Clinical Corner : General Information

Health Care Reform and LTC: Part V

Carol Kleinman — Wed, 25 Nov 2009 15:32:00 GMT

For patients, employers and payers to make well-informed health care decisions, they must have access to meaningful and easy-to-understand quality and cost data; such transparency is critical to overall health care reform.

Strategies to involve patients and families are essential. Examples of important patient feedback include:

An "experience mapping" program that gathers patient perspectives on the care they received
Patient and family advisory councils
Multiple opportunities for patients to provide candid feedback, including follow-up surveys, forms online and a patient relations hotline
Physician quality ratings that show consumers how often a physician meets certain targets when caring for their patients

Providing quality and cost information to the public will complement reforms in the payment system and help improve the access and affordability of health care.

Health Care Reform and LTC: Part II

Carol Kleinman — Thu, 15 Oct 2009 18:56:00 GMT

Issues of long-term care have dominated public concern since President Clinton proposed his health care reform plan in 1993. Efforts towards a universal long-term care policy address priority areas of aging and disability in various ways such as the use of Medicaid waivers. Problems of long-term care, such as the nature of entitlement programs, are now the major concerns of the Administration on Aging and the Department of Health and Human Services. Long-term care policies at state and local levels are necessary to meet the compelling needs of an aging population.

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.

Health Care and the Common Good

Carol Kleinman — Mon, 31 Aug 2009 16:58:00 GMT

So, the basic debate in the U.S. over healthcare is not really about costs or the freedom to choose one's own doctor. The facts are clear: The World Health Organization rates the U.S. 37^th (!) in healthcare while we spend a much higher percentage of our Gross Domestic Product on healthcare than Canada, Europe, New Zealand, Australia, or other industrial democracies for this lower quality coverage. A universal, single-payer, health insurance program would both increase the choices of physicians available to most Americans and would, after initial start-up costs, lower healthcare costs overall. These facts have been known for decades.

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.

Is Health Care a Right or a Privilege? Part 1 - Pro

Carol Kleinman — Mon, 20 Jul 2009 19:03:00 GMT

Once upon a time before the Military-Industrial-Government Complex, Americans were mostly rural and relied on direct sources of food, water, fuel, and shelter. Personal involvement in and responsibility for those needs has decreased with the transformation from direct personal sourcing modes to control of sourcing by corporate operations.

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

Pet Therapy Part IV: More Therapeutic Value

Carol Kleinman — Wed, 11 Mar 2009 14:41:00 GMT

A dog can draw out people who have problems communicating. Dogs communicate on an instinctual, nonverbal level that is easier to relate to by people who have difficulty communicating verbally. It may take days to engage certain patients or residents in conversation. Bringing in a pet therapy dog has been shown to allow uncommunicative residents to engage almost immediately and participate in activities and therapy sooner. Dogs do not place any expectations or demands on the person and are there strictly to provide comfort. Having a dog respond in a positive manner helps people feel better. With the dog present, people want to talk about the animal, beginning a conversation about how they feel and what they think and facilitating engagement in constructive therapy.

Studies have shown that low key tactile stimulation, i.e., stroking something soft like a dog's fur, tends to calm a person, lowering blood pressure and reducing the heart rate. In addition, animals can also be excellent tools to help combat depression, a common phenomenon, especially in the elderly. Reducing loneliness, one of the triggers of depression in long term care residents, is another of the benefits of pet therapy.

Dogs seem to be aware of illness and sadness and appear to want to provide companionship and comfort; they show an abundance of intelligence and are both intuitive and compassionate. I am sure any dog owner can relate to this assumption and agree that it is a warm feeling when their dog can detect their sorrow and lick their tears away. Silence may be broken and loneliness and isolation can be overcome through merely touching and petting a companion animal. These pets offer absolute and unconditional love and a level of boundless patience no human can replicate.

Dogs and cats have a calming and therapeutic effect on people. They can help individuals to cope with the emotional issues related to their illness and offer physical contact with another living creature.

Pet Therapy Part III: Therapeutic Value

Carol Kleinman — Fri, 27 Feb 2009 16:11:00 GMT

The therapeutic use of pets is considered to be a sensory modulation approach. The integration of animal-assisted therapy into practice has been discussed in nursing, psychology, and rehabilitation literature, as well as others. However, it has only in the last half of the twentieth century that professional recognition began to acknowledge the benefit of pet therapy.

Pet therapy influences the spirit-mind-body interconnectedness in many ways. Activities such as watching fish swimming in a fish tank or petting a cat or dog have been found to decrease blood pressure, lower heart rate, and reduce anxiety. Social interactions increase when pets are brought into nursing homes and mental healthcare settings. Therapeutic interactions with pets provide unconditional love, affection, and acceptance, helping people of all ages feel a greater sense of belonging and connectedness to the world. Positive experiences with pets tend to elicit nurturing instincts and behaviors.

Some of the common goals of pet therapy include:

The facilitation of communication and social interactions
To facilitate the expression of feelings
To brighten mood and affect and lessen anxiety
To help to explore grief and loss issues
To help to improve reality orientation
To help to improve the ability to cooperate
To increase the ability to trust
To help learn appropriate forms of touch
To help to improve self-esteem and self worth
To provide an opportunity to show affection

The Experience of Aging, Part VIII - Final Message

Carol Kleinman — Tue, 27 Jan 2009 19:50:00 GMT

This is a story I have read many times that I thought I would share in case you have not heard it. It provides an important message about the importance of a positive attitude and a spirit of inquiry.

The first day of school our professor introduced himself and challenged us to get to know someone we didn't already know. I stood up to look around when a gentle hand touched my shoulder. I turned around to find a wrinkled, little old lady beaming up at me with a smile that lit up her entire being.

She said, "Hi handsome. My name is Rose. I'm eighty-seven years old. Can I give you a hug?"

I laughed and enthusiastically responded, "Of course you may!" and she gave me a giant squeeze. "Why are you in college at such a young, innocent age?" I asked.

She jokingly replied, "I'm here to meet a rich husband, get married, have a couple of children, and then retire and travel.

"No seriously," I asked. I was curious what may have motivated her to be taking on this challenge at her age.

"I always dreamed of having a college education and now I'm getting one!" she told me.

After class we walked to the student union building and shared a chocolate milkshake. We became instant friends. Every day for the next three months, we would leave class together and talk nonstop. I was always mesmerized listening to this "time machine" as she shared her wisdom and experience with me.

Over the course of the year, Rose became a campus icon and she easily made friends wherever she went. She loved to dress up and she reveled in the attention bestowed upon her from the other students. She was living it up.

At the end of the semester, we invited Rose to speak at our football banquet. I'll never forget what she taught us. She was introduced and stepped up to the podium. As she began to deliver her prepared speech, she dropped her three by five cards on the floor.

Frustrated and a little embarrassed, she leaned into the microphone and simply said, "I'm sorry. I'm so jittery. I gave up beer for Lent and this whiskey is killing me! I'll never get my speech back in order so let me just tell you what I know."

As we laughed, she cleared her throat and began: "We do not stop playing because we are old; we grow old because we stop playing. There are only four secrets to staying young, being happy, and achieving success. You have to laugh and find humor every day. You've got to have a dream. When you lose your dreams, you die. We have so many people walking around who are dead and don't even know it!"

"There is a huge difference between growing older and growing up. If you are nineteen years old and lie in bed for one full year and don't do one productive thing, you will turn twenty years old. If I am eighty-seven years old and stay in bed for a year and never do anything, I will turn eighty-eight. Anybody can grow older. That doesn't take any talent or ability."

"The idea is to grow up by always finding the opportunity in change. Have no regrets. The elderly usually don't have regrets for what we did, but rather for things we did not do. The only people who fear death are those with regrets."

She concluded her speech by courageously singing "The Rose." She challenged each of us to study the lyrics and live them out in our daily lives.

At the year's end, Rose finished the college degree she had begun all those years ago. One week after graduation, Rose died peacefully in her sleep. Over two thousand college students attended her funeral in tribute to the wonderful woman who taught by example that it's never too late to be all you can possibly be.

What can we take away from this story? What was Rose's message?

"GROWING OLDER IS MANDATORY, GROWING UP IS OPTIONAL"

The Experience of Aging, Part VII - The Eden Alternative

Carol Kleinman — Wed, 07 Jan 2009 15:54:00 GMT

Long-term care has been considered many not to have evolved as quickly or as profoundly as other points along the health care continuum. However, many models have been and are continuing to be developed that provide a radically new way of viewing the care of older residents who often must live out their days in a care facility. One example is the Eden Alternative.

The Eden Alternative is an organization based on the core belief that aging should be a continued stage of development and growth, rather than a period of decline.

Founded in 1991 by Dr. William Thomas, a Harvard-educated physician and board-certified geriatrician, the Eden Alternative is being used in the U.S., Canada, Europe, and Australia. The staff and management of the facilities using this model work toward culture change through a dedication to improving the quality of life for those in their care.

The Eden Alternative shows how companionship, the opportunity to give meaningful care to other living things, and the variety and spontaneity that mark an enlivened environment can succeed where pills and therapies often fail. Places that have adopted the Eden Alternative typically are filled with plants, animals and are regularly visited by children.

Studies have shown that the Eden Alternative has been a tool for improving quality of life and quality of care for those living in long term care facilities. In those that have adopted Eden as an organizational-wide philosophy, there is often improved staff satisfaction and retention and significant decreases in the overuse of medications and restraints. Most importantly, Elders, supported by their caregivers, are better able to direct their own lives and feel a greater sense of control over their environment.

For more information, go to the Eden Alternative's Web site.

The Experience of Aging, Part VI - Intergenerational and Aging Training

Carol Kleinman — Tue, 23 Dec 2008 18:42:00 GMT

The introduction to the Macklin Intergenerational Institute on Aging states:

"The Macklin Intergenerational Institute provides compassionate care and spontaneous exchanges that result in contact between and among the generations. It's called intergenerational programming - a place where the young and old come together to share their talents, knowledge, and resources allowing their unique personal knowledge, experiences, and expectations to shape their interactions. Intergenerational programming offers an opportunity for generations to come together and to celebrate the uniqueness of one another. The Macklin Institute's mission is: To continually improve the lives of all ages through multi-age programming, care, community relationships, and creative communication."

Dr. Vicki Rosebrook of the Macklin Institute has developed an experiential learning workshop during which participants are provided with exercises that allow them to experience the functional limitations of an elderly person. Physical limitation, visual and auditory impairments, sensory distortions, cognitive impairments, and profound personal losses are all accurately simulated to replicate the experience of the older adult. Once the "impairments" are put in place, participants are given tasks to accomplish in their "aged" state.

Walking with corn kernels in their shoes, having joints tightly bandaged to limit movement, wearing glasses smeared with oil, wearing heavy gloves to minimize finger and hand movement all contribute to diminish capacity and functional ability. All frustrate the participant who begins to understand...and hopefully develop empathy and compassion for...the elderly.

According to Dr. Rosebrook, "Participants are empowered to identify and challenge common myths and stereotypes related to aging, participate in simulated experiences as an Elder, and develop strategies to help build enhanced Elder relationships."

http://www.mackliniginstitute.org/xtremeaging.aspx

The Experience of Aging, Part V - Overcoming Isolation

Carol Kleinman — Thu, 11 Dec 2008 18:30:00 GMT

It has been said that touch can reach through isolation and help alleviate feelings of loneliness and separation. Touch becomes especially important for those confined to health care institutions who may receive few visitors from the outside world. Though basic needs are met, these individuals often remain starved for the nurturing that is available through touch and skin-to-skin human contact.

Basic touch has become lost in the maze of modern medical technology, pills, and paperwork. Back rubs were once routinely administered by nurses as a non-invasive therapeutic tool to promote rest and relaxation. Touch techniques are particularly effective in providing comfort care and in enhancing quality of life for those who reside in a nursing home or extended care facility environments.

Touch and old-fashioned backrubs have been demonstrated to produce significant results in long term care residents. For example:

- Back rubs worked wonders for those confined to wheelchairs, for people in chronic pain and for residents exhibiting irritability or even anger.
- Hand massage or face stroking seemed to help those exhibiting anxiety, worry, sadness and fearfulness.
- Massaging the temples, scalp and forehead helped reduce headaches and tension, and shoulder and neck massage seemed useful for those exhibiting tiredness, irritability or mild upset.

Nursing manuals have long prescribed massage to prevent pressure sores, a chronic problem for the frail elders who spend most of their time in a bed or wheelchair. Even very gentle massage can improve circulation.

The use of touch to residents of health care facilities also has significant psychosocial benefits, including:

- one-on-one attention
- skin-to-skin contact
- tactile and sensory stimulation
- an opportunity for social interaction
- nurturing
- comfort
- reassurance

At least half the population in most skilled nursing facilities suffers from some form of dementia. Massage and touching provides therapeutic support by increasing body awareness and helping to ground those who are confused and disoriented. It can help focus attention, redirect energy, and promote calming.

http://www.massagetherapy.com/articles/index.php/article_id/192

The Experience of Aging, Part IV - Depression and Stress

Carol Kleinman — Fri, 05 Dec 2008 20:13:00 GMT

Decreased mobility, functional impairment, and multiple losses frequently lead to depression. It has been well established in the literature that the suicide rate among people over 65 is higher than any other age group. For more on this serious issue, read the information provided on the National Strategy for Suicide Prevention's Web site.

Chronic and acute health conditions requiring medical attention, a gradual decline in functioning, increased dependency on others, and the need to live in a residential environment that may not be the desire of the elderly individual are extremely stress-producing. Excessive and prolonged stress lowers resistance to viruses and can lead to more acute, chronic, or even life-threatening health problems.

Stress affects the physical body by causing muscular tightness, tension, stiffness and restricted energy flow. Continued stress can lead to muscle spasms, as well as bodily contraction, restricted movement and rigidity. Other signs of stress may include headaches, backache, fatigue, insomnia, stiff neck, cold hands and/or feet, perspiration, shortness of breath, constipation, etc. Physical stress tends to produce more emotional stress, thus setting up a cycle of disease, discomfort, and anxiety which can generate feelings of confusion, frustration, isolation, and vulnerability for the elderly. Such feelings eventually lead to inertia, despondency, withdrawal, and may even lead to a failure to thrive syndrome with gradual deterioration and even death.

The Experience of Aging, Part III - Loss of Independence

Carol Kleinman — Thu, 20 Nov 2008 20:52:00 GMT

The move into a health care facility is a major lifestyle change for the resident as well as for his or her family. It signals a significant loss of independence and may involve additional losses, including giving up the home that may have been a family residence for decades. There is also the loss of familiar surroundings and privacy. In addition, treasured possessions may be sold or given away. These losses are compounded by the fact that those living in care facilities usually have less contact with the outside world and fewer social relationships than those who live independently or with family.

When an individual becomes a resident of a care facility, his or her life is suddenly dominated by rules that are not of his or her own making...or even desire. Meals, rest periods, and activities are scheduled for the convenience of caregivers and for efficiency in management rather than according to individual preferences, lifestyle choices, or personal habits and rhythms.

Nursing Leadership and Education, Part II

Carol Kleinman — Fri, 26 Sep 2008 15:43:00 GMT

Two issues must be considered regarding nurse manager and director role preparation. First, given the importance of the role and the competencies required for success, nursing and health care administrators must support the possession or acquisition of a graduate degree as an essential requirement. A corollary to this imperative is the need to educate current and future nurse leaders about the necessity for this requirement.

Information about the business and nursing administration content typically included in graduate programs-particularly finance, clinical operations, human resource management, and legal and risk management-and the relevance of this content to specific responsibilities, may clarify the need for and benefit of graduate education.

The new health care leadership must possess synthesized competence that includes clinical health services and the management of these services from a business perspective. Nursing/health care administration is a discipline that combines the practice and caring aspects of nursing with the theories and methods of administration.

Nurses both provide care and manage the care environment. To maximize the interaction of these two roles, nurses in leadership positions must be as adequately prepared in the management aspects of the role as they are in the practice aspects.

For a review of the many types of advanced education available, see www.allnursingschools.com or www.petersons.com.

Part 10: More Budget Secrets

Carol Kleinman — Thu, 31 Jul 2008 17:31:00 GMT

Budgets are done initially as computer-modeled projections based on previous performance. What that means is that the computer looks at what was spent and models a budget for the next cycle based on that amount. Thus, if you spend less, you will get less. It's pretty weird, but it reflects the belief that you do not need as much as was allocated.

In the real world, while all budget line items are examined, the greatest focus is placed on staff costs, followed by supply costs. I work very hard to keep those two in line. But for other line items, I have a policy of not only spending every penny, but of going over five to ten percent every year. That is often not enough of a variance in these areas to attract much attention and it allows me to be allocated just a little more next year. This strategy allowed me, over several years, to develop a few subaccounts with money I could use in various ways to the benefit of my staff and the unit. I call this "creative accounting..."

Believe me, I learned this strategy the hard way by being very attentive to budget limits and staying just under budget across the board...only to be allocated less the following year! In general, as managers you should spend up to...and even slightly over...the limit for line items (other than salaries and patient supplies, of course). I even suggested to my managers when I was the CNE (though I deny I ever said it!) that they do so as it helps all the nursing units. Sometimes, there will even be money left over in various subaccounts.

Whether or not you will be able to use the money left over toward something else is a question you will need to find out from your organization. Some allow the transfer of funds from one subaccount to another and this should certainly be explored as it will allow you to spend the money where it is most needed. Even if this is not possible, I would spend all I could on, for example, journal subscriptions, because it will tell your staff you are interested in their growth as professionals. Using the funds for books and creating a unit-based library of reference books is often another way to use subscription funds. There are truly many ways to develop creativity in managing the budget!

In most of my facilities I was able to move money from one account to another through an interaccount transfer and that helped me pool funds for different purposes. I also worked directly with finance to create new subaccounts and transferred money into them from other subaccounts. For example, there was no account for journals and books and I was able to create one so staff could have resource books and current journals available on the units.

Another example was the staff request for new lockers, to which I believed they were entitled to keep their things safe. However, in total the lockers would have cost much more than $1000, putting them in the category of a capital request, which I knew would never be approved. The cost was also more than I could authorize at the time as a nurse manager, as my signing authority was limited to $1000 and my director would have had to approve the purchase, which she would not have done. So I ordered them but used the subaccount of minor equipment (which was for beepers and cell phones and the like), ordering six at a time and doing that every couple of months until everyone had a new locker.

Managers (and even administrators) have spending limits on what they can purchase on their signature alone. Going above that figure requires the signature of a higher-level manager. As I have no interest in bringing some of my activities to their attention, I am always below that number. So, if my limit is $1000, I may have three or four orders for $900. I share this with the vendors and ask for bills or invoices for those numbers and they always comply...they also know the game!

Part 7: Thoughts on Budgeting

Carol Kleinman — Thu, 19 Jun 2008 15:40:00 GMT

The operations budget, while based in part on expenses, is also based on revenue projections. Clearly we would not knowingly budget to spend more than we expect to earn from a product or service and so we budget accordingly. In general, we do not expect to have a great deal of money left over from revenues received after deducting all the operating costs, i.e., the costs of providing services. What we do have left...and it is usually a very small percentage...we do not leave in operations accounts, we move into an account that contains all the positive balances from various operations.

Essentially, capital budget funds come from these assets, ones that are left in the organization after all expenses are deducted. This includes not only operating expenses, but such expenses as depreciation, interest paid, taxes, etc. What is left is usually a pool of money call unrestricted net assets as we can do what we wish with them, up to a point. What is generally done is that the funds are used to replace outdated major equipment, expand existing services, and develop new product lines.

So, we expect operations to pay for themselves through the revenue we generate and we use the resources left to continue to grow our operations. We do this for various reasons. Sometimes we simply do this to remain competitive. In one place I worked, the L&D area was dismal, old and un-renovated, and no one care because most of the mothers were Medicaid recipients. Then another nearby hospital opened a state-of-the-art LDRP center and all the Medicaid moms went there. Despite the fact that the revenue was low on a per-patient basis, losing ALL of it was a blow. My hospital had to create an L&D area that was just as up-to-date in order to regain market share. Similarly, if we want to keep our primary referral sources, usually physicians and payers, we need to have the kind of environment and equipment they expect.

I wish we could allocate those funds back into operations and add to staffing ratios and so on, but you will find other compelling realities exist in the executive offices that require senior administration to make some difficult financial decisions.

Do you feel ready to do this?