I ran across this factsheet on Dementia from the Milton S Hershey Medical Center. The section entitled, What are the Symptoms, is particularly interesting.
Source Milton S Hershey Medical Center
Dementia
What is it?
Dementia is the gradual deterioration of mental functioning, such as concentration, memory, and judgment, which affects a person’s ability to perform normal daily activities.
Who gets it?
Dementia occurs primarily in people who are over the age of 65, or in those with an injury or disease that affects brain function. While dementia is most commonly seen in the elderly, it is not a normal consequence of the aging process.
What causes it?
Dementia is caused by the death of brain cells. Brain cells can be destroyed by brain diseases, such as Alzheimer’s disease, or strokes (called vascular or multi-infarct dementia), which decrease blood flow to the brain. Lewy body dementia is another common cause attributed to changes in brain tissue. Other causes can include AIDS, high fever, dehydration, hydrocephalus, systemic lupus erythematosus, Lyme disease, long-term drug or alcohol abuse, vitamin deficiencies/poor nutrition, hypothyroidism or hypercalcemia, multiple sclerosis, brain tumor, or diseases such as Pick’s, Parkinson's, Creutzfeldt-Jakob, or Huntington's. Dementia can also result from a head injury that causes hemorrhaging in the brain or a reaction to a medication.
What are the symptoms?
In most cases, the symptoms of dementia occur gradually, over a period of years. Symptoms of dementia caused by injury or stroke occur more abruptly. Difficulties often begin with memory, progressing from simple forgetfulness to the inability to remember directions, recent events, and familiar faces and names. Other symptoms include difficulty with spoken communication, personality changes, problems with abstract thinking, poor personal hygiene, trouble sleeping, and poor judgment and decision making. Dementia is extremely frustrating for the patient, especially in the early stages when he or she is aware of the deficiencies it causes. People with dementia are likely to lash out at those around them, either out of frustration or because their difficulty with understanding makes them misinterpret the actions of others. They become extremely confused and anxious when in unfamiliar surroundings or with any change in routine. They may begin a task, such as cooking, then wander away aimlessly and completely forget what they had been doing. Dementia is often accompanied by depression and delirium, which is characterized by an inability to pay attention, fluctuating consciousness, hallucinations, paranoia, and delusions. People in advanced stages of dementia lose all control of bodily functions and are completely dependent upon others.
How is it diagnosed?
Dementia is diagnosed through a study of the patient’s medical history and a complete physical and neurological exam. The doctor will speak with those close to the patient to document a pattern of behavior. He or she will also evaluate the patient’s mental functioning with tests of mental status, such as those that require the patient to recall words, lists of objects, names of objects, and recent events. Diagnostic tests, such as blood tests, x-rays, or magnetic resonance imaging (MRI), positron emission tomography (PET), or computed tomography (CT) scans, can help determine the cause of the dementia.
What is the treatment?
In some instances, treating the cause of dementia may successfully reverse some or all of the symptoms. This is the case when the cause is related to a vitamin/nutritional deficiency, tumor, alcohol or drug abuse, reaction to a medication, or hormonal disorder. When dementia is related to an irreversible destruction of brain tissue, such as with Alzheimer’s disease, Lewy body dementia, or multiple strokes, treatment involves improving the patient’s quality of life as much as possible. This includes maintaining a stable, safe, supportive environment and providing constant supervision. While this may be done in the home, people in the advanced stages of dementia may require round-the-clock care in a long-term healthcare facility. It is important to provide the patient with structured activities and avoid disruptions to his or her daily routine. Many patients enjoy therapeutic activities, such as crafts or games, designed specifically for people with dementia. Some medications, such as donepezil and tacrine, have been effective in improving the mental functions of those in the beginning stages of dementia. Patients with hallucinations and delusions may also be treated with antipsychotic drugs, while antidepressant medications are used to treat depression.
Self-care tips
There is currently no known way to prevent dementia associated with Alzheimer's disease. You can decrease your risk of dementia associated with stroke by maintaining a healthy lifestyle, following a heart-healthy diet, and controlling high blood pressure and high cholesterol. Healthy lifestyles, including not smoking and not abusing drugs and alcohol, go a long way in keeping most people in good health. Caring for a person with dementia is stressful. It is important to learn all you can about the disease, seek the help of support groups, and find a responsible caregiver who can give you a break when needed. There are daycare programs specifically designed for patients with dementia that are good for the patient and the family.
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This information has been designed as a comprehensive and quick reference guide written by our health care reviewers. The health information written by our authors is intended to be a supplement to the care provided by your physician. It is not intended nor implied to be a substitute for professional medical advice.
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Robert T DeMarco
AllAmerican Senior Care
AllAmerican Senior Care Weblog
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Tuesday, November 28, 2006
Sunday, November 26, 2006
The CareGiver: Americans Fear Alzheimer’s More Than Heart Disease, Diabetes or Stroke
A recent study by the MetLife Foundation found that Americans fear getting Alzheimer's disease more than heart disease, stroke, or diabetes. Alzheimer's ranks second in the minds of American's only to cancer.
MetLife Survey Highlights
The Complete MetLife Survey on Alzheimer's: What America Thinks (36 pages)
The Major Findings of the Study included the following:
Finding 1: Americans fear Alzheimer’s disease.
Finding 2: Americans Know Little or Nothing about Alzheimer’s.
Finding 3: One-third of Americans say they have direct experience with Alzheimer’s disease.
Finding 4: Most Americans are concerned that they will be responsible at some point for someone with Alzheimer’s disease.
Finding 5: Most Americans recognize the need to create a plan to address the possibility of Alzheimer’s disease, but very few have taken steps to do so.
Conclusion
Americans fear Alzheimer’s and the impact that it could have on their lives in the coming years. And although they may recognize the need to look toward the future, the majority hasn’t started making plans.
The downside of living longer has a high price: Nearly 50 percent of those who are 85 or older are affected, and the rate of Alzheimer’s increases exponentially every five years past the age of 65. And with the aging of America’s population these numbers are sure to become even more dramatic in the future, making it imperative that individuals and institutions plan for the future.
The growing number of people with Alzheimer’s will have an impact on every part of society. The vast majority of people know that this disease may someday affect them, either directly or as a caregiver. In addition, many already know a family member or friend who has Alzheimer’s. They strongly support the concept of planning now to cope with the life-changing impact of the
disease – at least in theory.
Despite widespread agreement, few have taken steps to prepare for the possibility of developing Alzheimer’s. Only a few have a solid understanding of the disease. The overwhelming majorityhas done nothing to plan.
The survey reveals a mismatch between fear of Alzheimer’s and acting on that fear to prepare for the future. The findings from this survey suggest that there is an opportunity to build awareness and help bridge the gaps that were identified in knowledge and behavior. Americans should learn all they can about the disease that will touch so many of us and plan for the future.
The CareGiver Blog
Robert T DeMarco
AllAmerican Senior Care
AllAmerican Senior Care Weblog
Senior Care Elder Care CareGiver Alzheimer’s Dementia CareGiver
MetLife Survey Highlights
The Complete MetLife Survey on Alzheimer's: What America Thinks (36 pages)
The Major Findings of the Study included the following:
Finding 1: Americans fear Alzheimer’s disease.
Finding 2: Americans Know Little or Nothing about Alzheimer’s.
Finding 3: One-third of Americans say they have direct experience with Alzheimer’s disease.
Finding 4: Most Americans are concerned that they will be responsible at some point for someone with Alzheimer’s disease.
Finding 5: Most Americans recognize the need to create a plan to address the possibility of Alzheimer’s disease, but very few have taken steps to do so.
Conclusion
Americans fear Alzheimer’s and the impact that it could have on their lives in the coming years. And although they may recognize the need to look toward the future, the majority hasn’t started making plans.
The downside of living longer has a high price: Nearly 50 percent of those who are 85 or older are affected, and the rate of Alzheimer’s increases exponentially every five years past the age of 65. And with the aging of America’s population these numbers are sure to become even more dramatic in the future, making it imperative that individuals and institutions plan for the future.
The growing number of people with Alzheimer’s will have an impact on every part of society. The vast majority of people know that this disease may someday affect them, either directly or as a caregiver. In addition, many already know a family member or friend who has Alzheimer’s. They strongly support the concept of planning now to cope with the life-changing impact of the
disease – at least in theory.
Despite widespread agreement, few have taken steps to prepare for the possibility of developing Alzheimer’s. Only a few have a solid understanding of the disease. The overwhelming majorityhas done nothing to plan.
The survey reveals a mismatch between fear of Alzheimer’s and acting on that fear to prepare for the future. The findings from this survey suggest that there is an opportunity to build awareness and help bridge the gaps that were identified in knowledge and behavior. Americans should learn all they can about the disease that will touch so many of us and plan for the future.
The CareGiver Blog
Robert T DeMarco
AllAmerican Senior Care
AllAmerican Senior Care Weblog
Senior Care Elder Care CareGiver Alzheimer’s Dementia CareGiver
Saturday, November 18, 2006
The CareGiver: Huperzine A Factsheet (Alzheimer's)
I recently read about Huperzine A. The following page contains a fact sheet about the herb. Huperzine A may have cognition-enhancing activity in some.
Source Huperzine A
TRADE NAMES
Huperzine A is available from numerous manufacturers generically. Branded products include Memorall (PharmAssure), Huperzine Rx-Brain (Nature's Plus).
DESCRIPTION
Huperzine A is a plant alkaloid derived from the Chinese club moss plant, Huperzia serrata, which is a member of the Lycopodium species. Huperzia serrata has been used in Chinese folk medicine for the treatment of fevers and inflammation.
Huperzine A has been found to have acetylcholinesterase activity. Huperzine B, also derived from Huperzia serrata, is a much less potent acetylcholinesterase inhibitor. Natural huperzine A is a chiral molecule also called L-huperzine A or (-)-huperzine A. Synthetic huperzine A is a racemic mixture called (±)-huperzine A. Huperzine A is also known as HUP, hup A and selagine. In Chinese medicine, the extract of Huperzia serrata is known as Chien Tseng Ta and shuangyiping. Huperzine A derivatives are being developed for pharmaceutical application.
ACTIONS AND PHARMACOLOGY ACTIONS
Huperzine A may have cognition-enhancing activity in some.
MECHANISM OF ACTION
Alzheimer's disease is a neurodegenerative disorder associated with neuritic plaques that affect the cerebral cortex, amygdala and hippocampus. There is also neurotransmission damage in the brain. One of the major functional deficits in Alzheimer's disease is a hypofunction of cholinergic neurons. This leads to the cholinergic hypothesis of Alzheimer's disease and the rationale for strategies to increase acetylcholine in the brains of Alzheimer's disease patients. Two FDA-approved drugs for the treatment of Alzheimer's disease, tacrine and donepezil, are acetylcholinesterase inhibitors.
Huperzine A is also an acetylcholinesterase inhibitor and has been found to increase acetylcholine levels in the rat brain following its administration. It also increases norepinephrine and dopamine, but not serotonin levels. The natural L or (-)-huperzine A is approximately three times more potent than the racemic or (±)-huperzine A in vitro.
PHARMACOKINETICS
There are limited pharmacokinetic studies with huperzine A. It appears that huperzine A is rapidly absorbed from the gastrointestinal tract and transported to the liver via the portal circulation. Some first-pass metabolism takes place in the liver, and huperzine A and its metabolites are distributed widely in the body, including to the brain. Following ingestion, the time to reach peak blood level is approximately 80 minutes.
INDICATIONS AND USAGE
Huperzine A has potent pharmacological effects and, particularly since long-term safety has not been determined, it should only be used with medical supervision. It may have some effectiveness in Alzheimer's disease and age-related memory impairment. It has been used to treat fever and some inflammatory disorders, but there is no credible scientific evidence to support these uses.
RESEARCH SUMMARY
Numerous studies, most of them from China, suggest that huperzine A may be as effective as the drugs tacrine and donepezil in Alzheimer's disease. This is not so surprising since in vitro and animal model tests have demonstrated that huperzine A effectively inhibits acetylcholinesterase, an enzyme that catalyzes acetylcholine breakdown. Tacrine and donepezil work in the same way to conserve acetylcholine in the brain--the mode by which they presumptively improve memory and cognition in those with Alzheimer's and age-related cognitive impairment. Huperzine A may prove superior to tacrine (dose-limited due to its hepatotoxicity) if long-range studies, yet to be conducted, demonstrate its safety.
In one double-blind, randomized study, huperzine A, in injectable form, was tested against a saline control in 56 patients with multi-infarct dementia or senile dementia and in 104 patients with senile and pre-senile simple memory disorders. Huperzine A produced significant positive effects as measured by the Wechsler Memory Scale. Dizziness was experienced by a few of the huperzine A-treated patients.
In another study, this one multicenter, double-blind, placebo-controlled and randomized, 50 subjects with Alzheimer's disease were given huperzine A or placebo for eight weeks. Significant improvement was noted in 58 percent of the patients in terms of memory, cognitive and behavioral functions. Research is ongoing.
CONTRAINDICATIONS, PRECAUTIONS, ADVERSE REACTIONS CONTRAINDICATIONS
None known.
PRECAUTIONS
Huperzine A should be avoided by children, pregnant women and nursing mothers.
Because of possible adverse effects in those with seizure disorders, cardiac arrhythmias and asthma, those with these disorders should avoid huperzine A. Those with irritable bowel disease, inflammatory bowel disease and malabsorption syndromes should avoid huperzine A.
ADVERSE REACTIONS
Adverse effects reported with huperzine A include gastrointestinal effects, such as nausea and diarrhea, sweating, blurred vision, fasciculations and dizziness. Possible adverse effects include vomiting, cramping, bronchospasm, bradycardia, arrhythmias, seizures, urinary incontinence, increased urination and hypersalivation.
INTERACTIONS DRUGS
Acetylcholinesterase Inhibitors: Use of huperzine A along with the acetylcholinesterase inhibitors donepezil or tacrine may produce additive effects, including additive adverse effects. Other acetylcholinesterase inhibitors include neostigmine, physostigmine and pyridostigmine, and use of these agents along with huperzine A may produce additive effects, including additive adverse effects.
Cholinergic Drugs: Use of huperzine A along with cholinergic drugs, such as bethanechol, may produce additive effects, including additive adverse effects.
NUTRITIONAL SUPPLEMENTS
Use of huperzine A with choline, phosphatidylcholine, CDP-choline and L-alpha-glycerylphosphorylcholine hypothetically might produce additive effects, including additive adverse effects.
OVERDOSAGE
There are no reports of overdosage with huperzine A.
DOSAGE AND ADMINISTRATION
There are various forms of huperzine A available, including extracts of Huperzia serrata, natural (-)-huperzine A and synthetic racemic (±)-huperzine A. Natural (-)-huperzine A is approximately three times more potent than the synthetic racemic mixture. The doses of natural (-)-huperzine A used in clinical studies ranged from 60 micrograms to 200 micrograms daily. Huperzine A should only be used with a physician's recommendation and monitoring.
HOW SUPPLIED
Capsules — 50 mcg
Tablets — 50 mcg
LITERATURE
Cheng DH, Tang XC. Comparative studies of huperzine A, E-2020 and tacrine on behavior and cholinesterase activities. Pharmacol Biochem Behav. 1998; 60:377-386.
Cheng DH, Ren H, Tang XC. Huperzine A, a novel promising acetylcholinesterase inhibitor. Neuroreport. 1996; 8:97-101.
Quian BC, Wang M, Zhou ZF, et al. Pharmacokinetics of tablet huperzine A in six volunteers. Chung Kuo Yao Li Hsueh Pao. 1995; 16:396-398.
Tang XC, Kindel GH, Kozikowski AP, Hanin I. Comparison of the effects of natural and synthetic huperzine A on rat brain cholinergic function in vitro and in vivo. J Ethnopharmacol. 1994; 44:147-155.
Xiong ZQ, Tang XC. Effect of huperzine A, a novel acetylcholinesterase inhibitor, on radial maze performance in rats. Pharmacol Biochem Behav. 1995; 51:415-419.
Xu SS, Gao ZX, Weng Z, et al. Efficacy of tablet huperzine-A on memory, cognition and behavior in Alzheimer's disease. Chung Kuo Yao Li Hsueh Pao. 1995; 16:391-395.
Ye JW, Cai JX, Wang LM, Tang XC. Improving effects of huperzine A on spatial working memory in aged monkeys and young adult monkeys with experimental cognitive impairment. J Pharmacol Exp Ther. 1999; 288:814-819.
Zhang RW, Tang XC, Han YY, et al. Drug evaluation of huperzine A in the treatment of senile memory disorders. [Article in Chinese] Chung Kuo Yao Li Hsueh Pao. 1991; 12:250-252.
Senior Care
Elder Care
CareGiver
Alzheimer’s
Source Huperzine A
TRADE NAMES
Huperzine A is available from numerous manufacturers generically. Branded products include Memorall (PharmAssure), Huperzine Rx-Brain (Nature's Plus).
DESCRIPTION
Huperzine A is a plant alkaloid derived from the Chinese club moss plant, Huperzia serrata, which is a member of the Lycopodium species. Huperzia serrata has been used in Chinese folk medicine for the treatment of fevers and inflammation.
Huperzine A has been found to have acetylcholinesterase activity. Huperzine B, also derived from Huperzia serrata, is a much less potent acetylcholinesterase inhibitor. Natural huperzine A is a chiral molecule also called L-huperzine A or (-)-huperzine A. Synthetic huperzine A is a racemic mixture called (±)-huperzine A. Huperzine A is also known as HUP, hup A and selagine. In Chinese medicine, the extract of Huperzia serrata is known as Chien Tseng Ta and shuangyiping. Huperzine A derivatives are being developed for pharmaceutical application.
ACTIONS AND PHARMACOLOGY ACTIONS
Huperzine A may have cognition-enhancing activity in some.
MECHANISM OF ACTION
Alzheimer's disease is a neurodegenerative disorder associated with neuritic plaques that affect the cerebral cortex, amygdala and hippocampus. There is also neurotransmission damage in the brain. One of the major functional deficits in Alzheimer's disease is a hypofunction of cholinergic neurons. This leads to the cholinergic hypothesis of Alzheimer's disease and the rationale for strategies to increase acetylcholine in the brains of Alzheimer's disease patients. Two FDA-approved drugs for the treatment of Alzheimer's disease, tacrine and donepezil, are acetylcholinesterase inhibitors.
Huperzine A is also an acetylcholinesterase inhibitor and has been found to increase acetylcholine levels in the rat brain following its administration. It also increases norepinephrine and dopamine, but not serotonin levels. The natural L or (-)-huperzine A is approximately three times more potent than the racemic or (±)-huperzine A in vitro.
PHARMACOKINETICS
There are limited pharmacokinetic studies with huperzine A. It appears that huperzine A is rapidly absorbed from the gastrointestinal tract and transported to the liver via the portal circulation. Some first-pass metabolism takes place in the liver, and huperzine A and its metabolites are distributed widely in the body, including to the brain. Following ingestion, the time to reach peak blood level is approximately 80 minutes.
INDICATIONS AND USAGE
Huperzine A has potent pharmacological effects and, particularly since long-term safety has not been determined, it should only be used with medical supervision. It may have some effectiveness in Alzheimer's disease and age-related memory impairment. It has been used to treat fever and some inflammatory disorders, but there is no credible scientific evidence to support these uses.
RESEARCH SUMMARY
Numerous studies, most of them from China, suggest that huperzine A may be as effective as the drugs tacrine and donepezil in Alzheimer's disease. This is not so surprising since in vitro and animal model tests have demonstrated that huperzine A effectively inhibits acetylcholinesterase, an enzyme that catalyzes acetylcholine breakdown. Tacrine and donepezil work in the same way to conserve acetylcholine in the brain--the mode by which they presumptively improve memory and cognition in those with Alzheimer's and age-related cognitive impairment. Huperzine A may prove superior to tacrine (dose-limited due to its hepatotoxicity) if long-range studies, yet to be conducted, demonstrate its safety.
In one double-blind, randomized study, huperzine A, in injectable form, was tested against a saline control in 56 patients with multi-infarct dementia or senile dementia and in 104 patients with senile and pre-senile simple memory disorders. Huperzine A produced significant positive effects as measured by the Wechsler Memory Scale. Dizziness was experienced by a few of the huperzine A-treated patients.
In another study, this one multicenter, double-blind, placebo-controlled and randomized, 50 subjects with Alzheimer's disease were given huperzine A or placebo for eight weeks. Significant improvement was noted in 58 percent of the patients in terms of memory, cognitive and behavioral functions. Research is ongoing.
CONTRAINDICATIONS, PRECAUTIONS, ADVERSE REACTIONS CONTRAINDICATIONS
None known.
PRECAUTIONS
Huperzine A should be avoided by children, pregnant women and nursing mothers.
Because of possible adverse effects in those with seizure disorders, cardiac arrhythmias and asthma, those with these disorders should avoid huperzine A. Those with irritable bowel disease, inflammatory bowel disease and malabsorption syndromes should avoid huperzine A.
ADVERSE REACTIONS
Adverse effects reported with huperzine A include gastrointestinal effects, such as nausea and diarrhea, sweating, blurred vision, fasciculations and dizziness. Possible adverse effects include vomiting, cramping, bronchospasm, bradycardia, arrhythmias, seizures, urinary incontinence, increased urination and hypersalivation.
INTERACTIONS DRUGS
Acetylcholinesterase Inhibitors: Use of huperzine A along with the acetylcholinesterase inhibitors donepezil or tacrine may produce additive effects, including additive adverse effects. Other acetylcholinesterase inhibitors include neostigmine, physostigmine and pyridostigmine, and use of these agents along with huperzine A may produce additive effects, including additive adverse effects.
Cholinergic Drugs: Use of huperzine A along with cholinergic drugs, such as bethanechol, may produce additive effects, including additive adverse effects.
NUTRITIONAL SUPPLEMENTS
Use of huperzine A with choline, phosphatidylcholine, CDP-choline and L-alpha-glycerylphosphorylcholine hypothetically might produce additive effects, including additive adverse effects.
OVERDOSAGE
There are no reports of overdosage with huperzine A.
DOSAGE AND ADMINISTRATION
There are various forms of huperzine A available, including extracts of Huperzia serrata, natural (-)-huperzine A and synthetic racemic (±)-huperzine A. Natural (-)-huperzine A is approximately three times more potent than the synthetic racemic mixture. The doses of natural (-)-huperzine A used in clinical studies ranged from 60 micrograms to 200 micrograms daily. Huperzine A should only be used with a physician's recommendation and monitoring.
HOW SUPPLIED
Capsules — 50 mcg
Tablets — 50 mcg
LITERATURE
Cheng DH, Tang XC. Comparative studies of huperzine A, E-2020 and tacrine on behavior and cholinesterase activities. Pharmacol Biochem Behav. 1998; 60:377-386.
Cheng DH, Ren H, Tang XC. Huperzine A, a novel promising acetylcholinesterase inhibitor. Neuroreport. 1996; 8:97-101.
Quian BC, Wang M, Zhou ZF, et al. Pharmacokinetics of tablet huperzine A in six volunteers. Chung Kuo Yao Li Hsueh Pao. 1995; 16:396-398.
Tang XC, Kindel GH, Kozikowski AP, Hanin I. Comparison of the effects of natural and synthetic huperzine A on rat brain cholinergic function in vitro and in vivo. J Ethnopharmacol. 1994; 44:147-155.
Xiong ZQ, Tang XC. Effect of huperzine A, a novel acetylcholinesterase inhibitor, on radial maze performance in rats. Pharmacol Biochem Behav. 1995; 51:415-419.
Xu SS, Gao ZX, Weng Z, et al. Efficacy of tablet huperzine-A on memory, cognition and behavior in Alzheimer's disease. Chung Kuo Yao Li Hsueh Pao. 1995; 16:391-395.
Ye JW, Cai JX, Wang LM, Tang XC. Improving effects of huperzine A on spatial working memory in aged monkeys and young adult monkeys with experimental cognitive impairment. J Pharmacol Exp Ther. 1999; 288:814-819.
Zhang RW, Tang XC, Han YY, et al. Drug evaluation of huperzine A in the treatment of senile memory disorders. [Article in Chinese] Chung Kuo Yao Li Hsueh Pao. 1991; 12:250-252.
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Elder Care
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Alzheimer’s
Thursday, November 16, 2006
All American Senior Care: Immigrants, increasingly, provide elder care in U.S.
Not only are immigrants a major source of employees right now this trend is expected to grow very fast in the future.
Immigrants, increasingly, provide elder care in U.S.
Source
Scripps News
By SUSAN FERRISS
Thursday, November 16, 2006
Wanda Moeller's blue eyes dance when she talks about Franklin D. Roosevelt, the Grand Ole Opry _ and Haydee Carrillo, the Salvadoran immigrant who has helped care for her for six years.
Three mornings a week, Carrillo lifts the partially paralyzed Moeller from bed and gives her a bath, breakfast and oxygen treatment. Then she applies lipstick for her 76-year-old client, and the two run errands or have fun talking or looking at photos of grandchildren.
"She's like a daughter to me," the Oklahoma-born Moeller said, as Carrillo, 60, smiled and wiped a drop of cafe latte from Moeller's chin.
In the same Sacramento, Calif., apartment building, another elderly client also praises Carrillo. "Her mother was killed in El Salvador's war," said Merle Heath, 78, as Carrillo hooked up his oxygen to treat severe bronchitis. "Her English isn't too good. But she's a loyal, good Christian."
As Heath has learned, Carrillo's life began a world apart from the universe she now shares with the American septuagenarians she cares for, at $10 an hour. That they have all crossed paths in the United States, however, is no longer a rare phenomenon.
Immigrants are rapidly taking on prominent roles as American families' caregivers, whether those immigrants are naturalized citizens, permanent residents, undocumented or _ like Carrillo _ in between. They nurture babies, keep house and, increasingly, care for America's surging population of senior citizens.
Immigrants make up nearly 18 percent of the nation's baby sitters and in-home aides for seniors or people with disabilities, according to the Migration Policy Institute, a nonpartisan research center.
At the same time, many involved in senior care are discovering that the U.S. immigration system offers few avenues for recruiting and legally employing caregivers to help meet exploding demand. A job like Carrillo's, that of home health aide, is expected to be the fastest-growing job in America for the next decade.
"Even if you substantially raise salaries, and I'm not sure you can, it's not clear there is enough of a latent native work force," said Michael Fix, the Migration Policy Institute's vice president. "You shouldn't idealize immigration as a solution," he said, but added that it could be helpful "to take this flow and make it a regulated flow."
Undocumented workers, senior advocates say, are filling many of these jobs, in private homes and even in facilities _ such as nursing homes _ where employers are required only to see, not authenticate, a green card.
Families, too, are dismayed to find out that if they try to do "the right thing," as one daughter of a 95-year-old said, and legalize a trusted caregiver, the process is next to impossible. Only 5,000 low-skilled immigrant work visas can be issued annually and waiting times are now up to more than five years.
Escalating demand for senior care is shared by Italy, Austria and other aging nations that already rely on caregivers from poorer countries, according to a 2005 report by AARP, an advocacy organization for older Americans.
That report urges an expansion of U.S. programs to train more American elder-care workers of all levels, but acknowledges that the supply of homegrown applicants for such programs is finite.
AARP's report notes: "Meeting the long-term care needs of the growing older populations in more developed nations requires more engagement across international boundaries."
Heath, who is virtually bedridden, said his own experience shows how much workers like Carrillo are already vital. "We should be helping people like her," he said. "Not a lot of able-bodied American men out on the street want to do this."
Carrillo cites her religious faith and difficult life _ her mother's murder, prolonged separation from her children _ as factors that have strengthened her empathy for "ancianos," as seniors are called in Spanish.
Caregivers like her must be strong and skilled enough to lift immobile adults and help them into wheelchairs, and patient enough to provide companionship and intimate needs, like washing, clipping nails and, for the most frail, changing diapers.
"You can't mechanize taking care of the elderly," said Ken Preede, director of government relations for the American Health Care Association, which has joined other industries in lobbying for an earned legalization of undocumented workers.
Health and Moeller live alone, in assisted-living apartments, while their children live too far away to shoulder the type of care Carrillo provides through California's In-Home Supportive Services program for seniors.
"I trust Haydee with my life," said Heath, who values his independence but is too weak to handle even simple personal tasks.
Carrillo entered the United States in 1983 _ illegally, like many who fled El Salvador's civil war. She worked cleaning houses and taking care of seniors in facilities and homes.
Her 1987 petition for political asylum eventually earned her a work permit, but her asylum was never fully approved. The U.S. government supported the Salvadoran government during the civil war, and many who fled that war were turned down for refugee status.
These days, Carrillo hangs her hopes on being granted legal permanent residency through the 1997 Nicaraguan and Central American Adjustment Act, which was designed to allow law-abiding refugees to finally integrate into the country after years of living in limbo.
"God willing, it will happen," she said in Spanish.
(The Sacramento Bee's Susan Ferriss can be reached at sferriss(at)sacbee.com.)
All American Senior Care
The CareGiver
Senior Care
Elder Care
CareGiver
Alzheimer’s
Immigrants, increasingly, provide elder care in U.S.
Source
Scripps News
By SUSAN FERRISS
Thursday, November 16, 2006
Wanda Moeller's blue eyes dance when she talks about Franklin D. Roosevelt, the Grand Ole Opry _ and Haydee Carrillo, the Salvadoran immigrant who has helped care for her for six years.
Three mornings a week, Carrillo lifts the partially paralyzed Moeller from bed and gives her a bath, breakfast and oxygen treatment. Then she applies lipstick for her 76-year-old client, and the two run errands or have fun talking or looking at photos of grandchildren.
"She's like a daughter to me," the Oklahoma-born Moeller said, as Carrillo, 60, smiled and wiped a drop of cafe latte from Moeller's chin.
In the same Sacramento, Calif., apartment building, another elderly client also praises Carrillo. "Her mother was killed in El Salvador's war," said Merle Heath, 78, as Carrillo hooked up his oxygen to treat severe bronchitis. "Her English isn't too good. But she's a loyal, good Christian."
As Heath has learned, Carrillo's life began a world apart from the universe she now shares with the American septuagenarians she cares for, at $10 an hour. That they have all crossed paths in the United States, however, is no longer a rare phenomenon.
Immigrants are rapidly taking on prominent roles as American families' caregivers, whether those immigrants are naturalized citizens, permanent residents, undocumented or _ like Carrillo _ in between. They nurture babies, keep house and, increasingly, care for America's surging population of senior citizens.
Immigrants make up nearly 18 percent of the nation's baby sitters and in-home aides for seniors or people with disabilities, according to the Migration Policy Institute, a nonpartisan research center.
At the same time, many involved in senior care are discovering that the U.S. immigration system offers few avenues for recruiting and legally employing caregivers to help meet exploding demand. A job like Carrillo's, that of home health aide, is expected to be the fastest-growing job in America for the next decade.
"Even if you substantially raise salaries, and I'm not sure you can, it's not clear there is enough of a latent native work force," said Michael Fix, the Migration Policy Institute's vice president. "You shouldn't idealize immigration as a solution," he said, but added that it could be helpful "to take this flow and make it a regulated flow."
Undocumented workers, senior advocates say, are filling many of these jobs, in private homes and even in facilities _ such as nursing homes _ where employers are required only to see, not authenticate, a green card.
Families, too, are dismayed to find out that if they try to do "the right thing," as one daughter of a 95-year-old said, and legalize a trusted caregiver, the process is next to impossible. Only 5,000 low-skilled immigrant work visas can be issued annually and waiting times are now up to more than five years.
Escalating demand for senior care is shared by Italy, Austria and other aging nations that already rely on caregivers from poorer countries, according to a 2005 report by AARP, an advocacy organization for older Americans.
That report urges an expansion of U.S. programs to train more American elder-care workers of all levels, but acknowledges that the supply of homegrown applicants for such programs is finite.
AARP's report notes: "Meeting the long-term care needs of the growing older populations in more developed nations requires more engagement across international boundaries."
Heath, who is virtually bedridden, said his own experience shows how much workers like Carrillo are already vital. "We should be helping people like her," he said. "Not a lot of able-bodied American men out on the street want to do this."
Carrillo cites her religious faith and difficult life _ her mother's murder, prolonged separation from her children _ as factors that have strengthened her empathy for "ancianos," as seniors are called in Spanish.
Caregivers like her must be strong and skilled enough to lift immobile adults and help them into wheelchairs, and patient enough to provide companionship and intimate needs, like washing, clipping nails and, for the most frail, changing diapers.
"You can't mechanize taking care of the elderly," said Ken Preede, director of government relations for the American Health Care Association, which has joined other industries in lobbying for an earned legalization of undocumented workers.
Health and Moeller live alone, in assisted-living apartments, while their children live too far away to shoulder the type of care Carrillo provides through California's In-Home Supportive Services program for seniors.
"I trust Haydee with my life," said Heath, who values his independence but is too weak to handle even simple personal tasks.
Carrillo entered the United States in 1983 _ illegally, like many who fled El Salvador's civil war. She worked cleaning houses and taking care of seniors in facilities and homes.
Her 1987 petition for political asylum eventually earned her a work permit, but her asylum was never fully approved. The U.S. government supported the Salvadoran government during the civil war, and many who fled that war were turned down for refugee status.
These days, Carrillo hangs her hopes on being granted legal permanent residency through the 1997 Nicaraguan and Central American Adjustment Act, which was designed to allow law-abiding refugees to finally integrate into the country after years of living in limbo.
"God willing, it will happen," she said in Spanish.
(The Sacramento Bee's Susan Ferriss can be reached at sferriss(at)sacbee.com.)
All American Senior Care
The CareGiver
Senior Care
Elder Care
CareGiver
Alzheimer’s
Tuesday, November 14, 2006
All American Senior Care: The Green House
What is a “Green House”?
What is a “Green House”?
Green Houses are homes for 6 to 10 elders who require skilled nursing care and want to live a rich life. They are a radical departure from traditional skilled nursing homes and assisted living facilities, altering size, design, and organization to create a warm community. Their innovative architecture and services offer privacy, autonomy, support, enjoyment and a place to call home. Green Houses are developed and operated by long-term care organizations in partnership with the Green House Project and NCB Capital Impact.
What is a “Green House”?
Green Houses are homes for 6 to 10 elders who require skilled nursing care and want to live a rich life. They are a radical departure from traditional skilled nursing homes and assisted living facilities, altering size, design, and organization to create a warm community. Their innovative architecture and services offer privacy, autonomy, support, enjoyment and a place to call home. Green Houses are developed and operated by long-term care organizations in partnership with the Green House Project and NCB Capital Impact.
Tuesday, November 07, 2006
All American Senior Care: Medicaid Advantage: A medical home for dual-eligibles
The authors propose a new Medicaid Advantage program that would integrate acute and long-term care benefits for dual-eligible beneficiaries into a single program.
Medicaid Advantage: A medical home for dual-eligibles
By Grace-Marie Turner and Robert B. Helms, Ph.D.
Submitted to the Medicaid Commission
Grace-Marie Turner of the Galen Institute and Bob Helms of the American Enterprise Institute have proposed a new Medicaid Advantage program that would integrate acute and long-term care benefits for dual-eligible beneficiaries into a single program. The program, submitted to the Medicaid Commission, would be managed by the states and would provide a medical home and better coordinated care for beneficiaries.
Background:
Our most vulnerable citizens – those dually eligible for Medicare and Medicaid – often fall into a fragmented care delivery system that perpetuates episodic rather than coordinated care. Patients may have difficulty accessing the medical care they need. And information about their care and their needs can be scattered among providers and facilities facing two different payment systems and sets of program rules.
Because physicians and others treating these patients don’t have the patient’s complete medical profile, patients can face gaps as well as duplication in treatments with no medical home responsible for optimizing their care.
To assure that Medicaid patients are receiving quality care, Medicaid must adopt new systems with better incentives to design more flexible and more effective care management programs for these recipients, especially those with disabilities and significant chronic illnesses. Having a medical home is central to this process. A comprehensive program that integrates Medicare and Medicaid coverage into a new integrated Medicaid Advantage plan would allow providers to focus on the best way to design and provide benefits to these beneficiaries with the right care in the right setting, rather than spending time on complying with rules for different payment systems. Significant efficiencies and better outcomes could be achieved through a comprehensive approach to providing health care for these Medicare and Medicaid-eligible beneficiaries.
Findings:
Cost-effectiveness studies of state Medicaid managed care programs have demonstrated that they generally save states money while providing better access to care for recipients. The commission also has heard numerous testimonies demonstrating the creativity of state and local governments in developing programs to target services to their vulnerable dually-eligible residents, often through contracts with private managed care organizations.
Vermont obtained a waiver to fine-tune delivery of long-term care services and demonstrated that better care can be provided more cost-effectively in appropriate settings when solutions are tailored to individual needs. We heard about similar examples in New York, Massachusetts, Arizona, and other states.
States are much more adept at tailoring these programs to their citizens than the Federal government because they are closer to the people being served and know better both their needs and the resources of the community to meet those needs. But states are not able to shoulder the full financial burden of providing these services. Continued Federal funding is essential.
Other options:
The Federal government has recognized the need to better integrate care for dually-eligible populations and has developed several programs as a result. The Program for All-Inclusive Care for the Elderly (PACE), targeted waivers, and Special Needs Plans (SNP) are the primary Medicare programs designed to achieve this goal.
• PACE is a capitated benefit program authorized by the Balanced Budget Act of 1997 and developed to provide better coordinated long-term care for Medicare and Medicaid recipients who have been certified as eligible for nursing facility care. PACE enables states to provide defined services to Medicaid recipients as a state option, and Medicare and Medicaid funds are integrated to allow a contracted plan to provide the care.
The state plan must include PACE as an optional Medicaid benefit before the state and HHS can enter into a program agreement with PACE providers.
While the program has had some success, it is a Medicare program with a Medicaid option and has not been widely adopted. And the BBA limits the number of PACE programs that may be implemented annually. As of January 2005, there were 73 PACE sites in the U.S. serving limited geographic areas.
• Several states (Massachusetts, Minnesota, and Wisconsin) obtained waivers to combine Medicaid and Medicare funds to purchase health care services for dually-eligible populations. But the waiver negotiations each took several years, limiting the appeal to other states interested in using this approach.
• The Medicare Modernization Act created a new coordinated care option called Special Needs Plans as part of the Medicare Advantage program. SNPs are distinct from regular Medicare Advantage plans in that they can enroll a group of individuals with “special needs,” such as 1) institutionalized beneficiaries; 2) dual eligibles; and 3) beneficiaries with severe or disabling chronic conditions.
SNPs are able to offer a full array of Medicare services, including supplemental benefits, through a single plan with a single benefit package and set of providers. Medicare Advantage payments to SNP plans are risk adjusted based upon beneficiary health conditions, dual eligible status, disability eligibility, and institutional status.
In 2006, 276 SNPs are available, with more than 500,000 enrolles, including 440,000 dually-eligible beneficiaries.
Absent other legislation, SNP authorization in the MMA will sunset on January 1, 2009.
But even with these programs, the Federal government -- through CMS -- still is in control of decisions for PACE, waivers, and SNPs, providing states much less flexibility than if they were running the plans themselves. For example, states must get authorization to put a dually-eligible patient into a managed care plan – an unnecessary administrative hurdle.
Recommendation for Medicaid Advantage
Some people have called for Medicare to take full responsibility for duals, but this centralization would move away from, rather than toward, more finely-tuned care for this vulnerable population. States need more flexibility than Medicare’s top-down system of rules can provide for patients requiring tailored care and services. States have demonstrated that they are up to the task.
On average, total spending for duals, including Medicare and Medicaid contributions, is more than twice as high as that for non-duals -- $20,840 compared to $10,050. It is essential to find a way to manage these costs and care delivery more efficiently.
We recommend creating a new Medicaid Advantage program modeled after the Medicare Advantage program, but with States, rather than the Federal government, in control.
Medicaid Advantage would offer dually-eligible recipients a medical home where they would receive a seamless continuum of medical care and care management under one program and not have care split between Medicare and Medicaid programs. But unlike Medicare Advantage, SNPs, and PACE, the states rather than the Federal government would be the primary managers of their Medicaid Advantage programs.
The Federal government would continue to provide financial support to the states for Medicare services, but through a risk-adjusted, capitated system of Medicare payments. States and the Federal government would continue to share the cost of the Medicaid portion of the benefit.
States or the plans they select could manage the full spectrum of services to provide an integrated care delivery program for dual eligible populations. These plans would be close to the patient, collecting and evaluating treatment data, and states would monitor the plans to make sure obligations are being met.
The Federal government would set and monitor goals, not micromanage processes, so that the states, in conjunction with health plans, can work to improve the quality of care, design plans to fit the needs of patients, and benefit from greater efficiency.
Mechanisms:
• The states would have the option of participating in the new Medicaid Advantage program which they would be primarily responsible for managing, with the goal of developing a better system of providing more efficient, coordinated care for their dually-eligible residents.
• Participating states would contract with competing health plans* to provide the full spectrum of care for dually-eligible populations and would enroll individuals into these integrated Medicaid Advantage care management plans.
o Patients could choose from among competing plans.
o Patients would have the ability to opt-out.
o Medicaid Advantage plans would be required to provide core Medicaid and Medicare services to duals, but states would have more authority and flexibility to design benefit packages that meet the specific needs of patients without having to request waivers.
o Plans would participate in a bidding process, submitting bids representing their cost of providing Medicare and Medicaid-covered services as well as other services determined by the states.
o States would build in incentives for plans to compete on the basis of quality and value and could reward health plans that provide higher quality care at a reduced price. States could also share in a portion of these savings.
o *States would have the option of managing the care and assuming the risks themselves, as Kentucky is doing with its new KY HealthChoices Medicaid reform plan.
• Financing: The states and the Federal government would each contribute, as they do today, to the costs of providing services to dually-eligible beneficiaries but through the new Medicaid Advantage program which would be managed by the states.
States and the Federal government already have some experience with the basic mechanisms that would be needed to calculate payments for this new program. The rate-setting and risk-adjustment systems that Medicare currently uses to pay Medicare Advantage plans and that states use to pay for standard Medicaid managed care programs would provide a foundation for their calculating payments that would fund this new integrated care management program for duals.
There would be three funding streams:
o Federal Medicare payments, which are generally provided through Medicare’s defined benefit structure, would be allocated to the states through a new funding mechanism. The Federal government would develop a system of capitated, risk-adjusted Medicare payments. These payments would be sent to the states to fund the Medicare portion of services for dual-eligible residents. This is not a block grant because funds would follow each recipient and would be adjusted for that patient’s risk profile. Medicare would use its actuarial data and payment history in determining the capitated rate it pays per dual eligible patient, and this funding stream would continue to be updated.
CMS is developing a system of risk adjustment that includes not only health status but also geographic payment variation, frailty, and other factors which could be employed in this new program.
o States would have two options in setting their payments for the Medicaid portion of services for their dual-eligible residents:
Those states that decide to contract with private managed care plans to provide coordinated care for their dual populations could calculate an actuarially-sound capitated rate for the state share of the Medicaid set of services. The plans, not the state, would be at risk.
• While many states have experience in setting payments for Medicaid managed care, their experience is in settings payments for acute care services, not long-term care support. As a result, they would need assistance in calculating these capitated payments for state-financed Medicaid services for duals.
Those states that decide to operate the program themselves and assume the risk (as well as potentially garnering more savings) could make contributions based upon their own Medicaid payment experience for services for duals, again with assistance in making the calculations.
In either case, a transition period would be required where the federal government and the states would share the risk until they have gathered enough information to refine this new system of payments.
Whether the state chooses to contract with Medicaid Advantage managed care plans or to operate the program itself, the states would still receive a federal match for their Medicaid contribution based upon existing formulas.
• Alternatively, CMS/Medicaid could determine a capitated amount of Medicaid funds that it would allocate per recipient based upon data about the cost of its share of Medicaid-covered services in that state for this population.
o Drug coverage, currently paid by Medicare, would be integrated into the Medicaid Advantage plans. Medicare would calculate a Part D allocation that would be returned to each state in the form of a capitated, risk-adjusted payment. This would be another part of the patient’s Medicaid Advantage funding stream.
Since implementation of Part D that assigned duals to drug plans, skilled nursing facilities have had many problems tracking many different drug plans and formularies for these residents. Medicaid Advantage would provide a mechanism to coordinate drug coverage, as well as medical care, through one plan.
States would have access to the pharmacy data that they lost after the transition to Part D in January, 2006.
• The joint Federal and state Medicaid contributions plus the Federal Medicare and part D contributions would be combined into one funding stream to finance care for duals through the new Medicaid Advantage plans. States could use this pool of money in designing benefits for duals and negotiating with health plans that would deliver required services. Duals would receive a full range of services currently financed separately through Medicare and Medicaid through this new integrated program, from hospitalization and skilled nursing care to physicians’ visits, personal care, home and community based services, prescription drugs, diagnostic and laboratory tests, etc.
o States would gain new flexibility in designing benefit packages in exchange for receiving a capitated, risk-adjusted payment from Medicare with fewer strings attached.
• Once the Medicaid Advantage plan has agreed on a contracted fee, the plans would be at risk for providing care to dual eligibles (except for those states that decide to carry the risk themselves). The plans or state contractors would be responsible for providing care, for collecting and providing performance data on treatments and outcomes for each patient, and for reporting this information to the states for their monitoring activities. The plans would be accountable for outcomes with strict oversight by the states, but they would have the flexibility to manage care creatively to meet the needs of patients.
• States also would be given greater flexibility to coordinate treatment for those with mental illness through Medicaid Advantage plans. Providing targeted case management, rehabilitation services, medication management, community mental health center services, and other less-costly services through a Medicare Advantage medical home could reduce the use of expensive hospital and emergency room services while providing improved care for these patients.
• The Federal government and the States would be responsible for carefully monitoring the plans and for bringing action against plans that do not meet their contractual obligations.
Benefits:
Medicaid Advantage (MD-Advantage) would minimize the current incentive to avoid caring for the most costly patients and would better align incentives for Medicare, Medicaid, plans, and recipients. Medicaid Advantage would allow states to:
• Integrate acute and long-term care benefits into a single program they would oversee in which competing private plans (or the states) would provide a coordinated care management program for dually-eligible beneficiaries
• Share in the savings achieved through innovative policies, such as disease management and care coordination
• Streamline cumbersome rules governing marketing, enrollment, performance monitoring, quality reporting, rate setting, bidding, and grievances and appeals
• Eliminate redundant and inefficient spending
• Provide both the Federal and state governments more predictability in budgeting for the significant part of their Medicare and Medicaid spending on dual eligibles.
All American Senior Care
The CareGiver
Medicaid Advantage: A medical home for dual-eligibles
By Grace-Marie Turner and Robert B. Helms, Ph.D.
Submitted to the Medicaid Commission
Grace-Marie Turner of the Galen Institute and Bob Helms of the American Enterprise Institute have proposed a new Medicaid Advantage program that would integrate acute and long-term care benefits for dual-eligible beneficiaries into a single program. The program, submitted to the Medicaid Commission, would be managed by the states and would provide a medical home and better coordinated care for beneficiaries.
Background:
Our most vulnerable citizens – those dually eligible for Medicare and Medicaid – often fall into a fragmented care delivery system that perpetuates episodic rather than coordinated care. Patients may have difficulty accessing the medical care they need. And information about their care and their needs can be scattered among providers and facilities facing two different payment systems and sets of program rules.
Because physicians and others treating these patients don’t have the patient’s complete medical profile, patients can face gaps as well as duplication in treatments with no medical home responsible for optimizing their care.
To assure that Medicaid patients are receiving quality care, Medicaid must adopt new systems with better incentives to design more flexible and more effective care management programs for these recipients, especially those with disabilities and significant chronic illnesses. Having a medical home is central to this process. A comprehensive program that integrates Medicare and Medicaid coverage into a new integrated Medicaid Advantage plan would allow providers to focus on the best way to design and provide benefits to these beneficiaries with the right care in the right setting, rather than spending time on complying with rules for different payment systems. Significant efficiencies and better outcomes could be achieved through a comprehensive approach to providing health care for these Medicare and Medicaid-eligible beneficiaries.
Findings:
Cost-effectiveness studies of state Medicaid managed care programs have demonstrated that they generally save states money while providing better access to care for recipients. The commission also has heard numerous testimonies demonstrating the creativity of state and local governments in developing programs to target services to their vulnerable dually-eligible residents, often through contracts with private managed care organizations.
Vermont obtained a waiver to fine-tune delivery of long-term care services and demonstrated that better care can be provided more cost-effectively in appropriate settings when solutions are tailored to individual needs. We heard about similar examples in New York, Massachusetts, Arizona, and other states.
States are much more adept at tailoring these programs to their citizens than the Federal government because they are closer to the people being served and know better both their needs and the resources of the community to meet those needs. But states are not able to shoulder the full financial burden of providing these services. Continued Federal funding is essential.
Other options:
The Federal government has recognized the need to better integrate care for dually-eligible populations and has developed several programs as a result. The Program for All-Inclusive Care for the Elderly (PACE), targeted waivers, and Special Needs Plans (SNP) are the primary Medicare programs designed to achieve this goal.
• PACE is a capitated benefit program authorized by the Balanced Budget Act of 1997 and developed to provide better coordinated long-term care for Medicare and Medicaid recipients who have been certified as eligible for nursing facility care. PACE enables states to provide defined services to Medicaid recipients as a state option, and Medicare and Medicaid funds are integrated to allow a contracted plan to provide the care.
The state plan must include PACE as an optional Medicaid benefit before the state and HHS can enter into a program agreement with PACE providers.
While the program has had some success, it is a Medicare program with a Medicaid option and has not been widely adopted. And the BBA limits the number of PACE programs that may be implemented annually. As of January 2005, there were 73 PACE sites in the U.S. serving limited geographic areas.
• Several states (Massachusetts, Minnesota, and Wisconsin) obtained waivers to combine Medicaid and Medicare funds to purchase health care services for dually-eligible populations. But the waiver negotiations each took several years, limiting the appeal to other states interested in using this approach.
• The Medicare Modernization Act created a new coordinated care option called Special Needs Plans as part of the Medicare Advantage program. SNPs are distinct from regular Medicare Advantage plans in that they can enroll a group of individuals with “special needs,” such as 1) institutionalized beneficiaries; 2) dual eligibles; and 3) beneficiaries with severe or disabling chronic conditions.
SNPs are able to offer a full array of Medicare services, including supplemental benefits, through a single plan with a single benefit package and set of providers. Medicare Advantage payments to SNP plans are risk adjusted based upon beneficiary health conditions, dual eligible status, disability eligibility, and institutional status.
In 2006, 276 SNPs are available, with more than 500,000 enrolles, including 440,000 dually-eligible beneficiaries.
Absent other legislation, SNP authorization in the MMA will sunset on January 1, 2009.
But even with these programs, the Federal government -- through CMS -- still is in control of decisions for PACE, waivers, and SNPs, providing states much less flexibility than if they were running the plans themselves. For example, states must get authorization to put a dually-eligible patient into a managed care plan – an unnecessary administrative hurdle.
Recommendation for Medicaid Advantage
Some people have called for Medicare to take full responsibility for duals, but this centralization would move away from, rather than toward, more finely-tuned care for this vulnerable population. States need more flexibility than Medicare’s top-down system of rules can provide for patients requiring tailored care and services. States have demonstrated that they are up to the task.
On average, total spending for duals, including Medicare and Medicaid contributions, is more than twice as high as that for non-duals -- $20,840 compared to $10,050. It is essential to find a way to manage these costs and care delivery more efficiently.
We recommend creating a new Medicaid Advantage program modeled after the Medicare Advantage program, but with States, rather than the Federal government, in control.
Medicaid Advantage would offer dually-eligible recipients a medical home where they would receive a seamless continuum of medical care and care management under one program and not have care split between Medicare and Medicaid programs. But unlike Medicare Advantage, SNPs, and PACE, the states rather than the Federal government would be the primary managers of their Medicaid Advantage programs.
The Federal government would continue to provide financial support to the states for Medicare services, but through a risk-adjusted, capitated system of Medicare payments. States and the Federal government would continue to share the cost of the Medicaid portion of the benefit.
States or the plans they select could manage the full spectrum of services to provide an integrated care delivery program for dual eligible populations. These plans would be close to the patient, collecting and evaluating treatment data, and states would monitor the plans to make sure obligations are being met.
The Federal government would set and monitor goals, not micromanage processes, so that the states, in conjunction with health plans, can work to improve the quality of care, design plans to fit the needs of patients, and benefit from greater efficiency.
Mechanisms:
• The states would have the option of participating in the new Medicaid Advantage program which they would be primarily responsible for managing, with the goal of developing a better system of providing more efficient, coordinated care for their dually-eligible residents.
• Participating states would contract with competing health plans* to provide the full spectrum of care for dually-eligible populations and would enroll individuals into these integrated Medicaid Advantage care management plans.
o Patients could choose from among competing plans.
o Patients would have the ability to opt-out.
o Medicaid Advantage plans would be required to provide core Medicaid and Medicare services to duals, but states would have more authority and flexibility to design benefit packages that meet the specific needs of patients without having to request waivers.
o Plans would participate in a bidding process, submitting bids representing their cost of providing Medicare and Medicaid-covered services as well as other services determined by the states.
o States would build in incentives for plans to compete on the basis of quality and value and could reward health plans that provide higher quality care at a reduced price. States could also share in a portion of these savings.
o *States would have the option of managing the care and assuming the risks themselves, as Kentucky is doing with its new KY HealthChoices Medicaid reform plan.
• Financing: The states and the Federal government would each contribute, as they do today, to the costs of providing services to dually-eligible beneficiaries but through the new Medicaid Advantage program which would be managed by the states.
States and the Federal government already have some experience with the basic mechanisms that would be needed to calculate payments for this new program. The rate-setting and risk-adjustment systems that Medicare currently uses to pay Medicare Advantage plans and that states use to pay for standard Medicaid managed care programs would provide a foundation for their calculating payments that would fund this new integrated care management program for duals.
There would be three funding streams:
o Federal Medicare payments, which are generally provided through Medicare’s defined benefit structure, would be allocated to the states through a new funding mechanism. The Federal government would develop a system of capitated, risk-adjusted Medicare payments. These payments would be sent to the states to fund the Medicare portion of services for dual-eligible residents. This is not a block grant because funds would follow each recipient and would be adjusted for that patient’s risk profile. Medicare would use its actuarial data and payment history in determining the capitated rate it pays per dual eligible patient, and this funding stream would continue to be updated.
CMS is developing a system of risk adjustment that includes not only health status but also geographic payment variation, frailty, and other factors which could be employed in this new program.
o States would have two options in setting their payments for the Medicaid portion of services for their dual-eligible residents:
Those states that decide to contract with private managed care plans to provide coordinated care for their dual populations could calculate an actuarially-sound capitated rate for the state share of the Medicaid set of services. The plans, not the state, would be at risk.
• While many states have experience in setting payments for Medicaid managed care, their experience is in settings payments for acute care services, not long-term care support. As a result, they would need assistance in calculating these capitated payments for state-financed Medicaid services for duals.
Those states that decide to operate the program themselves and assume the risk (as well as potentially garnering more savings) could make contributions based upon their own Medicaid payment experience for services for duals, again with assistance in making the calculations.
In either case, a transition period would be required where the federal government and the states would share the risk until they have gathered enough information to refine this new system of payments.
Whether the state chooses to contract with Medicaid Advantage managed care plans or to operate the program itself, the states would still receive a federal match for their Medicaid contribution based upon existing formulas.
• Alternatively, CMS/Medicaid could determine a capitated amount of Medicaid funds that it would allocate per recipient based upon data about the cost of its share of Medicaid-covered services in that state for this population.
o Drug coverage, currently paid by Medicare, would be integrated into the Medicaid Advantage plans. Medicare would calculate a Part D allocation that would be returned to each state in the form of a capitated, risk-adjusted payment. This would be another part of the patient’s Medicaid Advantage funding stream.
Since implementation of Part D that assigned duals to drug plans, skilled nursing facilities have had many problems tracking many different drug plans and formularies for these residents. Medicaid Advantage would provide a mechanism to coordinate drug coverage, as well as medical care, through one plan.
States would have access to the pharmacy data that they lost after the transition to Part D in January, 2006.
• The joint Federal and state Medicaid contributions plus the Federal Medicare and part D contributions would be combined into one funding stream to finance care for duals through the new Medicaid Advantage plans. States could use this pool of money in designing benefits for duals and negotiating with health plans that would deliver required services. Duals would receive a full range of services currently financed separately through Medicare and Medicaid through this new integrated program, from hospitalization and skilled nursing care to physicians’ visits, personal care, home and community based services, prescription drugs, diagnostic and laboratory tests, etc.
o States would gain new flexibility in designing benefit packages in exchange for receiving a capitated, risk-adjusted payment from Medicare with fewer strings attached.
• Once the Medicaid Advantage plan has agreed on a contracted fee, the plans would be at risk for providing care to dual eligibles (except for those states that decide to carry the risk themselves). The plans or state contractors would be responsible for providing care, for collecting and providing performance data on treatments and outcomes for each patient, and for reporting this information to the states for their monitoring activities. The plans would be accountable for outcomes with strict oversight by the states, but they would have the flexibility to manage care creatively to meet the needs of patients.
• States also would be given greater flexibility to coordinate treatment for those with mental illness through Medicaid Advantage plans. Providing targeted case management, rehabilitation services, medication management, community mental health center services, and other less-costly services through a Medicare Advantage medical home could reduce the use of expensive hospital and emergency room services while providing improved care for these patients.
• The Federal government and the States would be responsible for carefully monitoring the plans and for bringing action against plans that do not meet their contractual obligations.
Benefits:
Medicaid Advantage (MD-Advantage) would minimize the current incentive to avoid caring for the most costly patients and would better align incentives for Medicare, Medicaid, plans, and recipients. Medicaid Advantage would allow states to:
• Integrate acute and long-term care benefits into a single program they would oversee in which competing private plans (or the states) would provide a coordinated care management program for dually-eligible beneficiaries
• Share in the savings achieved through innovative policies, such as disease management and care coordination
• Streamline cumbersome rules governing marketing, enrollment, performance monitoring, quality reporting, rate setting, bidding, and grievances and appeals
• Eliminate redundant and inefficient spending
• Provide both the Federal and state governments more predictability in budgeting for the significant part of their Medicare and Medicaid spending on dual eligibles.
All American Senior Care
The CareGiver
Thursday, November 02, 2006
Vermont gives seniors more options for care
In this experimental program the State pays family, friends, or aides to assist seniors at home. This keeps them out of a nursing home. If successful this program could serve as a model for the entire nation.
Bob
Vermont gives seniors more options for care
BY JOHN CURRAN
ASSOCIATED PRESS
November 2, 2006
WINOOSKI, Vt. -- At 93, Florence (Tubby) Parsons has a lot going for her. She has her cat, Buddy, the plants in her one-bedroom apartment to tend to and a weekly 25-cent poker game with neighbors.
Best of all, she doesn't have to live in a nursing home. Instead, she gets daily visits from a longtime friend who makes $10 an hour from the state to care for her.
She is part of a unique experiment in Vermont. Under the Choices for Care program, older adults who are eligible for Medicaid and need someone to tend to their needs can be cared for at home by a relative, friend or neighbor paid by the state.
"A nursing home? They sit there and moan and holler and sit in a chair and sleep. I don't want that," said Parsons, who has heart and thyroid problems and uses a walker to get around her apartment building.
Experts say the closely watched project could spur dramatic changes in the way the United States handles long-term care for elderly people.
One year after enacting it, Vermont officials say it is reducing the number of people sent to nursing homes, cutting the cost of taxpayer-funded care and improving the quality of life for people such as Parsons.
The nursing-home industry and other critics say subsidized home care by family members and other nonprofessionals is far from a panacea. They say the care isn't as good.
Parsons' former tenant, Penny Walsh, 41, gets paid $10 an hour for 35 to 40 hours of work a week. She said she took the job of caring for Parsons because she was already doing some of her cleaning and other chores for free.
"It's like seeing my grandmother every day," she said, sitting by Parsons' side during a Monday morning visit.
Previously, Walsh was a clerk and a worker at a day-care center.
Elder-care experts say the Vermont program could help blunt one of the longstanding criticisms of Medicaid -- that it shunts people into institutions without regard to what they really want.
Medicaid, which spent $38 billion on institutional care last year, wants to shift more toward home care and community-based systems, where "the medical dollars follow the needs of the patient, rather than the other way around," said Mary Kahn, a spokeswoman for the Centers for Medicare & Medicaid Services, the federal agency that administers the programs.
It costs Vermont about $122 a day for Medicaid-covered senior citizens who live in nursing homes, compared with about $80 a day for those being cared for in their homes.
Mary Shriver, executive director of the Vermont Health Care Association, a nursing home trade group, said that in-home care works for some but that it cannot match nursing home care for quality.
"Good intentions can cause some damage sometimes," she said.
Sometimes, good intentions are not enough.
"Typically, a family says, 'Sure, we can do this' and brings their grandparent into the home and starts into the role of caregiving and the state is paying them," said J. Churchill Hindes, president of the Visiting Nurse Association of Chittenden and Grand Isle Counties, a nonprofit home health care agency.
"And after a few months or a year, they realize how exhausting the work is, how emotionally draining it might be and just how hard it is."
Parsons' caregiver said the arrangement is working out great so far. Parsons said she likes the company and the help.
"She's been as close as family for a long time," Parsons said of Walsh. "You know what they say: You have to put up with your family, but you choose your friends. I chose her."
Bob
Vermont gives seniors more options for care
BY JOHN CURRAN
ASSOCIATED PRESS
November 2, 2006
WINOOSKI, Vt. -- At 93, Florence (Tubby) Parsons has a lot going for her. She has her cat, Buddy, the plants in her one-bedroom apartment to tend to and a weekly 25-cent poker game with neighbors.
Best of all, she doesn't have to live in a nursing home. Instead, she gets daily visits from a longtime friend who makes $10 an hour from the state to care for her.
She is part of a unique experiment in Vermont. Under the Choices for Care program, older adults who are eligible for Medicaid and need someone to tend to their needs can be cared for at home by a relative, friend or neighbor paid by the state.
"A nursing home? They sit there and moan and holler and sit in a chair and sleep. I don't want that," said Parsons, who has heart and thyroid problems and uses a walker to get around her apartment building.
Experts say the closely watched project could spur dramatic changes in the way the United States handles long-term care for elderly people.
One year after enacting it, Vermont officials say it is reducing the number of people sent to nursing homes, cutting the cost of taxpayer-funded care and improving the quality of life for people such as Parsons.
The nursing-home industry and other critics say subsidized home care by family members and other nonprofessionals is far from a panacea. They say the care isn't as good.
Parsons' former tenant, Penny Walsh, 41, gets paid $10 an hour for 35 to 40 hours of work a week. She said she took the job of caring for Parsons because she was already doing some of her cleaning and other chores for free.
"It's like seeing my grandmother every day," she said, sitting by Parsons' side during a Monday morning visit.
Previously, Walsh was a clerk and a worker at a day-care center.
Elder-care experts say the Vermont program could help blunt one of the longstanding criticisms of Medicaid -- that it shunts people into institutions without regard to what they really want.
Medicaid, which spent $38 billion on institutional care last year, wants to shift more toward home care and community-based systems, where "the medical dollars follow the needs of the patient, rather than the other way around," said Mary Kahn, a spokeswoman for the Centers for Medicare & Medicaid Services, the federal agency that administers the programs.
It costs Vermont about $122 a day for Medicaid-covered senior citizens who live in nursing homes, compared with about $80 a day for those being cared for in their homes.
Mary Shriver, executive director of the Vermont Health Care Association, a nursing home trade group, said that in-home care works for some but that it cannot match nursing home care for quality.
"Good intentions can cause some damage sometimes," she said.
Sometimes, good intentions are not enough.
"Typically, a family says, 'Sure, we can do this' and brings their grandparent into the home and starts into the role of caregiving and the state is paying them," said J. Churchill Hindes, president of the Visiting Nurse Association of Chittenden and Grand Isle Counties, a nonprofit home health care agency.
"And after a few months or a year, they realize how exhausting the work is, how emotionally draining it might be and just how hard it is."
Parsons' caregiver said the arrangement is working out great so far. Parsons said she likes the company and the help.
"She's been as close as family for a long time," Parsons said of Walsh. "You know what they say: You have to put up with your family, but you choose your friends. I chose her."
Crist, Davis differ on Medicaid overhaul
Republican Charlie Crist would continue Gov. Jeb Bush's shift from government simply paying the health care bills of Medicaid recipients to placing them in managed-care insurance programs. Democrat Jim Davis, a Tampa congressman, is at least partly opposed, saying that shifting all Medicaid patients involuntarily into private plans tries to "balance the Medicaid budget on the backs of people who depend on the state's health insurance program to stay out of hospitals."
Crist, Davis differ on Medicaid overhaul
DAVID ROYSE
Associated Press
TALLAHASSEE, Fla. - Medicaid has been obscured by homeowners' insurance, taxes and prescription costs, but the future of the program that provides health care to the state's poor, disabled and many elderly may depend on who wins Tuesday's gubernatorial election.
Republican Charlie Crist would continue Gov. Jeb Bush's shift from government simply paying the health care bills of Medicaid recipients to placing them in managed-care insurance programs.
Democrat Jim Davis, a Tampa congressman, is at least partly opposed, saying that shifting all Medicaid patients involuntarily into private plans tries to "balance the Medicaid budget on the backs of people who depend on the state's health insurance program to stay out of hospitals."
Florida's Medicaid program will cost about $16 billion this year - about $1 out of every $5 the state spends. Only education costs more.
Traditionally, Medicaid recipients - mostly the disabled and women with children who are close to the poverty line - have gone to see a participating health care provider, who then seeks reimbursement from the government. The program's costs are split between the state and the federal government.
In 2004, Bush proposed that the state place recipients in private health plans. The plans would have the ability to limit some benefits, such as which medicines may be purchased, and add others, like care for patients with HIV/AIDS or extensive prenatal care.
The idea was to force Medicaid recipients and their doctors to take some responsibility for their own care, which should lead to better health and save the state money, too.
But some advocates have worried it could lead to the most vulnerable patients not being guaranteed the options they currently have.
The shift has already started through test programs in the Jacksonville and Fort Lauderdale areas.
Crist, the state's attorney general, hasn't been a huge cheerleader for the Medicaid overhaul, but supports it.
"I certainly think the pilot's worth a try," Crist said. "Any way that we can spread those dollars and therefore be able to offer health care to more of the poor in our state I think is worthy.
"I think we're all aware how much Medicaid takes up of our state budget currently, and if we don't do something to strive to get a handle on it we're not going to be able to continue to provide the kind of health care that the poor deserve," Crist said.
Those who are skeptical of the changes say they are concerned the issue has been relegated to the campaign's periphery.
Neither candidate talks much about it on the campaign trail, focusing their health care discussions instead on prescription drug costs, and the question of importing medicine from Canada.
Bob Wychulis, president of the Florida Association of Health Plans, said his sense is that while the two candidates may differ on the details, neither is against allowing a managed care approach for at least some Medicaid patients.
Almost 1 million Florida Medicaid patients - about half of the total - have already gone into voluntary managed care programs over the last decade, and few of those have returned to more traditional programs, Wychulis said.
"Member satisfaction rates have been high in all the managed-care plans," he said.
Advocates for the elderly are worried about the planned next phase of the Medicaid overhaul, which will shift more nursing home care into managed care plans as well.
Nearly 50,000 of the 75,000 Florida nursing home residents have that care paid for by Medicaid. Under the proposed "Florida Senior Care" plan, nursing home patients could be shifted into HMOs, which would manage their nursing home care.
One group that has concerns is the massive senior lobby, AARP, although like other nonprofits it can't endorse candidates.
AARP argues that managed care may be fine for some nursing home patients, but shouldn't be mandatory.
"Consumers want the opportunity to make their own decisions about long-term services and supports so they can maintain their dignity and maximize their independence," the group said in a recent issue paper.
AARP spokesman Dave Bruns said many managed-care plans wouldn't likely let seniors pick their own long-term care facility.
"Our biggest concern is freedom of choice," Bruns said.
Crist, Davis differ on Medicaid overhaul
DAVID ROYSE
Associated Press
TALLAHASSEE, Fla. - Medicaid has been obscured by homeowners' insurance, taxes and prescription costs, but the future of the program that provides health care to the state's poor, disabled and many elderly may depend on who wins Tuesday's gubernatorial election.
Republican Charlie Crist would continue Gov. Jeb Bush's shift from government simply paying the health care bills of Medicaid recipients to placing them in managed-care insurance programs.
Democrat Jim Davis, a Tampa congressman, is at least partly opposed, saying that shifting all Medicaid patients involuntarily into private plans tries to "balance the Medicaid budget on the backs of people who depend on the state's health insurance program to stay out of hospitals."
Florida's Medicaid program will cost about $16 billion this year - about $1 out of every $5 the state spends. Only education costs more.
Traditionally, Medicaid recipients - mostly the disabled and women with children who are close to the poverty line - have gone to see a participating health care provider, who then seeks reimbursement from the government. The program's costs are split between the state and the federal government.
In 2004, Bush proposed that the state place recipients in private health plans. The plans would have the ability to limit some benefits, such as which medicines may be purchased, and add others, like care for patients with HIV/AIDS or extensive prenatal care.
The idea was to force Medicaid recipients and their doctors to take some responsibility for their own care, which should lead to better health and save the state money, too.
But some advocates have worried it could lead to the most vulnerable patients not being guaranteed the options they currently have.
The shift has already started through test programs in the Jacksonville and Fort Lauderdale areas.
Crist, the state's attorney general, hasn't been a huge cheerleader for the Medicaid overhaul, but supports it.
"I certainly think the pilot's worth a try," Crist said. "Any way that we can spread those dollars and therefore be able to offer health care to more of the poor in our state I think is worthy.
"I think we're all aware how much Medicaid takes up of our state budget currently, and if we don't do something to strive to get a handle on it we're not going to be able to continue to provide the kind of health care that the poor deserve," Crist said.
Those who are skeptical of the changes say they are concerned the issue has been relegated to the campaign's periphery.
Neither candidate talks much about it on the campaign trail, focusing their health care discussions instead on prescription drug costs, and the question of importing medicine from Canada.
Bob Wychulis, president of the Florida Association of Health Plans, said his sense is that while the two candidates may differ on the details, neither is against allowing a managed care approach for at least some Medicaid patients.
Almost 1 million Florida Medicaid patients - about half of the total - have already gone into voluntary managed care programs over the last decade, and few of those have returned to more traditional programs, Wychulis said.
"Member satisfaction rates have been high in all the managed-care plans," he said.
Advocates for the elderly are worried about the planned next phase of the Medicaid overhaul, which will shift more nursing home care into managed care plans as well.
Nearly 50,000 of the 75,000 Florida nursing home residents have that care paid for by Medicaid. Under the proposed "Florida Senior Care" plan, nursing home patients could be shifted into HMOs, which would manage their nursing home care.
One group that has concerns is the massive senior lobby, AARP, although like other nonprofits it can't endorse candidates.
AARP argues that managed care may be fine for some nursing home patients, but shouldn't be mandatory.
"Consumers want the opportunity to make their own decisions about long-term services and supports so they can maintain their dignity and maximize their independence," the group said in a recent issue paper.
AARP spokesman Dave Bruns said many managed-care plans wouldn't likely let seniors pick their own long-term care facility.
"Our biggest concern is freedom of choice," Bruns said.
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