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Nursing shortage leaves families struggling to find at-home care

Families across California approved for at-home nursing care are having difficulty getting the help they desperately need. Health care advocates are pointing to a larger nationwide nursing shortage as one of the reasons demands are not being met.

The American Association of Nurses has noted a lack of younger nurses to replace older nurses who are retiring. A licensed vocational nurse (LVN) is among the most sought-after home care nurses. Licensed vocation nurses are responsible for providing basic nursing care under the guidance of a doctor or registered nurse.

The at-home nursing shortage is attributed in part to low Medi-Cal reimbursement rates which make it challenging to hire nurses with the desired skills. Nurses say they are already dealing with low pay and poor working conditions — problems that are only exacerbated by the nationwide nursing shortage. According to an ABC 10 News report, health care providers are struggling to recruit and retain nurses willing to work for considerably less than potential earnings in the private sector.

Assembly member Brian Maienschein proposed legislation that would partly raise Medi-Cal reimbursement rates. He said the bill would improve care and quality of life for children.

“It’s important to note that any change to Medi-Cal reimbursement rates, including Home Health Agency (HHA) services, are a part of the state budget process and must also receive approval from the Centers for Medicare and Medicaid Services,” a California Department of Health Care Services spokesperson said in a statement.

The department said it is developing a process to help families find nurses to fulfill the hours authorized for HHA services. They said a number of factors must be considered such as payment levels for HHA services as well as the geographic availability of care providers.

Safety tips to prepare the home for comfortable aging

Many elderly people wish to age in the comfort of their own home. According to the Administration on Aging’s 2016 Profile of Older Americans, over 13.6 million seniors live alone. However, what happens when the home’s once-familiar areas become hazardous? Will the house be able to handle one’s daily needs?

It is important to consider basic safety features as the majority of homes are not conducive to aging in place. As a result, as people grow older, their homes often need to be modified to accommodate the aging process. Here are some tips for elderly adults seeking to maximize the livability of their home.

Make sure the house has zero-step entrances that are easily accessible for individuals using assistive devices such as a cane, walker or wheelchair. In addition, having covered entrances reduces the chances for serious slip-and-fall accidents arising from water or snow buildup on porches.

Another key area of the home that should be designed for optimum convenience is the bathroom. Basic safety features like a handle bar and grip mats can help elderly adults avoid falls. Ensure that the shower, sink and toilet are accessible to individuals with limited mobility.

Many people often overlook the fixtures in a house. However, they are also worth modifying. Outlets and switches should be placed in optimal locations and at heights that can be reached while seated. Additionally, doors that have lever hardware instead of knobs will be easier to use for those who are injured or arthritic.

The home may also need simple additions installed such as stair railings, grab bars or bath chairs. For individuals hoping to age at home, the key is to adopt a long-term perspective and begin planning for the future now.

Gilfix & La Poll invites you to join the Walk to End Alzheimer’s on October 14

Alzheimer’s is becoming an increasingly common cause of death for the aging population in the United States. Over 5 million individuals are currently living with the disease, and it is expected to affect 16 million Americans by 2050. Recognizing the devastation that Alzheimer’s causes on a daily basis, Gilfix & La Poll Associates has decided to join the fight against the progressive brain disease.

Gilfix & La Poll is a proud sponsor of the Alzheimer’s Association’s 2017 Walk to End Alzheimer’s in Silicon Valley, California. Members of the law firm have also formed a team to participate in the walk. The event is held annually nationwide in an effort to create awareness about Alzheimer’s, as well as to raise funds for the advancement of research and the care of those living with the disease.

Gilfix & La Poll is inviting families and members of the community to join them for the walk on Saturday, October 14, 2017 in Arena Green, N. Autumn St., San Jose, California. Participants of all ages and abilities are welcome. As a united force, there is hope for finding a possible cure for the nation’s sixth-leading cause of death.

Those who are unable to join the walk are encouraged to make a $35 donation to the Gilfix & La Poll fundraising campaign. Every contribution helps the care, prevention and research efforts of the Alzheimer’s Association.

To register for participation in the walk or to make a donation, visit the Gilfix & La Poll Walk to End Alzheimer’s team page here: http://act.alz.org/goto/gilfixlapoll

Celebrity divorce highlights importance of updating advance directives

No one likes to think about themselves in a life-threatening medical situation. However, it is essential to establish what your wishes would be in case of an emergency. Living wills and other advance directives can provide you and your family with the peace of mind that important end-of-life and medical decisions will be made by someone you trust.

Last year, media outlets reported that former NBA player Lamar Odom was hospitalized in a Nevada hospital in a comatose condition. What surprised many was that his ex-wife Khloe Kardashian was responsible for making medical decisions about his treatment. Although the couple signed divorce papers several months before the incident, their divorce was not yet finalized due to the backlog of paperwork in California courts.

In the absence of a living will or other legal documents specifying Odom’s wishes in such a situation, as his legal spouse Kardashian found herself in the awkward position of having to make medical decisions on his behalf. Some couples end their marriages even though they still care about each other very much. As a result, they would not hesitate to entrust medical and end-of-life decisions to their former spouse. However, more commonly an ex-spouse may not be the person of choice for such important decision-making.

In preparation for any potential emergency that may arise, one should remember to update these planning documents as soon as possible whenever a major life change occurs. Consult with an experienced attorney to draft appropriate medical directives, powers of attorney, living wills and health-care proxies. Medical directives will specify a person of your choice to assume responsibility for medical decisions on your behalf should the need arise.

Study reveals misconceptions about long term care costs

Planning ahead for long term care and how to fund it can seem daunting. The average American underestimates in-home care costs by nearly 50 percent, according to the Genworth Financial 2016 Cost of Care Study. The findings indicate many adults risk being unprepared for their future needs.

The cost of receiving care has continued to increase significantly each year across all care options, except adult day care. The most expensive long term care option is a private nursing home. Since 2011, the median annual cost for a room has grown by nearly 19 percent to over $92,000.

Americans are also paying more for homemakers or home health aides. Although such in-home services are the most popular care option, nearly one-third of individuals have serious misconceptions about the expenses. Many incorrectly believe such services cost under $417 per month. In reality, the national and state-by-state median rate averages above $3,800 per month.

The annual caregiving survey analyzes state and national care costs. It aims to help Americans become aware of various long term care options and their potential costs. Many people do not understand long term care expenses until they experience them.

“At least 70 percent of Americans over age 65 will need some form of long term care services and support during their lives,” said Genworth President and CEO Tom McInerney. “[There is a] huge disparity between what consumers think costs are and what they actually are.”

As a result, it is important for individuals to have an honest conversation with family members about what type of care they would like to receive when the need arises. Learning about the costs will help Americans plan ahead for future expenses before it is too late.

Choosing Wisely: avoiding bad care and maximizing the chance of getting good care

By Myra Gerson Gilfix

The Choosing Wisely campaign, an initiative by the American Board of Internal Medicine Foundation in partnership with Consumer Reports (begun in 2012), is an attempt to alert both doctors and patients to problematic and commonly overused medical tests, procedures and treatments.

From their website:
 
“In 2012 the ABIM Foundation launched Choosing Wisely® with a goal of advancing a national dialogue on avoiding wasteful or unnecessary medical tests, treatments and procedures. http://www.abimfoundation.org/About-Us.aspx
 
“Choosing Wisely centers around conversations between providers and patients informed by the evidence-based recommendations of ‘Things Providers and Patients Should Question.’ More than 70 specialty society partners have released recommendations with the intention of facilitating wise decisions about the most appropriate care based on a patient’s individual situation.
 
“Consumer Reports is a partner in this effort and works with specialty societies to create patient-friendly materials to educate patients about what care is best for them and the right questions to ask their physicians. Through a coalition of consumer groups like AARP and the National Partnership for Women and Families, Consumer Reports is ensuring patients get the information they need just when they need it.”

Virtually every specialty has lists of procedures or tests to avoid doing
 
The collection of Choosing Wisely Lists can help a patient or patient advocate to resist recommendations of physicians — and nursing homes — which they are wary about, and allow them to make proactive choices. It’s nice to have the power of a major medical group to back up your concerns!
 
Working through professional organizations representing medical specialties, Choosing Wisely asked doctors to identify “Five Things Physicians and Patients Should Question.”
 
The idea was that doctors and their patients could agree on tests and treatments that are supported by evidence, that don’t duplicate what others do, that are “truly necessary” and “free from harm” — and avoid the rest. Needless to say, there are likely more tests and procedures that are not “wise,” but this is a great start. It also means that you should use our handout, “Suggested Questions to Ask Your Doctor” when any treatment or procedure is proposed … not just those on these lists.

For the elderly in particular to avoid

Although virtually every specialty has released lists, the recommendations from geriatricians and palliative care specialists may be of particular interest to you, since many are grappling with such issues in their own families.
 
Both the American Geriatrics Society and the American Academy of Hospice and Palliative Medicine agreed on one major “don’t.” Topping both lists was an admonition against feeding tubes for dementia patients. This is something most of you have already specified in your Advance Health Care Directive that you don’t want. This is important because many patients are still being tube fed by default — even without a conversation that would engender a good decision.
 
Feeding tubes
 
Research has shown that feeding tubes do not prevent aspiration pneumonia or prolong dementia patients’ lives, but they do exacerbate bedsores and cause such distress that people often try to pull them out and wind up in restraints. The doctors recommended hand-feeding dementia patients instead.
 
Antipsychotic medications

The geriatricians’ list goes on to warn against the routine prescribing of antipsychotic medications for dementia patients who become aggressive or disruptive. Though drugs like Haldol, Risperdal and Zyprexa remain widely used, “all of these have been shown to increase the risk of stroke and cardiovascular death,” Dr. Lee said. They should be last resorts, after behavioral interventions.
 
Meds to achieve ‘tight glycemic control’ for type 2 diabetes
 
Prescribing medications to achieve “tight glycemic control” (defined as below 7.5 on the A1c test) in elderly diabetics who need to control their blood sugar, but not as strictly as younger patients.
 
Avoid prescribing sleeping pills when possible. Dr. Sei Lee, a geriatrician at the University of California, San Francisco, and a member of the working group that narrowed more than 100 recommendations down to five, pointed out that doctors should not turn to sleeping pills as the first choice for older people who suffer from agitation, delirium or insomnia. Xanax, Ativan, Valium, Ambien and Lunesta “. . . don’t magically disappear from your body when you wake up in the morning,” Dr. Lee said. They continue to slow reaction times, resulting in falls and auto accidents. Other sleep therapies, such as cognitive therapy, are preferable.

Avoid prescribing antibiotics for many urinary tract infections (UTIs)
 
An informative case study:
 
Avoid prescribing antibiotics when tests indicate a urinary tract infection (the most common infection among nursing home residents) but the patient has no discomfort or other symptoms. Many older people have bacteria in their bladders but don’t suffer ill effects; repeated use of antibiotics just causes drug resistance, leaving them vulnerable to more dangerous infections. “Treat the patient, not the lab test,” Dr. Lee said.
 
Brown University geriatrician Dr. David Dosa observes, “As people get more frail and old, physicians tend to do more, when often we should do less.” This observation is so important that it should be a guiding principle in hospitals and nursing homes. DO MORE BY DOING LESS.
 
While younger people who get a positive test result almost always need antibiotics since it’s not normal for them to have bacteria in their urine, many older people are “colonized” with bacteria and thus don’t necessarily need treatment. Often they live in environments with more germs, and they’re subject to procedures — like catheterization — that can lead to infection. Yet even though they may have a positive urinalysis indicating the presence of bacteria, they’re not sick. “This is normal for them,” Dr. Dosa said. “Just because they’re colonized doesn’t mean they need to be treated.”
 
The McGeer criteria (named for the infectious disease specialist who published them) call for antibiotics only if an older patient has three of these five symptoms: a fever; increased frequency or urgency of urination, or burning associated with it; pain behind or near the bladder; a change in the smell or appearance of urine; or deteriorating function or mental state.
 
But in two Rhode Island nursing homes where Dr. Dosa and his colleagues reviewed the medical records of 172 residents with urinary tract infections, physicians routinely ignored those guidelines. As the researchers recently reported in The Archives of Internal Medicine, more than 40 percent of patients got antibiotics when the guidelines suggested no treatment was necessary. Even worse, not only are we treating people with antibiotics when they don’t need them,” Dr. Dosa said, “but we’re using the wrong drugs.” 

In the Rhode Island sample, 56 percent of patients who received antibiotics got the inappropriate medications, and almost half were taking the wrong doses. They were also taking the drugs for far too long. Women generally only need three days to treat a UTI, according to medical guidelines. Men, who get far fewer infections, need to take them for seven to 14 days. But in this Rhode Island sample, where the average age was 83, more than two-thirds of patients took antibiotics for far longer. And these are high-quality nursing homes.
 
Uncomplicated urinary tract infections should be treated first with narrow-spectrum drugs (Bactrim is an example), the guidelines say, rather than broad-spectrum ones like Cipro or Levaquin. Broad-spectrum antibiotics tend to wipe out all the bacteria in the gastrointestinal tract, including the helpful ones that help people digest food and ward off infection. “It’s like a nuclear bomb that takes out everything, as opposed to a sniper’s bullet that targets one bug,” Dr. Dosa said.
 
Some of us who have experienced uncomfortable UTIs may think, “Better safe than sorry.” But that really doesn’t apply here. It just isn’t safe for elderly folk to take unnecessary, unfocused antibiotics or to take them for longer than needed when they are actually appropriate.
 
“One of the most important findings, and other studies show similar results, is that under- treatment didn’t hurt anybody,” Dr. Dosa said. “Nobody in our sample who didn’t get an antibiotic had a bad outcome,” like a kidney infection, hospitalization or death.  But those patients who were over-treated — that is, given antibiotics when their symptoms didn’t fit the criteria — were far more likely to be struck by the virulent and dangerous C. difficile bacterium, which flourishes in the gut when patients’ own competing bacteria have been eliminated by potent drugs.
 
Palliative care
 
The palliative care doctors’ Five Things list cautions against delaying palliative care, which can relieve pain and control symptoms even as patients pursue treatments for their diseases.
 
Other specifics:
 
Implantable defibrillators
 
It also urges discussion about deactivating implantable cardioverter defibrillators, or ICDs, in patients with irreversible diseases. “Being shocked is like being kicked in the chest by a mule,” said Eric Widera, a palliative care specialist at the San Francisco VA Medical Center who served on the American Academy of Hospice and Palliative Medicine working group. “As someone gets close to the end of life, these ICDs can’t prolong life and they cause a lot of pain.” Turning the devices off — an option many patients don’t realize they have — requires simple computer reprogramming or a magnet, not the surgery that installed them in the first place.
 
Topical anti-nausea gels
 
The palliative care list also warned that topical gels to control nausea don’t work because they aren’t absorbed through the skin. Dr. Widera noted, “We have lots of other ways to give anti-nausea drugs.”  Evidence also shows patients suffering pain as cancer spreads to their bones get as much relief from a single dose of radiation than from 10 daily doses that require travel to hospitals or treatment centers.
 
Ways of applying ‘Choosing Wisely’
 
My hope is that this initiative will have far-reaching positive effects the more it is discovered and embraced by patients and professionals alike. I found an interesting example of how this might look from an article from “Choosing Wisely – Canada” written by medical students. By seeing their list, we can tailor our own questions of medical professionals. Here are their six ways “medical students and trainees can avoid unnecessary or inappropriate tests, treatments and procedures . . .” My comments follow the quotes.
 

• “Do not suggest ordering the most invasive test before considering other less invasive options.” 
A good rule in any situation. Always start with the least invasive, most helpful intervention or test possible to get what is needed for the patient.

• “Do not suggest a test, treatment or procedure that will not change the patient’s clinical course.”
Fundamental. In other words, if it won’t make a difference to the patient’s treatment plan, don’t do it!

• “Do not hesitate to ask for clarification on tests, treatments or procedures that you believe may be ordered inappropriately.”
SPEAK UP — whether you’re a medical student, trainee or an “advocate” for the patient.

• “Do not miss the opportunity to initiate conversations with patients about whether a test, treatment or procedure is necessary.”
This is a nice corollary to my admonition in our handout, “Suggested Questions to Ask Your Doctor,” always to ask these questions.

• “Do not suggest ordering tests or treatments preemptively for the sole purpose of anticipating what your supervisor would want.”
Don’t do what may be unnecessary and counterproductive with the hope of sucking up to your supervisor.

• “Do not suggest ordering tests or performing procedures for the sole purpose of gaining personal clinical experience.”

IMPORTANT. Many will justify that in a teaching hospital, this is appropriate. However, a teaching hospital should emphasize teaching that the patient comes first. Students should be learning that it is the patient’s welfare that trumps their learning how to do something that their own patient doesn’t need. That is the most important learning for medical students and trainees. No rationalization about training being important should trump the welfare of the patient first.

Stay well, people. But if you need medical help, do what you need to do to ensure it is best for you or your loved ones. 

Home Care and Financial Abuse

Over 8 million older Americans receive care at home or in facilities by strangers. Some caregivers are trained and managed by home health care agencies. Others are hired privately in an effort to save money. Privately hired caregivers may charge as little as $12 or $14 per hour. Caregivers hired through an agency may be as much as $18 to $30 per hour. The difference is very real.

Even more real is the danger posed by many caregivers who seek to take financial advantage. Retired emeritus professor John Wilson (not his real name) needed supplemental care in his life care community. He came to rely upon and trust a caregiver who was with him 40 hours per week. His trust was misplaced.

Over the period of two months, she used his credit card, had him sign checks made out to her for thousands of dollars, and forged his signature on other checks to pay for items that she purchased. In a short time, losses exceeded $60,000.

Professor Wilson was fortunate in that his care and finances were being monitored. The caregiver was fired, the agency reimbursed a portion of the funds, and other funds were recovered by other means. All estimates are that millions of dependent older Americans are victimized by this form of financial abuse every year.

To address, to reduce the possibility of financial elder abuse, much greater care must be taken when older Americans identify “attorneys in fact” when they sign Durable Powers of Attorney and when they choose successor trustees for their revocable trusts. Too few understand that individuals given such powers are in a position to misappropriate finances and otherwise take financial advantage. “A great disservice is done by online trust creators, such as LegalZoom,” warns Palo Alto attorney Mark Gerson Gilfix, “because they offer no counseling or effectively conveyed warnings about the need for an extremely conscientious and responsible person to serve in these roles.

Financial elder abuse is a plague that shows no signs of abating. Great care must be taken in choosing private caregivers, in particular, and carefully monitoring the financial affairs of vulnerable elders.

Women bear the brunt of costs for Alzheimer’s care, says study

A study by Emory University researchers has found that women shoulder six times the cost of Alzheimer’s disease care than men. The greater burden in expenses is mainly due to the informal care that women provide to family members who have the degenerative brain disorder.

Researchers examined three factors to calculate Alzheimer’s care costs using data collected from the Medicare Current Beneficiary Survey between 2000 and 2010. They looked at the chances of developing the disease, its duration, and the formal and informal care required for the patient. The findings were published in the journal Women’s Health Issues on Sept. 10.

Results showed that female Alzheimer’s patients have 16 percent higher Medicare costs and 70 percent higher Medicaid costs than male patients over their lifetime. The greatest gender difference was in the cost of informal care, which is often an inherent source of stress. For male patients, the value of the time and energy a female family member is likely to spend in caregiving is 20 times more than when the caregiver-patient roles are reversed, the researchers said.

“There is strong evidence that women face higher risks of being affected by Alzheimer’s as either patients or informal caregivers,” said Zhou Yang, one of the study’s authors. “It is critical to develop public policy interventions aimed at curing or slowing the progress of the disease to benefit the health and economic welfare of women everywhere.”

The researchers recommended policy reforms, such as to Medicare and Medicaid payments, to address the disparate economic impact of Alzheimer’s on women as caregivers and patients.

California’s Aging Population: Implications for Elders and Caregivers 

Today, the population of individuals over the age of 65 in California numbers approximately 4.5 million people. By the year 2050, it will exceed 11 million. These numbers are even more consequential when we consider the portion of the entire state's population represented by older individuals: 

About 11% of today’s 40 million Californians are 65 or older. By 2020, that population will be 15%. By 2030, it will be almost 20% and a staggering 22.3% by 2050. What are the implications of this?

A recent column by Dan Walters in the Sacramento Bee warns about the aging of health care providers in California. The column astutely warns that we have an aging population that will present unprecedented demands for services and support from our medical and caregiving infrastructures. Even today there is a shortage of trained, capable caregivers through home care agencies, at assisted living facilities, and in skilled nursing facilities. It will only get worse in the future. It is a looming crisis for all who need long-term care facilities and services.
 
“To rise to this challenge,” suggests estate planning and elder law attorney Michael Gilfix of Palo Alto, California, “we need a new, coordinated, multigenerational approach.” His focus is on the need for more coordination of services and more tailored, focused use of limited family resources. Careful planning to preserve assets and qualify for Medi-Cal, the only program that can pay all or most of the cost of skilled nursing care, must be part of the planning. Medi-Cal, California's Medicaid program, is needs-based. To qualify, assets must be limited and/or carefully organized. 

This approach is necessary, Gilfix suggests, because there must always be a financial safety net. If all family assets are exhausted before Medi-Cal coverage is obtained, there are no funds available to pay for services that are not covered by the Medi-Cal program.

Children and grandchildren must be viewed as part of the planning and part of the solution. They must participate, coordinate resources, add counsel, and devote time and attention to the needs of their elders. It is self-evident that this is typically a win-win for everyone, but it is rarely done. 
 
Such planning is more typically pursued by wealthier families through the use of "family offices," but the need is no less critical for the middle class. Middle class families have the power to preserve their homes, their savings, and their legacies. But they must take steps to plan ahead of time.

Attorneys Michael Gilfix and Mark Gerson Gilfix recently co-authored an article entitled, “A New Paradigm: Truly Multigenerational Planning,” published in the September issue of Trusts & Estates magazine, that expands this concept in very practical ways. Gilfix & La Poll Associates, one of the nation’s leading estate planning firms, follows this approach with its clients. For multigenerational planning to be effective, it is critical that steps are taken before the crisis stage.
 
The Gilfix & La Poll Team

Pioneers of Elder Law - For over 30 years, Gilfix & La Poll Associates LLP has innovated creative legal solutions to help you manage and plan the future of your estate. To contact an estate planning lawyer visit www.gilfix.com or call 800.244.9424.

A Warning About Ads to “Fix” Your Trust

Dear Friends,

You may have seen ads running in the Mercury News and perhaps other media outlets for Trust Seminars presented by a San Diego-based law firm. These specific ads attempt to entice you by promising a “free kindle” and a “free dinner” for those who attend the seminars they are giving while they visit the Bay Area.

They claim to “fix” trusts. Their ads suggest that any trust done by anyone other than them is flawed. No surprise: They conclude that only they can fix it. We have seen marketing like this many times over the years.

We have been national and community leaders in this field for over 30 years. We know and are familiar with the real-world issues that trusts must address. We author articles and legal form books that attorneys across the nation rely upon. We have successfully represented thousands of individuals in the Bay Area, including many business and community leaders.

We want to assure you, as a client of Gilfix & La Poll or individual who has a relationship with our office, that we give you the best and most comprehensive representation in the field. Our revocable trusts do not have the problems these marketers identify. Gilfix & La Poll addresses more issues, more comprehensively, than virtually any other firm in the nation.

We have seen this firm’s list of trust document “flaws” that they identify. These lists can be misleading and it is important for you to know that planning must go beyond overly simplistic checklists.

  • Our trusts and related planning documents cover every base and offer all the legal tools and protections needed to ensure that you have the power to keep your estate safe.
  • Our Family Protection Trusts offer the powerful protections for your children — protection against divorce, against litigation and against future estate tax — that their checklist correctly identifies as important.
  • We deal with and understand additional issues they and so many others do not address, including issues related to long-term care planning and special needs.

This type of marketing conjures many confusing “straw man” arguments, where a false problem is presented and then “solved.” Do not be misled by catchy marketing and offers of free meals or gadgets. If you have a trust with another firm, we are happy to take a look and to identify real issues, and we won’t use a superficial approach to do it.

If you have any questions about this, or any other issue related to your planning, give us a call.  We might not give you a free kindle, but we will take good care of you and your family.

The Gilfix & La Poll Team

Pioneers of Elder Law - For over 30 years, Gilfix & La Poll Associates LLP has innovated creative legal solutions to help you manage and plan the future of your estate. To contact an estate planning lawyer visit www.gilfix.com or call 800.244.9424.