly population continues to grow. Along with this will be long-term care needs that will continue to increase. As our country continues to sit on the issue with little or no response, and as the older adult population continues to increase concomitantly with their growing long-term care needs, a growing lag between these two areas also will continue to increase. As the lag continues to increase between elderly needs and political response, our country sits on a powder keg that can and will explode. Prior to getting to this point, where our country has to mobilize into an emergency mode and reactive response, the American people and their political representatives need to forestall this growing crisis by acting proactively and with prudent foresight.

References

Gleckman, H. (2007/April). Medicaid and long-term care: How will rising costs

affect services for an aging population, An Issue in Brief: Center for Retirement Research, Boston University: April, no 7-4,

Gleckman, H (2007/June) Financing long-term care: Lessons from abroad. An

Issue in Brief: Center for Retirement Research, Boston University: June, no 7-8

Walker, D.M (2002/March 21). Long-term care aging baby boom generation will

increase demand and burden on federal and state budgets. Testimony made by Comptroller General of the United States General Accounting Office Before the Special Committee on Aging, U.S. Senate.