We should consider supporting public policy initiatives that:

• Achieve universal coverage through market-based solutions while avoiding a one-size fits all approach
• Encourage patient responsibility and financial accountability for lifestyle and health care decisions
• Provide employers and individuals with access to affordable, high quality coverage options
• Establish the expectation that each American will maintain some form of insurance coverage

While health care reform has long been a topic of discussion in Washington, D.C., it has become a leading policy issue for the Obama Administration and Congress. Health care reform is no longer perceived as peripheral to our larger economic condition. Instead, it is viewed as an integral element to our long term economic stability as a nation.

As lawmakers debate health care reform proposals, it is critical that reform measures promote seamless integration within systems as well as between health care providers and insurers. Specific actions might include:

• Promoting widespread adoption of interoperable health information technology systems to reduce errors and maximize provider collaboration
• Developing policies to encourage a "medical home" or physician office responsible for coordinating the overall care for patients and to encourage patient care management
• Accelerating applied clinical research and demonstration programs which give patients access to advances in science and innovative treatments
• Supporting medical education, residency programs and other training efforts that prepare an adequate number of physicians, nurses and other health care workers for growing patient needs

Often "universal health care" is misconstrued as government-run health care, leading to passionate debate on all sides. In reality, universal health care means ensuring every American is covered by affordable and effective health insurance. This is a goal embraced by Spectrum Health and one our nation must aspire to for meaningful health care reform.

As the White House and Congress debate ways to cut costs and improve quality in the nation's health care system, it is essential that those in the industry keep a close eye on the details and ensure that vulnerable citizens are not marginalized in the process. Significant cuts in Medicare nursing home funding would be catastrophic. Hundreds of key frontline care jobs would be eliminated, quality improvement programs would lose vital funding and, ultimately, important long-term care facilities that are already struggling due to chronic underfunding would have to close.

According to the Census Bureau, the world's 65-and-older population is projected to triple by 2050, growing from 516 million today to 1.53 billion. During the same time span, the 85-and-older population is projected to increase more than fivefold, from 40 million to 219 million.

With these projected numbers, it is not difficult to see why those looking for ways to cut health care spending would like to consider cuts to long-term care. Health care spending increases after the age of 50 and continues to accelerate. The financial per capita burden at age 85 and older is nearly six times as high as the burden at ages 50 through 54. Costs of care for people during their last two years of life account for 40 percent of all Medicare health expenses.

Adequate, stable Medicare funding and patient outcomes go hand in hand, and our ability to maintain sufficient work force levels, to sustain comprehensive quality improvement programs and to continue caring for our patients and residents now and in the future is at stake.

Howard Gleckman's new book Caring for Our Parents could not be better timed. It looks at all the places-nursing homes, assisted living, home care-in which most of us, frail and lonely, will spend our final years.

We may say, "Shoot me first," but nobody ever does. We may pray for a sudden stroke, or a heart attack that takes us in our sleep, but four out of five of us won't leave this life so neatly.

Congress is tackling health care reform and Gleckman makes a persuasive argument that any new plan needs a strong long-term care component. After reading Gleckman's eloquent mix of compelling real-life stories and stunning statistics, you will come away with the firm conviction that any health care legislation that does not address the issue of long term care is, on the face of it, a failure.

Gleckman doesn't just address our failings; he looks at how other modern industrial nations cope with aging populations. It is hard, after reading his book, to not believe that a new social insurance program, like Germany's, built along the lines of Medicare and Social Security should be part of whatever health care reform leaves Capitol Hill.

If you're a conservative, and don't like the idea of federal entitlement programs, then a universal mandate to purchase long-term care insurance from the private U.S. insurance industry may sound more appealing.

In either case, it is something we will need to address.

The real issue is whether healthcare is a right (as most progressives believe) or a privilege for those who can afford it (as most conservatives believe). If healthcare is a right, then universal healthcare is mandatory. But if healthcare is simply another consumer commodity to be sold to the highest bidder, then we should simply leave things to be influenced by market forces.

These alternatives come down to basic convictions...basic ways of looking at the world. The "privilege" position sees human life as competition between autonomous, individuals, each looking out for her or his self interest only. But the "healthcare as a right" position sees us all as interconnected and validates the benefit of ensuring the common good.

We now save people who would have died 30 years ago. People with severe trauma, stroke, heart attack, brain damage, and so on. We save preemies who would never have survived even 20 years ago. We see people living with severe chronic illness, people in nursing homes unable to care for themselves, people with severe birth defects and disabilities whose conditions would have dramatically shortened their lifespan as recently as two or three decades ago. 

But thanks to technology, medication, early intervention, intensive care, first responders, organ transplant, a vastly expanded continuum of care, sophisticated treatments that are now available in the home, and much more, many of these people are able to survive. 

Notice I said survive...not live. What about quality of life? What about the emotional, physical, and financial costs to the families?  So we are all asking ourselves...what are people really entitled to?  Just because we CAN provide healthcare services...does that mean we should?

I find it astounding that an inmate in prison for a life sentence may receive a heart transplant--and be higher on the list than a working father of four--all paid for by our tax dollars.

While most goods and services adhere to the basic economic principle of supply and demand, in many ways healthcare does not. The principle of supply and demand describes a balance that develops between the supply of an item or service and the demand for it. The variable is that of price.  There is a simple balance in which as price goes up, demand goes down, and vice versa. Generally, supply reflects demand as who would continue to develop a product or supply a service for which demand has dropped? 

The problem in healthcare is that the consumer often pays little or nothing for services, despite the current reality of deductibles and copayments. When this is the case, price stops being a factor in demand and demand increases to virtually unlimited levels. 

There was a time when my health insurance cost me nothing (100% of the premium was paid by my employer), I had no deductible and no copayment.  So I had no out-of-pocket expenses whatsoever associated with healthcare.  Now I really don't like going to the doctor, so it did not matter to me all that much, I still did not use a great deal of care.  But many people, when costs are not a factor, use services at the drop of a hat. 

This is the reality that triggered the current healthcare crisis. Even now, despite out-of-pocket costs, utilization is at record levels.  People even tend to feel that since they are paying more for premiums (though nothing close to what employers are paying), they should get their money's worth. There is little to stop them from using services except the managed care initiatives that have been implemented in the last 20 years to address this situation. People in the first half of the 20^th century paid for healthcare themselves and were cautious about what services they used. When cost (price) stopped being a factor, desire for the product exploded and we have the runaway train that is currently eating up over 15 percent of our gross domestic product. 

So, how do we deal with this situation? How do we provide the comprehensive care for everyone indicated in this week's question? 

More importantly, how will we pay for it?

The notion of a right to health care is silly. The health care worker's labor is his/her own. What possible claim could be made to that person's valuable work that would not also apply to the barber, the farmer, or the auto mechanic? Should those people's work efforts also be a "right?" Just because you need something does not create a duty for it to be given to you. We have a market system that guides the exchange of property or services.

Cost issues and pricing problems stem from too much, not too little, government interference in the market. Prices are artificially inflated by the flood of government and third-party payments as people do not care what the bill is when they are not paying it.

We would all acknowledge that food is more important than health care as we would die pretty quickly without food. So do we have a "right" to food in America? What about shelter? Do we have a "right" to housing? If so, we must look carefully at the number of hungry and homeless in this country.

Should the government give us everything? Is that what the Founding Fathers intended? Food? Shelter? Medical care? When we have the "right"  to be given things we previously had to work for, there is no reason...none...to work for them. The goody bag has no bottom...

Our country was founded on principles of personal freedom. If you are not allowed to spend the money you worked hard to earn on what you wish, are you really free?

That transformation happens without anything one can reasonably consider as adequate citizen or government oversight. All too often, lack of transparency is intentional with the result that American citizens have woefully inadequate awareness of the long-term cost/benefit picture. With the advent of "globalization" this sorry state of affairs is now being propagated abroad by corporate entities in the form of WTO, NAFTA, World Bank, etc.

While some aspects of quality of life improve for some populations, it is undeniable that tragic consequences have befallen segments of populations with little or no opportunity for them to correct the wrongs of the larger society and improve their lot. Medical statistics have shown that degraded diet, water, and air quality are responsible for billions of dollars in AVOIDABLE health care costs. That degradation has happened largely without citizen involvement in the decisions that brought it about.

So one must ask, if YOU had cancer-right now-would you consider medical treatment a privilege?

Considering the above, one must conclude that

• Health care is a human right
• Preventive care must include broad revision and oversight of all commercial activity that has human health implications
• Federal level controls must be implemented to protect citizen health and quality of life, at least until citizens are equipped to take on that responsibility

The following recommendations are from the American Veterinary Medical Association:

Laws Governing AAA, AAT and RA Programs
Most states allow animals in long term healthcare facilities and other institutions, with some restrictions. Animals are usually not allowed in food preparation and serving rooms or in areas where sterile conditions are maintained. Health certificates for animals may be required. Program organizers should check with state and local officials for specific regulations.

Liability
Most institutions should be able to include an AAA, AAT or RA program as one of their operational programs without additional insurance riders. Individuals providing AAA, AAT, or RA programs for these institutions should be able to obtain protection for their work under their existing individual or agency personal insurance policy. They may also be covered under the institution's insurance policy as a welcomed visitor. In all cases, the institution, agency, therapist, and volunteers should consult their respective insurance agents to ensure adequate protection.

Getting Started
An AAA, AAT, or RA program should be implemented only after there has been adequate advance preparation and discussion by everyone involved. Program organizers should be familiar with AAA, AAT, and RA concepts, available animal certification methods and programs, and national, state, and local laws pertaining to use of animals in facilities. Good communication among all individuals involved is essential. Roles of participants must be clearly defined and basic standards must be established to protect human and animal health, ensure the safety of participants, manage associated risks, and appropriately allocate program resources. Workload for program and facility staff must be appropriately and carefully managed, and adequate training must be provided. Participants must understand and respect principles of confidentiality. All AAA, AAT and RA programs should include a veterinarian as a key participant so the health and well being of humans and animals involved are protected.

Checklist

1. Assess the need for an AAA, AAT or RA program. Will it augment, and can it be readily incorporated into, existing treatment programs?
2. Establish realistic and measurable goals and objectives. Evaluate staff, facility and financial resources to ensure that implementation is feasible.
3. Gain acceptance for your program by explaining its potential to key administrators and enlisting their assistance during development of protocols.
4. Determine what animals will best serve the needs of program participants. Consider the population to be served and any physical and psychological limitations. Become familiar with existing health department regulations concerning animals in facilities, because certain animals may be prohibited. If animals are to be resident, their husbandry must be addressed.
5. Develop protocols and training programs for staff, volunteers, and animals.
6. Assess zoonotic disease risks and develop appropriate procedures for minimizing those risks.
7. Measure the successes and failures of your program through medical record charting, case studies, questionnaires, videotapes or formal research.

Good luck!

The following recommendations are from the American Veterinary Medical Association:

Interdisciplinary cooperation. Successful AAA, AAT and RA programs are inherently interdisciplinary and present a wonderful opportunity for veterinarians, physicians, nursing staff, activity directors, therapists, and volunteers to work together toward a common goal.

Planning. Establish realistic goals and expectations. Anticipation of possible problems and development of solutions prior to their occurrence can avoid conflicts that cause program failure.

Supervision. Staff and administrative supervision of AAT, AAT and RA programs are required to protect the welfare of human and animal participants. All personnel need to be made aware that the program is in place and that it is considered to play an integral role in patient care. If an animal becomes a permanent resident of a facility, one individual should be assigned primary responsibility for its care and management, including arrangements for weekend and holiday care.

Animal selection. Animals should be selected on the basis of type, breed, size, age, sex and, particularly, natural behavior appropriate for the intended use. Only animals with known medical and behavioral histories should be used, and medical and behavioral assessments should be performed prior to placing animals in a program. Animals should have been, and should be, trained by use of positive reinforcement. Animals must be chosen with the target population in mind. A boisterous, overactive dog may be friendly, but inappropriate for a nursing home in which many patients are using walkers. A visiting calf or lamb may be more effective with patients who have rural backgrounds than would a caged rodent.

Animal health, human health and environmental concerns. A wellness program should be instituted for animals participating in AAA, AAT, and RA programs to prevent or minimize human exposure to common zoonotic diseases such as rabies, psittacosis, salmonellosis, toxoplasmosis, campylobacteriosis, and giardiasis. Need for specific screening tests should be cooperatively determined by the program's attending veterinarian(s) and physician(s). Animals should also be appropriately immunized and licensed. With respect to immunization for rabies, the current Compendium of Animal Rabies Prevention and Control (prepared by the National Association of State Public Health Veterinarians and published annually in the Journal of the American Veterinary Medical Association) and/or state guidelines should be followed. If the animal is to reside at a facility, provisions must be made for its feeding, watering, housing, grooming, and exercise. Associated noise and waste disposal problems must also be solved.

Human animal interactions and welfare. During interactive sessions, the welfare of residents, animals, volunteers, staff, and visitors must be considered. Introductions of animals and human participants must be arranged and supervised, because some individuals may not enjoy interacting with animals or may have physical or emotional problems that contraindicate such interactions. Animals should be an integral part of a treatment program and not a reward for appropriate behavior on the part of the human participant. Animals should be monitored closely for clinical signs of stress and should have ample opportunity and space for solitude. Any problems or incidents that occur must be reported to appropriate supervisory staff.

The following is the American Veterinary Medical Association's statement of policy, retrieved from: http://www.avma.org/issues/policy/animal_assisted_guidelines.asp

When the AVMA officially recognized, in 1982, that the human animal bond was important to client and community health, it acknowledged that the human animal bond has existed for thousands of years and that this relationship has major importance for veterinary medicine. As veterinary medicine serves society, it fulfills human and animal needs. Animal assisted activities, animal-assisted therapy, and resident animal programs are included and endorsed by human healthcare providers as cost effective interventions for specific patient populations in various acute and rehabilitative care facilities. Veterinarians, as individuals and professionals, are uniquely qualified to provide community service via such programs and to aid in scientific evaluation and documentation of the health benefits of the human animal bond. Animal assisted activities, animal-assisted therapy, and resident animal programs should be governed by basic standards, be regularly monitored, and be staffed by appropriately trained personnel. The health and welfare of the humans and animals involved must be ensured. Veterinarians' involvement in these programs from their inception is critical because they serve as advocates for the health and welfare of animals participating in these programs.

Animal assisted activities (AAA) provide opportunities for motivation, education, or recreation to enhance quality of life. Animal assisted activities are delivered in a variety of environments by specially trained professionals, paraprofessionals, or volunteers in association with animals that meet specific criteria.

Animal assisted therapy (AAT) is a goal directed intervention in which an animal meeting specific criteria is an integral part of the treatment process. Animal assisted therapy is delivered and/or directed by health or human service providers working within the scope of their profession. Animal assisted therapy is designed to promote improvement in human physical, social, emotional, or cognitive function. Animal assisted therapy is provided in a variety of settings, and may be group or individual in nature. The process is documented and evaluated.

Resident animals (RA) live in a facility full time, are owned by the facility, and are cared for by staff, volunteers, and residents. Some RA may be formally included in facility activity and therapy schedules after proper screening and training. Others may participate in spontaneous or planned interactions with facility residents and staff.

Human animal support services (HASS) enhance and encourage responsible and humane interrelationships of people, animals, and nature.

The way in which AAT is undertaken depends on the needs and abilities of the individual patient and the limitations of the facility. Dogs are the most common visiting therapy animals, but cats, horses, birds, rabbits, and other domestic pets can be used as long as they are appropriately screened and trained.

For patients who are confined, small animals can be brought to the bed if the patient is willing and is not allergic to the animal. A therapeutic plan may include a simple interaction aimed at improving communication and small motor skills, or a demonstration with educational content to engage the patient cognitively.

If the patient is able to walk or move around, more options are available. Patients can walk small animals outside, or learn how to care for farm animals. Both of these activities develop confidence and motor abilities. Horseback riding has recently gained great therapeutic popularity. It offers an opportunity to work on balance, trunk control, and other skills. Many patients who walk with difficulty, or not at all, get great emotional benefit from interacting with and controlling a large animal.

AAT does not involve just any pet interacting with a patient. Standards for the training of the volunteers and their animals are crucial in order to promote a safe, positive experience for the patient. Trained volunteers understand how to work with other medical professionals to set goals for the patient and keep records of progress.

Animals that have been appropriately trained are well socialized to people, other animals, and medical equipment. They are not distracted by the food and odors that may be present in the therapy environment and will not chew inappropriate objects or mark territory. Animals participating in AAT should be covered by some form of liability insurance.

Dogs that are used in animal therapy are generally certified as therapy dogs through the Therapy Dogs International and have received obedience training prior to certification. Dogs that participate in animal therapy programs are also trained in various settings like in elevators, noisy areas, and in public or confined locations to desensitize them from potential encounters like medical machinery, among others. The most important attribute of the prospective candidate for animal therapy is friendliness and a calm disposition.

Certified pet therapy dogs must pass rigorous training established by Pet Therapy International, Inc. They must not only pass an obedience test, but also a temperament test that simulates what a dog might encounter in a medical environment. For example, the dogs have to demonstrate their ability to approach patients who are in wheelchairs or on crutches. In one test, a metal pan is dropped behind the dog while the dog is being petted to see how the dog might react to unexpected loud noise.

Just as some people have a "special way with animals," it appears some animals have a "special way with people."

The literature is replete with anecdotal examples of the effectiveness of pet therapy. I selected several that are particularly relevant to long term care and I recount them here:

One example is of an elderly resident in a long term care facility who was not talking and who would lie in bed for hours, refusing to come out of her room. She was invited to all the therapy groups and activities throughout the day, but did not want to participate. Her psychiatrist recommended that the occupational therapist try her therapy dog. On the first visit, the woman sat down with the dog and began petting her. Within days of spending time with the dog, she was actively engaged in conversation with staff and other residents. She began talking about her past and things that were happening to her.

The next day, the goal was to help the patient become more active by going for a walk. After she spent some time with the dog, she was asked if she would like to take her for a walk. She replied she'd like that very much and they went for a leisurely walk. From that day forward, that patient participated in all the groups and became far more involved in the milieu.

Another example is that of a pregnant woman who was badly injured in a motor-vehicle accident and unresponsive. When a volunteer brought a dog into her room, the patient was asked to scratch the dog. Even though she had not responded to anything else anyone said or did, she scratched the dog-and soon, she was stroking its fur. Though it may not have been related to the dog, the next morning, she woke up and was able to talk to her family.

Animals can inspire patients who otherwise refuse to participate in their own treatment. In another example, a young man who had Down syndrome had broken his neck in a car accident. The man had no interest in physical therapy-until a dog was brought in. He started by throwing a ball for the dog, and eventually, he would participate in any physical therapy that directly involved the animal.

Finally, Ronnie was an African-American male, 50 years old, in a long term care facility with a history of nonischemic cardiomyopathy, diabetes mellitus type II, and chronic renal failure. He was withdrawn, depressed, and dependent on mechanical ventilation, and had acquired a sternal wound infection. He continued to require intensive care for continuous renal replacement therapy, as a result of an inactive, newly transplanted kidney. Ronnie was initially referred for AAT boost his morale and cope with his depression. Two or three times a week Ronnie was visited by four different dogs. Ronnie became physically and mentally stronger at an accelerating pace and was able to engage in self-car. He smiled, was oriented to person, place, and time and said the animal visitation gave Ronnie something to look forward to, which had a positive impact on his physical and mental health.

Pet therapy is often used for the treatment of the elderly. The elderly commonly face problems of loneliness and isolation. Having a pet provides a sense of companionship.

In Europe and the United States, many hospitals and long term care facilities have programs where animals, mostly dogs, visit patients at the facility or at home, a mode of therapy called canine visitation therapy. These animal visits give the patients a change in their routine and provide a sense of hope. It is also beneficial in pain management.

In the case of institutionalized Alzheimer's patients, a study found that placing an aquarium of fish in the dining area, increased the nutritional intake of Alzheimer's patients. Pets provide a general sense of well being, apart from some of the specific therapeutic services that have already been discussed. Animal therapy is gaining increasing attention from the scientific community as research continues to expand its scope.

Research Support

The research evidence supporting the efficacy of AAT is slim, though anecdotal support is extensive. Although it may not be given much credence by medical personnel as a therapy with the potential to assist the progress of the patients, some institutions do at least allow it as something that will uplift the patients or distract them from their discomforts. Below are two research studies that validate the benefits of pet therapy with the elderly.

• Banks, M.R. and Banks, W. A. (2002). The Effects of Animal-Assisted Therapy on Loneliness in an Elderly Population in Long-Term Care Facilities. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 57:428-432.

Animal-assisted therapy (AAT) is claimed to have a variety of benefits, but almost all published results are anecdotal. The authors studied the resident population in long-term care facilities and determined whether AAT can objectively improve loneliness. Of 62 residents, 45 met inclusion criteria for the study. These 45 residents were administered the Demographic and Pet History Questionnaire and the UCLA Loneliness Scale. They were then randomized into three groups (no AAT; AAT once/week; AAT three times/week) and retested near the end of the six-week study. AAT was shown to have significantly reduced loneliness scores in comparison with the no AAT group.

• Richeson, N.E. (2003). Effects of animal-assisted therapy on agitated behaviors and social interactions of older adults with dementia. American Journal of Alzheimer's Disease and Other Dementias, 18(6): 353 - 358.

The effects of a therapeutic recreation intervention using animal-assisted therapy AAT on the agitated behaviors and social interactions of older adults with dementia were examined. In a pilot study, 15 nursing home residents with dementia participated in a daily AAT intervention for three weeks. Results showed statistically significant decreases in agitated behaviors and a statistically significant increase in social interaction pretest to post-test.