Tuesday, November 28, 2006

The CareGiver: Dementia

I ran across this factsheet on Dementia from the Milton S Hershey Medical Center. The section entitled, What are the Symptoms, is particularly interesting.

Source Milton S Hershey Medical Center


What is it?

Dementia is the gradual deterioration of mental functioning, such as concentration, memory, and judgment, which affects a person’s ability to perform normal daily activities.

Who gets it?

Dementia occurs primarily in people who are over the age of 65, or in those with an injury or disease that affects brain function. While dementia is most commonly seen in the elderly, it is not a normal consequence of the aging process.

What causes it?

Dementia is caused by the death of brain cells. Brain cells can be destroyed by brain diseases, such as Alzheimer’s disease, or strokes (called vascular or multi-infarct dementia), which decrease blood flow to the brain. Lewy body dementia is another common cause attributed to changes in brain tissue. Other causes can include AIDS, high fever, dehydration, hydrocephalus, systemic lupus erythematosus, Lyme disease, long-term drug or alcohol abuse, vitamin deficiencies/poor nutrition, hypothyroidism or hypercalcemia, multiple sclerosis, brain tumor, or diseases such as Pick’s, Parkinson's, Creutzfeldt-Jakob, or Huntington's. Dementia can also result from a head injury that causes hemorrhaging in the brain or a reaction to a medication.

What are the symptoms?

In most cases, the symptoms of dementia occur gradually, over a period of years. Symptoms of dementia caused by injury or stroke occur more abruptly. Difficulties often begin with memory, progressing from simple forgetfulness to the inability to remember directions, recent events, and familiar faces and names. Other symptoms include difficulty with spoken communication, personality changes, problems with abstract thinking, poor personal hygiene, trouble sleeping, and poor judgment and decision making. Dementia is extremely frustrating for the patient, especially in the early stages when he or she is aware of the deficiencies it causes. People with dementia are likely to lash out at those around them, either out of frustration or because their difficulty with understanding makes them misinterpret the actions of others. They become extremely confused and anxious when in unfamiliar surroundings or with any change in routine. They may begin a task, such as cooking, then wander away aimlessly and completely forget what they had been doing. Dementia is often accompanied by depression and delirium, which is characterized by an inability to pay attention, fluctuating consciousness, hallucinations, paranoia, and delusions. People in advanced stages of dementia lose all control of bodily functions and are completely dependent upon others.

How is it diagnosed?

Dementia is diagnosed through a study of the patient’s medical history and a complete physical and neurological exam. The doctor will speak with those close to the patient to document a pattern of behavior. He or she will also evaluate the patient’s mental functioning with tests of mental status, such as those that require the patient to recall words, lists of objects, names of objects, and recent events. Diagnostic tests, such as blood tests, x-rays, or magnetic resonance imaging (MRI), positron emission tomography (PET), or computed tomography (CT) scans, can help determine the cause of the dementia.

What is the treatment?

In some instances, treating the cause of dementia may successfully reverse some or all of the symptoms. This is the case when the cause is related to a vitamin/nutritional deficiency, tumor, alcohol or drug abuse, reaction to a medication, or hormonal disorder. When dementia is related to an irreversible destruction of brain tissue, such as with Alzheimer’s disease, Lewy body dementia, or multiple strokes, treatment involves improving the patient’s quality of life as much as possible. This includes maintaining a stable, safe, supportive environment and providing constant supervision. While this may be done in the home, people in the advanced stages of dementia may require round-the-clock care in a long-term healthcare facility. It is important to provide the patient with structured activities and avoid disruptions to his or her daily routine. Many patients enjoy therapeutic activities, such as crafts or games, designed specifically for people with dementia. Some medications, such as donepezil and tacrine, have been effective in improving the mental functions of those in the beginning stages of dementia. Patients with hallucinations and delusions may also be treated with antipsychotic drugs, while antidepressant medications are used to treat depression.

Self-care tips

There is currently no known way to prevent dementia associated with Alzheimer's disease. You can decrease your risk of dementia associated with stroke by maintaining a healthy lifestyle, following a heart-healthy diet, and controlling high blood pressure and high cholesterol. Healthy lifestyles, including not smoking and not abusing drugs and alcohol, go a long way in keeping most people in good health. Caring for a person with dementia is stressful. It is important to learn all you can about the disease, seek the help of support groups, and find a responsible caregiver who can give you a break when needed. There are daycare programs specifically designed for patients with dementia that are good for the patient and the family.


This information has been designed as a comprehensive and quick reference guide written by our health care reviewers. The health information written by our authors is intended to be a supplement to the care provided by your physician. It is not intended nor implied to be a substitute for professional medical advice.

The CareGiver Blog

Robert T DeMarco

AllAmerican Senior Care

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Sunday, November 26, 2006

The CareGiver: Americans Fear Alzheimer’s More Than Heart Disease, Diabetes or Stroke

A recent study by the MetLife Foundation found that Americans fear getting Alzheimer's disease more than heart disease, stroke, or diabetes. Alzheimer's ranks second in the minds of American's only to cancer.

MetLife Survey Highlights

The Complete MetLife Survey on Alzheimer's: What America Thinks (36 pages)

The Major Findings of the Study included the following:

Finding 1: Americans fear Alzheimer’s disease.

Finding 2: Americans Know Little or Nothing about Alzheimer’s.

Finding 3: One-third of Americans say they have direct experience with Alzheimer’s disease.

Finding 4: Most Americans are concerned that they will be responsible at some point for someone with Alzheimer’s disease.

Finding 5: Most Americans recognize the need to create a plan to address the possibility of Alzheimer’s disease, but very few have taken steps to do so.


Americans fear Alzheimer’s and the impact that it could have on their lives in the coming years. And although they may recognize the need to look toward the future, the majority hasn’t started making plans.

The downside of living longer has a high price: Nearly 50 percent of those who are 85 or older are affected, and the rate of Alzheimer’s increases exponentially every five years past the age of 65. And with the aging of America’s population these numbers are sure to become even more dramatic in the future, making it imperative that individuals and institutions plan for the future.

The growing number of people with Alzheimer’s will have an impact on every part of society. The vast majority of people know that this disease may someday affect them, either directly or as a caregiver. In addition, many already know a family member or friend who has Alzheimer’s. They strongly support the concept of planning now to cope with the life-changing impact of the
disease – at least in theory.

Despite widespread agreement, few have taken steps to prepare for the possibility of developing Alzheimer’s. Only a few have a solid understanding of the disease. The overwhelming majorityhas done nothing to plan.

The survey reveals a mismatch between fear of Alzheimer’s and acting on that fear to prepare for the future. The findings from this survey suggest that there is an opportunity to build awareness and help bridge the gaps that were identified in knowledge and behavior. Americans should learn all they can about the disease that will touch so many of us and plan for the future.

The CareGiver Blog
Robert T DeMarco
AllAmerican Senior Care
AllAmerican Senior Care Weblog

Tuesday, November 21, 2006

The CareGiver: Benefits Check Up for Seniors

I recently stumbled on to BenefitsCheckUp offered by the National Council on Aging. All you need to do is fill out a short questionairre and the program identifies private and/or government programs that help pay for prescription drugs, health care, utilities, and other needs of seniors. Once you complete the questionairre the computer instantly generates a list of agencies and contact information that fit your profile. I was able to identify a real estate exemption that will save my mother more than $330 annually.

The questionairre is easy to understand and to fill out. It generates the results instantly. Since it check across all kinds of federal, state and local agencies it saves you the time of calling each one or filling out seperate questionairres. In terms of time it will save you many hours and it also provides contact information that was of great value to me.

This program makes it very easy to determine if you are eligible for additional Medicare or Medicaid benefits. It also determines if their are state or local tax exemptions or help with bills such as electricity.

Here is the link to BenefitsCheckUp

If you find this of value please pass on the link or feel free to send others to this blog.


The CareGiver Blog

Robert T DeMarco

AllAmerican Senior Care

AllAmerican Senior Care Weblog

Saturday, November 18, 2006

The CareGiver: Huperzine A Factsheet (Alzheimer's)

I recently read about Huperzine A. The following page contains a fact sheet about the herb. Huperzine A may have cognition-enhancing activity in some.

Source Huperzine A


Huperzine A is available from numerous manufacturers generically. Branded products include Memorall (PharmAssure), Huperzine Rx-Brain (Nature's Plus).


Huperzine A is a plant alkaloid derived from the Chinese club moss plant, Huperzia serrata, which is a member of the Lycopodium species. Huperzia serrata has been used in Chinese folk medicine for the treatment of fevers and inflammation.

Huperzine A has been found to have acetylcholinesterase activity. Huperzine B, also derived from Huperzia serrata, is a much less potent acetylcholinesterase inhibitor. Natural huperzine A is a chiral molecule also called L-huperzine A or (-)-huperzine A. Synthetic huperzine A is a racemic mixture called (±)-huperzine A. Huperzine A is also known as HUP, hup A and selagine. In Chinese medicine, the extract of Huperzia serrata is known as Chien Tseng Ta and shuangyiping. Huperzine A derivatives are being developed for pharmaceutical application.


Huperzine A may have cognition-enhancing activity in some.


Alzheimer's disease is a neurodegenerative disorder associated with neuritic plaques that affect the cerebral cortex, amygdala and hippocampus. There is also neurotransmission damage in the brain. One of the major functional deficits in Alzheimer's disease is a hypofunction of cholinergic neurons. This leads to the cholinergic hypothesis of Alzheimer's disease and the rationale for strategies to increase acetylcholine in the brains of Alzheimer's disease patients. Two FDA-approved drugs for the treatment of Alzheimer's disease, tacrine and donepezil, are acetylcholinesterase inhibitors.

Huperzine A is also an acetylcholinesterase inhibitor and has been found to increase acetylcholine levels in the rat brain following its administration. It also increases norepinephrine and dopamine, but not serotonin levels. The natural L or (-)-huperzine A is approximately three times more potent than the racemic or (±)-huperzine A in vitro.


There are limited pharmacokinetic studies with huperzine A. It appears that huperzine A is rapidly absorbed from the gastrointestinal tract and transported to the liver via the portal circulation. Some first-pass metabolism takes place in the liver, and huperzine A and its metabolites are distributed widely in the body, including to the brain. Following ingestion, the time to reach peak blood level is approximately 80 minutes.


Huperzine A has potent pharmacological effects and, particularly since long-term safety has not been determined, it should only be used with medical supervision. It may have some effectiveness in Alzheimer's disease and age-related memory impairment. It has been used to treat fever and some inflammatory disorders, but there is no credible scientific evidence to support these uses.


Numerous studies, most of them from China, suggest that huperzine A may be as effective as the drugs tacrine and donepezil in Alzheimer's disease. This is not so surprising since in vitro and animal model tests have demonstrated that huperzine A effectively inhibits acetylcholinesterase, an enzyme that catalyzes acetylcholine breakdown. Tacrine and donepezil work in the same way to conserve acetylcholine in the brain--the mode by which they presumptively improve memory and cognition in those with Alzheimer's and age-related cognitive impairment. Huperzine A may prove superior to tacrine (dose-limited due to its hepatotoxicity) if long-range studies, yet to be conducted, demonstrate its safety.

In one double-blind, randomized study, huperzine A, in injectable form, was tested against a saline control in 56 patients with multi-infarct dementia or senile dementia and in 104 patients with senile and pre-senile simple memory disorders. Huperzine A produced significant positive effects as measured by the Wechsler Memory Scale. Dizziness was experienced by a few of the huperzine A-treated patients.

In another study, this one multicenter, double-blind, placebo-controlled and randomized, 50 subjects with Alzheimer's disease were given huperzine A or placebo for eight weeks. Significant improvement was noted in 58 percent of the patients in terms of memory, cognitive and behavioral functions. Research is ongoing.


None known.


Huperzine A should be avoided by children, pregnant women and nursing mothers.

Because of possible adverse effects in those with seizure disorders, cardiac arrhythmias and asthma, those with these disorders should avoid huperzine A. Those with irritable bowel disease, inflammatory bowel disease and malabsorption syndromes should avoid huperzine A.


Adverse effects reported with huperzine A include gastrointestinal effects, such as nausea and diarrhea, sweating, blurred vision, fasciculations and dizziness. Possible adverse effects include vomiting, cramping, bronchospasm, bradycardia, arrhythmias, seizures, urinary incontinence, increased urination and hypersalivation.


Acetylcholinesterase Inhibitors: Use of huperzine A along with the acetylcholinesterase inhibitors donepezil or tacrine may produce additive effects, including additive adverse effects. Other acetylcholinesterase inhibitors include neostigmine, physostigmine and pyridostigmine, and use of these agents along with huperzine A may produce additive effects, including additive adverse effects.

Cholinergic Drugs: Use of huperzine A along with cholinergic drugs, such as bethanechol, may produce additive effects, including additive adverse effects.


Use of huperzine A with choline, phosphatidylcholine, CDP-choline and L-alpha-glycerylphosphorylcholine hypothetically might produce additive effects, including additive adverse effects.


There are no reports of overdosage with huperzine A.


There are various forms of huperzine A available, including extracts of Huperzia serrata, natural (-)-huperzine A and synthetic racemic (±)-huperzine A. Natural (-)-huperzine A is approximately three times more potent than the synthetic racemic mixture. The doses of natural (-)-huperzine A used in clinical studies ranged from 60 micrograms to 200 micrograms daily. Huperzine A should only be used with a physician's recommendation and monitoring.


Capsules — 50 mcg

Tablets — 50 mcg


Cheng DH, Tang XC. Comparative studies of huperzine A, E-2020 and tacrine on behavior and cholinesterase activities. Pharmacol Biochem Behav. 1998; 60:377-386.

Cheng DH, Ren H, Tang XC. Huperzine A, a novel promising acetylcholinesterase inhibitor. Neuroreport. 1996; 8:97-101.

Quian BC, Wang M, Zhou ZF, et al. Pharmacokinetics of tablet huperzine A in six volunteers. Chung Kuo Yao Li Hsueh Pao. 1995; 16:396-398.

Tang XC, Kindel GH, Kozikowski AP, Hanin I. Comparison of the effects of natural and synthetic huperzine A on rat brain cholinergic function in vitro and in vivo. J Ethnopharmacol. 1994; 44:147-155.

Xiong ZQ, Tang XC. Effect of huperzine A, a novel acetylcholinesterase inhibitor, on radial maze performance in rats. Pharmacol Biochem Behav. 1995; 51:415-419.

Xu SS, Gao ZX, Weng Z, et al. Efficacy of tablet huperzine-A on memory, cognition and behavior in Alzheimer's disease. Chung Kuo Yao Li Hsueh Pao. 1995; 16:391-395.

Ye JW, Cai JX, Wang LM, Tang XC. Improving effects of huperzine A on spatial working memory in aged monkeys and young adult monkeys with experimental cognitive impairment. J Pharmacol Exp Ther. 1999; 288:814-819.

Zhang RW, Tang XC, Han YY, et al. Drug evaluation of huperzine A in the treatment of senile memory disorders. [Article in Chinese] Chung Kuo Yao Li Hsueh Pao. 1991; 12:250-252.

Friday, November 17, 2006

Huperzine A in Alzheimer's Disease

I just finished reading an interesting article about Huperzine A. You can get an excerpt, the link to the article and the link to the clinical trial on the next page.

Follow this link to get the information about the clinical trial, Huperzine A in Alzheimer's Disease

Alzheimer's herb

Here is an excerpt from the article:

Karen says when it comes to her mom, "It made her want to get up out of the chair, it made her want to go out to the pool and swim laps, it made her want to go out and prune her flowers."

Another benefit Betty's family has seen: she has lost 50 pounds because she has been more active. Dr. DeCarli said this is just one example of clinical trials in action.

Follow this link to the complete article, Herb

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The CareGiver

Thursday, November 16, 2006

Immigrants, increasingly, provide elder care in U.S.

Not only are immigrants a major source of employees right now this trend is expected to grow very fast in the future.

Immigrants, increasingly, provide elder care in U.S.

Scripps News

Thursday, November 16, 2006

Wanda Moeller's blue eyes dance when she talks about Franklin D. Roosevelt, the Grand Ole Opry _ and Haydee Carrillo, the Salvadoran immigrant who has helped care for her for six years.

Three mornings a week, Carrillo lifts the partially paralyzed Moeller from bed and gives her a bath, breakfast and oxygen treatment. Then she applies lipstick for her 76-year-old client, and the two run errands or have fun talking or looking at photos of grandchildren.

"She's like a daughter to me," the Oklahoma-born Moeller said, as Carrillo, 60, smiled and wiped a drop of cafe latte from Moeller's chin.

In the same Sacramento, Calif., apartment building, another elderly client also praises Carrillo. "Her mother was killed in El Salvador's war," said Merle Heath, 78, as Carrillo hooked up his oxygen to treat severe bronchitis. "Her English isn't too good. But she's a loyal, good Christian."

As Heath has learned, Carrillo's life began a world apart from the universe she now shares with the American septuagenarians she cares for, at $10 an hour. That they have all crossed paths in the United States, however, is no longer a rare phenomenon.

Immigrants are rapidly taking on prominent roles as American families' caregivers, whether those immigrants are naturalized citizens, permanent residents, undocumented or _ like Carrillo _ in between. They nurture babies, keep house and, increasingly, care for America's surging population of senior citizens.

Immigrants make up nearly 18 percent of the nation's baby sitters and in-home aides for seniors or people with disabilities, according to the Migration Policy Institute, a nonpartisan research center.

At the same time, many involved in senior care are discovering that the U.S. immigration system offers few avenues for recruiting and legally employing caregivers to help meet exploding demand. A job like Carrillo's, that of home health aide, is expected to be the fastest-growing job in America for the next decade.

"Even if you substantially raise salaries, and I'm not sure you can, it's not clear there is enough of a latent native work force," said Michael Fix, the Migration Policy Institute's vice president. "You shouldn't idealize immigration as a solution," he said, but added that it could be helpful "to take this flow and make it a regulated flow."

Undocumented workers, senior advocates say, are filling many of these jobs, in private homes and even in facilities _ such as nursing homes _ where employers are required only to see, not authenticate, a green card.

Families, too, are dismayed to find out that if they try to do "the right thing," as one daughter of a 95-year-old said, and legalize a trusted caregiver, the process is next to impossible. Only 5,000 low-skilled immigrant work visas can be issued annually and waiting times are now up to more than five years.

Escalating demand for senior care is shared by Italy, Austria and other aging nations that already rely on caregivers from poorer countries, according to a 2005 report by AARP, an advocacy organization for older Americans.

That report urges an expansion of U.S. programs to train more American elder-care workers of all levels, but acknowledges that the supply of homegrown applicants for such programs is finite.

AARP's report notes: "Meeting the long-term care needs of the growing older populations in more developed nations requires more engagement across international boundaries."

Heath, who is virtually bedridden, said his own experience shows how much workers like Carrillo are already vital. "We should be helping people like her," he said. "Not a lot of able-bodied American men out on the street want to do this."

Carrillo cites her religious faith and difficult life _ her mother's murder, prolonged separation from her children _ as factors that have strengthened her empathy for "ancianos," as seniors are called in Spanish.

Caregivers like her must be strong and skilled enough to lift immobile adults and help them into wheelchairs, and patient enough to provide companionship and intimate needs, like washing, clipping nails and, for the most frail, changing diapers.

"You can't mechanize taking care of the elderly," said Ken Preede, director of government relations for the American Health Care Association, which has joined other industries in lobbying for an earned legalization of undocumented workers.

Health and Moeller live alone, in assisted-living apartments, while their children live too far away to shoulder the type of care Carrillo provides through California's In-Home Supportive Services program for seniors.

"I trust Haydee with my life," said Heath, who values his independence but is too weak to handle even simple personal tasks.

Carrillo entered the United States in 1983 _ illegally, like many who fled El Salvador's civil war. She worked cleaning houses and taking care of seniors in facilities and homes.

Her 1987 petition for political asylum eventually earned her a work permit, but her asylum was never fully approved. The U.S. government supported the Salvadoran government during the civil war, and many who fled that war were turned down for refugee status.

These days, Carrillo hangs her hopes on being granted legal permanent residency through the 1997 Nicaraguan and Central American Adjustment Act, which was designed to allow law-abiding refugees to finally integrate into the country after years of living in limbo.

"God willing, it will happen," she said in Spanish.

(The Sacramento Bee's Susan Ferriss can be reached at sferriss(at)sacbee.com.)

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Wednesday, November 15, 2006

The Silver Tsunami

The Baby Boomers are coming...What looms for this generation?

By Andra Coberly

With a thriving post-World War II economy and soldiers returned from service, the men and women of America did their civic duty.

And they did it again and again and again.

The Baby Boom began 60 years ago when economic prosperity—as it often does—translated into a flood of offspring. By the end of the 1940s, close to 32 million babies had been born, and families of 10 were not uncommon. The “fruit of demobilization,” a term coined by the Washington Post, didn’t end until 1964. Boomer Nation was about 75 million strong—a diverse generation defined by the Vietnam War, sexual revolution and even disco.

What concerns some is that the boom of babies between 1946 and 1964 will become a tsunami of seniors in 15 to 20 years. While Boomers will be the first to tell you how active, healthy and stable they are, the aging of this generation is now considered a looming crisis.

Ten million Americans will be 85 years or older by 2030, and Larimer County’s 75 and older population is expected to surge 48 percent between 2005 and 2020. With a large number of older seniors, some expect serious strains on the programs they often rely upon.

Actually, “strain” is an understatement when describing how these masses will impact the system in 20 years—a system that includes everything from social security to dental care to congregate meals to Medicare.

“Detriment” might be more appropriate.

When one turns 75, the likelihood of being placed in a nursing home or long-term care facility increases greatly. Aging, often, leads to more medical oversight, more medication and more services from federal, state or local entities.

According to Margaret Long of the Larimer County Office on Aging, funding is currently not meeting the needs of the community’s elderly. And when Larimer County’s 75 and older population hits 19,000 in 2020—as it’s expected to do—funding will increasingly fail to help those in need.

“We must keep providing service and we must also plan for the demographics and change in numbers,” Long says. “This is the time we have to start setting the wheels in motion.”

If agencies like Department of Human Services do not plan for this senior tsunami, as Long calls it, they will not be prepared to handle the need. While it is clear that the impacts of the aging Boomer population may not be known for at least 15 to 30 years, Long and others are beginning to prepare so this tsunami doesn’t turn into a disaster.

“It’s going to be a challenge to us all,” says Jill Taylor, manager of Poudre Valley Health System’s Aspen Club, which provides educational and screenings to local seniors. “But it’s a good challenge.”

Issues beyond funding are also expected to arise. Physicians and mental health practitioners who specialize in geriatric care will be in high demand. Senior-care businesses will likely be overrun with clients. And health-care facilities will be forced to change their offerings for a generation that is not afraid to demand its morning lattés and private rooms.

Largely, Baby Boomers will push the definition of what it means to be old. In fact, their maturity has been, and will continue to be, the focus of a certain amount of speculation.

“I don’t know what it will look like but I know the Boomers are not looking like status quo,” says Yvonne Myers, health systems coordinator for Columbine Health Systems.

Gary Sheldon couldn’t agree more that there is no way to pigeonhole the Baby Boomer generation.

“We’re a diverse group,” he says.

But as the 52-year-old talks about himself and his future, he realizes that he is a specimen of his generation.

“I’m the quintessential Baby Boomer, aren’t I?” he says, interrupting himself.

Sheldon is active, an enthusiastic cyclist, and he plans to stay spry and healthy into his older years. He hopes to see his grandchildren grow up, and the orthodontist feels comfortable about his plans for retirement and his aging—though he resists the term “senior.”

“It implies sedentary,” he says.

Sheldon seems to have his future set, like many his age who plan to spend their senior years traveling, doing yoga and taking bike tours of Italy.

But a large percentage of Sheldon’s generation will not be so lucky.

While several studies show the health and quality of life of older adults is steadily increasing, some worry that the growing senior population will translate into sizable numbers living in poverty, without health insurance and alone—requiring health care, nutrition, transportation and others services from government entities.

In a study by The Population Reference Bureau, two sociologists say Baby Boomers will stay employed and active longer. But, they counter, the group is also characterized by huge economic inequalities and a large population without health insurance—many Baby Boomers will be less healthy and less wealthy than seniors before them. Younger Boomers, now in midlife, have the highest poverty levels since before to World War I. Plus, there will be fewer workers contributing to endowments like Medicare and Social Security than there are now.

For Larimer County, that means that Department of Human Services and some non-profits will increasingly struggle to provide. The Office on Aging, a division of Department of Human Services, offers multiple services for the county’s elderly. Long, the program’s director, recently presented its four-year plan, the office’s predicted spending between 2007 and 2011. Simply, the budget holes over the next four years are gaping. The estimated funding shortfall for just the office’s external services could pass $200,000 by 2011.

Long considers her work on the four-year plan the start of preparation for the gigantic wave of feisty, silver-haired seniors.

“The really critical thing when looking at the Baby Boomers is to use the next eight years for planning,” she says.

The potential for a flood of seniors drives several issues for Long and others.

One is the need for more doctors and mental health specialists. Doctors will need to be aware of how medications and treatments affect aging bodies. Mental disorders such as depression and bipolar are increasingly problematic, and according to Long, “There are some real shortages in terms of practitioners who really specialize in the mental health issues of the geriatric population.”

No matter the specialty, Myers says, “if you are in the health-care business, you’ll want to like taking care of old people.”

The Baby Boomers, living longer and healthier, will post new challenges for those doctors. Finding and funding dental care—a new problem since seniors in the past largely didn’t have their teeth and required dentures—is a concern. As is learning to better treat those in their 100s, as that demographic is likely to grow.

Those who run nursing-care and assisted-living facilities expect Baby Boomers to remodel their services. Nursing-home activity directors, Myers says, will have one hell of a time pleasing the musical tastes of this generation—from The Beatles to John Fogerty to Michael Jackson. Nutrition programs, like congregate meals and fixed menus, will also need to be rethought.

“There was a woman in her 50s in here the other day and she said she would starve to death if she lived here,” Myers says. “She said she was a vegetarian, she’ll need her soy milk and tofu. I thought, ‘I’m not moving any place unless there’s an espresso machine.’”

Not all of this anticipation is treated like preparation for Armageddon.

Myers hopes the attention will bring a new appreciation for the elderly.

“It’s awesome when you’re a senior in high school,” says Myers, a Baby Boomer herself. “But not so much when you’re a senior in life. My hope is that we come to value their wisdom and value the roles that older people play.

“It’s an exciting time to be a senior,” she continues. “It’s a blank slate.

“I hope the Baby Boomers do it right.”


Tuesday, November 14, 2006

The Care Giver: With Alzheimer's, the Caregiver Is a Patient, Too

This is an interesting and thought provoking article that highlights the problems often effecting Alzheimer's care giver's.

With Alzheimer's, the Caregiver Is a Patient, Too

Alzheimer's Disease and other forms of dementia do not affect just the patient. These diseases gradually rob patients of memory and other intellectual abilities, leaving them unable to perform routine tasks. As the disease continues to destroy brain cells, patients increasingly depend on family members or others to carry out simple tasks like shopping and getting dressed. Ultimately, most patients will need complete care, adding to the caregiver's burden.

Alzheimer's disease is the most common form of dementia, affecting up to 4 million Americans - and untold millions of family members and others who care for them. Physicians now recognize that Alzheimer's caregivers themselves often require care and attention, says Diana R. Kerwin, MD, Medical College of Wisconsin Assistant Professor of Medicine in the Division of Geriatrics and Gerontology.

"What we're seeing is that Alzheimer's is not a typical disease model," she says, "precisely because the health and well-being of the caretaker is affected as well as the patient. I know when I assume the care of an Alzheimer's patient, I am also caring for the caregiver."

Caregivers who accompany patients to the Froedtert Senior Health Program's Geriatric Evaluation Clinic, where Dr. Kerwin practices, are screened for "caregiver stress" and see a gerontologic nurse and social worker who will answer their questions, provide information and help create a plan for care of the patient. Caregivers are given a kit with information about support groups and community services, including adult day care, home care agencies, assisted living, skilled nursing facilities and respite care.

Stress, Depression Are Common
According to the Alzheimer's Association, more than 80% of Alzheimer caregivers report that they frequently experience high levels of stress, and nearly half say they suffer from depression. It's not difficult to see why.

The national Family Caregiver Alliance terms caregiver depression "one of today's all-too-silent health crises." The alliance estimates that caregiving spouses between the ages of 66 and 96 who are experiencing mental or emotional strain have a 63% higher risk of dying than people the same age who are not caregivers.

"Alzheimer's causes progressive memory loss, and in the later stages patients can develop behavior problems," Dr. Kerwin says. "It's distressing for the caregiver to suddenly have to cope with their loved one's anger, hallucinations, paranoia, aggression or inappropriate conduct in public. It's upsetting when, as the disease progresses, the patient no longer recognizes the spouse or loved one."

Caregivers often experience feelings of guilt, believing they are not doing enough to help, she adds. Spouses and adult children feel grief and loss, not unlike a death in the family - except that instead of being sudden, it's spread out over years. Alzheimer's is a progressively worsening disease, but the rate of progression from mild to advanced can vary widely, from three to 20 years. As Alzheimer's progresses, the loss of brain function itself will cause death unless the patient has one or more other serious illness.

When the Child Becomes the Parent
For an adult child who cares for a parent with dementia, taking on the role of caregiver is a role reversal and takes some adjustment. "It can be a difficult transition for a child to take on the role of 'parent' and decision-maker," Dr. Kerwin says. "The child often needs to be empowered to step in and begin caring for their ailing parent - making sure their parent takes his or her medication, for instance, or telling their parent they should not drive, and making difficult decisions about when the parent is no longer able to safely live alone."

Those caregivers are often already juggling multiple responsibilities with their own spouses, children and careers. In some cases, adult-child caregivers with siblings feel resentful if they must bear the brunt of their parent's care, Dr. Kerwin says. If the adult-child caregiver is the only sibling living in the same city as the parent he or she often feels isolated, overwhelmed and underappreciated.

And sometimes, whether the caregiver is a spouse or an adult sibling, out-of-town siblings or other family members who see the parent infrequently may think the caregiver is exaggerating the extent of the Alzheimer's patient's decline. The out-of-town family members may feel guilty about not being able to help from a distance, and when they do visit, they may criticize or ask to change the care their parent is receiving.

Caregivers are often fatigued from carrying out their new responsibilities, Dr. Kerwin says. "I see them neglecting their own health. It's not unusual for caregivers to suffer not only depression but also higher levels of hypertension. We recommend they have annual physicals, during which they should be sure to tell their primary care physician that they are caregivers. We also recommend they participate in support groups and learn about the community resources available."

Other concerns caregivers regularly express are loss of concentration due to their caregiving responsibilities and fear that they themselves might eventually get the disease.

Warning Signs for Caregivers What are some warning signs of caregiver stress? According to the Alzheimer's Association, they include:

Health problems
Lack of concentration
Social withdrawal
Caregivers who regularly experience these conditions should seek help from their physician, says the Alzheimer's Association.

Financial Strain Heightens Burden
In some families, the presence of Alzheimer's disease also brings financial problems that can add to stress and depression. Caregivers sometimes give up paying jobs for the unpaid one of caring for a loved one. They often find additional responsibilities are thrust on them, such as overseeing medications for their patient, knowing if or when the patient's care should be transferred to a nursing home, and taking on power of attorney duties along with living wills and advanced directives that specify whether terminal patients should undergo extreme measures to keep them alive.

The national Family Caregiver Alliance estimates that approximately 80% of the long-term care in the United States is provided without compensation, sometimes around the clock.

"The responsibilities are vast," Dr. Kerwin notes. "It's important for caregivers to regularly take some time for themselves, away from their caring responsibilities."

Barbara Abel
HealthLink Contributing Writer

The Medical College's Center for Healthy Communities, along with the local non-profit organization Community Care for the Elderly Partnership, has developed a Caring for Caregivers Program to support Medicaid- and Medicare-eligible residents in the community who care for frail relatives, often those with dementia. For more information, contact Tovah H. Bates, PhD, Assistant Professor, Family & Community Medicine, at 414-456-4305, or Community Care for the Elderly at 414-385-6600.

For more information on this topic, see the HealthLink articles End-Stage Alzheimer's - the Long Goodbye and Current Research on Alzheimer's, Memory Loss, and Aging.

Article Created: 2003-11-14
Article Reviewed: 2003-11-14

All American Senior Care
AllAmerican Senior Care Weblog

The Green House

What is a “Green House”?

What is a “Green House”?

Green Houses are homes for 6 to 10 elders who require skilled nursing care and want to live a rich life. They are a radical departure from traditional skilled nursing homes and assisted living facilities, altering size, design, and organization to create a warm community. Their innovative architecture and services offer privacy, autonomy, support, enjoyment and a place to call home. Green Houses are developed and operated by long-term care organizations in partnership with the Green House Project and NCB Capital Impact.

Saturday, November 11, 2006

New concept in elder care

The Green House Project seeks to de-institutionalize traditional nursing homes with a homelike setting. Ten residents live in each house, where they have private bedrooms and make decisions about meals and activities.

New concept in elder care

Maura J. Halpern
The Arizona Republic
Nov. 10, 2006

The latest concept in long-term care has sprung from the ground at the Baptist Village campus in Youngtown with three 7,000-square-foot "Green Houses."

The Green House Project seeks to de-institutionalize traditional nursing homes with a homelike setting. Ten residents live in each house, where they have private bedrooms and make decisions about meals and activities.

Youngtown's Green Houses, at 115th and Peoria avenues, will be the first in the western United States.

Construction is almost complete on the first house, and residents will move in soon after a grand opening celebration Dec. 18. The other two will open early next year.

Green Houses contain no corridors, medicine carts or privacy curtains.

Instead, there are private bedrooms that lead to a spacious great room with a kitchen and dining area.

"It gives independence and control back to the elder," said Dave Ellis, president and chief executive of Arizona Baptist Retirement Centers. "Here, visitors will have to ring the doorbell to come inside."

At many nursing home facilities, employees plan activities in advance and meals follow a six-week rotation.

In the Green Houses, residents not only decide what to eat, but can help cook if they wish.

The Green House concept is rooted in the Eden Alternative, which aims to eliminate hopelessness, loneliness and boredom.

It focuses on three factors: warm, green and smart.

Warmth is created through décor, furnishings and the residents. Smart refers to cutting-edge technology. Green includes sunlight, plants and access to the outdoors.

Each Green House features a large outdoor patio for guest visits and barbecues.

Self-directed workers known as Shahbaz serve as caregivers, friends and homemakers. They help clean, cook and coordinate activities that the residents choose.

"This is the most exciting thing for us, because we know what a difference it will make," Ellis said.

This is encouraging news for Sandra Carter, a Sun City resident whose mother, Twila Kapfer, will live in one of the Green Houses.

"My mother has always been a good cook, and even though she might not be able to prepare a meal, she'd love to share recipes," Carter said. "She'll enjoy that."

Tuesday, November 07, 2006

The CareGiver: Why Didn't I Get It?

The signs were there but noone could see them not even me.

Number Two--Why Didn't I Get It?

Tuesday, November 07, 2006

I was talking to my sister one evening and she said to me, “You better call Mom she says she hasn’t talked to you in months.” I laughed and said I talked to her two days ago and for quite some time. Later in the evening I decided to call my mother. After she recognized my voice she said, “Well its about time you called.” When I said I just talked to you two days ago she just shrugged it off and we began our usual conversation.

I really don’t know why I wasn’t more concerned at the time but to be honest I wasn’t. And neither was anyone else. The typical comment, “she sounds good to me.” I guess like most people I just accepted the fact that she was getting old. Nobody saw a problem not even her friends who saw her on a daily basis.

Looking back there were plenty of signs. For one thing, she was developing a very negative attitude. But, it seemed when I spent time with her, a few days, she would turn back into her normal self and start to have a more positive outlook on things. Another sign occurred when she began to scrape her feet as she walked. I suppose I should have concluded something but I didn’t. We thought she was finally slowing down. I could go on and on.

Then Christmas came and I decided to take her shopping. To my surprise she could barely walk for five minutes without stopping. In fact, she was almost slumping over. Out of the clear blue sky, or so it seemed, she just couldn’t walk any distance and it was struggle just getting her back to the car. Clearly something was a-muck.

I went to talk to her doctor. Other than her high blood pressure, her heart was fine and her overall blood work was pretty good—more than pretty good for woman her age. Keep in mind we are talking about an 87 year old woman at the time, a woman who had never had a major illness or operation her entire life. The closest she had come to any of that was when she had an operation on a bunion on her foot.

Yet now for some reason she was no longer able to walk comfortably. I began to notice how she was somewhat unsteady, how she began to reach out and hold on to things as she walked, and how she no longer had an interest in doing anything that required her to walk. Two years earlier this woman, my mother, walked more than a mile round trip with me in New York to eat breakfast.

All American Senior Care

Medicaid Advantage: A medical home for dual-eligibles

The authors propose a new Medicaid Advantage program that would integrate acute and long-term care benefits for dual-eligible beneficiaries into a single program.

Medicaid Advantage: A medical home for dual-eligibles

By Grace-Marie Turner and Robert B. Helms, Ph.D.

Submitted to the Medicaid Commission

Grace-Marie Turner of the Galen Institute and Bob Helms of the American Enterprise Institute have proposed a new Medicaid Advantage program that would integrate acute and long-term care benefits for dual-eligible beneficiaries into a single program. The program, submitted to the Medicaid Commission, would be managed by the states and would provide a medical home and better coordinated care for beneficiaries.

Our most vulnerable citizens – those dually eligible for Medicare and Medicaid – often fall into a fragmented care delivery system that perpetuates episodic rather than coordinated care. Patients may have difficulty accessing the medical care they need. And information about their care and their needs can be scattered among providers and facilities facing two different payment systems and sets of program rules.
Because physicians and others treating these patients don’t have the patient’s complete medical profile, patients can face gaps as well as duplication in treatments with no medical home responsible for optimizing their care.
To assure that Medicaid patients are receiving quality care, Medicaid must adopt new systems with better incentives to design more flexible and more effective care management programs for these recipients, especially those with disabilities and significant chronic illnesses. Having a medical home is central to this process. A comprehensive program that integrates Medicare and Medicaid coverage into a new integrated Medicaid Advantage plan would allow providers to focus on the best way to design and provide benefits to these beneficiaries with the right care in the right setting, rather than spending time on complying with rules for different payment systems. Significant efficiencies and better outcomes could be achieved through a comprehensive approach to providing health care for these Medicare and Medicaid-eligible beneficiaries.
Cost-effectiveness studies of state Medicaid managed care programs have demonstrated that they generally save states money while providing better access to care for recipients. The commission also has heard numerous testimonies demonstrating the creativity of state and local governments in developing programs to target services to their vulnerable dually-eligible residents, often through contracts with private managed care organizations.
Vermont obtained a waiver to fine-tune delivery of long-term care services and demonstrated that better care can be provided more cost-effectively in appropriate settings when solutions are tailored to individual needs. We heard about similar examples in New York, Massachusetts, Arizona, and other states.
States are much more adept at tailoring these programs to their citizens than the Federal government because they are closer to the people being served and know better both their needs and the resources of the community to meet those needs. But states are not able to shoulder the full financial burden of providing these services. Continued Federal funding is essential.
Other options:
The Federal government has recognized the need to better integrate care for dually-eligible populations and has developed several programs as a result. The Program for All-Inclusive Care for the Elderly (PACE), targeted waivers, and Special Needs Plans (SNP) are the primary Medicare programs designed to achieve this goal.
• PACE is a capitated benefit program authorized by the Balanced Budget Act of 1997 and developed to provide better coordinated long-term care for Medicare and Medicaid recipients who have been certified as eligible for nursing facility care. PACE enables states to provide defined services to Medicaid recipients as a state option, and Medicare and Medicaid funds are integrated to allow a contracted plan to provide the care.
The state plan must include PACE as an optional Medicaid benefit before the state and HHS can enter into a program agreement with PACE providers.
While the program has had some success, it is a Medicare program with a Medicaid option and has not been widely adopted. And the BBA limits the number of PACE programs that may be implemented annually. As of January 2005, there were 73 PACE sites in the U.S. serving limited geographic areas.
• Several states (Massachusetts, Minnesota, and Wisconsin) obtained waivers to combine Medicaid and Medicare funds to purchase health care services for dually-eligible populations. But the waiver negotiations each took several years, limiting the appeal to other states interested in using this approach.
• The Medicare Modernization Act created a new coordinated care option called Special Needs Plans as part of the Medicare Advantage program. SNPs are distinct from regular Medicare Advantage plans in that they can enroll a group of individuals with “special needs,” such as 1) institutionalized beneficiaries; 2) dual eligibles; and 3) beneficiaries with severe or disabling chronic conditions.
SNPs are able to offer a full array of Medicare services, including supplemental benefits, through a single plan with a single benefit package and set of providers. Medicare Advantage payments to SNP plans are risk adjusted based upon beneficiary health conditions, dual eligible status, disability eligibility, and institutional status.
In 2006, 276 SNPs are available, with more than 500,000 enrolles, including 440,000 dually-eligible beneficiaries.
Absent other legislation, SNP authorization in the MMA will sunset on January 1, 2009.
But even with these programs, the Federal government -- through CMS -- still is in control of decisions for PACE, waivers, and SNPs, providing states much less flexibility than if they were running the plans themselves. For example, states must get authorization to put a dually-eligible patient into a managed care plan – an unnecessary administrative hurdle.
Recommendation for Medicaid Advantage
Some people have called for Medicare to take full responsibility for duals, but this centralization would move away from, rather than toward, more finely-tuned care for this vulnerable population. States need more flexibility than Medicare’s top-down system of rules can provide for patients requiring tailored care and services. States have demonstrated that they are up to the task.
On average, total spending for duals, including Medicare and Medicaid contributions, is more than twice as high as that for non-duals -- $20,840 compared to $10,050. It is essential to find a way to manage these costs and care delivery more efficiently.
We recommend creating a new Medicaid Advantage program modeled after the Medicare Advantage program, but with States, rather than the Federal government, in control.
Medicaid Advantage would offer dually-eligible recipients a medical home where they would receive a seamless continuum of medical care and care management under one program and not have care split between Medicare and Medicaid programs. But unlike Medicare Advantage, SNPs, and PACE, the states rather than the Federal government would be the primary managers of their Medicaid Advantage programs.
The Federal government would continue to provide financial support to the states for Medicare services, but through a risk-adjusted, capitated system of Medicare payments. States and the Federal government would continue to share the cost of the Medicaid portion of the benefit.
States or the plans they select could manage the full spectrum of services to provide an integrated care delivery program for dual eligible populations. These plans would be close to the patient, collecting and evaluating treatment data, and states would monitor the plans to make sure obligations are being met.
The Federal government would set and monitor goals, not micromanage processes, so that the states, in conjunction with health plans, can work to improve the quality of care, design plans to fit the needs of patients, and benefit from greater efficiency.
• The states would have the option of participating in the new Medicaid Advantage program which they would be primarily responsible for managing, with the goal of developing a better system of providing more efficient, coordinated care for their dually-eligible residents.
• Participating states would contract with competing health plans* to provide the full spectrum of care for dually-eligible populations and would enroll individuals into these integrated Medicaid Advantage care management plans.
o Patients could choose from among competing plans.
o Patients would have the ability to opt-out.
o Medicaid Advantage plans would be required to provide core Medicaid and Medicare services to duals, but states would have more authority and flexibility to design benefit packages that meet the specific needs of patients without having to request waivers.
o Plans would participate in a bidding process, submitting bids representing their cost of providing Medicare and Medicaid-covered services as well as other services determined by the states.
o States would build in incentives for plans to compete on the basis of quality and value and could reward health plans that provide higher quality care at a reduced price. States could also share in a portion of these savings.
o *States would have the option of managing the care and assuming the risks themselves, as Kentucky is doing with its new KY HealthChoices Medicaid reform plan.
• Financing: The states and the Federal government would each contribute, as they do today, to the costs of providing services to dually-eligible beneficiaries but through the new Medicaid Advantage program which would be managed by the states.
States and the Federal government already have some experience with the basic mechanisms that would be needed to calculate payments for this new program. The rate-setting and risk-adjustment systems that Medicare currently uses to pay Medicare Advantage plans and that states use to pay for standard Medicaid managed care programs would provide a foundation for their calculating payments that would fund this new integrated care management program for duals.
There would be three funding streams:
o Federal Medicare payments, which are generally provided through Medicare’s defined benefit structure, would be allocated to the states through a new funding mechanism. The Federal government would develop a system of capitated, risk-adjusted Medicare payments. These payments would be sent to the states to fund the Medicare portion of services for dual-eligible residents. This is not a block grant because funds would follow each recipient and would be adjusted for that patient’s risk profile. Medicare would use its actuarial data and payment history in determining the capitated rate it pays per dual eligible patient, and this funding stream would continue to be updated.
CMS is developing a system of risk adjustment that includes not only health status but also geographic payment variation, frailty, and other factors which could be employed in this new program.
o States would have two options in setting their payments for the Medicaid portion of services for their dual-eligible residents:
Those states that decide to contract with private managed care plans to provide coordinated care for their dual populations could calculate an actuarially-sound capitated rate for the state share of the Medicaid set of services. The plans, not the state, would be at risk.
• While many states have experience in setting payments for Medicaid managed care, their experience is in settings payments for acute care services, not long-term care support. As a result, they would need assistance in calculating these capitated payments for state-financed Medicaid services for duals.
Those states that decide to operate the program themselves and assume the risk (as well as potentially garnering more savings) could make contributions based upon their own Medicaid payment experience for services for duals, again with assistance in making the calculations.
In either case, a transition period would be required where the federal government and the states would share the risk until they have gathered enough information to refine this new system of payments.
Whether the state chooses to contract with Medicaid Advantage managed care plans or to operate the program itself, the states would still receive a federal match for their Medicaid contribution based upon existing formulas.
• Alternatively, CMS/Medicaid could determine a capitated amount of Medicaid funds that it would allocate per recipient based upon data about the cost of its share of Medicaid-covered services in that state for this population.
o Drug coverage, currently paid by Medicare, would be integrated into the Medicaid Advantage plans. Medicare would calculate a Part D allocation that would be returned to each state in the form of a capitated, risk-adjusted payment. This would be another part of the patient’s Medicaid Advantage funding stream.
Since implementation of Part D that assigned duals to drug plans, skilled nursing facilities have had many problems tracking many different drug plans and formularies for these residents. Medicaid Advantage would provide a mechanism to coordinate drug coverage, as well as medical care, through one plan.
States would have access to the pharmacy data that they lost after the transition to Part D in January, 2006.
• The joint Federal and state Medicaid contributions plus the Federal Medicare and part D contributions would be combined into one funding stream to finance care for duals through the new Medicaid Advantage plans. States could use this pool of money in designing benefits for duals and negotiating with health plans that would deliver required services. Duals would receive a full range of services currently financed separately through Medicare and Medicaid through this new integrated program, from hospitalization and skilled nursing care to physicians’ visits, personal care, home and community based services, prescription drugs, diagnostic and laboratory tests, etc.
o States would gain new flexibility in designing benefit packages in exchange for receiving a capitated, risk-adjusted payment from Medicare with fewer strings attached.
• Once the Medicaid Advantage plan has agreed on a contracted fee, the plans would be at risk for providing care to dual eligibles (except for those states that decide to carry the risk themselves). The plans or state contractors would be responsible for providing care, for collecting and providing performance data on treatments and outcomes for each patient, and for reporting this information to the states for their monitoring activities. The plans would be accountable for outcomes with strict oversight by the states, but they would have the flexibility to manage care creatively to meet the needs of patients.
• States also would be given greater flexibility to coordinate treatment for those with mental illness through Medicaid Advantage plans. Providing targeted case management, rehabilitation services, medication management, community mental health center services, and other less-costly services through a Medicare Advantage medical home could reduce the use of expensive hospital and emergency room services while providing improved care for these patients.
• The Federal government and the States would be responsible for carefully monitoring the plans and for bringing action against plans that do not meet their contractual obligations.
Medicaid Advantage (MD-Advantage) would minimize the current incentive to avoid caring for the most costly patients and would better align incentives for Medicare, Medicaid, plans, and recipients. Medicaid Advantage would allow states to:
• Integrate acute and long-term care benefits into a single program they would oversee in which competing private plans (or the states) would provide a coordinated care management program for dually-eligible beneficiaries
• Share in the savings achieved through innovative policies, such as disease management and care coordination
• Streamline cumbersome rules governing marketing, enrollment, performance monitoring, quality reporting, rate setting, bidding, and grievances and appeals
• Eliminate redundant and inefficient spending
• Provide both the Federal and state governments more predictability in budgeting for the significant part of their Medicare and Medicaid spending on dual eligibles.

All American Senior Care

The CareGiver

Thursday, November 02, 2006

The CareGiver: My mother the Dynamo

My mother at the age of 85 was a dynamo. She lived on her own, paid her own bills, and took care of herself.......

My mother at the age of 85 was a dynamo. She lived on her own, paid her own bills, and took care of herself. She had been doing this for more than ten years since the death of my father. She was on her own.

My mother was often spotted walking to the pool in her community. A tiny women the senior citizens all around her marveled. It seemed as if father time had forgotten about her. There was no limit to what she could do. Walk 20 blocks, no problem, you name it.

My mother was very funny, a real character. She made people laugh and smile. She was also a wonderful person: always welcoming people into her home. She was noted for all of my 50 years for her great Italian cooking. I remember as a kid that all of my friends really looked forward to staying over our house. Donuts, spaghetti and meatballs you name it. Ravioli anyone?

Me? I was thinking about her for years knowing that someday she had to live with one of us (I have a brother and sister). I was there when my fathered "passed away'; this was when I really started thinking about it. As the years flew by I started to think about it more and more.

Sometimes we had discussions about putting my mother into some kind of "facility". But to be honest, to be honest now, I knew I would never be able to do it. While I had only mentioned it to a few people, I had made a promise to my father not long before he died. I promised him no matter what I would take care of his wife of 55 years, my mother, our love. Dot. It was not a promise I made haphazardly. I had made up my mind about this while we were taking care of my dying father. It seemed as natural to me as breathing.

I knew the day would come. I just didn't know when. Or how.

All American Senior Care

Vermont gives seniors more options for care

In this experimental program the State pays family, friends, or aides to assist seniors at home. This keeps them out of a nursing home. If successful this program could serve as a model for the entire nation.


Vermont gives seniors more options for care


November 2, 2006

WINOOSKI, Vt. -- At 93, Florence (Tubby) Parsons has a lot going for her. She has her cat, Buddy, the plants in her one-bedroom apartment to tend to and a weekly 25-cent poker game with neighbors.

Best of all, she doesn't have to live in a nursing home. Instead, she gets daily visits from a longtime friend who makes $10 an hour from the state to care for her.

She is part of a unique experiment in Vermont. Under the Choices for Care program, older adults who are eligible for Medicaid and need someone to tend to their needs can be cared for at home by a relative, friend or neighbor paid by the state.

"A nursing home? They sit there and moan and holler and sit in a chair and sleep. I don't want that," said Parsons, who has heart and thyroid problems and uses a walker to get around her apartment building.

Experts say the closely watched project could spur dramatic changes in the way the United States handles long-term care for elderly people.

One year after enacting it, Vermont officials say it is reducing the number of people sent to nursing homes, cutting the cost of taxpayer-funded care and improving the quality of life for people such as Parsons.

The nursing-home industry and other critics say subsidized home care by family members and other nonprofessionals is far from a panacea. They say the care isn't as good.

Parsons' former tenant, Penny Walsh, 41, gets paid $10 an hour for 35 to 40 hours of work a week. She said she took the job of caring for Parsons because she was already doing some of her cleaning and other chores for free.

"It's like seeing my grandmother every day," she said, sitting by Parsons' side during a Monday morning visit.

Previously, Walsh was a clerk and a worker at a day-care center.

Elder-care experts say the Vermont program could help blunt one of the longstanding criticisms of Medicaid -- that it shunts people into institutions without regard to what they really want.

Medicaid, which spent $38 billion on institutional care last year, wants to shift more toward home care and community-based systems, where "the medical dollars follow the needs of the patient, rather than the other way around," said Mary Kahn, a spokeswoman for the Centers for Medicare & Medicaid Services, the federal agency that administers the programs.

It costs Vermont about $122 a day for Medicaid-covered senior citizens who live in nursing homes, compared with about $80 a day for those being cared for in their homes.

Mary Shriver, executive director of the Vermont Health Care Association, a nursing home trade group, said that in-home care works for some but that it cannot match nursing home care for quality.

"Good intentions can cause some damage sometimes," she said.

Sometimes, good intentions are not enough.

"Typically, a family says, 'Sure, we can do this' and brings their grandparent into the home and starts into the role of caregiving and the state is paying them," said J. Churchill Hindes, president of the Visiting Nurse Association of Chittenden and Grand Isle Counties, a nonprofit home health care agency.

"And after a few months or a year, they realize how exhausting the work is, how emotionally draining it might be and just how hard it is."

Parsons' caregiver said the arrangement is working out great so far. Parsons said she likes the company and the help.

"She's been as close as family for a long time," Parsons said of Walsh. "You know what they say: You have to put up with your family, but you choose your friends. I chose her."

Crist, Davis differ on Medicaid overhaul

Republican Charlie Crist would continue Gov. Jeb Bush's shift from government simply paying the health care bills of Medicaid recipients to placing them in managed-care insurance programs. Democrat Jim Davis, a Tampa congressman, is at least partly opposed, saying that shifting all Medicaid patients involuntarily into private plans tries to "balance the Medicaid budget on the backs of people who depend on the state's health insurance program to stay out of hospitals."

Crist, Davis differ on Medicaid overhaul

Associated Press

TALLAHASSEE, Fla. - Medicaid has been obscured by homeowners' insurance, taxes and prescription costs, but the future of the program that provides health care to the state's poor, disabled and many elderly may depend on who wins Tuesday's gubernatorial election.

Republican Charlie Crist would continue Gov. Jeb Bush's shift from government simply paying the health care bills of Medicaid recipients to placing them in managed-care insurance programs.

Democrat Jim Davis, a Tampa congressman, is at least partly opposed, saying that shifting all Medicaid patients involuntarily into private plans tries to "balance the Medicaid budget on the backs of people who depend on the state's health insurance program to stay out of hospitals."

Florida's Medicaid program will cost about $16 billion this year - about $1 out of every $5 the state spends. Only education costs more.

Traditionally, Medicaid recipients - mostly the disabled and women with children who are close to the poverty line - have gone to see a participating health care provider, who then seeks reimbursement from the government. The program's costs are split between the state and the federal government.

In 2004, Bush proposed that the state place recipients in private health plans. The plans would have the ability to limit some benefits, such as which medicines may be purchased, and add others, like care for patients with HIV/AIDS or extensive prenatal care.

The idea was to force Medicaid recipients and their doctors to take some responsibility for their own care, which should lead to better health and save the state money, too.

But some advocates have worried it could lead to the most vulnerable patients not being guaranteed the options they currently have.

The shift has already started through test programs in the Jacksonville and Fort Lauderdale areas.

Crist, the state's attorney general, hasn't been a huge cheerleader for the Medicaid overhaul, but supports it.

"I certainly think the pilot's worth a try," Crist said. "Any way that we can spread those dollars and therefore be able to offer health care to more of the poor in our state I think is worthy.

"I think we're all aware how much Medicaid takes up of our state budget currently, and if we don't do something to strive to get a handle on it we're not going to be able to continue to provide the kind of health care that the poor deserve," Crist said.

Those who are skeptical of the changes say they are concerned the issue has been relegated to the campaign's periphery.

Neither candidate talks much about it on the campaign trail, focusing their health care discussions instead on prescription drug costs, and the question of importing medicine from Canada.

Bob Wychulis, president of the Florida Association of Health Plans, said his sense is that while the two candidates may differ on the details, neither is against allowing a managed care approach for at least some Medicaid patients.

Almost 1 million Florida Medicaid patients - about half of the total - have already gone into voluntary managed care programs over the last decade, and few of those have returned to more traditional programs, Wychulis said.

"Member satisfaction rates have been high in all the managed-care plans," he said.

Advocates for the elderly are worried about the planned next phase of the Medicaid overhaul, which will shift more nursing home care into managed care plans as well.

Nearly 50,000 of the 75,000 Florida nursing home residents have that care paid for by Medicaid. Under the proposed "Florida Senior Care" plan, nursing home patients could be shifted into HMOs, which would manage their nursing home care.

One group that has concerns is the massive senior lobby, AARP, although like other nonprofits it can't endorse candidates.

AARP argues that managed care may be fine for some nursing home patients, but shouldn't be mandatory.

"Consumers want the opportunity to make their own decisions about long-term services and supports so they can maintain their dignity and maximize their independence," the group said in a recent issue paper.

AARP spokesman Dave Bruns said many managed-care plans wouldn't likely let seniors pick their own long-term care facility.

"Our biggest concern is freedom of choice," Bruns said.