Elder Living

Understanding CMS Guidelines for Nursing Home Visitation

Revised guidance for nursing home visitation has been issued by the Centers for Medicare and Medicaid (CMS). It is now possible to have visitation with nursing home residents for reasons other than urgent end-of-life scenarios and, in some instances, may include physical touch. Additionally, communal activities and dining are permissible as long as the social distancing rule of 6 feet of separation, and other precautions are observed. Encouraging outdoor visits is desirable as long as the weather permits. Indoor visits are permissible if no new cases were identified in the previous two weeks, and the facility adheres to the core principles of resident and staff testing, screening, proper hygiene, social distancing, and facility cleaning. 

The CMS memo contains “Core Principles of COVID-19 Infection Prevention” verbatim as follows:

  • Screening of all who enter the facility for signs and symptoms of COVID-19 (e.g., temperature checks, questions or observations about signs or symptoms), and denial of entry of those with signs or symptoms
  • Hand hygiene (use of alcohol-based hand rub is preferred) 
  • Face covering or mask (covering mouth and nose) 
  • Social distancing at least six feet between persons 
  • Instructional signage throughout the facility and proper visitor education on COVID19 signs and symptoms, infection control precautions, other applicable facility practices (e.g., use of face-covering or mask, specified entries, exits, and routes to designated areas, hand hygiene)
  • Cleaning and disinfecting high frequency touched surfaces in the facility often, and designated visitation areas after each visit 
  • Appropriate staff use of Personal Protective Equipment (PPE) 
  • Effective cohorting of residents (e.g., separate areas dedicated COVID-19 care)
  • Resident and staff testing conducted as required.

CMS acknowledges that the previous months of severe visitor restrictions to slow the spread of COVID-19 were at a high cost to nursing home residents’ overall wellbeing. The revision of visitor guidance compassionately addresses resident care needs beyond protection from the coronavirus. CMS Administrator Seema Verma states, “While we must remain steadfast in our fight to shield nursing home residents from this virus, it is becoming clear that prolonged isolation and separation from family is also taking a deadly toll on our aging loved ones.”

CMS is also making available Civil Monetary Penalty (CMP) funds to ensure greater and safer access to outdoor and indoor visits. The money can purchase tents for outdoor interaction and clear dividers such as plexiglass can create physical barriers, reducing the risk of transmission during in-person visits. Funding through CMP can also provide communication aids such as tablet devices and webcams that enable virtual visits. However, each facility has a limit of $3,000 to ensure a balance in distributing CMP funds.

Compassionate care situations now include more than the end-of-life scenarios and are also included in the CMS memo. Verbatim they include but are not limited to:

  • A resident, who was living with their family before recently being admitted to a nursing home, is struggling with the change in environment and lack of physical family support.
  • A resident who is grieving after a friend or family member recently passed away.
  • A resident who needs cueing and encouragement with eating or drinking, previously provided by family and/or caregiver(s), is experiencing weight loss or dehydration.
  • A resident, who used to talk and interact with others, is experiencing emotional distress, seldom speaking, or crying more frequently (when the resident had rarely cried in the past).

In addition to family members, compassionate care visits may now also include clergy or laypersons offering religious or spiritual support that meet the resident’s needs. Personal contact is permissible during these and family visits but only when following all appropriate infection prevention guidance. This more humanized approach to nursing home care encourages facility staff to work with residents, families, caregivers, and resident representatives to identify those in need of in-person compassionate care visitation. Exceptions to compassionate visits occur when facilities have experienced COVID-19 infections within the past two weeks or when a county is experiencing a high positivity COVID-19 rate. In the absence of a reasonable safety or clinical cause, the Centers for Medicare and Medicaid make clear that failure of nursing homes to facilitate in-person visitations can be cause for citations and other penalties as CMS deems appropriate.

CMS understands that nursing home residents derive physical, emotional, and spiritual value and support through family and friend visitations, especially in trying times. No one should be made to endure this pandemic alone, least of all the most vulnerable among us. This new CMS nursing home visitation guidance is designed to help American seniors remain happier, stronger, and more resilient in the face of adversity through the personal support of those who love them most.

If you have a loved one in a nursing home, check with the facility to see how or whether their visitation guidelines have changed. It may take time for local facilities to consider these new guidelines and make changes that are consistent with the recommendations from CMS.

We would be happy to discuss any questions you have, including how to choose appropriate long term care and how to pay for it. We can recommend legal ways to help ease the cost of long-term care and protect your savings and home. Please contact our Reno office by calling us at (775) 853-5700 to learn more about your legal options.

Elder Living

Among Elderly Americans, Isolation is Increasing Self-Neglect

Because of the coronavirus, our elder population is experiencing isolation from their family and extended community interaction, increasing the likelihood of neglect. With the flu season fast on approach this isolation and the possibility of a resurgence of COVID-19, older Americans will likely continue living 2020 in mostly solitary circumstances. Rising instances of loneliness can give way to clinical depression and foster feelings of hopelessness.

Common Signs of Self-Neglect

Some of the common signs that an older adult is self-neglecting include changes in how they communicate and a lack of interest in family or community events. A loved one who always presented themselves in a put-together manner may suddenly stop bothering to dress for the day, or perhaps they have gained or lost a startling amount of weight. A once tidy home may now be piled high with unopened mail and heaps of garbage. They may stop or have difficulty managing their medications. Their demeanor and mood may change, and often there is the incidence of a fall.

ASA

Neglect is often a person depriving themselves of necessary care, whether it be adequate nutrition and hydration, medical care, hygiene, and a suitable living environment. In some instances, neglect may be an extension of diminished capacity of physical or mental ability to provide self-care. In some cases, negligence can be the precursor to abuse by an active or passive negligent caregiver. As reported by the American Society on Aging (ASA) outside of financial abuse, the National Association of Professional Geriatric Care Managers identifies self-neglect as the more commonly encountered situation than physical or sexual abuse or neglect by others.

Each state has a mandatory reporting law requiring certain people to provide information about suspected abuse to the proper authorities. Typically, these people are nurses and doctors, as well as wellness check programs through CMS services. Some states require any person who suspects elder abuse to report the situation. Know your state law for reporting and be mindful that your elder loved one is isolated from medical professional groups who report signs of neglect.

What to Do if you Are Suspecting Elderly Abuse

If you have not already implemented virtual strategies to combat loneliness for your older adult, do so immediately. There are many communication, safety, health, and entertainment apps designed specifically with seniors in mind. If your loved one cannot manage a smartphone, use a larger tablet device. If that is unachievable, get a smart speaker where voice communication can provide the sorts of contact options, safety, and activity your senior needs.

Contact your loved one routinely. Implement fall detectors and set up video surveillance to identify any problems. Be sure not to create an overly invasive system allowing your senior some degree of privacy to protect their dignity. Always use firewalls, passwords, and other security options to address privacy concerns.

Take advantage of community programs such as Meals on Wheels or identify programs that check-in on independent living older adults or high-risk households. If they are so inclined, set up the technology for your family member to participate in the many religious services currently being conducted live on Facebook. Connect with their neighbors or local friends to request they occasionally check in on your family member.

AARP recommends whatever the legal obligation in your state to report any sign of elder neglect or abuse. If you believe the person may be in imminent danger, call 911 immediately. If not, address the concern with the person directly or with their caregiver or family member. Remember, you may be misinterpreting the situation. After you have raised your concerns, listen carefully to the other person’s point of view. There may be a quick fix for a small problem, or it could be something more profound. Act deliberately but with compassion. If you meet with resistance to change but still believe help is needed, learn how you can report your concern. Your local police department may have an Elder Affairs unit. Nationally, you can contact support through a public service of the US Administration on Aging called the Eldercare Locator (800-677-1116), connecting you with local protective service agencies.

If you believe your loved one can no longer manage their health, safety, and wellness needs, we can help by providing advice on legal options to protect your loved one. We would be honored to talk with you. Please contact our Reno office by calling us at (775) 853-5700 to learn more.

Elder Living

Living Alone in Your 50s and 60s Increases Your Risk of Dementia

Living arrangements for aging Americans are decidedly leaning towards aging in place. Nearly all older adults prefer to age in the comfort of their long time homes and familiar community surroundings. Aging in place often means living alone. Pew Research findings show that older people are more likely to live alone in the United States than in any other country worldwide. This preference of living solo, however, comes with hidden danger. Research from Science Times reports that living alone in your fifties and sixties increases the likelihood of dementia by thirty percent.

The conclusion drawn is based on a report from sciencedirect.com, a website replete with large databases of scientific, academic, and medical research. Findings indicate that social isolation is a more important risk factor for dementia than previously identified. In this age of gray divorce (also grey divorce) and social distancing due to the coronavirus pandemic, adults living alone in their fifties, sixties and beyond, are at greater risk than ever for cognitive decline, leading to dementia.

Understanding the Causes of Dementia Cases

The lead author of the study, Dr. Roopal Desai, says that overall increases in dementia cases worldwide can be due to loneliness, stress, and the lack of cognitive stimulation that living alone brings. Biologically, cognitive stimulation is necessary to maintain neural connections, which in turn healthily keep a brain functioning. Staying socially interactive is as important to cognitive health as staying physically and mentally active.

Strategies for Seniors Living Alone

Health care professionals in the U.S. are implementing a “social prescribing” strategy to improve the connection of a patient who lives alone to a prescribed range of services like community groups, personal training, art classes, counseling, and more. Unfortunately, in the days of COVID-19 social prescribing is limited to virtual connections between people. However, virtual social engagement is better than no social engagement at all.

Why can’t an adult, choosing to age alone, maintain their health with physical exercise, crossword puzzles, and other activities that stimulate their brains without the input of human socialization? It turns out that social isolation presents a greater risk for dementia than physical inactivity, diabetes, hypertension, and obesity. Brain stimulation is vastly different when a person engages in a conversation rather than in repetitive games and puzzles. Carrying on a conversation, whether in person or virtually, is far more stimulating and challenging to the brain’s regions.

Conversation with other people chemically evokes neurotransmitters and hormones, which translates into increased feelings of happiness and reduced stress through purpose, belonging, improved self-worth, and confidence. It turns out that being human is undeniably an experience at its most healthy when shared, and a mentally healthy person is prone to stay more cognitively capable.

The Importance of Human Connection to Decrease Dementia

Maintaining this human connection can be challenging, particularly if you are one of the many Americans who are opting to age in place. In the first place, aging is replete with reasons to reduce activity and become isolated when facing particular types of stressful events common to later life years. Role changes associated with spousal bereavement through death or divorce, household management, social planning, driving, and flexibility all fall prey to functional and cognitive limitations. Without the benefit of an involved family or social prescription, it is easy for an aging adult to spiral into social isolation, loneliness, and depression, all of which are causally linked to cognitive decline.

If you or your aging loved one actively chooses to live alone, it is imperative to maintain a vibrant social life. Staying cognitively healthy is associated to satisfying social engagement as well as physical activity. If you live alone, reducing the risk of developing dementia will allow you to continue living out your years as imagined, with independence and control, thanks to your continued human interactions.

If you have concerns about your current living arrangements (or those of a loved one who needs care), please reach out. We help families create comprehensive legal plans that cover care and financial concerns. Please contact our Reno office by calling us at (775) 853-5700. We’d be honored to speak with you.

Elder Law, Elder Living, Estate Planning, Healthcare

Will the Cost of Long-Term Care lead to the Loss of My Home?

People work hard all their lives to own a home, and it is often their most valuable and significant possession. Homeownership is the American Dream. So, when health begins to fail and the need for long-term care arises, we often get this fear-filled question from our clients: will they take away my home?

The enormous and on-going costs of nursing-home care are astronomical, on average around $8,500.00 a month depending on location. The joint federal and state Medicaid program foots the bill for one in four of around 75 million recipients in this country. This is an enormous drain on government funds. To recoup some of those costs, then, the Medicaid rules permit states to take the value of a recipient’s home in some cases, to reimburse the program for funds it has expended.

Yet, because a home is such an essential family possession, the rules treat a primary residence as exempt – that is, its value is not counted as available to pay for nursing-home care from the home-owner’s pocket, before Medicaid kicks in. The home is protected, to a certain extent, for the benefit of Medicaid recipients and their close relatives.

That protection can be lost, however. The value of the house can be counted against a Medicaid applicant, and benefits denied or curtailed, when:

*     A home-owner has no living spouse or dependents, and

*     The owner moves into a facility permanently, with no intent to return home, or

*     The owner dies.

In other words, as long as the owner expresses the intent to return home, and the owner’s spouse or disabled or blind child live in the home, the home will not be counted against the owner for Medicaid-eligibility purposes.

Once the owner passes, however the state may place a lien on the home, to secure reimbursement of the value of the Medicaid services the owner received. This lien makes it impossible to sell the home or refinance a mortgage, without first paying the state what it may be owed.

As elder law attorneys we know a number of ways to protect homes from this kind of attachment. If you come to us at least five years before you anticipate needing nursing-home care, we can preserve your home or its value such that Medicaid will not count it, or lien against it, at all.

Or, if a child moves into the home and cares for an ailing parent for two years, permitting the parent to stay home and out of a nursing home, the house can then be given as a gift to that child without any Medicaid penalty or disqualification. Ordinarily, Medicaid heavily penalizes giving away property, but this is one exception.

There are other strategies available. The home can be given to a disabled child without penalty or disqualification. Or, you might keep the right to live in the house for your lifetime and deed the remainder interest to others, who will then own the house after you pass. However, each strategy comes with risks that must be fully explored before determining the correct one.

An overall plan that is tailored to suit each individual, and to meet as many contingencies as possible, requires juggling a number of puzzle-pieces. There is no one cookie-cutter solution. The key is to plan before you or your spouse may need nursing-home care.

As one piece in the overall picture of a balanced estate plan, we can help you save your home. We welcome the opportunity to work with you, please contact our Reno office by calling us at (775) 853-5700.

Elder Living

Alternative Views on Facility Living with Alzheimer’s Patients

As the aging population rises, Alzheimer’s Disease is also on the rise for elderly moving into nursing home facilities. The National Institute of Health (NIH) Library of Medicine reports the most common form of dementia is Alzheimer’s disease, accounting for approximately two-thirds of all diagnosed cases of dementia. Alzheimer’s is also one of the most expensive diseases to treat and often results in financial strain on families trying to find and pay for the best care. In the past, care in facilities often resulted in Alzheimer’s patients being separated from others. However, as you’ll read below, facilities are now exploring better ways to treat Alzheimer’s patients while living in a facility.

Medical breakthroughs that increase our understanding of how to best treat and introduce disease modification therapies for people living with Alzheimer’s and other neurodegenerative diseases provides future hope. However, according to the Alzheimer’s Association, there are already more than 5.8 million Americans living with Alzheimer’s disease. These individuals may not live long enough to benefit from new therapy discoveries since new treatments must undergo rigorous testing and clinical trial phases. Current projections indicate that unless some of these medical breakthroughs have practical applications very soon, more than 14 million Americans will be clinically diagnosed to be living with Alzheimer’s by 2050, with many more struggling in the long-preclinical phase of the disease.

As senior living facilities become more saturated with dementia patients in all stages of progression, there is a shift underway towards non-segregated memory care living. Alzheimer’s patient reintegration into general senior living residence status is shifting dementia care into a human-centric model. It provides insights and lessons into eldercare facility living, its providers and staff, family members of residents, and all of the patients, not just memory care patients. This human-based approach is a kinder, more medically practical and appropriate, and in the long term, a more cost-effective method for facility residents who have dementia.

Before there were outcome-based clinical research findings to support the segregating of dementia patients care facilities began creating stand-alone memory care units, floors, and facilities.  Families knew their loved ones were safely locked away in a highly monitored unit, and staff could focus their training and efforts in a more specified range of care. Because this isolation model became overwhelmingly profitable for business operators, it became the de facto standard of memory care operation. Profits were trumping the human condition. At the outset, it seemed rational enough to put like-patients together, yet because everyone’s memory disease progression is unique, the concept was flawed. Living circumstances for humans is an emotional experience, and the sad outcome for assembled memory care patients was faster disease progression in their isolated, shrinking worlds. This accelerated mental decline was partially due to the lack of broader social and emotional connection with non-dementia residents. It seems integrating patients of all types and generations enriches and expands what residents can do, creating a diverse human model focusing on the positive aspects of life and personal interaction.

Some of the conditions all aging adults share, not just those living with dementia, include difficulty hearing and seeing, finding mental focus more demanding, becoming more concerned about being in large crowds, and noises that increase their stress levels. For a community of residents, no matter what the patient illness, facilities can create an atmosphere that addresses these common concerns. These shared needs include not only medical care but activities that are available in a 24-hour cycle and the encouragement of socialization in smaller, quieter circles. Interactions among residents in this calming style of environment tend to create friendships organically and provide enriching connections among patients irrespective of their illness type. The overall common conditions of aging require sameness in approach, no matter how varied the residents’ medical conditions are.

Technology that allows for digital wrist monitoring of patient location and vital signs permits ease of monitoring residents, particularly as they wander their living space.  Even the proper lighting, carpeting, and circular hallway architecture reassure residents’ feelings of safety, comfort, and familiarity, which appeals to all, regardless of diagnosis. When an entire senior living facility is dementia friendly, and all staff is trained in memory illness and care, every employee can add value to a resident’s enjoyment of life from the medical professionals to the social workers to the landscapers.

A diagnosis of Alzheimer’s can strike fear and worry in America’s aging population because of the emotional, physical, and financial upheaval associated with it. An older person might recognize the onset of some memory problems and become terrified, thinking about Alzheimer’s and the possibility of being relocated from their home and community to a dementia unit. There is a sense of dread that you may never feel seen, heard, and loved again by other people. Interpersonal relationships and connectedness are a hallmark of the aging communities in America. AARP reports large percentages of technology use in older Americans is related to interpersonal connections like email, viewing photos of family and friends, and using social media and the internet. Even in digital spaces and experiences, elderly community residents are looking to create personal networks, connecting to the world at large. The human spirit inclines to be expansive.

Appropriate social and physical environments play a significant role in healthy aging. Compartmentalizing memory care patients into homogeneous units will increase their memory decline, isolate their human connection, and spiral the patient into an ever-shrinking world of interaction, often making them non-verbal. Alzheimer’s patients who experience higher levels of social integration respond conversely, expanding their horizons as they experience and feel the extension of human love and support. There is no one set of symptoms for Alzheimer’s patients, and all patients are on their own trajectory of the disease. Mistakenly putting them together in a one size fits all approach of care has been a disservice to their health and well being and to the future care of others who will become afflicted with Alzheimer’s. The memory care model is shifting for the better and not a moment too soon.

We help families who have a loved one with dementia. We explore possible sources to help pay for care, like Medicaid, and we make sure our client’s wishes are stated in properly drafted legal documents. If you have a loved one with dementia, give us a call and let’s work on a plan to ensure your loved one has the best care possible, and their home and savings are protected. If you have questions, please do not hesitate to contact our Reno office by calling us at (775) 853-5700.

Elder Law, Elder Living, Healthcare

Lawmakers Discuss the Future of Healthcare

In June, Washington, D.C. political publication, The Hill hosted a Future of Healthcare Summit to address critical issues in healthcare, from the Medicare for All proposals made by Democratic presidential hopefuls to the opioid crisis. Speakers included policymakers, health officials, and industry leaders, on both sides of the aisle.

Sen. Joe Manchin (D-W.Va.), for example, took a critical stance on the idea of Medicare for All at the summit. His statements are summarized here. His concerns are practical; “We can’t even pay for Medicare for some,” he said, referring to an earlier report that Medicare will exceed its hospital insurance fund by 2026. Manchin, accordingly, prefers to fix the Affordable Care Act rather than create an entirely new system.

Another issue discussed at the summit was that of data security. As health care becomes increasingly digitized, the risk to people’s privacy rises, as evidenced by recent data breaches. Lawmakers are responding to these breaches, Sen. Mark Warner (D-Va.) by reaching out to health care groups for input on strategies to improve cybersecurity, and Sens. Amy Klobuchar (D-Minn.) and Lisa Murkowski (R-Alaska) by introducing the Protecting Personal Health Data Act. Read more about this here.

High-cost drugs are another upcoming issue in the health care world, discussed in this The Hill article. Innovative cures may merit a high price, but some companies are asking such massive sums for potentially life-saving solutions that they are inaccessible to the people who need them. Accordingly, lawmakers are trying to come up with solutions to make these drugs more affordable, such as Sen. Chuck Grassley (R-Iowa), who has considered allowing Medicaid to pay for drugs over time.

In the same vein, Rep. Tom Reed (R-NY.) called for the cost of insulin to be lowered in an op-ed in The Hill, available here; he notes that insulin prices have doubled in the last seven years, and tripled in the decade prior, that out-of-pocket insulin costs can exceed $300 a vial, and that patients are often racking up debt or skipping doses with serious health consequences. Reed is pushing for transparency from insulin manufacturers and has introduced the SPIKE Act, which would require justification for price hikes. Likewise, Rep. Buddy Carter (R-Ga.) has expressed his concern in a recent op-ed about the prices for drugs which treat cancer and is also pushing for transparency to lower costs.

Meanwhile, Reps. David Trone (D-Md.) and Donald Norcross (D-N.J.) wrote into The Hill, responding to issues of addiction raised at the conference. Trone drew attention back to the opioid crisis and its ongoing effects and described the steps being taken to combat it. Norcross called for enforcement of the 2008 requirement that insurance cover mental health and substance-use disorders to the same extent physical ailments are covered, and for continued funding and new strategies to deal with substance abuse.

Finally, Sen. Tammy Baldwin (D-Wis.) criticized the Trump administration as “sabotaging our health system” by destabilizing the health care market and creating difficulties in accessing it. She cites specific efforts the administration has made to reduce access, including supporting attempts to overturn the Affordable Care Act. Baldwin has responded by supporting the ENROLL Act to restore funding for the Navigator, which had previously been reduced by the Trump administration and by introducing the No Junk Plans Act to reel back the administration’s expansion of junk insurance plans.

From data security to drug prices, The Hill’s Future of Healthcare Summit covered a lot of ground. These issues in health care and the responses proposed to solve them continue to develop.

The Schulze Law Group can help you or a loved one create a thorough medical plan for the later years in your life. If you live in the Reno, Nevada area, and you have any questions, please give us a call at (775) 853-5700, or click here to message us through our website.