Summer 2022 Newsletter

By Matthew Harmon, MSN, RN, CNE
School of Nursing
Arkansas State University

Older adults (over the age of 65) are commonly a target of abuse. In fact, one in six older adults are affected by some type of elder abuse. When one thinks of abuse, one may think of physical violence. In fact, the National Center on Elder Abuse notes seven different types including; physical abuse, sexual abuse, emotional abuse, financial/material exploitation, neglect, abandonment, and self-neglect.

                Physical abuse encompasses bodily injury, impairment, or physical pain caused by physical force (NCEA, 2022). Noticing multiple bruises in different stages of healing is an important sign of abuse because it indicates separate instances of trauma at different times. Other worrisome signs would be bruises, black eyes, welts, broken bones, sudden change in behavior, broken eyeglasses, and broken hearing aids. It is not uncommon for an older adult to experience a couple of these signs after an accidental event like a fall. However, it would be more suggestive of abuse if several of these signs were noticed at different times, as it suggests recurring incidents related to abuse.

                Sexual abuse is sexual contact of any kind that is not-consensual (NCEA, 2022). Signs of sexual abuse in older adults include the report of sexual abuse from the individual, or sudden change in emotional status (NCEA, 2022). This type of abuse is harder to notice for some due to the lack of observable symptoms in the abused. 

                Emotional abuse or psychological abuse is defined as the infliction of anguish, pain, or distress through verbal or nonverbal acts (NCEA, 2022). This type of abuse consists of signs that are more behavioral-based. Signs that may suggest emotional abuse include irritability, isolating oneself, sudden change in emotional status, or report of emotional abuse.

                Financial/material exploitation refers to the illegal or improper use of an elder’s funds, property, or assets (NCEA, 2022). This type of abuse may also be difficult to identify in other individuals. The main identifiers of this type of abuse would be sudden change in financial status, addition of names to bank cards and credit cards, and abrupt changes to will or other financial documents. According to Dominguez et al. (2022), recognizing this type of abuse should show special consideration to those who may live alone or who already have a degree of isolation.

                Neglect is defined as the refusal or failure to fulfill any part of a person’s obligations or duties to an elder(NCEA, 2022).  Being so, this type of abuse is found in individuals who require aid/caregiver for some aspect of their care. This can be an individual who is being taken care of by family, or even those being cared for in a facility. Signs of neglect include unsafe living arrangements, dehydration, starvation, poor hygiene, bed sores, among any other sign of abuse mentioned above.

                Self-neglect characterized as the behavior of an elderly person that threatens his/her own health or safety(NCEA, 2022). The signs of this type of abuse mimic that of neglect as mentioned previously. The main difference of self-neglect to the other types of abuse is that this type of abuse has no identified abuser. Self-neglect is also different from neglect in that an individual who is a victim of neglect typically requires some type of supervision with their care while those who exhibit self-neglect do not.

Abandonment is the desertion of an elderly person by an individual who has assumed responsibility for providing care for an elder, or by a person with physical custody of an elder (NCEA, 2022). Abandonment may include the individual being abandoned at their home, or being abandoned at a medical facility. In some cases individuals may be abandoned at a public facility such as a supermarket, restaurant, or recreational area (NCEA, 2022).

                If you or any older adults you know shows signs of elder abuse, several resources are available to help. First and foremost, if the matter is life-threatening, call 911 for immediate assistance. If the suspected abuse is occurring within a facility that the abused is housed at, contact administration of that facility. If you feel uncomfortable doing so, and wish to remain anonymous, you may call the Arkansas Department of Human Services, Office of Long-Term care at 1-800-582-4887 for residents in long-term care facilities. Victims of abuse are not always individuals in long-term care facilities, so if the person is not in a long-term care facility, and you suspect abuse call the Arkansas Department of Human Services, Adult Protective Services at 1-800-482-8049.

References

Fraga Dominguez, S., Ozguler, B., Storey, J. E., & Rogers, M. (2022). Elder abuse vulnerability and risk factors: Is financial abuse different from other subtypes? Journal of Applied Gerontology, 41(4), 928-939. https://doi.org/10.1177/07334648211036402

National Center on Elder Abuse. (n.d.). Types of abuse. NCEA. Retrieved July 12, 2022, from https://ncea.acl.gov/Suspect-Abuse/Abuse-Types.aspx

Summer 2021 Newsletter

By Mark Foster, DNP, APRN, FNP-BC
Assistant Professor, School of Nursing
Arkansas State University

Importance of Oral Health

Adequate oral health is considered a crucial part of overall health and well-being (Llyas, Zahid, Rafiq, Bilal, & Ishaq, 2018). Oral health can be defined as having, “non-bleeding gums, free of infection, pain, xerostomia, halitosis, and sensitivity.” Oral health also encompasses the ability to smile, chew, taste, speak, swallow, and touch. This generally means that the person does not have any kind of oral disease. Poor oral health can also affect a person socially, physically, and psychologically (Llyas et al., 2018).

Despite what some may think, oral health is a crucial factor to overall general health. It has been proven that early oral hygiene practices lead to better overall oral health and general health (Llyas et al., 2018).

Llyas et al. (2018) conducted a study that examined the attitudes and beliefs regarding oral health. The researchers aimed to retrieve data from educated people as well as uneducated people. The results indicated that 55% of the educated participants knew what oral health was, but almost all of the uneducated participants were unaware of what oral health was. Seventy-three percent of the educated participants reported that bleeding gums are a sign of oral disease, while most of the uneducated participants said it is not. This study proved that uneducated individuals do not receive adequate information on oral health (Llyas et al., 2018).

The integration of medical care and oral health is important for people of all ages (Lee et al., 2018). Dental caries is the most chronic disease in the pediatric population, and it is found in 91% of the adult population. Medical professionals can take simple precautionary steps to examine the oral health of patients. The medical professional only needs gauze, tongue depressor, and light to conduct the quick, oral examination. This will help identify signs and symptoms of systemic disease and improve their quality of life (Lee et al., 2018).

It has been shown that there is a relationship between oral health and cardiovascular disease (Sanchez et al., 2017). Patients with periodontal disease are four times more likely to develop cardiovascular disease.

Sanchez et al. (2017) conducted a study in which they evaluated patients with cardiovascular disease, and the researchers asked questions about their perceptions toward oral health. The patients were asked questions regarding information given on oral health during their cardiac care, maintaining their oral health, and when oral health was important. The results showed that six (50%) of the patients reported they experienced bad breath, toothache, swollen gums, and painful teeth. Seven (58%) of the patients did not know that there was a connection between oral health and cardiovascular disease (Sanchez et al., 2017). This study validates that cardiac care professionals need to address oral health with all of their patients. This would allow the patients to receive adequate oral health education, care, and referrals (Sanchez et al., 2017).

Natural dentition in older adults is important for oral health despite the misconceptions (Muller, Shimazaki, Kahabuka, & Schimmel, 2017). Often, geriatric patients get assistance for activities of daily living and oral hygiene gets neglected. This can lead to caries which can result in tooth loss and reduced quality of life. One functional indicator is to examine the plaque and denture plaque indices. This buildup is linked to the patient’s ability to maintain oral hygiene (Muller et al., 2017).

Oral Health in Nursing Curriculum

As previously noted, the practice of oral health is critical to maintaining one’s overall health and hygiene (Opacich, 2014). Contrary to belief, the responsibility of oral health practice and education does not solely rely upon dentists and dental students. Nurses are very involved in an individual’s oral health. It’s important for nurse practitioner programs to educate students on the early signs of caries, how to educate patient caregivers, and providing preventative oral health care services (Kent & Clark, 2018).

When adding curriculum it is important to ensure that the teaching methodologies are efficient and effective (Kent & Clark, 2018). One university in Indiana found that the STAR Legacy Cycle was practical. The STAR Legacy cycle include basic principles that consist of five steps: a challenge, initial thoughts, perspectives and resources, wrap-up, and assessment. Therefore, before a lecture, the students were given a ten-question pretest. Students were also given out-of-class assignments concerning children’s oral health and a posttest. In the class, students practiced screenings and fluoride varnish application (Kent & Clark, 2018).

Furthermore, there is a growing amount of evidence that supports interprofessional education (Nash et al., 2018). A university in Colorado has implemented an interprofessional approach to expand the HEENT (head, eyes, ears, nose, and throat) assessment to HEENOT (head, ears, eyes, nose, oral, and throat) (Estes et al., 2018). Nurse practitioner students were taught how to conduct oral exams, apply fluoride varnish, and recognize oral health pathology by dental faculty. The nursing students then completed a survey concerning their comfort towards oral health and their opinions about the activities completed (Estes et al., 2018).

This interprofessional activity was completed during four different semesters (Estes et al., 2018). All of the nursing students reported that they felt more comfortable administering oral health exams after the activity in each of the four semesters. The senior-level students agreed with an interprofessional approach more than any other semester’s students. Also, senior students had a better report for organization and timing as well. This highlights an improvement in teaching methods and an increase in nursing students concerning oral health (Estes et al., 2018).

During a dissertation study by Opacich (2014), students participated in a pre-and post-test concerning oral health. The students had a pretest average of 59% and a posttest average of 82%. In the pretest, 21 students reported that they have not performed a comprehensive oral examination during a child’s welfare visit.

During the posttest, only five students reported they did not perform comprehensive oral examinations. Twenty-eight students (97%) also reported that they had not performed fluoride varnish on the pretest. During the posttest, only eight students reported not having performed fluoride varnish (Opacich, 2014).

During the pretest, 21% of the students felt as if they did not have enough knowledge to perform a comprehensive oral examination (Opacich, 2014). In the posttest, however all of the students felt as if they had the needed knowledge. When asked about fluoride varnishing in the pretest, 17 students did not feel like they had the proper knowledge, whereas only one student did not feel as if they had the proper knowledge on the posttest. This study emphasizes the positive effect that an oral health education program has on students (Opacich, 2014).

Therefore understanding the deficits to dental health in Arkansans and across the delta, Arkansas State University began integrating heavy content areas of dental health within their existing family nurse practitioner curriculum and having students complete the Smiles for Life oral health curriculum.  Educating future providers in the first step addressing growing dental health concerns across the delta region and curtailing future health issues that arise from poor dental health.

References

Estes, K. R., Callanan, D., Rai, N., Plunkett, K., Brunson, D., & Tiwari, T. (2018). Evaluation of an interprofessional oral health assessment activity in advanced practice nursing education. Journal of Dental Education, 82(10), 1084.

Kent, K., & Clark, C. A. (2018). Open wide and say A-Ha: Adding oral health content to the nurse practitioner curriculum. Nursing Education Perspectives (Wolters Kluwer Health), 39(4), 253–254.

Lee, J. S., & Somerman, M. J. (2018). The importance of oral health in comprehensive health care. JAMA, 320(4), 339–340.

Müller, F., Shimazaki, Y., Kahabuka, F., Schimmel, M., & Müller, F. (2017). Oral health for an ageing population: the importance of a natural dentition in older adults. International Dental Journal, 67, 7–13.

Nash, W. A., Hall, L. A., Lee Ridner, S., Hayden, D., Mayfield, T., Firriolo, J., … Crawford, T. N. (2018). Evaluation of an interprofessional education program for advanced practice nursing and dental students: The oral-systemic health connection. Nurse Education Today, 66, 25–32.

Opacich, E. (2014). Improving oral health for underserved populations: Graduate nursing student education. Dissertation Abstracts International: Section B: The Sciences and Engineering. ProQuest Information & Learning.

Riley, E. (2018). The importance of oral health in palliative care patients. Journal of Community Nursing, 32(3), 57-61.

Spring 2021 Newsletter

By Shawn Drake, PT, PhD, JoAnna Cupp, MS, RDN, LD, Brinda McKinney, PhD, MSN, RN, Lori Gatling, MSN, RN, CHSE
Arkansas State University

The College of Nursing and Health Professions (CNHP) at Arkansas State University and Center on Aging-Northeast partnered in 2004 and started the Healthy Ager Program (HAP).  The objective of the HAP is to promote interprofessional educational and collaboration (IPEC) opportunities for health professions students’ while working with community-dwelling, older adults (Healthy Ager).  The service-learning program provided students the opportunity to practice clinical skills learned in the classroom and apply their knowledge to improve the health and wellness in the older adult.  COVID-19 heavily impacted the continuation of the HAP in Spring 2020.  The program was suddenly halted, leaving the faculty with the question of how or if this program could continue. 

COVID-19 forced the HAP faculty to think “outside the box” to develop a meaningful, service-learning experience for healthcare students and the Healthy Ager, while maintaining COVID-19 restrictions.  In Spring 2021, the HAP moved to an online platform using Zoom.  Student learning modules included exposure, immersion and mastery activities related to IPEC competencies focused on the older adult.  Interprofessional teams comprised of students from nursing, physical therapy and nutritional science programs.     

Exposure activities included introducing students to:

1) IPEC competencies¹ (communication, roles and responsibilities, values/ethics and team-based practice),

2) Quadruple Aims² (improved clinician experience, better outcomes, lower costs and improved patient experience),

3) Multidisciplinary Competencies for Older Adults³, 

4) 4 M’s in the Care of Older Adults⁴ (what matters, medication, mentation, mobility), and

5) Team Strategies & Tools to Enhance Performance and Patient Safety⁵ (TeamSTEPPS)

The exposure activities were reinforced during Zoom activities, which included online simulation events (SBAR communication, dementia simulation) and collaborative sessions on home assessment, cultural competency and telemedicine. 

Students participated in immersion activities through the use of Standardized Participants (SP) using Zoom as the telehealth platform. Each team was assigned an SP, who was over the age of 60 and was instructed to “act as themselves”.  Each team completed an assessment using the 4M’s and provided interventions that focused on improving the 4Ms and Quadruple Aims for their SP.  At the completion of each activity, small and large group debriefing occurred with the SP and faculty facilitator.  The simulation activity allowed students time to practice telehealth presentation skills in a non-threatening environment, receive feedback on their team’s performance and implement changes before the real-life scenario.

Each team will participate in collaborative practice with their Healthy Ager in April.  Team will provide an educational video and educational patient-specific pamphlet for their Healthy Ager which will allow for each team member to meet mastery level of IPEC competencies.  In addition, the service-learning project allows for the Healthy Ager to improve his/her health and wellness with the expertise of each team. 

The HAP has transformed itself in light of COVID-19 for the better.  Despite the challenges of COVID-19, the HAP positively transformed.  The new format allows the learner to meet the IPEC competencies, geriatric competencies, and practice telehealth.

References:

1. McKearney, Shelley. “IPEC Core Competencies.” Interprofessional Education Collaborative, www.ipecollaborative.org/ipec-core-competencies.

2. “ACTS Supports the Quadruple Aim.” ACTS Supports the Quadruple Aim | AHRQ Digital Healthcare Research: Informing Improvement in Care Quality, Safety, and Efficiency, digital.ahrq.gov/acts/quadruple-aim.

3.  Author(s): Todd P. Semla, John O. Barr, Judith L. Beizer, Sue Berger, Ronni Chernoff, JoAnn Damron‐Rodriguez, Charlotte Eliopoulos, Carol S. Goodwin, Catherine L. Grus, Kathy Kemle, Ethel L. Mitty, Kenneth Shay, Gregg A. Warshaw. “Multidisciplinary Competencies in the Care of Older Adults at the Completion of the Entry-Level Health Professional Degree.” National Center for Interprofessional Practice and Education, 2 June 2020, nexusipe.org/informing/resource-center/multidisciplinary-competencies-care-older-adults-completion-entry-level.

 4. “What is an Age-Friendly Health System?:IHI”. Institute for Healthcare Improvement. www.ihi.org/Engage/Initiatives/Age-Friendly-Health-Systems/Pages/default.aspx

5. “TeamSTEPPS®.” AHRQ, www.ahrq.gov/teamstepps/index.html

Fall 2020 Newsletter

By Katie Axsom, SPT
College of Nursing and Health Professions
Arkansas State University

The elderly population, 65 years and older, have been the most affected by the pandemic whether they are a community dweller or living in a long-term nursing facility. With age, our immune system becomes fragile and cannot withstand the amount of distress an illness can bring. COVID-19 is primarily a respiratory illness. Aging internal body systems are weaker and individuals affected are usually unable to recover from sickness as easily, due to other health related issues that come with aging. Months into this pandemic, the elderly are still the group of people most at risk. The CDC states that older adults, 65 or older, account for 16% of the U.S. population, but 80% of the deaths from the pandemic. (CDC, Older Adults) That percentage is staggeringly high. The number continues to climb but over 100,000 elderly adults, 65 or older, have died due to COVID-19. (Freed)

From March until now, we have learned a lot about the Coronavirus, yet people are still being affected by this illness. Many states have mandated rules in place to keep the spread of the virus down. Even with these rules in place, the virus is still spreading and the elderly population continues to be the population most at risk. There are four main actions that we hear about on a daily basis to lower our risk and the risk of others obtaining the virus, which are practicing good hand hygiene, wearing a mask in public, staying six feet apart from people when possible, and disinfecting and cleaning surfaces regularly. (CDC, Older Adults) It doesn’t just take one person doing their part, it takes everyone.

Another factor that puts the elderly population at greater risk is their dependence on others whether at home or in an assisted living community. It is difficult for them to do everything on their own, so they may come in contact with more people. (LaFave) They rely on people to bring groceries and medications, help with cooking and cleaning, sorting through the mail or paying bills. It is paramount to be more cautious and aware of who we are coming into contact with. While it is good to isolate during COVID, we don’t want to isolate the older population to a point that impacts mental, physical, emotional and social health. It is important to stay connected. A few different ways to stay connected with the older population are through virtual avenues. Talking with someone virtually has gotten easier over the last few years. You can Skype, Facetime or Zoom by a click of button. Also, online you can play games with friends, through Arkadium.com or join a virtual book club to talk about your favorite books. A few things you can do outside of the virtual world is plan window visits, where you meet with your loved one through a window to keep social distancing a priority. You can rediscover sending snail mail to family and friends through letters or postcards. Something I just discovered is that you can go on a virtual vacation. There are many museums or national parks that have virtual tours. You can experience the fun and excitement of a vacation, virtually through your computer or phone. (Austrew) We need to keep our brains stimulated with positive thoughts and actions.

With no end in sight yet for this pandemic, another important task for the elderly population to do is to stay up to date with their vaccinations and continue seeing their primary care providers. In the cooler months ahead, flu season and the risk of getting pneumonia is another danger to the older population. Vaccinations reduce the risk for medical visits and hospitalizations. (CDC, Flu) The last thing the older population needs right now is to be in the hospital for the flu or pneumonia when COVID-19 is still present. Staying on top of screenings with primary care providers is also important to make sure their health hasn’t declined and that they are receiving the care that they need to remain in good physical shape for their age.

In closing, remember to keep the elderly population in mind. Know that they have challenges. Stay in contact and assist when you can. Checking in on family and friends is important. Working together to keep everyone healthy and safe in a top priority.

References:

Austrew, A. (2020, July 22). 7 Ways Families Can Stay Connected To Senior Loved Ones During Covid-19. Retrieved September 16, 2020, from https://www.care.com/c/stories/16765/stay-connected-seniors-covid/

CDC. (2020, August 28). Flu & People 65 Years and Older. Retrieved September 15, 2020, from https://www.cdc.gov/flu/highrisk/65over.htm

CDC. (2020, September 11). Older Adults and COVID-19. Retrieved September 15, 2020, from https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/older-adults.html

Freed, M. (2020, July 24). What Share of People Who Have Died of COVID-19 Are 65 and Older – and How Does It Vary By State? Retrieved September 15, 2020, from https://www.kff.org/coronavirus-covid-19/issue-brief/what-share-of-people-who-have-died-of-covid-19-are-65-and-older-and-how-does-it-vary-by-state/

LaFave, S. (2020, May 05). The impact of COVID-19 on older adults. Retrieved September 15, 2020, from https://hub.jhu.edu/2020/05/05/impact-of-covid-19-on-the-elderly/

By Dr. Angela Schmidt, Professor Emeritus
College of Nursing and Health Professions
Arkansas State University

 

Transitioning from one care setting to another in the United States Healthcare system, has become complex and problematic, especially for  older adults and other vulnerable populations.

Included in these transitions is hospice care, provided at home, in a hospital, a nursing home, or in a facility specifically designated for hospice care delivery.  This care delivery is holistic and is delivered by an interdisciplinary team of physicians, nurses, social workers, therapists, clergy, and often volunteers. It is available to any person regardless of age, race, or illness. The goal of hospice is comfort instead of cure, to be pain free with aggressive methods as necessary. The philosophy of hospice is to provide supportive care for the patient’s emotional, social, and spiritual needs, as well as these medical symptoms, as part of holistic care delivery.

Services provided in hospice care include prescribing drugs to control pain and manage other symptoms; physical, occupational, and speech therapy; medical supplies and equipment; medical social services; dietary and other counseling; continuous home care at times of crisis if home setting; and bereavement services. Although hospice care does not aim for cure of the terminal illness, it may treat potentially curable conditions such pneumonia and bladder infections, with brief hospital stays if necessary. Hospice programs also may offer respite care workers, people who are usually trained volunteers, who take over the patient’s care so that the family or other primary caregivers can leave the house for a few hours. Some facilities where hospice care is provided also include volunteer caregivers as a part of the hospice philosophy.

In the mid-1970s when hospice came to the U.S., most hospice patients had cancer. Today, more than half of hospice patients have other illnesses for which they are medically eligible for hospice services, such as late-stage heart, lung or kidney disease, and advanced Alzheimer’s disease or dementia. Hospice also once was exclusively for adults, especially elderly people, but today many hospice programs accept infants, children and adolescents

In a significant research study, published by The Journal of American Geriatric Society (Amann & LeBlanc, 2014), researchers found that cancer and advanced dementia were the conditions that most often resulted in being admitted for hospice care. The duration of hospice care was less than 13 days for half of these study participants. The short duration of hospice suggested that healthcare providers might need to consider discussing referrals to hospice sooner with people who are approaching the end of their lives.

Further, the study revealed that older adults who were frail were least likely to be admitted for hospice. However, the most common condition leading to death was frailty (syndrome of physiologic decline in later life), followed by organ failure, advanced dementia, and then cancer.  The researchers suggested that referral to hospice at the end of life should be based on an older adult’s burden of pain and other distressing symptoms including frailty, as well as consideration of earlier hospice referrals. (Amann & LeBlanc, 2014)

A National Hospice Foundation Survey noted that 90% of Americans were unaware that hospice care is a covered Medicare service. To be  eligible to receive hospice services, a hospice physician and a second physician (often the individual’s attending physician or specialist) must certify that the patient meets specific medical eligibility criteria; generally, the patient’s life expectancy is 6 months or less if the illness, disease or condition runs its typical course. However, if the individual lives longer than six months and the condition continues to decline,  recertification by a physician or nurse practitioner for additional time in hospice care. Similarly, if a hospice patient’s condition improves, the individual may be discharged from hospice care. The patient is eligible for hospice again if his or her condition begins to decline.  The decision to consider hospice services, as recommended by the Hospice Foundation of America, should include: 6 months or less to live, according to a physician; rapidly declining despite medical treatment (weight loss, mental status decline, inability to perform activities of daily living); and  readiness to live more comfortably and forego treatments aimed at prolonging life. Many health care service options for transitions of care are determined by financial considerations.  The type of insurance coverage the patient has determines of-of-pocket payments for hospice care.  Hospice services usually follow Medicare requirements to provide the following:

• Time and services of the care team, including visits to the patient’s location by the hospice physician, nurse, medical social worker, home-health aide and chaplain/spiritual adviser;
• Medication for symptom control and/or pain relief;
• Medical equipment, such as wheelchairs or walkers and medical supplies like bandages and catheters;
• Physical, occupational, and speech therapy if needed;
• Dietary counseling;
• Any other Medicare-covered services needed to manage pain and other symptoms related to the terminal illness;
• Short-term inpatient care if in home setting and pain and/or symptom management cannot be achieved;
• Short-term respite care if temporary relief from caregiving is needed to avoid or address “caregiver burnout”; and
• Grief and loss counseling for patient and loved ones.

However, not all services provided to patients enrolled in hospice care are covered by the Medicare Hospice Benefit. The hospice benefit will not pay for:

• Treatment intended to cure your terminal illness or unrelated to that illness;
• Prescription drugs to cure your illness or unrelated to that illness;
• Room and board in a nursing home or hospice residential facility; and
• Care in an emergency room, inpatient facility care or ambulance transportation, unless it is either arranged by the hospice team or is unrelated to the terminal illness.

(see https://hospicefoundation.org/Hospice-Care/Hospice-Services )

 

Note that not covered is “room and board” which is misunderstood by consumers when most resources state, “Medicare covers hospice care”.  Even care received in a hospice facility can charge the patient for room and board daily not covered by Medicare, although the above allowed services may be covered.  Six months or 180 days at 140-$200 per day (totaling $25,000-$36,000) for room and board, may be an out of pocket personal expense.  In addition, some medications are not included. For example, some intravenous (IV) medications that are not related to the terminal illness are not covered by hospice. Even dehydration occurring as a natural process in a terminal illness does not allow IV fluids.  Further, most antibiotics are not covered by hospice unless they are for palliative needs only.  What lacks clarification is that the patient can have these treatments/services but the patient would be responsible for payment.   Even though there are many exceptions to coverage, Medicare Part A supplies items such as diapers, medications, and equipment related to the terminal illness, while Medicare Part B covers physician charges.  The patient is responsible for any deductible amounts and for any charges not covered as described.

Most hospice patients, especially elderly ones, are eligible for Medicare, which covers most aspects of hospice care and services as long as it is related to the terminal illness. There is no deductible for hospice services although there may be a very small co-payment for prescriptions and for respite care. In most states, Medicaid offers similar coverage.  Medicare coverage also includes Medicare Advantage Plans. Many private health insurance plans offer hospice benefits but the extent to which they cover hospice care and services may differ from Medicare as well as from one another.  Military families have hospice coverage through Tricare. Most hospices will accept private payment, or “self-pay.”  Some hospices have mechanisms by which they can provide services to people who are medically eligible but have neither insurance nor the resources to pay for their care.

Hospice care is given in benefit periods. You can get hospice care for two 90‑day periods followed by an unlimited number of 60‑day periods. Although medical eligibility generally relies on the physician’s opinion that the patient’s life expectancy is 6 months or less, neither the patient nor the physician is penalized if the patient lives longer than 6 months. The patient can be re-certified for as long as he/she continues to be medically eligible.  It is also possible with hospice care that a patient’s condition stabilizes and may even improve sufficiently so they no longer meet medical eligibility for hospice services. At that time, the patient is “discharged” from the hospice program and their Medicare benefits revert to the coverage they had before electing hospice care.
(see https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Hospice )

Hospice patients may choose to pursue curative therapies such as entering a clinical study for a new medication or procedure. In order to do so, the patient must withdraw their selection of hospice care, called “revocation.”  Patients who are discharged as well as any who choose to leave hospice care can re-enroll at a later date without penalty at any time they meet the medical eligibility criteria.

To ensure health care providers, facilities, and consumers are aware of hospice service benefits, CMS announced a “Value-Based Medicare Advantage Model” in 2019.  This initiative is intended to accelerate the development and testing of new payment and service delivery models for hospice.  In October 2019, President Trump issued an Executive Order on “Protecting and Improving Medicare” for our nation’s seniors to include this hospice delivery model. Through both this announcement and a separate RFA that CMS released in January 2020 for other components of the VBID model, CMS is implementing key provisions of the President’s Executive Order. Medicare Advantage (MA) organizations will finalize their VBID plan designs for all components of VBID by the 2021 bid deadline of June 1, 2020.

“Hospice patients find themselves in a particularly vulnerable and difficult time, and the Trump Administration wants to make every provision possible to allow them to focus on their loved ones and their care, rather than government bureaucracy…….This Model is a vital element of that effort. By expanding benefits and coverage and igniting greater coordination, it promises to improve quality of care and quality of life for our nation’s seniors. The result of our efforts has been a dramatic increase of participation in the VBID Model and the value-based, coordinated care it can provide.”
(see press release https://www.cms.gov/newsroom/press-releases/cms-announces-strong-participation-value-based-medicare-advantage-model-cy-2020-and-new )

By reducing fragmentation and increasing financial accountability, CMS is enabling organizations to better coordinate palliative and hospice care for beneficiaries that choose Medicare Advantage.

Arkansans need to improve our knowledge and use of hospice care to ensure that all those who will benefit from hospice care earlier in the course of a serious illness have access to compassionate, high-quality care that proves to be an appropriate transition of care.  This needed resource for many elderly people is often overlooked and underused.   In 2018, the proportion of Medicare decedents enrolled in hospice at the time of death varied from a low of 13% (other) to a high of 59.4% (UT) with AR ranking 21^st at 50%.  More facts and figures for hospice care in the United States and Arkansas and the use of hospice services are available from, The National Hospice and Palliative Care Organization (NHPCO),  https://www.nhpco.org/wpcontent/uploads/2019/07/2018_NHPCO_Facts_Figures.pdf,  in their facts and figures report.

By Amanda Mohler, OTD, OTR/L
Department of Occupational Therapy
Arkansas State University

 

Driving is a dynamic task requiring the active engagement of an individual’s sensory, perceptual, cognitive, and motor systems. However, as individuals age, the systems are at risk of declining, resulting in poorer accuracy of driving performance. Research shows the effects of aging on physiologic systems often result in decreased muscle strength, coordination, and motor control. The aging systems can result in a slowing of emergency maneuvers and increased breaking time (Karthaus & Falkenstein, 2016). Furthermore, age-related degeneration of the peripheral sensory receptors results in decreased postural control of the lower limbs and decreased force production for pedal reaction (Lacherez, Wood, Anstey, & Lord, 2014; Woolnough et al., 2013). Researchers found cognitive functions relevant for safe driving decline with age as well. Imperative executive function skills such as the ability to visually scan the  driving field or shift attention decreases with age. The changes in executive function result in the decreased ability to monitor  the environment, react appropriately, and manage multiple tasks, therefore, resulting in an increased risk of accidents or traffic violations (Karthaus & Falkenstein, 2016; Hahn, Wild-Wall, Falkenstein, 2011; Richardson & Marottoli, 2003).

There is a misconception that stricter driving rules and policies for aging adults would resolve the behind the wheel risks.. However, research shows increased monitoring, such as undergoing medical or vision tests to renew one’s license, does not result in increased safe driving or decreased fatal accidents (Karthaus & Falkenstein, 2016). Some proponents of harsher driving laws have even recommended retracting a drivers’  license after a specific age. However, decreased access to driving often encourages individuals to use less safe methods of mobility, such as walking or driving without a license. Therefore, regulating older adult drivers with harsher policies is not the answer. Rather, the solution lies in finding strategies to promote safe driving designed explicitly for the aging population.

To address the growing population of older adults still driving, students from the Department of Occupational Therapy at Arkansas State University (AState) partnered with community civic agencies to promote older adult safe driving using driving simulation technology. Driving simulation is an evolving technology consisting of computer-aided technology to mimic real-life driving scenarios. Trained professionals use driving simulation for assessment and intervention purposes. The simulation technology allows professionals the capacity to assess one’s ability to drive, including physical and cognitive factors. The driving simulation produces real-world and evidence-based results that professionals can review with clients via a report or video replay to provide education and training on their changing needs related to aging and driving.

Because of the flexibility of driving simulation technology, all individuals benefit from it no matter  age, gender, disease, or injury. At AState, educated students and faculty use the technology to assess specific human functions related to driving, aging, and older adult diseases. Common assessments include, but are not limited to,  physical ability to sustain driving, reaction time, hazardous perceptions, memory, planning, safety, attention, and vehicle control. Each of the driving skills are relevant in assessing and enhancing cognitive, sensory, and motor skills. Following each drive, the health professional reviews the results with clients and provides feedback and recommendations on maintaining safe driving. If clients require additional training, they have the option to participate in a driving program using the simulator. During the driving program, clients receive education on specific impairments and safe driving skills including basic vehicle control skills (e.g., steering wheel, or gas and brake pedal), progressive roadway and driving tasks (e.g., construction zone or metropolitan city), and advanced driving safety and performance skills (e.g., defensive driving or hazard detection).

Since the simulation occurs in a controlled environment, it offers many benefits. One benefit is the ability to provide safe, objective, reliable, and repeatable performance measures (Classen & Brooks, 2014; Be ́dard, Parkkari, Weaver, Riendeau, & Dahlquist, 2010). Second, professionals can present situations that would not otherwise be available or may be too risky for the client at the time of the assessment. The simulator operator can control the simulation settings, including external conditions (e.g., weather, traffic, road surface), exposure to hazards such as school zones or pedestrians, and control the driving situations (e.g., suburban or rural).

Driving is an everyday and automatic task. For many older adults, driving is a way to remain independent and mobile. Losing the ability to drive puts one at risk for depression, isolation, and decreased health. Therefore, restricting or revoking an older adults’ ability to drive has the potential to increase the national economic burden and decrease one’s overall quality of life. It is not a matter of changing policies or restricting one’s license. Instead, professionals and policymakers should focus on educating older adults on safe driving and addressing their changing skills associated with the natural age-related process.

 

 

References

Be ́dard, M., Parkkari, M., Weaver, B., Riendeau, J., & Dahlquist, M. (2010). Brief Report— Assessment of driving performance using a simulator protocol: Validity and reproducibility. American Journal of Occupational Therapy, 64, 336–340.

Classen, S. & Brooks, J. (2014). Driving Simulators for Occupational Therapy Screening, Assessment, and Intervention. Occupational Therapy in Health Care, 28(2), 154-162. doi: 10.3109/07380577.2014.901590

Hahn, M., Wild-Wall, N., & Falkenstein, M. (2011). Age-related differences in performance and stimulus processing in dual task situation. Brain Research, 1414, 66–76.

Lacherez, P., Wood, J.M., Anstey, K.J., & Lord, S. (2014). Sensorimotor and postural control  factors associated with driving safety in a community-dwelling older driver population. Journals of Gerontology Series A: Biological Sciences & Medical Sciences, 69 (2), 240–244. Retrieved from http://dx.doi.org/10.1093/gerona/glt173

Richardson, E.D. & Marottoli, R.A. (2003). Visual attention and driving behaviors among community-living older persons. Journal of Gerontology: Series A, 58, M832–M836.

Woolnough, A., Salim, D., Marshall, S.C., Weegar, K., PorterM.M., Rapoport, M.J., Man Son-Hing, M.,…Vrkljan, B. (2013). Determining the validity of the AMA guide: A historical cohort analysis of the assessment of driving related skills and crash rate among older drivers. Accident Analysis & Prevention. 61, 311–316. Retrieved from: http://dx.doi.org/10.1016/j. aap.2013.03.020