Nursing Care Management News

Falling and Older Adults

matrix — Mon, 10 Feb 2014 21:46:24 +0000

Falls among those 65 years and older are a leading cause of accidental injury and death in the United States. According to the Centers for Disease Control and Prevention, in 2010, 2.3 million nonfatal fall injuries among older adults were treated in emergency departments and more than 662,000 of these patients were hospitalized.

It is possible to decrease the risk and incidence of falls in older adults and thereby decrease individual and societal cost as well as reducing trauma. The Geriatric Care Manager (GCM) has an important role in identifying risk factors specific to each client, developing strategies to eliminate or decrease these risks, and gaining the client’s cooperation in implementing these strategies.

By conducting a comprehensive assessment, the GCM can identify health concerns which contribute to an increased risk of falling. It is essential to determine whether an individual is experiencing fall-provoking side effects from medications, such as dizziness or blood pressure fluctuations. Additionally the GCM can help evaluate whether walking aides like canes and walkers are contributing or minimizing the risk of falls. Completing a neurobehavioral cognitive status exam will help identify cognitive impairments which predispose people to falls.

Conducting a thorough assessment of the home environment is essential to ensuring adequate lighting and removal of obstacles in walkways such as throw rugs, piles of clutter, items stored in doorways and stairways and furniture. Determining the need for handrails in stairways or long hallways, grab rails in bathrooms, use of shower assistive devices like non-slip mats and shower benches all help reduce the risk for falls.

Once risks for falling have been identified geriatric care managers provide the assistance and resources needed to make changes to the home, to aid daily mobility practices, to monitor medications and to enhance care regimes to minimize falls and injuries to older adults and those with disabilities.

Act Your Age… and other sound advice

matrix — Tue, 28 Jan 2014 17:46:02 +0000

In a time when older adults are not necessarily acting all that “old” it can be a bit misleading for families, friends and even the person himself in terms of risk from the plain old ordinary decisions we make day to day. As we age, even when we do so in a healthy and active fashion, there are physical, sensory and other changes that occur that put an older adult at risk. Often adults have come to find what works well for them; a consistent daily routine, preferred clothing and shoes, using the back stairway rather than the front and so on. Often these systems and habits are utilized because they have been shown to benefit the older adult, to make independence easier and promote greater comfort. While the older adult remains active and involved, changes of aging continue to occur including hearing or vision deficits, a decrease in ‘reserve’ energy to combat illness and injury, bone loss and risk of fracture and many other signs and symptoms. Then… we throw in a new twist, one that seems completely harmless and no one gives a second thought, new, top of the line, just like the kids and grandkids – running shoes.
When a family sees a vibrant, physically active, ‘young’ for his age grandfather they may treat him as such without understanding some very simple but very real risks. For instance, it may seem fun to purchase Grandpa the same neon colored running shoes all of the grandchildren are getting for Christmas. He is always such a good sport and loves to connect with his beloved grandchildren. These are “sturdy and sensible” just like the old broken-in leather loafers that he has worn forever, right? Not if Grandpa is unaccustomed to wearing such a shoe with a high and wide sole that catches and grips carpet. The fall Grandpa sustained while wearing these great new shoes ends up with a fractured hip and a long period of recovery and rehabilitation. The change in footwear, the heaviness compared to his usual shoes, the ‘gripping’ feature of the running shoe and the extra wide sole can throw off a senior’s balance, catch unsuspectingly while walking or change one’s gait just enough to create an increased fall risk.
Promoting active, healthy aging and greater independence is the goal for older adults but there are times when even the simplest decisions and changes need a few moments of thought about how they could pose a risk, what might be affected by a new item or a moved piece of furniture and is this really a good choice for this person?

Vital Choices – Naming a Durable Power of Attorney for Health Care

matrix — Wed, 14 Aug 2013 14:32:25 +0000

A Durable Power of Attorney for Health Care (DPAHC) is a legal document that must be completed by the person while he or she is of sound mind. A DPAHC is a document that gives the agent or health care representative considerable authority to make decisions regarding housing, skilled home care services, medical care and end of life care decisions when an individual is no longer able to do so. The decisions made should be those that the person (principal) would want or prefer and should not be based upon what the agent prefers.
The DPAHC should clearly state the principal’s preferences and choices related to significant health care decisions like whether resuscitative efforts should be attempted, whether life support measures should be utilized and for how long, how aggressive treatment should be pursued, where health care services should be provided, what end of life preferences they have, and so forth.

A person completing a DPAHC in Minnesota should carefully consider who they name as their agent(s) or health care representative(s) to be someone they trust to carry out their wishes as this will be done when they are not able to communicate their wishes or carry them out due to incapacity or incompetency. The principal may name more than one agent if they prefer and they should designate whether the agents work together or independently to make decisions, most often a second person is named to assure someone is available if the first designee is unreachable, or unable themselves (i.e. an elderly spouse). If a change in the capacity or relationship with this person or persons occurs, such as dementia, death or divorce, this document should be reviewed and changed as needed.
The DPAHC can be changed or revoked by the principal as long as they are capable of doing so, otherwise it remains in effect until one of the following occurs: a spouse so named is divorced from the principal (varies state-to-state), a judge deems the document as a whole to be invalid or revokes the powers of the health care agent or the principal dies.

It is not unusual for a Geriatric Care Manager to be called into a situation in which there is concern about the intention or ability of the agent(s) to assuredly work towards the best interest of the principal and to assist in determining what actual needs may be related to housing, skilled home care and medical or health related decisions.

Financial Power of Attorney – Understand what you are signing.

matrix — Mon, 05 Aug 2013 21:17:26 +0000

A Power of Attorney (POA) is a legal document that authorizes someone to act on another’s behalf regarding financial affairs. A POA is a legal document that must be completed by the person (referred to as the “principal”) while he or she is of sound mind. A Power of Attorney document should never be drafted by coercion or force, but is best planned well ahead of the time it may be needed and be well thought out. It is crucial when identifying and choosing a person to act on your behalf that you know the person well and trust them implicitly. The person you choose will be called the agent or the attorney-in-fact. If a change in this relationship occurs such as death or divorce, this document should be reviewed and changed as needed.

There are two options when drafting this document in the state of Minnesota, one providing the agent general power over all of the principal’s affairs and one that is limited and provides power over selected portions of the principal’s affairs, which may include things like paying bills; buying, selling and paying taxes on property; investing money or handling banking transactions and so forth, as specified by the principal.

When another person is given power to act on the principal’s affairs, it does not mean that the principal necessarily gives up that role as it may be / should be shared with the agent who has been named if the principal has the capacity to do so. The principal does not simply lose the right to control their own financial matters when a POA is signed. The principal can take back (revoke) the POA at any time. One should be cautioned that the named agent has the right to act without the principal once given the authority and in some cases this leads to a unexpected signficant financial impact on the principal. Though justly an agent should be working hand-in-hand with the principal, this is not always the case. The agent must keep a record or accounting of any transactions they undertake and they are supposed to make these decisions and take actions that are in the best interest of the principal.

A principal is able to select more than one agent and if done it is important to identify on the document whether or not each of these people can make decisions independent of each other or whether they must ask permission of the other(s) and proceed cooperatively. The principal can also list the agents in succession identifying who is first, who is second should the first person be unavailable and so forth.

A skilled care manager may be called upon to assist an agent in understanding an older adult principal’s housing, health and Minnesota home care needs to better prepare for proper management of assets and expenditures.

Telehealth Care – Health Care Technology for Older Adults

matrix — Tue, 30 Jul 2013 15:39:09 +0000

As the world of technology continues to explode around us the opportunity to enhance quality of life, minimize trips to the doctor’s office, manage chronic health problems and communicate more easily is coming to baby boomers and older adults with health needs.
Telehealth is a term currently being defined in a number of ways including: the use of telecommunication technologies to provide health care services; electronic access to medical and surgical information; delivery of health care via remote means or utilization of technologies to offer education, information and services via technological communication devices. In essence it is a means for gathering and transmitting data between health care users and health care providers to enhance the quality of life of older adults.

Telehealth brings the opportunity to:
• minimize trips to the doctor or hospital
• complete in-home monitoring of blood pressures, weights, oxygen levels, heart rhythms…
• provide health personnel and family members pertinent information
• optimize health care by using data to make treatment plan adjustments in the home
• mechanize home functions to enhance safety including lighting, door security, monitors and alarms and more
• connect otherwise isolated older adults to those who care for them
• provide a means for safety management, enhanced independence, reduced cost for medical care management and so much more

Telehealth is a growing field with a multitude of benefits available to the adult with chronic health issues or disabilities and the older adult to more fully manage health care needs from their home, wherever that may be. Telehealth is currently being used by in-home health care professionals to maximize efficiency without jeopardizing the patient’s care needs. Having the ability to monitor vital signs and other essential information allows doctors and nurses to make adjustments to medications and other patient needs without the patient having to make frequent clinic visits. Telehealth provides round the clock opportunity to check on client’s vital signs, oxygen levels, blood sugars and so forth which might otherwise be challenging to attain without having the person in a hospital or other 24-hour care setting.

In-home quality of life, safety and communication can all benefit from telehealth options and systems that are multi-functional to meet all of an individual’s needs. From opening the front door to turning on hallway and bathroom lights when a person steps out of bed at night to sending vocal reminders to take their pills and a text message to a concerned daughter indicating the pills were taken, telehealth opens the door to improving quality of life, enhancing dignity and minimizing isolation. Telehealth systems vary significantly in function, cost, access and ease of use and their implementation should be evaluated by and coordinated with the older adult’s health care team members to gain the most benefit.

Long Term Care insurance paperwork – A nightmare to some

matrix — Tue, 23 Jul 2013 13:40:42 +0000

For those who have Long Term Care (LTC) policies the ability to finally begin using the benefits can be a welcome relief to expensive care costs and overwhelming care needs of a loved one. Yet for many seniors and their families LTC paperwork can be daunting and complicated, at times to the point of seniors foregoing their benefits entirely as they are not able to navigate the complex document requirements. Whether the need to provide proof of eligibility, submit adequate documentation about the level of care provided and or make arrangements for benefit payments, the insurance paperwork can be a nightmare.
LTC benefits are paid when beneficiaries meet the terms of coverage in their policy, most frequently qualifying if they now require personal care assistance in 2 or more activities of daily living (ADLs) like dressing, grooming, bathing, toileting and eating or when they require constant supervision of another person due to severe cognitive impairment like dementia or Alzheimer’s Disease.
Initiating the benefit wait or elimination period, gathering necessary documentation to begin coverage and submitting ongoing documentation for the remainder of the time care coverage is provided can be more than an individual can manage alone. Many LTC processes require a large number of documents to be processed, some originating with the beneficiary or the responsible person for that individual and the others required from the professional care providers. Determining when an individual is able to utilize their LTC policy begins with contacting the company holding the policy, contacting the representative who brokered the policy or working with member services to walk through the entire process.
Once it is determined that a person qualifies to begin either the elimination process or covered services it is essential that documents are gathered which fulfill the company requirements to assure there is no delay in obtaining coverage once all conditions are met. For those who do not have the capacity to wade through the overwhelming paperwork, whether related to time, health or cognitive functioning other professionals including Geriatric Care Managers are available to assist in navigating the system with or for the individual. Additionally, those providing care (Home Health Care agencies, Assisted Living Care facilities…) for the patient can assist by providing or submitting all of the information necessary to initiate the claim and assure ongoing benefit payment throughout the duration of a person’s qualifying care.

Hospice Care – Must I have cancer to use hospice care?

matrix — Mon, 15 Jul 2013 14:51:50 +0000

Historically, people associated hospice care with cancer care as some of the earliest patients to use hospice care were those who had terminal cancer. Hospice care is not specific to cancer patients only but certainly cancer patients make up a portion of those served by hospice care. Hospice care is open to anyone who is dying or whose condition is deteriorating toward death and meets pre-determined criteria. Those eligible for hospice consideration include the person who is dying from a condition that is no longer treatable or curable, a condition that is progressive and fatal or from natural causes at any age. Hospice care is valuable and available to those from birth through old age and encompasses those with every type of medical condition and physical symptom one can imagine.
Hospice care in Minnesota is provided by a team of health professionals, supportive services and volunteers. A person receiving hospice care can expect regular visits of a registered nurse to evaluate their condition and needs and develop a plan to address symptoms and challenges. Home Health Aides are utilized to aid in personal care like bathing and showering. Supportive staff including Social Workers and Chaplains provide the patient and family supportive resources to aid in preparing for death and provide ongoing bereavement services after the death has occurred. Ancillary services like massage therapy, music therapy, volunteer visitors and other quality of life resources are added to the patient’s plan of care as desired and available per each individual agencies offerings.
Preparing for death in a manner that is supportive, well equipped, surrounded by health care professionals experienced in promoting comfort and symptom management creates an environment that enhances the opportunity to experience the final stage in life: death in a manner that enhances dignity and provides for the opportunity of healing and comfort during a time of loss and grief.

Choosing Hospice Sooner than Later, Making Hospice Part of Your Home Health Care Plan

matrix — Tue, 09 Jul 2013 15:40:03 +0000

When the word hospice is mentioned, frequently people shudder, connecting hospice to imminent death. For many, their experience with hospice care is historically related to quick arrangements made just prior to a loved one’s imminent decline and death. Therefore any mention of hospice care well before a loved one is actively dying can be very threatening and seem quite inappropriate. However, hospice care when timed well before active dying can provide an enhanced end of life experience for all involved.
Hospice care came to be more visible in the US in the 1970s and over the years has remained both a scary topic to whisper about and a well recognized and respected process that provides comfort and enhanced quality of life for those who are dying and opportunities of healing and support for their families, friends and caregivers. The philosophy of hospice is best accomplished when put into service well before imminent death is expected, although it can be beneficial no matter how short the time of services and care.
Implementing hospice care when a person is just learning that their condition is terminal, when a senior is learning that natural end of life is approaching or when curative measures are no longer available provides the person and those who care for them an opportunity to gradually prepare for death, to assure symptoms like pain and anxiety are addressed and reception of supportive resources like those provided by social workers, chaplains, music therapists and others.
Hospice care also provides a streamlined approach to attaining needed equipment and medications along with access to a supportive team of professional care providers 24 hours a day. Hospice services are based upon a patient qualifying for care as determined by an intake team and specific Medicare and/or insurance guidelines. All hospice costs are covered by insurance or Medicare.
In essence hospice care is designed for a person who has a life expectancy of 6 months or less and their condition is progressively deteriorating, however those who live longer than 6 months and continue to decline in condition often remain qualified for ongoing hospice coverage until their time of death occurs. When thought of in this manner, hospice care becomes a logical component of a thorough Minnesota home health care plan for elderly seniors and their families in the geriatric care management process.

Driving when it is no longer safe

matrix — Thu, 21 Mar 2013 19:36:56 +0000

Most seniors believe they retain safe driving habits and skills longer than they actually do. Changes in vision, hearing, and reaction time affect driving skills as people age. Many seniors compensate for these changes by avoiding driving during rush hour, staying off freeways, and not driving after dark. However, these limits do not affect such problems as confusing the accelerator and brake pedals or turning left in front of oncoming traffic, common reasons for crashes involving elderly drivers.

Additional signs of difficulty in driving may include drifting into other lanes of traffic, turning without signaling and driving the wrong way into oncoming traffic, each a significant risk to the elderly driver and those on the road at the same time.

Older adults with cognitive impairments such as memory loss or disorientation to time or place cause risk to themselves and others when they continue to drive. They may lose their way, ending up many miles from their intended destinations, they may lose their car in parking lots, and they may be unable to find their way home. Struggling with these issues creates a further hazard as concentration and focus on actual driving is affected once one realizes they are lost.

AARP and AAA offer programs to maximize the skills of older drivers. Some states offer a reduction in car insurance premiums for drivers who complete a safe driving course. Seniors should ask for input regarding their driving skills from their families and doctors. Driver testing can be arranged through the sites that test for driver’s licenses or through agencies that train disabled people to drive. Many agencies exist to evaluate seniors driving in their own familiar neighborhood to see what permissions may be possible and what restrictions may be needed. If drivers refuse to stop driving, a geriatric care consultant can intervene to arrange for proper evaluation and alternatives to driving.

Undue Influence and Financial Exploitation

matrix — Mon, 11 Mar 2013 12:56:26 +0000

Undue influence is a form of psychological abuse, related to the phenomena of mind-control. Defined as the substitution of one person’s will for the true desires of another, undue influence generally occurs when the victim is incapacitated by cognitive impairment, physical or mental illness or some other vulnerability such as recent bereavement. Undue influence is usually accompanied by fraud or duress by the perpetrator, generally someone in a position of trust or authority, who seeks financial gain at the expense of the victim.

Elderly people with assets such as their own homes, stocks, bonds, and other material and financial assets, are most likely to become victims of undue influence due to their life circumstances.

Perpetrators almost always begin with a close and trusting relationship with the victim, and most often perpetrators are family members. Family members sometimes have a financial duty to the victim as their attorney-in-fact, and use that relationship to take financial advantage of the victim. Some family members convince the vulnerable adult to make them attorney-in-fact in and may use any variety of means to accompish this including coercion and threats, some taking advantage of that elder because they have made a past mistake or error in managing finances.

How does one deal with supspected undue influence or financial explotiation? If there were an easy answer to this question, the prevalence of undue influence and financial exploitation would be less and when it occurred, it would be more easily resolved. When any of the warning signs listed above are identified, it is imperative that a trusted family member or professional – or even better, several people working together – insist on a private visit with the suspected victim. The client’s attorney should be contacted and notified about legal changes that were made by the perpetrator’s attorney. It is often necessary to contact authorities such as Adult Protective Services or police agencies to force the perpetrator to allow a visit from relatives or professionals such as an attorney, accountant or doctor.

Thorough documentation of any and all signs of undue influence is helpful in establishing the pattern of
isolation, siege mentality, dependency and powerlessness that allows the perpetrator to gain control of the victim. When they receive timely notification of undue influence and financial exploitation, law
enforcement officials are willing to prosecute this type of abuse and exploitation.

Excerpted from Issues on Aging.