Transcript Slide 1

How to Care for
Aging Parents
Thomas Cornwell, MD
Why an issue now?
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1900 average life expectancy 47, families close together,
most women are stay at home caregivers; 2013 average
life expectancy 78.2, families dispersed, women in the
work force
In past people had short period of illness and infirmity and
then death. Now they grow old, frail, and need almost
constant care not for days/weeks but for months/years.
People use to need a hot meal and loving attention, now
they need catheter care, oxygen, tube feeding, vitals taken
and eight different medications
The average caregiver (if there is such a thing) devotes
twenty hours per week for five years
January 1, 2011 the first of 76 million baby boomers will
turn sixty-five. 10,000 new Medicare beneficiaries daily.
Sandwich Generation
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Nearly half (47%) of adults in their 40s
and 50s have a parent age 65 or older
and are either raising a young child or
financially supporting a grown child (age
18 or older). And about one-in-seven
middle-aged adults (15%) is providing
financial support to both an aging parent
and a child.
http://www.pewsocialtrends.org/2013/01/30/the-sandwich-generation
Talk, Talk, Talk
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Parents needs and concerns: Parenting your
parent (Geriatric un-development)
Housing options (now and future)
Financial and legal
Health care
Death and funeral (“Honoring ceremony)
Start with areas of agreement. Try and have entire family
on the same page in regards to patient goals and
everyone’s responsibility. Avoid highly charged and
emotional words. Goal is to end all discussions peacefully
and not to seek victory.
Housing Options
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Accessory (In-law) apartments
Shared and congregate housing
Shared apartments
Assisted living
Life Care Retirement Communities
Nursing Homes
Live-in Caregivers
Try to discuss and plan before a crisis occurs. What are
the options if (when) you or your loved one declines?
Legal Issues
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Living will, durable power of attorney for
health care and finances, advanced
directives, “Do not resuscitate form” or
“POLST (Physician Orders for Life
Sustaining Treatment) form” (required in
Illinois for paramedics), last will and
testimony
National Academy of Elder Law Attorneys
www.naela.com (602-881-4005)
Caring for the Caregiver
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Set limits: Learn to say no, determine what is
truly necessary
Accept and enlist help
The Family and Medical Leave Act: 12 weeks of
unpaid leave to care for family member
Emotional minefields: Guilt and helplessness
Maintain your physical, emotional and spiritual
life
Medical Care
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Preventative care: Yearly flu shot, Pneumonia shot
(once (or twice 5 years apart) after age 65),
Tetanus shot every 10 years, balanced diet,
exercise, Multivitamin, stop smoking, Osteoporosis
screening
Doctor: “Avoid Ageism.” “Old age” is diagnosis of
last resort. Bring all medication including OTC
medications to visit. Bring list of concerns.
Consider Comprehensive Geriatric Assessment.
Yearly eye and dental exam. Audiologist if hearing
problem.
Medical Alert System: (e.g. Lifeline, Medical Alert)
Medical Care
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Medications: The less the better balanced
with “if it ain’t broke, don’t fix it.”
Ways to save money:
– Ask pharmacist (not the doctor) if generic
equivalent or larger pill that can be broken in
half.
– Pharmaceutical discount cards or indigent
programs.
Common Medical Problems
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Falls: Most common in bathroom. Consider raised
toilet seat with bars, bath chair that extends outside
tub, grab bars. Other rooms—remove throw rugs
and clutter and increase lighting.
Pressure sore prevention: avoid same position >2
hours, pressure reducing surfaces on hospital
bed/wheel chairs, no donut cushion, reduce friction.
Depression: very common in elderly, can “make
everything worse.” Signs: depressed mood, anger,
anxiety, decreased motivation, anhedonia (no longer
enjoys anything), loss of appetite, trouble sleeping.
Cannot “attitude it” away.
Common Medical Problems:
Dementia
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Dementia: Descriptive diagnosis of abnormal
memory loss and cognitive functioning. Most
common is Alzheimer’s Disease (65-75% of
dementia). Definitive diagnosis currently only at
autopsy (need brain tissue viewed with microscope).
Greatest problem is short term memory loss often
not realized by patient (and sometimes family).
Agitation can be a major problem. Three
communication rules: 1. Speak in a slow, calm voice,
2. They are “always” right, 3. Try redirecting when
they are upset—they can only focus on one thing at
a time (I use food to try and redirect their upset)
Common Medical Problems:
Dementia
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They use “cues” in their environment to
orient themselves and caregivers can take
advantage of this (e.g. lay out pajamas
when it is time to go to sleep)
Help to orient them: Calendars, dry-erase
boards to leave messages, people should
introduce themselves and not ask,” Do
you remember who I am?”
Consider neuropsychiatric testing for more
definitive diagnosis and coping strategies
Medical Care: Hospitalization
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Elderly need to have an advocate: need to
watch what is going on and keep the patient as
active as possible (get them walking as soon as
possible)
Discharge planning begins day one of
hospitalization: Is going home an option? Will
rehabilitation be necessary/helpful (Medicare
covers rehabilitation in a skilled nursing facility if
the patient was hospitalized for three midnights
and if therapy/further skilled treatment will
benefit the patient)?
Medical Care
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Medicare/Medicaid intermittent home health:
Must be homebound (a taxing effort to leave
the house and leaving the house is infrequent
(e.g. doctor visits/church/adult daycare)) and
must have a skilled need requiring a nurse,
physical therapist or speech therapist. If meet
above criteria can also get occupational therapy,
social worker and aide if needed. Medicare and
Medicaid do not pay for home health when only
custodial care is needed.
Quality vs. Crisis End of Life
Care
The death of a loved one will
always be sorrowful but it does not
need to be a crisis. It tends to be a
crisis in our country because we
avoid talking about it and planning
for it.
Dr. Thomas Cornwell
End-of-Life Care
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“To whatever extent you are able, acknowledge
this dying process and, is so doing, celebrate life.”
Start communicating preferably before he/she is
sick
Responses to a terminal diagnosis: Denial, Anger,
Bargaining, Depression, Acceptance
Greatest fear of terminally ill: Suffering and
abandonment—not death
Hospice care: life expectancy less than 6 months
and patient does not desire aggressive curative
care but does want aggressive comfort care
Communication is Key
Patients/Families need to know their options:
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Hospice: Hospice is a two way evaluation.
Hospice evaluates if the patient meets
Medicare criteria and the patient/family
evaluates if they would benefit from
hospice. The evaluation does not obligate
either party to hospice starting—it just
ensures that everyone is educated on their
options.
Communication is Key
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Hospice is an interdisciplinary home health service
for patients whose prognosis is less than six months.
Doctors and patients are poor at predicting when
end-of-life will occur which leads to 10% of hospice
patients dying on day one and over 50% dying in
the first two weeks. Hospice’s value is lessened if
length of service is less than two weeks.
A good question to ask is, “Would you be surprised if
the patient passed away in the next six months?”
Hospice can continue for longer than six months if
the patient’s condition warrants.
Communication is Key
Patients/Families need to know their options:
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DNR (DNAR)/POLST
Hospitalization
Ventilator
Tube Feedings
Dialysis
Antibiotics
Preferred site of death
FIVE WISHES
I.
II.
III.
IV.
V.
The person I want to make care
decisions for me when I can’t
The kind of medical treatment I want
or Don’t want
How comfortable I want to be
How I want people to treat me
What I want my loved ones to know
FIVE WISHES
WISH 1
The Person I Want to Make Health
Care Decisions for Me When I
Can’t Make Them for Myself
Picking the Right Person to
Be Your Health Care Agent
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Knows you well
Can make difficult decisions
Will stand up and advocate for you
Lives nearby
Must be 18 years old
Should not be your health care
provider, employee of health care
provider
Communicate Your Wishes
With Your Health Care Agent
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What level of medical care is desired and for how long
(Tube feedings, Ventilator Care, Hospitalization)
What level of Psychiatric care (Medication,
Hospitalization, Electro-convulsive shock treatment)
Release of Medical Records
Organ Donation
Review financial information to apply for/fill out
insurance forms
Desired location to spend your last days/hours
(hospital, nursing home, home)
Completing FIVE WISHES
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Sign and fill in demographic information
Have two witnesses sign (note the written
requirements for the witnesses)
No Notarization required in Illinois
Distribute copies and discuss with POAHC,
family, medical provider, nursing home,
assisted living facility, etc.
Fill in Five Wishes Wallet Card and keep it with
you to notify people where to locate the
document
DNR (Do Not (Attempt)
Resuscitation)/POLST Form
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ONLY Document paramedics can accept to not
do CPR (cardiopulmonary resuscitation)
Must be signed by patient, guardian, POA or
healthcare surrogate
Must have a witness
Must be signed by a doctor
State of Illinois transitioning to POLST
(Physician Orders for Life Sustaining
Treatment) Form
The “Honoring” Ceremony
If you really want to honor your parents at their
50th wedding anniversary it would be hard to do a
good job with only 3-4 days to prepare. We often
do this for our loved ones at the end of life. Their
funeral/memorial service is our last chance to
honor them but we usually give ourselves only 3-4
days to plan for it because we act like it will never
happen. I tell families it is never to early to start
planning the “honoring” ceremony. It can be
wonderful to reminisce with loved ones, ask them
what words of wisdom they would like said, what
songs they would like sung, etc. When the time
comes you will know you are doing exactly what
they wanted and the time is much less stressful.
Quality/Cost of End of Life
Care
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Nationally, only 25% of deaths occur at home,
although more than 70% of Americans say
that this is where they would prefer to die.
(“Means to a Better End: A Report on Dying in
America Today” Last Acts 2002—Funded by
RWJF). The 75% of patient that die in
hospitals and nursing homes often receive
high-tech interventions and are in pain (Sager,
et al., 1989)
26% of Medicare funds are spent on care in
the last year of life. 38% of this is spent in the
last 30 days (Hoover et. al., Health Services
Research 2002)
HomeCare Physicians’ Mission
1.
Improve the quality of life of homebound
patients
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Improve the quality of life of caregivers
3.
Decrease health care costs by enabling
patients to remain at home and avoid
expensive emergency departments,
hospitals and nursing homes
Three Reasons for the
Decline of the House Call
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Increased office/hospital based
technology
Fear of increased liability
Financial disincentives
Do these barriers still exist?
House call decline:
Financial disincentives
House Calls
1997
2012
Follow-up
$59.37
$131.38
New
$101.62
$188.35
Assisted Living
2005
2012
Follow-up
$48.30
$137.38
New
$75.00
$191.51
Why Home Care Medicine’s
Time Has Come
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Demographics: The aging of society
Technology allows quality care in the
home
COST SAVINGS
5/14/09 – 2/18/11
(1 year, 9 months (645 days))
 44 Emergency Department Visits (avg 16
days between visits)
 27 Hospitalizations—over half required
ICU days (avg 25 days between stays)
HCP First Visit 3/2/11 (365 Days)
 1 ED visit + 1 Hospitalization (May 2011)
 Expected: 25 ED visits, 15 hospitalizations
1 Year Cost Savings: $188,000
High-Cost Medicare Beneficiary Spending
Medicare Spending
Medicare Spending
% of
Total
Mean
% of
Total
Mean
85%
$24,800
Top 5 %
43.1%
$63,030
Second
Quartile
11%
$3,290
Top 6-10 %
18.4%
$26,900
Bottom
Half
4%
$550
Top 11-25%
23.5%
$11,430
Total
100%
$7,310
Top
Quartile
Source: Congressional Budget Office based on data from the Centers for Medicare and
Medicaid Services. Note: Spending reported in 2005 dollars
Costs of Care Before vs During HBPC for
2002 (per patient per year) *includes HBPC cost
N=11,334
$103,502,088
Total Cost
of VA Care
Hospital
Before
HBPC
During
HBPC
Change
$38,168
$29,036*
-$9,132
$18,868
$7026
- 63%
Nursing home
$10,382
$1382
- 87%
Outpatient
$6490
$7140
+ 10%
All home care
$2488
$13,588*
+ 460%
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Potential Savings
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Illinois population = 12,869,257
12.7% >65 = 1,634,396
3.4% ≥ 3 ADL deficiencies = 55,569
VA saved $9,132 per HBPC patient
Total Yearly Savings = $507,460,233
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Thanks to legislative sponsors Senators
Jim Oberweis and Linda Holmes and
Representatives Linda Chapa La Via,
Mike Fortner and Kay Hatcher
[email protected]
www.homecarephysicians.org