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Families Under Stress: Reflections On April’s Narrative Matters Essay On Dementia


April 16th, 2014
by Carol Levine

Editor’s note: This post responds to the April Narrative Matters essay by Gary Epstein-Lubow, a geriatric psychiatrist, which recounts the life-changing stress experienced by relatives who care for loved ones with dementia. Epstein-Lubow’s essay is freely available to all readers, or you can listen to him read it. You can also read an abridged version of the essay published April 15 in the Washington Post.

When my daughters were five and six years old, I took them to visit my grandmother in the Rosa Coplon Home in Buffalo, New York.

“Bubbie,” I said, “These are my little girls. Do you remember when I was this age?”

She looked at me and at them and finally held out her arms to embrace us and said (in Yiddish), “I don’t know who you are, but I know you belong to me.”

That experience so affected my elder daughter that when she was a teenager she undertook a project interviewing older people and creating a radio program from the tapes.

I thought of this moment when I read Gary Epstein-Lubow’s Narrative Matters essay, “A Family Disease: Witnessing Firsthand The Toll That Dementia Takes on Caregivers,” published in the April issue of Health Affairs.

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Companies Must Approach Advanced Health Events As A Business Issue


April 16th, 2014
 
by J. Brent Pawlecki and Dan Morhaim

Editor’s note: In addition to J. Brent Pawlecki, this post is also coauthored by Dan Morhaim. For more on this topic, see the April issue of Health Affairs, which features a series of articles on Alzheimer’s disease.

In the corporate world, every company has a chief financial officer charged with ensuring that the organization meets all tax and accounting mandates and to report the data to officers of the company, shareholders, employees and the general public.

Yet, while organizations expend great effort addressing these matters, many miss another opportunity to protect their employees’ well-being by failing to talk about end-of-life care.  Most companies consider advanced illness to be a private matter. But in fact, this hands-off approach most assuredly affects the financial health of any organization – and the emotional well-being of its workforce.

Beyond its direct impact on individuals’ health and well-being, advanced illness can take a heavy economic toll, including its effects on productivity, health and benefits costs, employee potential and engagement.  According to the MetLife Mature Market Institute study, the total estimated cost to employers for all full-time employed caregivers is a staggering $33.6 billion.  The average cost per employee for caregiving responsibilities ranges from $2,100 to $2,400.

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It’s Always Too Soon Until It’s Too Late: Advanced Care Planning With Alzheimer’s


April 10th, 2014
by Ellen Goodman

Editor’s note: This post is published in conjunction with the April issue of Health Affairs, which features a series of articles on Alzheimer’s disease.

I cannot write about Alzheimer’s disease without writing about my sister. For that matter, it is probably best to begin with the building where the word was first said to her. After all, my sister Jane was an architecture critic and buildings mattered to her, as did the urbanscape, and her whole vision of a people-centered city.

The building where she’d been diagnosed with “mild cognitive impairment” was a former military base now recycled into a labyrinth of medical offices, including the department where the people who clocked and studied—but could not curtail—the decline of her memory were lodged with their pencils and papers.

To get to the office, we had to drive into the imposing parking garage, take an elevator to the only floor where there was a bridge to the medical building, cross that bridge, then take a second elevator downstairs to register, get an electronic key, then ride upstairs again and find our way through a mysterious series of halls to the right door and unlock it.

This elaborate rite of passage never failed to strike me as a bizarre test in itself. Who designed this? What memory-impaired patient could remotely navigate this journey? Was this some sort of black humor, a way to triage those with or without the “executive function” to get there? Those with or without a caregiver who could lead her?

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New Health Affairs: Implications Of Alzheimer’s And The State Of Research


April 7th, 2014
by Chris Fleming

Health Affairs’ April issue addresses the litany of public and personal ramifications of Alzheimer’s disease—the most expensive condition in the United States both in terms of real costs and the immeasurable toll on loved ones. Articles examine best practices and models of care; a global view of the disease; the effects on caregivers; and what may lie ahead for a disproportionately underfunded research community.

Unnecessary hospital and emergency department (ED) visits are particularly difficult on people with Alzheimer’s—and costly to the health care system—but they experience them more often than their counterparts without dementia. Zhanlian Feng of RTI International and colleagues examined Medicare claims data linked to the Health and Retirement Study to determine hospital and ED use among older people with and without dementia across community and institutional settings. They found that in the community older people with dementia were more likely to have a hospitalization or ED visit than those without dementia, and that both groups had a marked increase in health care usage near the end of life.

Specifically, they found significant differences in hospitalizations and ED visits among community-dwelling residents, with 26.7 percent of dementia patients versus 18.7 percent of non-dementia residents experiencing hospitalization, and 34.5 percent versus 25.4 percent experiencing an ED visit. Differences were less pronounced among nursing home residents and tended to even out among all groups in the last year of life. The researchers suggest that policy makers consider promoting the use of alternative end-of-life options such as hospice care and providing supportive services and advance care planning to Medicare beneficiaries that can help reduce avoidable hospital-based care.

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Health Affairs Briefing Reminder: Long Reach Of Alzheimer’s Disease


April 4th, 2014
by Chris Fleming

Despite decades of effort, finding breakthrough treatments or a cure for Alzheimer’s has eluded researchers. In the April 2014 issue of Health AffairsThe Long Reach Of Alzheimer’s Disease, we explore the many subjects raised by the disease: the optimal care patients receive and the testing of new models, international comparisons of how the disease is treated, families’ end-of-life dilemmas, a new public-private research collaboration designed to produce improved treatments, and others.

Please join us on Wednesday, April 9, at W Hotel in Washington, DC, for a Health Affairs briefing where we will unveil the issue.  We are delighted to welcome Dr. Richard Hodes, director of the National Institute on Aging at the National Institutes of Health to deliver the Keynote. Read the full briefing agenda.

WHEN:
Wednesday, April 9, 2014
8:30 a.m. – 12:30 p.m.

WHERE:
W Hotel Washington
515 15th Street NW, Washington, DC (Metro Center)
Great Room, Lower Level

 REGISTER ONLINE

Follow live Tweets from the briefing @HA_Events, and join in the conversation with the hashtag #HA_Alzheimers.

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The Manifest Destinies Of Managed Care And Palliative Care


April 2nd, 2014
 
by Richard Bernstein and Karol DiBello

Editor’s Note: This post is also coauthored by Karol DiBello and is the sixth in a periodic Health Affairs Blog series on palliative care, health policy, and health reform. The series features essays adapted from and drawing on an upcoming volume, Meeting the Needs of Older Adults with Serious Illness: Challenges and Opportunities in the Age of Health Care Reform, in which clinicians, researchers and policy leaders address 16 key areas where real-world policy options to improve access to quality palliative care could have a substantial role in improving value.

Two unremitting forces are shaping changes in the U.S. health care system: (1) the graying of America or “silver tsunami,” in which 10,000 individuals are now turning age 65 each day and (2) the cost trends associated with caring for seniors and those with multiple chronic and often life-limiting conditions. Health care experts have identified palliative care and managed care as essential ways to address the special needs of an aging population and for providing care that can lower the rate of national health expenditures.

The complex set of clinical demands of this growing wave of Medicare members includes multimorbidity, frailty as well as functional and cognitive decline.  To effectively and cost-efficiently manage the needs of this population, Managed Care Organizations (MCOs) as well as other risk assuming entities must address the quality and cost of the most expensive segment of this group of seniors.

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Ethical Dilemmas In Prison And Jail Health Care


March 10th, 2014
by Nancy Dubler

Editor’s note: This post is published in conjunction with the March issue of Health Affairs, which features a cluster of articles on jails and health.

Prison and jail health care, despite occasional pockets of inspiration, provided by programs affiliated with academic institutions, is an arena of endless ethical conflict in which health care providers must negotiate relentlessly with prison officials to provide necessary and decent care.  The “right to health care” articulated by the Supreme Court pre-ordained these ongoing tensions.  The court reasoned that to place persons in prison or jail, where they could not secure their own care, and then to fail to provide that care, could result in precisely the pain and suffering prohibited by the Eighth Amendment to the Constitution.

Good reasoning was followed by a deeply flawed articulation of the “right” that defines the medical care entitlement as care provided to inmates without “deliberate indifference to their serious medical needs.” By forging a standard which was, and remains, unique in medicine and health care delivery — designed to avoid intruding on state malpractice litigation regarding adequacy of practice and standards of care — the court guaranteed that dispute would surround delivery.  That first framing, which did not establish a right to “standard of care” or to care delivered according to a “community standard,” set the stage for endless ethical and legal conflict.

The Eighth Amendment’s deliberate indifference standard, forbidding cruel and unusual punishment, presents a relatively demanding standard for proving liabil­ity.  The Eighth Amendment, as interpreted by the federal courts, does not render prison officials or staff liable in federal cases for malpractice or accidents, nor does it resolve inter-professional disputes — or patient-professional disputes — about the best choice of treatment. It does require, however, that sufficient resources be made available to implement three basic rights: the right to access to care, the right to care that is ordered, and the right to a professional medical judgment.

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Good Palliative Care Requires Good Long-Term Care: A Medicare Strategy To Strengthen Both


March 10th, 2014
 
by Judy Feder and Robert Berenson

Editor’s NoteThis post is also coauthored by Robert Berenson, an Institute Fellow at the Urban Institute. 

This post is the fifth in a periodic Health Affairs Blog series on palliative care, health policy, and health reform. The series features essays adapted from and drawing on an upcoming volume, Meeting the Needs of Older Adults with Serious Illness: Challenges and Opportunities in the Age of Health Care Reform, in which clinicians, researchers and policy leaders address 16 key areas where real-world policy options to improve access to quality palliative care could have a substantial role in improving value.

Alongside the challenge of improving insurance coverage for palliative care, caregivers and practitioners face a continuing challenge in mobilizing long-term services and supports (LTSS), that is, personal assistance to those unable to perform basic tasks of daily living.  These services are an essential part of palliative care.  Whatever a patient’s wishes, unless LTSS are available to support patients and caregivers at home, the emergency department and the hospital become the only option when a symptom or caregiver exhaustion crisis occurs.

But identifying, accessing and coordinating long-term care services are not easy.  Further, financing to support these services is beyond the scope of standard insurance. Few people have private long-term care insurance, and Medicare’s coverage of nursing homes and home health is contingent on the need for skilled nursing or therapy care. MedPac reports that in 2011, Medicare-covered nursing home stays averaged only about 27 days and home health aide (personal care) visits averaged only about five per home health user.  Although a recent legal settlement has required CMS to clarify that coverage is not contingent on evidence of patient improvement, the skilled care requirement remains intact.

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New Health Affairs: ACA’s Impact On Americans With HIV/AIDS And Jail-Involved Individuals


March 3rd, 2014
by Chris Fleming

Health Affairs’ March issue, released today, explores how the Affordable Care Act (ACA) could affect two key sectors of the population with unique public health needs—those living with HIV/AIDS and people who have recently cycled through local jails.

When it comes to HIV treatment, timing is everything. Dana Goldman of the University of Southern California and coauthors modeled HIV transmission and prevention based on when HIV-positive individuals started combination antiretroviral treatment (cART). They estimate that from 1996-2009, early treatment initiation in the US prevented 188,700 HIV cases and avoided $128 billion in life expectancy losses.

The authors highlight treatment at “very early” stages (when CD4 white blood cell counts are greater than 500, consistent with current treatment guidelines in the US) as responsible for four-fifths of prevented cases. Early treatment both reduces morbidity and mortality in people living with HIV/AIDS, and decreases the transmission of the disease to the uninfected. Goldman and coauthors conclude that early treatment has clear value for both HIV-positive and HIV-negative populations in the US.

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Implementing Health Reform: Medicaid Asset Rules And The Affordable Care Act


February 24th, 2014
by Timothy Jost

On February 23, 2014, the Centers on Medicare and Medicaid Services released a State Medicaid Directors Letter analyzing the application of Medicaid liens, estate recoveries, transfer-of-asset rules, and post-eligibility income rules to individuals who become eligible for Medicaid because of their modified-adjusted gross income (MAGI).

Background

Contrary to the flat-earth concept of Medicaid espoused by Chief Justice Roberts in National Federation of Independent Business v. Sebelius, Medicaid has never been a single program but rather a cluster of programs with quite different purposes and rules. One of its more controversial and problematic roles has been to serve as our nation’s default program for financing long-term care services. Nursing home care, and even community-based long term care, is very costly, and long-term care can easily overwhelm the income and resources of people who are otherwise comfortably middle income. From its inception, Medicaid has been available to pay for long-term care for people who are unable to afford it after they have effectively become impoverished by “spending down” their own assets and income.

From very early in the Medicaid program’s history, however, there has been a concern that people who could otherwise afford to pay for at least some long-term care services would voluntarily impoverish themselves, transferring assets to their children or to others to make themselves eligible for Medicaid. Congress and the states have therefore adopted laws and regulations to limit asset transfers by Medicaid recipients. These prohibitions were initially evaded through the use of trusts and other financial devices, resulting in the enactment of additional laws to bar these evasions.

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Care Delivery And Coordination In The Accountable Care Environment


February 19th, 2014

Editor’s Note: This post is the fourth in a periodic Health Affairs Blog series on palliative care, health policy, and health reform. The series features essays adapted from and drawing on an upcoming volume, Meeting the Needs of Older Adults with Serious Illness: Challenges and Opportunities in the Age of Health Care Reform, in which clinicians, researchers and policy leaders address 16 key areas where real-world policy options to improve access to quality palliative care could have a substantial role in improving value.

As we enter the world of accountable care, palliative care programs bring tremendous assets to our health care system. Accountable care organizations (ACOs) seek to improve quality and reduce costs for a defined population of patients, and palliative care offers value on both the quality and cost sides of the equation.

Palliative care improves quality

Patients facing a serious illness value survival, quality of life, and minimization of suffering for themselves and their families. For patients with far-advanced disease, hospice care is the “gold standard” of care in meeting these goals. Palliative care achieves these goals for patients who are living with a serious illness but may not be at the end of life. Many studies demonstrate a panoply of improved outcomes for patients receiving palliative care: improved quality of life, reduced symptoms, enhanced emotional support, improved communication with physicians, earlier and more frequent use of hospice, reductions in family distress, improved survival, and greater satisfaction with care.

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The PRIDE Initiative: Building The Capacity And Scalability Of Integrated Managed Care Plans


February 13th, 2014

As health care costs have increased, the challenges of managing complex chronic conditions, compounded by frailty, disability, mental illness, poverty, or limited education, have become more pressing. Correspondingly, individuals, families, and government entities alike are increasingly frustrated with the current health care system. Even people like me – a seasoned health services researcher working in a large integrated delivery system – find it difficult to assemble and coordinate an array of medical and long-term services and supports (LTSS) to meet our family members’ preferences and needs.

Coordinating services for my own mother – an upbeat 94-year old with considerable financial resources but advancing dementia, frailty, blindness, and a variety of health and LTSS needs – requires more of my time and that of other family members.  People with similar needs but fewer resources often face far more daunting problems in trying to understand diverse Medicare and Medicaid benefits, access appropriate services, and navigate among multiple health and LTSS providers that rarely communicate with each other.

Below I describe the early work of the PRIDE consortium, a small group of seven high potential health care organizations (CareSource, OH; Commonwealth Care Alliance, MA; iCare, WI; Health Plan of San Mateo, CA; Together4Health, IL; UCare, MN; and VNSNY CHOICE , NY) that aim to provide access to genuinely integrated medical and behavioral health and LTSS for people dually eligible for Medicare and Medicaid. The backdrop for PRIDE (Promoting Integrated Care for Dual Eligibles) is the new federal-state effort to align the Medicare and Medicaid programs and enroll high-needs, high-cost dually eligible beneficiaries in integrated health care entities that will offer better coordinated, more consumer-centric and lower-cost care. At the federal level, the Centers for Medicare & Medicaid Services (CMS) is the chief honcho for efforts to harmonize the workings of Medicare and Medicaid, test innovative payment and service delivery models, and reduce expenditures.

In 2011, CMS awarded contracts of up to $1 million to each of fifteen states to design coordinated care demonstrations involving capitation arrangements or fee for service entities.  Additionally, eleven states (plus those that received the $1 million planning awards) submitted proposals to participate in CMS’s “financial alignment initiative,” intended to improve alignment between Medicare and Medicaid policies affecting care for dual eligibles.  By September 2013, CMS had signed Memorandums of Understanding (MOU’s) with seven states to pursue coordinated care demonstrations, while others’ MOU’s were in the pipeline.

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Nursing Homes Are The Solution On Readmissions


January 17th, 2014
by David Gifford

A recent report from the Office of the Inspector General (OIG) within the Department of Health and Human Services (HHS) argues that skilled nursing care centers, or “nursing homes,” should be better monitored by the federal government when it comes to how frequently they send patients back to the hospital. OIG recommended that the Centers for Medicare and Medicaid Services (CMS) develop a quality measure to track and publicly report nursing centers’ hospitalization rates and to have state survey agencies review the measure as part of the survey and certification process. As the largest association representing skilled nursing care centers in the country, the American Health Care Association (AHCA) agrees. In fact, we do not think OIG goes far enough. We support linking Medicare payments to skilled nursing care centers based on their hospital readmission rates.

Frequent trips to the hospital are disrupting to seniors and put them at greater risk for complications and infections. It is also costly to the system, as the OIG report demonstrates. AHCA came to the same conclusion and is already acting on the issue. AHCA wrote to Congress earlier this year in support of measuring and publicly reporting hospitalization rates among skilled nursing centers when the legislative body requested comments on how to reform Medicare post-acute care payments.

We also support the expansion of CMS’ new inspection process, the Quality Indicator Survey (QIS), which includes a process to review a center’s hospitalization rates unlike the old survey process. However, only 26 states presently use the QIS process after CMS suspended nationwide implementation due to potential budget constraints. AHCA supports CMS continuing its expansion of the QIS to all states as designed, which will have surveyors review centers’ hospitalization rates as recommended by the OIG.

We’re not just encouraging measuring and reporting; we have also developed a hospitalization measure, which we have shared with the federal government. AHCA partnered with the data analytics company, PointRight, to calculate risk-adjusted hospital readmissions during the first 30 days of a skilled nursing stay. Previously, this data was not available to individual providers and was not risk adjusted. Instead, it was reliant on Medicare claims data which did not account for individuals covered by other insurance such as Medicaid, managed care, commercial insurance, or private pay, and resulted in a two-year lag time before data were available.

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Views From the Hospital Executive Suite Leads Health Affairs Blog December Top Ten


January 9th, 2014
by Tracy Gnadinger

Since the majority of Americans believe the Affordable Care Act will have a negative impact on the health care system, it’s no surprise Andrew Steinmetz, Ralph Muller, Steven Altschuler, and Ezekiel Emanuel‘s post about hospital executives’ largely positive view of health care reform was the most-read post on Health Affairs Blog in December. Next on the list, for the third month in a row, was James Rickert’s discussion of patient-centered care, followed by Timothy Jost‘s post on exemptions from the individual mandate and Mary Ersek and David Stevenson‘s post on challenges and opportunities of integrating palliative care into nursing homes, the first in a series on palliative care.

The full list appears below.

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Advanced Care Model Honors Dignity, Integrates Health System For Seriously Ill People And Loved Ones


December 23rd, 2013

Editor’s Note: This post is the second in a periodic Health Affairs Blog series on palliative care, health policy, and health reform. The series features essays adapted from and drawing on an upcoming volume, Meeting the Needs of Older Adults with Serious Illness: Challenges and Opportunities in the Age of Health Care Reform, in which clinicians, researchers and policy leaders address 16 key areas where real-world policy options to improve access to quality palliative care could have a substantial role in improving value. This post describes the Advanced Care model, a delivery system approach that includes palliative care and coordinates services for people with serious chronic illness across hospitals, medical groups, homes, and the community.

Like other initiatives to reform American health care, the movement to improve care for patients with advanced illness does not suffer from a lack of new ideas. The real barriers to improvement lie in replicating innovative models that have already addressed the problem and found scalable and sustainable solutions. Fortunately, promising initiatives are now prepared to transform care on a national scale. These developments are timely because reform is badly needed.

Our fragmented approach to advanced illness exacts a terrible toll from our sickest and most vulnerable citizens and their families. It also places a growing burden on our health care system. Hospital treatment of advanced illness absorbs a large fraction of the Medicare budget. Over one quarter of all Medicare expenditures pay for care in the last year of life, a proportion that has not changed in 35 years.  CMS research shows that about 30 percent of this final-year spending is concentrated in the month prior to death, and 80 percent of Medicare dollars spent during that final month go toward hospital treatment.

People suffering from advanced illness – multiple chronic conditions with declining function and poor prospects for full recovery – often fall through the cracks between current programs and providers.  Like patients under disease management, people with advanced illness have multiple chronic conditions, but their decline in health and function is more pronounced, faster, and in many cases, irreversible. In short, a person with advanced illness has entered the “gray zone” between treatable and terminal illness.

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Integrating Palliative Care Into Nursing Homes: Challenges And Opportunities


December 2nd, 2013
 
by Mary Ersek and David Stevenson

Editor’s note: The following post, on palliative care in the long term setting, is authored by Mary Ersek and David Stevenson (photos and linked bios above) and by Justine Sefcik, MS, RN, a fourth year doctoral student at the University of Pennsylvania School of Nursing, a 2012-2014 National Hartford Centers of Gerontological Nursing Excellence Patricia G. Archbold Scholar, and a previous Jonas Hartford Scholar. The post is the first in a periodic Health Affairs Blog series on palliative care, health policy, and health reform. The series will feature essays adapted from and drawing on an upcoming volume, Meeting the Needs of Older Adults with Serious Illness: Challenges and Opportunities in the Age of Health Care Reform, in which clinicians, researchers and policy leaders address 16 key areas where real-world policy options to improve access to quality palliative care could have a substantial role in improving value.

As we begin the series, we offer the following short introduction from Diane Meier and Amy Kelley: “Because of its focus on quality of care, the Affordable Care Act is poised to expand access to palliative care services for the sickest, most vulnerable, and therefore most costly, 5 percent of patients, who drive about 50 percent of all healthcare spending. Palliative care is specialized medical care for people with serious illnesses that focuses on providing relief from symptoms, pain, and stress, whatever the diagnosis or stage of illness. Patients (and family caregivers) receiving palliative care experience improved quality of life, better symptom management, lower rates of depression and anxiety, and improved survival. Because patient and family needs are met, crises are prevented, thereby directly reducing need for emergency department and hospital use and their associated costs.”

Around a quarter of older Americans die in nursing homes each year, including nearly 70 percent of individuals with advanced dementia. For these individuals, the delivery of coordinated, person-centered services at the end of life is a central component in the array of supportive and therapeutic services they receive. Although growing numbers of nursing home residents are accessing Medicare’s hospice benefit before death, substantial barriers continue to impede the meaningful integration of palliative and hospice care into the long-term services and supports that most nursing home residents receive. These barriers range from the orientation of nursing homes — and the regulatory standards that govern them — toward rehabilitative care, to the fragmented approach of Medicare and Medicaid in financing acute, post-acute, palliative, and supportive services.

The challenge of improving end-of-life care in nursing homes is broad, and no single policy reform or intervention alone will be sufficient. Nonetheless, there are several mechanisms by which policymakers and practitioners could improve end-of-life care in nursing homes. Importantly, these mechanisms align broadly with the guiding principles for long-term services and supports (LTSS) outlined by the US Commission on Long-Term Care in their final report to Congress. Specifically, the Commission concluded that there is an urgent need to enhance the quality of LTSS and improve the coordination among the providers that deliver these services. While emphasizing the need to finance and deliver services in a fiscally sustainable way, the Commission called for improving “the integration of LTSS with health care services in a person- and family-centered approach.”

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What Do You Mean I’m Getting Old? Denial About Aging And Our Impending Long-Term Care Crisis


June 12th, 2013
by Bruce Chernof

It is no secret that Americans are aging, but what is too often lost in this fact is that most people will need help as they grow older. Unfortunately, America does not have a strategy to deal with this growing demand. For some, this help comes in the form of needing just a little bit of assistance in the home with cooking meals or getting groceries. For others, it is more comprehensive daily help in assisted living or nursing home care.

As Chair of the newly created federal Commission on Long-Term Care, I believe it is imperative for Americans to understand that 70 percent of us who live beyond the age of 65 will need some form of long-term care, on average for three years. This is a potentially dangerous statistic given the reality that our nation’s system of care is outdated and lacks the tools to meet the needs of our growing senior population.

To better understand Americans’ attitudes and perceptions around aging and long-term care, as well as levels of preparedness for future care, the Associated Press – NORC Center for Public Affairs Research conducted a national poll of adults age 40 and older with funding from The SCAN Foundation. Implications of these findings are profound considering the population of adults over 65 will nearly double to 19 percent — nearly 72 million people — by 2030.

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Creating Realistic Long-Term Care Solutions As Part Of The Entitlement Reform Debate


January 23rd, 2013
by Bruce Chernof

Great struggles sometimes result in unexpected opportunities. In the waning moments of 2012, Congress remained in session to bridge partisan divides to solve the fiscal cliff impasse with the passage of the American Taxpayer Relief Act (ATRA). Signing the ATRA into law also achieved policy change on items far beyond the tax code.

For example, the new law repealed the Community Living Assistance Services and Support (CLASS) provision in the Affordable Care Act, which would have created a new, national, voluntary, long-term care insurance product. Yet the problem of how to best finance and deliver care for our vulnerable loved ones has been looming for years and endures. As a much-needed acknowledgment of this, the Congress created a new Commission to propose policy solutions to address the long-term care challenges that a growing number of Americans face.

Given the sheer magnitude of this issue, the current political climate, and the short time span for turning around a meaningful legislative proposal (six months), the Commission’s charge is nothing short of colossal. However, its creation in the wake of the CLASS repeal is an important step towards system transformation that will enable Americans to age with dignity, independence, and choice. The Commission will consist of 15 appointees, nine Democrats and six Republicans, to be named in the next month, who will report back to Congress by the summer. They must devise a plan on the financing and delivery of a comprehensive and coordinated system that ensures available long-term services and supports for people in need today, and options for Americans to plan for their future needs.

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Your (Untrained And Scared) Family Member Will Set Up Your IV Now!


November 2nd, 2012
 
by Carol Levine and Susan Reinhard

Time travel, both backward and forward, continues to be a favorite theme in popular culture. If we could travel back just 60 years or so, we would see a vastly different health care system, one geared to provide acute care, not chronic care, and one offering what today would be seen as rudimentary treatments. No one in 2012 would expect a surgeon to use techniques from that era or a doctor to prescribe medications long surpassed by more effective drugs. Yet one important area of health care and long-term care services and supports clings to outmoded terms and measures.

Welcome to the hidden world of family caregivers — broadly defined as the spouses, adult children, other family members, partners, friends and neighbors who provide or manage most of the care of the growing number of noninstitutionalized people with chronic illnesses and disabilities. As our recently released AARP Public Policy Institute and United Hospital Fund report (available here and here) puts it:

Family caregivers have traditionally provided assistance with bathing, dressing, eating, and household tasks such as shopping and managing finances. While these remain critically important to the well-being of care recipients, the role of family caregivers has dramatically expanded to include performing medical/nursing tasks of the kind and complexity once provided only in hospitals.

These tasks include managing multiple medications, not just pills but injections and infusions; wound care; operating medical equipment like feeding tubes, dialysis machines, and mechanical ventilators; and using electronic monitors and other devices.

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For Older Adults, Unexpected Hazards In Several Provisions Of The Affordable Care Act


June 21st, 2012
by Chris Fleming

One of the goals of the Affordable Care Act (ACA) is to reduce the fragmentation of services for patients. The problems of fragmentation are magnified for the six million Americans receiving long-term services. New analysis, released as a Web First by Health Affairs, examines the impact on this population of three provisions of the ACA—the […]

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