A New Meaning For Adoption

Elderpride Chapter 9


My good intentions of writing a new chapter each week has gone awry. I apologize; I am in the process of starting up a new business and I have simply gotten too busy! One of these days I will change my profile to include my new business! Meantime, the elderly need our attention.

In this chapter I digress from the Elderpride topic to talk about a very important program that the Dorotha C. White Foundation is bringing to nursing homes nationwide – the “Adopt A Nursing Home Patient” Program. Joining this program enables interested volunteers to adopt a nursing home patient who has no family to look after them. Volunteers visit “their” patient in the nursing home once a week and enjoy activities with their adoptee such as reading, drawing, playing cards, or just chatting.

The program has been good for both patients and volunteers. One of the high school volunteers Amy Dolezal requested to add an additional patient to her visits because her initial resident was a bit on the independent side and Amy wanted to also visit with someone a bit more challenged. After seeing the difference her visits made she was interested in making a difference in another person’s life.

The volunteers provide a valuable and needed service and the patients get very welcome attention. “For some patients, it is the first time anyone has visited them consistently,” said Shari Rhoads, CEO of the Foundation. “we welcome anyone who has compassion and respect for the elderly to sign up and become a volunteer in this program.” The Dorotha C. White Foundation will match volunteers, anywhere in the USA, with nursing home patients who are lonely and would benefit from having a “friend”. Anyone who is interested should either follow the link on the side of this blog or call 800-789-4836 and ask for a Dorotha C. White representative for more information.

“We have volunteers as young as 16”, said Mary Baqueiro, the Executive Director of the Foundation, “and they report that the patients enjoy their company. Several have mentioned that their Christmas holidays will be more special this year because they have been helpful to others.”

On second thought, I didn't digress at all from the concept of Elderpride... what better way to instill Elderpride in one of our elders than to be their friend. So, join us today!

More on the Polypharmacy Conundrum

Chapter 8



While we are on the topic of polypharmacy, let’s visit the question of how we got into this situation (mess). The fact that all of these elements we have been discussing have become part of our “system” of how we, the people provide for our elderly citizens is really quite disturbing! Polypharmacy is only one of these very disturbing factors.

Most nursing home administrators “contract” for certain services at their facility. Common things that are “contracted out” include pharmacy services, therapy services, and billing services. There may be other less common services contracted out – but the ones just mentioned are the ones that can make the most difference to patients in nursing homes.

Busy nursing home administrators fall into the trap of thinking that once these services are “contracted out” that the administrator’s problems are over. The administrator no longer focuses on the contracted services, instead thinking that now the problems belong to someone else. In that process, a loophole is created and accountability is lost. In the case of polypharmacy, the pharmaceutical company who has been contracted gains too much power over how much medication is administered via “recommendations” to the nursing staff and physicians.

The administrator certainly has a choice over which subcontractor they will use and that should establish a foundation for accountability, however, the administrator has so many problems on his/her plate, some of which we have already discussed, that they are simply grateful for the help. So because they are desperate for help, and the pharmaceutical company is more than happy to “take over” this responsibility, a system is established that does not benefit patients and costs we, the people billions.

The resulting conundrum, the use of medications is largely in the hands of the people who make money when patients take medications, is very low on the priority list of problems to be solved because on the face of it – the collective administrators believe it is solved.

Busy physicians who have to order the medications often respond to nurses or pharmacists phoned requests or recommendations that the patient “needs something” without examining the patient. The pharmacist or the pharmaceutical company who is contracted to provide these services makes money for every pill, injection, IV or topical medication that the patient receives. We, the people should not object to this if the medications are indeed benefiting the individual they are given to. Hopefully, we, the people will object strongly that often the benefit is for the staff rather than the patient.

There are estimates published by AARP on their website that indicate that 50% of the medications given to our elderly citizens in nursing homes may be unnecessary. That is huge! Not only subjecting a person to the risks and potential side effects of these medications, but also the cost to we, the people for providing them.

The average number of medications each nursing home patient is given in a day is 12 to 15. There are 16,000 nursing homes nationwide and on average each nursing home has 123 beds equaling 1.9 million nursing home beds. These beds are, on average, 85% occupied meaning that there are 1.6 million nursing home patients on any given day. On an average day, 25 million medications are given nationwide at a cost to we, the people of $300 million each day for an astonishing $109 billion each year. And half of that may be unnecessary!

Should we, the people balk at that? Not if the medication is required for the patient’s benefit. However, when the medication is given to the patient for the convenience of the staff; or, to overcome the staff’s feeling of helplessness. we, the people should protest. We, the people should ask for greater accountability. We, the people should insist that our legislators fix these systemic problems.

What the Heck is Polypharmacy Anyway?

Elderpride: Chapter 7


Polypharmacy is a big word and its meaning is not so obvious at first glance. What it means is that a patient is being prescribed too many medications. Too many for their condition, and often those medications that the patient doesn’t really require for their condition lead to side effects that diminish their ability to understand their surroundings, and comprehend all that is happening around them.

How can this happen? Don’t medications have to be prescribed by physicians? Why would the professionals caring for patients in Long Term Care facilities allow a patient to be taking too many medications? Doesn’t anyone care about these patients?

These are all legitimate questions and they are the same ones I asked myself when I first heard about polypharmacy. I suppose the fact that society, in general, thinks that there is a pill to solve all ills causing most of us to call our physician at the drop of a hat to ask for this common solution to every health problem is at the root of polypharmacy. We have all gotten used to receiving a pill for everything and physicians have gotten used to prescribing them, partly to get us off their back, partly because it is the easy way out, and partly because it keeps us returning to their office for checkups and refills which creates a revenue stream for the physician. And so, a prescription is viewed by society as appropriate and even a validation that the individual really does have something wrong – it’s not all in their head – whew! So most of us see nothing wrong with pills, lots of pills.

How does all this relate to the skilled nursing facility? I am getting to that. What happens is the nurse calls the doctor because Mrs. S. can’t sleep and she is calling out and disturbing everyone else. The next thing you know, Mrs. S. is taking a pill such as Haldol which is commonly used for dementia. And generally this prescription for the patient will be given without benefit of the physician visiting and examining the patient.

The medication prescribed may not be Haldol, it may be some other antipsychotic medication, or it may be two or three of these medications if one doesn’t do the trick. This is why many nursing home patients seem like they are “zombie-like”, or “just not themselves”, or perhaps you would describe them as “they seem to have given up”. It might not be the patient’s fault. Their only sin may have been to call out for help at night.

I think it is normal behavior for an elderly person to call out for help in an environment that is unfamiliar. I believe they are just scared. If you were elderly and your family dropped you off at a nursing home perhaps you would be fearful of your new environment. Or perhaps you would wake up in the middle of the night and not know where you were. You might call out too! I know that when my own father in law had to go to a nursing home for therapy when I went to see him the next day he said to me with a sense of relief, ”How did you find me?” In his mind, he didn’t know where he was, so he didn’t think we knew where he was either. He was quite pleased to see me and knew that everything was OK – for that moment. He had never been to this nursing home before. It was quite understandable that he didn’t know where he was. If he was fearful or calling out at night – it doesn’t mean he was psychotic and needed antipsychotic drugs. It simply meant he didn’t know where he was, nothing was familiar to him and he was scared.

The conclusion that I draw from this is that many patients are put on these drugs that turn them into zombies for the convenience of the staff. The patient is easier for the staff to manage. And no longer makes the staff feel as if they are not doing their job – listen, it is tough to be the staff too, and have to listen to a patient calling out and not have the skills or tools to manage the situation. What the staff learns is that the drugs work. The patient on drugs makes the staff feel like they have done something for the patient and the patient no longer bothers the staff.

However, the patient can be the loser here. As the systemic overmedicating of patients becomes the norm, the patient loses all his/her credibility. Since the patient seems “out of it” no one listens to the patient anymore. So if the patient complains about their care in the nursing home their complaints go unheard, un-noticed and unanswered. In my mind, this sets the stage for elder neglect as it reduces the accountability of the staff to care for the patient properly.

And this is only one example of how new medications get prescribed for nursing home patients, extrapolate that to the fact that on average every nursing home patient takes 12 to 15 medications per day, most medications are given two or three times a day – that can add up to as many as 45 pills each day!

What I am describing is all too common. It is a far cry from Elderpride. And again, I feel like we, the people can do a lot better. You might wonder why this is permitted to happen, what are the financial incentives behind polypharmacy? Well, I wondered that too – it is our next topic!

The Long Term Care Staffing Connundrum

Elderpride: Chapter 6

We have discussed the underlying payment methods to nursing homes and how the manner in which they have been structured leads to problems in the Long Term Care industry. But that is only the tip of the iceberg. Let’s pile on another layer….let’s start examining what it costs we,the people to care for patients in skilled nursing facilities and nursing homes. The layers are ultimately all connected and interwoven, but by examining them one at a time, I hope to increase your understanding of the magnitude of the multiple issues facing legislators, nursing home administrators, physicians, nurses, therapists, and aides; and, how those issues are in the forefront of what patients and families experience. It is frustrating for everyone involved and a very heavy burden for families and patients.

There are many things that happen in a nursing home that make the administrator and staff feel like victims of the system. We will just talk about one of those today. Let’s begin with the staff that cares for our loved ones. We all want to see people paid fairly for a day’s work – what I am talking about are the hidden costs involved in employing staff in the Long Term Care industry.

If you can, put yourself in their place for a moment, think about coming to work everyday, and each day a quarter of the staff doesn’t show up. Yes, that’s right – 25% of the staff, on average, call in sick on any given day! I suppose some are legitimately ill, however I think many of the “call-ins” are due to frustration with the work environment, discouragement with the system, disenchantment with the work, and lack of a plan to improve their circumstances.

The daily round of the Nursing directors include hours on the phone trying to find someone to come to work on their day off to fill vacancies left by “call-ins”. As the days go by staff begin telling the nursing director they have plans they can’t change that day – or they don’t answer the phone at all, now that Caller ID tells them they are once again being asked to work an extra shift. Aggravating to both the Nursing Director and the staff, there seems to be no way out of what they see as their plight. Whether you are the Nursing Director who is responsible for seeing that all the patients are cared for, or the staff who is continually asked to work extra shifts, job satisfaction is less than what any of us would want for ourselves.

The cost of absenteeism to the industry as a whole is $832 million annually in “sick pay” and replacement costs. Even if we could afford this price tag who wants to live this way? Productivity suffers. Morale suffers. Imagination for creating a better environment suffers. Going all out for the patient suffers. Reimbursement suffers. We have come full circle!

Added to this staffing concern is another even bigger concern. The average turnover of staff on an annual basis is 89%. Astounding, yes – but understandable when given the environment created by the issues we have already discussed. This kind of turnover generates another series of problems. When 89% of the nursing home staff is turning over each year, the staff available for your own elderly parent has likely only worked at the nursing home for 6 months or less. The corollary to that is the staff member you are meeting today is likely to be leaving for another job within the next 6 months. What is the motivation here for the staff members to get to know your auntie? Or your Mom?

Is it important that the staff understand that your Mom is a diabetic and shouldn’t be allowed to have cake at the birthday party being held in the dining room? What about your auntie? Is it important for staff to understand that she was an artist in her own right and has only had fuzzy thinking since her stroke? Yes, to both of these questions. It is important that your Mom and your auntie be well known to the staff in order for the staff to provide the best care; in order to provide Elderpride. Treating patients as the individuals they are is the hallmark of Elderpride. Treating patients as though they have lived their life and are now expendable is part of the problem we see in nursing homes.

There is a big price tag to the employee turnover that is rampant in the industry too. It is costing the American taxpayer a lot of money. The cost of employee turnover in nursing homes is an astonishing $7.1 billion each year in recruiting and training new staff.

It is an easy leap from here to see that accountability for the right task, at the right time for the right patient is impossible to establish. Administrators live in fear that the dedicated staff who do show up for work when they are supposed to will crumble under that kind of pressure. The resulting low productivity costs from absenteeism, high turnover and the paucity of accountability for the work performed is costing we, the people another $13 billion.

It seems to me there is a lot of room for improvement here. In how the industry faces issues, how these issues are allowed to impact the very people charged with the care of our loved ones and how our nation spends its tax dollar on eldercare.

Medicaid Reimbursement – Yet Another Puzzle Piece

Elderpride: Chapter 5


In a similar fashion to Medicare, Medicaid also reimburses nursing homes for care of patients and residents. I have an opinion about what makes an individual a resident of a nursing home rather than a patient. Shouldn’t nursing home care be transitional? And resident implies that this is where you live! I don’t want to live in a nursing home! Do you? I don’t want to be a resident! Do you? So in this blog we will always refer to individuals being treated in nursing homes or skilled nursing facilities as patients.

Medicaid is partially funded by revenue sharing to the 50 states from the federal government. The individual states also provide funding to the program. And the individual states are able to determine who qualifies and who does not although there are some broad federal requirements as well. Medicaid is basically healthcare provided for low income populations with a focus on children, pregnant women and the elderly. Therefore states may differ in who qualifies for Medicaid and who does not. The view I am giving here is a global view and there may be differences state to state. I encourage you to check your individual state requirements by searching on “Medicaid your state”.

Medicaid basically covers non-rehabilitative and unskilled care for elderly persons. This means care that usually can be given by an untrained person. No education or licensing is required for unskilled care. Some of the non-rehabilitative care may be given by licensed practical nurses, however it is not at the same level as skilled care covered by Medicare and does not cover therapies. Most states require that the individual is poor. This means if you are not, then you will need to spend down your assets to a specified level. In my own state, if there is a spouse then an individual can have a house, a car and enough money in the bank for burial – and that is all. If they individual does not have a spouse then they can only have enough money in the bank for burial. A patient must apply for Medicaid and qualify in order to receive these benefits. Once approved, however the individual is a Medicaid recipient.

Once an individual spends down their assets, they have fewer choices about their care. The patient (Medicaid recipient) is totally dependent upon the system at this point and if the system fails them, they are doomed. They will have no funds to implement another solution.

The reimbursement system works much like Medicare in that the nursing home completes a claim for services rendered and submits it to the appropriate state office. The claim is reviewed and either approved or denied. A denial can be appealed. However the similarity ends there. Medicaid coverage is much less of a mystery and the provider (nursing home facility) usually knows what is covered in advance because it is much more “cut and dried”. Therefore, there are fewer denials. Consider however that we are talking fewer dollars because skilled care is not covered by Medicaid and unskilled care is paid at a much lower rate. The rate varies state by state. Therefore, even though the dollars are more of a “sure thing” than Medicare, it is fewer dollars and unless a Long Term Care facility has a high percentage of “private pay patients” (patients who are paying the nursing home bill themselves, frequently in spend down mode), they cannot make it financially on Medicaid patients alone. The term “payer mix” refers to the ratio of patients who are on Medicare, Medicaid and Private Pay.

Many SNF and nursing homes are teetering on the brink of financial disaster if their payer mix is tipped toward the lower paying Medicaid patients. This impacts what they can offer patients in terms of treatment as well as amenities although what is considered an amenity (buildings in good repair, for instance) in a nursing home might be thought of as basic by most of us.

And yet, because the dollars lean towards being a “sure thing”, the tendency to move patients off Medicare, into spend down and subsequently Medicaid is rampant in the industry. And I don’t think it is even done consciously, it is simply done because it works marginally. But guess who is caught in that net? Yes, of course, the patient because had they received their full entitled Medicare benefits instead of the shift to spend down/Medicaid, a high percentage would be discharged home or graduate to a lower level of care. And, as I am going to show you later, restoring patients would save the government lots of dollars.

Please feel free to comment or share your stories of eldercare on my blog. It will take a nation to change things – that means all of us. I will try to be a catalyst, but I can’t do it alone!

The Denial Problem

Elderpride: Chapter 4


To quote myself in a previous post, “avoiding denials is a topic all by itself because it adds another layer of complexity; this will be our topic for the next post. We will discuss the definition of a denial, the appeal process for a denial, the avoidance of a denial and what a denial means to the patient and the facility.”

Today we are discussing the denial of a Medicare claim by CMS Fiscal Intermediaries. For comparison sake, Medicaid also denies claims that do not meet their criteria for payment.

Just to recap the relevance of this topic for a moment – a systemic problem has been created by the claim review process which causes some claims to be “denied” because it isn’t clear that the care was medically necessary or required a licensed professional to deliver it. When a claim is “denied” that means it is not paid. The facility who delivered the care in good faith is punished by not receiving any payment until the matter is resolved. The facility still has to meet their expenses for the staff, supplies and other things that were used to care for the patient in their facility and they have to meet those expenses with no revenue. Obviously, this cannot go on for very long.

According to Jerry Rhoads, CPA, and CEO of Caregiver Management Systems, a consultant to the Long Term Care Industry, when SNFs work to return a patient to their highest level of functioning it takes on average 55 days to do so. A patient is entitled to 100 days of skilled care for every episode of illness as defined by a physician order and a three day hospital stay. However, the FI begins to scrutinize claims after 21 days (a rule of thumb) and if the facility is in the mode of “avoiding denials”, it is common practice to discharge the patient from Medicare at that point. Therefore, on average the patients are only getting 22 days of skilled care leaving a 33 day variance. For many patients, these 33 days mean the difference between spending the rest of their days in the nursing home on Medicaid instead of returning to their home or other community based program such as Home Health Care.

The “denial” equation includes several components. Another is that Fiscal Intermediaries look for “reasons to deny” a claim based on “rules of thumb”; in a 1987 landmark case Fox v Bowen, the judge ruled that both of these practices were a violation of the Medicare Law. Yet the practice is still prevalent today. According to the judge who ruled on Fox v Bowen, the fiscal intermediary is to look for reasons to pay. The implication is that the FI is only to issue a “denial” when they cannot find a reason to pay. This split of hairs (theirs, not mine, as I am only explaining it) makes the difference between a few denials and many denials.

When a claim is denied, the SNF can appeal the denial on behalf of the patient. In order to appeal the denial, the SNF will have to write a letter stating why they are appealing the denial and offer new information proving that the skilled care was medically necessary. If the fiscal intermediary denies the claim again, the SNF can request a hearing. All the work involved in the appeal process is overwhelming for a SNF and there is no guarantee that the denial will be overturned. It is easier for the SNF to encourage the patient to be discharged from Medicare on the 22nd day and state that the patient can’t meet their goals, or set the goals lower than the patient is capable of achieving than to take a chance on the system working properly

When the FI is looking for “reasons to deny” by using “rules of thumb” here is an example of what happens. Let’s say a patient who is in a SNF is progressing reasonably well however on the 21st day has not achieved his or her highest level of functioning. Since the facility knows the fiscal intermediary will begin scrutinizing claims on the 22nd day because that is the “rule of thumb”, they often discharge the patient from Medicare to avoid the scrutiny and accept that Medicare will “only” pay for the first 21 days of skilled care. By avoiding the scrutiny, the SNF will receive their payment promptly and not have to go through the burdensome appeal process.

This discharge from Medicare is most frequently initiated by the therapists. Most SNF facilities consider therapists the experts in determining which patients qualify for Medicare benefits. This is backwards, it should be the registered nurse who qualifies the patient for skilled care, initiates a comprehensive care plan that includes therapies and then supervises the accomplishment of the care plan. It is my experience that nurses do not understand the Medicare definition of “skilled care” leading to the therapists driving the process by default. This is yet another element of the problem and adds a subtle layer of complexity to an already complex process.

The truth of the matter is that the patient is entitled to their full Medicare benefits which means Medicare is obligated to pay for the beneficiary’s care until they reach the highest level of functioning of which they are capable.

When SNF facilities habitually discharge patients from Medicare before they have achieved their highest level of functioning, the patient goes directly into paying for their care on their own (spend down) and ultimately to go on Medicaid (welfare) when their money is gone. Since Medicaid pays a nursing home a lot less money than Medicare, the patient’s skilled care is truncated; the patient who can't pay for their own skilled care is doomed. And even patients with resources are sometimes doomed in this way because they don’t understand the intricacies of Medicare and opt not to pay on their own for skilled care once they are discharged from Medicare on the 22nd day because they are told it is unlikely they will meet their goals. These things all happen frequently enough to be labeled “systemic”.

From the perspective of the patient, accepting or avoiding the denial deprives the patient of their entitled benefits that they and others worked all their lives to have available in the form of Medicare coverage. Since the additional 33 days of “skilled care” can be crucial to the patient’s ability to survive and thrive it is a significant problem that instead the patients are discharged from Medicare early.

From the perspective of the government, they falsely think they have saved money. Hold that thought. We will revisit it later in this series because, in actuality, the government could save billions by restoring patients.

Please feel free to post questions, I will do my best to answer them or refer you to the correct place for the information.

The Payment System is at the Root of Other Problems

Elderpride: Chapter 3

I am going to begin with the payment system because typically when there is a business problem, the approach to solving it is to follow the cash. Problems created by payment methods, rules and regulations end up leading to other problems and is one of the ways that big problems are created from small problems, and big problems become systemic if not held in check. Systemic problems are at the root of failing to restore Elderpride.

There are two major sources of payment for America’s elderly who are in need of medical or health related care. Medicare is one and Medicaid is the other. Many people also have supplemental insurance policies to take up where Medicare leaves off. This discussion is about the Medicare Payment System.

Medicare is funded by taxing employers and employees; all workers pay into the Medicare program throughout their working lifetime. These monies collected are diverted to the Centers for Medicare and Medicaid (CMS); they determine how these dollars will be spent. CMS is supposed to apply the law to the payment of health benefits. CMS is not the lawmaking arm of the Federal Government in this regard; they are merely charged with acting on the law with good stewardship to insure that benefits are fairly and equitably distributed. As it applies to Long Term Care, Medicare health coverage covers the patient’s need for skilled care certified by a physician. Skilled care is care requiring a licensed professional such as a nurse, a therapist or a social worker.

Strictly for comparison, Medicaid receives its funding from revenue sharing to the individual states from the federal government and the states determine how those monies will be spent. Medicaid covers custodial care and low level restorative care. In other words, Medicaid covers care that can be rendered by an untrained individual. We will fully discuss Medicaid in a later post.

When a covered beneficiary (patient), often an elderly person, is admitted to a facility for care the facility usually files a bill (claim) to Medicare or Medicaid on behalf of the beneficiary for the care rendered. It is the job of the Centers for Medicare and Medicaid (CMS) to review the claim and pay the facility on behalf of the beneficiary in the case of Medicare.

Inserting a dose of reality here – the government is both the beneficent provider of reimbursement dollars and the chokepoint for their disbursement. This little considered fact is responsible for the seeming illogical patterns of payment or nonpayment of claims.

CMS could not possibly review the millions of claims that are filed each month and therefore they have designated Fiscal Intermediaries (FI) who review the claims and pay (or not) them on behalf of CMS. In order to be eligible for payment, the nursing home or SNF must prove that the care was skilled and medically necessary as certified by a physician. Proof is provided in the form of nurses’ notes or therapists’ notes; therefore, as nursing home staff is documenting patient care, they must be very careful to write up their notes in a manner that makes it clear that it was medically necessary for the patient to receive this care. That is a tricky proposition and assumes that all nursing home staff understand Medicare’s definition of “skilled”. It also assumes that they have the time to thoroughly document on each patient which may not happen if they are too busy.

And so, because Medicare dollars are tight, the FI frequently issues a “denial” on the claim taking advantage of the fact that the nursing home or SNF will have a difficult time appealing that “denial” because of the lack of proper documentation. And because it adds cost to the process with no guarantee of a higher reimbursement most nursing homes and SNFs do not appeal the denial. And systemically, the facilities try to avoid the denial in the first place! Each denial is a delay in payment which stretches the nursing home or SNF beyond its capability to meet its expenses.

And I digress for a moment to say that avoiding denials is a topic all by itself because it adds another layer of complexity, this will be our topic for the next post. We will discuss the definition of a denial, the appeal process for a denial, the avoidance of a denial and what a denial means to the patient and the facility.

What this means for the Medicare patient is that they do not always receive their complete entitled benefit which is whatever care is required to restore them to their highest level of functioning or, in other words, Elderpride. This is expressly stated in the Medicare law. This is the first way that the payment system creates a “systemic” problem.

I want to cover Medicaid claims in a separate post because I want to keep these short and interesting. There is a ton of information to cover – our next two topics will be denials followed by the Medicaid payment system.

Please feel free to ask questions or comment so that I know if the information is helpful.