Aging and Long Term Care – Aging and Long Term Care – End of Life IssuesEnd of Life Issues

PRESENTED BY:PRESENTED BY:

•CarlyCarly

•DorothyDorothy

•IgorIgor

•LisaLisa

•MarkMark

Senior AssistanceSenior Assistance

Older American’s Act 1973Older American’s Act 1973

• Original Act in 1965Original Act in 1965 recognized need for commitment to older personsrecognized need for commitment to older persons

• Established Administration on Aging (AOA) under Established Administration on Aging (AOA) under Department of Health and Human ServicesDepartment of Health and Human Services

• Amendments to original in 1973Amendments to original in 1973 establish State Area Agency on Aging (AAA)establish State Area Agency on Aging (AAA) purpose of AAA…purpose of AAA… responsibilities of AAAresponsibilities of AAA

www.longtermcarelink.netwww.longtermcarelink.net

Federal RoleFederal Role• Development of National Aging Service NetworkDevelopment of National Aging Service Network

• 56 state unite56 state unite

• 655 Area Agencies on Aging (AAA)655 Area Agencies on Aging (AAA)

• 250 Tribal organizations250 Tribal organizations

• 29,000 Community based provider29,000 Community based provider

• 5000,000 volunteers5000,000 volunteers

www.longtermcarelink.netwww.longtermcarelink.net

Awards to StatesAwards to States

• Funding divided based on number of people over Funding divided based on number of people over 60 years of age60 years of age

• Small states get guaranteed minimum fundingSmall states get guaranteed minimum funding

• Some service categories require matching funds Some service categories require matching funds from state and local unitsfrom state and local units

AAA Information and referralAAA Information and referral

• Health Insurance CounselingHealth Insurance Counseling

• Client assessmentsClient assessments

• Care managementCare management

• TransportationTransportation

• Caregiver supportCaregiver support

• Retirement planning and educationRetirement planning and education

AAA community based servicesAAA community based services

• Employment servicesEmployment services

• Senior CentersSenior Centers

• Congregate mealsCongregate meals

• Adult day care servicesAdult day care services

• Volunteer opportunitiesVolunteer opportunities

AAA in home servicesAAA in home services

• Meals on wheelsMeals on wheels

• Home makersHome makers

• Chore servicesChore services

• Telephone ReassuranceTelephone Reassurance

• Friendly visitingFriendly visiting

• Energy assistanceEnergy assistance

• Emergency response systemEmergency response system

• Home health servicesHome health services

• Personal Care servicesPersonal Care services

• Respite careRespite care

AAA elder rightsAAA elder rights

• Legal assistanceLegal assistance

• Elder abuse prevention programElder abuse prevention program

• Ombudsmen servicesOmbudsmen services

Other servicesOther services

• Home based services vs institutionHome based services vs institution

costs costs

family preferencesfamily preferences

• Formal care Formal care

limited in number and scopelimited in number and scope

costlycostly

may have strict criteriamay have strict criteria

Seccombe (1987)Seccombe (1987)

Family vs. AgencyFamily vs. Agency• Family:Family: informalinformal sharedshared kinship systemkinship system routine assistance vs substitution principalroutine assistance vs substitution principal typically femaletypically female time or moneytime or money burnoutburnout• Agency:Agency: professional caregiversprofessional caregivers costlycostly eligibility criteriaeligibility criteria unintended consequencesunintended consequences loneliness and isolationloneliness and isolation poorer health outcomespoorer health outcomes agency qualityagency quality

Shuey (2003)Shuey (2003)

Short term vs long termShort term vs long term

• Short term:Short term:

nursing care and return homenursing care and return home

palliative or hospicepalliative or hospice

• Long term:Long term:

nursing care and institutionalizationnursing care and institutionalization

Home health care Home health care

• Certified careCertified care

paid by Medicare/Medicaidpaid by Medicare/Medicaid

costlycostly

qualificationsqualifications

• Not certified careNot certified care

not paid by Medicare/Medicaidnot paid by Medicare/Medicaid

private careprivate care

possibly sliding scalepossibly sliding scale

ResourcesResources

Day, Thomas. (2002). The Aging Network at the Local level-Area Agencies on Aging. Day, Thomas. (2002). The Aging Network at the Local level-Area Agencies on Aging. National National Care Planning Council.Care Planning Council. Retrieved October 30, 2011, from www.Longtermcrelink.net. Retrieved October 30, 2011, from www.Longtermcrelink.net.

Levine, Carol. , Albert, Steven. M., Hokenstad, Alene., Halper, Deborah, D., Hart, Andrea. Y., Levine, Carol. , Albert, Steven. M., Hokenstad, Alene., Halper, Deborah, D., Hart, Andrea. Y., Gould, David. A., (2006). “This Case is Closed”: Family Caregivers and the Termination of Home Gould, David. A., (2006). “This Case is Closed”: Family Caregivers and the Termination of Home Health Care Services for Stroke Patients, 84(2) 305-331. Health Care Services for Stroke Patients, 84(2) 305-331.

Seccombe, K., Ryan, R., & Austin, C. D. (1987). Care Planning: Case Managers' Assessment of Seccombe, K., Ryan, R., & Austin, C. D. (1987). Care Planning: Case Managers' Assessment of Elders' Welfare and Caregivers' Capacity.Elders' Welfare and Caregivers' Capacity.Family RelationsFamily Relations, , 3636(2), 171.(2), 171.   Shuey, K., & Hardy, M. A. (2003). Assistance to Aging Parents and Parents-In-Law: Does Lineage Shuey, K., & Hardy, M. A. (2003). Assistance to Aging Parents and Parents-In-Law: Does Lineage Affect Family Allocation Decisions. Affect Family Allocation Decisions. Journal Of Marriage & FamilyJournal Of Marriage & Family, , 6565(2), 418-431.(2), 418-431.

Yee, Donna. L., Capitman, John. A., (1996). Health Care Access, Health Promotion, and Older Yee, Donna. L., Capitman, John. A., (1996). Health Care Access, Health Promotion, and Older Women of Color. Women of Color. Journal of Health Care for the Poor and Underserved, 7(3). Journal of Health Care for the Poor and Underserved, 7(3). 252-272252-272. Retrieved . Retrieved October 23, 2011, from Project MUSE database.October 23, 2011, from Project MUSE database.

  

Cont.Cont.

• Seccombe, K., Ryan, R., & Austin, C. D. (1987). Care Seccombe, K., Ryan, R., & Austin, C. D. (1987). Care Planning: Case Managers' Assessment of Elders' Welfare Planning: Case Managers' Assessment of Elders' Welfare and Caregivers' Capacity.and Caregivers' Capacity.Family RelationsFamily Relations, , 3636(2), 171.  (2), 171.  

• Shuey, K., & Hardy, M. A. (2003). Assistance to Aging Shuey, K., & Hardy, M. A. (2003). Assistance to Aging Parents and Parents-In-Law: Does Lineage Affect Family Parents and Parents-In-Law: Does Lineage Affect Family Allocation Decisions?.Allocation Decisions?.Journal Of Marriage & FamilyJournal Of Marriage & Family, , 6565(2), (2), 418-431.418-431.

• Yee, Donna., Capitman, John A., (1996). Health Care Access, Yee, Donna., Capitman, John A., (1996). Health Care Access, Health Promotion, and Older Women of Color. Health Promotion, and Older Women of Color. Journal of Journal of Health Care for the Poor and Underserved, Health Care for the Poor and Underserved, 7(3), 252-2727(3), 252-272. . Retrieved October 24, 2011 from Project MUSE database.Retrieved October 24, 2011 from Project MUSE database.

• Levine, Carol., Albert, Steven, M., Hokenstad, Alene.,Halper, Levine, Carol., Albert, Steven, M., Hokenstad, Alene.,Halper, Deborah. E., Hart, Andrea. Y., Gould, David.A. (2006).”This Deborah. E., Hart, Andrea. Y., Gould, David.A. (2006).”This Case is Closed”: Family Caregivers and the Termination of Case is Closed”: Family Caregivers and the Termination of Home Health Care Services for Stroke Patients. The Milbank Home Health Care Services for Stroke Patients. The Milbank Quarterly, 84(2), 305-331Quarterly, 84(2), 305-331

Making the Right Home ChoiceIgor

In-Home CareIn-Home Care

• Rendering services Rendering services at clients own homeat clients own home

• Life assistance Life assistance servicesservicesActivities of daily living (ADL)Activities of daily living (ADL)

Instrumental activities of daily living Instrumental activities of daily living (IADL)(IADL)

• CaregiverCaregiverAgency, background check, trainingAgency, background check, training

• Case managerCase managerCare plan, monitoringCare plan, monitoring

• ClientClientFunctional eligibilityFunctional eligibilityFinancial eligibilityFinancial eligibility

Accessory Dwelling UnitsAccessory Dwelling Units

• Adding an accessory dwelling Adding an accessory dwelling unit (ADU) to an existing unit (ADU) to an existing home home

• Client’s independence and Client’s independence and accessibilityaccessibility

• Separate living and sleeping Separate living and sleeping area, a place to cook, and a area, a place to cook, and a bathroombathroom

• An upper floor, basement, An upper floor, basement, attic, or space over a garage attic, or space over a garage may be turned into an ADUmay be turned into an ADU

• Is ADUs are allowed in your Is ADUs are allowed in your area? Special rules?area? Special rules?

Home SharingHome Sharing

• Share a house or Share a house or apartmentapartment

• Not to live aloneNot to live alone• Separate bedrooms (and Separate bedrooms (and

possibly separate possibly separate bathrooms)bathrooms)

• Share a kitchen, living Share a kitchen, living spaces, and household spaces, and household choreschores

• Share costs of living or in Share costs of living or in exchange for assistance exchange for assistance with cooking, cleaning and with cooking, cleaning and other household tasksother household tasks

• Faith-based and Faith-based and community large homes community large homes shared by several shared by several individualsindividuals

Foster CareFoster Care

• Some families take in an Some families take in an older person who needs older person who needs help with daily living help with daily living

• The foster family cooks The foster family cooks meals and handles laundrymeals and handles laundry

• Surrogate family member Surrogate family member receives emotional support receives emotional support and companionship and companionship

• Supplemental Security Supplemental Security Income (SSI) may cover Income (SSI) may cover the cost of foster carethe cost of foster care

Subsidized Senior HousingSubsidized Senior Housing

• Federal and state Federal and state programs that help pay for programs that help pay for housinghousing

• Older people with low to Older people with low to moderate incomesmoderate incomes

• Help with meals, Help with meals, housekeeping, shopping, housekeeping, shopping, and doing the laundryand doing the laundry

• Live in their own Live in their own apartments in the complexapartments in the complex

• Rent payments are usually Rent payments are usually a percentage of your a percentage of your income (a sliding scale)income (a sliding scale)

Board and Care HomesBoard and Care Homes

• For folks who need some For folks who need some assistanceassistance

• Provides a room, helps with Provides a room, helps with daily activities: eating, daily activities: eating, bathing, and using the bathing, and using the bathroombathroom

• Smaller than assisted living Smaller than assisted living residences, and do not need residences, and do not need nursing home servicesnursing home services

• Not always licensed or Not always licensed or monitored by local monitored by local authoritiesauthorities

• Can provide nursing Can provide nursing services, but they are not services, but they are not medical facilitiesmedical facilities

Congregate Housing/Retirement Congregate Housing/Retirement CommunitiesCommunities

• Own apartment units but Own apartment units but share some meals in a share some meals in a central dining roomcentral dining room

• Housekeeping servicesHousekeeping services• Social and recreational Social and recreational

activitiesactivities• Rental fees vary widely, Rental fees vary widely,

and meals and other and meals and other services cost extraservices cost extra

• Some residences receive Some residences receive public subsidies - long public subsidies - long waiting lists - income waiting lists - income requirements.requirements.

Assisted Living FacilitiesAssisted Living Facilities

• Help with activities of daily living Help with activities of daily living like bathing, dressing, using the like bathing, dressing, using the bathroom, and taking medicinebathroom, and taking medicine

• Additional services like getting to Additional services like getting to appointments or preparing meals appointments or preparing meals (additional fees charged)(additional fees charged)

• Pay a regular monthly rent and Pay a regular monthly rent and live in your own room or live in your own room or apartmentapartment

• Have some or all of the meals Have some or all of the meals togethertogether

• Social and recreational activities Social and recreational activities are usually providedare usually provided

• Not all assisted living facilities Not all assisted living facilities provide the same services. It is provide the same services. It is important to contact the facility important to contact the facility and make sure they can meet and make sure they can meet Client's needs. Client's needs.

Nursing HomesNursing Homes

• The most widely The most widely recognized optionrecognized option

• Will be discoursed Will be discoursed later in the later in the presentationpresentation

Continuing Care Retirement Continuing Care Retirement CommunitiesCommunities

• Meeting the changing needs Meeting the changing needs of older peopleof older people

• Variety of housing options Variety of housing options and services on the same and services on the same campuscampus

• More expensive housing More expensive housing optionoption

• Start living independentlyStart living independently• Move to an assisted-living Move to an assisted-living

unit if help with daily unit if help with daily activities necessaryactivities necessary

• Move to the nursing unit if Move to the nursing unit if ongoing skilled nursing care ongoing skilled nursing care is requiredis required

Hospice CareHospice Care

• For people who are terminally ill For people who are terminally ill (with six months or less to live), (with six months or less to live), and for their familiesand for their families

• Includes physical care and Includes physical care and counselingcounseling

• Provide comfort for terminally ill Provide comfort for terminally ill patients and their families, not to patients and their families, not to cure illnesscure illness

• Medical and support services, Medical and support services, including nursing care, medical including nursing care, medical social services, doctor services, social services, doctor services, counseling, homemaker services, counseling, homemaker services, and other types of servicesand other types of services

• A team of doctors, nurses, home A team of doctors, nurses, home health aids, social workers, health aids, social workers, counselors and trained volunteers counselors and trained volunteers to help youto help you

• May get hospice care in a hospice May get hospice care in a hospice facility, hospital, or nursing homefacility, hospital, or nursing home

Respite CareRespite Care

• Some nursing homes and Some nursing homes and hospice care facilities hospice care facilities may provide respite caremay provide respite care

• Very short inpatient stay Very short inpatient stay given to a hospice given to a hospice patient so that they patient so that they usual caregiver can restusual caregiver can rest

• Medicare covers respite Medicare covers respite care for up to five days if care for up to five days if you are getting covered you are getting covered hospice carehospice care

• Inpatient respite care Inpatient respite care and short-term hospital and short-term hospital staysstays

Program for All Inclusive Care for the Program for All Inclusive Care for the Elderly (PACE)Elderly (PACE)

• Permits Client to live at Permits Client to live at home while receiving home while receiving services, rather than be services, rather than be institutionalizedinstitutionalized

• Provides long-term care Provides long-term care and acute medical servicesand acute medical services

• Older and disabled adults Older and disabled adults who meet nursing level who meet nursing level facility of carefacility of care

• A voluntary managed care A voluntary managed care programprogram

• Utilizes Medicare and Utilizes Medicare and Medicaid benefitsMedicaid benefits

Clients who may benefit from PACE Clients who may benefit from PACE (continued)(continued)

• A wide variety of needs, requiring A wide variety of needs, requiring close monitoring by a physician close monitoring by a physician because of medical conditions, because of medical conditions, which may include behavioral which may include behavioral conditions (i.e. dementia)conditions (i.e. dementia)

• Medically complex clients who Medically complex clients who have needs that can be addressed have needs that can be addressed by PACEby PACE

• An ongoing need for restorative An ongoing need for restorative therapies (OT, PT, Speech Therapytherapies (OT, PT, Speech Therapy

• A history of multiple A history of multiple hospitalizations and short nursing hospitalizations and short nursing facility staysfacility stays

• No access or limited use of No access or limited use of primary careprimary care

• Excessive emergency room visitsExcessive emergency room visits• Lack of family or informal support Lack of family or informal support

systemsystem

Home and Community-Based Waiver Home and Community-Based Waiver ProgramsPrograms

• Eligible for Medicaid Clients Eligible for Medicaid Clients may get help with the costs may get help with the costs of some home and of some home and community-based services community-based services

• Homemaker services, Homemaker services, personal care, and respite personal care, and respite carecare

• Home and community-Home and community-based waiver programs based waiver programs help people keep their help people keep their independenceindependence

• Provide care outside of an Provide care outside of an inpatient facilityinpatient facility

NURSING HOMESMarkNURSING HOMESMark

What is a nursing home?What is a nursing home?• A nursing home, also known as a A nursing home, also known as a skilled nursing facilityskilled nursing facility, is a place for people who , is a place for people who

don’t need to be in a hospital but can no longer be cared for at home. Being admitted to don’t need to be in a hospital but can no longer be cared for at home. Being admitted to a nursing home is based on medical need. Most nursing homes have aides and skilled a nursing home is based on medical need. Most nursing homes have aides and skilled nurses on hand 24 hours a day. nurses on hand 24 hours a day.

• Nursing homes can be:Nursing homes can be:

• Hospital-likeHospital-like. This type of nursing home is often set up like a hospital. Staff give . This type of nursing home is often set up like a hospital. Staff give medical care, as well as physical, speech, and occupational therapy. There can be a medical care, as well as physical, speech, and occupational therapy. There can be a nurses’ station on each floor. As a rule, one or two people live in a room. A number of nurses’ station on each floor. As a rule, one or two people live in a room. A number of nursing homes will let couples live together. Things that make a room special, like family nursing homes will let couples live together. Things that make a room special, like family photos, are often welcome.photos, are often welcome.

• Household-likeHousehold-like. These facilities are designed to be more like homes, and the day-to-day . These facilities are designed to be more like homes, and the day-to-day routine isn’t fixed. Teams of staff and residents try to create a neighborhood feel. routine isn’t fixed. Teams of staff and residents try to create a neighborhood feel. Kitchens are often open to residents, decorations give a sense of home, and staff are Kitchens are often open to residents, decorations give a sense of home, and staff are encouraged to develop relationships with residents.encouraged to develop relationships with residents.

• Some nursing homes have visiting doctors who see their patients on site. Other nursing Some nursing homes have visiting doctors who see their patients on site. Other nursing homes have patients visit the doctor’s office. Nursing homes sometimes have separate homes have patients visit the doctor’s office. Nursing homes sometimes have separate areas called Special Care Units for people with serious memory problems, like dementia. areas called Special Care Units for people with serious memory problems, like dementia. When looking for a nursing home, it’s important for families to think about special needs.When looking for a nursing home, it’s important for families to think about special needs.

• http://www.nia.nih.gov/HealthInformation/Publications/nursinghomes.htm

• ExampleExample: : Veterans Nursing HomesVeterans Nursing Homes are now called are now called Community Living Centers Community Living Centers (CLC) (CLC) of which a prime example is the Lakewood VA (new facility just built last year that of which a prime example is the Lakewood VA (new facility just built last year that is much more accommodating than the previous old and outdated structure) . There are is much more accommodating than the previous old and outdated structure) . There are 133 CLC’s in the United States (of which 3 are in Washington State). 133 CLC’s in the United States (of which 3 are in Washington State).

• http://www.va.gov/GERIATRICS/Veterans_Administration_Community_Living_Centers.asp

Who is eligible?Who is eligible?

• Covered under WAC 388-513-Covered under WAC 388-513-1315 Eligibility for long-term 1315 Eligibility for long-term care (institutional, waiver, and care (institutional, waiver, and hospice) services.hospice) services.

• http://www.dshs.wa.gov/manuals/eaz/sections/LongTermCare/LTCDeligreq.shtml#388-513-1315

• Veterans requiring nursing Veterans requiring nursing home care for a service-home care for a service-connected condition, or a connected condition, or a veteran rated 70% or more, veteran rated 70% or more, have mandatory eligibility. All have mandatory eligibility. All other veterans are eligible on other veterans are eligible on a resource and space-a resource and space-available basis. The best available basis. The best source for determining what source for determining what assistance is available for assistance is available for these VA services, is the these VA services, is the Social Work department at Social Work department at the nearest VA facility. the nearest VA facility.

• http://www2.va.gov/directory/guide/home.asp

How is nursing home care How is nursing home care paid for?paid for?

•MedicaidMedicaid. This is a State/Federal program that provides health benefits to some people with low . This is a State/Federal program that provides health benefits to some people with low incomes. Contact your county family services department to see if you qualify. Once you have met incomes. Contact your county family services department to see if you qualify. Once you have met the requirements of your State’s Medicaid program, it can take up to 90 days to be approved. the requirements of your State’s Medicaid program, it can take up to 90 days to be approved. •Private payPrivate pay. Some people pay for long-term care with their own savings for as long as possible. . Some people pay for long-term care with their own savings for as long as possible. When that is no longer possible, they may get help from Medicaid. If you think you may need to When that is no longer possible, they may get help from Medicaid. If you think you may need to apply for Medicaid at some point, make sure the nursing home accepts it. Not all homes do. apply for Medicaid at some point, make sure the nursing home accepts it. Not all homes do. •Long-term care insuranceLong-term care insurance. Some people buy private long-term care insurance. It can pay part . Some people buy private long-term care insurance. It can pay part of the costs for a nursing home or other long-term care. This type of insurance is sold by many of the costs for a nursing home or other long-term care. This type of insurance is sold by many different companies and benefits vary widely. Look carefully at several policies before making a different companies and benefits vary widely. Look carefully at several policies before making a choice. choice.

•Many people believe Many people believe MedicareMedicare will pay for long stays in a nursing home, but it doesn’t. For will pay for long stays in a nursing home, but it doesn’t. For example, Medicare will only cover the first 100 days in a skilled nursing home for someone who example, Medicare will only cover the first 100 days in a skilled nursing home for someone who needs special care after leaving the hospital. State/Federal Medicaid programs may pay for long-needs special care after leaving the hospital. State/Federal Medicaid programs may pay for long-term nursing home care, but there are many rules about qualifying. It is important to check with term nursing home care, but there are many rules about qualifying. It is important to check with Medicare, Medicaid, and any private insurance company to find out the current rules.Medicare, Medicaid, and any private insurance company to find out the current rules. •When thinking about costs, keep in mind that there can be extra out-of-pocket charges for some When thinking about costs, keep in mind that there can be extra out-of-pocket charges for some supplies, personal care like hair appointments, laundry, and services that are outside routine care.supplies, personal care like hair appointments, laundry, and services that are outside routine care.

•httphttp://www.nia.nih.gov/HealthInformation/Publications/nursinghomes.htm

Nursing Home Regulatory Nursing Home Regulatory Guidelines:Guidelines:

• Federal – Code of Federal Regulations Federal – Code of Federal Regulations (CFR) (CFR) Title 42 (Public Health) Section 483 Title 42 (Public Health) Section 483 (Requirements for states and long-term care (Requirements for states and long-term care facilities) & Section 488 (Survey and facilities) & Section 488 (Survey and certification of long term care facilities)certification of long term care facilities)

• http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&tpl=/ecfrbrowse/Title42/42cfr483_main_02.tpl

• State – Washington Administrative State – Washington Administrative Code (WAC)Code (WAC) Title 388-97 (Nursing Homes) Title 388-97 (Nursing Homes)

• http://apps.leg.wa.gov/WAC/default.aspx?cite=388-97

• State – Revised Code of Washington State – Revised Code of Washington (RCW) (RCW) Title 74.42 (Nursing Homes – Title 74.42 (Nursing Homes – resident care, operating standards)resident care, operating standards)

• http://apps.leg.wa.gov/RCW/default.aspx?cite=74.42

Aging and Disability Aging and Disability Services Administration Services Administration

(ADSA)(ADSA)• VisionVision – Safe, healthy – Safe, healthy

individuals, families and individuals, families and communities.communities.

• MissionMission – DSHS will – DSHS will improve the safety and improve the safety and health of individuals, health of individuals, families and communities families and communities by providing leadership and by providing leadership and establishing and establishing and participating in participating in partnerships.partnerships.

• ValuesValues - Excellence in - Excellence in Service, Respect, Service, Respect, Collaboration and Collaboration and Partnership, Diversity, Partnership, Diversity, AccountabilityAccountability

• http://www.adsa.dshs.wa.gov/about/mission.htm

• VisionVision - ADR seeks to create - ADR seeks to create and sustain livable communities and sustain livable communities for people of all ages throughout for people of all ages throughout Pierce County by better serving Pierce County by better serving older adults and adults with older adults and adults with disabilities and by enhancing the disabilities and by enhancing the capacity of communities to capacity of communities to support people of all ages.support people of all ages.

• MissionMission - The mission of ADR is - The mission of ADR is to ensure that Pierce County to ensure that Pierce County residents have available a range residents have available a range of community-based services of community-based services that allow older adults and that allow older adults and adults with disabilities to remain adults with disabilities to remain at home as long as possible, at home as long as possible, while promoting dignity and while promoting dignity and maximizing individual choice, maximizing individual choice, wherever they reside.wherever they reside.

• http://www.co.pierce.wa.us/pc/abtus/ourorg/altc/altc.htm

Aging and Disability Aging and Disability Resources (ADR)Resources (ADR)

Analysis of the Nursing Home ProgramAnalysis of the Nursing Home Program

• Federal OversightFederal Oversight: The : The Centers for Medicare & Medicaid Services (CMS) Centers for Medicare & Medicaid Services (CMS) establishes quality of establishes quality of care standards and conditions of participation for the Medicare and Medicaid programs. Such care standards and conditions of participation for the Medicare and Medicaid programs. Such requirements are carefully crafted to highlight key areas of quality and convey basic, enforceable requirements are carefully crafted to highlight key areas of quality and convey basic, enforceable expectations that nursing homes must meet. More than 4,000 Federal and State surveyors conduct on-expectations that nursing homes must meet. More than 4,000 Federal and State surveyors conduct on-site reviews of every nursing home at least once every 15 months (and about once a year on average). site reviews of every nursing home at least once every 15 months (and about once a year on average). CMS also contracts with quality improvement organizations (QIOs) to assist nursing homes to make vital CMS also contracts with quality improvement organizations (QIOs) to assist nursing homes to make vital improvements in an increasingly large number of priority areas. improvements in an increasingly large number of priority areas. http://www.cms.gov/CertificationandComplianc/Downloads/2008NHActionPlan.pdf

• Local OversightLocal Oversight: The : The Pierce County Aging and Disability Resources Advisory BoardPierce County Aging and Disability Resources Advisory Board is is composed of up to twenty-five (25) volunteer members, and a number of volunteer associate members. composed of up to twenty-five (25) volunteer members, and a number of volunteer associate members. In accordance with the bylaws, these members are representative of the senior and disabled In accordance with the bylaws, these members are representative of the senior and disabled populations within Pierce County. They are appointed by the Pierce County Council, under populations within Pierce County. They are appointed by the Pierce County Council, under recommendation of the Pierce County Executive. Members of the Advisory Board, through committee recommendation of the Pierce County Executive. Members of the Advisory Board, through committee participation, assist ADR in important areas such as planning, assessments, advocacy, education, and participation, assist ADR in important areas such as planning, assessments, advocacy, education, and public relations. The Advisory Board members not only assist program staff with essential elements in public relations. The Advisory Board members not only assist program staff with essential elements in each of the above areas, but they also represent Pierce County's aging and disabled populations on each of the above areas, but they also represent Pierce County's aging and disabled populations on issues of importanceissues of importance. . http://www.co.pierce.wa.us/pc/abtus/ourorg/altc/altcboard/overview.htm

• OmbudsmanOmbudsman: Ombudsman Program staff and certified volunteers work in nursing homes, adult : Ombudsman Program staff and certified volunteers work in nursing homes, adult family homes, and boarding homes. Certified Ombudsmen are a listening ear and a voice for family homes, and boarding homes. Certified Ombudsmen are a listening ear and a voice for residents of long-term care settings. Ombudsmen educate residents, staff, families, and the residents of long-term care settings. Ombudsmen educate residents, staff, families, and the community about long-term care issues, resources, resident rights, and quality of life in long-community about long-term care issues, resources, resident rights, and quality of life in long-term care. The Washington State Long-Term Care Ombudsman Program protects and promotes term care. The Washington State Long-Term Care Ombudsman Program protects and promotes quality of life for people living in licensed, long-term adult care facilities (e.g. adult family home, quality of life for people living in licensed, long-term adult care facilities (e.g. adult family home, boarding home, nursing home). An ombudsman: Advocates for the rights of clients in adult care boarding home, nursing home). An ombudsman: Advocates for the rights of clients in adult care facilities; works with clients, families and facility staff to meet the needs and concerns of the facilities; works with clients, families and facility staff to meet the needs and concerns of the people living there; and provides a way to get complaints and concerns heard and resolved. people living there; and provides a way to get complaints and concerns heard and resolved. The following people can use the Ombudsman Program: residents living in a care facility and The following people can use the Ombudsman Program: residents living in a care facility and his/her relatives or friends; administrators and staff of an adult family home, boarding home or his/her relatives or friends; administrators and staff of an adult family home, boarding home or nursing home. A local ombudsman is an excellent resource for information and help and is a nursing home. A local ombudsman is an excellent resource for information and help and is a trusted resource in mediating complaints or concerns you may have about anyone living in an trusted resource in mediating complaints or concerns you may have about anyone living in an adult care facility. Call them if there is a problem you can’t resolve or you need another adult care facility. Call them if there is a problem you can’t resolve or you need another knowledgeable resource that works in the long-term care communityknowledgeable resource that works in the long-term care community. . . .

• http://www.co.pierce.wa.us/pc/abtus/ourorg/humsvcs/altc/ombud/ombudhome.htm• http://www.adsa.dshs.wa.gov/pubinfo/help/agencies.htm#LTC_ombudsman

Resources that can help:Resources that can help:

The rules about programs and benefits for nursing homes The rules about programs and benefits for nursing homes can change. can change. MedicareMedicare has some helpful resources online. has some helpful resources online. Visit Visit www.medicare.gov for information about different for information about different care options. To learn more about the care options. To learn more about the MedicaidMedicaid program, program, see see www.cms.hhs.gov/home/medicaid.asp.. You can find nursing homes in your area that are You can find nursing homes in your area that are approved by the approved by the Centers for Medicare & Medicaid Centers for Medicare & Medicaid Services Services by visiting the Medicare website. You can also by visiting the Medicare website. You can also see summaries of recent inspection reports. Visit Nursing see summaries of recent inspection reports. Visit Nursing Home Compare at Home Compare at www.medicare.gov/NHCompare..The Nursing Home Checklist at the same website is a The Nursing Home Checklist at the same website is a good guide to use when thinking about choosing a good guide to use when thinking about choosing a nursing home. nursing home.

Many States have Many States have State Health Insurance Counseling State Health Insurance Counseling and Assistance Programs (SHIP)and Assistance Programs (SHIP). These programs can . These programs can help you choose the health insurance that is right for you help you choose the health insurance that is right for you and your family. Visit and your family. Visit www.medicare.gov/Nursing/Payment.asp.. Each State also has a Each State also has a Long-Term Care Ombudsman Long-Term Care Ombudsman office that helps people learn about long-term care. Your office that helps people learn about long-term care. Your local office may be able to answer general questions local office may be able to answer general questions about a specific nursing home. Also, once you are living in about a specific nursing home. Also, once you are living in a nursing home, the Ombudsman can help solve a nursing home, the Ombudsman can help solve problems you may have with a facility. The National Long-problems you may have with a facility. The National Long-Term Care Ombudsman Resource Center has more Term Care Ombudsman Resource Center has more information. Visit information. Visit www.ltcombudsman.org.. A veteran in need of long-term care might be able to get A veteran in need of long-term care might be able to get help through the help through the Department of Veterans Affairs Department of Veterans Affairs (VA). (VA). Visit Visit www.va.gov. You can also contact a VA . You can also contact a VA medical center near you.medical center near you.http://www.nia.nih.gov/HealthInformation/Publications/nursinghomes.htm

Death With Dignity ActDeath With Dignity Act

• Allows terminally ill adults seeking to Allows terminally ill adults seeking to end their life to request lethal doses end their life to request lethal doses of medication from medical and of medication from medical and osteopathic physicians. osteopathic physicians.

www.deathwithdignity.org

Washington Law: Revised Washington Law: Revised Code of WashingtonCode of Washington

• The Washington Death with Dignity Act, Initiative 1000The Washington Death with Dignity Act, Initiative 1000, codified , codified as RCW 70.245, as RCW 70.245, passed on November 4, 2008 and went into effect passed on November 4, 2008 and went into effect on March 5, 2009on March 5, 2009

• The act allows health-care facilities and individual health-care The act allows health-care facilities and individual health-care providers not to participateproviders not to participate

http://www.doh.wa.gov/dwda/

Requirements:Requirements:• Patient must be a resident of the state in which they live.Patient must be a resident of the state in which they live.

• Be 18 years of age or olderBe 18 years of age or older

• Mentally competentMentally competent

• The patient must make two oral requests, 15 days apartThe patient must make two oral requests, 15 days apart

• Submit a written request witnessed by two people, one of Submit a written request witnessed by two people, one of which must not be a relative, heir, attending doctor, or which must not be a relative, heir, attending doctor, or connected with a health facility where the requester livesconnected with a health facility where the requester lives

• Two doctors must certify that the patient has a terminal Two doctors must certify that the patient has a terminal condition and six months or less to livecondition and six months or less to live

• http://www.doh.wa.gov/dwda/

SafeguardsSafeguards

• There are multiple safeguards in Washington’s There are multiple safeguards in Washington’s death with dignity law. death with dignity law.

• Independently witnessed oral and written Independently witnessed oral and written requestsrequests

• Two waiting periodsTwo waiting periods

• Mental competency and prognosis confirmed by Mental competency and prognosis confirmed by two physicianstwo physicians

• Self-administration of the medication. Only the Self-administration of the medication. Only the patient – and no one else – may administer the patient – and no one else – may administer the medication.medication.

Safeguards cont’d…Safeguards cont’d…• Ensures only the patient can make a request and Ensures only the patient can make a request and

the patient must control the process from the patient must control the process from beginning to end beginning to end

• Require physicians to discuss Require physicians to discuss ALL ALL end of life end of life options with patients, including comfort care, options with patients, including comfort care, hospice care and pain controlhospice care and pain control

• This disclosure is required to be in writingThis disclosure is required to be in writing

Access to end-of-life resourcesAccess to end-of-life resourcesPlanning Ahead~Planning Ahead~

•Advance Directive FormsProvided through the National Hospice and Palliative Care Provided through the National Hospice and Palliative Care Organization. Here you can find, download and print your Organization. Here you can find, download and print your state's advance directive forms.state's advance directive forms.

•POLST (Physician Orders for Life-Sustaining Treatment) Registry Information

Many states have POLST programs to help ensure a patient’s Many states have POLST programs to help ensure a patient’s wishes are honored in emergency situations. wishes are honored in emergency situations.

http://www.wsma.org/patient_resources/end-of-life.cfm

Access to end-of-life resources Access to end-of-life resources cont’d…cont’d…

• Five WishesFive WishesFive Wishes represent the five main  represent the five main questions you need to consider when questions you need to consider when thinking about your end-of-life care thinking about your end-of-life care options. options. Five WishesFive Wishes has become  has become America’s most popular living will because America’s most popular living will because it is written in everyday language and it is written in everyday language and helps start and structure important helps start and structure important conversations about care in times of conversations about care in times of serious illness. It also meets the legal serious illness. It also meets the legal requirements in 42 states and is useful in requirements in 42 states and is useful in all 50.all 50.

Comfort Care and Pain Comfort Care and Pain Management:Management:

• Palliative Care-defined as “relieving or soothing the symptoms Palliative Care-defined as “relieving or soothing the symptoms of a disease or disorder.”of a disease or disorder.”

• Hospice Care-is a special concept of care designed to handle Hospice Care-is a special concept of care designed to handle the issues of the terminally ill:the issues of the terminally ill:– comfort and support to patients and their families when a comfort and support to patients and their families when a

life-limiting illness no longer responds to cure-oriented life-limiting illness no longer responds to cure-oriented treatmentstreatments

– The goal of hospice care is to improve the quality of a The goal of hospice care is to improve the quality of a patient's last days by offering comfort and dignitypatient's last days by offering comfort and dignity

http://depts.washington.edu/eolcare/

Palliative CarePalliative Care

• When death is imminent, it is important to have When death is imminent, it is important to have an organized team to handle issues of the an organized team to handle issues of the terminally ill. There are physical, psychological, terminally ill. There are physical, psychological, social, and spiritual aspects of suffering. social, and spiritual aspects of suffering.

• Palliative Care has the goal of providing comfort Palliative Care has the goal of providing comfort to the patient and the emotional acceptance of to the patient and the emotional acceptance of the event by the patient as well as by the family the event by the patient as well as by the family members.members.

http://www.wshpco.org/

Hospice CareHospice Care

• Is centered upon an interdisciplinary team that Is centered upon an interdisciplinary team that collaborates to provide comprehensive care to collaborates to provide comprehensive care to handle issues of the terminally ill and to prepare handle issues of the terminally ill and to prepare patients and families for acceptance of the patients and families for acceptance of the inevitable eventinevitable event

• The philosophy embraces the general principle of a The philosophy embraces the general principle of a comfortable death with dignitycomfortable death with dignity

• http://www.wshpco.org/

What are the benefits?What are the benefits?

• Death with Dignity Acts expand end of life Death with Dignity Acts expand end of life choices choices

• Improve end of life care for ALL terminally ill Improve end of life care for ALL terminally ill

patients, including those who lack health patients, including those who lack health insurance insurance or access to medical care. Making this or access to medical care. Making this choice legal.choice legal.

• Gives every terminal patient, rich or poor, access Gives every terminal patient, rich or poor, access to the to the comfort and hope that comes with comfort and hope that comes with having a choice.having a choice.

SafeguardsSafeguards• The safeguards in the Death with Dignity Acts The safeguards in the Death with Dignity Acts

ensure only the patient can make a request and ensure only the patient can make a request and the patient must control the process from the patient must control the process from beginning to end. beginning to end.

• Unlike in states without a Death with Dignity Act, Unlike in states without a Death with Dignity Act, the Acts require physicians to discuss ALL end of the Acts require physicians to discuss ALL end of life options with patients, including comfort care, life options with patients, including comfort care, hospice care and pain control. hospice care and pain control.

• This disclosure is required to be in writing. This disclosure is required to be in writing. Patients must take the medication themselves. Patients must take the medication themselves.

FundingFunding• Assisted-suicide advocacy groups provide major funding for I 1000Assisted-suicide advocacy groups provide major funding for I 1000

**Compassion & Choices of Washington, the state's largest aid-in-**Compassion & Choices of Washington, the state's largest aid-in-dying advocacy groupdying advocacy group

• The “Yes on I 1000″ committee reported receipts of $4,856,732, more than The “Yes on I 1000″ committee reported receipts of $4,856,732, more than $3.1 million of that from $3.1 million of that from cash contributions made by assisted-suicide  made by assisted-suicide advocacy groups; Booth Gardner (his family and his legacy fund) and from advocacy groups; Booth Gardner (his family and his legacy fund) and from Loren Parks (a self-described major contributor to the campaigns for Loren Parks (a self-described major contributor to the campaigns for Oregon’s assisted-suicide law)Oregon’s assisted-suicide law)

• The “Yes on 1 1000″ committee accepted hundreds of thousands of dollars The “Yes on 1 1000″ committee accepted hundreds of thousands of dollars in in foreign contributions

• Assisted-suicide groups also provided Assisted-suicide groups also provided in-kind contributions (donated goods  (donated goods and/or services) and made and/or services) and made pre-campaign expenditures in preparation for I- in preparation for I-10001000

• Coalition against Assisted Suicide reported contributions totaling Coalition against Assisted Suicide reported contributions totaling $1,510,442$1,510,442

http://www.patientsrightscouncil.org/site/funding-watch/

HandoutsHandouts

• Attending physician responsibilities. RCW Attending physician responsibilities. RCW 70.245.04070.245.040

• Washington Death with Dignity Act, I 1000Washington Death with Dignity Act, I 1000

• The Washington Death with Dignity Act, Chapter The Washington Death with Dignity Act, Chapter 246-978 WAC246-978 WAC

ResourcesResources

• www.deathwithdignity.orgwww.deathwithdignity.org

• http://www.compassionwa.orghttp://www.compassionwa.org

• http://www.wsma.orghttp://www.wsma.org

• http://www.wshpco.org/http://www.wshpco.org/

• http://www.doh.wa.gov/dwda/http://www.doh.wa.gov/dwda/

• http://www.patientsrightscouncil.org/site/washington/http://www.patientsrightscouncil.org/site/washington/

• http://dredf.org/assisted_suicide/assisted_suicide.shtmlhttp://dredf.org/assisted_suicide/assisted_suicide.shtml

• http://www.patientsrightscouncil.org/site/funding-http://www.patientsrightscouncil.org/site/funding-watch/watch/

• http://depts.washington.edu/eolcare/http://depts.washington.edu/eolcare/

Financing End of Life CareFinancing End of Life CareCarlyCarly

What Are The Options?What Are The Options?

MedicareWhat is Medicare?

Medicare is health insurance that is provided for the following populations:

• People over the age of 65•People under the age of 65 with some specific disabilities that allow for coverage•People of any age that require kidney transplant or dialysis due to kidney failure

There are three parts to Medicare:

Part A: Hospital Insurance (Hospitals, Skilled Nursing Facilities, Hospice and Home Health CarePart B: Medical Insurance (Doctor’s Visits, Outpatient Hospital Care, and Home Health Care)Part : Prescription Drug Coverage

**There is also a part C that can be purchased from private insurance companies(Medicare.gov, 2011)

MedicareMedicare

How is Medicare Accessed?•When a person in the United States turns 65 years old, there is a 7 month window to apply for Medicare.

•This window begins 3 months before your 65th birthday and ends 3 months after your 65th birthday.•If a person misses the enrollment window they can sign up for benefits during the special enrollment period of January 1st-March 31st after they turn 65. •There is a premium increase for Part A and Part B if you do not sign up when you are first eligible.(Medicare.gov, 2011)

Medicare Cont’dMedicare Cont’d

How is Medicare Funded?

The Hospital Insurance Trust Fund (HI)•Funded by payroll taxes from most employees and employers, along with income taxes paid on Social Security benefits, interest from trust fund investments and the premiums paid by people who are not eligible for free Part A coverage.•Funds Part A coverage

Supplementary Medical Insurance Trust Fund (SMI)•Funded by money authorized by congress, interest made off of trust fund investments, and premiums paid by people enrolled in Part B and Part D.•Funds Part B and Part D, along with the costs of the administrative aspects of Medicare (investigating fraud/abuse, paying out benefits)•Part B has a monthly premium of $115.40.(Medicare.gov, 2011)

MedicaidMedicaidWhat is Medicaid?Medicaid is a state funded program that allows people that are recognized as low-income by federal and state law to see medical providers.

Who is eligible?•Eligibility differs by state•In Washington State eligibility is based off of income, number of people in the applicant’s household, how many children live with the applicant, and how much money is paid in child support by the family of the applicant.(United States Department of Health and Human Services, 2011)

Medicaid ContinuedMedicaid Continued

How is it accessed in Washington?•A person over 18 or older in Washington State can fill out an application at their local Home and Community Services Office or online at the Department of Social and Health Services website (www.adasa.dshs.wa.gov)•A assessment of personal care needs will be completed to determine eligibility(Washington State Department of Social and Health Services, 2011)

How is Medicaid Funded?•Jointly funded by individual state tax dollars and federal tax dollars. (Social Security Online, 2011)

What is Covered in Terms of End of Life What is Covered in Terms of End of Life Care?Care?

Medicare:•Covers skilled nursing facilities, hospice and home health care if the recipient declines to have further treatment.

•Hospice coverage does not include any room and board (Medicare.gov, 2011)•Bereavement services are only provided under hospice care•Five days of respite care is only covered under hospice care (Moon & Boccuti, 2010)

Medicaid:•Covers hospice, nursing homes and home care if the recipient declines to have further treatment

•Some states require that all other home and community services be discontinued if the recipient is enrolled in hospice (Tilly & Wiener, 2010)

•Note: The recipient of both Medicare and Medicaid must be deemed to have only six months to live to receive end of life care. (Tilly & Wiener, 2010)

Putting Things Into PerspectivePutting Things Into Perspective

•3.5 Million people 65 and older in the United States live in poverty. (United States Census Bureau, 2011)•Medicare and Medicaid are the most relied on coverage for end of life care (Tilly & Wiener, 2010)•How much autonomy do seniors really have when it comes to end of life care?

THE ENDTHE END

ANY QUESTIONS?ANY QUESTIONS?

Resources (Dorothy)Resources (Dorothy)

Day, Thomas. (2002). The Aging Network at the Local level-Area Agencies on Aging. Day, Thomas. (2002). The Aging Network at the Local level-Area Agencies on Aging. National Care National Care Planning Council.Planning Council. Retrieved October 30, 2011, from www.Longtermcrelink.net. Retrieved October 30, 2011, from www.Longtermcrelink.net.

Levine, Carol. , Albert, Steven. M., Hokenstad, Alene., Halper, Deborah, D., Hart, Andrea. Y., Gould, Levine, Carol. , Albert, Steven. M., Hokenstad, Alene., Halper, Deborah, D., Hart, Andrea. Y., Gould, David. A., (2006). “This Case is Closed”: Family Caregivers and the Termination of Home Health Care David. A., (2006). “This Case is Closed”: Family Caregivers and the Termination of Home Health Care Services for Stroke Patients, 84(2) 305-331. Services for Stroke Patients, 84(2) 305-331.

Seccombe, K., Ryan, R., & Austin, C. D. (1987). Care Planning: Case Managers' Assessment of Elders' Seccombe, K., Ryan, R., & Austin, C. D. (1987). Care Planning: Case Managers' Assessment of Elders' Welfare and Caregivers' Capacity.Welfare and Caregivers' Capacity.Family RelationsFamily Relations, , 3636(2), 171.(2), 171.

  

Shuey, K., & Hardy, M. A. (2003). Assistance to Aging Parents and Parents-In-Law: Does Lineage Affect Shuey, K., & Hardy, M. A. (2003). Assistance to Aging Parents and Parents-In-Law: Does Lineage Affect Family Allocation Decisions. Family Allocation Decisions. Journal Of Marriage & FamilyJournal Of Marriage & Family, , 6565(2), 418-431.(2), 418-431.

Yee, Donna. L., Capitman, John. A., (1996). Health Care Access, Health Promotion, and Older Women of Yee, Donna. L., Capitman, John. A., (1996). Health Care Access, Health Promotion, and Older Women of Color. Color. Journal of Health Care for the Poor and Underserved, 7(3). Journal of Health Care for the Poor and Underserved, 7(3). 252-272252-272. Retrieved October 23, 2011, . Retrieved October 23, 2011, from Project MUSE database.from Project MUSE database.

Resources (Igor)Resources (Igor)

Resources (Mark)Resources (Mark)

Resources (Lisa)Resources (Lisa)

• www.deathwithdignity.orgwww.deathwithdignity.org

• http://www.compassionwa.orghttp://www.compassionwa.org

• http://www.wsma.orghttp://www.wsma.org

• http://www.wshpco.org/http://www.wshpco.org/

• http://www.doh.wa.gov/dwda/http://www.doh.wa.gov/dwda/

• http://www.patientsrightscouncil.org/site/washington/http://www.patientsrightscouncil.org/site/washington/

• http://dredf.org/assisted_suicide/assisted_suicide.shtmlhttp://dredf.org/assisted_suicide/assisted_suicide.shtml

• http://www.patientsrightscouncil.org/site/funding-watch/http://www.patientsrightscouncil.org/site/funding-watch/

• http://depts.washington.edu/eolcare/http://depts.washington.edu/eolcare/

Resources (Carly)Resources (Carly)