The VA will only pay for or subsidize veterans who need nursing home care due to a service-connected disability or any vet with a combined service-connected disability rating of 70% or more and who need skilled nursing care. The VA only provides nursing home care for individuals in other categories IF beds and resources are available.

Limitations of VA Nursing Homes in Michigan

One of the biggest limitations of VA Nursing homes, even if you qualify in Michigan is their location.  In Michigan there are two VA Nursing Homes in the whole state.  There is is one in Marquette and the other is in the Grand Rapids area.  Not very helpful if your loved one is a Veteran in the Brighton, Livonia, Metro-Detroit area.

Furthermore, you can’t just decide you are going to a VA nursing home, even if you believe you meet the level of care and rating requirements. There is a process to be evaluated for VA nursing home care. You must first be enrolled for Veterans Health Benefits, which is another process in and of itself and can include an evaluation of income and assets.  Then, once enrolled with the Veterans Health Administration, you must then be evaluated by a primary care provider or a geriatric specialist for nursing home care.

Moreover, if you are a surviving spouse of a Veteran you may not qualify for a VA Nursing Home at all.

You can learn more about VA Care at their website.

VA Benefits for Nursing Home, Assisted Living and Home Care

Now the VA will not pay your entire nursing home, but there is a VA Benefit that will help pay for home care, assisted living or nursing home care called the Aid & Attendance Benefit.

This year the VA Aid & Attendance Benefit maxes out at $2,120 per month.  Now this will not cover the whole cost of nursing home care, which can run over $12,500 per month in Michigan, but it will help ease some of the burden, especially of assisted living or home care.

Medicaid and VA Benefits Together

Typically, if you are a veteran or surviving spouse of a veteran we, at The Elder Care Firm, will help families link their VA Benefits and Medicaid by initially qualifying the family for the VA Benefit when they need home care or assisted living.  However, once the loved one transitions to a nursing home, we will help them qualify for Medicaid by sheltering their resources.  The net effect is until the family needs nursing home care, we help bring in up to $2,120 per month, then once nursing home is needed, Medicaid picks up a majority of the nursing home cost.

Planning ahead for VA Benefits and Medicaid

The earlier a family starts planning for a Veteran or surviving spouse of a veteran, the more options are on the table as the loved one navigates the long-term care journey.  Often, as VA Accredited Elder Law Attorneys, we utilize special asset protection trusts to help qualify for the VA Benefit or Medicaid.

The post Will The VA (Veteran’s Administration) Pay My Nursing Home Care appeared first on Michigan Estate Planning.

A life insurance conversion allows policy holders to use their life insurance as income to pay for assisted living. This process can be complex, and is not available with every policy; however, for many life insurance purchases, it can serve as a tax-free loan.

People who own life insurance policies also have the option of selling their policy with a life settlement or a viatical settlement. Both types of settlements allow the policy holder to sell the policy for more than its surrender value, but less than the death benefit.

Reverse mortgages allow homeowners to use the equity on their home to receive cash, allowing seniors to receive money to pay for assisted living expenses and other expenses they may not be able to cover otherwise. With a reverse mortgage, the lender actually makes payments to the borrower, rather than the other way around.

Long-term care insurance is available, but can be expensive for older adults, with potentially limited benefits. Older adults who already require assisted living are unlikely to qualify for long-term care insurance. Because of the high cost and potential limitations, long-term care insurance is not right for everyone.

Government benefits are also available to older adults who cannot afford assisted living on their own. Veterans may qualify for the Aid and Attendance Benefit through the Veterans Administration. Thanks to Medicaid expansion, more older adults than ever also qualify for Medicaid, which can help pay for assisted living in some cases.

The elder law attorneys at Hook Law Center assist Virginia families with will preparation, trust & estate administration, guardianships and conservatorships, long-term care planning, special needs planning, veterans benefits, and more. To learn more, visit http://www.hooklawcenter.com/ or call 757-399-7506.

by Thomas D. Begley, Jr., CELA

Families of many individuals who require long-term care believe that their only option is to place their loved one in a nursing home. Actually, there is an eight-step continuum of care:

• Informal Caregiving. Most care for Alzheimer’s patients is provided by informal caregiving provided by a family member or friend who aids and supervises the daily care of the patient.

• Geriatric Care Managers. Geriatric Care Managers generally perform six functions: an initial assessment of the patient, development of a Care Plan, implementation and coordination of the Care Plan, monitoring services, appropriate re-assessment, and appropriate discharge.

• Adult Day Care. There are two types of adult day care facilities. One is medical, the other is non-medical. Transportation is generally provided by the adult day care facility to pick up the patient at home and transport them to the adult day care center and return the patient at the end of the day.

• Home Health Care. Elderly persons who require care almost universally prefer to receive the care in the comfort of their own homes. They are familiar with their surroundings, often with loved ones nearby. Home health care is also often less expensive than institutional care.

• Assisted Living. Approximately one million people live in assisted living facilities. Typically, they provide custodial care and are usually not licensed to provide skilled care.

• Nursing Homes. Nursing homes provide skilled nursing care and related services as well as custodial care for residents.

• Continuing Care Retirement Communities. Continuing care retirement communities (CCRCs) are an excellent type of long-term care for the middle and upper-middle income population. Typically residents enter independent living facilities, such as an apartment, and then as their health declines they are eligible to move on to assisted living and then ultimately a nursing home at the same campus as such care is required.

• Hospice is designed for people who no longer want medical treatment and are preparing to die.

Preparing for retirement and the unexpected long term care costs can deplete some and all of your savings. Having a cushion of dollars set aside to protect your savings and your family members lifestyles when this event occurs can be an advantage to everyone.

Long Term Care insurance is one way to offset Home Care, Assisted Living and Nursing Home expenses. The average cost of care in Southeastern Michigan is anywhere between $85,000-$100,000 per year.

Premiums to protect these costs are built on a benefit amount and your age. Each year you wait to buy, premiums will be higher. Oh and don’t forget there is underwriting. Locking in your age and health is key to this protection!

Learn more about various options to pay for care, Nancy Boari is a Long Term Care Specialist with over 20 years experience in health care and 15 years as a LTC Specialist. Let Nancy educate you and your family with this important conversation.

To learn more contanct Nancy via email at nancy.boari@nm.com

The post Long Term Care Insurance…….One Way to Protect Yourself and Your Family appeared first on Estate Planning Lawyers | Elder Law Attorneys | Brighton | Novi | Livonia Elder Law Attorneys.

Assisted living facilities currently provide care for close to three quarters of a million seniors nationwide. a number that will surely rise as Baby Boomers continue to age.

Despite the growth over the past number of years, no federal regulation has been put in place, while supervision remains spotty, varying from state to state. And all indications suggest that the industry likes things just the way they are.

(Related: Seven Questions To Ask When Searching for Assisted Living)

“Assisted living is the rock we don’t want to look under,” said Catherine Hawes, a professor at Texas A&M University’s Health Science Center who conducted a national study of the system.

Consumer advocates say that at best, families are having trouble finding a safe, quality home for their loved one. At worst, loved ones are neglected in poor conditions that could even result in death.

As a reaction to nursing homes, assisted living started in 1980s a reaction to nursing homes, which were more geared toward hospitalizations, and as a means to provide seniors with additional choice and independence.

Over time, assisted living has evolved to house seniors who require specialized care, like dementia or Alzheimer’s patients. Constantine Lyketsos, a geriatric psychiatrist and researcher at Johns Hopkins University, told FRONTLINE that is a study of residents in assisted living in Maryland, two-thirds had dementia.

As a result, more people have greater needs, and more specialized attention — and, some senior advocates contend, more advanced regulations to guarantee the safety and quality of care of residents.

(Related: Obamacare and Long-Term Care Insurance)

Without federal regulations, states are able to determine their own standards to the point of creating their own definition of what constitutes an assisted-living facility. A number of states employ the hands-off approach as a result of lacking time and resources, or because they didn’t foresee the shift in residents.

“The largest problem was that assisted living was melding into nursing home care,” Dean Lerner, the former head regulator of assisted living in Iowa, told FRONTLINE. “Who’s taking care of these people, and what are the laws that require them to be kept safe?”

Most states enforce their own regulations through random surveys of facilities. Regulators log violations during these surveys that can result in fines or potentially losing their license.

Common when self-regulating, a number of states are failing to collect what consumer advocates say are key data point, like how many times residents fall, if mistakes were made in giving out medication, or other points that are easily acquired for nursing homes.

Even in the instances where information exists that consumers are looking for, accessing said information is a horse of another color. Certain states will make the information online or even issue “report cards” on facilities, but not all states offer such a courtesy.

Industry advocates feel that evaluating an assisted-living facility with data fails to capture the complete experience of residents.

“While regulation is important, it is not necessarily a panacea,” Mark Parkinson, president and CEO of the American Health Care Association, an industry trade group, told FRONTLINE. “Regulation that is done smartly, that promotes person-centered care, that promotes quality outcomes is great. But regulation that creates regimens, institutional-type settings and really takes away from some of the benefits of assisted living would be a negative thing.”

State affiliates operate on behalf of the industry to keep restrictions in check. “It’s easier for lobbyists in the industry to fight regulation on a state-by-state basis” because typically, state legislators lack the knowledge or expertise that the industry utilizes in the debate, said John Bowblis, an economist at Miami University’s Farmer School of Business.

In 2008, Lerner, the former head regulator for health facilities in the state, tried to increase the penalties for elder abuse and have those convicted of the offense placed on a registry barring them from working at a facility for a period of time.

(Related: Nursing Home Use By Medicaid Senior Plummeting)

The health-care industry vehemently fought the law, accusing Lerner of “criminalizing” those who work in their facilities. The law that eventually passed set higher standards for showing abuse, requiring the state to show gross misconduct opposed to negligence.

“All in all it was a good thing to have gotten it passed, even in a semi-watered down fashion,” he said.

Most states lack the resources to hold facilities accountable. Take California as an example, where they only visit facilities every five years. In the instances when they do find a violation, citations are so weak that they make little impact. In California, FRONTLINE found five deaths in recent years in Emeritus facilities for which the company was found negligent by the state. The standard fine? $150.

When they do find a violation, often the citations are so weak they don’t seem to make much of an impact. In California, for example, FRONTLINE and ProPublica found five deaths in recent years in Emeritus facilities for which the company was found negligent by the state. The typical fine? $150.

“The residents in these facilities are citizens of the state, and they’re physically and often cognitively vulnerable,” Hawes, the consumer advocate, said. “It’s the state’s responsibility to ensure that things are safe and the quality is adequate. The argument ought to be why isn’t the state adequately funding this process? Why isn’t the legislature providing the funds that are needed?”

The Assisted Living Federation of American, known as ALFA, says it supports “meaningful and appropriate oversight” of senior living in each state. A list of standards and policies that it supports is listed on the website, including background checks on employees and trained staff members.

With that said, ALFA is adamant that federal oversight isn’t necessary and lobbies in Washington D.C. to ensure that doesn’t happen. They maintain national branch with a political-action committee and sponsor annual fly-ins for members to meet with members of Congress to advocate for bills.

(Related: Long-Term-Care Insurance Dilemma)

“We’ve become a very powerful organization in just a few years, because our board of directors, our staff have realized the importance of advocacy towards achieving the kinds of things we want done,” said Richard Grimes, ALFA’s president and chief executive, in a promotional video posted online.

A major industry priority is legislation to allow seniors to sell their life-insurance policies to a third party to pay for assisted-living care. Texas and Kentucky have already passed such laws. Maine, Florida and Louisiana are considering it.

The Centers for Medicare and Medicaid Services, known as CMS, intends to establish a definition of assisted-living facilities, in what would result in the first federal effort to get involved in assisted-living standards.

While it isn’t expected to impose regulations like staffing quotas or training requirements, it would establish guidelines to distinguish these facilities from nursing homes, like the ability of residents to make private phones calls or receive visitors at any hour. A time frame for these guidelines has yet to be set.

Along with other industry advocates ALFA argues that the free market, more than state regulators, will keep the industry regulated. If residents or their families don’t like a facility, they can take their money elsewhere.

(Related: Health Insurance Scams On The Rise)

“The answer is [to] be an advocate for your mom or dad, go in to the facility, talk to the people that are actually going to take care of them, and then talk to other folks who have their moms or dads or grandparents and find out what it’s really like,” Parkinson said. “That’s the way that you find out what facilities are all about.”

Read more: http://www.pbs.org/wgbh/pages/frontline/social-issues/life-and-death-in-assisted-living/whos-looking-out-for-seniors/

Christopher J. Berry is an elder law lawyer in Michigan Dedicated to helping seniors, veterans and their families navigate the long-term care maze. To learn more visit http://www.theeldercarefirm.com/ or call 248.481.4000

It can be extremely difficult to find reliable data on assisted living. Federal and state statistics are not easy to discover and it’s often easier to search for hotel reviews in Mexico than it is to locate rating and reviews for a local assisted living facility.

So where should you begin to look if you are considering sending a loved one to assisted living? After questioning a number of experts, this is what they had to say.

1. What Are Your Needs?

First off, it is imperative to understand what level of care you require and how that may change with age. This is especially true in the case of seniors with dementia. A 2009 study by Johns Hopkins University found that 46 percent of assisted living residents suffered from at least three chronic conditions, yet only 54.5 percent of facilities surveyed in the study had a registered nurse or a licensed practical nurse on staff. As the survey authors note, “Some residents with multiple, complex medical conditions present a challenge that some [assisted living facilities] may not be prepared to manage.”

In some cases nursing homes may be the better solution for seniors.

“So many people have heard their mother say, ‘Promise me you’ll never send me to a nursing home.’ And a lot of people make a mistake in choosing assisted living because it looks nice rather than what the person really needs,” says Catherine Hawes, director of the Program on Aging and Long-Term Care Policy at Texas A&M University.

(Related: Alzheimer’s Disease Improved by Exercise, University of Maryland Study Shows)

2. Have You Made A Visit?

If you have decided on assisted living, visit prospective facilities a number of times. Experts recommend visiting at different times of the day — mealtimes are a great place to begin.

Don’t be content with a tour of the building from the director, they say. Take the time to speak with residents and staff for a sense of the facility’s culture and environment. Question the available services and what staffing is like throughout the day and at night. To gain insight into the reliability of their services, ask about turnover as well.

And for residents with dementia, it’s important to understand how the facility manages their care and safety: what type of programming is available? Are the doors locked at night for residents who wander?

Checklists for visiting an assisted living facility are available from several organizations, including the AARP, the Alzheimer’s Association, California Advocates for Nursing Home Reform, the Assisted Living Consumer Alliance and the Long Term Care Community Coalition, among others.

(Related: If you have Alzheimer’s or Dementia, there’s a Group waiting for You)

3. For-Profit or Non-Profit?

This designation may influence how resources are allocated for care. Close to 82 percent of residential care facilities are privates, for-profit facilities, with close to four in 10 belonging to a national chain. Such for-profit chains often have “requirements for a return on revenue that mean that they’re always pressing for higher occupancy and for constraining variable costs, and the variable costs are staffing and food, and to some degree, activities.”

From 2006 to 2011, for example, profit margins at privately owned assisted living facilities went from 3.5 percent to 6.4 percent, according to research from Sageworks, a financial information company. Those gains corresponded with drop in payrolls from 45 percent of sales in 2004 to 38 percent in 2012.

That’s not to say you ought to dismiss for-profits and focus exclusively on non-profits because there are good and bad facilities in each category.

4. Cost

Since assisted living is not covered by Medicare, it can be expensive. in 2012 the average monthly base rate in an assisted living facility rose to $3,550, according to a survey by MetLife. Rates can reach up $9,000 a month in some states.

Also, be weary of charges for additional services. Some facilities will charge a resident extra for meal delivery, while others tack on fees for services such as transportation to and from the facility, or laundry and housekeeping.

(Related: Obamacare and Long-Term Care Insurance)

5. What’s in the Admissions Agreement?

Experts advise you to take your time and the admission agreement carefully. On occasion the fine print will reveal language requiring 30 days notice to stop billing for service, even if the resident has died, says Patricia McGinnis, executive director of California Advocates for Nursing Home Reform.

Negotiated risk agreements are another red flag. These clauses are often offered as a way for residents to make preferred choices about their care, even if they prevent risks. McGinnis warns, if something goes wrong, “You have signed away your right to sue.”

The same problem can be realized through liability waivers, which are common in admission agreements.

“To me, that is a sign that the facility may not have either the ability or the commitment to meeting your needs,” says Nina Kohn, a professor of law specializing in elder law at Syracuse University.  ”If you’re confronted with a contract with that kind of liability waiver, I think it’s reasonable to say, ‘I’m going to cross out that provision.’ See how the facility responds.”

Consult with an elder law attorney if any portion of the admission agreement is unclear. The American Bar Association also provides a checklist for choosing an assisted living facility.

6. Where is the Facility?

While it’s convenient to find a residence that’s close to friends and family, experts caution against allowing that to be your deciding factor.

“It is really important to have a place that’s easy to visit, but it’s more important to find a facility that’s really good,” says Hawes of Texas A&M. “Don’t choose a facility that’s five minutes closer to you, or 10 minutes closer to you just because of that. Make sure that you’re getting the best facility for what your loved one needs, and be realistic about what they need.”

7. What Does the Ombudsman Say?

Experts recommend contacting the long-term care ombudsmen for your local area for additional checklists or information on any citations against a facility. Additionally, they will answer any other questions you may have

Karen Love, president of the Center for Excellence in Assisted Living, says to look out for any medication administration violations. She also suggests asking “Have they been cited for not having staff trained, if it’s a state requirement, and have they gotten dinged for not having enough staff, again if that is a state requirement?”

The National Long-Term Care Ombudsman Resource Center provides a map on its website with contact information for ombudsmen in all 50 states.

Read more: http://www.pbs.org/wgbh/pages/frontline/social-issues/life-and-death-in-assisted-living/seven-questions-to-ask-when-searching-for-assisted-living/

Christopher J. Berry is a Michigan elder law attorney Dedicated to helping seniors, veterans and their families navigate the long-term care maze. To learn more visit http://www.theeldercarefirm.com/ or call 248.481.4000

by Elizabeth Rosto Sitko
Culture change is driving most of the innovations we’re seeing in long-term care dining today.
Rather than cookie cutter meals, residents and their families are looking for updated dining
programs that allow for more choices on a daily basis. “Families want to ensure that their loved
ones are eating first and foremost, but also that they want to eat and enjoy what they are eating,”
said Jeremy T. Manners, CDM, CFPP, FMP, culinary and nutrition director, West Haven Manor,
a 257-bed skilled and personal care facility in Apollo, Pa. Residents who are happy and healthy
will ultimately have better outcomes. If you’re looking for new ways to innovate your dining
program, here’s a glance at some of the latest trends in the long-term care dining landscape.

Honoring Resident Requests
Most people don’t like to eat the same things over and over, so be sure to update your menus
frequently with new items. “Residents easily get bored with the same items all the time, so by
changing it up frequently and adding new items or recipes, they get refreshed,” Manners said.
West Haven Manor’s dining department is seeing a lot more requests for items such as tacos,
pizza and Chinese food, he added. Buena Vida CCRC, a 240-bed facility with a 30-bed assisted
living facility in Brooklyn, N.Y, has a large Hispanic population. So residents are always asking
for Spanish dishes, according to Evelyn Conner, CDM, CFPP, director of food and nutrition
services.

“We have added arroz con pollo, yucca four different ways weekly, white sweet potatoes and
sancocho soup [a nourishing stew popular throughout the Latin World]. Every month we have
menu planning meetings with the residents, which allow them to sample different food items,”
she explained. Recently, they sampled chana masala, an Indian dish of chickpeas with onions,
tomatoes and spice. “These meetings allow the residents to agree on items that they would like to
have added to the menus and enhances their evolvement in their care. I’m constantly looking for
Spanish entrees to add to the menus in order to increase the resident satisfaction with their dining
experience,” Conner said.

‘Round the Clock Service
West Haven Manor added a 24-hour menu and a third shift team member to create a 24-hour
foodservice program. The facility has seen an increase in non-traditional residents, middle aged
residents coming in for rehab after knee or hip surgery, and even younger residents in their 20s
and 30s coming for IV therapy. “Many of these residents lead different lifestyles while at home,
up late at night for example, and while in our care, we don’t expect them to just change their
usual habits. Many of these residents are taking advantage of an empty lounge to play Wii, others
are simply utilizing the WiFi from their room to surf the internet,” Manners said. “At home these
folks would be snacking on something more likely than not, so again, why make them change all
of their habits just because they are temporarily residing in a nursing home?” This service has
been very successful since they started the 24-hour meal program in January of 2012, Manners
said. To balance offering many options but not letting food go to waste, many of the items on the
24-hour menu are quick options that can be kept on hand and are easily prepared. After working
with their foodservice distributor, they selected a pre-cooked burger, pre-grilled chicken breast,
along with other choices like individual slices of stuffed crust pizza. These items are all quickly
prepared in a microwave or countertop pizza oven, Manners explained.

Buffet Stations
With the addition of a buffet table to the main dining room, Manners said, West Haven Manor
can offer a variety of options at meal times based on a par level system-that is, a stocking
quantity is established for each item based on average usage and a target number of days’ supply.
Many of the items already available on the late night menu can be offered here as well with the
addition of special items or seasonal items from time to time.
A Healthcare Team Without Doctors……Really???

by Dr. Steven Fuller
There are 624,434 U.S. physicians (AHRQ, 2010), but only 0.6% of them would ever consider
entering an Assisted Living Community (ALC) to provide on-site care. There are more than
36,000 ALCs in the US caring for over 1 million fragile older adults (ALFA 2011), but you are
literally more likely to be struck by lightning than to ever see a doctor walk through the doors of
any of these communities!

The first ALC began in 1981 to care for the Founder’s mother who was in her early 60s (The
History of Assisted Living, www.assistedlivinghistory.com). These Communities were
originally promoted to provide a supportive, primarily non-medical living environment to bridge
the gap between independent living and the nursing home. But the landscape for ALCs has
dramatically changed since their inception.

The average age of an ALC resident is now 87 years (Harris-Wallace et al, 2011, Seniors
Housing & Care Journal). Thirty-seven percent of residents receive assistance with 3 or more
activities of daily living (NCAL 2012), greater than half of the residents have 2 or more chronic
medical conditions and are taking multiple medications having a variety of potential side effects,
and 42% have at least some degree of memory impairment or dementia (NCAL 2012).

ALCs are no longer predominantly non-medical communities. They have high acuity residents,
and this will only intensify in the future due to a very competitive market as well as resident
expectations to age in place and experience the progression of chronic medical conditions in one
setting that provides ongoing care and monitoring.

In other words, times have changed. But the problem is…our thinking hasn’t! Our thinking is
stuck back in the 1980s and hasn’t kept pace with the changing demands and expectations
residents impose on ALCs. The healthcare team that provides medical oversight of residents in
ALCs is led either by non-medically trained administrators or by nurses with additional support
from aides and assistants. But there is a glaring omission: WHERE ARE THE DOCTORS???

Just as in the 1980s, we keep hauling our residents off-site all over town to a variety of doctor’s
offices just to get their basic primary care needs met. But this isn’t the 1980s any longer! These
residents are 20 years older, much more fragile on average, and all these off-site trips are
incredibly stressful not only on the residents but also their families as well as the ALCs and their
employees. We can and must do better!

It is no longer appropriate to be thinking as we did in the 1980s and have predominantly off-site
physician care. And it is no longer acceptable to have the supervisory medical team not include a
fully engaged physician who provides on-site care.

ALCs and physicians MUST come together and meet the demand of caring for high acuity
patients in the community setting. The direction of modern healthcare delivery is TOWARD
THE COMMUNITY to proactively keep people as healthy as possible at home and AWAY
FROM HIGH COST INSTITUTIONS that only care for patients reactively after they become ill.
This reversal in the direction of healthcare delivery falls right in the laps of ALCs, and the
pressure to care for higher acuity residents will therefore only increase. This also means that
on-site care by physicians offered to ALL residents should no longer be a luxury but MUST be a
REALITY.

There are a few innovative healthcare models now available that encourage ALCs and physicians
to each put “skin in the game” and come together as PARTNERS
(http://housecalls-llc.com/articles/physicians-must-partner-with-retirement-communities-and-her
es-why). To meet the new demands that confront this partnership is surprisingly easy and not
intimidating and can happen overnight. The biggest obstacle is in our thinking: WE MUST
THINK DIFFERENTLY
(http://housecalls-llc.com/articles/think-the-same-stay-the-same-think-differently-and-thrive/).

If we think differently…if we bring physicians and ALCs together as partners, we will discover
that EVERYBODY WINS!

Compression Therapy Equipment Available From Vascular PRN Treats Diabetic Ulcers

Vascular PRN offers compression therapy devices that help promote blood flow to prevent and
heal diabetic ulcers.

Ulcers on the legs and feet are a major complication of diabetes. They occur in 15% of all
diabetes patients. Without prompt and effective treatment, they can leave doctors no alternative
but partial leg amputation. Diabetic ulcers precede 84% of all lower leg amputations.

“Our compression therapy equipment gently compresses the leg to increase the flow of oxygen-
rich blood,” said Greg Grambor, president of Vascular PRN. “Compression therapy is effective,
inexpensive, and completely non-invasive.”

The direct cause of diabetic ulcers is the subject of debate within the medical community, but it
is widely agreed that insufficient blood flow is a dominant contributor to the condition.
Treatments for diabetic ulcers other than compression therapy include topical and internal drugs
and surgery, each of which has a number of potential complications.

Grambor also pointed out the use of compression therapy as a preventive measure.

“Compression therapy is a good option even after a diabetic leg ulcer has healed because it helps
prevent recurrences of the wounds,” Grambor said. “Studies have shown that up to half of all
diabetic ulcers recur within five years of healing.”

The U.S. Centers for Disease Control and Prevention last year released its Diabetes Report Card
2012, the result of a survey of diabetes patients nationwide. That survey showed that just over
two thirds of diabetic adults in the U.S. received their recommended annual foot exam in 2009-
10.

“Patients themselves take an active role in preventing these wounds as well through a regimen of
self-examination and proper cleaning of the feet. When doctors combine compression therapy
with patient education, the ongoing prevention of diabetic foot ulcers can be very manageable for
patients,” added Grambor.

Based in Tampa, Florida, Vascular PRN is a leading national distributor of compression therapy
equipment, serving nursing homes, hospitals, surgery centers and other institutions in all 50
states.

Assisted-living facilities became popular in the early 1980s, appealing to older individuals who wanted more support than they could afford to receive at home, while not yet needing the full services of a nursing facility. An assisted-living residence allows seniors to maintain much of their independence, with the added benefits of a built-in community and services. But keep in mind that though it is usually a transition residence, many seniors move in without thinking about how the move is a short-term solution. You may find a facility that offers a bus to take you shopping or has staff on hand to help with laundry, but if you become debilitated or develop a degenerative condition, the assisted-living facility may not be able to accommodate your needs. When looking for a facility, keep in mind what services and support you may need down the road, and if your changing needs can be accommodated.

In Texas, an assisted-living facility is defined as a facility which provides assistance with “activities of daily living.” Under that umbrella, there are several types of assisted living facilities:

Assisted Living – Type A
Residents must be able (both physically and mentally) to evacuate the facility unaided in the event of an emergency, must not require supervision during sleeping hours, must be able to follow directions.

Assisted Living – Type B
Residents may require staff assistance to evacuate the facility during an emergency, may be incapable of following directions, may require some supervision during nighttime sleeping hours, and may require assistance to transfer to and from a wheelchair. An assisted-living facility in Texas which has a unit solely for residents with dementia or Alzheimer’s is required to be a Type B licensed facility. The staff of that unit is required to have completed specific training to best work with the needs of those residents.

Assisted Living – Type C
Type C facilities are multiple-bed, adult foster care programs.

Assisted Living – Type D
Residents must be independent, needing no assistance with activities of daily living except for minor supervision such as the dispensing of medications or assisting with blood pressure monitoring. Residents must be able to evacuate the facility within three minutes during an emergency and need no supervision while sleeping.

While residents tend to think of an assisted-living facility as a place where they will be safer and well-cared-for, it is important to note that there is no uniform, federally-mandated licensing for assisted-living facilities, and no standard for training of staff. Some states require as many as 25 hours of training by staff, other states only require that specific topics are covered in training.

The cost to live in an assisted living residence in Texas can be as low as $1,300 per month to as high as $6,000 per month; the average cost is $2,600 per month, according to the database at www.assistedlivingfacilities.org which compiled information on the 54 largest facilities in the state.

If you have concerns about an assisted-living facility or want to know more about your options, contact an elder law attorney at The Hale Law Firm.

The Hale Law Firm believe the right solution to your estate planning, elder law, or probate needs can be identified in a free initial consultation with one of our attorneys and counselors at law. To learn more or to contact a Dallas estate planning attorney, visit http://www.thehalelawfirm.com/ or call 972.351.0000

Health systems are re-examining their post-acute care strategies and SNF partnerships.

By Julie Schulz, MD

After steadily migrating out of the skilled nursing facility (SNF) market over the past decade,health systems are re-examining their post-acute care (PAC) strategies and the potential value of SNF partnerships. This renewed consideration is directly tied to health systems’ growing accountability for the quality and cost of services delivered across the care continuum, including the need to improve care continuity, reduce readmissions and improve patient and family satisfaction.
Aside from discharges to home, SNFs are the most common post-acute destination, representing 19 percent of PAC transfers. Partnerships with freestanding SNFs provide an effective option for hospitals to improve PAC quality and efficiency without the financial risk of ownership.
Readmission penalties and a shift toward bundled payment for full episodes of care will require hospitals to more actively oversee the services their patients receive after transfer to a SNF. Congestive heart failure and pneumonia, two of the three conditions for which readmission penalties began in 2012, are among the top 10 diagnostic-related groups for SNF admissions.Additionally, joint replacements likely will be among the first procedures to be reimbursed through bundled payments that include PAC, given their high volumes and expenditures among Medicare patients.
New Care Pathways
Cost per case, length of stay and readmission rates vary significantly across SNFs. Even compared with other PAC sites, SNFs have notoriously high risk-adjusted readmission rates. The most effective health system-SNF relationships will have both the right partnership structure and care delivery model to avoid readmission penalties and improve PAC. To begin, there areseven major building blocks that can optimize the role SNFs play within a system of care(clinical alignment and resource effectiveness). How an individual system prioritizes these building blocks will depend on its service portfolio and local market dynamics.
Care pathways: Ensure that hospitals and SNFs work together to develop evidence-based protocols that standardize and optimize care across acute and PAC settings.Care coordination: Form cross-continuum teams that cover both PAC and acute care sites to identify and address problems in care transitions, using coordinators to bridge both settings.Quality rehabilitation: Ensure that inpatient discharge planners are familiar with the therapy staff and technology available at area SNFs to select destinations that best meet patients’ rehabilitation needs. Alignment strategy: Inventory area PAC facilities to determine SNF supply and alternate PAC options. Identify top performers in quality metrics to help patients make educated SNF choices.This may include the decision to create a formal SNF network. Handoffs/communication: Engage hospital physicians to increase their accountability for handoffs and any subsequent read missions. Better link patients’ primary care physicians with emergency department physicians to avert avoidable admissions. Create comprehensive medication and personalized care records for all patients.Information technology: Explore software applications that enable discharge planners to search electronically for area SNFs that best match patients’ care needs. Automate data sharing with SNF medical directors on key quality metrics.Transfers/access: Utilize a standardized transfer form, formalize a referral system with area SNFs and facilitate real-time information on bed availability. Future Considerations: A number of variables must be considered when determining how SNFs factor into your system’s ability to optimize care across the continuum and respond to changing market conditions and payment models.  Begin by determining your organization’s short- and long-term strategy for working with — and possibly within — the PAC sector (i.e., partnership, ownership, conversion to becoming a PAC provider). Along with this, evaluate whether your organization intends to pursue bundled payment projects or risk-sharing models that will include PAC services.  Next,assess your current case mix of patients discharged to SNFs to determine the demand for rehabilitation services vs. medically complex services. Hold regular forums for collaboration between hospital and SNF medical directors, as well as chief nursing officers and PAC nursing staff. Forums should include the sharing of data on potentially avoidable admissions and readmissions and root cause analyses for problematic trends.

Giving Positive Feedback to Staff Nurses managers can empower staff to advocate for quality care.

By Joan M. Lorenz, RN, PMHCNS-BC

When Mildred Jones, RN, became the nurse manager on an acute psychiatric unit that had experienced a lack of leadership for many years, her goal was to raise the quality of patient care by advancing the staffs’ knowledge and empowering them to advocate for themselves and their patients. Each time Mildred walked through the unit her critical-thinking mind went into overdrive thinking about how much work needed to be done.  Occasionally, she pulled staff aside to alert them to the problems she noticed and shared with them the best practices for the current patient care situation. Her intent was to use point-in-time learning to raise awareness and provide guidance; however, some staff saw her actions as condemnation and ridicule. What could Mildred do? She asked for help from a trusted colleague and set about developing ways to give positive feedback.
Many nurses are like Mildred. Nursing education emphasizes critical thinking. Nurses are taught to approach patient care situations with an eye for what is out of place or needs attention. This makes us excellent observers and keen problem solvers. It becomes natural for us to enter a patient care situation and begin immediate analysis, often taking action and giving direction at the same time. Being able to do this is a great asset. But like any asset it can also be a liability as Nurse Manager Jones found out. Her critical thinking mind, allowed to dominate, looked for and found problems and immediately began to problem solve. However, this had negative consequences on her relationships with others.
Use Your Critical Eye to Find What Works
Giving positive feedback to others is crucial to any nurse’s work success and collegialrelationships with co-workers.  But many of us find that it does not comes naturally. Indeed, ifwe allow our critical thinking minds to take over, constantly seeking out problems, we often donot even see what is working well. Giving positive feedback to others takes practice. Whennurses become aware of an overactive critical thinking mind they can begin to practiceredirecting themselves to look for what is going well in addition for looking for what needsattention. So the road to giving positive feedback is to develop a more balanced approach to ourwork and relationships with co-workers. Allow your critical thinking mind to see what areas needto be addressed at the same time that you ask it to seek out what is going well and needs to beacknowledged and praised.  There are a variety of ways that you can balance your point of viewat work and help your critical thinking mind to become a more appreciative mind. Four things topractice include:
1. Developing an attitude of gratitude.
2. Actively looking for what is going well.
3. Letting people know how much you appreciate them
4. Using a gentle positive approach when giving constructive criticism
Develop an Attitude of Gratitude
How do you develop an attitude of gratitude? It’s simple – start by saying ‘thank you’.
In a work situation you can start by noticing the little things that people do each day. A simple’thank you’ can mean a lot. Go ahead – try it. Thank the CNA for making up the bed, combing the patient’s hair, changing the bed linens, or passing out the water for the patients. Thank a colleague for giving out medications on time, talking with a distraught family member, or taking the time to answer a patient’s question (even though it wasn’t his patient). At the end of the day,express thanks to your team members for making it a pleasant day. It is especially helpful to thank others when things haven’t gone so well, “Thanks for holding your cool today when everything seemed to break loose at the same time.”  When you do this you might see a smile creep across your colleague’s face – that in itself is a simple reward for your efforts. Of course,some might be suspicious of this new behavior. Reassure them by letting them know that you are trying to acknowledge what you have always noticed by kept to yourself. When you begin to say’thank you’ you might find too that you begin to notice more and more things to be thankful for.And who knows – it might become contagious.
Actively Look for What is Going Well
When you walk into a patient’s room remind your critical mind to look for what is going well notjust for what is not. Do not passively wait for something to strike you as going well. Seek it out.Some teams use a three-part evaluation for debriefing urgent work situations which can easily beapplied to any work situation. The evaluation asks the group to answer these questions:
What went well? What didn’t go well? What can we do differently next time?
This three-part evaluation helps give balance to the situation. By starting out with what went well we shift the emphasis to the positive and that gives us the opportunity to tell others know that we noticed their contributions. Using this evaluation also models for others a way to give positive feedback. After a stressful staff meeting, the team leader asked the group to list what went well. Members were able to list that even though there were a lot of differing opinions they liked that everyone was given time to express themselves and others were polite enough to listen.
Let People Know How Much You Appreciate Them
How do you show your appreciation of others? Are you genuine in your approach to those you work with? How often do you express appreciation to your team leaders, your Nurse Manger,you nursing administrators for a job well done? A simple “thanks for representing our views” at a hospital wide meeting can go a long way in letting your supervisor know that you appreciate her effort.
Use a Gentle Approach to Constructive Criticism
We all know there are times when we need to offer constructive criticism to others. Following these guidelines suggested by Susan M. Heathfield in “How to Hold a Difficult Conversation”might help make it go smoother. Seek permission to provide the feedback, saying for example: “May I offer a suggestion that might make that go easier for you?” Don’t just dive right in. Let the person know that you need to provide feedback that is difficult but important to share. Share what you’ve noticed in a kind way. Keep it centered on being helpful and on you and the other person. It’s counterproductive to say something like, “Everyone is talking about it.”  Keep it simple, e.g.: “I am talking with you about this concern because it impacts patient safety (goes against policy, seems to cause anxiety for the patient, causes confusion on the unit, etc.).”  Let the nurse know the positive impact her behavioral change will have on the situation. For instance, to a charge nurse staff complains is too aggressive, a nurse manager might say: “You understand the importance of staff working together in an efficient manner. But by lowering your voice and asking others for their opinions you can gain cooperation, reduce anxiety, and help us all get the job done faster”.  After applying some of these techniques to provide positive feedback Jones walks though the nursing unit with a better-tuned appreciative mind. Because she acknowledges the good she sees the staff are more receptive to her guidance because they now hear praise along with the instruction.

Vascular PRN now offers custom sewn pneumatic garments for bariatric patients
By Greg Grambor

Fitting a bariatric patient, particularly a very large patient, with lymphedema sleeves can be quite a challenge. Therapists,  LTC and hospital personnel go through a great deal of trouble, sometimes without a good outcome. Leg and arm sleeves are zipped together, two or three extension inserts are tried, often with little or no success in some of the largest patients. This is no longer a problem! Medical professionals can now contact Vascular PRN for custom sewn lymphedema sleeves. The company provides a measuring guide, measuring advice from trained experts, and in a few weeks, the patient’s lymphedema is being properly treated with pneumatic compression. Custom sleeves for amputees are also available, so now, no patient with lymphedema, no matter what the complication, needs to go without adequate treatment.
Prescribers are reminded that compression therapy should not be used during the inflammatory phlebitis process or during episodes of pulmonary embolism, congestive heart failure, pulmonary edema, suspected deep vein thrombosis or in any instances where increased venous and lymphatic return is undesirable. Vascular PRN may be reached at 800-886-4331.

Elderly woman stuck in nursing home elevator for 29 hours
by Robert Walker

As the holidays of 2012 wrapped up, millions of families across North America gathered to enjoy each others’ company, exchange presents and enjoy sumptuous food. But for one woman living in a Canadian nursing home didn’t have the chance to spend the holidays with friends; instead, she spent 29 hours stuck in the home’s elevator. As reported in the Sun News Network, 87 year-old Rosalie Rowsell, a resident of Malton Village Long Term Care Facility, a Toronto assisted living community, returned to the community in the evening of December 23 after spending time with family. It was then Rowsell is believed to have been stuck in an off-duty residential elevator, and although she did not return to her room that evening, staff believed she was still with her family. Rowsell was found 29 hours, still in the elevator, after her family realized she never made it home. The news source reports that she could not reach the elevator’s emergency button to call for assistance. She was eventually found on December 25 in the elevator, and after being taken to hospital, she was released the same day. As a result of the incident, the Ontario Ministry of Health and Long-Term Care is conducting an investigation to determine what went wrong. The assisted living community is apologetic, and vows to prevent any such incidents in the future. “We sincerely regret that this gap in our duty resulted in endangering a resident and causing her family distress,” Emil Kolb of the Region of Peel, which operates the facility, told the news source.

Mean Girls in Assisted Living. What happens to bullies? Some of them become old bullies.

By Paula Span

When Rhea Basroon’s mother moved into a New Jersey assisted living facility a few years ago,she found a good friend in an new neighbor named Irene. Her daughters, long concerned that their widowed mother had become isolated and depressed, were initially delighted. “She and Irene were inseparable,” Ms. Basroon told me. “Whenever there was an activity, they’d both go.Whoever got there first saved a seat.” The two even discouraged others from joining them: “It was just her and Irene.” Then, disaster. Irene was lured away by another resident, abandoning Ms. Basroon’s mother. “She was so lonely. There was no one else she’d bonded with,” Ms. Basroon recalled. “She was completely devastated.” But wait! The third woman apparently eventually tired of her prize, or perhaps moved on to other prey. “She dumped Irene, and Irene came back to my mother,” Ms. Basroon said. They remained fast friends until Irene’s death several months later. In senior residences, Ms. Basroon concluded, “it’s like junior high, with that cliquishness, that excluding” of others. This phenomenon, a sort of social bullying, apparently comes as no surprise to administrators of senior apartments, assisted living facilities, nursing homes and senior centers. “What happens to mean girls? Some of them go on to be come mean old ladies,” said Marsha Frankel, clinical director of senior services at Jewish Family and Children’s Services in Boston, who has led workshops (innocuously called “Creating a Caring Community”) for staff and residents. What sort of behavior are we talking about? Ms. Frankeland Robin Bonifas, an assistant professor of social work at Arizona State who has begun research on senior bullying, described various situations:
Attempts to turn public spaces into private fiefdoms. “There’s a TV lounge meant to be used by everyone, but one person tries to monopolize it — what show is on, whether the blinds are open or shut, who can sit where,” said Dr. Bonifas.
Exclusion. “Dining room issues are ubiquitous,” said Ms. Frankel. When there’s no assigned seating, a resident may loudly announce that she’s saving a seat, even if no one else is expected,to avoid someone she dislikes. In an exercise class, added Ms. Frankel, who has gathered examples from administrators at several Massachusetts facilities, “one resident told another, in a condescending way, that she was doing it all wrong and shouldn’t be allowed to take the class.”General nastiness. “People loudly and publicly say insulting things. ‘You’re stupid.’ ‘You don’t know what you’re talking about.’” Ms. Frankel said. In a Newton, Mass., facility she observed, a resident actually discouraged her daughter from visiting, because the daughter was obese and her mother didn’t want her subjected to disparaging gossip. Racial and ethnic differences can also set off malicious comments.
Could all this be a consequence of cognitive impairment? Sometimes, Ms. Frankel said. Dementia can lead to disinhibition, and people say things they might once merely have thought.But social manipulation and exclusion seem to have more to do with acquiring power, a feeling of control, at a point in life when older people can feel powerless. (Adolescence is another of those points, of course.)  “Perhaps people don’t have ways to get that sense of control in healthy ways, so it’s done by dominating others,” said Dr. Bonifas, a former nursing home social worker.“It gives them a sense that they’re important.” Some intended victims can shrug off this petty tyranny, but others suffer. They withdraw from activities and social situations, perhaps experience anxiety or depression, want to move out. “It can get pretty nasty, and these are vulnerable people,” Ms. Frankel said.  She hasn’t found her caring community workshops very effective at getting mean seniors to behave better, since nobody considers himself or herself a bully, but they do appear to embolden the staff to intervene. That can make a difference: At a Massachusetts class in conversational English, five of the regulars — all elderly Russian women with scientific backgrounds — turned on a less-educated newcomer from Hong Kong. They rolled their eyes when she spoke, and they sniped in Russian. The instructor, a social work graduate student and former teacher, finally announced that she would not tolerate abusive behavior in the classroom and threatened to end the session the next time it happened. “That worked,” Ms. Frankel reported. But bolstering old people’s ability to stand up for themselves might also work. Dr. Bonifas has undertaken a pilot research program on bullying in two Phoenix senior apartment complexes and has noticed that, as with youth bullies, not everyone is equally likely to be a target. She’s contemplating how to teach someone to say, “You’re not going to treat me like that. Every chair here is available to anyone, and I’ll sit where I want.” That way, she thinks, “the bully doesn’t derive power from the interaction.” Perhaps it shouldn’t startle us that this behavior arises in senior residences — people are people, after all, wherever they live — but I’ll admit to some surprise. We all remember this harassment from the cafeteria, but we’d like to think that people learn something in the intervening seven or so decades, right? “We have expectations that as we grow older we become more mature — the stereotype of the wise old  person who knows how to conduct herself,” Dr. Bonifas said. “That’s not necessarily the case.”