U.S. Healthcare System, Long-Term Care, and Elder Abuse PDF

The U.S. Healthcare System, Long-Term Care, and Elder Abuse Sarah Parrott, DO FAAFP DMU Geriatrics Course Learning Objectives Describe what Part A, Part B, Part C, and Part D are, who has them, and what they are used for Compare and contrast Medicare and Medicaid in terms of the following: Who is el...

The U.S. Healthcare System, Long-Term Care, and Elder Abuse Sarah Parrott, DO FAAFP DMU Geriatrics Course Learning Objectives Describe what Part A, Part B, Part C, and Part D are, who has them, and what they are used for Compare and contrast Medicare and Medicaid in terms of the following: Who is eligible, what is covered, what are potential drawbacks to patients and providers Describe what a Medicaid spend-down means and when it might be needed Learning Objectives Describe the regulatory environment of long-term care facilities, including “right to fall” Describe and summarize the identification of the types of elder abuse and neglect and risk factors for the abuse and neglect of older adults Discuss the legal issues associated with elder abuse and neglect MEDICARE Basics - Not on Test but FYI In 1965, federal legislation passed Medicare and Medicaid for elderly and select low-income populations Over past 55 years or so, Medicare has gotten more and more complicated. Like anything that is run by the government, there are a LOT of rules CMS (Centers for Medicare and Medicaid Services) oversees these rules Who Qualifies for Medicare? Age 65 and older Maybe earlier if: – Disability – ESRD – ALS Four Main Parts of Medicare Part A Part B Part C (a.k.a. Medicare Advantage Plan) Part D Medicare Part A Hospital stays Some skilled nursing facilities (SNF) Hospice care Medigap Insurance for Medicare recipients to purchase to help cover Part A deductibles, travel outside the USA, etc. $$ has a lot of qualifications most older adults can’t meet. Medicare Part B Pays for provider visits and outpatient services Monthly premium Don’t need if still working and have employer plan too Medicare Part C** AKA “Medicare Advantage Plans” These plans are run by private companies They bundle services, usually include all of Part A, Part B, most fold in Part D Some provide dental and vision services Medicare Part D D for “Drugs” Patient still has a deductible and a copay Not Covered (except some Part C) Dental care, unless patient has emergency dental care while staying in a hospital Eye exams, unless patient has certain conditions like glaucoma or macular degeneration Long term care (nursing homes) Hearing aids Provider Reimbursement for Medicare Participating providers agree to accept assigned pay for all Medicare-covered services and to not bill patient for anything more (generally about 80% of what private insurance pays) Reimbursement can take months In 2019, switched to a flat fee for office visits, no matter how complicated the patient is MEDICAID Who Qualifies for Medicaid?** Generally, less financially stable segments of society, but must be US Citizen and resident of state. This is for Iowa: A child under age of 21 Accessed 4/3/2023 Parent living with child under age 18 at Woman who is pregnant https://hhs.iowa.gov /ime/members/who Person who is elderly (65 or older) receives-medicaid Age 19-64 income < 133% fed poverty level Disabled per Social Security standards What Medicaid Pays For: Mandatory Inpatient and outpatient hospital service EPSDT: Early & Periodic Screening, Diagnostic and Treatment Services Nursing facility services (long-term care) Physician and provider services Home health Rural health clinic services Nurse midwife services Family planning services Transportation for medical care Tobacco cessation counseling for pregnant women What Medicaid Pays For: Optional Prescription drugs, clinic services, eyeglasses, dental visits, dentures, PT/OT, speech/hearing/language services, optometry services, respiratory care services, chiropractic services, private duty nursing prosthetics, personal care, hospice, case management, lots of things for mental health and for people with intellectual or physical disabilities Interesting… Enrolling incarcerated people in Medicaid just prior to discharge enables them to have coverage immediately upon release. Medicaid Provider Reimbursement Medicaid fee schedules are typically lower than even Medicare, with even lower reimbursement rates. Some providers won’t accept Medicaid for this reason Other providers look view Medicaid fees as being subsidized by commercial insurance – it’s a balancing game Source: Physician Fee Schedules: How Do They Compare and What’s Next? Accessed April 17, 2021 at https://axenehp.com/physician-fee-schedules-compare-whats-next/ Medicaid Spend Down Process of moving around your money and assets so that you can qualify for Medicaid, which pays for long term care (nursing home). Medicaid Spend Down Some examples of medical expenses that qualify: Medical bills, past and current. Transportation services to get medical care Home improvements to help with medical care, like a chair-lift Medical expenses, such as eyeglasses or a hearing aid LONG-TERM CARE Long-Term Care Facilities Used to call them “nursing homes”. Now LTCFs. Offer a variety of services which help meet both the medical and non-medical needs of people with a chronic illness or disability who cannot care for themselves Services include nursing care (RN/LPN/CNA/CMA), dietary, PT/OT/ST, social services, activities, pharmacy, administration, medical oversight by MD or DO 25 GOAL: Avoid LTCF, Age in Place States offer aging services with the specific goal to help older adults live meaningful lives, sometimes administered at the county or even city level. Aging in Place is what most older adults want to do. Council on/Department of Aging Each city, county of state may call it something different. These organizations can provide help in the home (housework, cooking, laundry, etc.) to assist an older adult so they can stay in the home. Skilled Nursing Facility (SNF) Usually in a hospital or LTCF Care provided is less acute than in the hospital Integrates features of acute medical care, long-term care nursing and rehabilitation In some nursing homes they are called Transitional Care Units (TCU’s) or Post-acute Care Common services required include dialysis, orthopedic care, ventilators, post-operative, rehabilitative or wound care Paid for by Medicare IF there has been at least 3 days of care in the hospital (called a “qualifying hospital stay”) 29 LCTFs (“Nursing Homes”) A highly regulated institution for people who have severe physical and/or mental disabilities Paid for by Medicare with qualifying hospital stay. 30 Medicare Payments to LCTFs/SNFs Medicare Part A Must have qualifying 3 day stay in the hospital Pays entire cost of the first 20 days Days 21-100 require a co-pay No payments beyond 100 days (private insurance, personal savings, family support or time to do “Medicaid spend-down” 31 LTCF Stats 15,639 nursing homes, 1.7 million beds, 1.4 million residents Beds per home—average 107 (6% have 200+) 56% are a part of a chain Long-Term Care Providers and Services Users in the United States: Data From the National Study of Long-Term Care Providers, 2013–2014 32 LTCF—Regulations The Omnibus Budget Reconciliation Act (OBRA) – Passed in 1987 to set training guidelines and minimum staffing requirements for nursing homes – Bolstered resident’s rights Limited use of restraints Limited use of psychoactive medications – Initiated the Minimum Data Set (MDS) – Requires documentation of the need for all medications, particularly psychoactive agents 33 LTCF—Regulations OBRA requires monthly evaluation of medications by a pharmacist Medications must be reviewed at regular intervals and include no unnecessary drugs Unnecessary drugs are defined as those given: -In excessive doses -For excessive periods of time -Without adequate monitoring (needs to be documented) -Without adequate indications for use (needs to be documented) -In the presence of adverse consequences indicating the need for gradual dose reduction (GDR) or discontinuation 34 LTCF—Regulations The Minimum Data Set (MDS) – Periodic comprehensive clinical assessment of all residents – Used to compile nursing facility quality measures such as pain, pressure ulcers, weight loss, depression, rates of vaccination and restraint use – Identification of a current or potential problem triggers review of diagnostic and therapeutic protocols 35 Who Regulates LCTFs? Federal government (Center for Medicare and Medicaid Services) oversees quality nationwide, makes sure states know expectations. State officials survey the nursing homes and certify them. In Iowa, the Division or Inspections and Appeals does this (DIA is acronym) 37 Rules Regarding Restraints SAFETY! Resident, staff, other people Constant observation while restraints used Discontinue ASAP CMS Condition of Participation Standard 482.13 (e) Patient Rights: Restraint or Seclusion All patients have the right to be free from physical or mental abuse, and corporal punishment. All patients have the right to be free from restraint or seclusion, of any form, imposed as a means of coercion, discipline, convenience, or retaliation by staff. Restraint or seclusion may only be imposed to ensure the immediate physical safety of the patient, a staff member, or others and must be discontinued at the earliest possible time. CMS regulation: restraints & seclusion revised 5/2021 Types of Restraints Wrist/ankle soft restraints Vest restraints (can also support posture) Hand mitts (if pinned to pajamas or bedding) Enclosure (net) beds Bedrails Chemical restraints Vest Restraint Enclosure (“net”) bed Restraint Mittens Soft wrist restraints Bed rails Rules Regarding Restraints: “Right to Fall” ** Accessed 4/1/24 at https://www.legis.iowa.gov/docs/iac/rule/481.71.16.pdf Bed Rails as Restraints** “This means that the determination of bed rails as a restraint is based upon the ability of the resident to easily and voluntarily get in and out of bed when the equipment is in use. If the bed rail cannot be easily and voluntarily released, then it is considered to be a restraint. In this regard, it should be remembered that residents who are cognitively impaired are at a higher risk of entrapment or injury due to bed rails, and that serious injury from a fall is more likely from a bed equipped with bed rails.” Accessed 4/1/24 from https://www.mednetcompliance.com/bed-rails-legal-snf/ Alternatives to Restraints** Distract with activities Ask family/friends to visit more to reduce load on staff Remove dangers from resident’s vicinity Consider moving sleeping area to where nursing staff can observe continuously ELDER ABUSE/NEGLECT Prevalence of Elder Abuse At least 10% of people age > 65 victim of abuse in any given year, some more than one type Accessed 4/2/2023 at https://www.justice.gov/ file/1098056/download Risk Factors for Mistreatment Poverty Dependency Functional disability Family conflict Frailty Cognitive impairment 50 Identification of Mistreatment History and Physical – Interview both the older person and caregiver, separately and privately – Conduct a comprehensive assessment: Physical abuse, neglect, and abandonment Psychological abuse or mistreatment Financial exploitation Self-neglect Caregiver stress Keep in mind that different racial and ethnic groups may define abuse and neglect differently 51 Identification of Mistreatment—General Signs Clothing: inappropriate, soiled, or in disrepair Poor hygiene Deficient nutritional status Compromised skin integrity 52 Possible Signs and Symptoms of Neglect Evidence that patient is left alone without adequate arrangements for care Evidence of sudden withdrawal of care by caregiver Statements about abandonment by the patient 53 Possible Signs and Symptoms of Neglect Diarrhea, fecal impaction, or urine burns Failure to respond to obvious disease Contractures Dehydration or malnutrition Depression 54 Possible Signs and Symptoms of Neglect Medication use that is inadequate, excessive, or otherwise inappropriate Pressure ulcers Repeated falls Repeated hospital admissions 55 Self-Neglect Assess the patient’s capacity to understand the risks, benefits, and consequences of accepting or enduring mistreatment Clinicians must honor the patient’s right to autonomy and self-determination If the patient is capable of making their own decisions, intervention contrary to their choice is generally inappropriate 56 Signs of Possible Physical Abuse Repeated, unexplained, or inconsistently explained falls or injuries requiring office or emergency room visits Head injuries, hair loss, or hemorrhages beneath the scalp as a consequence of hair pulling Unusual discharges, bruising, bleeding, or trauma around the genitalia or rectum Delays in seeking treatment, inconsistent follow-up, or frequently changing providers 57 Signs of Possible Physical Abuse Anxiety or nervousness in presence of caregiver Excessive deference to the caregiver Lacerations and abrasions on face, lips, or eyes Statements about abuse by the patient 58 Signs of Possible Physical Abuse Rope burn Cigarette burn Fractures at different stages of healing 59 Signs of Possible Physical Abuse Bruises or welts in various healing stages, especially bilateral or on inner arms or thighs 60 Signs of Possible Financial Exploitation Recent marked disparity between patient’s living conditions or appearance and his/her assets Inability of patient to account for money and property, or to pay for essential care Reports of demands for money or goods in exchange for caregiving or services Unexplained loss of Social Security/pension checks Statements about exploitation by the patient 61 Signs and Symptoms of Possible Emotional Abuse Impatience, irritability, or demeaning statements of caregiver Ambivalence of patient to caregiver, or high levels of anxiety, fearfulness, or anger Unexpected depression or withdrawal Lack of adherence to treatment regimen or frequently canceled appointments Frequent requests for sedating medication 62 Now what? If you suspect it, make the report Reports in good faith have immunity from criminal or civil litigation Failure to report: – Knowingly and willingly failing to report is committing a simple misdemeanor – We are civilly liable for damages caused by failure to report 63 Support for Interventions Social work staff of local hospital, medical group, nursing home, or city/county health department State Adult Protective Services National Adult Protective Services Association (www.napsa-now.org) National Council on Elder Abuse (www.ncea.aoa.gov) 64 The Medical-Legal Interface Most states require clinicians to assess and report suspected mistreatment of older adults Clinicians should be willing to enlist the help of government agencies and the courts when mistreatment is clearly dangerous Risk management personnel can provide guidance Photographs and body charts may be required 65 Training for Mandatory Reporters Iowa Code section 235B.16 requires that a mandatory reporter whose work involves the examination, attending, counseling, or treatment of adults on a regular basis shall: Obtain a statement of the abuse reporting requirements from the person’s employer (or from DHS, if self-employed) within one month of initial employment or self-employment. Complete two hours of training relating to the identification and reporting of dependent adult abuse within six months of initial employment (or selfemployment). Complete at least two hours of additional dependent adult abuse identification and reporting training every five years. 66 Thank You References Williams, Geoff. How a Medicaid Spend Down Works. US News & World Report. Accessed 4/17/2021 at https://money.usnews.com/money/retirement/baby-boomers/articles/how-a-medicaid-spend-down-works Novikov D, Cizmic Z, Feng JE, Iorio R, Meftah M. The Historical Development of Value-Based Care: How We Got Here. J Bone Joint Surg Am. 2018 Nov 21;100(22):e144. doi: 10.2106/JBJS.18.00571. PMID: 30480607. Guyer J, Serafi K, Bachrach D, Gould A. State Strategies for Establishing Connections to Health Care for Justice-Involved Populations: The Central Role of Medicaid. Issue Brief (Commonw Fund). 2019 Jan 1;2019:1-12. PMID: 30645058. Manchikanti L, Helm Ii S, Benyamin RM, Hirsch JA. Evolution of US Health Care Reform. Pain Physician. 2017 Mar;20(3):107-110. PMID: 28339426. Mark TL, Parish W, Zarkin GA, Weber E. Comparison of Medicaid Reimbursements for Psychiatrists and Primary Care Physicians. Psychiatr Serv. 2020 Sep 1;71(9):947-950. doi: 10.1176/appi.ps.202000062. Epub 2020 Jul 24. PMID: 32703119. Huffman KF, Upchurch G. The Health of Older Americans: A Primer on Medicare and a Local Perspective. J Am Geriatr Soc. 2018 Jan;66(1):25-32. doi: 10.1111/jgs.15227. Epub 2018 Jan 10. PMID: 29124737. Reddy A, Marcotte LM, Zhou L, Fihn SD, Liao JM. Use of Chronic Care Management Among Primary Care Clinicians. Ann Fam Med. 2020 Sep;18(5):455-457. doi: 10.1370/afm.2573. PMID: 32928763; PMCID: PMC7489968. What happens when not all doctors accept Medicare – do you have to swtch? Accessed April 17, 2021 at https://www.ehealthmedicare.com/faq/doctor-no-longer-acceptsmedicare/#:~:text=This%20is%20known%20as%20a,as%20a%20%E2%80%9Climiting%20charge.%E2%80%9D Feke, T. Why Some Doctors Don’t Accept Medicaid or Other Insurance. Accessed April 13, 2021 at https://www.verywellhealth.com/doctors-accept-medicare-insurance-3976280 9 Things You Didn’t Know About Medicare. WebMD. Accessed 4/13/2021 at https://www.webmd.com/health-insurance/medicarewhat-you-need-to-know#1 A Brief History of Private Insurance in the United States, posted on Academic Health Plans website. Accessed 4/4/2021 at https://www.ahpcare.com/a-brief-history-of-private-insurancein-the-united-states/ References Menec VH, Means R, Keating N, Parkhurst G, Eales J. Conceptualizing age-friendly communities. Can J Aging. 2011 Sep;30(3):479-93. doi: 10.1017/S0714980811000237. Epub 2011 Jul 12. PMID: 21745427. Koelen M, Eriksson M, Cattan M. Older People, Sense of Coherence and Community. 2016 Sep 3. In: Mittelmark MB, Sagy S, Eriksson M, Bauer GF, Pelikan JM, Lindström B, Espnes GA, editors. The Handbook of Salutogenesis [Internet]. Cham (CH): Springer; 2017. Chapter 15. PMID: 28590647. Willink A, Kasper J, Skehan ME, Wolff JL, Mulcahy J, Davis K. Are Older Americans Getting the Long-Term Services and Supports They Need? Issue Brief (Commonw Fund). 2019 Jan 1;2019:1-9. PMID: 30681291. Madsen W, Ambrens M, Ohl M. Enhancing Resilience in Community-Dwelling Older Adults: A Rapid Review of the Evidence and Implications for Public Health Practitioners. Front Public Health. 2019 Feb 7;7:14. doi: 10.3389/fpubh.2019.00014. PMID: 30792974; PMCID: PMC6374312. Willink A, Davis K, Mulcahy J, Wolff JL, Kasper J. The Financial Hardship Faced by Older Americans Needing Long-Term Services and Supports. Issue Brief (Commonw Fund). 2019 Jan 1;2019:1-12. PMID: 30695855.\ Bangerter LR, Fadel M, Riffin C, Splaine M. The Older Americans Act and Family Caregiving: Perspectives from Federal and State Levels. Public Policy Aging Rep. 2019 Jun;29(2):62-66. doi: 10.1093/ppar/prz006. Epub 2019 May 11. PMID: 31205404; PMCID: PMC6549209. Wu HC, Tseng MH. Evaluating Disparities in Elderly Community Care Resources: Using a Geographic Accessibility and Inequality Index. Int J Environ Res Public Health. 2018 Jun 27;15(7):1353. doi: 10.3390/ijerph15071353. PMID: 29954156; PMCID: PMC6068710. Xiang X, An R, Heinemann A. Depression and Unmet Needs for Assistance With Daily Activities Among Community-Dwelling Older Adults. Gerontologist. 2018 May 8;58(3):428-437. doi: 10.1093/geront/gnw262. PMID: 28201617. Siegler, Eugenia L et al. “Community-Based Supports and Services for Older Adults: A Primer for Clinicians.” Journal of geriatrics vol. 2015 (2015): 678625. doi:10.1155/2015/678625 Research Report: Caregiving in the US 2015- Focused Look at Caregivers of Adults Age 50+ published June 2015, accessed online April 13, 2021 at https://www.aarp.org/content/dam/aarp/ppi/2015/caregivers-of-older-adults-focused-look.pdf A. Willink, K. Davis, J. Mulcahy et al., Use of Paid and Unpaid Personal Help by Medicare Beneficiaries Needing Long-Term Services and Supports, The Commonwealth Fund, November 2017, accessed April 13, 2021 Ujvari K, Fox-Grage W, Houser A. AARP Public Policy Institute’s Spotlight: Older Americans Act, posted February, 2019. Accessed April 18, 2021 at https://www.aarp.org/content/dam/aarp/ppi/2019/02/older-americans-act.pdf