Tonquita Davis November 19, 2008 Chapter 12 Assignment Design mgmt Multiple choice 1.

n True false Critical thinking Kinky Spontaneous Cajoles Hi-tech home help. (NURSE RESIDENTIAL CARE), 2007 Jul 9(7): 294 CINAHL with Full Text Tfelecare systems are sensor devices placed in a per.son's home to monitor their health and wel!t)eing and to reduce accidents. As such, they can provide adtiitional support to enable vulnerable older people, or those with longterm conditions, such as diabetes or high blood pressure, tt> live an independent life at home, thus reducing the need for emergency or unexpected admissions to hospital.

telecare devices, which act as sensors in the home, also have a role to play. The sensors can turn lights on and off to ensure that elderly people do not have to walk around in [he dark if they need to get out of bed during the night. They can also raise the alarm if the person does not come back to bed after a specified time, so that iHssistance can be summoned, if needed. and social needs, in adtlition to patients with chi'onic heart disease, chronic obstrut[ive pulmonary disorder and

type 2 diabetes. Averwater, N., & Burchfield, D. (2005, April). Technology. No place like home: telemonitoring can improve home care. hfm (Healthcare Financial Management), 59(4), 46. Retrieved November 23, 2008, from CINAHL with Full Text database.
patients in this market, These patients typically have the financial resources to pay for services themselves. Marketing campaigns can promote the home health agency's telemonitoring capability by offering the service for an attractive telemonitoring actually allows them to visit more patients and would be unlikely to affect their overall compensation. By facilitating daily monitoring of patient status, telemonitoring can help these agen> cies improve care delivery, and by requiring fewer patient visits by nurses, it can help reduce an agency's nurse salary and mileage expense. A short list of the arrangement to a single home health firm provided that firm increase its orders for new equipment in accordance with an agreed-upcn schedule.

In-home monitoring helps VAs manage their health: program reduces ED visits, hospitalization. (2008, February). Hospital Home Health, Retrieved November 19, 2008, from CINAHL with Full Text database. Independence through telecare. Authors: Nazarko L Independence through telecare. L 2007 Sep; 9(9): 414-6 (14 ref) NURSE RESIDENTIAL CARECINAHL with Full Text Computerized technology and the internet have made little impact on the day-to-day care in a person's home or in care homes. This is now changing, and the Department of Health (DH) is encouraging primary care trusts CO invest in telecare (DH, 2005).

people in their own homes are helping many people to maintain independence. Linda Nazarko introduces
Telecare devices can be used to monitor the environment, the person's activity within the environment, and the state of a person's health. These devices can be used to prevent problems, monitor health or to enable the person to obtain specialist advice and treatment without leaving home. Telehealth is the use of technology to monitor and diagnose people at home. The person remains at home, and technology is u.sed to monitor and manage an existing condition such as diabetes (Curry et al, 2003) or to diagnose a new condition (Fragasso et ai, 2006). Sophisticated lifestyle monitors can be combined with a range of sensors to build up a picture of a person's normal activities. These might include what time the person

gets up, how long the person spends in the bathroom, what time tbe person goes activity monitors can be used to reduce the risk of falls by turning on lights and by alerting monitors of possible pnjhlems. Fails detectors can be worn by people ai risk (jf falls. The devices detect the impact and also the angle of the fall. It then sets off an alen to inform the person that it is railing for help. The person can cancel the call ur allow the device to alert ihe monitor. Healthcare monitors can be used to monitor a pcrso[i"s health- These monitors enable people to screen various aspects of health including blood sugar, oxygen saturation levels, cardiac rhythm and blood pressure. The monitors work with a range of sensors that are tailored to a person's medical conditions. There are several types of activity monitors. These devices can either be passive infrared detectors (PIR detectors) or pressure sensors. The PIR devices can be used to alert monitors if a person has been still for some time. Swann, J. (2007, November). Telecare: Looking to the future. International Journal of Therapy & Rehabilitation, 14(11), 512-517. Retrieved November 20, 2008, from Health Source: Nursing/Academic Edition database. Sensors target one particular aspect of activity, e.g. falling, movement in a doorway and occupancy of a bed or chair {Figure 2a). Alternatively, sensors can monitor a specific area, such as pressure or passive infrared (PIR) sensors which detect movement. Other examples include flood detectors (Figuiv 2b), extreme temperature sensors, carbon monoxide monitors, automatic lighting when getting out of bed and epilepsy sensors. Telecare systems are useful for a range of people (Table 2) but may particularly benefit those with dementia or cognitive problems, especially people who may wander, are at risk of falling or have recently been discharged from hospital. Sensors can detect when a fall or an episode of incontinence occurs. bed. In these circumstances, it is essential for providers Bendekovits, R. (2002, January). Telemedicine in home care.. Orthopaedic Nursing, 21(1), 102. Retrieved November 20, 2008, from Health Source: Nursing/Academic Edition database. The nursing shortage and changes in reimbursement have

impacted the traditional data collection visits in the home care setting. daily coverage instead of a fixed number of visits per week. In addition, staff members are able to schedule visits while still empowering patients to be independent in their care. Telemedicine should be viewed as Today's health care addresses prevention and wellness on one end of the spectrum and management of chronic illness according to patient needs and thus make visits when appropriate rather than according to a schedule. an adjunct, not a replacement for the nurse. With the reality of a nursing shortage, use of telemedicine reduces Within a few minutes, a device can collect daily health indicators such as heart rate, blood pressure, oxygen saturation, temperature, weight, blood glucose, lung function, and prothrombin time. provide holistic, comprehensive care. Through digital imagery, the orthopaedic nurse will be able to provide care without leaving the office. Advantages of the video visits include patients. Nurses can humanize technology, using it as another patient care tool. Rita Bendekovits, MSN, RN, ONC, CRRN

innprove patient outcomes and resource

utilization. The nursing shortage and changes in reimbursement have impacted the traditional data collection visits in the home care setting. Today's health care addresses prevention and wellness on one end of the spectrum and management of chronic illness on the other, yet the majority of care needed is in the vast middle. More and more health care will be provided in the home or as communitybased care. Cost containment is still an important issue, and the use of technology to provide care at a distance will become an Important advantage.

Daily monitoring can increase the quality of life for patients and prevent costly readmissions to the hospital or emergency room. Application capabilities include tracking and trending patient data and recording and viev^ng nurse or physician notes. Parameters are set by the physician and the system alarms to notify the nurse when parameters are not within normal limits, allowing immediate intervention. contact are important, but they can be offset by making visits that are necessary while still empowering patients to be independent in their care. Telemedicine should be viewed as an adjunct, not a replacement for the nurse. With the reality of a nursing shortage, use of telemedicine reduces nursing visits while still providing daily care for a patient. Daily knowledge helps the nurse treat the patient better, improving quality of life and outcomes for the patient. Jerant, A. (1999, September 15). Home Telemedicine: Merging the Old and New Ways.. American Family Physician, p. 1096. Retrieved November 20, 2008, from Health Source: Nursing/Academic Edition database. Telemedicine systems are sensor devices placed in a person's home to monitor their health and well being and to reduce accidents. As such, they can provide additional support to enable vulnerable older people, or those with long-term conditions, such as diabetes or high blood pressure, t live an independent life at home, thus reducing the need for emergency or unexpected admissions to hospital.

'The use of monitoring devices in the home has the potentiai to create major
their own health. Sf> a person with diabetes can have their blood sugar monitored from home - meaning less unexpected or emergency trips to hospital.'

the
Support
The 12 million programme announced by the governmentaimst<i reduce the number of prescriptions

dispensed and the number of emergency hospital bed days and admissions. It is efficiently. lelecare devices, which act as sensors in the home, also have a role to play. The sensors can turn lights on and off to ensure that elderly people do not have to walk around in [he dark if they need to get out of bed during the night. They can also raise the alarm if the person does not come back to bed after a specified time, so that iHssistance can be summoned, if needed.

Confidence
As part of the government's programme, the pilot sites in Kent, Newham and Cornwall a way to give patients greater confiiience and security in tbeir own homes. Such additional confidence may prove particularly important for those who have recently returned home after a stay in hospital and who are worried about their ability to cope on their own. The pilot projects will also be subject to a major independent evaluation through the Department of Health's Policy Research Programme. This evaluation will highlight the major lessons to be learnt from these sites, as well as enabling the government to determine the best options for implementing Eden Alternative Alternatives to nursing home placement The Aging Process How to choose a nursing home Home Care Base Services Nursing homes are often thought of as the only option when seeking long term care services. However, there are alternatives available that may provide a more appropriate level of care and promote independent living. Alternatives to nursing homes include in-home care and retirement communities, as well as: Independent living apartments. Independent living apartments are ideal for seniors who do not need personal or medical care but who would like to live with other seniors who share similar interests. In most independent living facilities seniors can take advantage of planned community events, field trips, shopping excursions and on-premise projects. These apartments are not licensed or regulated. Adult homes. Adult homes are licensed and regulated for temporary or long-term residence by adults unable to live independently. They usually include supervision, personal care, housekeeping, and three meals a day.

Enriched housing. Enriched housing is similar to adult homes, with the exception that seniors live in independent housing units. They offer a minimum of one meal per day and are licensed by the State Department of Health. Family-type homes. Family-type homes offer long-term residential care, housekeeping, and supervision for four or fewer adults unrelated to the operator. The department of Social Services oversees their operations. Assisted living program (ALP). An excellent alternative to nursing homes for seniors who need help with their daily routines, but who do not need 24-hour care. Room, board, case management, and skilled nursing services come from an outside agency. This program accepts Medicaid, Supplemental Security Income (SSI), and home relief recipients. Continuing care retirement communities. Continuing care communities offer a continuum of living options, from independent living, enriched living, assisted living, and skilled nursing home, all on one campus. Residents can move from one level of care to the next as needs change. Transitions to different levels of care are easier because people are able to remain in familiar surroundings. In addition, spouses who age at different paces may also remain near each other. The Highlands at Pittsford is Strong Health's continuing care retirement community, offering independent living in cottage and apartment homes, enriched living in Laurelwood, and skilled nursing at The Living Center. Nursing home (or skilled nursing facility). Nursing homes offer 24-hour a day care for those who can no longer live independently. In nursing homes, trained medical professionals provide specialized care to seniors with severe illnesses or injuries. Specially trained staff assist residents with daily activities such as bathing, eating, laundry and housekeeping. They may specialize in short-term or acute nursing care, intermediate care or long-term skilled nursing care Homemaker and Companion Agencies Homemaker and companion agencies provide individuals to aid elderly and disabled individuals with general tasks. Homemakers provide assistance with routine household activities, such as cooking and cleaning. Companions provide assistance during trips and outings and may prepare and serve meals. By law, homemakers and companions may not provide hands-on personal care to a client, such as assistance in bathing or undergarment changing. They may not dispense medications. Homemaker and companion agencies must be registered by the state of Florida and include their registration number in public advertisements. Some individual homemakers and companions are employees of agencies. Some are contracted agents. Individual homemakers and companions are required to undergo criminal history checks. Complaints against the agencies may be investigated by the state of Florida, but the individuals are not licensed or inspected by the state. Continuing-Care Retirement Communities (CCRCs) Continuing Care Retirement Communities, also called Life-Care Communities, offer different levels of care based on the needs of the individual or couple. The care level ranges from an independent living apartment or house to skilled nursing in an affiliated nursing home. CCRC residents are guaranteed care for the rest of their lives. The CCRC residents move from one setting to another based on their needs but continue to remain a part of their CCRC community. Many Continuing Care Retirement Communities have an entrance fee prior to admission as well as a monthly charge. AHCA licenses and inspects the nursing facilities, assisted living facilities, or home health agencies that may be part of a CCRC. The Department of Financial Services regulates the CCRC contracts. Licensed Nurse Registries Nurse registries act as employment agencies between an individual patient and nurses, nursing assistants, home health aides, companions and homemakers for services in the patient's home. Each individual health care worker is contracted with the registry. Nurse registries provide nursing care services, but they are not licensed to provide physical therapy or other therapy services or medical equipment services. Unlike home health agencies, licensed nurse registries are not required to carry liability insurance. As the name implies, all licensed nurse registries must be licensed by the state of Florida and must include the nurse registry license number in public advertisements. Home Health Agencies Home health agencies deliver health and medical services and medical supplies through visits to private homes, assisted living facilities (ALFs), and adult family care homes. Some of the services include nursing care, physical therapy, occupational therapy, respiratory therapy, speech therapy, home health aide services, and nutritional guidance. Medical supplies are restricted to drugs and biologicals prescribed by a physician. Along with services in the home, an agency can also provide staffing services in nursing homes and hospitals. Home health agencies are required to be licensed and inspected by the state of Florida.

Adult Day Care Centers Adult day care provides a protective setting that is as noninstitutional as possible. Adult day care centers offer therapeutic programs of health services and social activities such as leisure activities, self-care training, rest, nutritional services, and respite care for a portion of a day. Some nursing homes provide adult day care services. Adult day care centers are required to be licensed and inspected by the state of Florida. Adult Family-Care Homes An adult family-care home provides a full-time, family-type living arrangement in a private home for up to five aged or disabled people who are not related to the owner. The owner lives in the same house as the residents and provides housing, meals, and personal services; however, services vary. Adult family care homes are required to be licensed and inspected by the state of Florida. Assisted Living Facilities An assisted living facility (ALF) provides housing, meals, and personal services. ALF services vary greatly in the types of residents served. For example, some accept residents who need assistance in bathing, others do not. All ALFs are required to be licensed and inspected by the state of Florida. Some ALFs are specially licensed to provide extended congregate care (ECC). This allows the ALF to care for residents as they become frailer in order for the resident to age in place. Some ALFs are specifically licensed to provide limited nursing services and/or limited mental health services. Hospice Hospice services emphasize comfort measures rather than aggressive curative treatment. Hospice provides a coordinated program of professional services, including pain control and counseling for patients who have a prognosis of six-months or less to live. Counseling and support for the family members and friends of the terminally ill patient are also provided. Hospice services are predominately provided in the patient's home. However, the services are also available in ALFs and nursing homes. Hospice providers are required to be licensed and inspected by the state of Florida. Nursing Homes A nursing home provides nursing care, personal care, and custodial care to people who are ill or physically infirm. This is the type of facility that you will find listings for in this Guide. Nursing homes are freestanding, which means that they are not part of a hospital. Some nursing homes are part of a continuing care retirement community (CCRC) and are governed through special contracts. All nursing homes listed in this Guide are licensed and regularly inspected by AHCA. Skilled Nursing Units Skilled Nursing Units (SNUs) are based in hospitals. They typically provide only short term care and rehabilitation services. Some SNUs are located inside the hospital, and some are located in a separate building. The skilled nursing unit is licensed as part of the hospital. They are regularly inspected by AHCA. Home and Community Care A person who is ill or disabled may be able to get help from a variety of home services that might make moving into a nursing home unnecessary. Home services include Meals on Wheels programs, friendly visiting and shopper services, and adult day care. These programs are found in most communities. If you are considering home care, discuss this option with family members to learn if they are able to help provide your care or help arrange for other care providers to come to your home. Some nursing homes may provide respite care and admit a person in need of care for a short period of time to give the home care givers a break. Depending on the case, Medicare, private insurance, and Medicaid may pay some home care costs that are related to medical care. Subsidized Senior Housing (Non-Medical) There are Federal and State programs that help pay for housing for older people with low to moderate incomes. Some of these subsidized facilities offer assistance to residents who need help with certain tasks, such as shopping and laundry. Residents generally live independently in an apartment within the senior housing complex. Assisted Living (Non-Medical Senior Housing) If you only need help with a small number of tasks, such as cooking and laundry, or reminders to take medications, assisted living facilities maybe an option worth considering. "Assisted living" is a general term for living arrangements in which some services are available to residents who still live independently with in the assisted living complex. In most cases, assisted living residents pay a regular monthly rent, and then pay additional fees for the services that they require. Board and Care Homes Board and Care homes are group living arrangements designed to meet the needs of people who cannot live independently, but do not require nursing home services. These homes offer a wider range of services than

independent living options. Most provide help with some of the activities of daily living, including eating, walking, bathing, and toileting. In some cases, private long-term care insurance and medical assistance programs will help pay for this type of living arrangement. Keep in mind that many of these homes do not get payment from Medicare or Medicaid and are not strictly monitored. Continuing Care Retirement Communities (CCRCS) CCRCs are housing communities that provide different levels of care based on the residents' needs from independent living apartments to skilled nursing care in an affiliated nursing home. Residents move from one setting to another based on their needs, but continue to remain a part of their CCRC community. Be sure to check the record of the CCRC's nursing home. Your CCRC contract usually will require you to use it. Many CCRCs require a large payment prior to admission and also charge monthly fees. For this reason, many CCRCs may be too expensive for older people with modest incomes. Summary of Options The options discussed above may work for people who require less than skilled care, or who require skilled care for only brief periods of time. Many people with long-term skilled care needs require a level and amount of care that cannot be easily handled outside of a nursing home.

Assisted Living Facilities. An assisted living facility is a primarily residential setting which offers some supportive services for people who are able to live fairly independently but need some assistance with medications, activities of daily living, or meals. An assisted living facility is not primarily medical (it may or may not have professional nursing staff) and it provides less intensive nursing and medical supportive services than a nursing home. It may be a good option for someone who may not be safe or comfortable living alone, even with in-home services, but who does not yet need nursing home care.

Other Services. In addition to the specific alternatives to nursing home care set out above, there are a number of services which may help an individual stay in her home. Such services include Meals on Wheels, a program which delivers prepared meals to the homes of home-bound disabled persons; companion or chore services; Personal Emergency Response System electronic devices for help should the person fall or have a medical emergency.
Home care allows the elderly or disabled person to remain in his or her home in the community and builds upon, rather than replaces, care by relatives. It enables patients to be discharged from hospitals and avoid unneeded institutionalization - often at less expense to the taxpayer. The average annual cost for a home-care client is $12,000, as compared with an average annual cost of $14,600 at a health-related facility or $29,500 at a skilled nursing facility. Home care is not intended to replace nursing-home care where that is needed, but it can provide a valuable, viable option for some hospital patients ready for discharge. CAROL RAPHAEL, Assistant Deputy, Administrator Office of Home Care Services, Human Resources Administration, New York, Nov. 12, 1982 A substantial number of people are accused of becoming qualified for Medicaid nursing home beds only because they artificially spend down their mother's or father's money or "hide" their assets with creative accounting. In order to be eligible for Medicaid, you have to be poor, otherwise you'd have to pay private rates which are currently $3545,000 a year. If we could reduce the number of people who are in fact artificially spending down their parent's money in order to qualify for a Medicaid nursing home, then these persons might be more inclined to look for cheaper alternatives given that the cost is coming out of their own pockets. Assuming that scenario, assisted living facilities would gain greater credibility and money because they would be a less expensive alternative. There are many aspects that are attractive but one of them is that they are increasingly providing care for physically and mentally frail older persons but in an environment that more closely resembles a hotel or an inn as opposed to a hospital or nursing home. Residents have their own rooms or their own little suites. They have much more freedom to come and go as they wish and they have more say in the types and frequency in which they receive services.

They're treated less like patients and more like residents. In general, these facilities are able to deal with an older person's frailty in a much more home-like or humane-type setting than a nursing home. Assisted living is an attempt to give people who are frail a chance to live their own lives according to their own rules as much as possible," says Whitney Redding, a spokeswoman with the Assisted Living Federation of America (ALFA),which represents more than 7,000 for-profit and nonprofit communities across the country. Assisted living centers cost about a third less than living in a nursing home, but they're not a cheap living arrangement. The average cost of a private room or studio in an assisted living center in 2004 averaged $2,100 to $2,900 a month according to a review by Health Policy Tracking Services. The centers -- some of which cater to people with Alzheimer's disease and other forms of dementia -- may also offer a range of housekeeping, transportation, personal services, and social activities. Summerville at Creekside Lodge, for example, hosts bingo as well as health-oriented exercise classes and blood pressure screenings. And there are recreation rooms to watch travel videos and play games or music -- something that the Vandenbergs particularly enjoy. "My husband plays pool practically every day," Altave Vandenberg says. About 38 percent of all assisted living communities also offer some type of nursing service, which costs more, Redding says. But most assisted-living communities stress independent lifestyles. There's no question that assisted living is an attractive group housing alternative, and the book will argue that there's a strong possibility assisted living can replace nursing homes for the majority of frail elders if: we don't overregulate them; we're careful to insure that the public has a stronger and more informed understanding of what this alternative is about; the private sector can, to some extent, police themselves through private accreditation programs as opposed to creating a heavy regulatory environment; and if assisted living facilities don't attempt to bite off more than they can chew. These facilities probably won't ever be used by more than a minority of the population because of the attractiveness of home care, but nonetheless, it's an alternative that should be nurtured and supported as a long-term shelter and care alternative for older persons who become physically or mentally frail. Advocates for senior citizens are looking for ways to attract more workers and they're also looking for alternatives to nursing homes. One such alternative is senior foster care. The system works much like foster care for kids. A family is paid to care for up to five seniors in their home. This new version of a nursing home is catching on. About 50 families in Olmsted County provide senior foster care. There is training required and homes must meet specific safety guidelines. The program is less expensive than a nursing home would be. On average, senior foster care in Olmsted County costs $300 to $500 a month less than nursing home care. That vignette, excerpted from the website of the Center for Health Care Strategies Inc., highlights a basic fact of life in America: that many older and disabled adults live in nursing homes simply because no other alternatives are available to them. The bias toward institutional care is rooted in the foundation of Medicaid, which for years has devoted the bulk of its long-term care budget almost exclusively to services in nursing homes and other such facilities. As a result, the $214 billion program continues to pay for care for nearly two of every three nursing home residents. But a confluence of factorsconsumer preference, the high cost of institutional care and court decisions, most notably the U. S. Supreme Courts 1999 ruling in L.C. & E.W. vs. Olmstead, which held that disabled people must be cared for in the community if they wish, assuming that such a setting is appropriate to their needs and that the state in which they live can afford itis slowly but surely eroding the bias. In FY 1990, for example, 90 percent of Medicaid long-term care dollars were allocated to institutional care (nursing homes and intermediate care facilities for the mentally retarded) and 10 percent to home and community-based services. By 2001, the gap had narrowed, to 71 percent and 29 percent respectively. Since 1993, nursing home occupancy rates nationally have also declined. To encourage the trendand save money for Medicaid in the bargainstates are experimenting with a variety of programs that provide services and supports at home or in the community, so that frail elders and people with disabilities can avoid institutional care for as long as possible. Two of the latest vehicles: nursing home transition grants, which let states shift residents from nursing

homes into the community or divert unnecessary placements by intervening during hospital discharge planning, and nursing home conversion grants and loans, which help the homes transform themselves into assisted living facilities or offer alternatives such as respite care and adult day care. Betty Ann Shaughnessys move, for instance, was facilitated by a $100,000 Olmstead planning grant, awarded by the center as part of a larger seven-state, $700,000 program funded by the RobertWood Johnson Foundation. According to the centers summary, the project confirmed for Utah officials that a lack of accessible, affordable housing is the greatest barrier to transition for those currently residing in nursing homes or in swing-bed hospitals, or facilities that are allowed to redefine acute-care beds as long-term care beds as need dictates. As of last January,it reported, the states Division of Health Care Financing had helped 30 people move out of nursing homes into more integrated community settings. The high cost of nursing homes and the desire of folks to live in the community have also prompted the federal Centers for Medicare and Medicaid Services (CMS) to channel money into the nursing home transition grant program, according to Mary Fran Laverdure, a CMS health insurance specialist. Since its inception in 1998, the program has awarded funds to a total of 27 states and over time, both the size of the grants and the number of grantees have grown, from $160,000-175,000 to each of 4 states in year one to $550-800,000 to each of 11states this year. COVER STORY 1 Though most people in nursing homes would like to be someplace else, in-home and community care options are few. States are changing that by diverting patients or letting homes offer other services. BEHAVIORAL HEALTH NEWS 2 More patients with depression are turning to their primary care physicians, who often arent trained to diagnose and treat the disease. A look at Colorados efforts to help. HIGHLIGHTS 3 FL Medicaid Rx drug decision Insurance costs NM HIFA waiver MS malpractice session List of questionable docs AL plan for abused women Studies on women and exercise OH, NYC smoking bans Drug abuse survey Kids and marijuana ER drug visits IL assisted living facility licenses. TRACKING TRENDS 7 Despite a return of double-digit increases, health insurance has been

largely a back-burner issue this year. FYI 8 Police in Minneapolis are receiving comprehensive training on dealing with mentally ill in everyday situations and tense confrontations. Page 2 5 S TATE H EALTH N OTES -S EPTEMBER 23, 2002 [Nursing Home Care, p.6] NEW JERSEY: COMMUNITY CHOICE One of the first and largest of the CMSsponsored programs is New JerseysCommunity Choice. Started in March 1998 by the Department of Health and Senior Services with a small infusion of state funds, the program provides nursing home residents and hospital patients with information on in-home services, housing alternatives and community resources. In the past, nursing home admission was a one-way ticket, explained Rebecca McMillen, the programs coordinator. We didnt want that to continue. Through June of this year, more than 4,000 people have made the move from nursing homes back into the community, said McMillen. The majority of those who did so were elderly, and most went back to their own homes or families though some went to senior housing projects. In order to make sure none of the states 350 nursing homes are excluded, the program employs 29 counselors and 60 preadmission screening nurses to help guideresidents through the transition process. The federal support has enabled the program to grow. In 1999, Community Choice received a $500,000 grant from CMS, en-

abling it to hire three project specialists to help with marketing, identifying barriers and assuring quality of care. With a renewed grant of $600,000 this year, it will expand its focus to help younger people with disabilities move back into the community. Though the program is widely seen as a success, not everyone has been happy with it. At first, McMillen said, the nursing home industry perceived [us] as an enemy. Toease tensions, the counselors did presentations on the program to nursing home staffs, explaining that the purpose was not to empty beds but rather to give people who didnt belong in the home more choices. Addressing the nursing home transition program in general, Janice Zalen, director of special programs for the American Health Care Association, which represents 12,000 providers of assisted living and nursing, residential and subacute care, said the industrys biggest concern isntthe downsizing of nursing facilities. We believe that people should live in the least-restrictive setting. Whatsobjectionable, she said, is the counselors wandering in and looking for people to talk to because, after all, they are in peoples homes. It would be better if such decisions could be Nursing Home Care, from p. 1 Conference Slate Third International Conference on Family Care: Empowerment Through Innovation.Oct. 12-14. Arlington, Virginia. Hosted by the National Alliance for Caregiving, conference topics include family care around the world; eldercare; care for people with mental illness and disabilities; grandparents caring for grandchildren; and caregiving by young people. For additional information, call (301) 7188444. Surviving Adversity: A Critical Access Hospital Conference. Oct. 9-11, Kansas City, Missouri. Sponsored by the National Rural Health Association, the meeting will feature discussions on recruitment and retention; benchmarking for success; and financing, in-

cluding maximizing reimbursement and facility/equipment replacement. Questions? Goto http://www.NRHArural.org or call the association at (816) 756-3140. 24 th Annual Meeting of the Society for Medical Decision Making. Oct. 19-23, Baltimore. Jointly sponsored by the Society and the George Washington University Medical Center, the meetingstheme will be genomics and decision making, with a panel discussion on the impact of the genomics revolution on diagnostic testing and therapy decisions. For information, call (202) 994-8929 or go to http://www.smdm.org In Print In Our Hands: How Hospital Leaders Can Build a Thriving Workforce. Prepared by the American Hospital AssociationsCommission on Workforce for Hospitals and Health Systems, the report is aimed at helping hospitals deal with current and coming health care workforce shortages. Its five key themes: fostering meaningful work; improving workplace partnerships; broadening the base of health care workers; collaborating with others; and building societal support. For details, go to http://www.asahp.org/newsacross theprofessions.htm The Medicare Payment Advisory Committee has released two reports to Congress: Medicare Payment to Advanced Practice Nurse and Physician Assistants and Medicare Coverage of Nonphysician Practitioners, including surgical technologists, mental health service provides and clinical pharmacists. For additional information, go to http://www.medpac.gov Barriers to Medicaid Enrollment for Seniors: Findings from 10 Focus Groups with Low-Income Seniors. Published by the Henry J. Kaiser Family Foundation, the report is an effort to understand why low-income elderly who are eligible for Medicaid do not enroll. In addition to describing seniors experiences with the health care system and how well

programs like Medicaid are working for them, it offers a list of strategies for removing the barriers and increasing enrollment. Toobtain a copy of the report, (publication #4029), go to http://www.kff.org On Tape Heart-to-Heart: Improving Care for the Dying Through Public Policy. Produced by the Midwest Bioethics Center and Last Acts,the two-part audio series is directed at the information needs of state policymakers. PartI focuses on painmanagement,exploring barriers doctors face in easing pain and identifying potential policy solutions. Part II describes the achievements of public officials in three state a legislator, an attorney general and a cabinet officerin providing leadership in the area. Order copies by calling (800) 989-9455 SAVE THE DATE!! NCSLs Sixth Annual Health Conference will take place Nov. 17-19 in New Orleans. Among concurrent sessions: the state of emergency rooms; cancer screening programs; state environmental health services; the link between chronic disease and the environment; the dentist shortage; pathways to prevention; childhood obesity; challenges to treating mental health and substance abuse; prescription drug costs and coverage; Medicaid costs and coverage; long-term care costs; nursing home liability; health insurance affordability; and more. For details, visit http://www. ncsl.org/programs/ health/health.htm or call Joanne Stroud at (303) 364-7700. Page 3 6 S TATE H EALTH N OTES -S EPTEMBER 23, 2002

ADVISORY BOARD Rep. Charlie Brown, Indiana Rep. Dianne White Delisi, Texas Kurt DeWeese, Speakers staff, Illinois Rep. Susan Gerard, Arizona Rep. Peter Ginaitt, Rhode Island Del. Marilyn Goldwater, Maryland John Kasprak, Senior Attorney, Connecticut Legislature Sen. William Martin, North Carolina Sen. Sandy Praeger, Kansas Sen. John J.H. Schwarz, Michigan RESEARCH & EDITORIAL STAFF Dick Merritt Forum Director Linda Demkovich Editor Anna C. Spencer Assistant Editor Contributors: Donna Folkemer, Wendy Fox-Grage, Shelly Gehshan,Tim Henderson, Johanna Keely, Kala Ladenheim, Jordan Lewis, Greg Martin, Anna B. Scanlon,Tara Straw Published biweekly (24 issues/yr.) by the FORUM FOR STATE HEALTH POLICY LEADERSHIP, an information and research center at the National Conference of State Legislatures in Washington, DC. For more information about Forum projects, visit our web site at: www.ncsl.org/programs/health/forum HEALTH POLICY TRACKING SERVICE M. Lee Dixon HPTS Director Staff: Deirdre Byrne, Allison Colker, James Cox, Eileen Crean, Teresa Floridi, Patrick Johnson, Lillian MacEachern, Rachel Morgan, Stephanie Norris, Carla Plaza, Rachel Tanner EDITORIAL INQUIRIES Linda Demkovich, Editor Tel: 202-624-5400 Fax: 202-737-1069 email: linda.demkovich@ncsl.org CUSTOMER SERVICE & SUBSCRIPTIONS NCSL, 1560 Broadway, #700, Denver, CO 80202 Tel: 303-830-2200 Fax: 303-863-8003

Nursing Home Care, from p. 5 made prior to the residents placement in the institution. Since the establishment of Community Choice and the implementation of an assisted living Medicaid waiver program, New Jersey has experienced a slight decline of several thousand Medicaid nursing home residents, said McMillen. The number of nursing home beds hasnt dwindled, however, because the aging population continues to grow. As for anticipated cost savings, We are trying to gather that information, she said, though a back-of-the-envelope calculation looks like this: The Medicaid nursing home per diem is between $3,000-$3,500 per resident per month compared to $1,800 for assisted living facilities. That means moving an individual could net savings of $1,200$1,700. And as McMillen observed, there is even more potential for savings because most people whove benefited from Community Choice have moved back into their own homes, not into assisted living. The programs focus, though, has been on improving quality of life, not cost savings, McMillen insisted. Dignity, choice and options are what we are all about. An evaluation of Community Choice by Rutgers Universitys Center for State Health Policy will be released soon. Indeed, CMS requires all state grantees to build in a strong evaluation component, and an initial comparative analysis of the 12 FY 2001 grantees by the Research Triangle Institute is due to be completed this month; over the lifetime of the grants, the institute will prepare a series of reports, which will then be published on the agencys website. In addition, the MedStat Group, a subcontractor to the institute, is preparing case studies on several of the programs. Though the evaluation is still in the works, 1,300 people are supposed to be transitioned or diverted for the FY 2001 grantees alone, CMS Laverdure said. Because of tight budgets, however, some states were

reluctant to target a [specific] number, which means the numbers who benefit from the grants could exceed the preliminary estimate. NEBRASKA: MAKING CONVERTS With much the same goals in mind, three states in the MidwestIowa, Nebraska and North Dakotahave initiated nursing home conversion programs, offering grants and/or low-cost loans that allow the facilities to make a transformation to assisted living or to provide other alternatives, like respite care and adult day care. Unlike transition grants, conversion grants are solely state-financed, and homes voluntarily apply for the funds. The option serves a real need, especially in rural areas where itshard to support free-standing assisted living because of a dearth of residents and workers, observed Lyn Bentley, senior policy director at the National Center for Assisted Living. The Legislatures decision to create the program in the economic boom years of the 1990s was fortuitous. In Nebraskawhich has had the most experience and the most success of the three statesthe Legislature created the Nursing Facility Conversion Cash Fund in 1998 as a follow-up to a 1996 Department of Health study on the state of the stateslong-term care system. Targeted to low-density rural areas, the goal was to give nursing home owners financial incentives to incorporate assisted living and adult day care into their existing business in order to maximize their cost-effectiveness. To qualify for the fundsa maximum grant of $52,000 per assisted living unit, up to a total of $1.1 millionowners agreed to reserve 40 percent of the newly constructed units for Medicaid-eligible residents, reduce licensed nursing home beds by at least the number of assisted living units created and run as an assisted living facility for 10 years. In addition, applicants were required to come up with a 20 percent match, which dissuaded

a number of facilities from applying for the funds. The money could be used for start-up costs, construction, training expenses and first-year operating losses. Over the life of the programthe last of threerounds of applications closed more than a year agothe state awarded $52.5 million to rural homes to convert wings or entire facilities. According to Medicaid Director Bob Seiffert, that has resulted in a total of 74 project conversions, yielding 967 new assisted living units, 16 respite care suites and 27 adult day care programs. (Once an application has been submitted, it takes about 18 months between design and completion, which means construction on the last of the projects should wrap up bythe end of this year.) From a financial standpoint, the program appears to have met the Legislatures objective of reducing the cost of care for Medicaid-eligible residents. The state projects $5.5 million in savings to Medicaid, said Seiffert, taking into account the $31 per patient day differential between nursing home ($68) and assisted living ($37) costs. In addition, nursing home occupancy has dropped 12.5 percent over the time of the program, though he noted that several other factorsmany more assisted living facilities in urban areas of the state, for instance, and other services under the states broader Medicaid home and community-based services waiveralso contributed to the decline. From a consumer satisfaction standpoint, on the other hand, the conversion program certainly doesnt meet all the need, Seiffert admitted. There are, he estimated, 25 to 35 communities that could have benefited from it but that for one reason or another chose not to apply. Still, he said, it goes a long way in offering residents of some rural areas an otherwise unavailable luxuryof assisted living. Call it luck or call it what you will, but the Legislatures decision to create the program in the economic boom years of the 1990s was fortuitous. Given todays devas-

tating deficit, its highly unlikely wed be able to get it off the ground. Timing, as they say, is everything. WFG Before deciding on a nursing home, you may want to consider other options. ome people have an aversion to nursing homes and want to try out almost anything else before they go into one. Others do not necessarily need the 24hour, total supervisory care of a nursing home. Even for someone who cannot live independently and needs a high level of care, however, there are lternatives, and it makes good sense to understand and evaluate them. Alternatives will vary widely depending on whether you live in a city, a suburb or a rural area. Generally, people in rural areas have fewer options than those in cities or suburbs. Some of the alternatives to nursing homes may include the following COMMUNITY SERVICES These can include transportation services, telephone reassurance programs, home maintenance and repair services, senior centers, Meals on Wheels programs and home observation programs. ADULT DAY SERVICES These programs offer all-day, morning, afternoon and sometimes evening care for seniors. HOMEMAKING AND PERSONAL CARE SERVICES These provide assistance with homemaking (such as cooking and cleaning) and personal care (such as dressing and bathing). SUBSIDIZED, NONMEDICAL SENIOR HOUSING Some federal and state programs subsidize housing for low-tomoderate income seniorsoffering assistance with shopping, laundry and cleaning. Usually, residents live in independent apartments within a larger complex. HOME HEALTH CARE Semi-skilled and skilled services are available, for a few hours a day or 24 hours a day, for people who need medical care at home. ASSISTED LIVING FACILITIES Generally unsubsidized, assisted living facilities charge a regular monthly rent, with fees charged for any special services. Assistance may include help with tasks like cooking, laundry or remembering medications. BOARD AND CARE HOMES These group-living arrangements provide some care services as well as opportunities for socialization. They often provide help

with some daily activities, like eating, walking, bathing and other general personal care tasks. The homes are usually not covered by Medicare or Medicaid, and often they are not strictly monitored by State or Federal agencies. Under some circumstances, they may be covered by private long-term care insurance or other medical assistance programs. During the past 10 to 15 years, an increasing number of elderly persons began living in settings that are neither traditional home settings nor traditional nursing homes. There has been a proliferation of facility-like residential alternatives to nursing homes. These settings go by various names including assisted living facilities, continuing care facilities, retirement communities, staged living communities, age-limited communities, etc. For simplicity in this article we will refer to all these types of living arrangements as elderly group In February 2006, another lawsuit accused the state of Connecticut of forcing psychiatric patients into nursing homes when community living would provide more suitable alternatives. Connecticut Lt. Gov. Kevin Sullivan is championing efforts to make sure that individuals with mental illnesses are placed in community-based care rather than nursing homes. Nursing home beds are far more costly than home or community care, Sullivan notes. The situation that prompted the lawsuit is "wrong as a matter of law and as a matter of smart public policy," he says. "Nursing homes do not provide effective care and recovery for the nongeriatric mental health patients who are trapped there." And it shouldn't take a lawsuit to make Connecticut do the "right thing," Sullivan adds. Many family members, unfamiliar with the full range of aging services available, assume that nursing home placement is the only alternative when an older person is unable to manage their own care at home. While that is sometimes the right solution, a good assessment process could ensure no better alternative exists before that decision is made.

Types of Aging Services Available

There is a wide range of services and housing options available for older persons. The brief descriptions will assist you in determining what degree of care or type of service you or your loved ones need. Senior Housing/Independent Living You may want to think about senior housing if you want to live on your own, but don't want to have all the chores that go along with having a home. It's also a great option for people who want to live in a community with other seniors. Depending on the community you choose, you can rent an apartment either at the market rate or if your income level applies, a lower rate. They are often specially designed with things like railings in bathrooms or power outlets higher up on the wall. They may also offer a 24-hour emergency call service if residents need help right away. Some places may also offer different kinds of services to the people who live there like meals, transportation, social activities and other programs. Search for Not-for-Profit Aging Service Providers Continuing Care Retirement Communities (CCRCs) are multilevel continuums that bring various levels of care together, often on one campus, so that residents can stay in the same community as their needs change. CCRCs offer their residents a contract that generally secures living accommodations and services. There are three common types of contracts: 1) unlimited nursing care for little or no substantial increase in the usual monthly payments; 2) specified amount of nursing care beyond which the resident is responsible for payment; 3) residents pay full daily rates for all long term nursing care required. Search for Not-for-Profit Aging Service Providers Assisted Living Residences combine apartment-like living with a variety of support services including meals,

assistance with personal care, housekeeping, laundry, social and recreational programs, oversight of residents self administration of medication, 24-hour security, and on-site staff to respond to emergencies. In Massachusetts, Assisted Living Residences are regulated by the Executive Office of Elder Affairs. Most assisted living residences are paid for privately, while some accept payment for eligible residents through Medicaids Group Adult Foster Care program. Some long-term care insurance policies also pay for assisted living. Search for Not-for-Profit Aging Service Providers Rest Homes / Residential Care Facilities provide housing, meals, 24-hour supervision, social and recreational programs, administration of medications, and personal care to individuals who do not routinely require nursing or medical care. In Massachusetts, residential care facilities are licensed and regulated by the Department of Public Health. Public assistance through the Supplemental Security Income (SSI) program and Emergency Aid to Elderly, Disabled and Children (EAEDC) is available at some residential care facilities for individuals who cannot afford to pay for their care privately. In addition, some long-term care insurance policies may pay for residential care. Search for Not-for-Profit Aging Service Providers. Nursing homes, Nursing homes offer round-the-clock care if someone is too sick to live on their own, or if they need to recover after having an illness or operation. Some people stay for a short time in a nursing home and then go home. Other people may be sicker and need more care for longer. Some nursing homes have special units for residents with dementia or Alzheimer s disease. In Massachusetts nursing homes are licensed by the Department of Public Health. Some residents or their families pay for nursing home care out of their own private funds or with private long-term care insurance. Others, who have limited finances or who spend-down their finances on their care become eligible for Medicaid. Medicare covers some nursing home care in limited circumstances following a hospitalization. Search for Not-for-Profit Aging Service Providers.

Like most people, you probably want to stay in your home for as long as possible. But you may also need help and support to stay there. That's where Home and Community-based services (HCBS) can help you. HCBS providers can offer everything from help with the chores to health care services, or even just someone to call and check in on you. Also, if you are taking care of a family member or friend, these services can give you the help and support that you need as well. While there are many different services available, not every community has them. The Executive Office of Elder Affairs or your local Aging Service Access Point can provide you with more information.

Adult Day Care: Provides a variety of health, social and related support services in a safe setting during the day. Some day care programs are designed especially for people with Alzheimer's disease. Care Managers: Helps people figure out what services are needed and what services. Together, managers and their clients come up with a care plan that best fits an individual's lifestyle and arranges the services. Congregate Meal Programs: Offer free or low-cost meals in group settings (often in a senior center or senior housing). Financial Counseling Programs: Help an individual balance a checkbook, file taxes and pay bills. They also help with Medicaid, Medicare or other insurance forms. Friendly Visiting: Provides volunteers who will come to visit and talk in a person's home. Home Health Care Services: Includes part-time nursing services, personal care, help with chores, medical supplies or equipment and different kinds of therapies (physical, occupational, and speech) to help a person recover from an illness or surgery.

 Homemaker or Chore Services: Helps with different chores around the house, such as cleaning, preparing meals or doing laundry. They also help with harder tasks such as washing floors, windows and walls and shoveling snow. Hospice Care: Provides comfort, nursing care and other services, such as grief counseling, to people who are dying (and their families). Hospice care is provided in your home, in a nursing facility or in a free-standing hospice. Home-Delivered Meals: Bring meals in to individuals if they cannot prepare them on their own. Personal Care Services: Provide help with things like bathing and dressing. Respite Care: Gives families a break from caring for older people who are unable to care for themselves. Respite care can take place in the older person's or caregiver's home. Transportation Services: Helps people get to and from shopping centers, doctor's appointments, senior centers and other places.