Vol. 20, No. 5
August 3, 2020

When the pandemic began, Darcy Scott worried most about her parents, who are in their 80s and among the most vulnerable to the coronavirus. To keep them safe, her brother drove them 27 hours from Kerrville, Texas, to Churchton, Maryland, where Scott and her husband were hunkered down. But after a couple of months, Texas started to open up and her parents wanted to go home. “Mom went back to the gym, to aqua aerobics. Dad went out to pick up the recycling around town,” Scott said. “So there you go, we expended 11 weeks of our lives, and now our parents are wading around in a cesspool of germs.” Her father, W.J. Scott, 80, said he appreciates his daughter’s concern but thinks she’s being a little bit of a mother hen. “Let’s face it, I’m 80 years old and I don’t have a whole lot to lose in the end anyway. It’s just at what level you’re willing to take your edge. I’m a Marine. I was in Vietnam, people shot at me, so this isn’t that much more dangerous than that, I don’t think.” “Even when older people do understand the risks, it may not terrify them as much,” said Laura Carstensen, director of the Stanford Center on Longevity. “Older people in general experience less stress in everyday life,” she said, adding that surveys show that older people are doing just as well now as in pre-coronavirus times. “They absolutely see themselves at risk, [but] there is lots of evidence that as people come to the end of their life, they come to live in the present and they stop worrying about the what-ifs.”
— Tara Bahrampour, The Washington Post
  • HHS establishes the Coronavirus Commission on Safety and Quality in Nursing Homes
  • CMS sends $5 billion to nursing homes for COVID-19 expenses and testing
  • New central coronavirus data hub replaces CDC’s
  • Critical FEMA PPE supplies fall short on quality
  • McConnell conditions new rescue package on liability waivers
  • AARP tackles health facility visitations
  • Congress and CMS explore the future of Medicare telehealth
The United States in mid-summer, 2020: a nation on tenterhooks, awakening each day to news of economic disaster, civil and political strife and a social fabric increasingly devoid of normal human interactions. For families seeking to cope with the ramifications of the coronavirus siege, the major caregiving challenges continue to center around access to care facilities and home-based services, interaction with loved ones and caregiving staff amid crushing social distancing restrictions, and oversight of facilities’ COVID-19 safety and prevention protocols.
HHS establishes the Coronavirus Commission on Safety and Quality in Nursing Homes
Now at work to address some of these issues, the recently appointed 25-member Coronavirus Commission on Safety and Quality in Nursing Homes is seeking to assess the overall response to the COVID-19 pandemic in nursing homes and recommend actions and best practices for immediate and future actions. Three key areas of focus for the commission include:
  • Ensuring nursing home residents are protected from COVID-19 and improving the responsiveness of care delivery to maximize the quality of life for residents;
  • Strengthening efforts to enable rapid and effective identification and mitigation of COVID-19 transmission (and other infectious disease) in nursing homes; and
  • Enhancing strategies to improve compliance with infection control policies in response to COVID-19.
CMS sends $5 billion to nursing homes for COVID-19 expenses and testing
Five billion dollars in new federal grant funds is on the way to nursing homes courtesy of the $175 billion Provider Relief Fund Congress created to help providers compensate for coronavirus-related costs and lost income. CMS previously sent $4.9 billion to nursing homes. In addition, reported Modern Healthcare’s Rachel Cohrs, CMS will begin requiring nursing homes to test all nursing home staff weekly in states with a COVID-19 test positivity rate of 5% or greater. CMS announced that it will ship 15,000 rapid point-of-care testing devices to nursing homes over the next few months. LeadingAge, an association of aging services including nursing homes, called the new funding a good step but called for a coordinated national plan for testing. ‘There are important unanswered questions about this program, including how far this funding will go to support the new mandate of increased staff testing. We look forward to learning more.’”
New central coronavirus data hub replaces CDC’s
At the same time, MedPage’s Joyce Frieden writes, “HHS has unveiled a new Coronavirus Data Hub to replace CDC’s National Healthcare Safety Network (NHSN), to which states and hospitals had previously been submitting COVID-19 data such as intensive care unit capacity, ventilator use, personal protective equipment (PPE) levels, and staffing shortages. Most healthcare groups were initially unhappy with the data switch. The move to cut CDC out of the loop is ‘troubling and, if implemented, will undermine our nation’s public health experts,’ Infectious Diseases Society of America (IDSA) President Thomas File Jr. said in a statement. ‘Placing medical data collection outside of the leadership of public health experts could severely weaken the quality and availability of data, add an additional burden to already overwhelmed hospitals and add a new challenge to the U.S. pandemic response.’ Nevertheless, the administration is pressing ahead with the new system. On a conference call with reporters, José Arrieta, HHS’s chief information officer, was upbeat, noting that the CDC used data from only 3,000 of the nation’s 6,200 hospitals to project COVID-19 trends, although the data they did get was 100% complete. ‘Our goal is to take a different approach,’ he said. ‘We're reporting on over 4,500 hospitals and if a hospital doesn’t submit a complete dataset, we’re [still] going to provide the data.’”
Critical FEMA PPE supplies fall short on quality
Meanwhile, according to The New York Times’ Andrew Jacobs, not all has been well on the protective equipment supply front. “Expired surgical masks. Isolation gowns that resemble oversize trash bags. Extra-small gloves that are all but useless for the typical health worker’s hands. Nursing home employees across the country have been dismayed by what they’ve found when they’ve opened boxes of protective medical gear sent by the federal government, part of a $134 million effort to provide facilities a 14-day supply of equipment considered critical for shielding their vulnerable residents from the coronavirus. The shipments have included loose gloves of unknown provenance stuffed into unmarked Ziploc bags, surgical masks crafted from underwear fabric and plastic isolation gowns without openings for hands that require users to punch their fists through the closed sleeves. Adhesive tape must be used to secure them. ‘People hate to complain about personal protective equipment they’re getting for free but many of these items are just useless,’ said Brendan Williams, president of the New Hampshire Health Care Association, which has been fielding a flurry of calls about the defective gear from nursing homes it represents. ‘It’s mystifying that the government would think this is acceptable.’
The Federal Emergency Management Agency began shipping the masks, gowns and gloves this spring to 15,000 nonprofit nursing care facilities whose limited finances have made it difficult to buy protective equipment on the open market. The first cache of shipments was completed in mid-June, and the second round will wrap up by early August. ‘It’s really mind-boggling and frustrating that five months into this pandemic we still can’t get facilities the PPE they need,’ said David C. Grabowski, a professor of health care policy at Harvard Medical School. ‘I don’t know whether it’s a matter of incompetence or just indifference about older adults and the people who care for them.’”
McConnell conditions new rescue package on liability waivers
Amid CMS’s administrative pronouncements, Congress has continued to struggle over passage of a fourth COVID-19 rescue package. “While an unemployment insurance extension and size of the package dominate the interparty battle,” reports Modern Healthcare’s Rachel Cohrs, “Congress’ top Republican, Senate Majority Leader Mitch McConnell, has staked the fate of the final push before the 2020 election on protecting businesses from lawsuits. McConnell has positioned himself as providers’ champion on legal protections. He has called for sweeping protections for all businesses — including healthcare workers and hospitals — a ‘red line’ in the upcoming legislation. Liability protections for healthcare providers are usually handled at the state level, and roughly two dozen states have scrambled to push special protection from lawsuits related to COVID-19. But hospitals, nursing homes and physicians are clamoring for a universal standard to ensure long-lasting, firm federal protections to underpin a widely varying patchwork of state measures. The state-level variation in liability protections provides a roadmap for what’s at stake in the federal legislation. Providers are leery that care decisions made while they were confronted with supply shortages, relaxation of some state licensure laws, and expansion of telehealth, not to mention continued unknowns about the virus itself, could expose them to costly lawsuits and drain already strained budgets. But skeptics say liability protections that are too broad could take away patients’ last line of defense and allow nursing homes in particular to get away with poor preparation and chronic understaffing. The vast majority of coronavirus-related lawsuits against providers so far have been filed against nursing homes, according to a COVID-19 complaint tracker maintained by the law firm Hunton Andrews Kurth. James Hodge, the director of the Center for Public Health Law and Policy at Arizona State University, said the protections are controversial because healthcare providers likely already have protections under existing law that could accommodate the extenuating circumstances of a pandemic. ‘A federal shield should balance protecting vulnerable healthcare workers while still incentivizing healthcare entities to adhere to crisis standards of care.’”
AARP tackles health facility visitations
AARP has begun a three part series of blog posts addressing the effects of health facility visitor restrictions on older patients and families. The entries follow CMS’s most recent guidance concerning an easing of such restrictions in nursing homes. “We must not turn away when older patients who are more vulnerable to complications from COVID-19 need the health care system now more than ever. We must find ways to attend to both virus-related risk and mental health and well-being. Mary Beth Kingston, chief nurse officer of Advocate Aurora Health, an integrated health system serving Illinois and Wisconsin, explained that ‘balancing infection risk with compassionate care requires deep exploration of the many facets of a restriction policy — all having a profound impact on patients, families and their providers.’ Restricting visitors is not only an emotional hardship for patients and families. The absence of a family member or friend at the bedside is felt by clinical staff as well, sometimes getting in the way of their ability to deliver care. Providers report that, starting with hospital admission, they are experiencing critical gaps in information gathering — an area where family caregivers were once invaluable before the advent of visitor restrictions. Clinicians are stretched to triage patients and accurately assess their symptoms, pain levels, and mental health status without communication from a family caregiver. Then there’s the issue of delirium. A common and often unrecognized condition more often present in patients over age 65 diagnosed with Alzheimer’s or dementia, delirium involves severe confusion — typically caused by overmedication, lack of sleep, uncontrolled pain, or insufficient food and drink. New research reveals one in three caregivers are caring for a loved one with Alzheimer’s or dementia in the U.S. The presence of a family member at the hospital bedside for those patients most at risk of delirium has proven to reduce delirium and functional decline. Many hospitals have nimbly adapted, implementing new policies and practices to work around the negative effects of visitor restrictions. Family caregivers are brought into discussions with providers by telephone or iPad for video conferencing. The American Geriatrics Society’s Hospital Elder Life Program offers resources for providers to help older adults maintain cognitive and physical functioning and reduce delirium. Those are just some examples of how the system is beginning to respond. A one-size-fits-all approach to restrictions is problematic.”
Congress and CMS explore the future of Medicare telehealth
Telehealth services have emerged as a potential healthcare delivery game changer in the wake of COVID-19. Already they have spawned a congressional caucus — the Congressional Telehealth Caucus — co-chaired by California Democratic Representative Mike Thompson. Thompson has introduced the Protecting Access to Post-COVID-19 Telehealth Act. As reported by Modern Healthcare’s Jessica Kim Cohen, “the proposed legislation would authorize CMS to continue reimbursement for telemedicine services for 90 days after a public health emergency ends, as well as giving HHS the authority to waive telemedicine restrictions in Medicare during future emergencies and disasters, as the agency did for COVID-19. It would also remove some originating site requirements for Medicare beneficiaries, such as by making a patient's home an eligible site to receive care via telemedicine. Telemedicine use has soared in response to the COVID-19 outbreak, helped by a host of regulatory flexibilities from Medicare. That has led healthcare providers to voice concern that patients will lose access to virtual care services when the public health emergency ends, calling for CMS to keep expanded Medicare reimbursement in place after the outbreak subsides. HHS officials have said the agency is reviewing possible steps to extend regulatory changes but have stressed some statutory barriers would require intervention by Congress.”
CMS administrator Seema Verma took to the pages of Health Affairs to offer a preliminary assessment of the agencies COVID-19 expansion of Medicare-reimbursed telehealth. “With the transformative changes unleashed over the last several months, it’s hard to imagine merely reverting to the way things were before. As the country re-opens, CMS is reviewing the flexibilities the administration has introduced and their early impact on Medicare beneficiaries to inform whether these changes should be made a permanent part of the Medicare program. With wide-ranging telemedicine flexibilities, there has been a surge in the number of beneficiaries getting telemedicine services. Before the public health emergency, approximately 13,000 beneficiaries in fee-for-service (FFS) Medicare received telemedicine in a week. In the last week of April, nearly 1.7 million beneficiaries received telehealth services. In total, over 9 million beneficiaries have received a telehealth service during the public health emergency, mid-March through mid-June. Evaluation and management (E/M) visits, or office visits, have been the most common form of telehealth, with nearly 5.8 million beneficiaries receiving an E/M telehealth visit since the public health emergency started. Additionally, during the pandemic, CMS expanded the availability of telehealth services in other settings of care, including nursing homes, where beneficiaries may be particularly vulnerable. We found that 26 percent of beneficiaries who received nursing home visits did so by telehealth. Lastly, nearly 1.5 million beneficiaries have been able to access preventive health services during this time, and 19 percent of those beneficiaries received such services by telehealth. Telehealth will never replace the gold-standard, in-person care. However, telehealth serves as an additional access point for patients, providing convenient care from their doctor and health care team and leveraging innovative technologies that could improve health outcomes and reduce overall health care spending. Looking ahead it is important, first, to assess whether the mode of telehealth service delivery is clinically appropriate and safe for patients, as compared to an in-person visit. Second, we need to assess the Medicare payment rates for telehealth services. Lastly, it is vital that beneficiaries and taxpayer dollars are protected from unscrupulous actors. As more health care providers use telehealth to treat beneficiaries, CMS is examining our data from many angles. We are monitoring program integrity implications such as practitioners who may be offering shorter telehealth visits with patients to maximize payment or billing more visits than are possible in a day. We know the path forward to expanding telehealth relies on CMS addressing the potential for fraud and abuse in telehealth, as we do with all services.” 
Weighing in on the future of telehealth, three beneficiary advocacy organizations propose a number of considerations and recommendations to guide policy development. For Families USA’s see here; the joint Medicare Rights Center and Center for Medicare Advocacy statement can be found here.
  • Court OKs ‘skimpy’ health insurance plans
  • HHS appeal to Supreme Court keeps Medicaid work requirement issue alive
  • CMS tightens leash on Joint Commission accreditation surveys
Court OKs ‘skimpy’ health insurance plans
Not all recent healthcare news is COVID-19 related. In mid-July, reports The Washington Post’s Amy Goldstein, “A divided federal appeals court ruled that the Trump administration acted legally when it expanded the availability of skimpy, inexpensive health plans that skirt the Affordable Care Act and that critics say can strand customers without adequate coverage if they get sick. The 2-1 opinion by a panel of the U.S. Court of Appeals for the District of Columbia Circuit was a victory for the administration, finding that, even if such short-term insurance policies were bad for consumers, the departments of Health and Human Services, Treasury and Labor had the authority to let them be sold for longer periods of time. Near the end of the Obama administration, these short-term plans were limited to three months, out of concern they might siphon customers from ACA marketplaces. In 2018, the Trump administration rewrote the rules, saying customers could purchase them for just under a year at a time and then renew them twice.
HHS appeal to Supreme Court keeps Medicaid work requirement issue alive
In a related judicial development, it now appears that February’s unanimous Circuit Court decision invalidating Medicaid work requirements will not in fact be the end of the matter. The Trump administration, Goldstein reports, has decided to ask the Supreme Court to review the opinion.
CMS tightens leash on Joint Commission accreditation surveys
Simmering tension between CMS and the nation’s leading hospital accreditation body, the Joint Commission, has yielded a reduced two-year approval period based on the agency’s ongoing issues with the commission’s survey process. “CMS,” writes Modern Healthcare’s Maria Castellucci, “grants accrediting organizations that survey healthcare facilities for participation in Medicare and Medicaid approval for up to six years. This week, CMS issued a notice to the Joint Commission that its hospital accreditation program was only approved for two years or until mid-July 2022. CMS was explicit that the shortened approval period was based on ‘concerns’ related to Joint Commission surveyor performance and comparability of the Joint Commission's survey process to the agency's. The stricter CMS oversight comes amid continued efforts by the Trump administration to crack down on accrediting organizations. CMS Administrator Seema Verma said during a speech in February the agency will enhance oversight of accreditors with standards that differ from the CMS’ conditions of participation, calling it ‘simply not acceptable.’ The Joint Commission had previously touted that its standards go beyond CMS standards. Verma also said the practice of acting as both an accreditor and consultant is ‘a glaring conflict of interest.’ Additionally, in 2018, CMS announced it will publicly post more information from accrediting organization surveys such as a list of providers out of compliance with CMS standards. CMS has also made changes to the audit process for accrediting organizations that involve state survey agencies accompanying them on surveys to directly observe them.”
  • ACL seeks caregiver volunteers for input
  • African-American family caregivers panel and discussion
  • PIMs (potentially inappropriate medications) get renewed scrutiny
  • AD spotlight falls on diagnostic and prevention breakthroughs: a predictive blood test, modifiable risk factors, and lifestyle choices
  • CMA highlights availability and limitations of Medicare home health services
ACL seeks caregiver volunteers for input
The Administration for Community Living (ACL) is seeking volunteers for web-based caregiver focus groups to provide input to the RAISE Family Caregiving Advisory Council. The groups are scheduled for August 6 and August 7. Full information is available here or by calling 310-306-6866 and referencing Study #19086.
African-American family caregivers panel and discussion
On Wednesday, August 12, from 5:30 p.m. to 6:30 p.m., the USC Leonard Davis School of Gerontology will host Resilience & Strength: African-American Family Caregivers Discussion. Moderated by USC’s Dr. Donna Benton, the panelists will discuss how systemic racism has impacted their personal caregiving experiences and share how resilience has helped them to continue and allowed them to heal. Information and registration are available here. Download the flyer here.
PIMs (potentially inappropriate medications) get renewed scrutiny
Inappropriate medication use in older adults has been a persistent target of prevention efforts. Canadian researchers have now made an important contribution to the research literature with a study documenting the effects of potentially inappropriate medications (PIMs). “We found that two in three were prescribed a PIM overall at discharge and one in three was prescribed at least one new PIM. Increasing numbers of both community PIMs and new PIMs were associated with an increased odds of having an adverse drug event (ADE) within 30 days as well as the risk of ED visits, hospital readmission, and death. The strength of these associations was consistently highest for new PIMs. The most commonly prescribed PIMs included benzodiazepines and proton pump inhibitors. The high prevalence of PIM prescribing suggests that the intended outcomes of campaigns such as Choosing Wisely and other deprescribing initiatives, are not yet being fully realized. Some clinicians may continue legacy PIMs due to fears of diminished credibility, potential for litigation, and potential conflict with other prescribers and health professionals as well as concerns over withdrawal syndrome or symptom relapse. Standing order sets for medications in hospital may also inadvertently increase potentially inappropriate prescribing. For example, the administration of benzodiazepines for sleep during hospitalization is unfortunately standard practice in many institutions, as is the administration of proton pump inhibitors within intensive care units for gastroprotection or the use of antipsychotics for delirium or sleep. However, these medications may be inadvertently continued once patients leave the hospital. Given the increased risk of adverse health outcomes observed for patients prescribed PIMs at discharge, it is important to consider potential solutions for this issue. Effecting change likely requires a multifaceted approach. Accurate medication reconciliation is a first step to ensure that all medications, including PIMs, can be appropriately identified. An important next step is to consider each of the medications and its role in the context of the individual patient.”

Commenting on the findings, Pennsylvania State University College of Nursing’s Dr. Donna M. Fick observed that “This study is important because it takes a longer term look at inappropriate medication use and the potential harm of starting these medications by examining post-discharge and all-cause adverse events. These medications were prescribed without apparent indication; recent studies show that many of these medications may worsen conditions like delirium and dementia and should not be a first-line approach. The high frequency of PIM use in this study and the documented harms of these medications reinforces the call to reduce use of problematic medications We have growing evidence that stopping medications is possible; however, most guidelines do not address this issue, and, more importantly, work processes do not support a system for communicating with other clinicians and older adults about deprescribing.”
AD spotlight falls on diagnostic and prevention breakthroughs: a predictive blood test, modifiable risk factors, and lifestyle choices
While breakthrough pharmaceutical treatments for Alzheimer’s disease remain elusive several intriguing new studies provide some novel approaches to confronting it.
  • Swedish researchers have revealed the results of an Alzheimer’s disease blood test study that portends a dramatic breakthrough in the quest for a simple, affordable and widely available path to early AD diagnosis. “The test,” reports The New York Times’ Pam Belluck, “determined whether people with dementia had Alzheimer’s instead of another condition. And it identified signs of the degenerative, deadly disease 20 years before memory and thinking problems were expected in people with a genetic mutation that causes Alzheimer’s, according to research published in JAMA and presented at the Summer 2020 Alzheimer’s Association International Conference. Such a test could be available for clinical use in as little as two to three years, the researchers and other experts estimated, providing a readily accessible way to diagnose whether people with cognitive issues were experiencing Alzheimer’s rather than another type of dementia that might require different treatment or have a different prognosis. A blood test like this might also eventually be used to predict whether someone with no symptoms would develop Alzheimer’s. The test, which measures a form of the tau protein found in tangles that spread throughout the brain in Alzheimer’s, proved remarkably accurate in a study of 1,402 people from three different groups in Sweden, Colombia and the United States. It performed better than MRI brain scans, was as good as PET scans or spinal taps and was nearly as accurate as the most definitive diagnostic method: autopsies that found strong evidence of Alzheimer’s in people’s brains after they died. ‘This test,’ said Maria Carrillo, chief science officer at the Alzheimer’s Association, ‘really opens up the possibility of being able to use a blood test in the clinic to diagnose someone more definitely with Alzheimer’s. Amazing, isn’t it? I mean, really, five years ago, I would have told you it was science fiction.’” 
  • From Shanghai comes a meta analysis identifying “10 targets for reducing Alzheimer’s risk.” The 10 risk factors, as reported by MedPage’s Judy George: diabetes, hyperhomocysteinemia, poor BMI management, reduced education, hypertension in midlife, orthostatic hypotension, head trauma, less cognitive activity, stress, and depression. “Nine other risk factors,” writes George, “had Class 1 Level B weaker evidence: obesity in midlife, weight loss in late life, physical exercise, smoking, sleep, cerebrovascular disease, frailty, atrial fibrillation, and vitamin C, they added. Two interventions with Class III evidence were not recommended: estrogen replacement therapy and acetylcholinesterase inhibitors. ‘Evidence is building rapidly that modifiable risk factors play a key role in whether a person will develop cognitive decline and impairment as they age, whether that be due to Alzheimer's disease or any other dementia,’ observed Keith Fargo, Ph.D., director of scientific programs and outreach at the Alzheimer's Association in Chicago. ‘However, it can be difficult to separate the wheat from the chaff. While no proposed intervention has been shown to be perfect — we can reduce risk, but not yet eliminate risk altogether — meta-analyses such as these are helping us hone in on some of the most important factors, as well as helping us steer clear of things that may not be as impactful.’ The suggestions that emerge from this meta-analysis should be particularly noted by non-demented but high-risk individuals — people who carry APOEε4 or who have a high polygenic score, family history of dementia, or amyloid-positive evidence — and their primary care physicians.”
  • Taking aim at lifestyle changes that might cut the threat of dementia, researchers at the Rush University Medical Center in Chicago have linked five such choices to a 60% reduced risk for Alzheimer dementia, strengthening ties between healthy behaviors and lower dementia risk. As reported by MedScape’s Megan Brooks, “the study authors defined a healthy lifestyle score on the basis of the following factors: not smoking; engaging in ≥150 min/wk of physical exercise of moderate to vigorous intensity; light to moderate alcohol consumption (between 1 and <15 g/day for women and between 1 and <30 g/day for men); consuming a high-quality Mediterranean-DASH Diet Intervention for Neurodegenerative Delay; and engaging in late-life cognitive activities. The overall score ranged from 0 to 5. In multivariable-adjusted models, the risk for Alzheimer dementia was 27% lower with each additional healthy lifestyle factor. Commenting on the new study for Medscape Medical News, Luca Giliberto, M.D., Ph.D., a neurologist with the Litwin-Zucker Research Center for Alzheimer’s Disease and Memory Disorders at the Feinstein Institutes for Medical Research in Manhasset, New York, said this analysis is ‘further demonstration that a healthy lifestyle is essential to overcome or curb the risk for Alzheimer’s disease.’ Numerous clinical trials testing lifestyle interventions for dementia prevention are currently underway. The MIND Diet Intervention to Prevent Alzheimer’s Disease, for example, is an interventional clinical trial comparing parallel groups with two different diets. MIND has enrolled more than 600 participants and is ongoing. The anticipated completion date is 2021. Another is the U.S. Study to Protect Brain Health Through Lifestyle Intervention to Reduce Risk (US POINTER), a multisite randomized clinical trial evaluating whether lifestyle interventions — including exercise, cognitively stimulating activities, and the MIND diet — may protect cognitive function in older adults who are at increased risk for cognitive decline. ‘What needs to be determined is how early should we start “behaving,”’ said Giliberto. ‘We should all aim to score four to five factors across our entire lifespan, but this is not always feasible. So, when is the time to behave? Also, what is the relative weight of each of these factors?’”
  • Prior to the onset of the COVID-19 pandemic, one of the most ubiquitous harbingers of the onset of fall was the admonition to “get your flu shot.” How this will all play out in the coming flu-coronavirus season remains to be seen, but the advice takes on new meaning in the wake of three new studies associating reduced AD risk with flu — and pneumonia — vaccination. The studies, reported at the 2020 Alzheimer’s Association International Conference, suggest that at least one flu vaccination was associated with a 17% reduction in Alzheimer’s incidence. More frequent flu vaccination was associated with another 13% reduction in Alzheimer’s incidence. Vaccination against pneumonia between ages 65 and 75 reduced Alzheimer’s risk by up to 40% depending on individual genes. The researchers found the protective association between the flu vaccine and the risk of Alzheimer’s was strongest for those who received their first vaccine at a younger age — for example, the people who received their first documented flu shot at age 60 benefited more than those who received their first flu shot at age 70. As for pneumonia vaccination, researchers found that pneumococcal vaccination between ages 65–75 reduced risk of developing Alzheimer’s by 25–30% after adjusting for sex, race, birth cohort, education, smoking, and number of G alleles. The largest reduction in the risk of Alzheimer’s (up to 40%) was observed among people vaccinated against pneumonia who were non-carriers of an identified AD risk gene.
CMA highlights availability and limitations of Medicare home health services
The Center for Medicare Advocacy has published a comprehensive Issue Brief examining Medicare’s coverage of home healthcare services. “As the population ages, and lives longer with chronic conditions, the need for family caregiving, and support for caregivers, is increasing. Concurrently, however, access to Medicare-covered home health aide care continues to decline. This is often true even for individuals who meet the Medicare law’s qualifying criteria. Unfortunately, Medicare beneficiaries are often given inaccurate information regarding Medicare home health coverage in general, and home health aides in particular. Sometimes they are told Medicare simply does not cover home health aides. Further compounding this problem, Medicare does not provide coverage for family caregivers. Coverage is only available for personal care through home health aides, provided through a Medicare-certified home health agency; the individual must have an authorized practitioner’s order, be homebound, and need nursing or physical or speech therapy. While Medicare does not cover or help pay for family caregivers, the fact that caregivers are — or are not — available, willing, or able to provide needed care frequently interferes with a beneficiary’s ability to obtain Medicare covered in-home care. On the one hand, beneficiaries and their families may be told that a home health agency will not provide care because it is not safe for the individual to be home since there is no caregiver available. On the other hand, when caregivers are available, patients may be told that, as a result, Medicare will not cover in-home care since that caregiver should provide the care. In fact, neither of these is true. Medicare coverage is not dependent on whether there is or is not a family caregiver — or other caregiver — available. Medicare beneficiaries are eligible for Medicare covered home care regardless of whether they do or do not have family or other caregivers in place. The Center’s Brief makes several recommendations, including: Ensure the scope of current Medicare home health benefits, generally, and home health aides, specifically, are actually provided; Create a new stand-alone home health aide benefit that would provide coverage without the current skilled care or homebound requirements, using Medicare’s existing infrastructure as the vehicle for the new coverage; and Identify other opportunities for further exploration within and without the Medicare program, including additional Medicare revisions, demonstrations, and initiatives overseen by the Center for Medicare and Medicaid Innovation (CMMI).
  • Sabatino calls for ‘defunding’ current nursing home model and expanding The Green House Project
  • Dutch nursing home operator embraces ‘yes’ to nursing home culture
  • COVID-19 halt to physician office visits and elective hospitalizations: a benefit to patients?
  • Return to gym revitalizes 91-year old Art Ballard
  • Nursing home evictions leave vulnerable residents homeless
  • Critical care doctor takes brief time out to reflect on COVID-19’s toll
Sabatino calls for ‘defunding’ current nursing home model and expanding The Green House Project
The devastating statistics and images COVID-19 has visited upon the country’s long-term care facilities has led to a plethora of demands for greater infusions of resources and oversight. For some observers, however, the answer lies not in reform but transformation. “I believe,” writes the ABA’s longtime Commission on Law and Aging director Charles Sabatino, “it is time to defund the institutional model and replace it with a radically different model. Today’s typical nursing home has never come close to meeting the public’s desire for humane and dignified long-term care. Warehousing large numbers of frail elders in hospital-like buildings with residents in double or triple rooms along with staff turnover as high as 100% unavoidably creates a high risk for resident safety and compromises quality of care. The COVID-19 pandemic is a 9/11 moment for nursing home care and a test of our ability to reimagine nursing home care that puts the ‘home’ into nursing homes. As the largest payor for nursing home care, Medicare and Medicaid hold the key. Now is the time to change facility requirements to gradually limit participation in the program only to facilities that provide the following:
  • Small home-like facilities
  • Single rooms and bathrooms
  • A flattened, more flexible staff hierarchy with cross-trained staff
  • A culture focused first on residents’ goals, interests and preferences

Fortunately, there is already a model for this kind of facility: the nonprofit The Green House Project created by Next Avenue Influencer in Aging Dr. Bill Thomas in 2003. There are 300 Green House facilities nationally, each with 10 or 12 residents who have single rooms and private baths. Some call this ‘the household model.’ In Green House, facilities are designed around a living room with a fireplace and an open kitchen where meals are prepared and shared. The cross-trained staff, backed by nurses and doctors, engage with residents, serving as nurse aides, cooks, cleaners and participants in meals and social activities. Not surprisingly, Green House staff turnover is far below that of traditional nursing homes.”
Dutch nursing home operator embraces ‘yes’ to nursing home culture
Endorsing that sentiment, New York Magazine’s Justin Davidson characterizes nursing homes as “places nobody would choose to live. ‘People ask me,’ says Harvard’s David Grabowski, ‘after COVID, is anyone going to want to go into a nursing home ever again? The answer is: Nobody ever wanted to go to one. And yet 1.5 million people do, mostly because they have no other choice.’” “So,” writes Davidson, “yes to The Green House Project. Green House’s senior director Susan Ryan says that The Green House network has fared relatively well during the pandemic. Its 229 nursing homes nationwide have experienced a total of 32 coronavirus infections. Only one resident has died of COVID-19. Meanwhile a guru of the old-age good life is Hans Becker, an elfin 78-year-old Dutchman who spent two decades as CEO of the social-services agency Humanitas and now runs a nursing home of his own, Residence Roosenburch, outside Rotterdam. The design matters less than the philosophy. ‘The first value is that people are the bosses of their own lives. We have a “yes” culture — we are not allowed to say no,’ he says. Becker involves residents in the life of the place, encouraging them to cook, party, and gather for a drink at the in-house bar. ‘A barkeeper with velvet eyes and white teeth is just as important as a doctor.’ Becker can sound glib about his charges’ physical ailments, but he is emphatic in his opinion that the old see too many doctors. ‘You should make an organization where people don’t complain too quick. In nursing homes, the residents are right away complaining, “Doctor, my knee’s hurting.” So the doctor comes, and the nurse, and the physical therapist. But that knee is going and it’s not coming back. It’s better to focus on other things. Happiness lowers cost.’”
COVID-19 halt to physician office visits and elective hospitalizations: a benefit to patients?
Hans Becker appears to have a kindred soul in cardiologist Sandeep Jauhar; “people have stopped going to the doctor,” he notes in The New York Times, “and most seen just fine.” For months now, routine care has been postponed. Elective procedures — big moneymakers — were halted so that hospitals could divert resources to treating COVID-19 patients. Routine clinic visits were canceled or replaced by online sessions. This has resulted in grievous financial losses for hospitals and clinics. Medical practices have closed. Hospitals have been forced to furlough employees or cut pay. Most patients, on the other hand, at least those with stable chronic conditions, seem to have done OK. It will probably take years to understand why. Perhaps patients mitigated the harm of delayed care by adopting healthful behaviors, such as smoking less and exercising more. Perhaps the huge increases in stress were balanced out by other things, such as spending more time with loved ones. However, there is a more troubling explanation to consider: Perhaps Americans don’t require the volume of care that their doctors are used to providing. It is well recognized that a substantial amount of health care in America is wasteful, accounting for hundreds of billions of dollars of the total health care budget. If beneficial routine care dropped during the past few months of the pandemic lockdown, so perhaps did its malignant counterpart, unnecessary care. If so, this has implications for how we should reopen our health care system. Doctors and hospitals will want to ramp up care to make up for lost revenue. But this will not serve our patients’ needs. The start-up should begin with a renewed commitment to promoting beneficial care and eliminating unnecessary care. Most doctors recognize the importance of this distinction, even if we don’t always act on it. The pandemic has given us a glimpse of a world in which business as usual in our health care system was upended. It has also provided an opportunity to start up again in a healthier and more financially responsible way. Reflexively returning to the status quo may be good for our bottom line, but it won’t serve our patients well.”
Return to gym revitalizes 91-year old Art Ballard
Not every 91-year-old pumps iron five days a week, beats on a punching bag, rides a stationary bike or works his abs. “But,” writes Kaiser Health News’ Heidi de Marco, “that’s exactly what Art Ballard started to do five years ago at Foothill Gym in Monrovia California. At 91, he’s still spry and doesn’t take any medication other than an occasional Tylenol for aches and pains. ‘Doctors love me,’ he said. But when California enacted a statewide stay-at-home order in mid-March, his near-daily physical exercise and social interactions abruptly ended. Ballard’s health started to deteriorate: His back hurt, his legs cramped, and he started becoming short of breath. As happens too often with older people, he also started to feel isolated and depressed. Ballard, a retired jeweler, lives alone in a one-bedroom condo in Monrovia, a city of about 36,000 people about 20 miles northeast of downtown Los Angeles. After a couple of months of not visiting the gym, Ballard began feeling sad and frustrated, and his health started to slide. He relied more on his walker and sometimes struggled to breathe. Not going to the ‘club,’ as he calls it, was taking a toll on his mental and physical health, so he decided to visit Brian Whelan, the owner of the small, family-run gym, in late May. Whelan broke the rules. He invited Ballard to visit the gym even before it officially reopened to the public. ‘The gym business is more than physical health,’ said Whelan. ‘It’s mental health.’ Day after day, Ballard improved. ‘Now he comes in without a walker, head up straight, and the spark in his eyes is getting brighter.’ The gym reopened June 15. Son Dan Ballard said he’s worried about his dad being around people but realizes the benefits. ‘It’s a scary balance. If he stops going to the gym and can’t see anybody, I know he’s going to deteriorate. At the end of the day, it’s a quality-of-life decision that’s his to make.’ Ballard believes not being able to socialize was a bigger threat to his health than the risk of contracting the coronavirus. ‘I found out how important my routine and exercise is,’ said Ballard senior. ‘It’s given me back my life. And it’s only going to get better.’”
Nursing home evictions leave vulnerable residents homeless
As if the ravages of COVID-19 in nursing homes were not enough, according to The New York Times, residents are increasingly facing another threats. “Nursing homes nationwide are kicking out old and disabled residents — among the people most susceptible to the coronavirus — and shunting them into homeless shelters, rundown motels and other unsafe facilities, according to 22 watchdogs in 16 states, as well as dozens of eldercare lawyers, social workers and former nursing home executives. Nursing homes have long had a financial incentive to evict Medicaid patients in favor of those who pay through private insurance or Medicare, which reimburses nursing homes at a much higher rate than Medicaid. More than 10,000 residents and their families complained to watchdogs about being discharged in 2018, the most recent year for which data are available. Nursing homes are allowed to evict residents if they aren’t able to pay for their care, are endangering others in the facility or have sufficiently recovered. Under federal law, before discharging patients against their will, nursing homes are required to give formal notice to the resident and to the ombudsman’s office. They must also find a safe alternative location for the resident to go, whether that is an assisted living facility, an apartment or, in rare circumstances, a homeless shelter. But some homes have figured out a workaround: They pressure residents to leave. Many residents assume they have no choice, and the nursing homes often do not report them to ombudsmen. Take the example of RC Kendrick,” The Times reporters write, “an 88-year-old with dementia, living at Lakeview Terrace, a Los Angeles nursing home with a history of regulatory problems. His family had placed him there to make sure he got round-the-clock care after his condition deteriorated and he began disappearing for days at a time. But on April 6, the nursing home deposited Mr. Kendrick at an unregulated boardinghouse — without bothering to inform his family. Less than 24 hours later, Mr. Kendrick was wandering the city alone. The next day, the police called Mr. Kendrick’s nephew, Darryl Kennedy. They had found his uncle, who had wandered away from the boardinghouse. ‘They just dumped him like trash,’ Mr. Kennedy said. After the police found Mr. Kendrick, Mr. Kennedy agreed to let his uncle stay with him, even though he could not provide the level of supervision that Mr. Kendrick would have received at Lakeview. About a month later, Mr. Kennedy woke up at 3 a.m. to find Mr. Kendrick standing over him with a steak knife. His uncle stabbed him in the back and the head. Mr. Kennedy called the police. He needed 30 stitches. Mr. Kendrick turned 89 on May 6. He spent his birthday at the Los Angeles County jail, about four miles from Lakeview Terrace.”
Critical care doctor takes brief time out to reflect on COVID-19’s toll
“It has been nearly three months,” writes critical care physician Daniela J. Lamas “since we reconfigured our hospital to care for the COVID-19 surge. And as our numbers fall, from more than 100 critically ill patients to fewer than 20, most of our coronavirus units are closing. This is good news. But there is no celebration. How can there be? Nearly 1,000 Americans continue to die every day from this virus, while others dance in crowded clubs and refuse to wear masks in public places. We were tragically unprepared for the initial deluge of patients with a virus we still cannot cure. And now, I am not sure how to feel about what comes next. So we keep the closed unit empty and waiting. Though the hospital is filling once again with heart attack and cancer patients and those who are awaiting transplants, we don’t move any of them into these COVID-19 beds. Not yet. We maintain a backup schedule of critical care doctors who will return to work in the event of another surge. These empty beds remind us that the virus is still here, and if we do not stay far from one another and wear our masks and wash our hands, if we do not continue to sacrifice our desires and do these uncomfortable things, the beds will inevitably fill again. Everyone is tired. The adrenaline of those early days has turned to profound fatigue. I am on my way out of the hospital in the morning and pass a man heading into the lobby with a rolling suitcase behind him. He is trying to find the labor and delivery unit, he tells the security guard. His wife is about to have a baby. He sounds proud and I realize that it has been months since I last saw a visitor who is not coming for a death. Outside, the air is humid, the sun so bright that my eyes tear up a bit. For a moment, there is no one nearby. I loosen my mask a bit and let the stale air fall away before pulling it tight once again.”
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FCA's Connections e-newsletter focuses on issues and information important to family caregivers. The newsletter regularly covers tips, articles, and helpful advice that can assist families with the numerous daily care tasks that caregiving for loved ones presents—including the often overlooked “caring for yourself.” While much of the content can prove helpful to caregivers nationwide, the events included are local to the six-county region of FCA’s Bay Area Caregiver Resource Center.

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