ADVANTAGE – Long Term and Post Acute Care

Addressing the Sexual Needs of Seniors
by Brian Garavaglia

Older adults have sexual needs, which have often been minimized by the rest of the population. Furthermore, older adults that live in nursing home environments also have sexual needs that often are left unaddressed. Although addressing the topic has often been a sticky subject, a British nursing home has recently made the news by addressing the sexual needs of their elderly in a less than commonly accepted therapeutic modality.  They have used prostitutes! Chaseley nursing home in Eastbourne, England has allegedly been using prostitutes to come into the facility to address the sexual needs of their older adult clientele.  The Times of London writes that those that have these special sexual encounters meet with the prostitute in a special designated room of the facility that is often identified by a hanging “red sock” on the door to in form everyone that the room is currently being used for the sexual therapeutic intervention.  A former manager for the nursing care center says that the nursing home’s use of prostitutes, which supposedly are acquired through a “third party contact,” helps to serve the sexual needs of the elderly. According to the staff member, not only is this serving a therapeutic need of the individual, but once their sexual needs are satisfied, it helps to address the needs of the institutional environment as well, by preventing residents from touching or groping other residents due to unsatisfied sexual needs.
A note from the editor of this blog: Prostitution is a legal business activity in England. The only place in the USA where prostitution is legal is the state of Nevada. If your facility is not in Nevada, proceed with caution!

Emeritus Gets Clobbered – Is it fair?
by Steve Moran

It was painful to read the news reports about the Emeritus guilty verdict.  After reading the first article about the case a few weeks ago, I assumed Emeritus was going to get dinged on this one,but it was unclear how bad it would be.  I first wrote about it in this article:  Case Study – “Suit:Facility let woman ‘waste away’”.  According to the story in the March 6, Sacramento Bee Story,the jury found Emeritus to be guilty, finding that “that an employee, officer, director or a managing agent acted with recklessness, malice, oppression and fraud.”  The family was given an initial award of more than $4,000,000 which will likely be reduced to around $250,000 because of statutory pain and suffering limits.  Then on Friday the jury awarded an additional $23 million in punitive damages. In the damage story, it came out that Emeritus had made a pretrial settlement offer of $3.5 million suggesting that from the very beginning they were expecting to get hurt.

What it Means

Emeritus is not known as a company that scrimps on resident care.  In fact the Emeritus people I know have a huge commitment to providing quality care and services to their resident.  It seems pretty clear this was an isolated problem at one community, with one resident  . . . something that happened 5 years ago.  Don’t get me wrong, I do think it was probably not unreasonable that Emeritus pay something.

That being said . . .
To take one single incident and use it to imply “recklessness, malice, oppression and fraud” is a huge stretch.  This is particularly true because in Emeritus is a good company and runs good senior communities. It is particularly frustrating that the Sacramento Bee was essentially a shill for the plaintiff attorneys.  They ran at least 3 stories that were heavily slanted against Emeritus. Most egregious is it appears that the article on closing arguments only covered the plantiff’s side and not the Emeritus defense. That is not reporting. To be honest, it appears there were some real problems with this particular situation:

●Several people have wondered if this woman should have ever been admitted.  It is a good question, but without seeing the specific facts, it seems to me that it was a reasonable, better quality of life for the resident, decision.

●It sounds like this woman was frail and was probably assisted with bathing, so the fact that the decubitus ulcers were not caught, documented, reported and addressed earlier is problematic.

●This has to be the worst nightmare for operators, because assuming there was a problem, it could very well come down to one or two staff members who didn’t do the things should have done.

●It seems unlikely that whatever happened had a substantial impact on the resident’s longevity which makes the $23 million look ridiculous.

●There seem to be several “facts” that proved Emeritus provided substandard care, that even if true, don’t seem to have substantive relevance to the case.  The one that really caught my eye was the allegation that on at least one occasion, there was no dedicated night shift memory care staff member (or at least no record of it).  This seems to be mostly emotional smoke without fire;surely not an ideal thing, but the implication that somehow this caused the community to miss the skin problems makes no sense

●I feel particularly bad for all the hardworking dedicated Emeritus team members who work hard each day providing great care for their seniors that have now been tainted.

●It suggests it is now open season, at least in California, for assisted living providers.  Again something that will make it harder to provide great care for seniors.
In truth, this week and in the weeks to follow, the fine providers of assisted living, includingthose who work for Emeritus will continue to provide quality compassionate care to seniors in the state of California.  This case and the on-going threat of litigation will force senior communities to be more careful, to expend more time and energy on protecting themselves from predatory attorneys.  This in turn means higher costs.
Union contracts drive 5 Connecticut nursing homes into bankruptcy.
By Bill McMorris

The Washington Free Beacon

Lucrative union contracts have driven five Connecticut nursing homes at the center of a labor dispute into bankruptcy. HealthBridge Management has entered five of its nursing homes into Chapter 11 bankruptcy to escape labor contracts that left the company losing $1.3 million each month, according to senior vice president of labor relations Lisa Crutchfield.  “The centers have a bright future if they can operate under labor agreements that reflect today’s financial realities, but the fact is the centers will not survive unless we have relief from the crushing burden of unsustainable labor costs, especially the spiraling costs of pension and health care obligations,” Crutchfield said in a press release.  The nursing homes’ costs have soared after negotiating lush contracts with the politically powerful Service Employees International Union Local 1199 NE in 2004, according to the company. The company spent nearly 50 percent more on employee benefits than the average Connecticut nursing home.  “There is no getting around the fact that SEIU District 1199 labor agreements are the leading reason for nursing home closures in Connecticut. That’s bad for patients, employees, physicians and the communities they serve,”Ms. Crutchfield said. “In our case, the union’s collective bargaining agreements hobble the centers with labor costs that are well above state averages and which are simply unsustainable.”  The nursing homes are asking a New Jersey bankruptcy court to amend the contracts since the union has not accepted concessions on pay and benefits. “This bankruptcy filing is the latest in along string of actions by HealthBridge aimed at avoiding their legal obligations to more than 600 hardworking nursing home caregivers across Connecticut and at chipping away at the quality of care for patients—a cynical evasion of responsibility to Connecticut working families and their communities,” District 1199 president David Pickus said.  HealthBridge was left with few options after the embattled National Labor Relations Board ordered the company to rehire 600 striking union members despite allegations that the workers endangered patients during a July walkout. The Connecticut State Police are investigating whether union members mixed up patient medical records and identification documents during the strike.
Lorraine Mulligan, a veteran nurse, pleaded with the NLRB to keep the accused union members away from patients. “The nature and severity of the … incidents … put the safety, health, and well-being of the residents of those facilities in immediate jeopardy,” she said in a legal brief filed by HealthBridge. “A court order requiring the reinstatement of any of them or additionally those who had knowledge of sabotage and failed to act would expose the residents to immediate danger and put them at risk of suffering serious harm or death.”  HealthBridge and Care One,another nursing home company, are suing the union on charges of racketeering and extortion in connection to the walkout and other instances of alleged vandalism. The bankruptcy declaration will put that suit on hold for the time being, according to a source familiar with the case. The company claims it is just the latest victim of financial giveaways to the union. SEIU 1199represents 19,000 workers in Connecticut and has contracts in place at nearly 30 percent of state nursing homes. Nearly 70 percent of state nursing home bankruptcies have emerged in centers with SEIU contracts in place, according to HealthBridge.

Conquering C. difficile in LTC
by Pamela Tabar, Senior Editor, Long Term

Living Clostridium difficile (C. diff.) leads to 14,000 deaths per year in the United States, and the numbers are on the rise. The illness often plagues those who have received antibiotics,exacerbated by the fact that C. diff itself is resistant to antibiotic treatments. A single infected patient costs an average of $35,000 to treat, according to the newly updated Guide to Preventing Clostridium difficile Infections released yesterday. The virulent microbe and the challenges it poses across healthcare settings is the topic of a two-day educational conference this week hosted by the Association for Professionals in Infection Control and Epidemiology (APIC).  C. diff outbreaks can be especially difficult to contain and eradicate within long-term and post-acutecare settings, said Phenelle Segal, RN, CIC, president of Infection Control Consulting Services, Delray Beach, Fla., in her presentation “Practical Strategies to Control the Spread of C. difficile in Healthcare,” broadcast during the 2013 Clostridium difficile Educational and Consensus Conference. The community-based nature of skilled nursing facilities (SNFs) often creates special problems when caring for residents with C. diff, especially if there is no way to cohort infected residents. Semi-private rooms with shared bathrooms can cause issues if a resident needs the toilet immediately, yet using bedside commodes or bedpans can pose risks to caregivers. The ideal protocol would be to isolate infected residents, but it’s not practical or even possible in most long-term care settings, Segal says. “You can’t just move them. It’s their bedroom in their home, they have all their things set up and their pictures on the wall. it’s a huge challenge for long-term care.”  One thing caregivers can do is control what happens upon entering and exiting the resident’s room. The use of gloves and gowns is crucial since the disease is capable of surviving on surfaces for five months and also spreads via spores, Segal explains.  Vibrant disagreement surrounds the effectiveness of alcohol-based hand sanitizers vs. hand-washing.Alcohol-based sanitizers are appropriate in many instances, but they are not a silver bullet for everything. For example, hand-washing is crucial if the skin comes into contact with feces, since alcohol-based hand sanitizers cannot penetrate protein material, Segal says. “We’ve come a long way with hand hygiene, but we still have a long way to go. One of the biggest problems in LTCis the injudicious use of antimicrobials.”  Segal also suggests that all LTC facilities form an antimicrobial stewardship program to educate all staff, including non-medical departments like housekeeping. Stewardship techniques include Positive Deviance and Team STEPPS, but Segal says regardless of the approach, teams should include housekeeping, administration and  pharmacists as well as nurses and physicians. “The best approach is a group of healthcare workers who are experts in different areas united as a team,” she says. APIC’s Guide to Preventing Clostridium difficile Infections encourages SNFs to use the following strategies when caring for a resident with C. diff.:

●Gloves should be put on before entering and taken off before exiting the resident’s room.

●If a bedpan is needed, use a disposable one. For commodes, consider disposable liners.

●Suspend the use of rectal thermometers.

●Don’t share medical devices or equipment among infected and non-infected residents.

●If a roommate is unavoidable, choose someone who is not taking antibiotics and is healthy enough to fend off infections.

●Anything that has come in contact with fecal material from an infected patient should beconsidered infectious material. Proper cleaning and/or proper disposal is essential.

●Cleaning products must be able to kill the C. diff spores as well as the cells in order to beeffective. The Environmental Protection Agency considers bleach-based or strong hydrogenperoxide disinfectants to be the best spore-killers.

Policy Experts Agree: The U.S. System for Financing Long-Term Care is Crumbling
By Howard GleckmanAmerica’s system for financing long-term care is failing, and the window for creating a paymentsystem that works is rapidly closing. That was the conclusion of a morning-long expert sessionsponsored last week by the SCAN Foundation. While the participants differed on specificsolutions, most agreed on four key issues:
●The existing system for funding paid long-term supports and services is built on a wobblythree-legged stool: low private savings, an underfunded Medicaid program, and a hobbled privatelong-term care insurance market.

●The solution must include an affordable way for Americans to prefund their long-term care costs. This could include tapping financial assets or home equity, or buying insurance (either government, private, or some combination of both). Low-income people would require some form of safety net protection.

●Any future system should finance high-quality long-term supports and services that are well-integrated with medical care. This is especially important since recipients of care services suffer from chronic disease or injury that often requires complex medical interventions.

●There is currently no political consensus on how to do any of this.

That is where everyone agreed. Here is where they did not:
Several panelists focused on ways to enhance private insurance, where the market for traditional long-term care coverage has effectively collapsed. A paper by Marc Cohen of Lifeplans, Inc. and professors Richard Frank and Neale Mahoney of Harvard described a broad package of design changes that might make policies more attractive. Their ideas include simplifying and standardizing insurance products, indexing premiums annually instead of requiring carriers to ask for big rate increases every few years, allowing insurers to sell high-deductible plans (where buyers could be responsible for as much as two years of LTC costs), and better educating consumers about the price of long-term care and the limited government resources available to pay for it.  They also propose industry-funded reinsurance pools that would protect in insurers against unanticipated risks. Another suggestion: Require that companies over a certain size offer LTC insurance and force workers to buy unless they make an active choice to reject insurance.They also recommend new highly-targeted government subsidies, such as tax credits, to encourage moderate-income consumers to purchase long-term care insurance.  Finally, they suggest linking long-term care and health insurance, an idea I raised last year.  Several of their proposals, such as catastrophic coverage and standardized plan designs, are aimed at substantially lowering rates.  Expanding the role of employers may be especially critical since 80 percent of workers currently have no access to coverage through their jobs, according to a separate paper by Jeremy Pincus and colleagues at the insurance industry consulting firm Forbes Consulting Group. Like Cohen, Frank, and Mahoney; Pincus also believes an employer mandate would significantly boost the number of workers who would buy LTC insurance. But all that may not be enough.Other conference participants felt that even with these broad-based changes, voluntary private insurance would remain unattractive for many people. As a result, some sort universal coverageis the only way to make LTC insurance truly affordable for middle-income households.Voluntary insurance, even with reforms, would remain out of reach for tens of millions of middle-income people.  Anne Tumlinson of the consulting firm Avalere Health, Josh Wiener of RTI International  and their co-authors found that mandatory insurance would be significantly less expensive than voluntary coverage. Tumlinson said that maintaining the voluntary system would do little more than preserve the unworkable status quo. Insurance officials tell me privately that, even in the best case, perhaps 20 percent of Americans would buy voluntary LTC insurance. Perhaps another one-third have lifetime incomes so low that they can’t be expected to pay for their own care, either through savings or insurance, and will need some sort of public support.  That leaves perhaps half the country at risk. The challenge for policy makers and the market is to figure out what will work for them. The SCAN program was a great start, but much more needs to be done.